a b s t r a c t

Background: Laceration closure is one of the most common procedures performed in the emergency department (ED). While sutures and staples have been the traditional wound closure device, topical skin adhesives (TSA) were introduced in the United States 20 years ago as a non-invasive alternative for simple, low-tension wounds. We determined which closure devices were used to close ED lacerations and explored patient and provider char- acteristics associated with choosing TSA. We also tested the hypothesis that use of TSA would be associated with shorter ED length of stay than sutures/staples.

Methods: We extracted demographic and clinical data on all patients with a laceration from the publicly available website of the National Hospital Ambulatory Medical Care Survey for the years 2012-2015. This database is pro- vided by the National Center for Health Statistics of the CDC. Based on weighted sampling, national estimates are made for all ED visits in the US. We determined the association between patient characteristics (age, sex, insur- ance type, geographic location, laceration site, type of ED provider) and use of TSA. We also compared ED LOS be- tween patients whose wounds were closed with TSA or sutures/staples using the t-test and a linear regression model.

Results: There were an estimated 540 million ED patient visits, and 26.1 million patients (4.8%) had at least one laceration. Of the 15.4 million patients with a single laceration, 9.2 million were closed with either sutures/staples (7.2 million), TSA (1.5 million), or both (0.5 million). Mean (SE) age was 30 (1) years, 63% were male and 42% were under age 18 years. Lacerations were on the upper extremity (42%), face (30%), lower extremity (14%) and scalp (8%). Of patients with a single laceration closed with either TSA or sutures/staples, use of TSA did not differ by age, sex, year, geographic location or wound site. ED LOS was significantly shorter in patients whose wounds were closed with TSA (101 +- 7 vs. 136 +- 4 min; P b 0.001). After adjusting for potential confounding variables, use of TSA was associated with a 26 (95% CI 9-44) minute shorter ED LOS (P = 0.004) then sutures/ staples.

Conclusion: Topical skin adhesives are used in about 1 of 4 wound closures in the ED. Use of TSA did not differ based on demographic characteristics or wound site. Use of TSA is associated with a shorter ED LOS than su- tures/staples.

(C) 2019

Introduction

Traumatic lacerations are a common reason for patients to present to the emergency department (ED), accounting for approximately 8.2% of ED visits in the US annually [1]. Various wound closure techniques exist, including adhesive tape strips, sutures, staples, and topical skin adhesives (TSA). The chosen closure technique often depends on sev- eral variables, including wound characteristics and provider preference. Ideally, wound closure materials should be quick and easy to use, pro- vide adequate tensile strength, and should optimize cosmetic outcome while minimizing pain.

* Corresponding author at: Department of Emergency Medicine, HSC, Level 4, Room 050, Stony Brook University, Stony Brook, NY 11794, United States of America.

E-mail address: [email protected] (K. Otterness).

TSAs work by forming strong bonds between the approximated wound edges, which creates a protective barrier to hold the wound edges together and allow healing to occur. Among the most commonly used TSAs are the cyanoacrylate derivatives, which were developed in 1949 and approved by the Food and Drug Administration in 1998 [2]. Several randomized controlled trials have demonstrated sim- ilar cosmetic outcomes for wounds repaired with TSAs compared to those repaired via standard wound care (SWC) methods, including su- turing and stapling [3-10]. Furthermore, TSAs are quicker to apply [2,3,10], and are associated with less pain [2,8] compared to SWC methods. Another advantage is that they do not require a follow-up visit for removal, as the TSAs naturally slough off approximately 5-10 days post-wound closure.

Despite the advantages of TSAs, they are not optimal for every wound. They are most commonly used for low tension, uncompli- cated linear wounds. provider practice is variable when it comes to

https://doi.org/10.1016/j.ajem.2019.158365

0735-6757/(C) 2019

K. Otterness et al. / American Journal of Emergency Medicine 38 (2020) 1058-1061 1059

choosing a wound closure device. The objective of this study was to determine which closure devices were used for ED laceration repair, as well as patient and provider characteristics associated with the choice of closure device. We also tested the hypothesis that TSA use would be associated with a shorter ED length of stay compared to SWC methods.

Methods

Study design

This was a retrospective review which included all patients from 2012 to 2015 with lacerations from the website for the National Hospi- tal Ambulatory Medical Care Survey (NHAMCS). This publicly accessible website database is from the National Center for Health Statistics of the Centers for Disease Control (CDC). The survey collects data from hun- dreds of participating hospitals regarding the utilization and provision of services rendered. It then uses weighted sampling to estimate nation- wide ED statistics. Additional information can be found at the website: https://www.cdc.gov/nchs/nhcs/index.htm.

Patients and setting

Eligible patients were adult and pediatric patients presenting to the ED with an isolated traumatic laceration between 2012 and 2015, based off of International Classification of Diseases codes (ICD-9 codes 870-897).

Data source and collection

Demographic and clinical data extracted from the NHAMCS included patient age, sex, Insurance type, residence, geographic location, lacera- tion site, type of provider seen, and wound closure device. ED length of stay for each visit was also collected.

Study outcomes

The main outcomes of interest were the type of wound closure de- vice used and ED LOS.

Data analysis

Data are summarized as numbers and percentages for binary data and means with standard error (SE) for continuous data. Multivariate analysis was performed, and a t-test and linear regression model were used to compare ED LOS between patients whose wounds were closed with TSA or sutures/staples. The level of significance was set at a P value of b0.05.

Results

Of the estimated 540 million ED visits in the U.S. between 2012 and 2015, 26.1 million (4.8%) patients had at least one traumatic lac- eration. Of these 26.1 million patients, 15.4 million (59%) had an iso- lated diagnosis of an open wound. Of the 15.4 million patients with an isolated open wound, 9.2 million (59.7%) received either su- tures/staples or TSA for wound closure, with 7.2 million (78.2%) re- ceiving only sutures or staples, 1.5 million (16.3%) receiving only TSA, and 0.5 million (5.4%) receiving both. Subtracting out the 0.5 million who received both, the 8.7 million patients who received ei- ther sutures/staples or TSA are the patients who were included in the study.

The patient and provider characteristics are outlined in Table 1. 37% of the patients were male and 63% were female. Pediatric patients (under age 18) comprised 42% of the study patients, and the mean (SE) age was 30 (1) years. 84% of patients were evaluated by an ED

Table 1

Patient and provider demographic data.

N (millions) unless otherwise specified %

Sex

Male 3.2 37

Female 5.4 63

Age

Mean age (SE), years 30 (1)

Pediatric 3.6 42

Mean length of visit (SE), minutes 130 (4) Year of visit

2012 2.3 26

2013	2.2	26
2014	2.0	24
2015	2.1	25
Residence Private	8.3	98
Nursing home	0.1	1
Homeless	b0.1	0.1
Other	0.1	1
Insurance Private	3.3	42
Medicare	1.0	13
Medicaid	2.0	25
Workers Comp	0.3	4
Self-pay	1.1	14
No Charge	b0.1	0.3
Other	0.2	3
MSA area Provider seen	5.0	79
ED Attending	7.3	84
Resident	0.6	7
Consulting Physician	0.3	4
RN	8.2	95
NP	0.9	11
PA	1.5	17
Location of laceration(s) Face	2.6	30
Scalp	0.7	8
Trunk	0.6	7
Upper extremity	3.6	42
Lower extremity	1.2	14
Closure device Suture/Staple	7.2	78.2
Adhesive	1.5	16.3
Both	0.5	5.4

attending physician, 7% by a resident, 4% by a consulting physician, and 28% by a PA or NP. The most common location for the lacerations was the upper extremity (42%), followed by the face (30%), then lower extremity (14%), scalp (8%) and trunk (7%).

As seen in Table 2, the use of TSA did not vary by sex, age (pediatric versus adult), year of visit, geographic region, or wound site. Although not statistically significant, patients who came from nursing homes had the highest percentage of TSA use (27%) compared to patients com- ing from other locations, and patients coming from private homes had the lowest percentage of TSA use (17%). The use of TSA versus su- tures/staples did seem to vary depending on insurance type, with those patients who were privately insured, workers compensation, or self-pay having the lowest TSA use (16%, 12%, and 10% respectively).

TSAs were used infrequently in patients who were seen by residents (6%) and consulting physicians (7%). Although not statistically signifi- cant, lacerations of the trunk (26%), upper extremity (19%), and head (17%) were repaired with TSA more often than lacerations of the scalp (7%) or lower extremity (14%). The mean length of visit was shorter for those repaired with TSA compared to sutures/staples (101 +- 7 min versus 136 +- 4 min, respectively).

After adjusting for potential confounding variables, use of TSA was associated with a 26 (95% CI 9-44) minute shorter ED LOS (P = 0.004) than sutures/staples (Table 3). Patients seen by a PA had an 18- min shorter ED LOS (P b 0.02). In contrast, patients seen by a specialist, and MSA region were associated with longer ED LOS.

1060 K. Otterness et al. / American Journal of Emergency Medicine 38 (2020) 1058-1061

Table 2

Comparison of suture/staples versus TSA.

Suture/staple		Adhesive	P
Gender % Male	84	16	0.30
% Female	81	19
Mean age (SE), years	38 (1)	31 (2)	0.09
Age group			0.85
% Pediatric	83	17
% Adult	83	17

Mean length of visit (SE), minutes 136 (4) 101 (7) b0.001 Year of visit 0.63

2012	83	17
2013	84	16
2014	85	15
2015 Residence	80	20	0.65
Private home	83	17
Nursing home	73	27
Homeless	82	18
Other	80	20

Insurance 0.01

Private 84 16

Medicare 76 24

Medicaid 78 22

Workers comp 88 12

Self-pay 90 10

No charge 50 50

Other 80 20

Metropolitan area 0.99

MSA area 83 17

Non-MSA area 83 17

Providers seen

ED attending 84 16 0.44

No ED attending 80 20

Resident 93 6 0.02

82 93	18 7	0.03 need to use sutures to justify their consultation and professional fees.
83	17	However, the reason for this difference remains uncertain.

No resident Consulting physician

No consulting physician RN

83	17	0.63
81	19
85	15	0.57
83	17

No RN NP

No NP

ED length of stay in patients whose lacerations were closed with TSA vs sutures or staples. Patients with lacerations repaired using TSA had a 26-min shorter ED LOS compared to those receiving sutures or staples. If this finding is corroborated in future prospective studies, it could have a significant impact on ED flow and throughput, since traumatic lacera- tions are a common presenting complaint in the ED.

In our study, TSAs were used in approximately 1 in 4 ED laceration repairs, with slightly varying (yet not statistically significant) rates of use compared to sutures/staples depending on the location of the lacer- ation. We found a trend toward scalp lacerations being closed less often with TSA (7%) compared to lacerations in other locations. Traditionally, scalp lacerations are repaired with either sutures or staples. However, newer data suggests that closure using the hair apposition technique with TSA is a cost-effective option [11]. As this technique was found to be quicker and less painful, with high patient acceptance rates, fewer complications and similar or superior wound healing compared to su- turing for scalp lacerations [12], we may see a trend toward increased use of TSAs to close scalp lacerations in the future, although further studies are needed.

Although it did not reach statistical significance, we found a trend to- ward use of TSAs in patients presenting from nursing homes compared to patients presenting from other types of living situations. The reason for this is uncertain, however one could theorize that this trend may be due to the fact that elderly patients with fragile skin often sustain skin tears which are not amenable to suturing or stapling, but can be repaired adequately with TSAs with or without adhesive strips.

We also found that TSAs were used less frequently when the patient was seen by a resident or a consulting physician. Perhaps the reasoning behind the consulting physician data is that, if a consultant is being re- quested, the wounds may be more technically complex and not amena- ble to closure with TSAs. It is also possible that consultants feel that they

Our multivariate analysis found that use of TSAs were associated with a 26-min shorter ED LOS, whereas patients seen by consulting phy- sicians, and patients in a metropolitan statistical area (MSA) were asso-

PA 82	18	0.72 ciated with longer ED LOS (+46 min and +31 min, respectively).
No PA 83	17	Consulting physicians are often commuting to the hospital from home,
Laceration location		0.08 which could account for the longer ED LOS. Also, the fact that the patient

must be evaluated by more than one practitioner when a consult is placed will inherently add time to the LOS. The fact that LOS is greater in metropolitan areas is not surprising since compared with suburban and rural EDs they may suffer from more crowding and limited resources.

Head	83	17
Scalp	93	7
Trunk	74	26
Upper extremity	81	19
Lower extremity	86	14

Discussion

Whereas previous studies have found that use of TSAs leads to faster procedure times, our study is unique in that it demonstrated a shorter

Table 3

Multivariate model for length of ED visit (effects are in minutes).

Parameter Effect^a P

PA seen 0.02

-18

No Reference

Consulting physician seen b0.001

Yes +46

No Reference

MSA region b0.001

MSA region +31

Non-MSA region Reference

Closure method 0.004

Suture/staple Reference

Adhesive -26

^a Change in ED LOS per 1 min of waiting time.

Study limitations

Our study has several limitations. Due to the retrospective design of the study, we cannot rule out the presence of confounding variables which could potentially threaten validity. Such confounding variables may include laceration length, depth and complexity as well as patient preferences. The NHAMCS database does not include procedure codes and the ICD-9 codes do not distinguish laceration size or depth, which is why we could not include this information in our study. Also, our data were extracted from a survey of participating hospitals, which may not be generalizable when applied to different patient populations. Furthermore, the NHAMCS database utilizes weighted sampling based off of survey results from participating hospitals in order to estimate the nationwide statistics, which potentially confounds our study. Sev- eral of the p values calculated from our data did not reach a level of sta- tistical significance, which is another limitation. Lastly, although some data suggests improved wound closure strength when adhesive strips are added to TSAs [13], the NHAMCS database does not code for adhe- sive strips and thus, the use of adhesive strips could not be evaluated in our study.

K. Otterness et al. / American Journal of Emergency Medicine 38 (2020) 1058-1061 1061

Conclusions

Topical skin adhesives are used in about 1 of 4 wound closures in the ED. Use of TSA did not differ based on demographic characteristics or wound site. Use of TSA is associated with a shorter ED LOS than su- tures/staples.

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