Physician compliance with tetanus guidelines for admitted versus discharged patients.

Abstract: The Advisory Committee of Immunization Practice (ACIP) (1) has established guidelines for tetanus immunoprophylaxis for patients who present to the emergency department (ED) with wounds. We assessed physician compliance with these guidelines for admitted versus discharged patients. The data in this study comes from one institution involved in a recently published prospective observational study that was conducted at 5 university-affiliated hospitals. (2) Of 400 patients enrolled, 65/397 (16.3%) did not receive tetanus immunoprophylaxis in accordance with ACIP guidelines. Emergency physicians were less likely to adhere to the ACIP tetanus guidelines when admitting patients to the hospital. Of patients discharged, (89%), 292 of 325 were treated in accordance with ACIP guidelines compared with 39/71 (55%) of admitted patients (P < 0.001). Admitted patients were also more likely to sustain tetanus-prone wounds. Despite a propensity to present with tetanus-prone wounds, patients admitted to the hospital were less likely to receive tetanus immunoprophylaxis in accordance with ACIP guidelines.

Key Words: tetanus, immunization, compliance, wounds

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With the advent of tetanus toxoid and immunoglobulin, the incidence of tetanus has declined dramatically. In 1947, the first year of national surveillance, tetanus was reported in 460 people nationwide and carried a case-fatality rate of 91%; (3) recent surveillance shows an average of 44 cases per year with a five-fold decrease in case fatalities to 18%. (3) Beyond reducing the incidence of tetanus, adequate immunization decreases the severity of illness and curtails its ultimate death toll; (3) in fact there were no reported tetanus deaths between the years of 1998 and 2000 among adequately immunized individuals. (3) Just one third of tetanus victims seek emergency wound care for the precedent injury, and only 63% of these individuals ultimately receive adequate tetanus prophylaxis. (3) While this is a marked improvement from the 19% of tetanus victims who received appropriate wound care in 1987, (4) it suggests that some tetanus deaths are still preventable.

By virtue of routine access to individuals who may not otherwise receive medical attention, emergency departments have found themselves at the forefront of immunization efforts. Talan et al (2) demonstrated a 57% compliance rate with the Advisory Committee on Immunization Practices (ACIP) guidelines for tetanus immunization in academic emergency departments. The vast majority of deficiencies consisted of under immunization despite the wide availability of ACIP guidelines for appropriate tetanus wound prophylaxis.

Objective

The aim of this study was to determine if patient disposition affects emergency physician compliance with ACIP tetanus prophylaxis guidelines

Materials and Methods

Adult patients over the age of 18 who presented to a university-affiliated emergency department with soft tissue wounds between April 1999 and May of 2000 were enrolled. Our data is from one center in a multicenter, prospective observational "Care of Wounds Study" (COWS) whose findings were published elsewhere. (2) Excluded patients were those treated by the principal investigator, those unable to follow-up, and those previously enrolled. Patients with wounds older than two weeks, or who had received tetanus immunoglobulin (TIG) within the previous six months were also ineligible. Informed consent was obtained from each participant.

The treating professionals were blinded as to the nature of the study. A data collection sheet which contained information regarding wound descriptors, antibiotic administration, past medical history, wound care and patient disposition was completed by the clinician. No queries regarding previous tetanus immunization were contained within the initial data sheet; this information was obtained by investigators on follow-up surveys.

All patients underwent a follow-up interview between day five and seven. During this visit, information was recorded regarding previous patient immunization and emergency department administration of tetanus prophylaxis. Race, region of birth and educational level were recorded. All subjects were given appropriate tetanus immunoprophylaxis according to ACIP guidelines if it had not already been administered.

Investigators established tetanus-prone wounds according to the criteria set forth by the ACIP. (1) Appropriateness of emergency department care was determined using the wound descriptors obtained by the treating professional on day zero, and the historical data regarding previous patient immunization subsequently obtained by the investigators. ACIP guidelines as illustrated in Table 1 were then applied to determine if accurate care had in fact been administered.

Compliance data was summarized for patients that were not treated according to ACIP guidelines, and for those that were under immunized, and over immunized. The Institutional Review Board approved this study.

Results

Four hundred patients were enrolled in this study and 332 (83%) received care compliant with ACIP tetanus prophylaxis guidelines. Sixty-five of the 400 patients (16%) received care not in accordance with these guidelines (Table 2). For three (0.8%) of the patients, the management with respect to the ACIP guidelines was unknown.

Among the 65 patients who did not receive treatment in accordance with ACIP guidelines, 87.7% (57/65) were under immunized and 12.3% (8/65) were over immunized (Table 3).

Of all participants, 165/400 (41.3%) had tetanus-prone wounds. Tetanus-prone wounds were most often a result of infection (79 patients; 47.9%), followed by non-needle related puncture wounds (21 patients; 12.7%), burn/frostbite (16 patients; 9.7%), avulsion (15 patients; 9.1%), laceration involving fascia/tendon (14 patients; 8.5%), crush injury (8 patients; 4.9%), injection (needle-related) (6 patients; 3.6%), laceration involving joint/bone (5 patients; 3.0%), and ischemia (1 patient; 0.6%). Two hundred and thirty-five (58.7%) of the 400 patients evaluated had wounds that were characterized as nontetanus prone.

For the patients with "clean" wounds, 227/235 (97%) were treated according to guidelines, whereas only 108/165 (65%) of those with tetanus-prone wounds received appropriate immunoprophylaxis. Of the 165 patients with tetanus-prone wounds, 57 (34.5%) were under immunized, and no patients were over immunized. On the other hand, 8 of the 235 (3.4%) patients with clean wounds were over immunized with tetanus immunoprophylaxis, and none were under immunized.

Of all 400 patients, 328 were discharged and 71 were admitted. Disposition was unknown for one patient, and compliance was not determined for three discharged patients. A far greater percentage of admitted patients sustained tetanus-prone wounds when compared with those patients discharged: 56/71 (78.9%) of admitted patients sustained wounds characterized as tetanus prone compared with only 33.2% of discharged patients (109/328). Forty-five of 56 (80%) tetanus-prone wounds in admitted patients were a result of infection.

A discrepancy between the treatment of admitted and discharged patients was observed (Table 4). Despite the increased incidence of tetanus-prone wounds in admitted patients, these individuals were less likely to receive care in accordance with ACIP guidelines. Tetanus guidelines were successfully followed in 54.9% of admitted patients and (89%) of discharged patients (p < 0.001). Among admitted patients, all emergency physician noncompliance resulted from under immunization (Table 5).

Discussion

The 1998 to 2000 Morbidity and Mortality Weekly Report (MMWR) (3) surveillance reported no deaths among the 130 United States tetanus victims who were up to date on tetanus immunization. This suggests that proper implementation of ACIP tetanus immunoprophylaxis prevents tetanus deaths. (8) Our study re-examined the immunization practices of one medical center, and evaluated if treatment discrepancies between admitted and discharged patients exist.

We found that 16% of patients presenting to the ED were not treated according to ACIP guidelines with the majority of cases (87%) represented by under immunization practices (failure to administer dT or TIG prophylaxis). Talan et al (2) found an even higher incidence of noncompliance in their multicenter trial with a 35% noncompliance rate for all patients presenting with wounds, 58% of whom were under immunized. This is consistent with national data from MMWR indicating that 37% of tetanus victims who seek care for an injury are not appropriately administered dT. (3) There appears to be a trend toward under immunization when compared with a 1983 study (9) that showed a 23% compliance failure rate, and only a 6% under immunization rate (most noncompliance in this study resulted from over-aggressive dT administration).

Despite this tendency to err on the side of under immunization, rates of tetanus seroprotection among the community remain high and tetanus deaths stay on the decline. (3) Approximately 90% of the population possess adequate protection against tetanus. (2,10) Those more likely to have low titers in the US are immigrants from countries outside North America and Western Europe, the elderly, the inadequately immunized and the uneducated. (2)

It has been demonstrated previously that patients at increased risk of tetanus are more likely to be treated not according to guidelines. (2,9,11) Specifically, Talan et al (2) demonstrated that, of the 504 patients who presented with tetanus-prone wounds and inadequate immunization history, none received tetanus toxoid and immunoglobulin as indicated. (11) Our study supports this eyidence by demonstrating a 34% noncompliance rate on tetanus-prone wounds. (all of which were accounted for by under immunization). This contrasts with the 8% noncompliance rate we found for "clean wounds," entirely accounted for by an excess administration of dT. Although over immunization with dT is likely preferable to the potential toll of tetanus disease, it does lead to excess cost, and the potential for Arthus-type reactions and allergic phenomena. (9)

Reasons for physician noncompliance with ACIP guidelines are likely due to lack of familiarity of the guidelines, or failure to document the appropriate history. Studies have noted that up to 80% of physicians fail to document a primary immunization history. (2,11) Alternatively, caregivers may be reluctant to administer pooled human blood product given the low overall incidence of tetanus in the United States. despite the documented safety of TIG. (2) Comfort with TIG administration should be encouraged, particularly in light of the recently resolved dT shortage. (12)

Also of distinct importance is the disparity between compliance in admitted versus discharged patients. (55% versus 89%). Moreover, all physician noncompliance in the admitted patient subset resulted from under immunization compared with 76% of discharged patients. This disparity is more concerning in light of admitted patients' propensity for tetanus-prone wounds: 79% of the admitted patient pool suffered wounds characterized as tetanus prone (mostly as a result of infection) compared with only 33% of discharged patients. It is evidenced, once again, (2,9,11) that those patients most at risk of developing tetanus are least likely to receive aggressive prophylactic tetanus care by the emergency physician.

It is difficult to explain why such disparity exists between the treatment of admitted and discharged patients. Presumably, those patients admitted to the hospital suffer illnesses of higher acuity, which may detract from the caregiver's attention to preventive medicine. Alternatively, physicians may assume that the admitting service will administer appropriate wound care and prophylaxis. Although further study is needed to determine if admitting teams indeed adhere to ACIP tetanus guidelines when caring for patients with wounds, it is still of the utmost importance that ER physicians maintain consistency with respect to compliance with ACIP guidelines regardless of patient disposition.

There has been a 10-fold reduction in the incidence of tetanus and a five-fold reduction in case mortality within the United States over the last half century. (3) This success coincides with the advent of tetanus immunoprophylaxis and underscores its successful implementation. With heightened efforts to adhere to ACIP guidelines. we can further decrease the incidence of this preventable, potentially fatal, disease. Under immunized groups have previously been identified, including the elderly, diabetics, IV drug abusers, immigrants. and the undereducated. (2,3,10,13) Our study identifies patients admitted to the hospital with soft tissue wounds as another under immunized population for which vaccination efforts should be targeted.

Limitations

No comparison between the physician's report of previous immunization and the investigator's follow-up report was made. If this data were significantly inconsistent, determination of compliance with ACIP guidelines would be flawed.

Although blinding to the nature of the study was attempted, the principal investigator is known to the hospital community to be involved with tetanus research. This may have resulted in a higher than expected level of compliance at our university. This is evidenced by the 83% compliance (in discharged patients) versus the expected 63% according to national data. However, it should not have affected the difference between compliance in those admitted versus those discharged. In addition, the Hawthorne effect is known to improve outcomes in studies, but this also should not account for the difference between the groups.

Conclusions

Among patients presenting to the emergency department with wounds, those admitted to the hospital are more likely to have sustained injuries which are tetanus prone when compared with those patients who are discharged. Our study revealed that patients admitted to the hospital receive care less which is compliant with ACIP tetanus immunoprophylaxis guidelines than those who are discharged.

References

1. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991; 40 (RR-10): 1-28.

2. Talan DA, Abrahamian FM, Moran GJ. et al. Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med 2004;43:305-314.

3. Pascual FB, McGinley EL, Zanardi LR, et al. Tetanus surveillance: United States, 1998-2000. MMWR 2003; 52: 1-8.

4. Izurieta HS, Sutter RW, Strebel PM, et al. Tetanus surveillance: United States, 1991-1994. MMWR 1997; 46: 15-25.

5. Current trends tetanus: United States, 1987 and 1988. MMWR 1990; 39: 37-41.

6. Tetanus among injecting-drug users: California, 1997. MMWR 1998; 47:149-51.

7. Sangalli M, Chierchini P, Aylward RB, Forastiere F, Tetanus: a rare but preventable cause of mortality among drug users and the elderly. Eur J Epidemiol 1996:12:539-540.

8. Sanford JP. Tetanus: forgotten but not gone. N Engl J Med 1995;332: 812-813.

9. Brand DA, Acampora D, Gottlieb LD, et al. Adequacy of antitetanus prophylaxis in six hospital emergency rooms. N Engl J Med 1983;309:636-640.

10. Gergen PJ, McQuillian GM, Kiely M. et al. A population-based serologic survey of immunity to tetanus in the United States. N Engl J Med 1995;332:761-766.

11. Roper MH. Tetanus prophylaxis in the emergency department. Ann of Emergency Med 2004;43:315-317.

12. Centers for Disease Control and Prevention. Notice to readers: shortage of tetanus and diptheria toxoids. MMWR Morb Mort Wkly Rep 2000; 49:1029-1030.

13. Alagappan K, Rennie W, Kwiatkowski T, et al. Seroprevalence of tetanus antibody titers in adults over 65 years of age. Ann Emerg Med 1996;28:18-21.</p> <pre> It is often merely for an excuse that we say things are impossible. --Francois de La Rochefoucauld </pre> <p>Kumar Alagappan, MD, Gina Pulido, MS-4, Juliet Caldwell, MD, and Frederick M. Abrahamian, DO

From the Department of Emergency Medicine, North Shore, Long Island Jewish Health System, New Hyde Park, NY; Albert Einstein College of Medicine, Bronx, NY; and the Department of Emergency Medicine, Olive View, UCLA Medical Center, Los Angeles, CA.

Reprint requests to Kumar Alagappan, MD, Associate Chairman, Emergency Medicine, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY. Email:[e-mail]

Accepted October 26, 2005.

RELATED ARTICLE: Key Points

* Physician compliance with tetanus immunoprophylaxis guidelines in the emergency department (ED) appears to be influenced by patient disposition. Patients admitted to the hospital from the emergency department are less likely to get adequate tetanus immunization compared to patients who are discharged from the ED.

* Patients admitted to the hospital were more likely to have tetanus-prone wounds.

* Inadequate immunization occurred 44% of the time because tetanus immunoglobulin was not administered.

Table 1. Summary of recommendations for tetanus wound prophylaxis,
1991 (4)

History of tetanus        Clean, minor wounds  All other wounds (a)
immunization (doses)      Td (b)  TIG (c)      Td      TIG

Uncertain or less than 3  Yes     No           Yes     Yes
3 or more (d)             No (e)  No           No (f)  No

(a) Such as, but not confined to, puncture wounds; wounds contaminated
with feces, dirt, soil, saliva; avulsions; and wounds as a result of
missiles, crushing, burns, or frostbite.
(b) If person is [greater than or equal to] 7 years of age, adult type
tetanus-diphtheria toxoid (Td) is preferred to tetanus toxoid (TT)
alone. If the patient is < 7 years, DTP or DT (if pertussis vaceine is
contraindicated) is given.
(c) Tetanus Immune Globulin (Human).
(d) If only three doses of fluid tetanus toxoid have been received, a
fourth dose of toxoid, preferably an adsorbed toxoid, should be given.
(e) Yes, if more than 10 years since the last dose.
(f) Yes, if more than 5 years since the last dose. More frequent
boosters are not needed and can accentuate side effects.

Table 2. Physician Compliance with ACIP guidelines (a)

               N    %

Compliance     332  83.0
Noncompliance   65  16.3
Unknown          3   0.8
Total          400

Table 3. Types of noncompliance (a)

           Over immunized  Under immunized
Treatment  n  %            n   %

Td         7  10.8         32  49.2
TIG        1   1.5         15  23.1
Td/TIG     0  -            10  15.4
Totals     8  12.3         57  87.7

(a) Td, Diphtheria-tetanus toxoid; TIG, human tetanus immunoglobulin.

Table 4. Differences in treatment between admitted and discharged
patients

             Compliant  Noncompliant
Disposition  N    %     n   %

Discharged   292  89.0  33  10.1
Admitted      39  54.9  32  45.1
Unknown        1   0.3   0  -
Totals       332        65

Table 5. Types of noncompliance in admitted versus discharged
patients (a)

                                    Admitted  Discharged
Treatment                           n   %     n   %

Td
 Not administered                   15  46.9  17  51.5
 Inappropriately administered        0  -      7  21.2
TIG
 Not administered                   10  31.3   5  15.2
 Inappropriately administered        0  -      1   3.0
Td/TIG
 Not administered                    7  21.9   3   9.1
 Inappropriately administered        0  -      0   -
Total not administered              32  -     25   -
Total inappropriately administered   0  -      8   -
Total overall                       32        33

(a) Td, Diphtheria-tetanus toxoid; TIG, human tetanus immunoglobulin.