Retrospective analysis of photographic evaluation of burn depth

Changes in attitudes towards telemedicine in acute burn care following the Covid-19 pandemic

BACKGROUND

Telemedical referrals after burn injury had been shown to be advantageous over telephone referrals for multiple reasons, however there were several key barriers towards complete implementation. The Covid-19 pandemic facilitated the adoption of telemedicine to ensure the safety of both clinicians and patients. Due to the circumstances, it was unclear whether the pre-pandemic barriers still existed despite the complete implementation of telemedicine. This study aims to evaluate clinicians' views about the barriers towards implementation of a specific telemedicine system for burns referrals, and their changing attitudes following the pandemic, to identify key domains for improvement in current and future telemedicine systems.

METHODS

A questionnaire was created to evaluate the attitudes of referring clinicians towards telemedicine, following literature searches and administration of a pilot questionnaire. This was administered via telephone to staff working in EDs and MIUs which referred to the South-West United Kingdom Burns Network using the Medical Data Solutions and Services (MDSAS) system, in both 2019 and 2022. A statistical analysis was performed to compare the attitudes of clinicians towards telemedicine both pre- and post-pandemic.

RESULTS

100 respondents completed the survey in 2019 and 70 in 2022, with similar demographics of respondents. Out of the twelve barriers identified, the lack of reliable Wi-Fi and need to duplicate notes were identified as the main obstacles to implementation in both time periods. In both years, the single greatest barrier reported was poor access to reliable Wi-Fi (p = 0.944). Miscommunication between clinicians using the system, inadequate numbers of devices and financial constraints were identified less frequently as barriers in 2022 than 2019 (p = 0.005, p = 0.047 and p < 0.001 respectively). However, significantly more respondents reported time pressures when waiting for a response to their telemedicine referral in 2022 (p = 0.022).

CONCLUSION

Overall, clinicians displayed a positive attitude towards the MDSAS system for acute burns, with clinicians identifying fewer concerns with the system following the Covid-19 pandemic. However, concerns over the time pressures that this telemedicine system places on the referring clinician and existing Wi-Fi infrastructure persist. Further streamlining of the system and investment in internet access is recommended, with continued input from all stakeholders.

Photographic Evaluation of Burn Depth via Telemedicine: Insights from Iranian Surgeons

Background

The accurate assessment of burn depth is crucial for determining appropriate treatment. Telemedicine has emerged as a promising tool for supporting burn diagnosis and decision-making, as it allows for remote consultation with burn specialists and access to high-quality imaging. The aim of this study was to evaluate the diagnostic capabilities of telemedicine in diagnosing burn depth.

Methods

A total of 15 Iranian surgeons participated in this study; they were presented with 13 images of partial thickness burn ulcers located on the extremities and trunk of patients. The participating surgeons were required to provide their diagnoses of burn type and depth, as well as the necessity of surgical intervention, and their responses were recorded.

Results

Data from 11 participants and 143 responses were analyzed. The average diagnostic accuracy for superficial burns was 79.3%, while for deep burns, it was 13.72%. The mean total diagnostic accuracy was 75.2%.

Conclusion

The results of this study suggest that photographs can be a reliable diagnostic tool for evaluating superficial burns. However, photographs are neither valid nor reliable for assessing burn depth. These findings have important implications for the use of telemedicine in burn diagnosis and indicate that additional diagnostic tools may be necessary for accurate assessment of deep burns.

Telehealth in surgery: an umbrella review

BACKGROUND

Telehealth use has increased worldwide during the COVID-19 pandemic. However, hands-on requirements of surgical care may have resulted in slower implementation. This umbrella review (review of systematic reviews) evaluated the perceptions, safety and implementation of telehealth services in surgery, and telehealth usage in Australia between 2020 and 2021.

METHODS

PubMed was searched from 2015 to 2021 for systematic reviews evaluating real-time telehealth modalities in surgery. Outcomes of interest were patient and provider satisfaction, safety, and barriers and facilitators associated with its use. Study quality was appraised using the AMSTAR 2 tool. A working group of surgeons provided insights into the clinical relevance to telehealth in surgical practice of the evidence collated.

RESULTS

From 2025 identified studies, 17 were included, which were of low to moderate risk of bias. Patient and provider satisfaction with telehealth was high. Time savings, decreased healthcare resource use and lower costs were reported as key advantages of the service. Inability to perform comprehensive examinations was noted as the primary barrier. In Australia, peak telehealth usage coincided with the introduction of temporary telehealth services and increased lockdown measures.

CONCLUSIONS

Patients and providers are broadly satisfied with telehealth and its benefits. Barriers may be overcome via multidisciplinary collaboration. Telehealth may benefit surgical care long-term if implemented correctly both during and after the COVID-19 pandemic.

Ongoing Development and Evaluation of a Method of Telemedicine: Burn Care Management With a Smartphone

In cases involving small burns in patients without a comorbidity or associated pathology, a referral from a surgeon is necessary and sometimes it cannot be ascertained when the patient is not brought in by a specialized team. The purpose of this retrospective study was to evaluate the quality of our method for performing telemedicine. This retrospective study included the 323 patients who were initially treated using the telemedicine system implemented between 2011 and 2016. This procedure only involved patients burned over a small portion of their body's surface area (ie, ≤15%) who were between 15 and 75 years of age and who did not have a major comorbidity. The purpose of the procedure was to evaluate the need for surgery. The initial diagnosis regarding the need for a surgical procedure was accurate in 94.4% (305/323) of the cases. Eleven patients (3.4%) were transferred unnecessarily as they ultimately did not require surgery, and seven patients (2.2%) were ultimately transferred even though the need for surgery was not initially established at the time that the pictures were viewed. No initial errors in the photographic evaluation caused a worsening in the life-threatening, functional, or aesthetic prognoses. We have recently opted to use telemedicine for initial patient management. In 94.4% of cases, the opinion that was provided was accurate. Only 3.2% of the patients for whom outpatient treatment was recommended ultimately underwent surgery without subsequently experiencing the slightest injury due to any delay in therapy. Although it will never replace clinical examination, these results have encouraged us to develop telemedicine based on digital photography.

Accuracy of Currently Used Paper Burn Diagram vs a Three-Dimensional Computerized Model

Burn units have historically used paper diagrams to estimate percent burn; however, unintentional errors can occur. The use of a computer program that incorporates wound mapping from photographs onto a three-dimensional (3D) human diagram could decrease subjectivity in preparing burn diagrams and subsequent calculations of TBSA burned. Analyses were done on 19 burned patients who had an estimated TBSA burned of ≥20%. The patients were admitted to Shriners Hospitals for Children or the University of Texas Medical Branch in Galveston, Texas, from July 2012 to September 2013 for treatment. Digital photographs were collected before the patient's first surgery. Using BurnCase 3D (RISC Software GmbH, Hagenberg, Austria), a burn mapping software, the user traced partial- and full-thickness burns from photographs. The program then superimposed tracings onto a 3D model and calculated percent burned. The results were compared with the Lund and Browder diagrams completed after the first operation. A two-tailed t-test was used to calculate statistical differences. For partial-thickness burns, burn sizes calculated using Lund and Browder diagrams were significantly larger than those calculated using BurnCase 3D (15% difference, P < .01). The opposite was found for full-thickness burns, with burn sizes being smaller when calculated using Lund and Browder diagrams (11% difference, P < .05). In conclusion, substantial differences exist in percent burn estimations derived from BurnCase 3D and paper diagrams. In our studied cohort, paper diagrams were associated with overestimation of partial-thickness burn size and underestimation of full-thickness burn size. Additional studies comparing BurnCase 3D with other commonly used methods are warranted.

Imaging Techniques for Clinical Burn Assessment with a Focus on Multispectral Imaging

Significance: Burn assessments, including extent and severity, are some of the most critical diagnoses in burn care, and many recently developed imaging techniques may have the potential to improve the accuracy of these evaluations. Recent Advances: Optical devices, telemedicine, and high-frequency ultrasound are among the highlights in recent burn imaging advancements. We present another promising technology, multispectral imaging (MSI), which also has the potential to impact current medical practice in burn care, among a variety of other specialties. Critical Issues: At this time, it is still a matter of debate as to why there is no consensus on the use of technology to assist burn assessments in the United States. Fortunately, the availability of techniques does not appear to be a limitation. However, the selection of appropriate imaging technology to augment the provision of burn care can be difficult for clinicians to navigate. There are many technologies available, but a comprehensive review summarizing the tissue characteristics measured by each technology in light of aiding clinicians in selecting the proper device is missing. This would be especially valuable for the nonburn specialists who encounter burn injuries. Future Directions: The questions of when burn assessment devices are useful to the burn team, how the various imaging devices work, and where the various burn imaging technologies fit into the spectrum of burn care will continue to be addressed. Technologies that can image a large surface area quickly, such as thermography or laser speckle imaging, may be suitable for initial burn assessment and triage. In the setting of presurgical planning, ultrasound or optical microscopy techniques, including optical coherence tomography, may prove useful. MSI, which actually has origins in burn care, may ultimately meet a high number of requirements for burn assessment in routine clinical use.

A Smartphone App and Cloud-Based Consultation System for Burn Injury Emergency Care

Background

Each year more than 10 million people worldwide are burned severely enough to require medical attention, with clinical outcomes noticeably worse in resource poor settings. Expert clinical advice on acute injuries can play a determinant role and there is a need for novel approaches that allow for timely access to advice. We developed an interactive mobile phone application that enables transfer of both patient data and pictures of a wound from the point-of-care to a remote burns expert who, in turn, provides advice back.

Methods and Results

The application is an integrated clinical decision support system that includes a mobile phone application and server software running in a cloud environment. The client application is installed on a smartphone and structured patient data and photographs can be captured in a protocol driven manner. The user can indicate the specific injured body surface(s) through a touchscreen interface and an integrated calculator estimates the total body surface area that the burn injury affects. Predefined standardised care advice including total fluid requirement is provided immediately by the software and the case data are relayed to a cloud server. A text message is automatically sent to a burn expert on call who then can access the cloud server with the smartphone app or a web browser, review the case and pictures, and respond with both structured and personalized advice to the health care professional at the point-of-care.

Conclusions

In this article, we present the design of the smartphone and the server application alongside the type of structured patient data collected together with the pictures taken at point-of-care. We report on how the application will be introduced at point-of-care and how its clinical impact will be evaluated prior to roll out. Challenges, strengths and limitations of the system are identified that may help materialising or hinder the expected outcome to provide a solution for remote consultation on burns that can be integrated into routine acute clinical care and thereby promote equity in injury emergency care, a growing public health burden.

Postoperative Care Using a Secure Online Patient Portal: Changing the (Inter)Face of General Surgery

BACKGROUND

Many patients seek greater accessibility to health care. Meanwhile, surgeons face increasing time constraints due to workforce shortages and elevated performance demands. Online postoperative care may improve patient access while increasing surgeon efficiency. We aimed to evaluate patient and surgeon acceptance of online postoperative care after elective general surgical operations.

STUDY DESIGN

A prospective pilot study within an academic general surgery service compared online and in-person postoperative visits from May to December 2014. Included patients underwent elective laparoscopic cholecystectomy, laparoscopic ventral hernia repair, umbilical hernia repair, or inguinal hernia repair by 1 of 5 surgeons. Patients submitted symptom surveys and wound pictures, then corresponded with their surgeons using an online patient portal. The primary outcome was patient-reported acceptance of online visits in lieu of in-person visits. Secondary outcomes included detection of complications via online visits, surgeon-reported effectiveness, and visit times.

RESULTS

Fifty patients completed both online and in-person visits. Online visits were acceptable to most patients as their only follow-up (76%). For 68% of patients, surgeons reported that both visit types were equally effective, while clinic visits were more effective in 24% and online visits in 8%. No complications were missed via online visits, which took significantly less time for patients (15 vs 103 minutes, p < 0.01) and surgeons (5 vs 10 minutes, p < 0.01).

CONCLUSIONS

In this population, online postoperative visits were accepted by patients and surgeons, took less time, and effectively identified patients who required further care. Further evaluation is needed to establish the safety and potential benefit of online postoperative visits in specific populations.

Utilization of laser Doppler flowmetry and tissue spectrophotometry for burn depth assessment using a miniature swine model

Currently, the diagnosis of burn depth is primarily based on a visual assessment and can be dependent on the surgeons' experience. The goal of this study was to determine the ability of laser Doppler flowmeter combined with a tissue spectrophotometer to discriminate burn depth in a miniature swine burn model. Burn injuries of varying depth, including superficial-partial, deep-partial, and full thickness, were created in seven Göttingen minipigs using an aluminium bar (100 °C), which was applied to the abdominal skin for periods of 1, 3, 6, 12, 30, and 60 seconds with gravity alone. The depth of injury was evaluated histologically using hematoxylin and eosin staining. All burns were assessed 3 hours after injury using a device that combines a laser light and a white light to determine blood flow, hemoglobin oxygenation, and relative amount of hemoglobin. The blood flow (41 vs. 124 arbitrary units [AU]) and relative amount of hemoglobin (32 vs. 52 AU) were significantly lower in full thickness compared with superficial-partial thickness burns. However, no significant differences in hemoglobin oxygenation were observed between these depths of burns (61 vs. 60%). These results show the ability of laser Doppler flowmeter and tissue spectrophotometer in combination to discriminate between various depths of injury in the minipig model, suggesting that this device may offer a valuable tool for burn depth assessment influencing burn management.

Review of burn research for the year 2011

The year 2011 was another robust year for burn research. Over 1100 articles were published on a wide range of burn injury and treatment topics. In this review, we highlight some of the interesting and potentially influential research in the following areas: critical care, infection, inhalation injury, epidemiology, wound characterization and treatment, nutrition and metabolism, pain management, burn reconstruction, psychology, and rehabilitation. As in years past, burn injury research reflects the multidisciplinary and holistic care that is needed to treat this challenging injury condition.

The year in burns 2011

For 2011, approximately 1746 original research articles in burns were published in English in scientific journals. This article reviews those with the most potential impact on for burn therapeutics and outcomes according to the Editor of one of the major journals (Burns) and his colleague. As done previously, articles were found and divided into these topic areas: epidemiology of injury and burn prevention, wound and scar characterisation, acute care and critical care, inhalation injury, infection, psychological considerations, pain and itching management, rehabilitation and long-term outcomes, and burn reconstruction. Each selected article is mentioned briefly with editorial comment.