SLR - May 2014 - Wesley Drew Chapman
Reference: Shore B, Hutchinson S, Harris M, Bae D, Kalish L, Maxwell W, Waters P. Epidemiology and Prevention of Cast Saw Injuries. The Journal of Bone and Joint Surgery, 2014: 96:e31(1-8).
Scientific Literature Review
Reviewed By: Wesley Drew Chapman, DPM
Residency Program: Grant Medical Center Podiatric Surgery
Podiatric Relevance: Casting of patients for non-operative management of injuries or post-operatively for immobilization is very common practice in the podiatric community. When it is time for the cast to come off, an oscillating cast saw is the tool of choice in most instances. These saws are engineered to cut through hard cast material but not through padding or skin. Despite this design, they still pose an injury risk to patients including but not limited to: abrasions, lacerations, and burns.
Methods: A single institution with multiple care sites collected data from January 2010 through December 2012 on all casts removed or bivalved with an oscillating saw. Data collection points included: time, location (emergency department, operating room, inpatient unit, orthopedic clinic, or satellite clinic), level of patient consciousness, cast saw operator (resident, fellow, midlevel provider, attending physician, or ortho technician), casting and padding materials, cast dimensions, and any associated adverse events. They implemented educational training sessions which included a hands-on certification process for all persons who would be performing cast cuts. Biweekly equipment checks were also preformed of all cast saws used. This later progressed to daily checks by the end of the study.
Results: Over the three year study there were 29 cast-saw injuries in 23,615 casts cut, for an overall rate of 1.23 per 1000. There was a minor decrease in the number of injuries over the course of the study but it was not statistically significant. There was a statistically significant variation in rates of injury across locations with the emergency department being the highest 15 in 785 cuts (19.11 per 1000). There was also a diurnal pattern in injuries with significantly greater rate at night; 11 of 1293 (8.51 per 1000) vs. 15 of 19,419 (0.77 per 1000). All 15 injuries in the emergency department occurred at the hands of a resident and 11 of these happened at night. Seventy-six percent of the injuries (22 of 29) occurred in unconscious or uncooperative patients. Eight of the first 13 incidents in the emergency department occurred when the saw had been serviced more than four days prior. There were on two further incidents after a switch to daily saw checks. None of the cast saw injuries required further surgical treatment and no medico-legal actions were taken.
Conclusions: Cast saw injuries can and do happen. They are more likely to happen at night, on unconscious or uncooperative patients, and in the hands of residents. Although a dedicated quality improvement initiative was implemented to improve the education and skill of cast saw users, they were unable to show a statistically significant decrease in the number of injuries. There was a decrease in the number of injuries once daily maintenance of cast saws was performed but this was unable to be substantiated statistically. By properly training personnel and identifying situations with increased risk, (unconscious/uncooperative patient, in the emergency department, at night, with a resident, who has a dull saw), there is a possibility to reduce cast saw injuries to zero in the future.