Developing clinical quality indicators for a Bi-National Burn Registry

Quality indicators for hospital burn care: a scoping review

BACKGROUND

Burn treatments are complex, and for this reason, a specialised multidisciplinary approach is recommended. Evaluating the quality of care provided to acute burn patients through quality indicators makes it possible to develop and implement measures aiming at better results. There is a lack of information on which indicators to evaluate care in burn patients. The purpose of this scoping review was to identify a list of quality indicators used to evaluate the quality of hospital care provided to acute burn patients and indicate possible aspects of care that do not have specific indicators in the literature.

METHOD

A comprehensive scoping review (PRISMA-ScR) was conducted in four databases (PubMed, Cochrane Library, Embase, and Lilacs/VHL) between July 25 and 30, 2022 and redone on October 6, 2022. Potentially relevant articles were evaluated for eligibility. General data and the identified quality indicators were collected for each included article. Each indicator was classified as a structure, process, or outcome indicator.

RESULTS

A total of 1548 studies were identified, 82 were included, and their reference lists were searched, adding 19 more publications. Thus, data were collected from 101 studies. This review identified eight structure quality indicators, 72 process indicators, and 19 outcome indicators listed and subdivided according to their objectives.

CONCLUSION

This study obtained a list of quality indicators already used to monitor and evaluate the hospital care of acute burn patients. These indicators may be useful for further research or implementation in quality improvement programs.

TRIAL REGISTRATION

Protocol was registered on the Open Science Framework platform on June 27, 2022 ( https://doi.org/10.17605/OSF.IO/NAW85 ).

Development of a value-based healthcare burns core set for adult burn care

BACKGROUND

Value-based healthcare (VBHC) is increasingly implemented in healthcare worldwide. Transparent measurement of the outcomes most important and relevant to patients is essential in VBHC, which is supported by a core set of most important quality indicators and outcomes. Therefore, the aim of this study was to develop a VBHC-burns core set for adult burn patients.

METHODS

A three-round modified national Delphi study, including 44 outcomes and 24 quality indicators, was conducted to reach consensus among Dutch patients, burn care professionals and researchers. Items were rated on a nine-point Likert scale and selected if ≥ 70% in each group considered an item 'important'. Subsequently, instruments quantifying selected outcomes were identified based on a literature review and were chosen in a consensus meeting using recommendations from the Dutch consensus-based standard set and the Dutch Centre of Expertise on Health Disparities. Time assessment points were chosen to reflect the burn care and patient recovery process. Finally, the initial core set was evaluated in practice, leading to the adapted VBHC-burns core set.

RESULTS

Twenty-seven patients, 63 burn care professionals and 23 researchers participated. Ten outcomes and four quality indicators were selected in the Delphi study, including the outcomes pain, wound healing, physical activity, self-care, independence, return to work, depression, itching, scar flexibility and return to school. Quality indicators included shared decision-making (SDM), the number of patients receiving aftercare, determination of burn depth, and assessment of active range of motion. After evaluation of its use in clinical practice, the core set included all items except SDM, which are assessed by 9 patient-reported outcome instruments or measured in clinical care. Assessment time points included are at discharge, 2 weeks, 3 months, 12 months after discharge and annually afterwards.

CONCLUSION

A VBHC-burns core set was developed, consisting of outcomes and quality indicators that are important to burn patients and burn care professionals. The VBHC-burns core set is now systemically monitored and analysed in Dutch burn care to improve care and patient relevant outcomes. As improving burn care and patient relevant outcomes is important worldwide, the developed VBHC-burns core set could be inspiring for other countries.

Adherence with early allied health assessments in specialist burn services

Appropriate multidisciplinary allied health assessment during the early stages of admission following burn injury positively influences recovery and quality of life. Variation in allied health care may affect patient outcomes. We aimed to explore adherence in providing early allied health assessments in accordance with local parameters. Associations between the number of assessments and hospital length of stay (LOS) were also explored. The Burns Registry of Australia and New Zealand was queried for adult (≥ 16 years) burn injured patients admitted to a specialist burn service for > 48 hours between July 2016 and June 2020. Quality indicator data relating to allied health assessment processes were examined; patients were grouped according to the number of assessments they received within 48 hours of admission. Of the 5789 patients included in the study, 5598 (97%) received at least one allied health assessment within 48 hours of admission and 3976 (69%) received all three assessments. A greater proportion of patients who received no assessments were admitted on a Saturday. Patients receiving three assessments had more severe injuries compared to their counterparts who received fewer assessments. Hospital LOS was not associated with the number of allied health assessments during an acute admission following burn injury after accounting for confounding factors, particularly TBSA. Multidisciplinary allied health teams provide routine burn care to Australian and New Zealand burns patients at a consistent level. Further, this study provides evidence that allied health input is prioritised towards patients with increasing severity of burn injury, playing an integral role in early rehabilitation.

"The home, the bathroom, the taps, and hot water": The contextual characteristics of tap water scalds in Australia and New Zealand

INTRODUCTION

Scalds from hot tap water can have devastating consequences and lifelong impact on survivors. The aims of this study were to (i) describe the frequency, demographic profile, injury event characteristics, and in-hospital outcomes for people with tap water scalds admitted to Australian and New Zealand burn centres; and (ii) determine whether variation was present in the frequency and epidemiological characteristics of tap water scalds between jurisdictions.

METHODS

Data were extracted from the Burns Registry of Australia and New Zealand for people with tap water scalds admitted to Australian or New Zealand burn centres between January 1, 2010 and December 31, 2018. Demographic, injury severity and event characteristics, surgical intervention, and in-hospital outcomes were investigated.

RESULTS

We included 650 people with tap water scalds admitted to Australian and New Zealand burn centres during the study period. Australians with tap water scalds (median [IQR] 29 [1-69] years) were older than New Zealanders (2 [1-36] years). Most tap water scalds occurred in the home, and 92% of these occurred in the bathroom. More than 55% of injuries occurred due to the accidental alteration of water temperature at the tap fixture. Two thirds of patients underwent a surgical wound procedure. The overall mortality rate was 3.7%, and the median hospital length of stay was 8.8 days.

CONCLUSION

Tap water scalds remain a public health problem in Australia and New Zealand. Our research highlights where gaps in current heated water regulations in residential homes perpetuate risks of tap water scalds, particularly in high-risk groups at the extremes of age. Extending current heated water regulations to include all Australia and New Zealand homes is urgently needed in conjunction with design safety improvements, and ongoing education of key stakeholders.

Driving improved burns care and patient outcomes through clinical registry data: A review of quality indicators in the Burns Registry of Australia and New Zealand

BACKGROUND

In 2009, the Burns Registry of Australia and New Zealand (BRANZ) published a set of clinical quality indicators (QIs) to monitor performance, improve quality of care, and inform and change policy. With several years of data collected since the initial development of the indicators for burns, the BRANZ QI Working Party reviewed the clinical QIs for relevance and meaning, and considered new QIs that had not been collected previously.

METHOD

Using published literature and expert opinion, the QI Working Party, consisting of multidisciplinary burn clinicians, reviewed the QIs for burn care to be included as routine data items in the BRANZ.

RESULTS

In July 2016, the list of clinical QIs in the BRANZ was updated to 23 QIs/data items, covering structure, process, and outcome measures. Four QIs were removed as they were not found to be useful, nine QIs/data items were revised, and eight new QIs/data items were added as they were considered to be clinically useful.

CONCLUSION

This review outlines the changes made to the QIs collected by the BRANZ four years since their development and implementation. Ongoing refinement of the BRANZ QIs will ensure that high quality data is collected to drive improvements in clinical and patient outcomes.

Pain assessment following burn injury in Australia and New Zealand: Variation in practice and its association on in-hospital outcomes

BACKGROUND

Pain is common following burn injury. Pain assessments are required to ensure appropriate pain management is provided. This study aimed to describe the prevalence and potential variation in practice of validated and documented pain assessment following burn injury in Australian and New Zealand burn units, identify clinical characteristics of patients who receive a pain assessment, and explore the associations between receiving a pain assessment and in-hospital outcomes.

METHODS

Burns Registry of Australia and New Zealand (BRANZ) admissions data were extracted. Responses to the pain assessment field were presented by contributing burns unit using frequencies and percentages. Demographic, injury severity and event, and in-hospital outcomes data were assessed.

RESULTS

There were 3009 admissions over the study period; 2481 of these received an assessment. The rate of pain assessment varied considerably between units. Women and adult patients more commonly received a pain assessment. Receiving a pain assessment was associated with a 53% adjusted increase in LOS.

CONCLUSIONS

There are differences in the profile of patients who receive a pain assessment after burn injury. The findings of this study will be reported back to designated burns units to improve pain assessment rates and patient care.

Validation of the burn intervention score in a National Burn Centre

The Linköping burn score has been used for two decades to calculate the cost to the hospital of each burned patient. Our aim was to validate the Burn Score in a dedicated Burn Centre by analysing the associations with burn-specific factors: percentage of total body surface area burned (TBSA%), cause of injury, patients referred from other (non-specialist) centres, and survival, to find out which of these factors resulted in higher scores. Our second aim was to analyse the variation in scores of each category of care (surveillance, respiration, circulation, wound care, mobilisation, laboratory tests, infusions, and operation). We made a retrospective analysis of all burned patients admitted during the period 2000-15. Multivariable regression models were used to analyse predictive factors for an increased daily burn score, the cumulative burn score (the sum of the daily burn scores for each patient) and the total burn score (total sum of burn scores for the whole group throughout the study period) in addition to sub-analysis of the different categories of care that make up the burn score. We retrieved 22301 daily recordings for inpatients. Mobilisation and care of the wound accounted for more than half of the total burn score during the study. Increased TBSA% and age over 45 years were associated with increased cumulative (model R² 0.43, p<0.001) and daily (model R² 0.61, p<0.001) burn scores. Patients who died had higher daily burn scores, while the cumulative burn score decreased with shorter duration of hospital stay (p<0.001). To our knowledge this is the first long term analysis and validation of a system for scoring burn interventions in patients with burns that explores its association with the factors important for outcome. Calculations of costs are based on the score, and it provides an indicator of the nurses' workload. It also gives important information about the different dimensions of the care provided from thorough investigation of the scores for each category.

The Burns Registry of Australia and New Zealand: progressing the evidence base for burn care

OBJECTIVE

Analysis of data from the Burns Registry of Australia and New Zealand (BRANZ) to determine the extent of variation between participating units in treatment and in specific outcomes during the first 4 years of its operation.

DESIGN

BRANZ, an initiative of the Australian and New Zealand Burn Association, is a clinical quality registry developed in accordance with the Australian Commission on Safety and Quality in Healthcare national operating principles.

SETTING

Patients with burn injury who fulfil pre-defined criteria are transferred to and managed in designated burn units. There are 17 adult and paediatric units in Australia and New Zealand that manage almost all patients with significant burn injury. Twelve of these units treat adult patients.

PARTICIPANTS

Data on 7184 adult cases were contributed by ten acute adult burn units to the registry between July 2010 and June 2014.Major outcomes: In-hospital mortality, hospital length of stay, skin grafting rates, and rates of admission to intensive care units.

RESULTS

Considerable variations in unit profiles (including numbers of patients treated), in treatment and in outcomes were identified.

CONCLUSIONS

Despite the highly centralised delivery of care to patients with severe or complex burn injury, and the relatively small number of specialist burn units, we found significant variation between units in clinical management and in outcomes. BRANZ data from its first 4 years of operation support its feasibility and the value of further development of the registry. Based on these results, the focus of ongoing research is to improve understanding of the reasons for variations in practice and of their effect on outcomes for patients, and to develop evidence-informed clinical guidelines for burn management in Australia and New Zealand.

Water First Aid Is Beneficial In Humans Post-Burn: Evidence from a Bi-National Cohort Study

Introduction

Reported first aid application, frequency and practices around the world vary greatly. Based primarily on animal and observational studies, first aid after a burn injury is considered to be integral in reducing scar and infection, and the need for surgery. The current recommendation for optimum first aid after burn is water cooling for 20 minutes within three hours. However, compliance with this guideline is reported as poor to moderate at best and evidence exists to suggest that overcooling can be detrimental. This prospective cohort study of a bi-national burn patient registry examined data collected between 2009 and 2012. The aim of the study was to quantify the magnitude of effects of water cooling first aid after burn on indicators of burn severity in a large human cohort.

Method

The data for the analysis was provided by the Burn Registry of Australia and New Zealand (BRANZ). The application of first aid cooling prior to admission to a dedicated burn service, was analysed for its influence on four outcomes related to injury severity. The patient related outcomes were whether graft surgery occurred, and death while the health system (cost) outcomes included total hospital length of stay and admission to ICU. Robust regression analysis using bootstrapped estimation adjusted using a propensity score was used to control for confounding and to estimate the strength of association with first aid. Dose-response relationships were examined to determine associations with duration of first aid. The influence of covariates on the impact of first aid was assessed.

Results

Cooling was provided before Burn Centre admission for 68% of patients, with at least twenty minutes duration for 46%. The results indicated a reduction in burn injury severity associated with first aid. Patients probability for graft surgery fell by 0.070 from 0.537 (13% reduction) (p = 0.014). The probability for ICU admission fell by 0.084 from 0.175 (48% reduction) (p<0.001) and hospital length of stay (LOS) fell by 2.27 days from 12.9 days (18% reduction) (p = 0.001). All outcomes except death showed a dose-response relationship with the duration of first aid. The size of burn and age interacted with many of the relationships between first aid and outcome and these are described and discussed.

Discussion & Conclusion

This study suggests that there are significant patient and health system benefits from cooling water first aid, particularly if applied for up to 20 minutes. The results of this study estimate the effect size of post-burn first aid and confirm that efforts to promote first aid knowledge are not only warranted, but provide potential cost savings.

Long term outcomes data for the Burns Registry of Australia and New Zealand: Is it feasible?

BACKGROUND

Incorporating routine and standardised collection of long term outcomes following burn into burn registries would improve the capacity to quantify burn burden and evaluate care.

AIMS

To evaluate methods for collecting the long term functional and quality of life outcomes of burns patients and establish the feasibility of implementing these outcomes into a multi-centre burns registry.

METHODS

Five Burns Registry of Australia and New Zealand (BRANZ) centres participated in this prospective, longitudinal study. Patients admitted to the centres between November 2009 and November 2010 were followed-up at 1, 6, 12 and 24-months after injury using measures of burn specific health, health status, fatigue, itch and return to work. Participants in the study were compared to BRANZ registered patients at the centres over the study timeframe to identify participation bias, predictors of successful follow-up were established using a Generalised Estimating Equation model, and the completion rates by mode of administration were assessed.

RESULTS

463 patients participated in the study, representing 24% of all BRANZ admissions in the same timeframe. Compared to all BRANZ patients in the same timeframe, the median %TBSA and hospital length of stay was greater in the study participants. The follow-up rates were 63% at 1-month, 47% at 6-months; 40% at 12-months, and 21% at 24-months after injury, and there was marked variation in follow-up rates between the centres. Increasing age, greater %TBSA and opt-in centres were associated with greater follow-up. Centres which predominantly used one mode of administration experienced better follow-up rates.

CONCLUSIONS

The low participation rates, high loss to follow-up and responder bias observed indicate that greater consideration needs to be given to alternative models for follow-up, including tailoring the follow-up protocol to burn severity or type.

Scald burns in children aged 14 and younger in Australia and New Zealand—an analysis based on the Burn Registry of Australia and New Zealand (BRANZ)

INTRODUCTION

Scalds are a common injury in children and a frequent reason for hospitalisation despite being a preventable injury.

METHODS

This retrospective two year study reports data from 730 children aged 14 years or younger who sustained a scald between 2009 and 2010 and were admitted to a burns centre in Australia or New Zealand. Data were extracted from the Burn Registry of Australia and New Zealand (BRANZ), which included data from 13 burns centres in Australia and New Zealand.

RESULTS

Scald injury contributed 56% (95% CI 53-59%) of all pediatric burns. There were two high risk groups; male toddlers age one to two, contributing 34% (95% CI 31-38%) of all scalds, and indigenous children who were over 3 times more likely to experience a scald requiring admission to a burns unit than their non-indigenous peers. First aid cooling by non-professionals was initiated in 89% (95% CI 86-91%) of cases but only 20% (95% CI 16-23%) performed it as recommended.

CONCLUSION

This study highlights that effective burn first aid reduces hospital stay and reinforces the need to encourage, carers and bystanders to deliver effective first aid and the importance of targeted prevention campaigns that reduce the burden of pediatric scald burns in Australia and New Zealand.

Impact of reduced resuscitation fluid on outcomes of children with 10-20% body surface area scalds

'Permissive hypovolaemia' fluid regimes in adult burn care are suggested to improve outcomes. Effects in paediatric burn care are less well understood. In a retrospective audit, outcomes of children from the South West Children's Burn Centre (SWCBC) less than 16 years of age with scalds of 10-20% burn surface area (BSA) managed with a reduced volume fluid resuscitation regime (post-2007) were compared to (a) an historical local protocol (pre-2007) and (b) current regimes in burn services across England and Wales (E&W). Outcomes included length of stay per percent burn surface area (LOS/%BSA), skin graft requirement and re-admission rates. 92 SWCBC patients and 475 patients treated in 15 other E&W burn services were included. Median LOS/%BSA for patients managed with the reduced fluid regime was 0.27 days: significantly less than pre-2007 and other E&W burn services (0.54 days, 0.50 days, p<0.001). Skin grafting to achieve healing reduced post-2007 compared to pre-2007 and remains comparable with other E&W services. Re-admission rates were comparable between all groups. A reduced fluid regime has significantly shortened LOS/%BSA without compromising burn depth as measured by skin grafting to achieve healing. A prospective trial comparing permissive hypovolaemia to current regimes for moderate paediatric scald injuries would help clarify.

WITHDRAWN: Scald burns in children aged 14 and younger in Australia and New Zealand-An analysis based on the Bi-National Burns Registry (BiNBR)

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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.