Elsevier

Vaccine

Volume 26, Issues 29–30, 4 July 2008, Pages 3634-3639
Vaccine

Appropriate tetanus prophylaxis practices in patients attending Emergency Departments in Italy

https://doi.org/10.1016/j.vaccine.2008.04.072Get rights and content

Abstract

Objective

This study evaluated the physician compliance with tetanus prophylaxis and immunization practices for patients with wounds attending Emergency Departments (EDs) of four randomly selected non-academic acute care public hospitals in Italy.

Methods

All presenting patients (≥16 years) within randomly selected week periods were studied. Physician and nurse, who were not involved in care, interviewed each patient regarding: socio-demographics, wound characteristics, and tetanus immunization history; they also collected, through direct observation, data of the physician practices for tetanus prophylaxis and immunization.

Results

A total of 29.8% patients had a wound tetanus-prone and this was more frequently observed in those lower educated, who arrive at the ED with medical referral during daytime and in the weekday, whose injury occurred outdoor, who had not completed the primary vaccination series or has received a booster dose ≤10 years before, and for a wound in abdomen, pelvis, and lower extremity. Overall, 54% of the physicians recorded for each patient information about the characteristics of the wound and the tetanus immunization history and this was more frequently for those patients traumatized outdoor, injured less than 1 h before, when the wound was non-tetanus-prone, and less frequently when the wound site was head and neck. Only 1.5% of the physicians correctly adhere to guidelines on tetanus prophylaxis and immunization in wound management and this more frequently adopted for younger patients’ and when the physician recorded information about tetanus immunization history.

Conclusion

Health policies and programs should be aimed at improving the quality of health care.

Introduction

It is well know that tetanus is sporadic in several industrialized countries and the availability of a highly safe and effective childhood primary vaccination programs have made a major contribution in the drastic reduction in morbidity and deaths although an increasing proportion of cases occur among the elderly [1], [2], [3], [4]. Tetanus remains significantly prevalent in the developing countries and mortality is high particularly among the neonates [5]. Tetanus cases continue to occur almost exclusively among people who had never been or inadequately vaccinated with the three-shot primary series or whose immunization history is unknown or uncertain [4], [6]. In Italy, a total of 49 cases were notified in 2005 with an annual incidence of 0.84 per million population, the majority occur among people aged ≥65 years and 79.6% of all cases were in females [7]; while 19 deaths have been reported in the 2002 [8].

The sporadic cases in Western countries are mainly due to acute wounds, and primary and emergency care providers are key figures in the tetanus prophylaxis. It is common that patients with wounds typically attend accident and emergency facilities, so tetanus prophylaxis and immunization performed in this care setting is extremely important. Still, care in this setting is frequently misused and misunderstood and in particular many trauma patients often are routinely given tetanus immunoglobulin for any kind of wound, whereas the decision whether or not to give prophylaxis depends on the characteristics of the wound and on the evaluation of patient's immunization history.

Although data exist on physician behavior mainly in the United States [9], [10], [11], [12], [13], the examination of this topic has not been explored in other countries. Therefore, because information would be very useful, the present epidemiological survey was undertaken to evaluate the physician compliance with tetanus prophylaxis and immunization practices according to current recommendations for patients with wounds who present at hospital Emergency Departments (EDs) in Italy.

Section snippets

Material and methods

The data were collected between April 2006 and August 2007, within a random sample of 59 weeks including all 24 h of 3 randomly selected days per week, in four randomly selected EDs among the eight non-academic acute general public hospitals in the geographic area of Naples, Italy. The four hospitals have 190 beds with an annual volume of 390,000 ED visits; 158 beds with 50,000 visits; 150 beds with 74,000 visits; and 112 beds with 50,000 visits. The population eligible for inclusion in this

Results

In total, 750 patients were approached in the EDs during the study period and the total sample included 715 patients resulting in a global participation rate of 95.3%. The principal characteristics of the patients in the study are presented in Table 1. The mean age of respondents was 40 years, 71% were male, 25% reported more than 12 years of education, in more than half the injury occurred more than 1 h before and in a place closer to the ED. Domestic injury was the most common mechanism, the

Discussion

To the best of our knowledge, the current study is the first that investigates the physician compliance with tetanus prophylaxis and immunization practices according to the current recommendations for patients with wounds who attend EDs and its determinants on a representative population sample of adults in Italy.

Our study describes a profile of patients who attend an ED with a wound tetanus-prone according to the ACIP guidelines and multivariate logistic regression analysis indicates that

Acknowledgements

The authors gratefully acknowledge the staff of the EDs and the participant patients that made the study possible.

References (16)

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Preliminary results were presented at the X National Conference of the Italian Public Health Association, October 14–16, 2007, Pisa, Italy.

1

Members of the Collaborative Working Group are as follows: Andrea De Stefano (Hospital Santa Maria della Pietà, Nola, Naples), Michele Ferrara (Hospital Pellegrini, Naples), Roberto Russo (Hospital San Giovanni Bosco, Naples), and Maria Anna Stingone (Hospital Evangelico Villa Betania, Naples).

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