Does the use of surgical face masks reduce postoperative infections in traumatic wounds sutured outside hospital? A randomized study at a Norwegian casualty center.

OBJECTIVE: To investigate if wearing surgical face mask by doctors and nurses during suturing of traumatic wounds has any impact on postoperative infection rate. DESIGN: Randomized controlled study with masked or unmasked health personnel groups. SETTING: A Norwegian Minor Injury Department. SUBJECTS: Adult patients with traumatic wounds sutured at the clinic between 7 October 2019 and 28 May 2020. MAIN OUTCOME MEASURES: Postoperative infections of sutured wounds. RESULTS: One hundred and sixty-five patients with 176 wounds were included in the study. Nine out of 88 wounds (10.2%) in the masked group and 11 out of 88 wounds in the unmasked group (12.5%) had a wound infection. CONCLUSIONS: Despite a higher percentage of postoperative infections in the unmasked than in the masked group (12.5% versus 10.2%), the difference was not statistically significant (p = .6). This might imply that the use of facemasks during suture of traumatic wounds in an outpatient setting does not significantly reduce the number of infections. However, due to the covid pandemic, the study had to be prematurely stopped before the planned number of participants had been recruited (n = 594). This increases the risk of type II error.

Few studies from hospital setting have found significant difference in postoperative wound infections if surgical face masks were worn or not during surgery.High quality studies about face masks and wound infections from primary care are lacking.This randomized study at a minor injury department outside hospital found no significant difference in frequency of postoperative wound infection if health personnel had worn surgical face masks or not while suturing traumatic wounds.

Acute management of fractures in primary care - a cost minimisation analysis.

BACKGROUND: In Norway, primary healthcare has first-line responsibility for all medical emergencies, including traumas and fractures. Normally, patients with suspected fractures are referred to specialist care in hospitals. However, the cooperating municipalities of Bykle and Valle have X-ray facilities and handle minor fractures locally. The aim of this study was to estimate the costs of X-ray diagnosis and initial treatment of fractures at the local primary care centre compared with initial transport and treatment in hospital. METHODS: We conducted a cost minimisation analysis by comparing expected costs of initial examination with X-ray and treatment of patients with fractures or suspected fractures at two possible sites, in the local municipality or at the hospital. A cost minimisation analysis is an economic evaluation based on the assumption that the outcomes of the two treatment procedure regimens are equal. Costs were estimated in Euros (EUR) using 2021 mean exchange rates. RESULTS: In 2019, we identified a total of 403 patients with suspected fractures in the two municipalities. Among these, 12 patients bypassed the primary care system as they needed urgent hospital care. A total of 391 injured patients were assessed with X-ray at the primary health care centres, 382 received their initial treatment there, and nine were referred to hospital. In an alternative hospital model, without X-ray and treatment possibilities in the municipality, the 382 patients would have been sent directly to hospital for radiological imaging and treatment. The total cost was estimated at EUR 367,756 in the hospital model and at EUR 69,835 in the primary care model, a cost saving of EUR 297,921. CONCLUSION: Based on cost minimisation analysis, this study found that radiological diagnosis of suspected fractures and initial treatment of uncomplicated fractures in primary care cost substantially less than transport to and treatment in hospital.

Patient-reported outcomes after initial conservative fracture treatment in primary healthcare - a survey study.

BACKGROUND: Primary healthcare in Norway has first-line responsibility for medical emergencies, including traumas and fractures. Normally, patients with suspected fractures are referred to specialist care. However, some municipalities have X-ray facilities and handle minor fractures locally. We investigated patient-reported outcome measures after initial treatment of radiologically diagnosed fractures of the wrist, collarbone, and ankle at a primary healthcare centre in a rural municipality with a large ski resort. The patients' general satisfaction with the treatment was also investigated. METHODS: Validated questionnaires were sent to patients with fractures of the wrist or collarbone (Quick DASH-Disability of Arm, Shoulder and Hand) or the ankle (FAOS -The Foot and Ankle Outcome Score). Patients with wrist and collarbone fractures also answered the Quality-of-life questions that are a subscale of the FAOS questionnaire for ankle fractures. Patient satisfaction was measured for all fracture groups. The Quick DASH scale ranges from 0 (no disability at all) to 100 (great disability), while for FAOS a score of 100 indicates no symptoms and 0 indicates extreme disabilities. RESULTS: A total of 148 of 238 patients answered the questionnaire (62% response rate). Patients with distal radius fractures had a mean Quick DASH score of 5.1 (median 0, range 0-77), and scores were significantly lower for males (p = 0.013) and increased with age (p = 0.024). Patients with collarbone fractures had a mean Quick DASH score of 2.1 (median 0, range 0-32) with no significant age or gender differences. Patients with ankle fractures had the following mean subscale-scores: Pain, 93.8; Symptoms, 71.4; Activities of daily living, 97.4; Sport, 90.0; and Quality of life, 92.1. The scores did not differ significantly by specialization of the physician. A total of 88% of the patients were highly or very highly satisfied with the handling of their fracture. CONCLUSIONS: The patients reported low rates of functional disability and high rates of satisfaction after initial radiological diagnosis and treatment of their fracture at the primary healthcare centre. Specialisation of the treating physician was not associated with the outcome in any of the fracture types.

Physician factors associated with medical errors in Norwegian primary care emergency services.

OBJECTIVE: The aim of this study was to examine the associations between characteristics of physicians working in primary care emergency units (PCEUs) and the outcome of assessments of the medical records. DESIGN: Data from a previous case-control study was used to evaluate factors related to medical errors. SETTING: Ten Norwegian PCEUs were included. SUBJECTS: Physicians that had evoked a patient complaint, and a random sample of three physicians from the same PCEU and time period as the physician who had evoked a complaint. Recorded physician characteristics were: gender, seniority, citizenship at, and years after authorization as a physician, specialty in general practice, and workload at the PCEU. Main outcome measures: Assessments of the medical records: errors that may have led to harm, no medical error, or inconclusive. RESULTS: In the complaint group 77 physicians were included, and in the random sample group 217. In the first group, 53.2% of the medical records were assessed as revealing medical errors. In the random sample group, this percentage was 3.2. In the complaint group the percentages for no-error and inconclusive for the female physicians were 30.8 and 15.4; and for the male physicians 9.8 and 27.3, p = 0.027. CONCLUSION: In the group of complaints there was a higher percentage with no assessed medical error, and a lower percentage with inconclusive assessments of medical errors, among female physicians compared to their male colleagues. We found no other physician factors that were associated with assessed medical errors. Future research should focus on the underlying elements of these findings.Key pointsMedical errors are among the leading causes of death and they are essentially avoidable. Primary care emergency units are a vulnerable arena for committing medical errors.By assessing the medical records of a group of physicians who had evoked a complaint, no differences related to physician factors were revealed in the incidence of medical errors.In the group of female physicians, the proportion of no-errors, was higher, and the percentage of inconclusive medical records was lower than for their male colleagues.The Norwegian regulations on independent participation in PCEUs may have modulated these results.

Physician factors associated with increased risk for complaints in primary care emergency services: a case - control study.

BACKGROUND: Patient safety incidents defined as any unintended or unexpected incident that could have or were judged to have led to patient harm, are reported as relatively common. In this study patient complaints have been used as an indicator to uncover the occurrence of patient safety incidents in primary care emergency units (PCEUs) in Norway. METHODS: Ten PCEUs in major cities and rural parts of Norway participated. These units cover one third of the Norwegian population. A case-control design was applied. The case was the physician that evoked a complaint. The controls were three randomly chosen physicians from the same PCEU as the physician having evoked the complaint. The following variables regarding the physicians were chosen: gender, citizenship at, and years after authorization as physician, and specialty in general practice. The magnitude of patient contact was defined as the workload at the PCEU. The physicians' characteristics and workload were extracted from the medical records from the fourteen-day period prior to the consultation that elicited the complaint. The rest of the variables were then obtained from the Norwegian physician position register. Logistic regression was used to estimate odds ratio for complaints both unadjusted and adjusted for the independent variables. The data were analyzed using SPSS (Version25) and STATA. RESULTS: A total of 78 cases and 217 controls were included during 18 months (September 1st 2015 till March 1st 2017). The risk of evoking a complaint was significantly higher for physicians without specialty in general practice, and lower for those with medium low and medium high workload compared to physicians with no duty during the fourteen-day period prior to the index consultation. The limited strength of the study did not make it possible to assess any correlation between workload and the other variables (physician's gender, seniority and citizenship at time of authorization). CONCLUSIONS: Continuous medical training and achieving the specialty in general practice were decisively associated with a reduced risk for complaints in primary care emergency services. Future research should focus on elements promoting quality of care such as continuing education, duty rosters and other structural and organizational factors.

Fractures diagnosed in primary care - a five-year retrospective observational study from a Norwegian rural municipality with a ski resort.

Objective: The aim of this study was to characterize fractures recorded at a Norwegian primary care centre near a ski resort.Design: A retrospective five-year observational study in the period 2010-2014.Setting: A primary care centre equipped with an x-ray machine and located near a ski resort in a small rural municipality of 931 inhabitants in Norway. The X-ray images are digitalized and instantly transferred for assessment of a radiologist and/or an orthopedic surgeon both before and after treatment.Subjects: All patients with radiologically confirmed fractures.Results: A total of 1154 X-ray examinations were done, out of which 480 (41.6%) were fractures verified by a radiologist. The most frequent fractures were in the wrist (30%), collarbone (15%), shin (11%), humerus (9%) and ankle (8%). 316 (66%) of the fractures were in males and of these 225 were in age group 10-19 years. Males dominated among fractures in collarbone (92% males), finger (80% males), and foot (85% males). Women with fractures of the wrist, ankle, humerus and metacarpal bones, had a higher median age than men with similar fractures. Nonsurgical treatment with cast or braces was initially offered in 371 (77%) of the fracture-cases at the primary care level.Conclusion: Young men acquired most of the fractures, predominantly in the wrist, and mostly during the winter sport season. Nearly eight of ten fractures were treated locally in primary care centre.Key pointsA large seasonal variation was found in number of patients with fractures.More than 60% had fractures in the wrist, collarbone, shin or ankle.More than half of the patients with a fracture were males and below 20 years old.Most fractures were ski-related.

[Sterile or non-sterile gloves in minor surgical procedures in general practice]. / Sterile eller rene hansker ved småkirurgi i allmennpraksis.

BACKGROUND: Minor surgical procedures are regularly performed in general practice. The practice with regard to routine use of sterile or non-sterile gloves varies. The purpose of this article was to review the scientific basis for choice and recommendation in this area. MATERIAL AND METHOD: A search was conducted in PubMed, Cochrane, Medline and Embase for clinical studies in English which had investigated the use of sterile or non-sterile gloves and the prevalence of wound infection related to minor surgery. This applied primarily to general practice, including accident and emergency departments, but also encompassed other fields of medicine. The reference lists for the relevant articles were also scrutinised. RESULTS: Three randomised prospective studies from general practice were found. These showed no difference in frequency of infection. Two of the studies were of moderately good quality. A further five randomised prospective studies and four observational studies were also found, which had examined the association between the use of sterile or non-sterile gloves and infection related to minor surgery. Common to all of these was that they came from fields of medicine other than general practice, namely dermatology and odontology. No difference was found in the majority of these (six out of nine). However, the scientific quality was low or very low. INTERPRETATION: The research data on the use of sterile or non-sterile gloves in minor surgery in general practice and the consequences for wound infection are very limited. No clear difference in infection frequency was demonstrated.

Infections in traumatic wounds sutured at a Norwegian Accident and Emergency Department.

BACKGROUND: Different countries have different wound treatment traditions. We have studied the incidence and different factors related to infections in wound injuries sutured at a Norwegian A&E department. METHOD: In this prospective study, clinical data were collected on 102 patients with traumatic wound injuries treated with sutures at Bergen Accident and Emergency Department between 30 February 2011 and 30 June 2011. Any wound infections in 97 of these patients at the time of suture removal were assessed and classified according to severity on a scale of grade 0 to grade 4. RESULTS: There were no serious infections, but mild clinical wound infections occurred in 15% of patients: 11% grade 1 and 4% grade 2 infections. Patients less than 65 years old had often cut themselves with knives (n = 33, 37%), and on their hands (n = 60, 67%), Men were most frequently injured at work (n = 38, 54%) and women most often at home (n = 18, 56%). No statistically significant correlation was found between the incidence of wound infections and the length of the wound, the time elapsed before suturing, the wound's location on the body, contamination or underlying chronic diseases. Two of the three self-inflictors in our study had clinical wound infections. Half of the bacteriological samples from ten of 15 wounds with clinical infection had plentiful growth of Staphylococcus aureus. One patient received oral antibiotic treatment for wound infection, and two had local antibiotic treatment. INTERPRETATION: Mild clinical infections were found in almost one of six wounds sutured at a Norwegian A&E department. More studies are necessary to provide basic data to enable targeted improvements in wound treatment in the primary healthcare service.

Costs analysis and comparison of usefulness of acute MRI and 2 weeks of cast immobilization for clinically suspected scaphoid fractures.

BACKGROUND AND PURPOSE: Fractures of the scaphoid are often not detected on initial plain radiographs. Conventional management of clinically suspected scaphoid fractures is cast immobilization for 2 weeks and then reassessment. Early MRI is a diagnostic alternative. We compared the cost and usefulness of the early MRI diagnostic strategy with that of conventional management. PATIENTS AND METHODS: This prospective pseudo-randomized study included patients between 18 and 49 years of age who attended Bergen Accident and Emergency Department, Bergen, Norway during 1 year in 2009-2010, after sustaining an acute wrist trauma in the previous week and with a clinically suspected scaphoid fracture. 61 patients were investigated with acute MRI, while 63 patients received standard treatment as a control group. We used cost-minimization analysis to estimate the cost of the 2 patient groups. RESULTS: Concerning cost, there were no statistically significant differences in the total direct medical costs or in indirect costs between the groups. Concerning usefulness, patients in the MRI group without a fracture (n = 35) used a cast for fewer days (mean 1 day) than patients in the control group with no fractures (n = 52) (mean 14 days; p < 0.001). They had less than half the number of days on sick leave than patients in the control group (mean 7 days vs. 15 days; p = 0.002). INTERPRETATION: In a Norwegian setting, an early MRI was of value in patients with clinically suspected scaphoid fracture and normal plain radiographs.

[Should traumatic wounds be closed within eight hours?]. / Bør traumatiske hudsår lukkes innen åtte timer?

BACKGROUND: It has been common practice in general medicine to refrain from primary closure of traumatic wounds that are more than six to eight hours old. It was thought that the primary closure of wounds later than this substantially increases the risk of infection. This time limit has its origin in old animal studies, and it is only in more recent decades that clinical studies have been conducted on unselected patients in general practice. The purpose of this article was to examine the scientific basis for this time limit. METHOD: A search was made in PubMed for clinical studies conducted on unselected patients with acute traumatic wounds treated with closure in general practice, including in accident and emergency departments, plus the time from the injury to primary closure versus the risk of infection. RESULTS: The search yielded five clinical studies. These did not find that wounds must be closed within six to eight hours in order to avoid a greater risk of infection. They were all prospective observational studies from accident and emergency departments. The studies were heterogeneous, and all of them were of low research quality. INTERPRETATION: More recent clinical research does not define an absolute time limit of six to eight hours during which traumatic wounds can be closed without an increased risk of infection. Many wounds can presumably be closed later than this with no greater risk of infection. Good research-based guidelines will not be available until the results from robust randomised controlled studies have been published.

Clinical scaphoid score (CSS) to identify scaphoid fracture with MRI in patients with normal x-ray after a wrist trauma.

INTRODUCTION: The aim of this study was to compare a combination of three commonly used tests to identify scaphoid fractures with MRI in patients with normal x-ray after a wrist trauma. PATIENTS AND METHODS: This prospective MRI study included patients between 18 years and 49 years, who attended the Emergency Department, Bergen, Norway after sustaining an acute wrist trauma within the previous week. Initial x-rays of the wrist were normal. MRI was done within a median of 1 day after the trauma. The study period lasted 1 year. The patients were examined with three commonly used clinical scaphoid tests; tenderness in the anatomical snuffbox with the wrist in ulnar deviation (3 points), tenderness over the scaphoid tubercle (2 points) and pain upon longitudinal compression of the thumb (1 point). The clinical scaphoid score (CSS) is a sum of these points, which was compared with MRI verified fracture of the scaphoid. RESULTS: We included 154 patients with wrist sprain and normal x-rays; 13 had occult scaphoid fracture. A CSS of 4 or more was the only statistically significant 'cut-off' value to identify occult scaphoid fractures (p<0.05). Diagnostic sensitivity increased with more experienced Emergency Department doctors. CONCLUSIONS: If a patient with wrist pain after injury and normal x-ray has a CSS≥4 (pain in the anatomical snuffbox in addition to pain at scaphoid tubercle or longitudinal compression or both) we recommend MRI. A CSS <4 has a negative predictive value of 96%, which makes scaphoid fracture unlikely.

[Out-of-hours medical services for retirement and nursing homes]. / Legevakt for alders- og sykehjemmene.

BACKGROUND: Effectivization of the Norwegian out-of-hours primary care medical services has probably rendered the services less available to residents in nursing homes in many places. In Bergen, an out-of-hours medical service especially dedicated to residents in retirement and nursing homes and people with special needs living at home, was established in March 2006. We wanted to assess this medical service after its first year of activity. MATERIAL AND METHODS: Data were prospectively recorded on when the services were used and characteristics of the users . Information about the institutions was also recorded. RESULTS: 926 patients used the services during the first year; more than half of them received sick calls. Pneumonias and urinary tract infections were the most common diagnoses. A high level of doctor staffing at the nursing homes did not lead to decreased use. Neither the total number of beds nor the number of short - time beds in the nursing homes had a significant influence on the use of this service. INTERPRETATION: This targeted out-of-hours service was used less than expected during its first year. The nursing homes' use of this service is determined by factors other than the number of beds and doctor staffing.

[The Giardia epidemic in 2004 and out-of-hours service in Bergen]. / Giardiaepidemien i 2004 og Bergen Legevakt.

BACKGROUND: From October to December 2004, 1,300 individuals were infected with Giardia lamblia in Bergen, Norway. The aim of this study was to explore this epidemic from the perspective of an accident and emergency department in Bergen. MATERIAL AND METHODS: Patient files from 2004 were searched retrospectively in Bergen accident and emergency department, for patients with a diagnosis of infectious gastroenteritis or with the word Giardia: in the laboratory section of their files. Information from the files where Giardia tests had been done, was collected and analysed. RESULTS: A total of 1,603 patients with infectious gastroenteritis were found. The number of patients with gastroenteritis more than doubled six weeks before the Giardia epidemic was recognized. 420 patients had been tested for Giardia, and 200 of them had positive tests. Most of the patients with positive Giardia tests were in their twenties. Symptoms and findings of the gastroenteritis patients with positive Giardia tests were unspecific and not very alarming. INTERPRETATION: The Giardia epidemic probably started six weeks before it was recognized as such. Giardia infection is difficult to recognize on clinical grounds alone.

Gender and physical violence.

This study examines incidents of physical violence in relation to the sex of both assault victim and attacker. A survey of all assault victims attending an urban accident and emergency department (AED) in Norway during a 2-year period was carried out. All the assault victims were interviewed using a structured questionnaire administered by the attending physician as part of the initial consultation at the AED. During this interview, information about the victims, the attackers and the assaults was collected from the victims. Information on the sex, age, alcohol state of victims, and any referral to hospitals and specialists, was collected from the victim's medical notes at the AED. The severity of the victim's injuries was rated retrospectively using Abbreviated Injury Scale (AIS) and Shepherd's Injury Severity Scale for rating of injuries of assault. A total of 1234 men (74%) were attacked by other men, 354 women (21%) were attacked by men, 33 men (2%) by women, and 59 women (4%) by other women. The characteristics of the assaults carried out amongst female victim-female attacker and male victim-male attacker groups had many similarities. The same was found for the female victim-male attacker and male victim-female attacker groups. We conclude that changes in the traditional behaviour associated with women and men in relation to physical violence may be taking place.

[The new list patient system and emergency service in Bergen]. / Fastlegeordningen og legevakt i Bergen.

BACKGROUND: The purpose of this study was to explore the attitudes of patients seeking emergency care, with special emphasis on the role of the recently introduced list patient system. MATERIAL AND METHOD: During a twelve-day period in January 2003, patients seeking emergency care in Bergen, Norway were asked to fill in a questionnaire that explored whether they knew the name of the physician on whose list they were, their assessment of the accessibility of this physician, whether they had tried to contact him or her prior to coming in for emergency care, why they had contacted emergency care, and if they were willing to wait one or several days for a consultation if they were certain to get an appointment with their own physician. RESULTS: 1504 questionnaires were analyzed (72% of the study population). Most patients knew the name of their physician (84%) and were reasonably satisfied with his or her accessibility. Nevertheless, three in four patients had not tried to contact their physician prior to coming in to the emergency centre. Half of them were willing to wait until the next day to see their personal physician. INTERPRETATION: There is a considerable potential for change of patient behaviour in primary care emergencies.

Violence in an urban community from the perspective of an accident and emergency department: a two-year prospective study.

BACKGROUND: Information about violence in a given community is usually based on crime statistics. The aim of this study was to explore violence in an urban community from the perspective of an accident and emergency department. MATERIAL/METHODS: All assault victims treated at the Bergen Accident and Emergency Department (AED) during a two-year period (1994-1996) were prospectively registered, and data were collected about the patients and the assault incidents. To assess the proportion of unrecognized assault victims treated at the AED, an anonymous questionnaire was sent to all adult patients (first-time consultations) who visited the AED during a ten-day period in 1997. RESULTS: 1803 assault victims were registered, 433 of whom (24%) were females. Most of the victims were young men assaulted at public locations, under the influence of alcohol, often by unknown attackers, and frequently feeling that the attack was unprovoked (and thus defined as street violence). Few victims of child abuse or elder abuse were identified. About 40% of the females were victims of domestic violence. Non-Norwegians, unemployed, and people living in economically deprived areas of the community were over represented. A minority of the assault victims wanted to press legal charges. From the postal survey (n=1264, response rate 43%) few unrecognized victims of violence could be identified among our patients. CONCLUSIONS: An accident and emergency department registration of violence victims will mostly identify male victims of street violence.

Medical consequences of violence: a two-year prospective study from a primary care accident and emergency department in Norway.

OBJECTIVE: To assess the medical consequences of violence from the perspective of a primary care accident and emergency department. DESIGN: Prospective observational study. SETTING: Bergen Legevakt (AED). SUBJECTS: All assault victims treated at the AED 1994-96. MAIN OUTCOME MEASURES: Diagnoses, treatments, number of consultations at the AED, sickness certificates, rates of admittances to hospitals, referrals to specialists and injury severity ratings using Abbreviated Injury Scale (AIS) and Shepherd's injury severity scale. RESULTS: 1803 assault victims were registered, 433 (24%) females and 1370 (76%) males. Most injuries were of slight severity, corresponding to AIS 0 to 1 (82%) or Shepherd's scale 0 to 1 (74%). Bruises/contusions and cuts/lacerations dominated. The majority of patients did not receive any specific treatment at the AED and they were not given sickness certificates, but 11% were admitted to hospitals and 30% were referred to specialists. Males were more likely to be seriously injured than females. CONCLUSION: Most physical injuries caused by violence and treated at a primary care accident and emergency department are minor.