Abstract!of!thesis!entitled! - University of Hong Kong Wai Ching.pdf · ! 5!...

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Abstract!of!thesis!entitled!

“Evidence)based-guidelines-on-tap-water-irrigation-for-patients-

presenting-to-accident-and-emergency-department-with-simple-

acute-traumatic-lacerations”-

Submitted!by!!

Lam-Wai-Ching-

For!the!degree!of!Master!of!Nursing!

at!the!University!of!Hong!Kong!

in!August!2015!

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Abstract! !

Simple!acute!traumatic!lacerations!refer!to!a!type!of!skin!injuries,!which!is!

the! most! common! reason! that! patients! attend! Accident! and! Emergency!

Departments! (AEDs).! Nurses! play! the! role! in! choosing! dressing! solutions! for!

wound!management! although!wound!management! varied! in! local! AEDs.! Using!

tap!water!for!irrigation!is!a!cost!effective!method!for!wound!management.!There!

is!no!difference!between!using!tap!water!and!normal!saline!irrigation!in!infection!

rates!according!to!latest!evidence.!However,!there!is!currently!no!local!studies!or!

evidenceLbased!guidelines!using!tap!water!for!irrigation!in!Hong!Kong.!The!aim!

of!this!dissertation!is!to!find!out!latest!evidence!and!develop!an!evidenceLbased!

protocol!of!using!tap!water!for!irrigation!in!local!AEDs.!

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Four! electronic! bibliographical! databases! including! PubMed,! CINAHL,!

Medline!(OvidSP)!and!Cochrane! library!were!used!and! four! latest!studies!meet!

the! inclusion! criteria! in! this! dissertation.! And! the! studies! were! evaluated! by!

using!Scottish!Intercollegiate!Guideline!Network!(SIGN),!which!is!an!assessment!

tool!to!evaluate!the!studies!quality.!!

The!result!of!the!findings!suggested!there!is!no!difference!between!using!

tap!water!and!normal!saline!for!irrigation!in!infection!rates.!Using!tap!water!as!

an! alternative! for! wound! irrigation! in! AEDs! poses! benefits! to! patients,! health!

care! professionals! and! whole! health! care! systems! in! the! long! run.! The!

implementation!potential!will!be!assessed!in!terms!of!transferability,!feasibility,!

and! costLbenefit! analysis.! In! addition,! an! evidenceLbased! guideline! was!

established!for!local!AEDs.!

!! After! assessing! the! implementation! potential,! it! is! necessary! to!

communicate!with!various!stakeholders.!The!pilot!study!will!be!performed!and!

evaluation! will! be! done.! The! evaluation! includes! patient! outcome,! healthcare!

provider! outcome! and! organization! outcome.! The! proposed! innovation!will! be!

regarded! as! a! success! if! there! is! no! difference! between! using! tap! water! and!

normal!saline!for!irrigation!in!infection!rates.!!

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Evidence)based-guidelines-on-tap-water-irrigation-for-patients-

presenting-accident-and-emergency-department-with-simple-

acute-traumatic-lacerations-

By!!

Lam!Wai!Ching!

BN,!RN!

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A!thesis!submitted!in!partial!fulfillment!of!the!requirements!for!

the!Degree!of!Master!of!Nursing!

at!the!University!of!Hong!Kong!

August,!2015!

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Declaration!

I! declare! that! this! thesis! represents! my! own! work,! except! where! due!

acknowledgement! is! made,! and! that! it! has! not! been! previously! included! in! a!

thesis,! dissertation! or! report! submitted! to! this! University! or! to! any! other!

institution!for!a!degree,!diploma!or!other!qualifications.!!

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Lam!Wai!Ching!

August,!2015!

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Acknowledgement--

I!would!like!to!express!my!gratitude!to!my!supervisors,!Dr.!Janet!Wong!Yuen!Ha,!

Assistant! Professor! and! Director! of! Master! of! Nursing! Programme,! for! her!

guidance!and!support.!I!would!like!to!thank!Dr.!Kelvin!Wang!Man!Ping,!Assistant!

Professor,! for! his! assistance,! opinions,! and! encouragement.! This! dissertation!

could!not!have!been!completed!without! their!support,!especially! I!encountered!

critical!period!in!2013L2015.!!

In! addition,! I! would! like! to! thank! all! my! AEDs! colleagues! and! family!

members! for! their! understanding,! kindness! and! generosity! throughout! my!

studies.!!

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Content!Abstract! ! ! ! ! ! ! ! ! ! !!!1!Declaration!! ! ! ! ! ! ! ! ! !!!4!Acknowledgement! ! ! ! ! ! ! ! !!!5!!Chapter!1!Introduction!1.1!Background!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!7!1.2!Affirming!the!needs!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!8!!!!!!!!!!!!!!!!1.3!Significance!and!objectives!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!9!!Chapter!2!Critical!Appraisals!2.1!Search!and!Appraisal!strategies!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!12!2.2!Results!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!13!2.3!Summary!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!17!2.4!Synthesis!of!findings!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!18!!Chapter!3!Translations!and!Application!3.1!Implementation!potential!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!20!3.2!Feasibility!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!21!3.3!CostLbenefit!ratio!of!the!innovation!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!25!3.4!EvidenceLbased!practice!guideline!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!28!!Chapter!4!Implementation!plan!4.1!Communication!plan!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!29!4.2!Pilot!study!plan!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!31!4.3!Evaluation!plan!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!33!! ! ! ! ! ! ! ! !!Reference!list!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!38!Appendix!ALR!

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Chapter-1-

Introduction-

1.1-Background-

Acute!traumatic!lacerations!defined!as!a!type!of!skin!injuries!in!which!the!

topmost! layer! is!scratched!off.!This! is!a!common!reason!that!people!present! to!

Accident! and! Emergency! Departments! (AEDs),! requiring! wound! dressing! and!

suturing.! It! accounts! for! 8L17%! of! all! emergencies! in! United! States! (US),! and!

approximately!8!million!traumatic!wound!every!year!(Weiss!et!al.,!2013;!Moscati!

et! al.,! 2007;!Zehtabchi!et! al.,! 2012).! Some!with!minor! skin! injuries!may!handle!

the!wounds!by!themselves!instead!of!seeking!medical!cares.!This!implies!that!the!

actual! number! of! skin! injuries! is! much! more! than! estimation.! Many! of! skin!

lacerations! occur! in! children! and! the! occurrences! more! likely! in! males! than!

females!(Weiss!et!al.,!2013;!Valente!et!al.,!2003;!Bansal!et!al.,!2002).!!

Wound!infection!is!the!leading!cause!of!morbidity!and!mortality,!which!is!

associated!with!several!factors,!such!as!the!time!present!to!AEDs,!the!anatomical!

site,!the!type!and!the!amount!microorganisms,!the!medical!status!of!the!patient.!

For! instance,!wound! infection! in!diabetes!mellitus!has!a!poorer!prognosis! than!

others! (Quinn! et! al.,! 2014).! Untreated! wound! with! more! than! 12L24! hours! is!

more! susceptible! to! infections.! Severe! wound! infections! not! only! affect!

functioning! but! also! cosmetic! outcomes! (Fernandez! et! al.,! 2005).! Thus,! great!

effort! was! usually! devoted! by! health! care! professionals! to! reduce! the! risk! of!

infection.!(Weiss!et!al.,!2013;!Quinn!et!al.,!2014;!Fernandez!et!al.,!2005).!!

Using! antiseptics! such! as! povidoneLiodine,! chlorhexidine! for! wound!

cleansing!is!common!but!remain!controversial!as!they!may!impede!normal!tissue!

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growth.! Normal! saline! (NS)! is! the! most! common! solution! used! for! wound!

management!in!the!AEDs!in!Hong!Kong.!NS!is!isotonic,!easily!available!and!cost!

effective!when!compared!with!other!antiseptics!(Weiss!et!al.,!2013;!Moscati!et!al.,!

2007;!Valente!et!al.,!2003;!Bansal!et!al.,!2002).!!

1.2-Affirming-the-Needs-

Wound!management!varied! in!different!AEDs! in!Hong!Kong.!Some!AEDs!

washed!wounds!with!antiseptics!and!some!used!irrigation.!Irrigation!is!a!wound!

dressing!method!to!remove!debris,!devitalized!tissue!and!bacteria!(Weiss!et!al.,!

2013).! Irrigation! was! usually! performed! using! an! 18! gauge! needle! or!

angiocatheter!and!copious!normal!saline!dilution!to!generate!pressure!through!a!

syringe! to! remove! bacteria! and! debris.! Around! 250L300! ml! normal! saline! is!

usually! used! for! irrigation.! The! actual! volume! used! is! dependent! on! the! size,!

depth!of!the!wound!and!the!suggested!pressure!between!8L45!psi!(Dulecki!et!al,!

2005).!!

Nurses! usually! play! the!main! role! in! choosing! the! solutions! for! wound!

irrigation! and! tap! water! is! increasingly! considered! as! another! choice! than!

normal!saline.!Tap!water!was!defined!as!water!that!comes!out!of!the!tap!faucets!

in!a!building!that!are!connected!to!the!main!supply!of! the! local!systems.! It!was!

the!most!common!solutions! for! irrigation!outside!hospitals! for! first!aids!and! in!

the! community! (Fernandez!et! al.,! 2005).! !The!variability!of! irrigation! solutions!

suggests!that!an!evidenceLbased!protocol!for!irrigation!in!AEDs!is!needed.!

Tap! water! is! less! expensive! than! normal! saline! and! other! antiseptics,!

especially!when!plenty!of!solutions! is!needed!for! irrigation.!Weiss!et!al.! (2013)!

estimated!that!using!tap!water! for! irrigation!could!generate!millions!of!savings!

for!the!hospitals,!significantly!further!lowering!the!cost!for!wound!management!

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if!it!is!as!effective!as!normal!saline!in!reducing!infection.!Normal!saline!solutions!

have!shelf!lives!and!expiry!dates.!For!a!bottle!of!1000ml!normal!saline,!it!usually!

needs! to! be! discarded! within! 24! hours! once! open! no! matter! used! up! or! not.!

These! bottles! occupy! significant! space! for! storage.! If! tap! water! is! used! for!

irrigation,! it!may! lower!medical!costs,! space! for!storage!and!hence!reduces! the!

financial! burden! of! society! and! individuals.! And! the! bottles! of! sterile! normal!

saline! can!be!used! in! rural,! poor!developed!area!where!did!not!have! clean! tap!

water! supply! (Weiss! et! al.,! 2013;! Moscati! et! al.,! 2007;! Valente! et! al.,! 2003).!

However,!using!tap!water!for!irrigation!in!the!community!is!common,!but!using!

tap! water! for! irrigation! in! the! AEDs! received! minimal! attention.! In! addition,!

there!are!no!guidelines!on!using!tap!water!for!irrigation!in!local!AEDs.!

Emergency! services! become! an! important! part! of! health! care! systems!

since! the! demand! of! emergencies! service! rises! in! accordance! with! the! rapid!

growing! populations.! In! Hong! Kong,! the! attendance! of! AEDs! is! 2253310!

according! to! Hospital! Authority! statistical! report! in! 2012L2013.! Cost!

management! is! necessary! to! health! care! systems,! especially! to! encounter! the!

challenge!with!growing!populations!and!the!need!of!medical!services.!Hong!Kong!

is!a!wellLdeveloped!country!and!the!medical!standard,!water!quality!are!able!to!

meet! the! standard! of! World! Health! Organization! (WHO).! The! applications! of!

using!tap!water! for! irrigation!pose!benefits! to!not!only!the! local!AEDs,!but!also!

the!whole!health!care!systems!in!Hong!Kong.!!

1.3-Significance-and-Objectives-

As! there! is! a! dearth! of! evidence! on! using! tap! water! to! manage! acute!

traumatic!lacerations!in!the!HK!AEDs,!the!aim!of!this!study!is!to!compare!the!tap!

water! and! normal! saline! on! reducing! infection,! specifically! focuses! on! the!

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effectiveness! of! tap! water! solution! in! managing! of! simple! acute! traumatic!

lacerations!and!to!translate!the!findings!with!justifications!to!manage!traumatic!

wounds! of! patients! present! to! AEDs.! A! new! guideline! or! protocol! of! using! tap!

water!was! then! set!up!according! the!best! available!evidence,! and! translate! the!

finding!to!the!AEDs.!!

Objectives-

1. To!systematic!review!the!existing!literature!on!comparing!tap!water!and!

normal!saline!for!irrigation!in!AEDs!

2. To!critically!appraise! the!existing! literature!of! comparing! tap!water!and!

normal!saline!for!irrigation!in!AEDs!

3. To! gather! empirical! evidence! of! using! tap! water! and! normal! saline!

irrigation! for! patient! present! to! AEDs! with! acute! simple! traumatic!

lacerations.!

4. To!develop!an!evidenceLbased!guideline!for!using!tap!water!for!irrigation!

in!patients!with!acute!simple!traumatic!lacerations!!

5. To!assess!the!implementation!potential!of!using!tap!water!for!irrigation!in!

Hong!Kong!

6. To!evaluate!the!effectiveness!of!using!tap!water!for!irrigation!in!patients!

with!acute!simple!traumatic!lacerations!

!

The!Stetler!model!is!the!evidenceLbased!practice!that!promote!and!facilitates!

critical!thinking!about!the!application!of!research!findings!in!practice.!It!consists!

of! 5! phases:! preparation,! validation,! comparative! evaluation/decision! making,!

translation!and!evaluation!in!Appendix!A.!

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Chapter-2-

Critical-appraisal-

The!background,!affirming!needs,!significance!was!discussed!in!chapter!1,!

the!next!step!is!to!search!and!extract!relevant!evidence!related!to!the!question.!A!

question!was!formulated!using!PICO!format!to!gather!relevant!evidence.!

Questions:! In! patients! with! acute! traumatic! wounds,! is! tap! water! effective! as!

normal!saline!irrigation!in!reducing!infection?!

Patient/Problem:!Patients!attend!AEDs!with!acute!simple!traumatic!lacerations.!!

Intervention:!Tap!water!irrigation!!

Comparison:!Normal!saline!irrigation!

Outcome:!reduced!infection!

Selection-criteria--

All! randomized! controlled! trials,! quasiLrandomized! controlled! trials,! and!metaL

analysis! of! human! studies! that! compared! using! tap! water! and! normal! saline!

irrigation!in!AEDs!was!included.!

Inclusion-criteria--

Patients! attend! AEDs! with! acute! simple! traumatic! lacerations,! with! age! more!

than!1!year!were!included.!

Exclusion-criteria-

Patients! with! underlying! illness! such! as! diabetes,! immune! disease,! cancer,!

current! use! of! antibiotics,! immunosuppressant,! and! complicated! wound! with!

injury! to! tendon,! major! blood! vessels,! attend! AEDs! more! than! 9! hours! were!

excluded.!

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2.1-Search-strategies-

A!systematic! search!was! conducted!between!1! July!2014!and!4!October!

2014.! ! The! databases! of! PubMed,! CINAHL,! Medline! (OvidSP)! and! Cochrane!

library! were! searched.! The! searching! keywords! included! “normal! saline”,!

“lacerations”,! “acute! traumatic! wound”,! “tap! water”! between! 2004! and! 2014!

were! searched! so! as! to! obtain! latest! studies.! However,! only! 2! relevant!

randomized!controlled!trials!and!between!2005!and!2012!were!found.!In!order!

to!gather!the!latest!relevant!studies,!further!searching!was!extended!to!2003!and!

subsequently! to! 1994! so! as! to! capture! the! latest! studies! for! best! available!

evidence.!Those! studies!were! limited! to!English!and!Chinese!with! full! text.!For!

those!without!the!full!text,!the!abstracts!were!screened!for!eligibility.!The!flow!of!

searching!was!shown! in!Appendix!C!with!PRISMA! flow!diagram!(Mocher!et.!al,!

2009).! In!addition,! the!references!of! the!selected!studies!were!also!screened! in!

order! to! extend! the! searching! area! to! obtain! relevant! information.! The! search!

result! is! available! in! Appendix! B.! The! quality! of! the! selected! studies! will! be!

assessed!using!Scottish!Intercollegiate!Guidelines!Network!(SIGN).!!

Data-Extraction-

After! searching! the! relevant! studies,! some! irrelevant! studies! were!

excluded.!The!remaining!were!extracted!and!organized!in!the!table!of!evidence!in!

Appendix!D.!!

2.1-Appraisal-strategies!

Scottish!Intercollegiate!Guidelines!Network!(SIGN)!was!developed!as!a!set!

of!checklists! to!assess!study!quality.! If! the!studies!are!able! to!meet!most!of! the!

criteria!in!the!checklist,!it!will!be!rated!as!high!quality!(++).!!The!searched!studies!

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were! assessed! and! formulated.! All! studies! were! relevant! to! the! key! questions!

and! the! quality! assessment! of! each! study! will! be! shown! in! Appendix! E! to!

Appendix!H.!

2.2-Results-

Research-design-

There! are! four! randomized! controlled! trials! that! are! relevant! to! the!

research! question.! The! remaining!were! screened! and! eliminated! based! on! the!

selection! criteria.! ! Three! trials!were! conducted! in! the!US! (Moscati! et! al.,! 2007;!

Valente!et!al.,!2003;!Bansal!et!al.,!2002)!and!one!trial!was!conducted! in! the!UK!

(Weiss!et!al.,!2013).!No!local!study!was!found!for!using!tap!water!for!irrigation!in!

AEDs.!Three! trials! (Weiss!et! al.,! 2013;!Valente!et! al.,! 2003;!Bansal! et! al.,! 2002)!

conducted!in!single!center!while!one!was!conducted!in!multicenter!(Moscatic!et!

al.,!2007).!!

Weiss! et! al.! (2013)! are! the! latest! double! blind! randomized! controlled!

clinical!trial.!And!this!trial!was!rated!as!high!quality!(++)!since!it!could!meet!most!

of!the!criteria!in!the!checklist!of!SIGN!in!Appendix!2!with!the!detail!description!of!

the!randomization!process.!The!others!(Moscatic!et!al.,!2007;!Valente!et!al.,!2003;!

Bansal!et!al.,!2002)!were!rated!as!acceptable!quality!since!they!only!meet!some!

of!the!criteria!in!the!checklist.!

Randomization-and-allocation-concealment-

Weiss! et! al.! (2013)!used! the! computer! to! randomly! assign!patients! into!

groups! with! adequate! concealment.! Moscatic! et! al.! (2007)! also! used! the!

computer!to!generate!the!sequence!for!randomization!which!was!then!kept!in!an!

envelope.! Participants!would! be! assigned! to! either! tap!water! group! or! normal!

saline!group!by!opening!the!next!envelop.!This!trial!used!convenience!sampling!

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to! enroll! participants,! which! might! undermine! the! representativeness! of! the!

findings.! Valente! et! al.! (2003)! cannot! ensure! adequate! concealment.! Patients!

were!allocated!to!either!normal!saline!or!tap!water!group!based!on!the!odd!and!

even! days! of! the! month.! Random! allocation! and! concealment! is! regarded! as!

inadequate! in! this! trial! and! may! lead! to! selection! bias.! Bansal! et! al.! (2002)!

mentioned! using! a! randomization! schedule!without! detail! information! on! how!

randomization!schedule!was!generated!in!the!trial.!!

Blinding-

Only!Weiss! et! al.! (2013)! can! ensure! double! blinding! among! four! trials.!

Technician!prepared!500!ml!tap!water!or!normal!saline!solution!in!a!bowl,!and!

the!physician!will!use!the!bowl!of!solution!for! irrigation.!Therefore,! the!patient!

and! physician! were! blinded! about! the! solution! used! for! irrigation.! Another!

physician! assessed! the! wound! condition! for! infection! in! followLup! thus! the!

outcome! measure! were! also! blinded.! Blinding! can! be! performed! in! this! trial.!

However,!Moscatic!et!al.!(2007)!and!Valente!et!al.!(2003)!cannot!ensure!blinding!

in! the! trial! since!wounds!were! irrigated! directly! under! the! running!water! tap.!

Patients! and! physicians! know! that! wounds! were! irrigated! with! tap! water! so!

blinding!cannot!be!performed.!!

Intervention-

Weiss! et! al.! (2013)! controlled! the! other! extraneous! variables! like! the!

pressure,! the!volume!of!solution!and!technique!of! irrigation.!Normal!saline!and!

tap!water!were!prepared!in!the!basin!for!irrigation!so!that!the!volume!of!solution!

was!standardized.!However,!not!all!the!extraneous!variables!were!controlled!in!

this!trial.!!For!example,!the!temperature!of!tap!water!and!normal!saline!was!not!

controlled.! The! technique! of! irrigation! and! volume! of! solution! was! not!

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standardized!in!Moscatic!et!al.!(2007).!Plastic!tubing!was!connected!to!the!tap!of!

the! faucet!and! the!handle!was! turned! to! the!preset!position! to! standardize! the!

pressure!and!flow!rates!in!Valente!et!al.!(2003).!But!the!time!and!temperature!of!

irrigation! was! not! controlled! in! this! trial.! Both! tap! water! and! normal! saline!

groups!used!a!syringe! to!generate!pressure!between!25L40!psi! for! irrigation! in!

Bansal!et!al.!(2002).!

Sample-size-

Weiss!et!al.!(2013)!estimated!adequate!sample!sizes!with!power!analysis.!

The!mean! age,!mechanism! of! injury,! anatomical! site,! and! length! of! the!wound!

were!well! presented! in! the! trial.! The! sample! size! is! adequate! and! the! attrition!

rate! is! small! (1%).! In! Moscatic! et! al.! (2007),! the! sample! size! is! adequate! and!

there! are! approximately! 10%! lost! to! followLup.! The! attrition! rate! is! 7.5%! in!

Valente!et!al.!(2003).!The!attrition!rate! is!similar! in!both!normal!saline!and!tap!

water!irrigation!groups!in!all!trials.!However,!all!trials!did!not!mention!the!use!of!

intention!to!treat!principle!for!data!analysis.!

Study-populations-

The!study!populations! in! four!randomized!controlled! trials!were!mainly!

in!the!US!(Moscati!et!al.,!2007;!Valente!et!al.,!2003;!Bansal!et!al.,!2002)!and!UK!

(Weiss!et!al.,!2013).!

Number-of-participants--

!The!number!of!participants!ranged!from!46!to!715.!Moscati!et!al.!(2007)!

and!Weiss! et! al.! (2013)! estimated! the! sample! size! and! power! of! 80%! before!

having!the!study.!But!the!power!is!insufficient!in!Moscati!et!al.!(2007).!Two!trials!

did!mention! having! sample! size! estimation! (Valente! et! al.,! 2003;! Bansal! et! al.,!

2002).! All! trials! recruited! participants! within! a! period! ranged! from! 14L18!

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months!with!adequate!sample!size.!The!sample!size!is!small!(n=46)!in!Bansal!et!

al.!(2002).!

Wound-characteristics--

All! trials! recruited! participants!with! simple! acute! traumatic!wound! and!

had!wound!management! in!AEDs.!Two!trials! (Weiss!et!al.,!2013;!Moscati!et!al.,!

2007)!enrolled!participants!with!age!more!than!1!year!while!two!trials!(Valente!

et!al.,!2003;!Bansal!et!al.,!2002)!enrolled!pediatric!patients!with!age!between!1!

and!17.!Patients!with!complicated!wounds!such!as!bite!wound,!extension!deep!to!

tendons!were!excluded!in!all!trials.!All!anatomic!sites!of!lacerations!such!as!face,!

trunk,! upper! and! lower! extremities,!were! included! in! three! trials! (Weiss! et! al.,!

2013;!Moscati!et!al.,!2007;!Bansal!et!al.,!2002).!Hand!lacerations!were!excluded!

in!Valente!et!al.!(2003).!

Intervention-and-duration--

All!patients!received!tropical!or!local!anesthesia!for!pain!relief!during!the!

procedures.!A!35!ml!syringe!and!500!ml!of!either!normal!saline!or!tap!water!was!

used! for! irrigation! (Weiss! et! al.,! 2013;! Bansal! et! al.,! 2002).! The! pressure! of!

irrigation! is! more! than! 8! psi! in!Weiss! et! al.,! (2013)! and! between! 25L40psi! in!

Bansal!et!al.,!(2002).!Wounds!were!irrigated!with!running!tap!water!for!at!least!2!

minutes! in!Moscati! et! al.! (2007).!Wounds!were! irrigated!with! tap!water! for! a!

minimum! of! 10! seconds! in! Valente! et! al.! (2003).! Physicians! then! closed! the!

wound! by! suture! and! patients! will! have! followLups! for! wound! assessment.!

(Weiss!et!al.,!2013;!Moscati!et!al.,!2007;!Valente!et!al.,!2003;!Bansal!et!al.,!2002).!

Follow-up-

All! participants! receiving! either! tap! water! or! normal! saline! irrigation!

received!also!followLup!within!48!hours!to!30!days!to!assess!signs!and!symptoms!

! 17!

of! infection! by! physicians! or! nurses.! Patients! lost! to! followLup! will! further!

contacted!by!phone!calls.!

2.3-Summary-

Outcome-measures-

The!outcome!measures!of!all! trials!are! infection!rate.!Three!randomized!

controlled!trials!(Weiss!et!al.,!2013;!Moscati!et!al.,!2007;!Bansal!et!al.,!2002)!and!

one! quasiLexperimental! trial! (Valente! et! al.,! 2003)! have! subjective! outcome!

measurements,! which! included! assessment! of! the! wound! infection!

characteristics.!Only!Bansal!et!al.!(2002)!included!the!objective!measurement!of!

infection!by!the!bacterial!count!and!wound!culture!result.!!

Effect-size--

The!overall!infection!rate!is!4.9%!in!Weiss!et!al.!(2013).!The!infection!rate!

was! 6.4%! in! normal! saline! group! and! 3.5%! in! tap!water! irrigation! group.! The!

difference! (2.9%)!was! not! statistically! significant.! In!Moscati! et! al.! (2007),! the!

infection! rates! of! normal! saline! group! and! tap!water! group! are! 3.3%! and! 4%!

respectively,!the!difference!between!two!groups!is!0.7%,!which!also!showed!no!

statistical! significance.!Valente!et!al.! (2003)!and!Bansal!et!al.! (2002)!compared!

tap!water!and!normal!irrigation!in!pediatric!patients.!The!result!showed!that!no!

statistically! different! between! two! groups! in! pediatric! patients.! The! infection!

rates!of! normal! saline! and! tap!water! group!are!2.8%!and!2.9%!respectively! in!

Valente!et!al.!(2003).!The!infection!rates!of!normal!saline!and!tap!water!are!8.3%!

and!9.5%!respectively!in!Bansal!et!al.!(2002).!All!4!trials!reported!that!there!is!no!

difference! between!using! tap!water! or! normal! saline! for! irrigation! in! infection!

rates.!

! 18!

Although! the! quality! of! the! above! studies! varied! from! high! quality! to!

(Weiss!et!al.,!2013)!acceptable!quality!(Moscati!et!al.,!2007;!Valente!et!al.,!2003;!

Bansal!et!al.,!2002),!all!trials!suggested!that!using!tap!water!irrigation!as!effective!

as! normal! saline! for! irrigation,! there! is! no! difference! between! normal! saline!

irrigation!and!tap!water!irrigation!in!infection!rates.!The!cost!of!using!tap!water!

for! irrigation! is! lower! than! the!normal! saline!and!evidenceLbased!guidelines!of!

using!tap!water!is!needed!(Dulecki!et!al,!2005).!

2.4-Synthesis-of-findings-

The!difference!of!infection!rates!varied!from!0.1!to!2.9%!in!four!trials.!The!

variation! might! attribute! to! the! study! design,! extraneous! variables! like! the!

anatomical! site! of! the!wound,! irrigation! technique.! Judicious! study! design! can!

enhance! internal! validity,! which! implies! the! outcome! was! caused! by! the!

intervention!instead!of!extraneous!factors.!Random!assignment!and!blinding!can!

be!performed!in!Weiss!et!al.!(2013)!and!Bansal!et!al.!(2002).!The!internal!validity!

of!Moscati! et! al.! (2007)!and!Valente!et! al.! (2003)! lowered!when!blinding!were!

not! be! performed.! In! Moscati! et! al.! (2007),! convenient! sampling! was! used! to!

enroll! subjects! and! allocation! concealment! cannot! be!performed!which! lead! to!

selection!bias,!that!also!affect!the!representativeness!of!the!results.!- -!

In! Valente! et! al.! (2003),! foot! lacerations! are!more! prone! to! infection! if!

irrigated!with!tap!water!and!the!number!of! foot!wounds!was!small! in!pediatric!

patients.! More! hand! wounds! were! assigned! into! tap! water! group.! Hand!

lacerations!were!excluded!and! facial!wounds!were! less! infected! in!Bansal!et!al.!

(2002)!and!the!reason!of!hand!laceration!exclusion!was!not!clearly!stated!in!the!

trial.!Based!on!the!findings!of!the!above!two!trials!(Valente!et!al.,!2003;!Bansal!et!

al.,!2002),!suggested!that!the!anatomical!site!can!be!an!extraneous!variable!that!

! 19!

affect!infection!rate,!especially!in!the!pediatric!patients,!as!discussed!in!chapter!1.!

In! addition,! the! outcome! measures! of! four! trials! are! signs! and! symptoms! of!

infection,!which!is!a!subjective!assessment,!may!impose!bias!in!results.!

Bansal! et! al.! (2002)! suggested!using!wound! culture! results,! or! bacterial!

counts!for!outcome!measures.!Positive!culture!result!was!29%!in!normal!saline!

group! and!52%! in! tap!water! group! that!was!not! significantly! different! in! both!

groups.! However,! the! sample! size! is! small! (n=46)! and! Bansal! et! al.! (2002)!

suggested! further!validation! is!needed!for!using!wound!culture!as! the!outcome!

measure.!

Controlling!the!pressure,!volume!and!irrigation!technique!is!essential!for!

tap! water! irrigation! for! acute! traumatic! lacerations.! The! pressure! should! be!

within!8L45!psi!and!the!irrigation!solutions!should!be!prepared!in!the!basins!and!

a! 35L60!ml! syringe!was! used! for! irrigation! so! as! to! standardize! the! irrigation!

technique.!!

To! summarize,! tap! water! is! as! effective! as! normal! saline! for! irrigation!

based! on! existing! evidence! although! there! is! no! local! study! comparing!normal!

saline! and! tap!water.! According! to!water! supply! department! in! Hong! Kong,! it!

states! that! the! water! quality! comply! with! the! guidelines! of! World! Health!

Organization!(WHO).!It!is!safe!to!drink!and!similar!to!the!standard!of!the!United!

States!and!Western!countries.!Water!samples!were!taken!from!time!to!time!for!

checking! so!as! to!make!sure! that! the! tap!water! supply! is! safe! for! consumption!

and!the!cost! is! lower!than!normal!saline.!There! is!no!clinical!guideline!of!using!

tap!water! for! irrigation! in!HK!AEDs,! so! a! clinical! guideline!was! set! up! and! the!

implementation!plan!will!be!further!discussed!in!next!chapter.!!

-

! 20!

Chapter-3-

Translation-and-Application-

3.1-Implementation-potential-

-- The!literature!review!in!the!previous!chapter!showed!that!tap!water!is!as!

effective!as!normal!saline!in!reducing!wound!infection!rates.!The!transferability,!

feasibility,!and!costLbenefit!should!be!prudently!considered!before!adopting!this!

new!innovation! in!clinical!settings.!This!chapter!will! focus!on!how!to!apply! the!

latest! evidence! to! develop! an! evidenceLbased! protocol! for! using! tap!water! for!

wound!irrigation!in!HK!AEDs.!

Target-setting/audience-

-- The!target!setting!is!a!large!size!AED!in!Hospital!Authority.!It!is!one!of!the!

five!trauma!centers!in!Hong!Kong!that!consists!of!resuscitation!room,!acute!care!

room! and! minor! operating! theater! to! carry! out! wound! care! procedures.! It!

provides! 24! hours! emergency! service! and! the! attendance! rate! is! around! 500!

every!day.!The!target!audiences!are!patients!who!attend!AEDs!with!simple!acute!

traumatic!lacerations!and!the!majority!is!Chinese.!!

Transferability-of-the-finding!!

Before!adopting!the!proposed! innovation,! it! is!necessary!to!consider!the!

philosophy!of!care,!whether!the!proposed!innovation!fit!the!target!setting.!!

The! aim! of! the! AED! in! local! setting! is! to! provide! efficient! emergency!

services! with! costLeffective! manner! by! implementing! evidenceLbased! practice.!

Previously,!there!were!several!evidenceLbased!protocols!successfully!carried!out!

in!the!local!setting.!Patients!were!satisfactory!with!nursing!practice!according!to!

the!evidenceLbased!protocol.!Patients!are!willing!to!accept!changes!with!robust!

! 21!

evidence!support.!The!target!setting!in!local!AEDs!employed!similar!mission!and!

vision!with!selected!studies.!!

Hong! Kong! shares! similar! medical! development! and! background! with!

western! countries! of! selected! studies! (Weiss! et! al.,! 2013;!Moscati! et! al.,! 2007;!

Valente! et! al.,! 2003;! Bansal! et! al.,! 2002;! Dulecki! et! al,! 2005;! Fernandez! et! al.,!

2008).! The! AED! is! equipped! with! a! resuscitation! room,! acute! care! room! to!

handle! emergencies! and! disasters! such! as! traffic! accidents,! hazmat! incidents,!

influenza! outbreak,! which! is! similar! to! western! countries.! The! proposed!

innovation! will! benefit! a! significant! number! of! patients! and! generate! annual!

savings!for!hospitals!similar!to!selected!studies!since!there!are!about!8!wounds!

requiring!suture!every!day!in!local!AEDs.!!

With! reference!of! the! selected! studies! (Weiss! et! al.,! 2013;!Valente! et! al.!

2003),!the!proposed!innovation!will!take!about!18!months!to!implement.!It!takes!

1! month! for! preparation! and! communication,! 5! months! for! the! pilot! study,! 1!

month!for!progress!evaluation,!5!months!for!full! implementation!and!6!months!

for! outcome! evaluation! and! data! analysis.! The! details! will! be! attached! in!

Appendix!J.!!

3.2-Feasibility-

Apart!from!transferability,!feasibility!also!needs!to!be!assessed.!It!includes!

the! nursing! autonomy,! availability! of! staff! and! resources,! organization! climate,!

and!anticipated!resistance.!!

Nursing-autonomy-

Nurses! play! an! important! role! in! wound! management! in! HKAEDs.!

Wounds!were!mainly!closed!by!physicians!in!the!selected!studies!while!wounds!

were! closed!by!emergency!nurses! in!Hong!Kong.!Emergency!nurses! received!a!

! 22!

course! from! the! Accident! and! Emergency! Training! Center! (AETC)! for! wound!

management! training! in!Hong!Kong.! It! is! necessary! for! an! emergency!nurse! to!

pass! the!course!provided!by!AETC! in!order! to!provide!wound!management! for!

patients.!This!credential!process!ensures!emergency!nurses!possess!knowledge!

of!wound!management.!Thus,!emergency!nurses!have!the!autonomy!in!choosing!

materials!in!wound!management!based!on!evidence!and!terminate!the!proposed!

innovation!if!the!outcome!is!undesirable.!

Availability-of-staff-and-administrative-support-

!! One!factor!affect!the!feasibility!of!the!proposed!innovation!is!manpower.!

However,! resuscitation!occurs!any! time! in!AEDs!and! is! considered!as! the!most!

important! care! in! AEDs.! When! multiple! resuscitations! occur! in! the! AEDs,! the!

waiting! time! will! be! prolonged! and! minor! procedures! such! as! wound!

management! will! be! delayed! since! nurses! are! prioritized to! manage! lifeL

threatening!case.!When!a!patient!attends!AEDs!for!more!than!8!hours,!the!wound!

cannot!be!sutured!owing!to!higher!infection!rates.!Although!wound!dressing!will!

be!provided!for!the!patient,!the!patient!will!have!a!higher!chance!of!infection!due!

to! prolong! waiting! time.! The! infection! rate! is! the! outcome! of! the! proposed!

innovation!and!waiting! time! is! a! significant! factor! that!will! affect! the!outcome.!

The! longer! the!waiting! time,! the!higher! the! infection!rates.! In!addition,! it! takes!

time!for!data!collection!and!evaluation!when!implementing!proposed!innovation.!

Adequate!manpower!is!needed!to!compensate!for!the!time!used!for!unexpected!

resuscitation! and! data! collection.! It! can! be! achieved! by! duty! arrangement! and!

use!of!Special!Honorarium!Scheme!(SHS).!According! to!Hospital!Authority,!SHS!

provides! leave! encashment! for! nursing! or! medical! staff! who! provide! extra!

! 23!

service!in!AEDs.!So,!when!implementing!the!proposed!innovation,!support!from!

administration!is!needed.!!

Department! of! manager! (DOM),! Chief! of! Service! (COS),! Ward! Manager

�WM)!and!Health!Care!Assistant!(HCA)!will!also!involve!in!proposed!innovation.!

Medical!officer!(MO)!will!be!responsible!for!wound!assessment!when!a!patient!is!

present! to! AEDs! and! followLup,! and! provide! assistance! and! training! to! other!

health! care! professionals! if! necessary.! There! are! 8! Advanced! Practice! Nurses!

(APN),!32!Registered!nurses! (RN)!and!2!Enrolled!nurses! (EN)! received!wound!

care!training!from!AETC.!They!are!capable!of!providing!wound!care!in!AEDs!and!

are!available! for! the!proposed! innovation.! It! is!necessary! to! seek!approval!and!

consensus!from!the!administration!for!duty!arrangement!to!implement!proposed!

innovation.!A!communication!plan!with!the!administration!is!needed!and!will!be!

further!discussed!in!next!chapter.!

Availability-of-resources--

The!materials!used!are!also!similar!to!those!in!selected!studies!(Weiss!et!

al.!2013;!Valente!et!al,!2003).!The!suggested!syringe!used!in!the!selected!studies!

is! a! 35ml! syringe!with! the! splash! shield.! However,! the! 35ml! syringe!with! the!

splash! shield! is! not! available! in! local! AEDs.! A! 50! ml! syringe! with! 18! gauge!

angiocatheter!will!be!used!to!provide!the!suggested!pressure!of!more!than!8!psi!

for!irrigation!(Weiss!et!al.!2013).!A!50!ml!syringe!with!18!gauge!angiocatheter!is!

available! in! local! AEDs.! The! other! equipment! such! as! dressing! set,! suture!

materials! are! available! in! the! minor! operating! theater.! AntiLtetanus! injection!

(ATT)!will! be! provided! in! local! AEDs!when! patients! are! present! to! AEDs!with!

simple!acute!traumatic!lacerations.!But!whether!anti!tetanus!injection!was!given!

was!not!mentioned!in!the!selected!studies.!!

! 24!

Tap!water,!as!the!main!intervention!of!evidenceLbased!practice,!is!another!

important! resource! consideration.!According! to! the!Hong!Kong!Water!Supplies!

Department! (HKWSD),! tap! water! is! safe! to! consume! if! the! water! pipe! is! well!

maintained!in!the!buildings.!Quality!Water!Recognition!Scheme!for!Buildings!is!a!

scheme!provided!by!Hong!Kong!Water!Supplies!Department!to!ensure!the!water!

quality! complied! with! the! guidelines! of! World! Health! Organization! (WHO).! A!

certificate!will!be!issued!by!HKWSD!if!the!plumbing!systems!of!buildings!are!well!

maintained.!This!monitoring!system!ensures!tap!water!quality!complied!with!the!

standard! of! WHO.! Apart! from! attestation,! HKWSD! will! be! responsible! for!

checking!the!quality!of!tap!water!and!maintenance!of!plumbing!systems!for!AEDs!

under!Hospital!Authority.!The!target!settings!are!under!this!scheme!so!tap!water!

is!readily!available.!

Anticipated-resistance--

The! proposed! new! innovation! might! pose! potentially! increased! the!

workload!of!nursing!staff,!medical!officer,!and!health!care!assistant.!It!takes!extra!

time! to!get! familiarize!with! the!new!protocol!and! to!prepare! the!materials!and!

equipment!need!for!wound!irrigation!and!suturing!although!it!will!be!a!minimal!

change.! In! addition,! potential! challenges! by! patients! and! other! health! care!

professionals! will! be! anticipated! since! they! will! have! the! concern! about! the!

quality!of! tap!water!and! the! infection!rates.! It! is!common!before! implementing!

any! changes! from! current! practice.! Patients! will! have! questions! and! want! to!

obtain!more! information! about! proposed! innovation.! Effective! communication!

skill! is! essential! to! disseminate! information! of! proposed! innovation.! Staff!

training!and!education!is!important!for!developing!effective!communication!skill.!

In!addition,!the!pilot!study!is!necessary!and!it!involves!the!preliminary!test!of!an!

! 25!

innovation! to! estimate! the! materials! and! manpower,! thereby! reducing! the!

resistance! of! the! new! innovation.! The!details! of! the! pilot! study!will! be! further!

discussed!in!next!chapter.!!

3.3-Cost)benefit-Ratio-of-the-innovation-

Based! on! the! findings! from! the! selected! studies! (Weiss! et! al.,! 2013;!

Moscati!et!al.,!2007;!Valente!et!al.,!2003;!Bansal!et!al.,!2002;!Dulecki!et!al,!2005;!

Fernandez!et!al.,!2008),!it!is!estimated!that!the!new!innovation!will!benefit!both!

patients! and! local! AEDs! when! nursing! professionals! are! willing! to! provide!

compassionate!care!with!evidence!support.!!

Normal! saline!was! used! for! irrigation! in! current! practice,! using! normal!

saline! still! have! a! risk! of! having! an! infection.! Most! importantly,! it! is! much!

cheaper!than!using!normal!saline!if!a!large!amount!was!used!for!irrigation.!It!is!

estimated!that!$85440!will!be!saved!every!year!when!tap!water!is!used!instead!

of!normal!saline.!There!are!17!AEDs!in!Hospital!Authority,!it!is!estimated!that!the!

annual!savings!will!be!$1452480!for!17!AEDs!per!year!if!implementing!proposed!

innovation.!Normal!saline!need!to!be!discarded!within!24!hours!once!open,!and!

the!storage!place!cannot!take!into!accounts!by!costs.!!!

Comparison-of-materials-between-using-normal-saline-and-tap-water-

! Normal!saline! Tap!water!Cost!for!materials! 1000ml!Normal!saline!!

$30!per!bottle!Free! and! available!in!hospital!

Annual!savings! Normal! saline! per! bottle! X! number! of!wounds!per!day!X!356!=$30X8X356!=$85440!

The! other! materials! such! as! a! 50! ml! syringe,! 18! gauge! angiocathter,!

dressing!set!will!be!same!in!both!groups.!!

! 26!

Changing! current! practice! require! substantial! periods! of! training! for!

nurses.! A! brief! training!workshop!will! be! given! to! nurses! to! illustrate! how! to!

implement! the! innovation.! This! section! will! also! involve! HCA! since! they! are!

responsible! for! materials! and! equipment! preparation! in! the! minor! operating!

theater.! Ten! nurses! and! five! HCA! will! attend! the! workshop! and! share! the!

information! to! other! colleagues.! The! proposed! innovation! will! invite! Medical!

Officer! (MO)! to! share! the! knowledge! of! wound! care.! According! to! Hospital!

Authority! (HA),! the!median! salary! for!RN! is! about! $160!per!hour.! The!median!

salary!for!HCA!is!$60!and!the!median!salary!for!MO!is!$350!per!hour.!The!nonL

material!cost!will!include!training!hours!of!nurses!and!HCA.!!

Estimated-Cost-for-training-workshop-of-using-tap-water-for-irrigation-

Cost! for! Medical! Officer! 1Lhour!session!

�350-

Cost!for!RN!for!1Lhour!session!Cost!for!EN!for!1Lhour!session-

$160!X10=!$1600!$110X2=$220!

Cost! for! HCA! for! 1Lhour!session!

$60X5=$300!

Materials!for!demonstration!Expired! Normal! saline,!angiocatheter,!50!ml!syringe!

Available!in!AED!training!set!Free!

Total! $2470!From! the! above! calculations,! the! benefits! of! the! proposed! innovation!

outweigh!the!costs.!The!annual!savings!generated!from!this!proposed!innovation!

can! be! allotted! for! nurse! recruitment! or! study! subsidies! and! sponsorship! for!

further!development.!The!proposed!innovation!can!generate!more!savings!in!the!

long! run.! As! mention! previously,! resuscitation! can! occur! at! any! time! and!

adequate!manpower!is!needed.!It!can!be!achieved!by!duty!arrangement!and!the!

introduction! of! SHS.! It! estimated! that! the! budget! spend! on! the! proposed!

innovation! with! SHS! should! be! less! than! $70000! so! as! to! strive! a! balance!

between! cost! and! benefit.! The! estimated! amount! for! SHS! was! based! on! the!

! 27!

previous! protocol! developed.! The! actual! costs! depend! on! the! attendance! rate,!

waiting!time!and!conditions!of!patients!in!the!AEDs.!!!

Staff! moral! is! associated! with! a! desirable! working! environment.! A!

desirable! working! environment! includes! working! well! with! patients! and!

colleagues.!Clinical!experience!and!skills,!research!ability!are!essential!elements!

for!nurses.!When!nurses!are!competent!to!provide!evidenceLbased!care,!patients!

will!satisfy!with!nurses!and!increase!acceptance!of!the!role!of!nurses!in!AEDs.!It!

can! be! achieved! through! the! process! of! implementing! proposed! innovation.!

Promoting!evidenceLbased!care!not!only!poses!benefits!to!nurses!but!also!to!the!

department!as!it!associates!with!the!image!of!the!department!and!turnover!rate.!

The! department! will! develop! a! positive! image! by! research! utilization! and!

evidenceLbased! practice.! The! turnover! rate! will! decrease! by! the! lure! of! a!

comfortable!working!environment.!Local!AEDs!and!the!health!care!systems!will!

benefit!from!the!proposed!new!innovation!if!successfully!carried!out.!!

!

3.4-Evidence)based-practice-guideline-

Introduction-

This!guideline!is!developed!based!on!latest!systematic!reviews!and!trials.!

The!evidence!suggested!that!using!tap!water!is!as!effective!as!normal!saline!for!

wound! irrigation.!The! recommendations!were! synthesized!by!SIGN!50!and!are!

attached!in!Appendix!K!&!L.!The!transferability,!feasibility!and!costLbenefits!ratio!

from!the!above!suggested!that!it!is!worth!implementing!the!proposed!innovation!

in!the!clinical!setting.!

Summary-of-the-recommendations-

! 28!

The! purpose! of! the! guideline! is! to! equip! emergency! nurses! to! provide!

evidenceLbased!care!to!patients!attend!AEDs!with!acute!traumatic!lacerations.!!

According!to!SIGN!50,!the!levels!of!evidence!are!classified!into!level!1!to!

level!4!by!assessing!the!methodology!design!of!the!studies.!Level!1!is!articulated!

to!robust!evidence!such!as!RCT!whereas!level!4!is!articulated!to!weak!evidence!

such!as!an!expert!opinion.!With!higher!levels!of!evidence!(level!1),!it!implied!that!

the!risk!of!bias!is!the!lowest!and!lower!levels!of!evidence!(level!4),!the!risk!of!bias!

is!the!highest.!

For!the!grading!system!of! the!recommendations,! it!ranged!from!grade!A!

to!D!by!assessing! the!bodies!of!evidence!of! the!selected!studies.!Grade!A! is! the!

recommendation!with!higher!evidence!whereas!grade!D!is!the!recommendation!

with!lower!evidence!from!the!studies!and!reviews.!The!grading!system!helps!to!

differentiate!recommendations!from!which!levels!of!evidence.!!

The!details!of!the!recommendations!are!attached!in!the!Appendix!M!and!

the!details!of!grading!system!are!attached!in!Appendix!N.!The!recommendations!

are! graded! between! A! and! B! in! this! protocol,! it! implies! that! the!

recommendations! are! based! on! robust! evidence! from! the! studies.! Robust!

evidence!from!the!studies!is!essential!for!nurses!to!provide!care.!!

-

-

-

-

-

-

-

! 29!

Chapter-4-

Implementation-Plan-

4.1-Communication-plan-

- In! order! to! successfully! implement! the! proposed! innovation! to! AEDs,!

careful! planning! and! communication! with! the! administration! is! essential.! The!

first! step! is! to! identify! the! stakeholders! and! gain! support! for! the! proposed!

innovation.!

Identification-of-stakeholders---

Stakeholders!refer!to!an!individual!or!groups!that!will!be!affected!by!the!

result! of! the! innovation.! The! stakeholders! in! this! proposed! innovation! involve!

Chief! of! Service! (COS),! Medical! officers! (MO),! Department! Of!Manager! (DOM),!

Ward! Manager! (WM),! Advanced! Practice! Nurse! (APN),! Registered! nurses! RN,!

Enrolled!nurses!(EN),!Healthcare!assistance!(HCA)!and!patients!who!are!present!

to! AEDs! with! simple! traumatic! lacerations.! COS,! DOM! and! WM! are! top!

administration! and! they! have! mission! and! vision! to! promote! evidenceLbased!

guidelines.! In!order! to!adopt!proposed! innovation! in! local!AEDs,!obtain!mutual!

agreement!and!support!from!identified!stakeholders!are!necessary.!!

Communication-strategies-

Chief! of! Services! (COS),! Department! Operations! Manager! (DOM),! and!

Ward! Manager! (WN)! are! first! approach! since! they! play! an! important! role! in!

promoting! evidenceLbased! guidelines! in! local! AEDs! and! enhancing! positive!

attitudes! of! proposed! innovation.! In! addition,! they! are! at! the! top!management!

level! and! responsible! for! manpower,! finance! management,! and! resource!

allocation.!It!is!necessary!to!arrange!a!meeting!to!disseminate!information!about!

! 30!

the! significance,! feasibility,! transferability,! cost! and! benefits! ratio! of! the!

proposed! innovation.! The! major! concern! of! proposed! innovation! is! tap! water!

quality.! It! is! essential! to! include! the! risks!and!strategies!of!using! tap!water! for!

irrigation! in! the!meeting.! Furthermore,! it! is! necessary! to! liaise! and! coordinate!

with! Hospital! Engineering! Department! and! Hong! Kong! Water! Supplies!

Department! (HKWSD)! for! maintenance! of! water! plumbing! system,! routinely!

check!up!of!tap!water!quality.!It!can!be!achieved!by!writing,!sending!eLmail,!fax!

or!phone!to!the!corresponding!offices!for!accessing!information!and!application!

of!changing!plumbing!systems.!Water!samples!were!taken!for!microbial!analysis!

by!HKWSD!laboratories!in!order!to!comply!with!the!standard!with!WHO.!Before!

setting!up!the!liaison!between!local!AEDs!and!HKWSD,!communication!with!the!

top!administration!is!of!utmost!importance!for!adopting!proposed!innovation.!!

Apart!from!the!quality!of!tap!water,!manpower!and!finance!management!

are! other! significant! issues! of! proposed! innovation.! The! proposed! innovation!

involves! extra! manpower,! duty! arrangement! and! the! introduction! of! Special!

Honorary! Scheme! (SHS).! Since!manpower,! finance,! and! resource!management!

are! crucial! factors! that! affect! the! feasibility! of! the! innovation,! it! further!

emphasizes!the!necessity!of!communication!with!top!administration.!!

!When! proposed! innovation! endorsed! by! the! top! administration,! the!

second! approach! is! to! gain! support! from! APN,! NS! and! MO! as! they! are!

experienced!and!knowledgeable!in!wound!management.!Another!meeting!will!be!

arranged!with!APN,!NS!and!MO!to!invite!them!for!the!participation!of!proposed!

innovation.! With! support! from! APN! and! NS,! they! can! provide! assistance,!

opinions!about!proposed!innovation!and!act!as!nurse!coordinators!of!proposed!

innovation.! Regarding! the! quality! of! emergency! nurses,! to! ensure! emergency!

! 31!

nurses! are! capable! of! providing! wound! management! to! patients,! emergency!

nurses! need! to! have! wound! management! workshops! of! using! tap! water! for!

irrigation.! APN,! NS,! and! MO! are! responsible! for! the! workshop,! outcome!

evaluation! and! provide! wound! assessment! when! patient! followLup.! Then!

information! about! proposed! innovation!will! be! presented! to! registered! nurses!

and!enrolled!nurses!in!the!meeting!as!they!are!users!of!the!protocols!and!most!

importantly,! they! provide! wound! management! to! patients.! Since! HCA! will!

prepare!wound!management!materials,!it!is!necessary!to!provide!information!of!

proposed!innovation!to!them.!!

4.2-Pilot-study-plan!

With!reference!of!selected!studies!(Weiss!et!al.,!2013;!Moscati!et!al.,!2007;!

Valente! et! al.,! 2003),! the! proposed! innovation! takes! 5L18! month! for! subject!

enrollment!and!data!analysis.!Since!there!are!no!local!studies!using!tap!water!for!

wound!management,!it!is!suggested!that!the!pilot!study!will!last!for!5!months!for!

feasibility!test!and!conducted!by!nurse!coordinators.!The!aim!of!the!pilot!study!is!

to! gather! information! regarding! manpower,! resource,! and! finance! so! that! the!

proposed! innovation! can! be! refined! before! full! implementation.! In! addition,!

resources! such!as!wound! care! leaflets!will! be!prepared.!The! content!of!wound!

care! leaflets! will! include! information! about! signs! and! symptoms! of! wound!

infection.!The!details!of!wound!care!leaflets!will!be!attached!in!Appendix!O.!!!

Subject-recruitment-

The! subject! recruitment!will! be! patients!who! are! present! to! AEDs!with!

simple!acute!traumatic!lacerations!by!using!convenient!sampling!since!there!are!

no! local! studies! using! tap! water! for! wound! management.! The! inclusion! and!

! 32!

exclusion!criteria!will!be!the!same!as!the!proposed!innovation!so!as!to!assess!the!

feasibility!and!be!consistent!with!the!proposed!innovation.!!

Nature-and-numbers-of-clients-

The! wound! characteristics! such! as! wound! length,! width,! depth! and!

location! will! be! collected.! Based! on! the! statistics! of! local! AEDs,! there! are!

approximately!8!wounds!requiring!suture!every!day.!With!reference!of!selected!

studies,!the!attrition!rate!is!about!10%!(Moscati!et!al.,!2007;!Valente!et!al).!Using!

online!calculation!(Lenth,!2009),!assume!the!baseline! infection!rate!of!5%,! it! is!

estimated!that!the!sample!size!will!be!139!with!95%!confidence!interval.!!

Calculations!of!sample!size!(n)!for!pilot!study!Max!tolerable!error=5%!Anticipated!proportion!=!10%!Using!online!calculation!(Lenth,!2009)!N=139!!

Ethical-consideration-

-- It! is! crucial! to! obtain! approval! from! Hospital! Authority! to! carry! out!

proposed! innovation.! Informed! consent!will! be! obtained! prior! to! intervention,!

enable! patients! obtain! adequate! information! regarding! intervention.! Patients!

will! receive!wound!management! according! to! the! guideline! as! attached! in! the!

previous!chapter!and!will!be!instructed!to!follow!up!on!day!2!and!extra!follow!up!

will! be! provided! according! to!wound! characteristics! of! patients.! The! details! of!

pilot!study!as!follow:!

-

-

-

-

! 33!

Flow-of-pilot-study--

!

4.3-Evaluation-plan--

Evaluation!is!a!process!of!the!judgment!of!the!worthiness!of!the!proposed!

innovation.! An! evaluation! plan! is! crucial! to! determine! the! success! of! the!

innovation.! It! consists!of!patient!outcomes,!health! care!provider!outcomes!and!

system!outcomes.!

Outcome-evaluation!-

With!reference!of! the!selected!studies!(Weiss!et!al.,!2013;!Moscati!et!al.,!

2007;!Valente!et!al.,!2003;!Bansal!et!al.,!2002;!Dulecki!et!al,!2005;!Fernandez!et!

al.,!2008),!the!infection!rate!will!be!primary!patient!outcome!of!innovation!and!it!

is! significant! to! test! the! effectiveness! of! the! proposed! innovation.! Patients! are!

invited! to! come! back! AEDs! at! day! 2! for! wound! assessment.! The! signs! and!

symptoms! of! infection! include! redness,! increased! pain,! increased! wound! size,!

swelling!and!fever.!Wound!evaluation!will!be!done!by!wound!care!team!with!one!

nurse!and!one!medical!officer!during!followLup!(Weiss!et!al.,!2013;!Moscati!et!al.,!

Follow!up!!

Analysis!

Enrollment!Assess!for!eligibility!!(n!>139)!

Follow!up!at!!day!2!

Infection!rate!!!Patient!satisfaction!score!

Lost!to!follow!up!

Phone!contact!

Intervention!

! 34!

2007;!Valente!et! al.,! 2003;!Bansal! et! al.,! 2002).!They!are! required! to! fill! in!one!

assessment!as!attached!in!Appendix!P!for!a!record.!!

The! wound! culture! will! only! be! taken! if! wound! considered! as! infected!

when!followLup!at!Day!2!(Bansal!et!al.,!2002).! !Wounds!will!be!infected!if!more!

than!105!bacteria!per!gram!were! found! in! tissue! (Moscati! et! al.,! 2007).!Normal!

wound!heal!within!2!to!30!days!for!simple!acute!traumatic!lacerations.!Delayed!

wound! healing! more! than! 30! days! and! early! removal! of! stitches! regarded! as!

infection!(Moscati!et!al.,!2007).!!

Since! interpersonal!wound!management! techniques!will!be!a! factor! that!

affects! infection! rates,! it! is!necessary! to! form!a!wound!management! team!with!

nurses! and! medical! officers! to! monitor! wound! management! technique.! In!

addition,!extraneous!variables!such!as!patient!‘s!education!level!and!selfLhygiene!

might!affect!patient!‘s!health!condition.!So,!it!is!necessary!to!provide!wound!care!

leaflet!and!education!before!discharge.!If!a!patient!does!not!return!for!followLup!

on!day!2,!nurse!coordinators!will!contact!the!patient!by!phone.!Patients!who!fail!

to!contact!will!regard!as!lost!to!followLup!(Weiss!et!al.!2013).!!!

Health! care! provider! outcomes! include! staff! satisfaction! level.! A!

questionnaire! will! be! given! to! staff! after! innovation! in! order! to! assess! the!

acceptability!of!the!proposed!innovation.!Health!care!providers!need!to!fill!in!the!

questionnaire.!The!questionnaire!will!be!attached!in!Appendix!Q.!After!receiving!

the!questionnaire! from!staff,!a!meeting!will!be!arranged!for!staff! to!resolve!the!

concern!of!the!proposed!innovation.!The!meeting!will!focus!on!the!quality!of!tap!

water!in!Hong!Kong.!The!content!include!the!latest!studies!of!using!tap!water!for!

irrigation,!advantages!of!using!tap!water!for!wound!irrigation,!comparison!with!

normal!saline,!thereby!reducing!the!resistance!of!proposed!innovation.!!

! 35!

System!outcomes! include!average!waiting! time! in!AEDs!and!costs!of! the!

innovation.! The!waiting! time! in!AEDs! and! costs! spent! on! proposed! innovation!

will! be! counted!and!monitored.!The!average!waiting! time! can!be! calculated!by!

using! the! Accident! and! Emergency! Information! System! (AEIS)! in! local! AEDs!

(Chan.! 2000).! The!waiting! time!of! using! tap!water! for! irrigation! should!be! the!

same! as! using! normal! saline.! Prolong! waiting! time! will! affect! infection! rate,!

which!is!the!patient!outcome!of!proposed!innovation.!

!AEIS! is! the! computer! system! with! intraLnetwork! that! link! all!

workstations!in!the!hospitals!in!Hong!Kong.!Patient!‘s!clinical!data,!for!instance,!

allergy!history,!diagnoses,!drug!treatment,!medical!history,!immunization!record,!

AED!attendance! record,! triage! category,! laboratory! and! radiology! investigation!

and! result! can! be! viewed! and! retrieved! efficiently.! In! addition,! with! the!

development!of!bar!code!technology,!the!triage,!waiting!and!discharge!time!will!

be!recorded! in!AEIS.!The! introduction!of!AEIS! facilitates!not!only!AEDs!service!

but!also!clinical!research.!Most!importantly,!AEIS!was!used!since!1991!and!now!

available!in!all!HKAEDs.!!The!materials!used!for!wound!management!can!also!be!

anticipated!since!clinical!data!of!patients!will!be!recorded!in!AEIS.!!

Using! tap! water! for! wound! irrigation! will! generate! annual! savings! for!

AEDs!when!compared!with!using!normal!saline!(Weiss!et!al.,!2013;!Moscati!et!al.,!

2007;!Valente!et!al.,!2003;!Bansal!et!al.,!2002).!So! the!cost!and!waiting! time! in!

AEDs! need! to! be! counted! for! system! outcome.! In! addition,! severe! wound!

infection!might! lead!to! the!use!of!antibiotics!or!even!admission.!The!admission!

rate! and! use! of! antibiotics! relate! to! propose! innovation! will! be! monitored! by!

AEIS! as! well.! Space! for! storage! of! normal! saline! cannot! be! quantified! and!

analyzed!after!implementation!of!proposed!innovation.!!!!

! 36!

Data-analysis--

The!difference!in!the!infection!rate!will!be!evaluated!by!using!one!sample!

tLtest!with!95%!confidence!level!to!determine!statistical!significance!before!and!

after!implementing!proposed!innovation.!!

Wound! characteristics! are! quantitative! variables! such! as! length,! width!

and!depth!are!measured!by!mean!and!standard!deviations.!The!cost!and!average!

waiting! time! in! AEDs! will! be! described! and! analyzed! by! means! and! standard!

deviations.!Intention!to!treat!will!be!used!when!the!patient!lost!to!follow!up.!!

Regarding!patient!satisfaction!level,!patients!need!give!a!satisfaction!score!

ranged! from!1! to!5! in!AEDs.!The!questionnaire! is! attached! in!Appendix!R.!The!

score!will!be!analyzed!by!the!mean.!!!

Effectiveness-of-the-guideline-

With!reference!of!selected!studies!(Weiss!et!al.,!2013;!Moscati!et!al.,!2007;!

Valente! et! al.,! 2003;! Bansal! et! al.,! 2002;! Dulecki! et! al,! 2005;! Fernandez! et! al.,!

2008),!the!infection!rate!is!around!5!%!for!normal!saline!and!tap!water!irrigation.!!

The!protocols!will!be!regarded!as!effective!when!the!infection!rate!of!using!tap!

water!for!wound!irrigation!is!lower!than!or!the!same!as!using!normal!saline.!The!

waiting!time!should!be!less!than!8!hours!when!patients!attend!AEDs!with!simple!

acute! traumatic! lacerations.!Apart! from!waiting! time,! the! guidelineL! regards! as!

effective!when! the! cost! of! using! tap!water! outweighs! the! cost! of! using! normal!

saline.! It! is!expected!that!the!annual!savings!will!be!$85400!each!year! in!AEDs.!

There! is! no! existence! of! local! studies! for! reference,! the! target! of! the! proposed!

innovation! is! to! generate! 50%! of! savings,! and! the! pilot! study! is! necessary! for!

further! verification.!With! regard! to!patient! satisfaction! level,!mean! score!more!

! 37!

than! 2! will! be! considered! as! satisfactory! based! on! previous! evidenceLbased!

protocols.!!!

- The! success! of! implementing! proposed! innovation! includes! careful!

planning!and!preparation.!The!key! components! consist!of! communication!with!

top! administration! and! support! from! various! stakeholders.! The! pilot! study!

should!be!done!to!test!the!feasibility!before!full!implementation!of!the!proposed!

innovation.! The! proposed! innovation! can! be! successfully! implemented! with!

communication!plan,!pilot!study,!and!evaluation.!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

! 38!

References-

1. Chan! JTS.!What!will!be! the!percentage!drop! in!attendance!of!Accident!&!

Emergency! department! after! implementation! of! charges?! Hong! Kong!

Journal!of!emergency!medicine!2001;8:241L246!

2. Lauren!MW,!Hao!Y,!Pamela!LO,!Raynard!W.!Overview!of! children! in! the!

emergency! Department,! 2010.! Available! from:" http://hcup)

us.ahrq.gov/reports/statbriefs/sb157.jsp!!

3. Berwald! N,! Khan! F,! Zehtabchi! S.! Antibiotic! prophylaxis! for! ED! patients!

with! simple! hand!lacerations:! a! feasibility! randomized! controlled! trial.!

Am!J!Emerg!Med.!2014!Jul;32(7):768L71.!!

4. Weiss! EA,! Oldham! G,! Lin! M,! Foster! T,! Quinn! JV.! Water! is! a! safe! and!

effective!alternative! to! sterile!normal!saline!for!wound!irrigation!prior! to!

suturing:!a!prospective,!doubleLblind,!randomised,!controlled!clinical!trial.!

BMJ!Open.!2013!Jan!16;3(1).!

5. Moscati!RM,!Mayrose!J,!Reardon!RF,!et!al.!A!multicenter!comparison!of!tap!

water! versus! sterile! saline! for! wound! irrigation.!Acad! Emerg!

Med!2007:14:404–10!

6. Valente!JH,!Forti!RJ,!Freundlich!LF,!ZandiehSo,!Crain!EF.!Wound!irrigation!

in!children:!saline!solution!or!tap!water.!Ann!Emerg!Med!2003:41:609L16.!

7. Bansal!BC,!Wiebe!RA,!Perkins!SD,!Abramo!TJ.-Tap!water!for!irrigation!of!

lacerations.!Am!J!Emerg!Med.!2002!Sep:20(5):469L72.-

8. Quinn!JV,!Polevoi!SK,!Kohn!MA.!Traumatic!lacerations:!what!are!the!risks!

for! infection!and!has!the! `golden!period'!of! laceration!care!disappeared?-

Emerg!Med!J.!2014!Feb;31(2):96L100.!-

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9. Zehtabchi!S,!Tan!A,!Yadav!K,!Badawy!A,!Lucchesi!M.!The!impact!of!wound!

age!on!the!infection!rate!of!simple!lacerations!repaired! in! the!emergency!

department.!Injury.!2012!Nov;43(11):1793L8.!Epub!2012!Mar!15.!Review.-

10. -Stetler,! C! (2001).! Updating! the! Stetler! Model! of! research! utilization! to!

facilitate! evidence! practice.! Nursing,! 49(6a0,! 272L278.- Available! from:!

http://www.ktdrr.org/ktlibrary/articles_pubs/ktmodels/figures1L

6.html#figure5ste-

11. -Dulecki!M,!Pieper!B.!Irrigating!simple!acute!traumatic!wounds:!A!review!

of!the!current!Literature.!J!Emerg!Nurs;31:156L60!

12. !Fernandez!R,!Griffiths!R.!Water!for!wound!cleansing.!Cochrane!Database!

Syst! Rev.! 2008! Jan! 23;(1):CD003861.! Review.! Update! in:! Cochrane!

Database!Syst!Rev.!2012;2:CD003861.!

13. SIGN!Available!from: http://www.sign.ac.uk/methodology/checklists.html-

14. Hospital! Authority! Statistical! Report! 2012L2013! Available! from:!

http://www.ha.org.hk/upload/publication_15/491.pdf-

15. Hong! Kong! Water! Supply! department.! Available! from:!

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760706/pdf/12245_20

09_Article_98.pdf-

16. Scottish! Intercollegiate! Guidelines! Network.! (SIGN)! Available! from:!

http://www.sign.ac.uk/pdf/qrg50.pdf-

17. Special! Honorarium! Scheme! (SHS).! http://www.legco.gov.hk/yr12L

13/english/panels/hs/papers/hs0318cb2L758L9Le.pdf-

18. Lenth,! R.,! V,! (2009).! Sample! size! calculations!

http://www.cs.uiowa.edu/~rlenth/Power/!!

! 40!

19. Chan!JT.!(2000).!Computerisation!of!accidents!and!emergency!systems!in!

Hong!Kong.!HKMJ!2000;6:276L82!

20. Moher! D,! Liberati! A,! Tetzlaff! J,! Altman! DG,! The! PRISMA! Group! (2009).!

Preferred! Reporting! Items! for! Systematic! Reviews! and! MetaLAnalyses:!

The!PRISMA!Statement.!PLoS!Med!6(6):!e1000097.!

!

!

Appendix(A(

The(Stetler(Model(of(Research(Utilization!

Appendix(B(

Search'results'

Keywords) Searched)Databases)PudMed)<199482014>) Medline(OVIDSP)) CINAPHL) Cochrane)

1.)tap)water) 5490) 6719) 101) 7)

2.)laceration) 5949) 1862) 70) 18)

3.)traumatic)wound) 36375) 165) 9) 15)

4.)normal)saline) 18756) 13511) 273) 32)

5.)Irrigation) 30945) 26556) 469) 36)

1and)2) 10) 3) 0) 5)

1)and)4) 82) 44) 2) 1)

1)and)3) 10) 0) 0) 2)

3)and)4) 125) 0) 0) 9)

4)and)5) 672) 489) 29) 3)

1)and)4)and)5) 21) 11) 0) 1)

1)and)2)and)4)and)5) 6) 2) 0) 4)

1)and)3)and)4)and)5) 2) 0) 0) 0)

Appendix(C(

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097

For$more$information,$visit$www.prisma2statement.org.

PRISMA$2009$Flow$Diagram

Records(identified(through(database(searching(

(n(=((6()(

Screen

ing$

Includ

ed$

Eligibility$

Iden

tification$

Additional(records(identified(through(other(sources(

(n(=((2()(

Records(after(duplicates(removed((n(=(6()(

Records(screened((n(=(6((()(

Records(excluded((n(=((0()(

Full?text(articles(assessed(for(eligibility(

(n(=(4(()(

Full?text(articles(excluded,(with(reasons(

(n(=(0(()(

Studies(included(in(qualitative(synthesis(

(n(=((0()(

Studies(included(in(quantitative(synthesis(

(meta?analysis)((n(=((4()(

Table&of&evidence& Appendix(D&Questions:(In(patients(with(acute(traumatic(wounds,(is(tap(water(effective(as(normal(saline(irrigation(in(reducing(infection?(

Citation Study design Patient and

Characteristics

Intervention Comparison Length of

Follow-up

Outcome Measures Effect size

Weiss et

al, 2013

Prospective,

RCT, double

blind, single

center

>1 year old

Present to ED

less than 9 hours

Wounds were anesthetized.

A 35 ml syringe and 18-gauge catheter were used

to generate pressure (>8psi) for normal saline and

tap water irrigation.

Wound closed by physician using standard

technique.

Normal saline: 308 Tap water:

317

Structured

follow up

at 48 hr

and 30

days

Signs of infections

1) Stitch abscess

2) Erythema>1cm

3) Gross exudate

4) Fever>38°C

Infection

Normal saline: 20(6.4%)

Tap water: 11(3.5%)

Difference: 2.9%

Moscati

et al,

2007

Prospective,

multicenter,

Unblinded

convenient

sampling,

>17 year old

Present to ED

less than 8 hour


Wounds were irrigated with tap water from

plastic water tubing connect with water tap for at

least 2 minutes. For normal saline irrigation, a 35

ml syringe with splash shield was used. Wound

then closed by physician.


300

Follow up

between

5-14 days

Signs of infection

1) Need early removal of

stitches

2) Drainage

3) Start antibiotics

Infection

Normal saline: 11(3.3%)

Tap water: 12(4%)

Difference: 0.7%

Valente

et al,

2003

Quasi

Randomized

controlled

trial

Age:>1and <17

year old


Wounds were irrigated with running tap water

from the faucet with standard pressure and flow

with minimum of 10 sec. For normal saline group,

a minimum of 100 ml normal saline with a 30-60

ml syringe with a 18-gauge angiocatheter


259

Wound

check

between

48-72

hours

Signs of infection

1) Tenderness

2) Warmth

3) adenopathy

4) Fever

5) Lymphangitis

Infection Normal saline: 7(2.6%)

Tap water: 7(2.7%)

Difference: 0.1%

Bansal et

a, 2002

Prospective,

Pilot study

Single

blinding

Age:>1and <18

Hand

lacerations were

excluded.

500 ml solution of tap water or normal saline was

prepared in a basin. Wounds were irrigated by

using a 35 ml syringe to generate pressure

between 25-40 psi.

Normal saline:

24

Tap water: 21

Wound

check after

48hours

Signs of infection

1) Cellulitis or erythema

>4mm with tenderness

2) Purulent discharge

3) lymphangitis

4) Dehiscence>2mm

Wound culture positive

Infection

Normal saline:2

Tap water:2

Difference:1.2%

Wound culture result positive

Normal saline: 29%(positive in 7 of

24)

Tap water: 52% (positive in 11 of 21)

Difference: 23%

Appendix(E(

File name : Checklist 2 – Controlled Trials Version 2.0 28/05/2012 Produced by: Carolyn Sleith Page 1 of 3 Review date: None

S I G N

Methodology*Checklist*2:*Controlled*Trials*

Study identification (Include author, title, year of publication, journal title, pages) 1. Weiss( EA,( Oldham( G,( Lin( M,( Foster( T,( Quinn( JV.( Water( is( a( safe( and( effective( alternative( to(

sterile(normal(saline(for( wound(irrigation(prior( to( suturing:( a( prospective,( doubleGblind,(randomised,(controlled(clinical(trial.(BMJ(Open.(2013(Jan(16;3(1).(

Guideline topic: Key Question No: Reviewer:

Before completing this checklist, consider:

1. Is the paper a randomised controlled trial or a controlled clinical trial? If in doubt, check the study design algorithm available from SIGN and make sure you have the correct checklist. If it is a controlled clinical trial questions 1.2, 1.3, and 1.4 are not relevant, and the study cannot be rated higher than 1+

2. Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention Comparison Outcome). IF NO REJECT (give reason below). IF YES complete the checklist.

Reason for rejection: 1. Paper not relevant to key question ! 2. Other reason ! (please specify):

SECTION 1: INTERNAL VALIDITY

In a well conducted RCT study… Does this study do it?

1.1 The study addresses an appropriate and clearly focused question.i

Yes

1.2 The assignment of subjects to treatment groups is randomised.ii

Yes (By computer)

1.3 An adequate concealment method is used.iii

Yes (By coding that assign the solutions on the numbered bowl.The bowl was filled with solution by technician, then the label was removed, physician used the bowl of solutions for irrigation)

1.4 Subjects and investigators are kept ‘blind’ about treatment allocation.iv

Yes (Double blind)

1.5 The treatment and control groups are similar at the start of the trial.v

Yes (no difference in the demographic or clinical characteristics)

1.6 The only difference between groups is the treatment under investigation.vi

Yes

1.7 All relevant outcomes are measured in a standard, valid and reliable way.vii

Yes (signs of infection)

Appendix(E(


1.8 What percentage of the individuals or clusters recruited into each treatment arm of the study dropped out before the study was completed?viii

0.96%

1.9 All the subjects are analysed in the groups to which they were randomly allocated (often referred to as intention to treat analysis).ix

Can’t say (no mention)

1.10 Where the study is carried out at more than one site, results are comparable for all sites.x

Does not apply (single center)

SECTION 2: OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimise bias? Code as follows:xi

High quality (++) 8 of 10 criteria

2.2 Taking into account clinical considerations, your evaluation of the methodology used, and the statistical power of the study, are you certain that the overall effect is due to the study intervention?

Yes

2.3 Are the results of this study directly applicable to the patient group targeted by this guideline?

Yes

2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the study, and the extent to which it answers your question and mention any areas of uncertainty raised above.

i Unless a clear and well defined question is specified, it will be difficult to assess how well the study has met its objectives or how relevant it is to the question you are trying to answer on the basis of its conclusions. ii Random allocation of patients to receive one or other of the treatments under investigation, or to receive either treatment or placebo, is fundamental to this type of study. iii Allocation concealment refers to the process used to ensure that researchers are unaware which group patients are being allocated to at the time they enter the study. Research has shown that where allocation concealment is inadequate, investigators can overestimate the effect of interventions by up to 40%. iv Blinding refers to the process whereby people are kept unaware of which treatment an individual patient has been receiving when they are assessing the outcome for that patient. It can be carried out up to three levels. Single blinding is where patients are unaware of which treatment they are receiving. In double blind studies neither the clinician nor the patient knows which treatment is being given. In very rare cases studies may be triple blinded, where neither patients, clinicians, nor those conducting the analysis are aware of which patients received which treatment. The higher the level of blinding, the lower the risk of bias in the study. v Patients selected for inclusion in a trial must be as similar as possible. The study should report any significant differences in the composition of the study groups in relation to gender mix, age, stage of disease (if appropriate), social background, ethnic origin, or co-morbid conditions. These factors may be covered by inclusion and exclusion criteria, rather than being reported directly. Failure to address this question, or the use of inappropriate groups, should lead to the study being downgraded.

Appendix(E(


vi If some patients received additional treatment, even if of a minor nature or consisting of advice and counselling rather than a physical intervention, this treatment is a potential confounding factor that may invalidate the results. If groups were not treated equally, the study should be rejected unless no other evidence is available. If the study is used as evidence it should be treated with caution. vii The primary outcome measures used should be clearly stated in the study. If the outcome measures are not stated, or the study bases its main conclusions on secondary outcomes, the study should be rejected. Where outcome measures require any degree of subjectivity, some evidence should be provided that the measures used are reliable and have been validated prior to their use in the study. viii The number of patients that drop out of a study should give concern if the number is very high. Conventionally, a 20% drop out rate is regarded as acceptable, but this may vary. Some regard should be paid to why patients dropped out, as well as how many. It should be noted that the drop out rate may be expected to be higher in studies conducted over a long period of time. A higher drop out rate will normally lead to downgrading, rather than rejection of a study. ix In practice, it is rarely the case that all patients allocated to the intervention group receive the intervention throughout the trial, or that all those in the comparison group do not. Patients may refuse treatment, or contra-indications arise that lead them to be switched to the other group. If the comparability of groups through randomisation is to be maintained, however, patient outcomes must be analysed according to the group to which they were originally allocated irrespective of the treatment they actually received. (This is known as intention to treat analysis.) If it is clear that analysis was not on an intention to treat basis, the study may be rejected. If there is little other evidence available, the study may be included but should be evaluated as if it were a non-randomised cohort study. x In multi-site studies, confidence in the results should be increased if it can be shown that similar results were obtained at the different participating centres. xi Rate the overall methodological quality of the study, using the following as a guide: High quality (++): Majority of criteria met. Little or no risk of bias. Results unlikely to be changed by further research. Acceptable (+): Most criteria met. Some flaws in the study with an associated risk of bias, Conclusions may change in the light of further studies. Low quality (0): Either most criteria not met, or significant flaws relating to key aspects of study design. Conclusions likely to change in the light of further studies.

Appendix(F(


S I G N


Study identification (Include author, title, year of publication, journal title, pages) 1. Moscati RM, Mayrose J, Reardon RF, et al. A multicenter comparison of tap water versus sterile saline for

wound irrigation. Acad Emerg Med 2007;14:404–10









Yes


Yes (By computer)


Yes (in a envelop)


No (patients know they are irrigated with tap water as wound were irrigated under the water tap)


Yes (No difference between two groups)


Yes


Yes (Signs of infection)


10%


Can’t say (No mention)

Appendix(F(



Yes (two center)



Acceptable (+) 7 of 10 criteria


Yes


Yes


i Unless a clear and well defined question is specified, it will be difficult to assess how well the study has met its objectives or how relevant it is to the question you are trying to answer on the basis of its conclusions. ii Random allocation of patients to receive one or other of the treatments under investigation, or to receive either treatment or placebo, is fundamental to this type of study. iii Allocation concealment refers to the process used to ensure that researchers are unaware which group patients are being allocated to at the time they enter the study. Research has shown that where allocation concealment is inadequate, investigators can overestimate the effect of interventions by up to 40%. iv Blinding refers to the process whereby people are kept unaware of which treatment an individual patient has been receiving when they are assessing the outcome for that patient. It can be carried out up to three levels. Single blinding is where patients are unaware of which treatment they are receiving. In double blind studies neither the clinician nor the patient knows which treatment is being given. In very rare cases studies may be triple blinded, where neither patients, clinicians, nor those conducting the analysis are aware of which patients received which treatment. The higher the level of blinding, the lower the risk of bias in the study. v Patients selected for inclusion in a trial must be as similar as possible. The study should report any significant differences in the composition of the study groups in relation to gender mix, age, stage of disease (if appropriate), social background, ethnic origin, or co-morbid conditions. These factors may be covered by inclusion and exclusion criteria, rather than being reported directly. Failure to address this question, or the use of inappropriate groups, should lead to the study being downgraded. vi If some patients received additional treatment, even if of a minor nature or consisting of advice and counselling rather than a physical intervention, this treatment is a potential confounding factor that may invalidate the results. If groups were not treated equally, the study should be rejected unless no other evidence is available. If the study is used as evidence it should be treated with caution. vii The primary outcome measures used should be clearly stated in the study. If the outcome measures are not stated, or the study bases its main conclusions on secondary outcomes, the study should be rejected. Where outcome

Appendix(F(


measures require any degree of subjectivity, some evidence should be provided that the measures used are reliable and have been validated prior to their use in the study. viii The number of patients that drop out of a study should give concern if the number is very high. Conventionally, a 20% drop out rate is regarded as acceptable, but this may vary. Some regard should be paid to why patients dropped out, as well as how many. It should be noted that the drop out rate may be expected to be higher in studies conducted over a long period of time. A higher drop out rate will normally lead to downgrading, rather than rejection of a study. ix In practice, it is rarely the case that all patients allocated to the intervention group receive the intervention throughout the trial, or that all those in the comparison group do not. Patients may refuse treatment, or contra-indications arise that lead them to be switched to the other group. If the comparability of groups through randomisation is to be maintained, however, patient outcomes must be analysed according to the group to which they were originally allocated irrespective of the treatment they actually received. (This is known as intention to treat analysis.) If it is clear that analysis was not on an intention to treat basis, the study may be rejected. If there is little other evidence available, the study may be included but should be evaluated as if it were a non-randomised cohort study. x In multi-site studies, confidence in the results should be increased if it can be shown that similar results were obtained at the different participating centres. xi Rate the overall methodological quality of the study, using the following as a guide: High quality (++): Majority of criteria met. Little or no risk of bias. Results unlikely to be changed by further research. Acceptable (+): Most criteria met. Some flaws in the study with an associated risk of bias, Conclusions may change in the light of further studies. Low quality (0): Either most criteria not met, or significant flaws relating to key aspects of study design. Conclusions likely to change in the light of further studies.

Appendix(G(


S I G N


Study identification (Include author, title, year of publication, journal title, pages) 1. Valente JH, Forti RJ, Freundlich LF, ZandiehSo, Crain EF. Wound irrigation in children: saline solution or tap

water. Ann Emerg Med 2003;41:609-16.









Yes


Can’t say (patients were allocated to tap water or normal saline group based on the basis of the month)


No


No (Wounds were irrigated under the water tap)


Yes


Yes


Yes (Signs of infection)


7.5%

Appendix(G(



Can’t say ( No mention)


Does not apply (single center



Acceptable (+) 5 of 10 criteria


Yes


Yes


i Unless a clear and well defined question is specified, it will be difficult to assess how well the study has met its objectives or how relevant it is to the question you are trying to answer on the basis of its conclusions. ii Random allocation of patients to receive one or other of the treatments under investigation, or to receive either treatment or placebo, is fundamental to this type of study. iii Allocation concealment refers to the process used to ensure that researchers are unaware which group patients are being allocated to at the time they enter the study. Research has shown that where allocation concealment is inadequate, investigators can overestimate the effect of interventions by up to 40%. iv Blinding refers to the process whereby people are kept unaware of which treatment an individual patient has been receiving when they are assessing the outcome for that patient. It can be carried out up to three levels. Single blinding is where patients are unaware of which treatment they are receiving. In double blind studies neither the clinician nor the patient knows which treatment is being given. In very rare cases studies may be triple blinded, where neither patients, clinicians, nor those conducting the analysis are aware of which patients received which treatment. The higher the level of blinding, the lower the risk of bias in the study. v Patients selected for inclusion in a trial must be as similar as possible. The study should report any significant differences in the composition of the study groups in relation to gender mix, age, stage of disease (if appropriate), social background, ethnic origin, or co-morbid conditions. These factors may be covered by inclusion and exclusion criteria, rather than being reported directly. Failure to address this question, or the use of inappropriate groups, should lead to the study being downgraded. vi If some patients received additional treatment, even if of a minor nature or consisting of advice and counselling rather than a physical intervention, this treatment is a potential confounding factor that may invalidate the results. If groups

Appendix(G(


were not treated equally, the study should be rejected unless no other evidence is available. If the study is used as evidence it should be treated with caution. vii The primary outcome measures used should be clearly stated in the study. If the outcome measures are not stated, or the study bases its main conclusions on secondary outcomes, the study should be rejected. Where outcome measures require any degree of subjectivity, some evidence should be provided that the measures used are reliable and have been validated prior to their use in the study. viii The number of patients that drop out of a study should give concern if the number is very high. Conventionally, a 20% drop out rate is regarded as acceptable, but this may vary. Some regard should be paid to why patients dropped out, as well as how many. It should be noted that the drop out rate may be expected to be higher in studies conducted over a long period of time. A higher drop out rate will normally lead to downgrading, rather than rejection of a study. ix In practice, it is rarely the case that all patients allocated to the intervention group receive the intervention throughout the trial, or that all those in the comparison group do not. Patients may refuse treatment, or contra-indications arise that lead them to be switched to the other group. If the comparability of groups through randomisation is to be maintained, however, patient outcomes must be analysed according to the group to which they were originally allocated irrespective of the treatment they actually received. (This is known as intention to treat analysis.) If it is clear that analysis was not on an intention to treat basis, the study may be rejected. If there is little other evidence available, the study may be included but should be evaluated as if it were a non-randomised cohort study. x In multi-site studies, confidence in the results should be increased if it can be shown that similar results were obtained at the different participating centres. xi Rate the overall methodological quality of the study, using the following as a guide: High quality (++): Majority of criteria met. Little or no risk of bias. Results unlikely to be changed by further research. Acceptable (+): Most criteria met. Some flaws in the study with an associated risk of bias, Conclusions may change in the light of further studies. Low quality (0): Either most criteria not met, or significant flaws relating to key aspects of study design. Conclusions likely to change in the light of further studies.

Appendix(H(


S I G N


Study identification (Include author, title, year of publication, journal title, pages) 1. Bansal BC, Wiebe RA, Perkins SD, Abramo TJ. Tap water for irrigation of lacerations. Am J Emerg Med. 2002

Sep;20(5):469-72.









Yes


Yes (Using a randomization schedule)


Yes (Non investigator prepare the bowl of solutions for irrigation)


Yes (single blindling)


Yes


Yes


Yes (Signs of infection and wound culture result)


0%

Appendix(H(



Can’t say (No mention)


Does not apply (Single center)



Acceptance (+) 7 of 10 criteria


Yes


Yes


Comments: Hand lacerations were excluded, small sample size.

i Unless a clear and well defined question is specified, it will be difficult to assess how well the study has met its objectives or how relevant it is to the question you are trying to answer on the basis of its conclusions. ii Random allocation of patients to receive one or other of the treatments under investigation, or to receive either treatment or placebo, is fundamental to this type of study. iii Allocation concealment refers to the process used to ensure that researchers are unaware which group patients are being allocated to at the time they enter the study. Research has shown that where allocation concealment is inadequate, investigators can overestimate the effect of interventions by up to 40%. iv Blinding refers to the process whereby people are kept unaware of which treatment an individual patient has been receiving when they are assessing the outcome for that patient. It can be carried out up to three levels. Single blinding is where patients are unaware of which treatment they are receiving. In double blind studies neither the clinician nor the patient knows which treatment is being given. In very rare cases studies may be triple blinded, where neither patients, clinicians, nor those conducting the analysis are aware of which patients received which treatment. The higher the level of blinding, the lower the risk of bias in the study. v Patients selected for inclusion in a trial must be as similar as possible. The study should report any significant differences in the composition of the study groups in relation to gender mix, age, stage of disease (if appropriate), social background, ethnic origin, or co-morbid conditions. These factors may be covered by inclusion and exclusion criteria, rather than being reported directly. Failure to address this question, or the use of inappropriate groups, should lead to the study being downgraded. vi If some patients received additional treatment, even if of a minor nature or consisting of advice and counselling rather than a physical intervention, this treatment is a potential confounding factor that may invalidate the results. If groups

Appendix(H(


were not treated equally, the study should be rejected unless no other evidence is available. If the study is used as evidence it should be treated with caution. vii The primary outcome measures used should be clearly stated in the study. If the outcome measures are not stated, or the study bases its main conclusions on secondary outcomes, the study should be rejected. Where outcome measures require any degree of subjectivity, some evidence should be provided that the measures used are reliable and have been validated prior to their use in the study. viii The number of patients that drop out of a study should give concern if the number is very high. Conventionally, a 20% drop out rate is regarded as acceptable, but this may vary. Some regard should be paid to why patients dropped out, as well as how many. It should be noted that the drop out rate may be expected to be higher in studies conducted over a long period of time. A higher drop out rate will normally lead to downgrading, rather than rejection of a study. ix In practice, it is rarely the case that all patients allocated to the intervention group receive the intervention throughout the trial, or that all those in the comparison group do not. Patients may refuse treatment, or contra-indications arise that lead them to be switched to the other group. If the comparability of groups through randomisation is to be maintained, however, patient outcomes must be analysed according to the group to which they were originally allocated irrespective of the treatment they actually received. (This is known as intention to treat analysis.) If it is clear that analysis was not on an intention to treat basis, the study may be rejected. If there is little other evidence available, the study may be included but should be evaluated as if it were a non-randomised cohort study. x In multi-site studies, confidence in the results should be increased if it can be shown that similar results were obtained at the different participating centres. xi Rate the overall methodological quality of the study, using the following as a guide: High quality (++): Majority of criteria met. Little or no risk of bias. Results unlikely to be changed by further research. Acceptable (+): Most criteria met. Some flaws in the study with an associated risk of bias, Conclusions may change in the light of further studies. Low quality (0): Either most criteria not met, or significant flaws relating to key aspects of study design. Conclusions likely to change in the light of further studies.

I Appendix(I(

! Proposed(innovation(

Weiss(et(al.( Moscati(et(al.( Valente(et(al.( Bansal(et(al.(

Patients( ( Age(>1( Age>1( Age>17( Age(>1(<17( Age>1(<18(AEDs(presentation( (

Wound(<(8(hours( Wound(<(9(hours( Wounds(<8(hours( Wound<(8(hours! Wounds(<(8(hours(

Wound(size( Mean(3(cm( <3cm(3.1F6cm(>6(cm(

Around(0.5F15(cm(Mean(3cm(

No(mention(Claim(similar(in(both(groups(

<=3(cm(4F5cm(>6(cm(

Wound(site/(location(

Head(and(neck(Trunk(!

Head(and(neck(Trunk(Prox(extremity(Distal(extremity(

Head(and(neck(Trunk(Upper(extremity(Lower(extremity(Unknown!

FaceFscalp(Trunk–upper(extremity(Hand(Lower(extremity(Foot(!

Leg( (Hand( (Foot( (Arm!

Sample(size( Convenience(sampling( (

Normal(saline:(308(Tap(water:(317!

Normal(saline:(334(Tap(water:(300(

Normal(saline:(271(Tap(water:(259(

Normal(saline:(24(Tap(water:(21!

AEDs(setting( Local(ED( ED( ED( Paediatric(ED( ED(Estimated(cost(and(materials(of(using(tap(water(and(normal(saline(

Normal(saline(1L($30(per(bottle((Annual(savings( (30X8X356=85440((Dressing(set,(suture(materials(will(be(the(same(in( (

Normal(saline:(500(ml(Normal(saline($0.75((Charge(for(patients($10((Tap(water:(free(of(charge((Annual(savings( ($7.5(million(for(hospital($100(million(for(patients!

Normal(saline:($9.11(500(ml(SS$3.08(35ml(syringe($0.90(Splash(shield:($5.13((Tap(water($0.0015(per(patient(With(extension(tubing($0.22(per(patients((Normal(saline(irrigation:($72,880,000(Tap(water(irrigation:($7,280,000(Annual(savings:($65,600,000!

Normal(saline(1(L:($2.01(per(bottle((60(ml(syringe(Splash(shield((Cost(of(60(ml(syringe(and(splash(shield(did(not(mention(in(the(study(!

500(ml(Normal(Saline( (35ml(syringe( (Sterile(basins(Splash(shield(!Cost(of(the(materials(did(not(mention(in(the(study(

Appendix(J( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( (

Timeline for using tap water for irrigation in AEDs

Month& & 1& 2& 3& 4& 5& 6& 7& 8& 9& 10& 11& 12& 13& 14& 15& 16& 17& 18&

Communication&And&preparation& &

& & & & & & & & & & & & & & & & & &

Pilot&study& & & & & & & & & & & & & & & & & & &

Progress&evaluation&

& & & & & & & & & & & & & & & & & &

Full&implementation&

& & & & & & & & & & & & & & & & & &

Outcome&evaluation&

& & & & & & & & & & & & & & & & & &

Data&analysis& & & & & & & & & & & & & & & & & & &

Appendix(K(Quality(of(selected(studies((

(((((((

Studies( Design( Ratings(Weiss,(E.(A.,(Oldham,(G.,(Lin,(M.,(Foster,(T.,(&(Quinn,(J.(V.((2013).( Water( is( a( safe( and( effective( alternative( to(sterile( normal( saline( for( wound( irrigation( prior( to(suturing:( a( prospective,( doubleRblind,( randomised,(controlled(clinical(trial.(BMJ$Open,$3(1).(((

RCT,(double(blind(

1+(

Moscati,(R.(M.,(Mayrose,(J.,(Reardon,(R.(F.,(Janicke,(D.(M.,(&( Jehle,( D.( V.( (2007).( A(multicenter( comparison( of( tap(water( versus( sterile( saline( for( wound( irrigation.( Acad$Emerg$Med,$14(5),(404R409.((

Prospective,(multicenter,(Controlled(study(

2+(

Valente,(J.(H.,(Forti,(R.(J.,(Freundlich,(L.(F.,(Zandieh,(S.(O.,(&( Crain,( E.( F.( (2003).( Wound( irrigation( in( children:(saline( solution( or( tap( water?( Ann$ Emerg$ Med,$ 41(5),(609R616.(((

Quasi(RCT( 2R(

Bansal,(B.(C.,(Wiebe,(R.(A.,(Perkins,(S.(D.,(&(Abramo,(T.(J.((2002).( Tap( water( for( irrigation( of( lacerations.( Am$ J$Emerg$Med,$20(5),(469R472.(((

Prospective( 2+(

Dulecki( M,( Pieper( B.( Irrigating( simple( acute( traumatic(wounds:( A( review( of( the( current( Literature.( J( Emerg(Nurs;31:156R60((

Review( 3(

Fernandez,( R.,( &( Griffiths,( R.( (2012).(Water( for(wound(cleansing.(Cochrane$Database$Syst$Rev,$2,(Cd003861.(((

Systematic(review(

1++(

Appendix(L(

(

A(clinical(guideline(of(tap(water(irrigation(for(patients(present(to(accident(and(emergency(departments(with(acute(simple(traumatic(lacerations(

Intended(user:(Emergency(nurse(

Target(population:(The(target(populations(are(patients(present(to(AEDs(with(simple(acute(traumatic(lacerations(

Recommendations( ( Grading(

1.#Providing#aesthesis#prior#to#wound#suturing(

1%(Xylocaine(was(given(with(4mg/kg( A(

2.(Using#tap#water#as#irrigation#solution(

Using(tap(water(as(irrigation,(sterile(kidney(dish(or(basin(was(used(to(carry(the(solution(

A(

3.#The#suggested#pressure#of#irrigation#is#between#8#and#45#psi(

Pressure(should(be(more(than(8(psi(and(less(than(40(psi(

B(

4.#Using#a#50ml#syringe#with#18#gauge#angiocatheter#for#irrigation(

A(50(ml(syringe(with(18(gauge(should(be(used(to(generate(the(pressure(of(between(8(and(40(psi(

A(

5.#The#suggested#volume#of#irrigation#solutions#is#more#than#500#ml(

The(volume(should(be(500,(more(than(500(ml(can(used(if(visible(debris(present(

B(

6.(The#suggested#length#of#follow#up#should#be#within#48#hours#to#30#days##(

Follow(up(between(48(hours(and(30(days((because(wound(infection(occur(within(this(period(

B(

7.#Providing#educational#leaflet#of#wound#care#to#patients#upon#discharge(

A(wound(care(leaflet(was(given(to(patient(about(wound(care(

B(

(

Appendix(M((Evidence(based,guideline,

Title,,

A(clinical( guideline(of( tap(water( irrigation( for(patients(present( to( accident( and(

emergency(departments(with(acute(simple(traumatic(lacerations,

The,intended,user,,

This( guideline( is( intended( to( support( emergency( nurse( in( AEDs( who( care(

patients(with(simple(acute(traumatic(lacerations( (

The,target,population,

The(target(populations(are(patients(present(to(AEDs(with(simple(acute(traumatic(

lacerations(

Objectives,

1. To(summarize( the(evidence( from(the( trials( for(patients(present( to(AEDs(

with(simple(acute(traumatic(lacerations(

2. Formulate(clinical(practice(instructions(for(using(tap(water(irrigation(for(

patients(present(to(AEDs(with(simple(acute(traumatic(lacerations(

3. To(promote(costBeffective(wound(management(in(local(AEDs(

(

Recommendations,

Recommendations,1.,Providing,aesthesis,prior,to,wound,suturing,(Grading,

of,recommendation:,A),

In( patients( with( simple( acute( traumatic( lacerations,( it( is( essential( to(

provide( anesthetic( prior( to( suturing( (Weiss( et( al.,( 2013[1+];( Moscati( et( al.,(

2007[2+];(Valente(et(al.,(2003[2B];(Bansal(et(al.,(2002[2+]).( (Providing(aesthesis(

for(minimizing( pain( and( discomfort( during( procedure( is( essential.( All( selected(

trials( also(provide(aesthesis( for(patients( (Weiss( et( al.,( 2013[1+];(Moscati( et( al.,(

2007[2+];(Valente(et(al.,(2003[2B];(Bansal(et(al.,(2002[2+];(Dulecki(et(al,(2005[3];(

Fernandez(et(al.,(2008[1++]).(

Recommendations, 2., Using, tap, water, as, irrigation, solution, (Grading, of,

recommendation:,A),

Irrigation( is( a( wound( cleansing( method( to( remove( bacteria( by( copious(

dilution(of(the(solution.(Tap(water(is(readily(available(in(the(local(AEDs.(Evidence(

suggested( that( tap(water( is( as( effective( as( normal( saline( for( wound( irrigation(

(Weiss(et(al.,(2013[1+];(Moscati(et(al.,(2007[2+];(Valente(et(al.,(2003[2B];(Bansal(

et(al.,(2002[2+];(Dulecki(et(al,(2005[3];(Fernandez(et(al.,(2008[1++]).(

Recommendation,3.,The,suggested,pressure,of,irrigation,is,between,8,and,

45,psi,(Grading,of,recommendation:,B),,

The(suggested(pressure(of( irrigation(should(be(more(than(8(psi(and( less(

than(45(psi.(It(is(achieved(by(using(a(50(ml(syringe(with(18(gauge(angiocatheter.(

High( pressure( irrigation( cause( damage( to( localized( tissue,( hinder( recovery(

process,(result( in(poor(cosmetic(outcome((Weiss(et(al.,(2013[1+];(Moscati(et(al.,(

2007[2+];(Valente(et(al.,(2003[2B];(Bansal(et(al.,(2002[2+];(Dulecki(et(al,(2005[3];(

Fernandez( et( al.,( 2008[1++]).( So( the( optimal( pressure( for( irrigation( should( be(

within(8(and(45(psi(so(as(to(remove(bacteria(without(damage(the(local(tissue(and(

to(promote(the(recovery(process.(

Recommendation,4.,Using,a,50ml,syringe,with,18,gauge,angiocatheter,for,

irrigation,(Grading,of,recommendation:,A),

(( In(order(to(generate(the(optimal(pressure,(a(30B(60(ml(syringe(with(18B19(

gauge(catheter(was(used((Weiss(et(al.,(2013[1+];(Valente(et(al.,(2003[2B];(Bansal(

et(al.,(2002[2+]).(Two(trials(suggested(wounds(irrigated(directly(under(water(tap,(

however,(this(method(may(not(suitable(for(wounds(located(at(special(area(such(

as(trunk((Moscati(et(al.,(2007[2+]).(It(is(suggested(that(using(a(50(ml(syringe(with(

18(gauge(angiocatheter.(

Recommendation,5.,The,suggested,volume,of, irrigation,solutions, is,more,

than,500,ml,(Grading,of,recommendation:,B),

, The( suggested( volume( of( irrigation( is( 500( ml.( (Weiss( et( al.,( 2013[1+];(

Bansal(et(al.,(2002[2+]).(However,( two( trials( suggested(using(more( than(500ml(

irrigation( solution( if( visible( debris( can( be( seen( in( the( wound( (Moscati( et( al.,(

2007[2+];(Valente(et(al.,(2003[2B]).(

Recommendation,6.,The,suggested,length,of,follow(up,should,be,within,48,

hours,to,30,days,,(Grading,of,recommendation:,B),

The(suggested(length(of(followBup(is(at(48(hours(to(30(days((Weiss(et(al.,(

2013[1+];( Moscati( et( al.,( 2007[2+];( Valente( et( al.,( 2003[2B];( Bansal( et( al.,(

2002[2+]).(FollowBup( is(necessary( to(assess(patients’(wound(condition(and( the(

sign( of( infection,( which( include( fever,( erythema,( gross( exudate( or( drainage,(

tenderness.(Dressings(need(to(be(kept(for(intact(for(first(2(days(and(off(stitches(at(

day(5.(The(suggested(length(of(follow(up(should(be(within(48(hours(and(30(days(

since( the(occurrence(of(wound( infection( is(within( this(period.(Early(removal(of(

stitches(regarded(as(infection((Moscati(et(al.,(2007[2+]).((

Recommendation,7.,Providing,educational,leaflet,of,wound,care,to,patients,

upon,discharge,(Grading,of,recommendation:,B),

( Patients( should( receive( wound( care( leaflet( at( discharge.( Continuing(

wound(care(is(essential(to(prevent(wound(infection(until(wound(healed((Moscati(

et( al.,( 2007[2+]).( The( leaflet( should( contain( information( how( to( subsequently(

mange( wound,( provide( knowledge( about( the( complications( of( infection( and(

prevent(further(injury.(

(

!!!!!!!!!!Appendix!N!

Source!from:!Scottish!Intercollegiate!Guidelines!Network!(2008)!SIGN!50.!A!guideline!developer’s!handbook!!

!

Appendix(O(

(

Wound(care(leaflet((Discharge( instruction( for( patients( with( simple( acute( traumatic(lacerations(General(instructions((1. Keep(wound(intact(for(2(days(2. Keep(wound(site(and(surrounding(clean(and(dry(3. Due(to(local(anesthesia,(mild(localized(swelling(after(immediate(closure(regard(as(normal(

4. If(wound(located(at(scalp,(please(do(not(wash(hair(for(2(days.((5. Avoid(strenuous(exercise,(particularly(wound( located(at( joints(such(as(elbow,(knee((

6. If( outer( dressing( become( soil,( please( wash( your( hands( with(soap(

7. Gently( pat( wound( with( clean( gauze( if( outer( dressing( comes(loose(

8. If(you(experience(bleeding(from(wound,(press(the(wound(for(10(minutes((

9. If(bleeding(continue,(apply(ice(bag(over(wound(site(for(10(more(minutes(

((Location:( ( ( ( ( ( ( ( ( ( (Number(of(stitches:( ( ( ( ( ( ( ( (Stitch(will(be(removed(on:(( ( /( /( ( ( ( (((Please(contact(AEDs(immediately(if(you(experience(as(follow:(The(signs(and(symptoms(of(infection(1. Increased( pain( over(wound( site( and( not( controlled( by( use( of(analgesia(such(as(paracetamol(

2. Increased(warmth(on(touch(3. Unpleasant(odor(from(wound(4. Exudate(from(wound(5. Severe(bleeding(from(wound(6. Fever(more(than(38(°C((

(((

Appendix((P(

(

Assessment(form(of(simple(acute(traumatic(lacerations(in(AEDs(

(Patient(characteristics:(Age:(((((((((((((((((((Body(weight:((( ( Date(of(presentation:(( ( ((Medical(history:((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((Injury(mechanism:( ( (((((((( ( ( ((((((((((((((((((((((((((((((((( ((((((( ((((Date(of(follow(up:(( ( ( ((((((((((((((((((((((((((((((((((((((((((( ( ( (((((((((((((((((ATT(injection(given:(1st(dose(,(2(nd((dose,(3(rd(dose,(Immune,(booster(((Wound(characteristics:(( Day(0( Day(2(Wound(location:( ( (Wound(size:(((Length(X(width(X(depth)(Before(suture(After(suture(

(((

cm(X(((((cm(X((((((cm(cm(X(((((cm(X((((((cm(

((

cm(X(((((cm(X((((((cm(cm(X(((((cm(X((((((cm(

Dressing(materials(used:(Solution(

Tap(water/(Normal(saline(irrigation(

Tap(water/(Normal(saline(irrigation(

Name(of(Anesthesia((Dosage:(Route:(

1%(Xylocaine(((((((((ml(

Digital(Block/Field(block/wound(filtration((

1%(Xylocaine(((((((((ml(

Digital(Block/Field(block/(wound(filtration((

Number(of(suture:(Suture(materials:(Stitch(method:(

(Ethlion/(Mersik/(Vicryl(Simple/Buried/Mattress(

(Ethlion/(Mersik/(Vicryl(Simple/Buried/Mattress(

Signs(of(infection:(Redness,(swelling(Pain(score((NRS):(Temperature((>38°C)(Exudate:(

((Y/N)(/10((

(Y/N)(

((Y/N)(/10((

(Y/N)(Antibiotics(given:((Wound(care(leaflet(given:(Wound(culture(taken:(Staff(Signature(((

(Y:((((((((((((((((((((((/N)((

(Y/N)((Y/N)((

(Y:((((((((((((((((((((((/N)((

(Y/N)((Y/N)((

(Extra(date(of(follow(up:((Y:((((((((((((((((((((((/N)(Reason(for(extra(date(of(follow(up:((( ( ( ( ( ((( ( ( ( ( (( ( ( ( ( ( ((((( ( ( ( ( ( (( ( ( ( ( (((

Appendix(Q(

(

Staff(questionnaire(Questionnaire(regarding(using(tap(water(for(wound(irrigation(in(AEDs((You(are(invited(to(fill(the(questionnaire(below(

( ( Strongly(disagree(

Disagree( Neutral( Agree( Strongly(agree(

(1.(

About(workshop(The(workshop(is(well(designed.(

( ( ( ( (

2.( The(workshop(has(provided(up–to(date(knowledge(in(wound(care.(

( ( ( ( (

3.( Taking(this(workshop(has(better(equipped(me(using(tap(water(for(irrigation(is(AEDs.(

( ( ( ( (

4.( The(goals(of(the(workshop(were(made(clear(to(me.( ( ( ( ( (5.( The(use(of(teaching(materials((angiocatheter,(

syringe)(is(appropriate.(( ( ( ( (

6.( The(workshop(has(provided(opportunity(to(integrate(knowledge(into(practice.(

( ( ( ( (

(7.(

About(proposed(innovation(The(proposed(innovation(has(provided(knowledge(that(I(need.(

( ( ( ( (

8.( The(proposed(innovation(has(provided(opportunity(of(evidencePbased(practice(

( ( ( ( (

9( ( ( ( ( ( ((What(do(you(think(about(the(tap(water(quality(in(Hong(Kong?(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ((((((((((((((((((((((((((((((((((((((((((( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ((((((((((((((((((((((((((((( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( (((((((((((((((((((((((((((((Do(you(think(tap(water(is(safe(to(consume?( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( (((((((( (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( ((((((((((((( (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( ((((((((((((( (Did(you(use(tap(water(for(wound(management(before?(If(yes,(in(what(situation?(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( (((((((( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( (((((((((( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( (((((((((((((((((((( (Will(you(consider(using(tap(water(for(irrigation?(If(not,(what(is(your(concern?(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( (( ( (((((((((((( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( (((((((( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ((((((((((( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( (((((((((((( ((Other(comments:(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( (

~Thanks(for(your(opinions~(

Appendix(R(

(

Questionnaire(regarding(using(tap(water(for(wound(irrigation(in(AEDs((You(are(invited(to(fill(the(questionnaire(below((Please(tick(one(below(( 1( Strongly(dissatisfied(( 2( Dissatisfied(( 3( Neutral(( 4( Satisfied(( 5( Strongly(satisfied((Please(answer(following(questions(What(do(you(think(about(the(tap(water(quality(in(Hong(Kong?(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ((((((((((((((((((((((((((((((((((((((((((( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ((((((((((((((((((((((((((((( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( (((((((((((((((((((((((((((((Do(you(think(tap(water(is(safe(to(consume?( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( (((((((( (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( ((((((((((((( (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( ((((((((((((( (Did(you(use(tap(water(for(wound(management(before?(If(yes,(in(what(situation?(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( (((((((( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( (((((((((( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( (((((((((((((((((((( (Will(you(consider(using(tap(water(for(irrigation?(If(not,(what(is(your(concern?(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( (( ( (((((((((((( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( (((((((( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ((((((((((( ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( (((((((((((( ((Other(comments:(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( (

((

~Thanks(for(your(opinions~(((((

Abstract!of!thesis!entitled! - University of Hong Kong Wai Ching.pdf · ! 5!...

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