The development of the Delivery Assessment Tool (DAT) to facilitate quality improvement in burns services in low-middle income countries.

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 with a mixed, multidisciplinary team of staff working at the burn service, typically 6-10 participants. This usually lasts 2-3 h. 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.

A comprehensive, integrated approach to quality improvement and capacity building in burn care and prevention in low and middle-income countries: An overview.

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.

Estimating the cost impact of dressing choice in the context of a mass burns casualty event.

Mass casualty burn events (MCBs) require intense and complex management. Silver-infused longer use dressings might help optimise management of burns in an MCB setting. We developed a model estimating the impact of dressing choice in the context of an MCB. The model was developed in Excel in collaboration with experienced emergency response clinicians. The model compares use of silver-infused dressings with use of traditional dressings in patients with partial thickness burns covering 30% of their body. Costs were estimated from a UK perspective as a proxy for a funded emergency response team and limited to cost of dressings, bandages, padding, analgesia and staff time. Expected patient costs and resource use were summarised over an acute 2-week intervention period and extrapolated to estimate possible time savings in a hypothetical MCB. Per patient costs were estimated at £2,002 (silver) and £1,124 (traditional) (a daily additional spend of £63). Per patient staff time was estimated at 864 minutes (silver) and 1,200 minutes (traditional) (a daily time saving of 24 minutes). Multiplying up to a possible MCB population of 20 could result in a saving equivalent to 9 staff shifts over the 2-week intervention period. The model was sensitive to type of silver dressing, frequency of dressing change and staff costs. We found increased costs through use of silver dressings but time savings that might help optimise burns management in an MCB. Exploring the balance between costs and staff time might help future MCB response preparation.

Les catastrophes demandent une planification et une organisation rigoureuse. Les pansements à base d'argent nécessitant des changements moins fréquents peuvent être un bon compromis dans ces situations. En collaboration avec des urgentistes expérimentés, nous avons développé, sur un tableur, un modèle simple pour estimer l'impact du choix du pansement lors d'événements engendrant de nombreux blessés. Il compare l'utilisation de pansements à l'argent et celui des pansements généralement utilisés pour les patients avec des brûlures du deuxième degré couvrant 30 % de la surface corporelle. Le coût a été estimé en tenant compte du volume des pansements, de l'analgésie et temps/nombre soignants pour une durée d'intervention sur site de 2 semaines. Le coût par patient a été estimé à 2 002 £ pour les pansements à l'argent et 1 124 £ pour les pansement traditionnels soit une augmentation de 63 £/j. Le temps de soins par patient a été estimé à 864 minutes (pansements à l'argent) et 1 200 minutes (pansements traditionnel) soit un gain de temps 24 mn/j. Dans une hypothèse de 20 blessés, nous arrivons à une économie 9 journées (de 8 heures) de travail. L'utilisation des pansements à l'argent est plus onéreuse en termes de matériel mais permet d'économiser du temps/soignant. Nous pourrions améliorer la prise en charge des victimes dans de telles situations en explorant les possibilités d'un meilleur équilibre entre le coût et le nombre de personnel requis.

Where to from here? A quality improvement project investigating burns treatment and rehabilitation practices in India.

OBJECTIVE: To describe the capacity of the Indian healthcare system in providing appropriate and effective burns treatment and rehabilitation services. RESULTS: Health professionals involved in burns treatment or rehabilitation at seven hospitals from four states in India were invited to participate in consultative meetings. Existing treatment and rehabilitation strategies, barriers and enablers to patient flow across the continuum of care and details on inpatient and outpatient rehabilitation were discussed during the meetings. Seventeen health professionals from various clinical backgrounds were involved in the consultation process. Key themes highlighted (a) a lack of awareness on burn first aid at the community level, (b) a lack of human resource to treat burn injuries in hospital settings, (c) a gap in burn care training for medical staff, (d) poor hospital infrastructure and (e) a variation in treatment practices and rehabilitation services available between hospitals. A number of opportunities exist to improve burns treatment and rehabilitation in India. Improvements would most effectively be achieved through promoting multidisciplinary care across a number of facilities and service providers. Further research is required to develop context-specific burn care models, determining how these can be integrated into the Indian healthcare system.

Rehabilitation practices for burn survivors in low and middle income countries: A literature review.

OBJECTIVE: To systematically review the delivery and effectiveness of rehabilitation for burn survivors in low and middle income countries (LMIC). METHODS: We systematically searched the literature through 11 electronic databases and the reference lists of relevant studies. Studies were suitable for inclusion if they were primary research with a focus on burns rehabilitation in LMIC settings describing either service delivery or treatment effectiveness. No time, design or other limitations were applied, except English language. RESULTS: Of 226 studies identified, 17 were included in the final review, including 7 from India. The results were summarised in a narrative synthesis as the studies had substantial heterogeneity and small sample sizes, with many relying on retrospective data from non-representative samples with no control groups. Most studies (12) described service delivery and 5 examined the effectiveness of different types of rehabilitation. Multiple studies stressed the need for rehabilitation and multidisciplinary teams for burns management. CONCLUSIONS: The published research on burns rehabilitation is very limited and little is known about current practices in LMIC settings. In order to inform policy and service delivery, the effectiveness, feasibility and sustainability of current services needs to be investigated.

Pilot project in rural western Madhya Pradesh, India, to assess the feasibility of using LED and solar-powered lanterns to remove kerosene lamps and related hazards from homes.

BACKGROUND: Globally, 300,000 deaths are estimated to occur annually and the incidence is far greater as a large majority of burns are small and go unreported. Ninety-five percent of the global burden of burns is found in low- and middle-income countries; however, there is relatively little in the literature regarding effective primary prevention in these areas. Flame is the most common cause of burn in Madhya Pradesh, the central state of India. The most common demographic among the burn unit inpatient of Choithram hospital Indore, is young women from 21 to 40 years of age, whose burns are primarily caused by kerosene lamps. A non electrical source of illumination is essential for every household in rural areas due to the infrequent and poor power supply. At the baseline, 23 kerosene lamp burns were reported by villagers in the past 5 years among the study population of this pilot project. METHOD: A pilot project to investigate the strategies for reducing the incidence of domestic burns in rural villages around the city of Indore was performed, by replacing kerosene lamps with safer and more sustainable alternatives, including solar-powered and light-emitting diode (LED) lamps. A total of 1042 households were randomly chosen from 18 villages within the Malwa region of Madhya Pradesh (population of 28,825) to receive the alternative light source (670 LED and 372 solar lamps). We investigated the efficacy of this strategy of reducing the incidence of burns, measured the social acceptance by villagers, and quantified the cost implications and availability of LED lamps in rural communities with a high incidence of burns. RESULTS: Replacing kerosene lamps with LED and solar alternatives was deemed socially acceptable by 99.34% of the participants and reduced the cost of lighting for impoverished rural villagers by 85% over 1 year. We successfully demonstrated a significant decrease in the use of kerosene lamps (p<0.01). More evidence is required to investigate the efficacy of this strategy in reducing burns. CONCLUSION: This pilot study highlights the viability of the approach of replacing kerosene lamps as an effective primary prevention strategy for reducing burns in rural areas. However, barriers remain to the wider adoption of these lamps, including accessibility and availability for the populations of rural India.

Paediatric injuries due to home treadmill use: an emerging problem.

INTRODUCTION: The use of home exercise equipment is increasing and treadmills are becoming more popular. This has brought with it an emerging but preventable problem. We present our experience, highlight the importance and promote public awareness of this type of injury. To our knowledge this has not been reported previously in the UK. METHODS: A retrospective review was conducted of the medical records at two regional burn units of children who sustained treadmill-related injuries between July 2003 and July 2009. Data on patient demographics, mechanism of injury, management, surgical intervention and outcome were recorded. RESULTS: Twenty-nine children (15 boys, 14 girls) sustained treadmill-related injuries. The mean age was 3.8 years (range: 1-13 years). All injuries occurred at home and the majority of children trapped their hand under the running belt when an adult was using the machine. Most of the injuries were to the upper limb (97%) with less than 1% of the total body surface area burnt. More than two-thirds of patients had deep burns and 17 (58%) required surgical intervention. Five patients developed hypertrophic scars. All patients achieved a good functional outcome. CONCLUSIONS: Treadmills can pose a significant danger to children. These injuries are preventable. Regulatory authorities, manufacturers and parents should take steps to prevent this emerging health problem.

Inhalation injury associated with smoking, alcohol and drug abuse: an increasing problem.

This study investigated the association of inhalation injury (IHI) with smoking, alcohol and drug abuse in patients admitted to the Welsh Centre for Burns between 1995 and 2006. Common characteristics of these individuals were identified and contrasted with inhalation injury not associated with these social factors. Two hundred and fourteen patients were identified with inhalation injury. Ninety-two of these were associated with smoking, alcohol abuse and/or drug abuse. The proportion of IHI cases associated with smoking remained stable but IHI associated with alcohol and drug abuse increased dramatically over the course of the study and if current trends continue will increase further in future years. This study also showed that IHI associated with smoking alcohol and drug abuse were found to be largely caused by housefires and deliberate self-harm, and occurred between 22:00 and 05:59 h. These results were in sharp contrast with IHI not associated with these factors.

A systematic review of the features that indicate intentional scalds in children.

BACKGROUND: Most intentional burns are scalds, and distinguishing these from unintentional causes is challenging. AIM: To conduct a systematic review to identify distinguishing features of intentional and unintentional scalds. METHODS: We performed an all language literature search of 12 databases 1950-2006. Studies were reviewed by two paediatric/burns specialists, using standardised methodology. Included: Primary studies of validated intentional or accidental scalds in children 0-18 years and ranked by confirmation of intentional or unintentional origin. Excluded: neglectful scalds; management or complications; studies of mixed burn type or mixed adult and child data. RESULTS: 258 studies were reviewed, and 26 included. Five comparative studies ranked highly for confirmation of intentional/unintentional cause of injury. The distinguishing characteristics were defined based on best evidence. Intentional scalds were commonly immersion injuries, caused by hot tap water, affecting the extremities, buttocks or perineum or both. The scalds were symmetrical with clear upper margins, and associated with old fractures and unrelated injuries. Unintentional scalds were more commonly due to spill injuries of other hot liquids, affecting the upper body with irregular margins and depth. CONCLUSIONS: We propose an evidence based triage tool to aid in distinguishing intentional from unintentional scalds, requiring prospective validation.

A review of current objective and subjective scar assessment tools.

An ideal scar assessment tool should include both objective and subjective methods aspects of a scar. This review examines the evidence on existing tools, and emphasises the importance of taking the patient's perspective into account.

Electric hair straightener burns an epidemiological and thermodynamic study.

Hair straighteners are a popular beauty product in the UK. An alarming rise in admissions to the Welsh Centre for Burns and Plastic Surgery, for burns caused by hair straighteners has led to this study. A thermodynamic study was also performed to look at temperature range and cooling profiles of these devices. Thirty-one cases were identified over a 32-month period, January 2003 to August 2006. Ninety-three percent (29 cases) were children with an average age of 4 years. The majority of burns were partial thickness to hands and feet, but 23% (seven cases) required admission and 10% (three cases) required surgical intervention. The hair straighteners reached a maximum temperature of 145 degrees C within 2min of activation and took up to 7min to cool below a temperature that would burn adult skin with a 1s contact. Children and crawling babies are at particular risk from preventable burns from hair straighteners. The frequency of burns from hair straighteners is rising and even small burns to the hand can have serious sequelae and need to be treated in specialist centres. Health promotion and discussion with the industry is required to stop this new and increasing problem.

Foot burns: epidemiology and management.

This is a retrospective study of the epidemiology and management of isolated foot burns presenting to the Welsh Centre for Burns from January 1998 to December 2002. A total of 289 were treated of which 233 were included in this study. Approximately 40% were in the paediatric age group and the gender distribution varied dramatically for adults and children. In the adult group the male:female ratio was 3.5:1, however in the paediatric group the male:female ratio was more equal (1.6:1). Scald burns (65%) formed the largest group in children and scald (35%) and chemical burns (32%) in adults. Foot burns have a complication rate of 18% and prolonged hospital stay. Complications include hypertrophic scarring, graft loss/delayed healing and wound infection. Although isolated foot burns represent a small body surface area, over half require treatment as in patients to allow for initial aggressive conservative management of elevation and regular wound cleansing to avoid complications. This study suggests a protocol for the initial acute management of foot burns. This protocol states immediate referral of all foot burns to a burn centre, admission of these burns for 24-48 h for elevation, regular wound cleansing with change of dressings and prophylactic antibiotics.

Bangers, burgers and burns. A 10-year review of barbeque burns in South Wales.

This is a retrospective study of the epidemiology of barbeque burns presenting to the Welsh Centre for burns from January 1994 to December 2004. A total of 68 were treated of which 57 are included in this study 25% are in the paediatric age group. The epidemiology varies between adults and paediatrics. Males are the most commonly injured in both groups. The paediatric group have a different aetiology compared with the adult group. All paediatric barbeque burns were caused by direct contact with either the barbeque or hot sand. This compares to the adult group, where 51% were caused by flash burns and only 40% were contact burns. Sixty-one percent of the paediatric group were burnt from low lying disposable barbeques compared to only 5% of adults. The hands were the most common sites of burn for adults (28%) compared to the feet in the paediatric group (36%). Barbeque burns in children seem to be increasing in the United Kingdom and we suspect that disposable barbeques are the causal factor as they are readily available, low-lying and cheap. We suggest preventative measures for such burns.

Aquacel ag® in paediatric burns - a prospective audit.

A variety of dressings are used for the management of paediatric burns. Aquacel Ag® is a silver-impregnated hydrofibre that releases silver within the dressing for up to two weeks. It has been reported in the literature that it is a beneficial dressing for the management of partial-thickness burns. It promotes an appropriate environment for re-epithelialization of the burn wound. The aim of this study was to evaluate the use and outcomes of Aquacel Ag® dressing in paediatric burn patients. This was a prospective audit carried out in the period January-July 2005. The healing time was satisfactory. The dressing normally adheres to the burn wound for up to two weeks and thus requires less frequent changes. In our study, patients required three to four outer dressing changes. However, Aquacel Ag® has not been compared with other dressings. Overall pain requirements were reduced during subsequent dressing changes. It was also easy to apply the dressing in the majority of our patients. Non-adherence was one of the problems encountered but, overall, Aquacel Ag® appeared to be a safe, effective, and comfortable dressing.

Neonatal accessory digits: a survey of practice amongst paediatricians and hand surgeons in the United Kingdom.

AIM: To describe the management of neonatal accessory digits, comparing views of paediatricians with those of hand surgeons, giving particular emphasis to the form of partial, ulnar duplication of the little finger (ulnar or postaxial polydactyly type B) which has a narrow pedicle. METHODS: Postal questionnaire of management preference using three photographs of ulnar accessory digits of varying complexity. RESULTS: The response rate was 64% in 234 paediatricians and 25% in 260 surgeons. All respondents would intervene in cases of ulnar polydactyly type B with a narrow pedicle: 79% of paediatricians but only 67% of hand surgeons would recommend referral of these cases for specialist assessment, the remainder advocating ligation by the paediatrician in the nursery. Paediatricians and neonatologists working in regional centres or with an on-site specialist service were more likely to refer. There was almost unanimous agreement on the management of the most complex case, but no general consensus on that of the simplest form. CONCLUSION: There is uncertainty and inequality in initial treatment decisions for infants with all but the most complex of accessory digits. Despite published evidence that ligation gives satisfactory results, most respondents in this survey advocate specialist referral, with evidence that the availability of specialist services influences decision making.

The use of ADCON-T/N after repair of zone II flexor tendons.

This double-blinded randomised clinical trial investigated whether application of ADCON-T/N to zone II tendon repairs improved their outcome. Fifty-nine patients were randomised into control or ADCON-T/N treated groups and all followed an early mobilisation regime following tendon repair. Tendon rupture rates were comparable between the control and ADCON-T/N treated patients. At six months follow-up, the ADCON-T/N treated group had better proximal interphalangeal motion.

Isolated buttock burns: epidemiology and management.

This is a retrospective study of the epidemiology and management of isolated buttock burns presenting to the Welsh Regional Burns Centre from January 1996 to December 1999. A total of 36 cases have been treated of which 31 are included in this study. Approximately, 50% are in the paediatric age group and the sex distribution is equal for both adults and children. Contact burns form the largest group, and in children resulted in superficial burns requiring dressings only. The adult population is more likely to sustain deeper burns that require skin grafting, and approximately 50% will have a contributing premorbid condition. Despite difficulties in dressing and positioning of the patients, grafting of full thickness burns is appropriate without recourse to faecal diversion.

Meningococcal septicaemia and plastic surgery--a strategy for management.

Meningococcal septicaemia is a severe life threatening illness that is part of the spectrum of meningococcal disease. It is of particular concern to the plastic and reconstructive surgeon because as the medical and intensive care of these patients improves, more are surviving the acute phase of the septicaemia and suffering from the associated complications such as skin necrosis and extremity loss. Recently there have been several reports in the literature concerning the management of skin infarction with both skin grafting and free flap surgery. This paper will provide an update on the proposed pathophysiological mechanisms involved, summarise the present data on plastic surgical care and suggest a stratagem for future management of these difficult cases.