A tough laceration. It's too splayed open for steri-strips or glue, but too small to justify sedation for suturing. What would you do? This 3 year old presented to our ED with a a tough laceration. It’s too splayed open for steri-strips or glue, but too small to justify sedation for suturing. What would you do?

When it comes to lac repairs, a lot of people believe that the only thing that the patient (or parent of the patient, in this case) cares about is the end result, eg what the lac looks like after it’s been repaired. This is certainly part of the story, but the truth is that there is more to good wound repair than just this.  While most patients obviously come to you because they want to minimize scarring, there are certainly patients who are visiting you for all sorts of wound care misconceptions. We’ve all seen patients who ask for sutures because “they don’t want the wound to get infected,” and could care less about the scar on the back of their shin.  And when it comes to children, remember, the first time the kids feels pain or fear, that therapeutic alliance is out the window–and you have doubled your work. What I am getting at here is that half the battle in a laceration repair ED visit is good customer service and patient education. There are even studies to back this up.

This interesting study addressed the question, “what do parents want out of of an ED visit when they take their kid in for a laceration repair?” It was a cross sectional observational study performed at Children’s Hospital Boston at Harvard.  Boston Children’s is an academic tertiary care children’s ED, which, as you can imagine, is a referral center for some complex lacerations. The authors included patients younger than 18 yrs who had lac repairs, including those performed under procedural sedation and by plastic surgeons; it was convenience-based enrollment of English & Spanish speaking parents; and they performed a subgroup analysis of the 0-4 yr age group, where parent stress is (anecdotally) the highest. They performed a logistic regression analysis of data they collected on an ED exit survey to parents to determine those factors most predictive of parent satisfaction.

Notably, this was a study looking at factors predicting immediate parent satisfaction with their children’s ER visit; not long term cosmetic outcomes, which is the way previous studies looking at parent satisfaction for laceration repair have traditionally been designed. The study was survey-based, with a response rate of 75%; most of the lacerations were facial, repaired with sutures, and repaired by Attending Emergency Physicians.

Their analysis revealed these 3 factors with significant Odds Ratios of a parent giving the highest rating of “Excellent” for their child’s ED visit:

  1. Provider performance (OR 11.6, CI 6.2-21.6)
  2. Cosmetic appearance (OR 2.71, CI 1.7-4.2)
  3. Anxiety & pain (OR 1.35, CI 0.9-1.9)

What is interesting is that provider performance far trumps cosmetic outcome AND anxiety and pain experienced by the child in terms of the odds ratios of a parent rating the ED visit/procedure as excellent. Before learning of this study, I would have incorrectly assumed that cosmetic appearance trumps all. I would have thought alleviating anxiety & pain would have ranked higher; but I guess that parents actually assume there will be some discomfort associated with their child’s visit. Obviously these things are important, but there is so much more to a good visit, as this study shows.

Ah, what actually goes in to “provider performance?,” you ask.  I’ll spare you the statistical modeling which led to the decision-making, but “provider performance” is actually a composite variable based on a group of variables in their logistic regression analysis, which include:

  1. Explanation given before procedure
  2. Caring attitude of physician/nurse
  3. Communication
  4. Hygiene
  5. Confidence (specifically exhibited by the physician)

What’s also interesting is that they had enough enrolled patients to perform a subgroup analysis of the 0-4 yr age group, which they believed to be the most sensitive age group. What they found here was that an additional predictor emerges: the caring & kindness of the physician and nurse, underscoring the importance of this factor.

The take home point here: there is so much more that goes in to a good lac repair visit, from start to finish, than the procedure itself. We know that the truth is that most of the lacs we take care of (especially in kids) are going to have a great cosmetic outcome–so maybe its’s these elements of provider performance that we really want to focus on.

Jimmy at work An incredible example of “provider performance.” The physician creates a therapeutic alliance with the child by allowing him to lay in mother’s arms as he injects anesthesia. Note also the iPhone hypnotism and the nurse holding his hand for comfort.

Jimmy at work

 The appearance of the wound after painless and sedation-less application of simple interrupted sutures.