The correlation between intra-operative 2D- and 3D fluoroscopy with postoperative CT-scans in the treatment of calcaneal fractures.

OBJECTIVES: The aim of this study was to determine the correlation of the intra-operative fluoroscopic 2D- and 3D-images compared with a postoperative CT-scan, in terms of quality of reduction and fixation of calcaneal fractures. METHODS: Patients requiring open reduction and internal fixation (ORIF) of a calcaneal fracture were recruited as part of the EF3X-trial. During surgery, intra-operative images of fluoroscopic 2D- and 3D-imaging were obtained to assess the quality of the reduction and implant position. All patients received a postoperative CT-scan within one week. The operating surgeon evaluated intra-operatively both 2D- and 3D-images according to a 23-item scoring protocol on a 3-point Likert scale. A scoring panel, consisting of three clinical experts, evaluated all images in a blinded and independent fashion. Intraclass correlation coefficients (ICC) with their 95% confidence intervals (CI) were calculated using a two-way-random model with absolute agreement. RESULTS: A total of 102 calcaneal fractures were included. Agreement of 3D-imaging for the quality of reduction was better than 2D-imaging, although still fair, but for fixation moderate to good. Agreement between the 2D-images and the CT-scans was poor to fair. Intra-operative 2D-imaging received the highest ratings for image quality and interpretability, followed by CT-scanning. CONCLUSION: Implant position can be evaluated satisfactory with the aid of intra-operative 3D imaging. Although intra-operative 3D imaging had a better agreement with postoperative CT-scanning than 2D-imaging, there is a need to improve image quality and suppress scattering from implants to improve the additional value of intra-operative 3D imaging in calcaneal fracture reduction and fixation.

Hospital referral of detainees during police custody in Amsterdam, The Netherlands.

This study describes how many detainees have been referred to emergency departments for further evaluation or emergency care while in police custody in Amsterdam (years 2012/2013). It provides insights into the diagnoses assigned by forensic doctors and hospital specialists and the appropriateness of the referrals. We made use of the electronic registration system of the Forensic Medicine Department of the Public Health Service Amsterdam. This department is in charge of the medical care for detainees in the Amsterdam region. Hospital diagnoses were obtained through collaboration with several Amsterdam-based hospitals. According to our results, in 1.5% of all consultations performed, the detainee was referred to hospital. The most frequent reasons for referral were injuries (66%), intoxication/withdrawal (11%) and cardiac problems (7%). In 18% of all referrals, hospital admission (defined as at least one night in the hospital) was the consequence. After review of hospital files, the indication for referral as stated by the forensic physician was confirmed in 77% of all cases. A minority of referrals was considered unnecessary (7%). The identified cases allow for a discussion of cases of over-referral. Future research should focus on the problem of under-referral and associated health risks.

Indications for total-body computed tomography in blunt trauma patients: a systematic review.

PURPOSE: Total-body CT scanning (TBCT) could improve the initial in-hospital evaluation of severe trauma patients. Indications for TBCT, however, differ between trauma centers, so more insight in how to select patients that could benefit from TBCT is required. The aim of this review was to give an overview of currently used indications for total-body CT in trauma patients and to describe mortality and Injury Severity Scores of patient groups selected for TBCT. METHODS: A systematic review was performed by searching MEDLINE and Embase databases. Studies evaluating or describing criteria for selection of patients with potentially severe injuries for TBCT during initial trauma care were included. Also, studies comparing total-body CT during the initial assessment of injured patients with conventional imaging and selective CT in specific patient groups were included. RESULTS: Thirty eligible studies were identified. Three studies evaluated indications for TBCT in trauma with divergent methods. Combinations of compromised vital parameters, severe trauma mechanisms and clinical suspicion on severe injuries are often used indications; however, clinical judgement is used as well. Studies describing TBCT indications selected patients in different ways and were difficult to compare regarding mortality and injury severity. CONCLUSIONS: Indications for TBCT in trauma show a wide variety in structure and cut-off values for vital parameters and trauma mechanism dimensions. Consensus on indications for TBCT in trauma is lacking.

High rates of clinically relevant incidental findings by total-body CT scanning in trauma patients; results of the REACT-2 trial.

OBJECTIVES: To determine whether there is a difference in frequency and clinical relevance of incidental findings detected by total-body computed tomography scanning (TBCT) compared to those by the standard work-up (STWU) with selective computed tomography (CT) scanning. METHODS: Trauma patients from five trauma centres were randomized between April 2011 and January 2014 to TBCT imaging or STWU consisting of conventional imaging with selective CT scanning. Incidental findings were divided into three categories: 1) major finding, may cause mortality; 2) moderate finding, may cause morbidity; and 3) minor finding, hardly relevant. Generalized estimating equations were applied to assess differences in incidental findings. RESULTS: In total, 1083 patients were enrolled, of which 541 patients (49.9 %) were randomized for TBCT and 542 patients (50.1 %) for STWU. Major findings were detected in 23 patients (4.3 %) in the TBCT group compared to 9 patients (1.7 %) in the STWU group (adjusted rate ratio 2.851; 95%CI 1.337-6.077; p < 0.007). Findings of moderate relevance were detected in 120 patients (22.2 %) in the TBCT group compared to 86 patients (15.9 %) in the STWU group (adjusted rate ratio 1.421; 95%CI 1.088-1.854; p < 0.010). CONCLUSIONS: Compared to selective CT scanning, more patients with clinically relevant incidental findings can be expected by TBCT scanning. KEY POINTS: • Total-body CT scanning in trauma results in 1.5 times more incidental findings. • Evaluation by TBCT in trauma results in more patients with incidental findings. • In every category of clinical relevance, TBCT detects more incidental findings.

Feedback learning and behavior problems after pediatric traumatic brain injury.

BACKGROUND: Feedback learning is essential for behavioral development. We investigated feedback learning in relation to behavior problems after pediatric traumatic brain injury (TBI). METHOD: Children aged 6-13 years diagnosed with TBI (n = 112; 1.7 years post-injury) were compared with children with traumatic control (TC) injury (n = 52). TBI severity was defined as mild TBI without risk factors for complicated TBI (mildRF- TBI, n = 24), mild TBI with ⩾1 risk factor for complicated TBI (mildRF+ TBI, n = 51) and moderate/severe TBI (n = 37). The Probabilistic Learning Test was used to measure feedback learning, assessing the effects of inconsistent feedback on learning and generalization of learning from the learning context to novel contexts. The relation between feedback learning and behavioral functioning rated by parents and teachers was explored. RESULTS: No evidence was found for an effect of TBI on learning from inconsistent feedback, while the moderate/severe TBI group showed impaired generalization of learning from the learning context to novel contexts (p = 0.03, d = -0.51). Furthermore, the mildRF+ TBI and moderate/severe TBI groups had higher parent and teacher ratings of internalizing problems (p's ⩽ 0.04, d's ⩾ 0.47) than the TC group, while the moderate/severe TBI group also had higher parent ratings of externalizing problems (p = 0.006, d = 0.58). Importantly, poorer generalization of learning predicted higher parent ratings of externalizing problems in children with TBI (p = 0.03, ß = -0.21) and had diagnostic utility for the identification of children with TBI and clinically significant externalizing behavior problems (area under the curve = 0.77, p = 0.001). CONCLUSIONS: Moderate/severe pediatric TBI has a negative impact on generalization of learning, which may contribute to post-injury externalizing problems.

High Rates of Postoperative Wound Infection Following Elective Implant Removal.

INTRODUCTION: Metal implants placed during fracture surgery are often removed for various reasons (i.e. pain, prominent material, patients request). The removal of implants is considered a 'clean' procedure and as low risk surgery. The incidence of wound infections following implant removal has received little attention in the literature. The aim of the current study was to assess the incidence and risk factors of postoperative wound infections (POWIs) following implant removal. MATERIAL AND METHODS: All consecutive adult patients in a Level 1 and Level 2 Trauma Center who had their implants removed during a 6.5 years period were included. Exclusion criteria were removal of implants because of an ongoing infection or fistula and removal followed by placement of new implants. Primary outcome measure was a POWI as defined by the US Centers for Disease Control and Prevention. Patient characteristics and peri-operative characteristics were collected from the medical charts. RESULTS: A total of 452 patients were included (512 procedures). The overall POWI rate was 11.6% (10% superficial, 1.6% deep). A total of 403 procedures (78.7%) comprised of implant removal below the knee joint with a 12.2% POWI rate. A POWI following initial fracture treatment was associated with a higher rate of POWI following implant removal (p=0.012). A POWI occurred more often in younger patients (median age 36 versus 43 years; p=0.004). CONCLUSION: The overall incidence of postoperative wound infection was 11.6% with 10% superficial and 1.6% of deep infections in patients with elective implant removal. A risk factor for POWI following implant removal was a previous wound infection.

Complete medial column dislocation at the cuneonavicular joint: an unusual Lisfranc-like injury.

Lisfranc injuries represent a wide spectrum of different injuries at the tarsometatarsal joint. Not all types fit the currently available classifications. This case illustrates a rare subtype of a Lisfranc injury, with a dislocation of the entire first ray. It is presented to create more awareness for midfoot injuries. This article reviews the literature and provides recommendations for the treatment of similar cases in the future.

Time to intervention in patients with splenic injury in a Dutch level 1 trauma centre.

BACKGROUND: Timely intervention in patients with splenic injury is essential, since delay to treatment is associated with an increased risk of mortality. Transcatheter Arterial Embolisation (TAE) is increasingly used as an adjunct to non-operative management. The aim of this study was to report time intervals between admission to the trauma room and start of intervention (TAE or splenic surgery) in patients with splenic injury. METHODS: Consecutive patients with splenic injury aged ≥ 16 years admitted between January 2006 and January 2012 were included. Data were reported according to haemodynamic status (stable versus unstable). In haemodynamically (HD) unstable patients, transfusion requirement, intervention-related complications and the need for a re-intervention were compared between the TAE and splenic surgery group. RESULTS: The cohort consisted of 96 adults of whom 16 were HD unstable on admission. In HD stable patients, median time to intervention was 105 (IQR 77-188) min: 117 (IQR 78-233) min for TAE compared to 95 (IQR 69-188) for splenic surgery (p=0.58). In HD unstable patients, median time to intervention was 58 (IQR 41-99) min: 46 (IQR 27-107) min for TAE compared to 64 (IQR 45-80) min for splenic surgery (p=0.76). The median number of transfused packed red blood cells was 8 (3-22) in HD unstable patients treated with TAE versus 24 (9-55) in the surgery group (p=0.09). No intervention-related complications occurred in the TAE group and one in the splenic surgery group (p=0.88). Two spleen related re-interventions were performed in the TAE group versus 3 in the splenic surgery group (p=0.73). CONCLUSIONS: Time to intervention did not differ significantly between HD unstable patients treated with TAE and patients treated with splenic surgery. Although no difference was observed with regard to intervention-related complications and the need for a re-intervention, a trend towards lower transfusion requirement was observed in patients treated with TAE compared to patients treated with splenic surgery. We conclude that if 24/7 interventional radiology facilities are available, TAE is not associated with time loss compared to splenic surgery, even in HD unstable patients.

Evaluation of reduction and fixation of calcaneal fractures: a Delphi consensus.

BACKGROUND: Postoperative radiological assessment of the quality of reduction and fixation of calcaneal fractures is essential when evaluating treatment success. However, a universally accepted radiological evaluation protocol is currently unavailable. The aim of this study was to obtain an expert-based consensus on the most important criteria for the radiological assessment of the quality of reduction and fixation of calcaneal fractures. METHODS: The Delphi method, consisting of three rounds, was used to obtain consensus. Each round focused on four main topics of calcaneal fracture evaluation: imaging technique (38 items), anatomical landmarks (21 items), fracture reduction (16 items) and position of the fixation material (9 items). We invited ten radiologists and 44 surgeons from the USA and Europe (all calcaneus experts) to complete online questionnaires. They were asked which aspects require evaluation to determine the quality of fracture reduction and fixation. Agreement was expressed as the percentage of respondents with identical answers. Consensus was defined as an agreement of at least 80 %. RESULTS: All experts were invited for the three Delphi rounds and 16, 18, and 15 specialists responded per round, respectively. Agreement was reached for 23/38 (60 %) items regarding imaging techniques, 20/21 (95 %) anatomical landmarks, 13/16 (81 %) items regarding fracture reduction and 8/9 items (89 %) regarding fracture fixation. CONCLUSION: This Delphi consensus shows that more aspects require evaluation than currently used in radiological evaluation protocols. With this consensus, we provide the basis for a universal evaluation protocol to assess the radiological outcome of calcaneal fracture treatment.

A Dutch regional trauma registry: quality check of the registered data.

BACKGROUND: Quality indicators have become increasingly important in the healthcare sector. Data from a trauma registry (TR) should be accurate and reliable as they are used to describe and evaluate (the quality of) trauma care. OBJECTIVE: To investigate the reliability of injury coding, injury severity scoring and survival status in a regional TR. The feasibility of the format that was developed for this study was also investigated. METHODS: A random sample, without replacement, was taken from the TR of a Dutch regional trauma care network. All 343 patients in the sample were then recoded by another trauma registrar (rater). Reliability was expressed in the percentage agreement between the raters. RESULTS: In the total study sample of 333 patients, the reliability of the number of Abbreviated Injury Scale (AIS) codes was substantial (intraclass correlation coefficient (ICC)=0.70); and the reliability of the Injury Severity Score (ISS) (ICC=0.84) and survival status were 'almost perfect' (Cohen's κ=0.82). Both raters had given 129 patients one AIS code. The reliability of the body region of the AIS was 'almost perfect' (Cohen's κ=0.91); and the reliability of the severity of the injury and the ISS were 'almost perfect' (weighted κ=0.88 and ICC=0.90). The reliability of the ISS in the patients who were assigned at least two AIS codes (n=128) was 'almost perfect' (ICC=0.86). The reliability of the number of AIS codes and the number of body regions was 'moderate' (ICC=0.56 and Cohen's κ=0.52). CONCLUSIONS: The reliability of injury coding in a regional trauma registry was 'substantial' and the reliability of the ISS and survival status was 'almost perfect'. The format and design of this study were feasible and could be used to investigate the quality of (trauma) registries.

Locking Compression Plates are more difficult to remove than conventional non-locking plates.

PURPOSE: Locking Compression Plates (LCPs) have been introduced in the last decade. Clinicians have the impression that hardware removal of LCPs are more difficult and associated with more complications than conventional (non-locking) plates. Therefore, this study compares the complication rates of Locking Compression Plate (LCP) removal and conventional non-locking plate removal. PATIENTS AND METHODS: Patients who underwent open reduction and internal fixation and subsequent hardware removal at the Department of Trauma Surgery at our Level 1 Trauma Centre between 1993 and 2007 were included through the hospital's information system. The primary outcome measure was the occurrence of complications during implant removal. RESULTS: A total of 210 patients were included. The females were significantly older than the males [median age, 51.5 vs. 42.6 years (p < 0.001)]. The median operation time of LCP removal was significantly longer than the operation time of non-locking plate removal (72 vs. 54 min, p < 0.001). In the total study population, complications during implant removal occurred in 25 patients (11.9%). The complication rate of conventional non-locking plate removal was 2.5%. The complication rate of LCP removal was significantly higher (17.7%, p = 0.001). CONCLUSION: LCP removal is associated with significantly more complications than conventional non-locking plate removal. The indication for removal of locking compression should be made cautiously, and surgical instruments for LCP removal should be optimized.

Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients.

BACKGROUND: The aim of this review was to assess the value of immediate total-body computed tomography (CT) during the primary survey of injured patients compared with conventional radiographic imaging supplemented with selective CT. METHODS: A systematic search of the literature was performed in MEDLINE, Embase, Web of Science and Cochrane Library databases. Reports were eligible if they contained original data comparing immediate total-body CT with conventional imaging supplemented with selective CT in injured patients. The main outcomes of interest were overall mortality and time in the emergency room (ER). RESULTS: Four studies were included describing a total of 5470 patients; one study provided 4621 patients (84.5 per cent). All four studies were non-randomized cohort studies with retrospective data collection. Mortality was reported in three studies. Absolute mortality rates differed substantially between studies, but within studies mortality rates were comparable between immediate total-body CT and conventional imaging strategies (pooled odds ratio 0.91, 95 per cent confidence interval 0.79 to 1.05). Time in the ER was described in three studies, and in two was significantly shorter in patients who underwent immediate total-body CT: 70 versus 104 min (P = 0.025) and 47 versus 82 min (P < 0.001) respectively. CONCLUSION: This review showed differences in time in the ER in favour of immediate total-body CT during the primary trauma survey compared with conventional radiographic imaging supplemented with selective CT. There were no differences in mortality. The substantial reduction in time in the ER is a promising feature of immediate total-body CT but well designed and larger randomized studies are needed to see how this will translate into clinical outcomes.

Preventability of trauma deaths in a Dutch Level-1 trauma centre.

BACKGROUND: Monitoring the quality of trauma care is frequently done by analysing the preventability of trauma deaths and errors during trauma care. In the Academic Medical Center trauma deaths are discussed during a monthly Morbidity and Mortality meeting. In this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a Dutch Level-1 trauma centre for (potential) preventability. METHODS: All patients who died during or after presentation in the trauma resuscitation room in a 2-year period were eligible for review. All information on trauma evaluation and management was summarised by an independent research fellow. An external multidisciplinary panel individually evaluated the cases for preventability of death. Potential errors or mismanagements during the admission were classified for type, phase and domain. Overall agreement on (potential) preventability was compared between the external panel and the internal M&M consensus. RESULTS: Of the 62 evaluated trauma deaths one was judged as preventable and 17 were judged as potentially preventable by the review panel. Overall agreement on preventability between the review panel and the internal consensus was moderate (Kappa 0.51). The external panel judged one death as preventable compared with three from the internal consensus. The interobserver agreement between the external panel members was also moderate (Kappa 0.43). The panel judged 31 errors to have occurred in the (potential) preventable death group and 23 errors in the non-preventable death group. Such errors included choice or sequence of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies. CONCLUSIONS: The preventable death rate in the present study was comparable to data in the available literature. Compared to internal review, the external, multidisciplinary review did not find a higher preventable death rate, although it provided several insights to optimise trauma care.

Observer agreement of the Manchester Triage System and the Emergency Severity Index: a simulation study.

OBJECTIVES: To compare inter and intra-observer agreement of the Manchester Triage System (MTS) and the Emergency Severity Index (ESI). METHODS: 50 representative emergency department (ED) scenarios derived from actual cases were presented to 18 ED nurses from three different hospitals. Eight of them were familiar with MTS, six with ESI and four were not familiar but trained in both systems. They independently assigned triage scores to each scenario according to the triage system(s) they were familiar with. After 4-6 weeks the same nurses again judged the scenarios in a different order. Unanimity in judgement and unweighted and quadratic-weighted kappas were calculated. RESULTS: Unanimity in judgement for MTS was 90% and for ESI 73%. One-level disagreement was found in 8% and 23% of the cases, respectively. Interobserver unweighted kappas were 0.76 (95% CI 0.68 to 0.83) for MTS and 0.46 (95% CI 0.37 to 0.55) for ESI. Quadratic-weighted kappas were 0.82 (95% CI 0.74 to 0.89) and 0.73 (95% CI 0.64 to 0.83), respectively. At 4-6 weeks, one-level intra-observer disagreements were 10% and 22% and 2-level disagreement 1% and 2%, respectively. Intra-observer unweighted kappas were 0.84 (95% CI 0.73 to 0.94) for MTS and 0.65 (95% CI 0.59 to 0.72) for ESI. CONCLUSION: Using paper-based clinical scenarios, MTS was found to have a greater inter and intra-observer agreement than ESI.

Staircase falls: high-risk groups and injury characteristics in 464 patients.

INTRODUCTION: Few data are available about the epidemiology and injury characteristics in staircase falls. The available literature mainly concerns children and autopsy studies. OBJECTIVE: To describe the epidemiology and injury characteristics of staircase falls, and to identify high-risk groups for these falls. METHODS: All patients who reported to an academic Accident & Emergency (A&E) department in 2005 after a staircase fall were selected in the Dutch Injury Surveillance System These data were linked to the hospital Trauma Registry database. RESULTS: Four hundred and sixty-four patients (42% male, p=0.001), with a median age of 35 years were included. Children under five suffered significantly more head injuries. Male patients showed significantly more thoracic injuries than female patients. Spinal column fractures were only seen in patients over 25 years of age. Older patients tended to accumulate more rib fractures and lower extremity fractures and were admitted more frequently than the younger patients. Sixty-one patients (13%) required admission. Two patients, both with severe traumatic brain injury (TBI), died. National data on staircase falls were comparable with our hospital data. However, in comparison to the national population data, senior citizens in this study had an incidence that was markedly higher than in the younger patients. CONCLUSION: Injuries due to staircase falls occur in all age groups, however, children under five years are relatively over-represented with higher rates of head injury. Senior citizens showed a markedly higher incidence than younger patients. Most injuries occur to the distal extremities and are relatively mild.

Does intraoperative fluoroscopic 3D imaging provide extra information for fracture surgery?

Fracture surgery of the extremities using 2D fluoroscopy frequently fails to detect the suboptimal positioning of implants and joint incongruities. The use of intraoperative 3D-rotational X-ray (3D-RX) imaging with a new X-ray device potentially reveals these failures. We compared 50 intraoperative (2D) results of surgery and certainty about the effectiveness of different aspects of fracture reduction as interpreted from conventional (2D) methods versus intraoperative 3D-RX in 42 distal extremity fractures by means of a surgery questionnaire. In addition, we investigated the need for revision surgery based on postoperative radiological findings in 81 patients. After fracture reduction, just before a 3D-RX scan, the surgeon preoperatively assessed the result of surgery. Three months after surgery, the 3D-RX scan was judged by three experienced surgeons independently. Intraoperative 3D-RX showed significantly more information as to screw positioning and rotation of the fracture reduction than the conventional method (p < 0.005). None of the 81 patients in whom 3D-RX was performed needed surgical revision based on postoperative radiological examinations. Intraoperative 3D-RX with this new device scanning offers additional information about extremity fracture reduction as compared to conventional intraoperative 2D imaging, and may reduce the need for revision surgery. The value of 3D-RX on functional outcomes still needs to be assessed.

Hip fractures in nonagenarians: perioperative mortality and survival.

The nonagenarian population is increasing yet there is little known about their survival and mortality rates following hip fractures. The aim was to review and evaluate all the nonagenarians who underwent surgery for intra- or extracapsular hip fracture at the Trauma Unit of the Department of Surgery at the Academic Medical Center (AMC) in Amsterdam in the past 20 years. In this retrospective study, 155 nonagenarians sustaining hip fractures between 1982 and 2001 were included and reviewed. In this population there were 128 women (83%) and 27 men (17%). Mortality in women was higher than in men. In men more intracapsular fractures (70%) were diagnosed compared to extracapsular fractures. The opposite, 38% intracapsular and 62% extracapsular fractures were found in women (p=0.002). A trend in higher perioperative mortality for extracapsular fractures and increasing ASA-classification was observed. Mean survival for the whole population, men and women was 756, 544 and 787 days, respectively. This study shows that ASA-II nonagenarians with hip fractures have comparable life expectancy compared to nonagenarians without a hip fracture. Shortening of hospital stay after hip fracture surgery reduces the costs and will benefit the patient.

Rating of internal fixation and clinical outcome in displaced femoral neck fractures: a prospective multicenter study.

The influence of precise surgical technique on the clinical outcome of internal fixation for displaced femoral neck fractures is an under-reported and potential confounding factor in randomized studies involving internal fixation as a treatment modality. Two experienced surgeons blindly rated internal fixation techniques on the perioperative radiographs of 102 patients selected for internal fixation in a prospective multicenter 2-year followup study. Overall technical, fracture reduction, and implant positioning ratings were given according to instruction. One or both raters assigned an inadequate overall rating in 25% of patients. There was a correlation with 2-year clinical internal fixation failure for overall technique and fracture reduction rating. Implant positioning did not correlate with 2-year internal fixation failure. Correlation increased if both raters agreed on inadequate technique. One inadequate rating indicated a problem could arise, whereas two inadequate ratings strengthened this problem likelihood. Adjudication of technique by independent rater(s) is useful, may have clinical implications, and should be performed routinely in future studies involving internal fixation in patients with displaced femoral neck fractures.

A consensus process on management of major burns accidents: lessons learned from the café fire in Volendam, The Netherlands.

PURPOSE: The optimum response to the different stages of a major burns incident is still not established. The fire in a café in Volendam on New Year's Eve 2000 was the worst incident in recent Dutch history and resulted in mass burn casualties. The fire has been the subject of several investigations concerned with organisational and medical aspects. Based on the findings in these investigations, a multidisciplinary research group started a consensus study. The aim of this study was to further identify areas of improvement in the care after mass burns incidents. DESIGN/METHODOLOGY/APPROACH: The consensus process comprised three postal rounds (Delphi Method) and a consensus conference (modified nominal group technique). The multidisciplinary panel consisted of 26 Dutch-speaking experts, working in influential positions within the sphere of disaster management and healthcare. FINDINGS: In response to the postal questionnaires, consensus was reached for 66 per cent of the statements. Six topics were subsequently discussed during the consensus conference; three topics were discussed within the plenary session and three during subgroup meetings. During the conference, consensus was reached for seven statements (one subject generated two statements). In total, the panel agreed on 21 statements. These covered the following topics: registration and evaluation of disaster care, capacity planning for disasters, pre hospital care of victims of burns disasters, treatment and transportation priorities, distribution of casualties (including interhospital transports), diagnosis and treatment and education and training. ORIGINALITY/VALUE: In disaster medicine, the paper shows how a consensus process is a suitable tool to identify areas of improvement of care after mass burns incidents.