John
L Harden1 John A Hiscox 2
1
Specialist Registrar in Emergency Medicine
2 Consultant in Emergency Medicine, Emergency Department, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, United Kingdom, AB25 2ZN
Correspondence
to: john.harden@nhs.net
SMJ 2006 51(3): 30-33
Aim
- To determine if the instruments found in single-use suture kits are of
satisfactory quality when compared with re-useable instruments and to determine
the cost implications of changing to these kits.
Methods
- Audit of established practice, followed by trial of new suture kits and their
introduction to the department. The new practice was then audited. A cost
analysis was conducted.
Results
- The audit showed numerous problems with the traditional suture kits
(instruments were breaking or no longer suitable for suturing wounds). A trial
of single-use instruments demonstrated them to be high quality and provided new
instruments each time.
Conclusion
- Single use instruments would appear to be safe and cost effective in the
emergency department setting.
Key
Words: Emergency Medicine; Suturing; Single-use Instruments
Wound
closure is a core skill of the emergency medicine doctor. Despite the increasing
use of tissue adhesive, suturing remains a commonly used method of wound
closure. Basic suturing techniques are well established.1 The
instruments available to allow suturing of wounds have however, evolved in
recent years.
Recent
concerns over prion-mediated disease has driven the development and introduction
of disposable instruments for a variety of surgical procedures (e.g.
tonsillectomy).2, 3, 4 Companies producing such instruments have
widened their range to produce surgical instruments for use in other fields. For
emergency departments, single-use suture kits have been developed which are for
single use and discarded after use via the sharps disposal route.
In
Aberdeen Royal Infirmary Emergency Department, the equipment used for the
suturing of wounds came in a “casualty incision pack” which was designed for
a variety of tasks including some operative procedures in theatre. This
contained basic instruments:
needle
holder
scissors
toothed
and non toothed forceps
In
addition the pack contained swabs and sterile drapes, a collection of various
types of retractors and probes, artery clamps and a tourniquet. This array of
instruments was felt not to be necessary for the majority of procedures being
undertaken in the emergency department.
The
aim of this study was to identify if these kits could be introduced safely to
routine practice and evaluate if they were cost effective.
An
audit of current practice of suturing was performed within the emergency
department of Aberdeen Royal Infirmary. Following a short evaluation of the new
single-use suture kits, they were introduced to the department. Their use was
reassessed at one year.
A
simultaneous cost analysis of the new versus old suture kits was performed. Data
from the first audit allowed a projected cost to be calculated using the average
usage of kits which was provided from the hospital Central Sterile Supplies
Department (CSSD). This process was repeated at the second assessment to provide
an actual cost of change.
Audit
The
initial audit revealed that there were numerous problems arising with the use of
the suture kits in use in the department. These packs contained standard
surgical instruments which were re-sterilised after use. The kits were assessed
using the following criteria and graded in each using the scale shown:
general
packaging
ease
of use
feel
of instruments
confidence
in using them/overall impression
problems/comments
Scale:
Very Poor; Poor; Adequate; Good; Very Good
The
main findings of this audit are shown in Figure
1
These
packs contained basic instruments required for suturing as outlined above and
the instruments were made from stainless steel. A simple dressing pack, to
provide a sterile field drape, swabs, and galipot for cleaning solutions was
added.
During
the trial phase, the kits were assessed by the same criteria as above, with an
initial twelve packs trialled. The pack was felt to be fit for purpose and none
of the problems found with the re-usable instruments were identified. However,
some problems were identified with the needle holders. (Table
I)
Following
this positive result, fine and standard suture kits were introduced in the
department. Traditional fine needle holders were made available for 6/0 suture
procedures.
One
year following implementation reassessment using the same criteria was
performed. The criteria were graded as before. In general, the new kits were
found to perform well. Table II
Cost
Analysis
The
cost for sterilising the traditional suture packs was identified as £4.45 per
pack. The single-use packs cost £2.56 per pack. The cost of the dressing pack (£0.49
each) was added giving a total cost of £3.05 per patient. Using these figures,
and assuming an average usage of 150 kits/month, a projected cost saving of £2520
was calculated. (Table III)
During
the study period an average of 118 packs was used each month. This resulted in
an actual saving of £1981.50. (Table
IV)
The
cost for using supplemental fine needle holders is not considered in these
figures. The cost for sterilisation of these was £0.60 each. If these had been
required for each case where fine instruments were used, the overall saving
would have been reduced to £1502.20.
The
use of single-use suture kits within an emergency department is desirable due to
the nature of the patient group (e.g. high levels of intravenous drug misusers,
etc). These kits remove the need to worry about the risk of cross infection from
sources resistant to standard sterilisation techniques. Wear and tear on
traditional instruments in such a high volume area is removed by using
disposable kits.
However,
the use of single-use instruments does raise waste disposal issues. In Scotland,
the centralisation of sterilisation services and the introduction of tighter
controls on decontamination processes has been recommended.5, 6 The
use of single-use instruments is also recommended where possible.7, 8
Single-use
instruments are disposed of in “sharps bins” which are decontaminated by two
methods. The first method is by shredding, then heat treating to remove the risk
of contamination. The resultant waste is disposed of in landfill sites. The
second method of decontamination is by incineration. This eliminates the risk of
spreading prion diseases but the resultant waste is also disposed of in landfill
sites. The shredding, heat treatment and landfill route of disposal is employed
in NHS Grampian as the number of instruments used is relatively small.
This
study addresses two main issues. The first is; are single-use kits suitable and
safe, i.e. are they adequate for wound closure?
The
audit indicated the kits to be of a high standard and no significant problems
were reported. Subjectively, they were felt to be superior to the old
instruments and eliminated wear and tear issues. Confidence in using the
instruments was high. Overall, they were fit for purpose. We accept there is
potential for observer bias in this study, given the results are completely
reliant on subjectivity.
Secondly;
was introducing single use kits cost effective?
With
current sterilisation costs, changing to single-use kits produced an overall
saving of departmental resources. These savings may be reproducible in other
emergency departments. To determine whether this may be the case, in May 2004 33
hospitals were contacted and asked whether they had trialled and/or were using
single use suture kits. Over half were still using reusable instruments for
suturing, with only 30% using single use kits. (Table
V)
Therefore,
potential exists for significant savings to be made within emergency departments
by introducing single use kits.
This
study has subjectively shown that single use suture kits may be introduced
safely into routine practice. It has also demonstrated that their introduction
is likely to result in cost savings. We would recommend their introduction in
Emergency Departments for routine use.
Wardrope
J. and Smith JAR. The Management of Wounds and Burns. Oxford: Oxford
University Press,1992
Collinge
J. Variant Creutzfeldt-Jakob disease. Lancet 1999; 354: 317-23
Frosh
A, Joyce R, Johnson A. Iatrogenic vCJD from surgical instruments. BMJ
2001; 322: 1558-59
Bingham
B. New variant CJD-BSE(mad cow disease). The need for disposable ENT
instruments. Int. J. Paediatric Otorhinolaryngology 2002: 62; 203-6
NHS
Scotland: Sterile services provision review Group: 1st Report –
The Glennie Framework
Scottish
Executive Health Department. NHS HDL(2001)66. Healthcare associated
infection: review of decontamination services and provision across NHS
Scotland.
Scottish
Executive Health Department. NHS HDL(2002)67. Decontamination – NHS
Scotland sterile services provision review group.
Scottish
Executive Health Department. NHS HDL(2003)42. Decontamination – NHS
Scotland sterile services provision review group (Glennie Group).
Staff
of Emergency Department Aberdeen Royal Infirmary
Robinson
Heathcare INSTRAPAC
Rocialle (Dressings Packs)