Best evidence statement (BESt) Use of irrigation solution, warm versus room temperature, for irrigation procedures in the emergency department and urgent care


Guideline Developer(s)

Cincinnati Children's Hospital Medical Center

Date Released

2012 May 21

Evidence Supporting the Recommendations

References Supporting the Recommendations

Ernst AA, Gershoff L, Miller P, Tilden E, Weiss SJ. Warmed versus room temperature saline for laceration irrigation: a randomized clinical trial. South Med J. 2003 May;96(5):436-9. PubMed
Ernst AA, Takakuwa KM, Letner C, Weiss SJ. Warmed versus room temperature saline solution for ear irrigation: a randomized clinical trial. Ann Emerg Med. 1999 Sep;34(3):347-50. PubMed
Ernst AA, Thomson T, Haynes M, Weiss SJ. Warmed versus room temperature saline solution for ocular irrigation: a randomized clinical trial. Ann Emerg Med. 1998 Dec;32(6):676-9. PubMed

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Audit Criteria/Indicators

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

In addition to providing the optimum wound healing environment use of warmed solution may improve comfort with the procedure and foster a positive patient/family experience.

Potential Harms

Warming methods will need to be monitored to maintain the solution between 32.2° and 37.8°C (equivalent to 90°-100°F).

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength Definition
It is strongly recommended that…
It is strongly recommended that… not…
There is consensus that benefits clearly outweigh risks and burdens (or vice versa for negative recommendations).
It is recommended that…
It is recommended that…not…
There is consensus that benefits are closely balanced with risks and burdens.
There is insufficient evidence and a lack of consensus to make a recommendation…

See the original guideline document for the dimensions used for judging the strength of the recommendation.

Qualifying Statements

Qualifying Statements

This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Methodology

Methods Used to Collect/Select the Evidence

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Search Strategy

Databases used: MEDLINE, CINAHL, Cochrane Library, National Guideline Clearinghouse

Keywords: warm saline, irrigation, comfort, laceration, experience, pediatrics

Limits: English only; 1995-present

Last search performed on March 29, 2012

Children's Hospital Association inquiry returned 2 responses and neither hospital warms solutions for irrigation.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5a or 5b General review, expert opinion, case report, consensus report, or guideline
5 Local consensus

†a = good quality study; b = lesser quality study

Methods Used to Analyze the Evidence

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

This Best Evidence Statement has been reviewed against quality criteria by 2 independent reviewers from the Cincinnati Children's Hospital Medical Center (CCHMC) Evidence Collaboration.

Identifying Information and Availability

Bibliographic Source(s)

Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Use of irrigation solution, warm versus room temperature, for irrigation procedures in the emergency department and urgent care. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2012 May 21. 6 p. [9 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

Cincinnati Children's Hospital Medical Center

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Team Leader: Diane Morris RNIII, Emergency Service staff nurse – Urgent Care

Support/Consultant: Carolyn Smith MSN, RN, Evidence-Based Practice Mentor – Center for Professional Excellence, Research & EBP

Financial Disclosures/Conflicts of Interest

No financial conflicts of interest were found.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Availability of Companion Documents

The following are available:

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

In addition, suggested process or outcome measures are available in the original guideline document.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on August 30, 2012.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of this Cincinnati Children's Hospital Medical Center (CCHMC) Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

  • Copies may be provided to anyone involved in the organization's process for developing and implementing evidence based care.
  • Hyperlinks to the CCHMC website may be placed on the organization's website.
  • The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents.
  • Copies may be provided to patients and the clinicians who manage their care.

Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.

Scope

Disease/Condition(s)

Simple laceration repairs, eye or ear irrigations requiring solution irrigation

Guideline Category

Treatment

Clinical Specialty

Emergency Medicine
Family Practice
Internal Medicine
Ophthalmology
Otolaryngology
Pediatrics

Intended Users

Advanced Practice Nurses
Nurses
Physician Assistants
Physicians

Guideline Objective(s)

To evaluate, among pediatric patients presenting to the Emergency Department or Urgent Care needing a simple procedure that requires irrigation, if using warm irrigation solution compared to using room temperature irrigation solution leads to increased comfort and improved patient experience

Target Population

Pediatric patients (0-21 years old) presenting to the Emergency Department or Urgent Care requiring solution irrigation for simple laceration repairs or eye or ear irrigations

Interventions and Practices Considered

Warm solution (32.2-37.8°C) before performing irrigation on ear or eye lacerations

Major Outcomes Considered
  • Comfort level
  • Patient experience

Recommendations

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a‒5b) are defined at the end of the "Major Recommendations" field.

It is recommended that solution be warmed to 32.2°-37.8°C (equivalent to 90°-100°F) before performing irrigation on lacerations, ears or eyes to improve patient comfort (Ernst et al., 2003 [2a]; Ernst et al., 1999 [2a]; Ernst et al.,1998 [2a]).

Definitions:

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5a or 5b General review, expert opinion, case report, consensus report, or guideline
5 Local consensus

†a = good quality study; b = lesser quality study

Table of Recommendation Strength

Strength Definition
It is strongly recommended that…
It is strongly recommended that… not…
There is consensus that benefits clearly outweigh risks and burdens (or vice versa for negative recommendations).
It is recommended that…
It is recommended that…not…
There is consensus that benefits are closely balanced with risks and burdens.
There is insufficient evidence and a lack of consensus to make a recommendation…

See the original guideline document for the dimensions used for judging the strength of the recommendation.

Clinical Algorithm(s)

None provided

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better

IOM Domain

Effectiveness

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