Search

Highlights • Quality improvement requires a comprehensive integrated approach. • Clinical standards are a vital first step in improving outcomes for LMICs. • Capacity building needs a range of educational courses from basic to advanced. • Evaluation tools are needed to measure progress., Consistent evidence has emerged over many years that the mortality and morbidity outcomes for burn patients in low and middle-income countries (LMICs) lag behind those in more resource rich countries. Interburns is a charity that was set up with the aim of working to reduce the disparity in the number of cases of burns as well as the outcomes for patients in LMICs. This paper provides an overview of a cyclical framework for quality improvement in burn care for use in LMICs that has been developed using an iterative process over the last 10 years. Each phase of the process is outlined together with a description of the tools used to conduct a gap analysis within the service, which is then used to frame a programme of capacity enhancement. Recent externally reviewed projects have demonstrated sustained improvement with the use of this comprehensive and integrated approach over a three-year cycle. This overview paper will be supported by further publications that present these results in detail.

Background: A significant burn can severely impact the lives of survivors and their carers. This systematic review sought to incorporate the experiences of guilt, blame and shame across the lifespan for burn survivors, their families as well as the experiences of the parents of burned children.\ud Methods: A systematic review of qualitative studies on the experiences and perspectives of guilt, blame and shame by those affected by burn trauma across the lifespan. The databases, Pubmed, Scopus, EMBASE, CINAHL, PsychINFO were systematically searched. Authors independently rated the reporting of the qualitative studies included. Thematic synthesis was used to analyse the data. The search identified 230 papers. Eighteen research papers met the study inclusion criteria.\ud Results: Guilt and ruminations of guilt, blame attribution and shame and body image were identified during thematic analysis as pivotal factors across the lifespan for burn survivors, their families as well as the experiences of the parents of burn injured children. Accounts presented, suggest that the impact of burns on the lives of the survivor and family covers a diverse spectrum of impact; personal, cultural and societal.\ud Conclusion: From the findings of the literature searches and the post-burn experiences described in this review there is a gap in the psychological care for burn survivors and their caregivers. This is specifically relevant around issues of parental guilt and blame, ruminations of guilt and shame as well as body image. These findings may not be new to burns professionals but the key message is that management of these issues fall short of delivering comprehensive post trauma care. Identifying and highlighting the importance of residual psychosocial problems will ultimately influence positive outcomes for burn survivors

Background: Only a few papers are published on the safety and effectiveness of acute burn care in low-income countries. A cohort study was therefore carried out to determine such outcomes.Methods: The study was conducted in a rural Tanzanian hospital in 2017–2018. All patients admitted with burns were eligible. Complications were scored during admission as an indication for safety. Survivors of severe burn injuries were evaluated for time of reepithelialization, graft take, disability (WHODAS2.0) and quality of life (EQ5D-3L) up to 3 months post-injury, as an indication of effectiveness.Results: Patients presented on average at 5 days after injury (SD 11, median 1, IQR 0–4). Three patients died at admission. The remaining 79 were included in the cohort. Their median age was 3 years (IQR 2–9, range 0.5–49), mean TBSA burned 12% (SD10%) and mortality rate 11.4%. No surgery-related mortality or life-threatening complications were observed. Skin grafting was performed on 29 patients at a delayed stage (median 23 days, IQR 15–47). Complications of skin grafts included partial (25% of procedures) and complete graft necrosis (8% of procedures). The mean time to reepithelialization was 52 (SD 42) days after admission. Disability and quality of life improved from admission to 3 months after injury (pConclusion: In this resource-limited setting patients presented after a delay and with multiple complications. The mortality during the first two weeks after admission was high. Surgery was found to be safe and effective. A significant improvement in disability and quality of life was observed.

Education in burn care can be broken down into three main components: surgical education, inter-professional education, e.g. critical care education and mentorship. To date these components have been used in varying degrees in most health institutions and to even lesser extent in burn care. The aim of this paper is to highlight each component and how they have been utilised in other fields to develop teams and foster education, and how they can be translated for burn teams. These ideas are not novel; however, this paper will aim to shed light on how these concepts can be implemented in burn care, thus not only improving education, but also enabling recruitment and retention of health care providers in this field.

Implementation science is a useful tool to consider ways in which we can introduce improvements to burn services in low-and-middle income countries (LMICs), where the majority of the burden of burn injury is now experienced. This paper outlines the development of the Delivery Assessment Tool (DAT), a method for facilitating quality improvement in burn services in LMICs. We used a participatory approach that ensured that local clinicians and experts were fully involved in piloting the tool. The DAT is based on internationally agreed operational standards for burn care service delivery and has undergone an iterative process of improvement and refinement through an initial three-year project in Nepal and Bangladesh. The DAT, a 50-item tool organised into 10 subsections, is used to assess a service through a participatory focus group discussion (FGD) with a mixed, multidisciplinary team of staff working at the burn service, typically 6-10 participants. This usually lasts 2 to 3hours. The staff in the unit then select priority areas for quality improvement programmes that are within their control to achieve, which starts a cycle of audit and review. The final version of the tool was used in a further three-year project to evaluate 11 hospitals in Nepal and Bangladesh. Education and training are key components of this work; both were provided by Interburns as part of on-going support for the clinical teams. At the end of the project a >19% improvement in scores was demonstrated using the final version of the DAT in both Nepal and Bangladesh; this achievement is remarkable given the continued difficulties in service provision where patient numbers far outstrip the resources available to care for them. As a result of this work, we have made a digital version of the tool available free of charge.

The use of robust evidence is a key component of providing high quality care to patients. Synthesised evidence to support clinical decision-making is lacking for many aspects of clinical burn care. Identifying the most important areas of care that lack high quality evidence and requires research is necessary, as funding for primary research is limited. Priority setting research studies are a joint endeavour between patients, carers and clinicians to identify and rank topics for research in a healthcare area in order to reduce research waste. Such an exercise has yet to be undertaken in burns. The aim of this paper is to outline the importance of research prioritisation in burn care, to discuss how it facilitates the maximum benefit from limited research funding and to explain the methodologies used.

COVID-19 pandemic is sweeping the globe. Any outpatient or new inpatient especial in burn department during the pandemic should be as a potential infectious source of COVID-19. It is very important to manage the patients and wards carefully and correctly to prevent epidemic of the virus in burn centers. This paper provides some strategies regarding management of burn ward during the epidemic of COVID-19 or other respiratory infectious diseases.

Purpose The study objective was to test the utilization of a crosslinked, thiolated hyaluronic acid (CMHA-S) film for treating corneal chemical burns. Methods Burns 5.5 mm in diameter were created on 10 anesthetized, male New Zealand white rabbits by placing a 1N NaOH soaked circular filter paper onto the cornea for 30 s. Wounds were immediately rinsed with balanced salt solution (BSS). CMHA-S films were placed in the left inferior fornix of five injured and five uninjured animals. Five animals received no treatment. At 0 h, 48 h, 96 h, and on day 14 post chemical burn creation, eyes were evaluated by white light imaging, fluorescein staining, and optical coherence tomography (OCT). Corneal histology was performed using H&E and Masson's Trichrome stains. Results Image analysis indicated biocompatible CMHA-S treatment resulted in significant decreases in the areas of corneal opacity at 48 h, 96 h, and on day 14 postoperatively. A significant increase in re-epithelialization was seen 14 days post injury. CMHA-S treated corneas showed significantly less edema than untreated burns. No pathological differences were observed in corneal histological samples as a result of CMHA-S treatment. Conclusions CMHA-S films facilitate re-epithelialization and decrease the area of corneal opacity in our corneal alkali burn rabbit model.

Dear Professor Wolf, Re: “Mixed messages” — Ongoing confusion with hydrogel dressings in burn 1st aid. Commentary on the trial report from Holbert et al. 2018/19 which was a comment on the protocol paper entitled “Effectiveness of a hydrogel dressing as an analgesic adjunct to first aid for the treatment of acute paediatric thermal burn injuries: study protocol for a randomised controlled trial”

Introduction Current methods of assessing burn depth are limited and are primarily based on visual assessments by burn surgeons. This technique has been shown to have only 60% accuracy and a more accurate, simple, noninvasive method is needed to determine burn wound depth. Forward-looking infrared (FLIR) thermography is both noninvasive and user-friendly with the potential to rapidly assess burn depth. The purpose of this paper is to determine if early changes in burn temperature (first 3 days) can be a predictor of burn depth as assessed by vertical scarring 28 days after injury. Methods While under general anesthesia, 20 burns were created on the backs of two female Yorkshire swine using a 2.5cm×2.5cm×7.5cm, 150g aluminum bar, for a total of 40 burns. FLIR imaging was performed at both early (1, 2 and 3 days) and late (7, 10, 14, 17, 21, 24 and 28 days) time points. Burns were imaged from a height of 12 inches from the skin surface. FLIR ExaminIR © software was used to examine the infrared thermographs. One hundred temperature points from burn edge to edge across the center of the burn were collected for each burn at all time points and were exported as a comma-separated values (CSV) file. The CSV file was processed and analyzed using a MATLAB program. The temperature profiles through the center of the burns generated parabola-like curves. The lowest temperature (temperature minimum) and a line midway between the temperature minimum and ambient skin temperature at the burn edges was defined and the area of the curve calculated (the "temperature half-area"). Results Half-area values 2 days after burn had higher correlations with scar depth than did the minimum temperatures. However, burns that became warmer from 1 day to 2 days after injury had a lower scar depth then burns that became cooler and this trend was best predicted by temperature minima. When data were analyzed as a diagnostic test for sensitivity and specificity using >3mm scarring, i.e. a full-thickness burn, as a clinically relevant criterion standard, temperature minima at 2 days after burn was found to be the most sensitive and specific test. Conclusions FLIR imaging is a fast and simple tool that has been shown to predict burn wound outcome in a porcine vertical injury progression model. Data showed that more severe burn wounds get cooler between 1 and 2 days after burn. We found four analytic methods of FLIR images that were predictive of burn progression at 1 and 2 days after burn; however, temperature minima 2 days after burn appeared to be the best predictive test for injury progression to a full-thickness burn. Although these results must be validated in clinical studies, FLIR imaging has the potential to aid clinicians in assessing burn severity and thereby assisting in burn wound management.

Keloids and hypertrophic scars occur anywhere from 30 to 90% of patients, and are characterized by pathologically excessive dermal fibrosis and aberrant wound healing. Both entities have different clinical and histochemical characteristics, and unfortunately still represent a great challenge for clinicians due to lack of efficacious treatments. Current advances in molecular biology and genetics reveal new preventive and therapeutical options which represent a hope to manage this highly prevalent, chronic and disabling problem, with long-term beneficial outcomes and improvement of quality of life. While we wait for these translational clinical products to be marketed, however, it is imperative to know the basics of the currently existing wide array of strategies to deal with excessive scars: from the classical corticotherapy, to the most recent botulinum toxin and lasers. The main aim of this review paper is to offer a useful up-to-date guideline to prevent and treat keloids and hypertrophic scars.

It has been accepted for many years that the cost of care for the burn-injured patient is high. There is, however, little published data to show how "expensive" it is. At the Welsh Centre for burns we have undertaken a costing exercise in an attempt to define the true cost to the treatment of burns. Using our current cost base and activity, we established a cost per health related group (HRG) for burns and also prospectively calculated costs for three inpatients to determine whether HRG-based burn tariffs accurately represent these costs. The NHS is under increasing pressure to provide evidence to support budgetary requirements; we feel this paper offers a framework for burn care costing upon which calculations could be based.

a b s t r a c t Burn scars are frequently accompanied with sensory deficits often remaining present months or even years after injury. Clinimetric properties of assessment tools remain understudied within burn literature. Tactile sense of touch can be examined with the touch pressure threshold (TPT) method using the Semmes Weinstein monofilament test (SWMT). There is in recent research no consensus on the exact measurement procedure when using the SWMT. The aim of this paper was to determine the interrater and intrarater reliability of TPT within burn scars and healthy controls using the ‘ascending descending’ measurement procedure. We used the newly developed guidelines for reporting reliability and agreement studies (GRRAS) as a basis to report this reliability study. In total 36 individuals were tested; a healthy control group and a scar group. The interrater reliability was excellent in the scar group (ICC = 0.908/SEM = 0.21) and fair to good in the control group (ICC = 0.731/SEM = 0.12). In the scar group intrarater ICC value was excellent (ICC = 0.822/SEM = 0.33). Within the control group also an excellent intrarater reliability (ICC = 0.807/SEM = 0.27) was found. In conclusion this study shows that the SWMT with the ‘ascending descending’ measurement procedure is a feasible and reliable objective measure to evaluate TPT in (older) upper extremities burn scars as well as in healthy skin.

Presented in this paper are the surgical considerations in the management of 8 electrically injured patients, with special reference to the care for wrist damage associated with impaired blood flow, and the prospect for effective recovery. Sound surgical principles, such as early diagnosis and repair of artery damage, complete debridement of dead tissue, and effective wound closure, in conjunction with intensive general treatment and overall planning, are necessary for maximally rehabilitated limbs. The electrically injured seem to have benefited a great deal from the procedures outlined, with a lowered incidence of amputation and a better functional recovery.