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Improving the Initial Evaluation of Hand Injuries
Joshua Mirrer, MD; John Stranix, MD; Vishal Thanik, MD
New York University, New York, NY

Introduction: Hand trauma is one of the commonest presentation to emergency departments. However, there is significant variability in the quality of examination and documentation. Due to the complexity of hand anatomy and function, a comprehensive examination is difficult. This is particularly true for those who do not perform exams regularly, and typically delays appropriate care.

Standardized checklists improve efficiency, enhance documentation, and minimize errors. However, there is no published literature regarding the utility of a standardized worksheet for the hand exam. To improve evaluation and documentation of injuries, we created a standardized worksheet. Our goal was to develop a resource that would enable clinicians of all levels of training to perform a complete examination of the injured hand and document in a standardized manner.
Methods: Prospective pilot study to evaluate the effectiveness of our clinical worksheet and establish educational validity. Surgical interns rotating on the hand surgery service completed a worksheet to guide examination and documentation. Residents were tested at the beginning and end of their rotation to evaluate hand exam knowledge and level of comfort performing a hand examination to measure the degree of improvement in clinical knowledge and comfort over time.

The control group of residents evaluated used a rudimentary worksheet with minimal information. The experimental group of residents were provided a comprehensive checklist. The pre- and post-rotation test scores and reported comfort levels were compared.
Results: Twenty-six residents were included in the pilot study, 16 in the control group and 10 in the experimental. Average number of incorrect answers in the control pre-test was 5.94 (±4.23) with a mean score of 78.0% (±15.7%), and for the post-test was 3.31 (±2.55) with a mean score of 87.7% (±9.4%). The control improved by an average of 2.62 correct questions and increased scores by 9.7% (p=0.042). Average correct answers for the experimental pre-test averaged 6.9 (±4.4) with a mean score of 70.2% (±16.3%), post-test incorrect answers averaged 2.1 (±1.9) with a mean of 92.2% (±7.8%). This group improved by 4.8 correct questions and increased scores by 22% (p=0.049). Comparison between control and experimental groups’ average scores did not demonstrate statistical significance (p=0.48). Resident’s general confidence in their ability to examine hand injuries improved regardless of worksheet or checklist utilized.
Conclusion: Checklists are an effective tool for improving efficiency. This pilot study demonstrates that a worksheet or standardized checklist can be helpful in an acute medical setting for evaluating hand injuries.

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