Development of wound management record form for traumatic persons in Emergency Department, Maharaj Nakorn Chiang Mai Hospital
Keywords:
trauma patients, wound management, traumatic wounds, wound documentationAbstract
Objectives To develop a wound management record form for traumatic patients in the emergency department and to explore the feasibility of using the form to record wound management of traumatic patients in an emergency department.
Methods This developmental study used the National Health and Medical Research Council’s Guide to the Development of Clinical Practice Guideline (1999) as the research framework for development of the record form. The form was tested for feasibility by 20 emergency nurses who recorded wound management for 70 trauma patients who also completed a Wound Management Record Form Feasibility Questionnaire. The data were analyzed using descriptive statistics.
Results The Wound Management Record Form developed was a one-page paper form which includes a checklist, standard abbreviations, a full-body anatomical picture for recording location, and space for additional information. The form includes five components: wound assessment, wound cleansing, wound closure and dressing, antibiotics and vaccination, and follow-up. Evaluation of use of the form found the completeness of components 1-5 to be 88.57, 82.86, 90.00, 81.43, and 82.86 percent, respectively. The majority of participating nurses either agreed or strongly agreed that the form was easy and convenient, precise and valid, appropriate as a wound management record for the emergency department, and saved time in recording information. The majority felt the form to be effective and feasible for use in an emergency department.
Conclusion The Developed Wound Management Record Form is both appropriate and feasible for use in emergency departments.
References
Prevaldi C, Paolillo C, Locatelli C, Ricci G, Catena F, Ansaloni L, et al. Management of traumatic wounds in the Emergency Department: position paper from the Academy of Emergency Medicine and Care (AcEMC) and the World Society of Emergency Surgery (WSES). World Journal of Emergency Surgery: WJES. 2016;11:30.
Umbrello L, Maniaci V, Garcia Peña BM, Lozano JM, Friedman M. Accuracy of laceration length estimation in a pediatric emergency department and its impact on billing practices. Pediatr Emerg Care. 2013;29:1066-9.
Emergency unit. Annual statistical report. Chiang Mai: Maharaj Nakorn Chiang Mai Hospital, Faculty of Medicine 2018. [in Thai]
World Health Organization. Department for the Management of Noncommunicable Diseases DVaIP. Injuries and violence: the facts 2014. Geneva, Switzerland: Department for the Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, World Health Organization; 2014. [cited 2019 July 4]. Available from: http://apps.who.int/iris/bitstream/10665/149798/1/9789241508018_eng.pdf?ua=1.
Coleman S, Nelson EA, Vowden P, Vowden K, Adderley U, Sunderland L, et al. Development of a generic wound care assessment minimum data set. Journal of Tissue Viability. 2017;26:226-40.
Ubbink DT, Brölmann FE, Go PMNYH, Vermeulen H. Evidence-Based Care of Acute Wounds: A Perspective. Advances in wound care. 2015;4:286-94.
Brown G. Wound documentation: managing risk. Adv Skin Wound Care. 2006;19:155-65, quiz 65-7.
Scott-Thomas J, Hayes C, Ling J, Fox A, Boutflower R, Graham Y. A practical guide to systematic wound assessment to meet the 2017-19 CQUIN target. Journal of Community Nursing. 2017;31:30-4.
Panngoen W. The completeness of gun-shot wound register in medical record at Siriraj Hospital: Silpakorn University; 2011.
Goldsmith H. Wound care documentation. Podiatry Management. 2007;26:83-5.
Armstrong M, Strack GB. Recognition and Documentation of Strangulation Crimes: A Review. JAMA Otolaryngol Head Neck Surg. 2016;142:891-7.
Moore J. A Step-by-Step Approach to Billing Wound Care Products Through Your Office. Podiatry Management. 2016;35:85-4.
Schaum KD. Lack of Documentation Is Costly to Wound Care Patients. Adv Skin Wound Care. 2016;29:344-6.
Kanegaye JT, Cheng JC, McCaslin RI, Trocinski D, Silva PD. Improved documentation of wound care with a structured encounter form in the pediatric emergency department. Ambul Pediatr. 2005;5:253-7.
Fackler ML, Mason RT. Gunshot wounds: evaluating the adequacy of documentation at a level I trauma center. J Trauma. 1999;46:741-2.
Haworth S, Bates AS, Beech A, Knepil G. Quality improvement in documentation for patients with suspected facial fractures: use of a structured record keeping tool. Emerg Med J. 2016;33:268-72.
Wrenn K, Rodewald L, Lumb E, Slovis C. The use of structured, complaint-specific patient encounter forms in the emergency department. Annals of Emergency Medicine. 1993;22:805-12.
Cullen L, Adams SL. Planning for Implementation of Evidence-Based Practice. J Nurs Adm. 2012;42:222-30.
Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003; 362 (9391):1225-30.
National Health and Medical Research Council [NHMRC]. A guide to the development, implementation and evaluation of clinical practice guideline 1999. [online] 1999 [cited 2019 March 25]. Available from: https://www. health. qld.gov.au/__data/assets/pdf_file/0029/143696/nhmrc_clinprgde.pdf
The Joanna Briggs Institute [JBI]. New JBI Levels of Evidence. [online] 2019 [cited 2019 September 2]. Available from: http://joannabriggs.org/jbi-approach.html#tabbed-nav=Levels-of-Evidence
Nantachipan P. The CPGs quality evaluation questionnaire. Chiang Mai: Faculty of Nursing: 2006. [in Thai]
de Jonge SW, Boldingh QJJ, Solomkin JS, Allegranzi B, Egger M, Dellinger EP, et al. Systematic Review and Meta-Analysis of Randomized Controlled Trials Evaluating Prophylactic Intra-Operative Wound Irrigation for the Prevention of Surgical Site Infections. Surg Infect (Larchmt) 2017;18:508-19.
Wynne MM. HSE National Wound Management Guidelines 2018. [online] 2018. [cited 2019 June 27]. Available from: https://www.hse.ie/eng/services/publications/nursingmidwifery%20services/wound management-guidelines-2018.pdf
Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012 15;(2):CD003861. doi: 10.1002/14651858.CD003861.pub3.
Nicks BA, Ayello EA, Woo K, Nitzki-George D, Sibbald RG. Acute wound management: revisiting the approach to assessment, irrigation, and closure considerations. Int J Emerg Med. 2010;3:399-407.
Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. Am Fam Physician. 2017;15;95:628-36.
Peterson N, Stevenson H, Sahni V. Size matters: how accurate is clinical estimation of traumatic wound size? Injury. 2014;45:232-6.
Devriendt N, de Rooster H. Initial Management of Traumatic Wounds. Vet Clin North Am Small Anim Pract. 2017;47:1123-34.
National Health Service [NHS]. Guildlines for the assessmemt and management of wounds. [online] 2014. [cited 2019 June 25]. Available from: https://www.nhft.nhs.uk/download.cfm?doc=docm93jijm4n1793.pdf&ver=17402
Fleck CA. Why “wet to dry”? J Am Col Certif Wound Spec. 2009;1:109-13.
World Health Organization. Rabies vaccines and immunoglobulins: WHO position: summary of 2017 updates. [online] 2018. [cited 2019 June 25]. Available from: https://apps.who.int/iris/bitstream/handle/10665/259855/WHO-CDS-NTD-NZD-2018.04eng.pdf;jsessionid=CB2B9C97F72889D51B005A20258FB99A?sequence=1
Coleman S, Nelson EA, Vowden P, Vowden K, Adderley U, Sunderland L, et al. Development of a generic wound care assessment minimum data set. J Tissue Viability. 2017; 26:226-40.
Young SJ, Barnett PL, Oakley EA. 10. Bruising, abrasions and lacerations: minor injuries in children I. Med J Aust. 2005;182:588-92.
Cuzzell J. Wound assessment and evaluation: wound documentation guidelines. Dermatol Nurs. 2002;14:265-6.
Bryant R, Nix D. Acute and chronic wounds: current management concepts. [online] 2015. [cited 2019 March 28]. Available from: https://www.clinicalkey.com/nursing/#!/browse/book/3-s2.0-C20130013394
Liang JL, Tiwari T, Moro P, Messonnier NE, Reingold A, Sawyer M, et al. Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2018; 67:1-44.
Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003; 362(9391):1225-30.
National Health and Medical Research Council [NHMRC]. How to put the evidence iinto practice: implementation and dissemination strategies. [online] 2000. [cited 2019 March 25]. Available from: https://nhmrc.gov.au/sites/default/ files/2018-03/how-to-put-the-evidence-into-practice-implementation-and-dissemination.pdf
Downloads
Published
How to Cite
Issue
Section
License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
