EVALUATION OF HAND INJURY MANAGEMENT AT THE EMERGENCY DEPARTMENT - ARE WE GETTING BETTER? PROCENA LEČENJA POVREDA ŠAKE U URGENTNOM CENTRU - DA LI NAPREDUJEMO?

Introduction. Hand injuries are one of the most common injuries seen in emergency departments. Inadequate treatment can lead to prolonged healing, complications, significant morbidity and serious disability. The aim of this study was to evaluate epidemiology, risk factors and treatment of hand injuries in one tertiary care level clinical center in order to be able to suggest targeted strategies for better management of injuries. Methods. This study was designed as a descriptive retrospective epidemiological study that involved all patients with hand injuries that were treated in Clinical center of Vojvodina in a seven year period. Authors collected sociodemographic and clinical data such as age, gender, mechanism of injury, type of injury, days of hospitalization, type of defect reconstruction, time of injury, timing of surgery and reasons for operative treatment delay. For every hospitalized patient modified hand injury severity score (MHISS) was calculated. All data was analyzed using SPSS IBM 21.0 software. Results. There were 34796 patients from 2012. to 2018. treated for hand injury at the Clinical Center of Vojvodina, with 554 (1,6%) being hospitalized. Mean age of patients was 43.2, majority (87.55%) were men and most of them were injured at home (47,2%). Most injuries occurred during knife handling. Average length of stay for hospitalized patients was 4 days. MHISS score for most patients was over 50 and was classified as severe. Waiting time for operation was observed to get shorter throughout selected years. Conclusion . Hand injuries present a complex problem that can be sometimes underestimated by patients. Requirement of highly specialized hand surgeons, sometimes special equipment (e.g. microscope), multiple operations, prolonged rehabilitation, possible invalidity and high cost of treatment calls for careful evaluation of problem and development of proper strategies in order to be able to lower the costs and obtain better medical care for all people with higher injury risk.

Hand injuries are one of the most common injuries seen in emergency departments (ED). As almost every human activity involves hands they are the most exposed part of   The aim of this study was to get a closer insight in treatment of hand injuries at the Clinical Center of Vojvodina, a tertiary care level center, and to present epidemiological data of hand injuries in previous years in order to analyze potential risk factors that could lead to injury. Another aim was to evaluate medical treatment strategies that patient received upon ED admission so that targeted strategies for prevention, risk management and better medical treatment can be suggested. Creating public health initiatives based on national injury registry could allow professionals to target current problems and thus better allocate limited resources.

Methods
This study was designed as a descriptive retrospective epidemiological study that   Figure   3. shows distribution of patients according to place of injury.

Fig. 3-Distribution of patients according to place of injury
Injuries that occurred as work-occupational hand injuries (77; 13.9%) were also independently analyzed. Mean age of patient injured while working was 40,92 (SD±15,03) years. Trend of incidence of such injuries is shown in Figure 4. Percentage % year
Most of the patients required to wear safety gloves at work according to safety standards did wear protective gloves during injury (40/61, 65.57%).
Most injuries occurred while handling sharp items such as knife blade. Distribution of mechanisms of hand injuries/tools is shown in Figure 5.

Fig. 5-Distribution of injury mechanisms/tools
Average length of stay in hospital after hand injury in hospitalized group of patients was 4.07 days. Figure 6. presents length of stay for various mechanisms/tools of injury.   Average time from injury to arrival to the Clinical Center of Vojvodina was 2,5 hours. This was data obtained from patients recalling time of injury so it has to be taken with caution.
Most often as a reason for the delay of arrival to the Clinical Center of Vojvodina patients reported: initial referral to secondary level hospital, waiting for transportation, underestimating the need for surgical treatment, being injured far away from referral center. As reasons for delay of surgical treatment after arrival to the ED two group related causes were identified: patient related (consumption of alcohol, prior food intake, arrival after midnight, comorbidities, need for additional diagnostic procedures, associated injuries that required delay of surgical treatment) and hospital related (occupancy of OR or surgeon). Yearly distribution of cause related delay by groups is shown in Figure 9.  Reason for patient related operative treatment delay such as alcohol abuse, as one of preventable factors, had special attention paid to. It was present in 11% of entire cluster and 40% of patients who abused alcohol had arrived after midnight. Figure 11. shows daily quartered distribution of patients who abused alcohol upon admission.

Discussion
Hand injuries often present multilevel impact on society in general. Costs of medical treatment, rehabilitation, absence from work, health insurance reimbursements and costs of prequalification are just some of the problems that have to be taken in consideration.
Our study reveals that just 1,6% of all patients who suffered hand injury that were referred to ED, required hospitalization. One must acknowledge that this does not mean that injuries that were managed under local or regional anesthesia in outpatient department didn't result in invalidity or produce considerable final costs. In our study we focused on patients whose injuries required hospitalization. All of them according to MHISS score were classified as severe (MHISS> 50) or moderate (MHISS 21-50) as represented in presented results that are similar to ours where most of injured were males with females being dominant just in group of assault victims who were older than 65 5 . They also found that 1 out of every 55 Dutch and 1 out of every 28 Danish people presented to ED with hand injuries, thus confirming importance of adequate management and good primary surgical treatment of these injuries. In our study, men were dominant in all age groups. In group of patients older than 65, women presented just 9,2% of entire cluster.
It is also interesting to analyze occupational hand injuries presented in different studies. Occupational acute hand injuries were responsible for 13.9% of all hand injuries in our sample of patients. Usually, in the region of Vojvodina, most severe injuries were hand or finger conquassation, which occurred in agricultural industry while working with heavy machinery such as corn snappers or harvesters (Figure 1 and 2). Those injuries are characterized by "T triad" as in: excess TIME until treatment, TRESH/wound contamination and big TRAUMA and often require more operative procedures, have more complications and longer hospitalization in general 8,9 . In this study, patients injured by agricultural machinery had the longest hospitalization of average 11.9 days, which is significantly longer that average 4 days for all injury mechanisms in general.
As this survey reveals, men are often injured while working at home with circular saw and table saw as part of their DIY activity (Figure 3). Women are also more likely to suffer injury at home, but usually suffer minor cuts, small burns and lacerations that can be treated without hospital admission. Working during off hours is also category presented as a place/circumstance of injury (15.7%). As seen in previous studies, illegal or off-license work often puts workers in position to work without proper protection, in unsafe conditions, with prolonged working hours, without adequate training and education for that particular job. All of these factors are known to facilitate injuries.
Wide palette of reconstructive procedures (skin graft, local flaps, direct sutures, amputations) is being done in order to adequately treat hand injuries. Most of the hospitalized patients had good skin coverage that didn't require skin grafts or skin flaps in order to close the wound, but despite that had to be hospitalized as complex reconstructions of tendons, nerves and bone fractures are usually done in general anesthesia.
Golden standard/window for wound closure is within 6 hours from the moment injury. This means that best results and lowest risk of infection can be expected if primary wound care is being done in above-mentioned time-window. In practice, it is very difficult to arrange all the necessary stages of treatment in such a short period of time, especially if large area of one medical center is the referral hospital for vast area of region. There are many factors that contribute to operative treatment delay. In our study patients needed an average of 2,5 hours just to arrive to ED. This data is uncertain as patients were recalling time of injury and sometimes were not sure about it. Average waiting time in ED for operative treatment in these seven years was 6 hours and 39 minutes, but this time is getting significantly shorter throughout years which suggest that changes that made in organizational structure have been giving good results. Shorter time from admission to definite treatment and thus improved medical care was achieved by better organization of triage system, employment of more specialists in ED, implementation of new information system that covers all patient steps through ED service, and for sure by continuous struggle to continuously educate doctors and nurses. In 2018., last year analyzed, time to definite treatment was around 5 hours which is considered very good compared with more developed countries. This is common problem seen in all ED worldwide. ED setting is specific and complex. Numerous attempts have been made to improve ED care services in the world 10,11,12 . Reviewing literature addressing this issue authors came across many models that have been proposed in different ED settings: various systems of patient grouping (Emergency severity index triage system-ESI, tree-level triage evaluation system, etc.), "fast track" models, senior doctor assessment at triage instead of nurse triage model, are just being some of the possible solutions to a problem in which one may achieve better results within available resources 10 needed, blood transfusion is administered. This means that patient is under constant medical supervision. As it was already underlined, loss of time before surgery is a big problem in cases such as injuries in agriculture, which are unfortunately often most violent ones, as injured patient is somewhere in the field, far from nearest local ambulance, usually alone. It takes more for them to reach the hospital and medical help than for people working near regional health center or being at home. Besides direct costs of medical treatment and time of work absence one has to keep in mind that permanent disability often requires prequalification or even early retirement, so that these injuries may impose significant burden for society as presented in de Putters et al. study 16