Adherence to National Burn Care Review referral criteria in a paediatric Emergency Department

Clinical decision-support for acute burn referral and triage at specialized centres - Contribution from routine and digital health tools

BACKGROUND

Specialized care is crucial for severe burn injuries whereas minor burns should be handled at point-of-care. Misdiagnosis is common which leads to overburdening the system and to a lack of treatment for others due to resources shortage.

OBJECTIVES

The overarching aim was to evaluate four decision-support tools for diagnosis, referral, and triage of acute burns injuries in South Africa and Sweden: referral criteria, mortality prediction scores, image-based remote consultation and automated diagnosis.

METHODS

Study I retrospectively assessed adherence to referral criteria of 1165 patients admitted to the paediatric burns centre of the Western Cape of South Africa. Study II assessed mortality prediction of 372 patients admitted to the adults burns centre by evaluating an existing score (ABSI), and by using logistic regression. In study III, an online survey was used to assess the diagnostic accuracy of burn experts' image-based estimations using their smartphone or tablet. In study IV, two deep-learning algorithms were developed using 1105 acute burn images in order to identify the burn, and to classify burn depth.

RESULTS

Adherence to referral criteria was of 93.4%, and the age and severity criteria were associated with patient care. In adults, the ABSI score was a good predictor of mortality which affected a fifth of the patients and which was associated with gender, burn size and referral status. Experts were able to diagnose burn size, and burn depth using handheld devices. Finally, both a wound identifier and a depth classifier algorithm could be developed with relatively high accuracy.

CONCLUSIONS

Altogether the findings inform on the use of four tools along the care trajectory of patients with acute burns by assisting with the diagnosis, referral and triage from point-of-care to burns centres. This will assist with reducing inequities by improving access to the most appropriate care for patients.

Adherence to the emergency management of severe burns referral criteria in burn patients admitted to a hospital with or without a specialized burn center

BACKGROUND

The primary aim was to determine to what extent referral and admission of burn patients to a hospital with or without a burn center was in line with the EMSB referral criteria.

METHODS

This was a retrospective, multicenter cohort study. Burn patients admitted from 2014 to 2018 to a hospital in the Southwest Netherland trauma region and Network Emergency Care Brabant were included in this study. Outcome measures were the adherence to the EMSB referral criteria.

RESULTS

A total of 1790 patients were included, of whom 951 patients were primarily presented to a non-burn center. Of these patients, 666 (70.0%) were managed according to the referral criteria; 263 (27.7%) were appropriately not referred, 403 (42.4%) were appropriately referred. Twenty (2.1%) were overtransferred, and 265 (27.9%) undertransferred. In 1213 patients treated at a burn center 1119 (92.3%) met the referral criteria. Adherence was lowest for electrical (N = 4; 14.3%) and chemical burns (N = 16; 42.1%), and was highest in 'children ≥5% total body surface area (TBSA) burned' (N = 109; 83.2%).

CONCLUSION

The overall adherence to the referral criteria of patients presented to a non-burn center was fairly high. However, approximately 25% was not transferred to a burn center while meeting the criteria. Most improvement for individual criteria can be achieved in patients with electrical and chemical burns.

Emergency Care of Pediatric Burns

Although the overall incidence of and mortality rate associated with burn injury have decreased in recent decades, burns remain a significant source of morbidity and mortality in children. Children with major burns require emergent resuscitation. Resuscitation is similar to that for adults, including pain control, airway management, and administration of intravenous fluid. However, in pediatrics, fluid resuscitation is needed for burns greater than or equal to 15% of total body surface area (TBSA) compared with burns greater than or equal to 20% TBSA for adults. Unique to pediatrics is the additional assessment for non-accidental injury and accurate calculation of the percentage of total burned surface area (TBSA) in children with changing body proportions are crucial to determine resuscitation parameters, prognosis, and disposition.

Assessing guidelines for burn referrals in a resource-constrained setting: Demographic and clinical factors associated with inter-facility transfer

AIM

The aim was to assess demographic and clinical factors associated with inter-facility referrals for patients with burns in a resource-constrained setting.

METHODS

This was a cross-sectional case review of patients presenting with a burn at the trauma unit at the Red Cross War Memorial Children's Hospital (RXH) in Cape Town, South Africa.

RESULTS

Six hundred and eleven-(71%) children were referred to the burns or the intensive care unit and 253 children were treated and discharged from the trauma unit. Of those admitted as inpatients 94% fulfilled at least one of the criteria for referral and 80% of those treated and discharged fulfilled the criteria for referral.

CONCLUSIONS

Almost three out of four children evaluated at the trauma unit were referred to the burns unit for further management. However, a large number of patients were treated and discharged from the trauma unit despite being eligible for referral.

Referral Patterns in Pediatric Burn Patients

Though multiple studies have demonstrated superior outcomes amongst adult burn patients at verified burn centers (VBCs) relative to nondedicated burn centers (NBCs), roughly half of such patients meeting American Burn Association (ABA) referral guidelines are not sent to these centers. We sought examine referral patterns amongst pediatric burn patients. Retrospective review of a statewide patient database identified pediatric burn patients from 2000 to 2007 using International Classification of Disease (ICD-9) discharge codes. These injuries were cross-referenced with ABA referral criteria to determine compliance with the ABA guidelines. 1831 children sustained burns requiring hospitalization during the study period, of which 1274 (70%) met ABA referral criteria. Of 557 treated at NBCs, 306 (55%) met criteria for transfer. Neither age, gender, nor payer status demonstrated significant association with treatment center. VBCs treated more severely injured patients, but there was no difference in survival or rate of discharge home from NBCs versus VBCs. Studies to evaluate differences in functional outcomes between pediatric burn patients treated at VBCs versus NBCs would be beneficial to ensure optimization of outcomes in this population.

Epidemiology and referral patterns of burns admitted to the Burns Centre at Inkosi Albert Luthuli Central Hospital, Durban

RATIONALE

The epidemiology, referral patterns and outcome of patients admitted to a tertiary burns unit in southern Africa were reviewed.

MATERIALS AND METHODS

The charts of all patients with thermal injury presenting to the Burns Centre at Inkosi Albert Luthuli Central Hospital (IALCH) between 1 January 2008 and 31 December 2010 were reviewed. Information collected included age, gender, past medical history, cause of burn, size of burn, presence of inhalation injury, time before admission, time to excision, length of hospital stay, complications and mortality.

FINDINGS

Four hundred and sixty two patients were admitted, 296 (58%) children and 193 (42%) adults. The female-male ratio was 1:1.13. The mean total body surface area (TBSA) burned was 12% (interquartile range 8-25%) for children and 18% (interquartile range 10-35%) for adults. Common causes for the burns were in children: hot liquids (71%) and open flame (24%). Major causes in adults were: open fire (68%) and hot liquids (25%). Epilepsy was a contributing factor in 12.7%. Inhalation injury was seen in 13.6% of adults and 14.3% of children with a flame burn. Forty-four percent of referrals from general surgical units were for burns <30% in adults, and 30% for burns <10% in children. More than one in four patients was referred between 1 and 6 weeks post-injury. Overall mortality was 9.1% (5.7% in children and 15.1% in adults). Complications occurred in 21.6% of children and 36.7% in adults, the most common being lung complications such as ARDS and infection, severe sepsis, skin graft failure and contractures. The length of stay was 1 day/% TBSA burn for all burns in children and for burns between 10 and 49% in adults.

CONCLUSIONS

The epidemiology and outcome of severe burns referred to the Burns Centre at IALCH is similar to those in other units in Africa. The management and referral of burns patients by other hospitals are inappropriate in a significant number of patients.

Burn injuries

PURPOSE OF REVIEW

To summarize and highlight recent advances in the understanding and management of burn injuries.

RECENT FINDINGS

The review focuses on topics which are of particular relevance for critical care practitioners involved in burn care: resuscitation, management of infection and sepsis, epidemiology and outcome, and organization and costs of burn care.

SUMMARY

While being the mainstay of early survival in burn victims, various aspects of burn resuscitation are still contentious and highlighted in this review. In particular, several strategies to overcome the repeatedly observed 'fluid creep' in burn patients are discussed, including the use of computerized resuscitation algorithms and the administration of colloids. Sepsis and multiorgan failure have become the major causes of death in patients surviving the initial phase of burn shock. Various aspects of sepsis management are reviewed, amongst which diagnosis, antibiotic treatment and prophylaxis. Recent epidemiologic data allow to identify risk factors associated with mortality as these are potentially amenable to targeted prevention and therapy. Examples are acute kidney injury and sepsis. The overview is completed by recent findings on organization and costs of burn care, including the adherence to referral criteria and the main determinants of cost.

The year in burns 2010

For 2010, roughly 1446 original burn research articles were published in scientific journals using the English language. This article reviews those with the most impact on burn treatment according to the Editor of one of the major journals (Burns) and his colleagues. As in previous reviews, articles were divided into the following topic areas: epidemiology, demographics of injury, wound characterisation and treatment, critical care, inhalation injury, infection, metabolism and nutrition, psychological considerations, pain and itching management, rehabilitation and long-term outcomes, and burn reconstruction. Each paper is considered very briefly, and the reader is referred to full manuscripts for details.