Authors

1. Wiechula, Rick RN, BA, BN, MNSc, DNurs
2. Everett, Iain RN, MPH, MNP

Abstract

Review question/objective: Is the use of pro-formas in the assessment of minor hand injuries effective in minimizing diagnostic error, inappropriate investigations, referral, mismanagement and suboptimal patient care?

Background: Injuries of the hand are a common health problem and account for around a fifth of all cases presenting to the emergency departments (EDs) of most hospitals, worldwide.1 Not all hand and upper limb injuries require treatment by a specialist physician and increasingly, many of these patients will be assessed and treated by other health professionals including nurse practitioners (NPs). Hand and upper limb injuries can be deceptively complex and if not managed appropriately can have significant long-term sequelae. Timely and accurate assessment is important in directing appropriate referral and treatment. One strategy that can promote a structured approach to assessment of upper limb injuries is the use of assessment pro-formas by non-physician clinicians.

The hand is a very complex structure capable of a number of diverse functions, such as gripping and punching, which can be performed with a high level of precision and speed. It is also an extremely sensitive sense organ used for detecting touch, temperature and pressure. The upper limbs are essential to a range of everyday activities, from lifting and carrying to more complex tasks such as driving and swimming. Given this complexity, sensitivity and utility, the upper limbs are extremely susceptible to damage and injury. Consequently, even minor injuries including burns, contusions, lacerations and fractures, can lead to permanent disability if not treated promptly and effectively. Hand and upper limb injuries can affect an individual's ability to function in the workplace, reduce involvement in social situations and impair their ability to undertake self-care.1,2,3 As such, poorly treated upper limb injuries can create both physical and psychological disability, which negatively impacts upon the individual, their social network, their community and the nation as a whole. A 2006 retrospective study found that hand injuries were the most frequent type of injury sustained on presentation to the ED, contributing to 6.6% of all injuries and 28% of injuries to the musculo-skeletal system.4 Furthermore, a UK study found that more than [pounds]100 million was spent in 2000 alone, on the management of hand injuries nationally.1 Taken together, this information indicates that hand injuries significantly contribute to the burden on healthcare systems. In addition, this estimation of hand injury expenditure accounts only for direct treatment costs and does not consider the indirect expenses to the patient and those associated with permanent disability. To reduce both the financial and social costs of hand and upper limb injuries, appropriate clinical decisions need to be made early and executed competently.1 This recommendation is supported by evidence which indicates that the preservation of optimal function is dependent upon the receipt of a rapid and accurate assessment of the injury, appropriate treatment and if necessary, early specialist referral.5,6,7 If these conditions are met, then the majority of hand injuries have a good prognosis for recovery.5

In order to effectively diagnose and treat injuries to the hand and upper limbs, clinicians require a detailed understanding of their anatomy and functioning. A comprehensive assessment requires the ability to take a detailed and focused history, as well as a thorough physical assessment of the hand or limb. Indeed it is only through an in depth knowledge of the hand that clinicians have the ability to compile and integrate both subjective and objective observations to appropriately diagnose and treat the injury. Such comprehensive assessments are challenging given the complexity of the hand; such complexity stems from the intricately interconnected nature of the underlying structures comprised of muscles, tendons, connective tissue, nerves, blood vessels and bones. Additionally, emergency care departments comprise a range of health professionals whose familiarity with the physiology of the hand may vary by profession, level of education and years of experience to create a situation in which the quality of the hand and upper limb assessments may vary widely. If there is inadequate assessment of the injury by individuals with only a basic understanding of the underlying structures, then incorrect diagnosis may occur leading to improper or untimely referral to a hand specialist and potentially, to negative effects on prognosis. This has been a long-standing issue in emergency medicine, as indicated by commentary as far back as the 1920s, regarding the irregularity of diagnosis of hand injuries based upon poorly conducted hand assessments.8

Clearly, there is a need to improve the accuracy, consistency and efficiency of upper limb injury diagnosis and treatment and it has been proposed that this may be achieved through the use of hand assessment pro-formas. Indeed, JJ Scanlon, a surgeon working during the First World War, recommended using a diagram of a hand to describe the injury as a pro-forma to minimize variance in assessment and ensure accuracy.8 More recently, there have been trials of computer-based hand injury assessment pro-formas assessing the utility of such tools for accurate and thorough assessment, followed by specialized treatment.9 Such tools utilize prompts following the entry of particular information regarding the injury.9

The use of a set pro-formas can assist clinicians to recognize possible 'red flags' or vital clinical findings, which may impact upon treatment pathways. The use of a pro-forma may enable quicker assessment processes; whilst still maintaining accuracy and assisting clinicians to identify the crucial elements of injury, such that serious pathology or injury are not missed. It is thought that this process can contribute to a reduction in time spent documenting findings, thereby streamlining and improving referral processes which result in appropriate management.

In summary, the reasons for the inquiry into whether pro-formas are effective assessment tools in the management of minor injuries, specifically hand and upper limb injury, are as follows:

* Hand and upper limb injuries are the most common musculo-skeletal minor injury presenting to most major EDs and contribute considerably to hospital and community care costs.

* The outcomes for individuals with poorly managed hand and upper limb injuries are poor in terms of both physical and psychological wellbeing.

* To minimize error through timely and accurate assessment of the hand injury, being aware of the crucial 'red flags' for serious/subtle injury and enabling early appropriate diagnostic testing and referral leading to optimal function of the hand for the patient.