1
|
Boissin C. Clinical decision-support for acute burn referral and triage at specialized centres - Contribution from routine and digital health tools. Glob Health Action 2022; 15:2067389. [PMID: 35762795 PMCID: PMC9246103 DOI: 10.1080/16549716.2022.2067389] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Constance Boissin
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
2
|
Rakhshan M, Joolaee S, Mousazadeh N, Hakimi H, Bagherian S. Causes of futile care from the perspective of intensive care unit nurses (I.C.U): qualitative content analysis. BMC Nurs 2022; 21:225. [PMID: 35953793 PMCID: PMC9371949 DOI: 10.1186/s12912-022-01004-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 08/01/2022] [Indexed: 11/12/2022] Open
Abstract
Background Medical care that has therapeutic effects without significant benefits for the patient is called futile care. Intensive Care Units are the most important units in which nurses provide futile care. This study aimed to explain the causes of futile care from the perspective of nurses working in Intensive Care Units are. Method The study was conducted using a qualitative approach. Qualitative content analysis was used to analyze the data. Study participants were 17 nurses who were working in the Intensive Care Units are of hospitals in the north of Iran. They were recruited through a purposeful sampling method. Data was gathered using in-depth, semi-structured interviews from March to June 2021. Recruitment was continued until data saturation was reached. Results Two main themes, four categories, and thirteen subcategories emerged from the data analysis. The main themes were principlism and caring swamp. The categories were moral foundation, professionalism, compulsory care, and patient’s characteristics. Conclusion In general, futile care has challenged nursing staff with complex conflicts. By identifying some of these conflicts, nurses will be able to control such situations and plan for better management strategies. Also, using the findings of this study, nursing managers can adopt supportive strategies to reduce the amount of futile care and thus solve the specific problems of nurses in intensive care units such as burnout, moral stress, and intention to leave.
Collapse
Affiliation(s)
- Mahnaz Rakhshan
- Community Based Psychiatric Care Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Soodabeh Joolaee
- Department of Evaluation & Research Service, Fraser health authority, Surrey, Canada.,Research Center of Health Evaluation & Outcome Science, UBS, Vancouver, Canada.,Nursing Care Research Center, Iran University of Medical Science, Tehran, Iran
| | - Noushin Mousazadeh
- Department of Nursing, Amol Faculty of Nursing and Midwifery, Mazandaran University of Medical Science, Sari, Iran.
| | - Hamideh Hakimi
- Clinical Research Development Unit of Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Samaneh Bagherian
- Department of Operating Room, School of Paramedical Sciences, Birjand University of Medical Sciences, Birjand, Iran
| |
Collapse
|
3
|
den Hollander D, Albertyn R, Amber J. Palliation, end-of-life care and burns; concepts, decision-making and communication - A narrative review. Afr J Emerg Med 2020; 10:95-98. [PMID: 32612916 PMCID: PMC7320205 DOI: 10.1016/j.afjem.2020.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 12/31/2019] [Accepted: 01/06/2020] [Indexed: 12/03/2022] Open
Abstract
Palliative care is the turn from cure as the priority of care to symptom relief and comfort care. Although very little is published in the burn literature on palliative care, guidelines can be gleaned from the general literature on palliative care, particularly for acute surgical and critical care patients. Palliative care may be started because of futility, on request of the patient, or because of limited resources. The SPIKES acronym is a useful guide to avoid errors in communication with terminal patients and their relatives.
Collapse
Affiliation(s)
- Daan den Hollander
- Burns Unit Inkosi Albert Luthuli Central Hospital, Durban, South Africa
- Department of Surgery, University of KwaZulu Natal, South Africa
| | - Rene Albertyn
- Red Cross Memorial Children's Hospital, South Africa
| | - Julia Amber
- Palliative Care Practitioner, Department of Pediatrics, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| |
Collapse
|
4
|
Bayuo J, Bristowe K, Harding R, Agyei FB, Agbeko AE, Agbenorku P, Baffour PK, Allotey G, Hoyte-Williams PE. The Role of Palliative Care in Burns: A Scoping Review. J Pain Symptom Manage 2020; 59:1089-1108. [PMID: 31733355 DOI: 10.1016/j.jpainsymman.2019.11.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/06/2019] [Accepted: 11/06/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT Patients with severe burns may face distressing symptoms with a high risk of mortality as a result of their injury. The role of palliative care in burns management remains unclear. OBJECTIVE To appraise the literature on the role of palliative care in burns management. METHODS We used scoping review with searches in 12 databases from their inception to August 2019. The citation retrieval and retention are reported in a PRISMA statement. FINDINGS 39 papers comprising of 30 primary studies (26 from high-income and four from middle-income countries), four reviews, two editorials, two guidelines, and one expert board review document were retained in the review. Palliative care is used synonymously with comfort and end-of-life care in burns literature. Comfort care is mostly initiated when active treatment is withheld (early deaths) or withdrawn (late deaths), limiting its overall benefits to burn patients, their families, and health care professionals. Futility decisions are usually complex and challenging, particularly for patients in the late death category, and it is unclear if these decisions result in timely commencement of comfort care measures. Three comfort care pathways were identified, but it remained unclear how these pathways evaluated "good death" or supported the family which creates the need for the development of other evidence-based guidelines. CONCLUSION Palliative care is applicable in burns management, but its current role is mostly confined to the end-of-life period, suggesting that it is not been fully integrated in the management process. Evidence-based guidelines are needed to support the integration and delivery of palliative care in the burn patient population.
Collapse
Affiliation(s)
- Jonathan Bayuo
- Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Agogo, Ghana; School of Nursing, The Hong Kong Polytechnic University, Hong Kong.
| | - Katherine Bristowe
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, Kings College, London, United Kingdom
| | - Richard Harding
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, Kings College, London, United Kingdom
| | - Frank Bediako Agyei
- Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Agogo, Ghana
| | | | - Pius Agbenorku
- School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Plastics, Burns and Reconstructive Surgical Division, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Prince Kyei Baffour
- Burns Intensive Care Unit, Plastics and Reconstructive Surgical Unit, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Gabriel Allotey
- Burns Intensive Care Unit, Plastics and Reconstructive Surgical Unit, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Paa Ekow Hoyte-Williams
- Plastics, Burns and Reconstructive Surgical Division, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| |
Collapse
|
5
|
Ribeiro AF, Martins Pereira S, Gomes B, Nunes R. Do patients, families, and healthcare teams benefit from the integration of palliative care in burn intensive care units? Results from a systematic review with narrative synthesis. Palliat Med 2019; 33:1241-1254. [PMID: 31296110 DOI: 10.1177/0269216319862160] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Burn units are intensive care facilities specialized in the treatment of patients with severe burns. As burn injuries have a major impact in physical, psychosocial, and spiritual health, palliative care can be a strengthening component of integrated care. AIM To review and appraise the existing evidence about the integration of palliative care in burn intensive care units with respect to (1) the concept, model and design and (2) the benefits and outcomes of this integration. DESIGN A systematic review was conducted following PRISMA guidelines. Protocol registered with PROSPERO (CRD42018111676). DATA SOURCES Five electronic databases were searched (PubMed/NLM, Web of Science, MEDLINE/TR, Ovid, and CINAHL/EBSCO) until May 2019. A narrative synthesis of the findings was constructed. Hawker et al.'s tool was used for quality appraisal. RESULTS A total of 299 articles were identified, of which five were included for analysis involving a total of 7353 individuals. Findings suggest that there may be benefits from integrating palliative care in burn units, specifically in terms of patients' comfort, decision-making processes, and family care. Multidisciplinary teams may experience lower levels of burden as result of integrating palliative care in burn units. CONCLUSION This review reflects the challenging setting of burn intensive care units. Evidence from these articles suggests that the integration of palliative care in burn intensive care units improves patients' comfort, decision-making process, and family care. Further research is needed to better understand how the integration of palliative care in burn intensive care units may be fostered and to identify the outcomes of this integration.
Collapse
Affiliation(s)
| | - Sandra Martins Pereira
- Instituto de Bioética, Universidade Católica Portuguesa, Porto, Portugal.,UNESCO Chair in Bioethics, Instituto de Bioética, Universidade Católica Portuguesa, Porto, Portugal.,Centro de Estudos em Gestão e Economia (CEGE), Porto Católica Business School, Universidade Católica Portuguesa, Porto, Portugal
| | - Barbara Gomes
- Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal.,Cicely Saunders Institute, King's College London, London, UK
| | - Rui Nunes
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,International Network UNESCO Chair in Bioethics
| |
Collapse
|
6
|
Bartley CN, Atwell K, Cairns B, Charles A. Predictors of withdrawal of life support after burn injury. Burns 2018; 45:322-327. [PMID: 30442381 DOI: 10.1016/j.burns.2018.10.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 10/05/2018] [Accepted: 10/15/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Discussions regarding withdrawal of life support after burn injury are challenging and complex. Often, providers may facilitate this discussion when the extent of injury makes survival highly unlikely or when the patient's condition deteriorates during resuscitation. Few papers have evaluated withdrawal of life support in burn patients. We therefore sought to determine the predictor of withdrawal of life support (WLS) in a regional burn center. METHODS We conducted a retrospective analysis of all burn patients from 2002 to 2012. Patient characteristics included age, gender, burn mechanism, percentage total body surface area (%TBSA) burned, presence of inhalation injury, hospital length of stay, and pre-existing comorbidities. Patients <17years of age and patients with unknown disposition were excluded. Patients were categorized into three cohorts: Alive till discharge (Alive), death by withdrawal of life support (WLS), or death despite ongoing life support (DLS). DLS patients were then excluded from the study population. Multivariate logistic regression was used to estimate predictors of WLS. RESULTS 8,371 patients were included for analysis: 8134 Alive, 237 WLS. Females had an increased odd of WLS compared to males (OR 2.03, 95% CI 1.18-3.48; p=0.010). Based on higher CCI, patients with pre-existing comorbidities had an increased odd of WLS (OR 1.28, 95% CI 1.08-1.52; p=0.005). There was a significantly increased odds for WLS (OR 1.09, 95% CI 1.06-1.12; p<0.001) with increasing age. Similarly, there was an increased odd for WLS (OR 1.08, 95% CI 1.07-1.51; p<0.001) with increasing %TBSA. An increased odd of WLS (OR 2.47, 95% CI 1.05-5.78; p=0.038) was also found in patients with inhalation injury. CONCLUSION The decision to withdraw life support is a complex and difficult decision. Our current understanding of predictors of withdrawal of life support suggests that they mirror those factors which increase a patient's risk of mortality. Further research is needed to fully explore end-of-life decision making in regards to burn patients. The role of patient's sex, particularly women, in WLS decision making needs to be further explored.
Collapse
Affiliation(s)
- Colleen N Bartley
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States
| | - Kenisha Atwell
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States
| | - Bruce Cairns
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States.
| |
Collapse
|
7
|
Abstract
Infrequent presentation of this patient group to emergency departments can cause stress and anxiety to front-line clinicians when they are faced with patients with a traumatic burn injury. Assessment relies on accurate evaluation of burn aetiology, size and depth, and initial management is directly responsible for patients' outcomes and quality of life. This is the second article in a two-part series that gives an overview of the minimum standard of care in burns first aid, and highlights the likely challenges in assessment of burn depth and size. The aim of the two articles is to enhance emergency clinicians' knowledge and confidence in burn management, and to build awareness of the life-changing implications of the initial clinical interventions in burn care.
Collapse
Affiliation(s)
- Kristina Stiles
- London and South East of England Burn Network, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, England
| |
Collapse
|
8
|
Creation of a decision aid for goal setting after geriatric burns: a study from the prognostic assessment of life and limitations after trauma in the elderly [PALLIATE] consortium. J Trauma Acute Care Surg 2017; 81:168-72. [PMID: 26885996 DOI: 10.1097/ta.0000000000000998] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES We hypothesized that a decision-support aid to predict index admission mortality and discharge disposition for geriatric burns could be constructed using the well-accepted Baux score (age +total body surface area burned) in a geriatric-specific cohort. METHODS National Burn Repository version 8.0 (2002-2011) was queried for all subjects aged 65 years or older. Baux scores were calculated and patients grouped into deciles. Three discharge outcomes (death,home, discharge to nonhome setting) were measured per decile. A receiver operating characteristic analysis was used to determine optimal Baux score cutpoints based on the Youden Index. The odds of mortality at various Baux score cutoffs were estimated using logistic regression. RESULTS The sample was composed of 8,001 subjects. Withdrawal of care was documented in 264 deaths; median time to withdrawal was three days. As Baux score increased, three peaks in disposition were seen. Less than 50% of patients with a Baux score of 80 or greater were discharged home. Patients with a moderate Baux score (80-130) had an increased likelihood of discharge to a nonhome setting. Baux scores of 130 or greater were nearly uniformly fatal (mortality, 94-100%). Baux score of 86.15 or less was predictive of discharge home (area under the curve, 0.698; sensitivity, 75.28%; specificity, 54.64%), and a score greater than 93.3 was predictive of mortality (area under the curve, 0.779; sensitivity, 57.46%; specificity, 87.08%). CONCLUSION For geriatric patients whose Baux scores exceed 86, return-to-home rates drop drastically; mortality increases at a score greater than 93, and mortality is nearly universal at a score ≥130 or greater. We are piloting a display of these findings as a decision-making aid when setting goals of care with stakeholders after geriatric burns. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III; therapeutic/care management, level IV.
Collapse
|
9
|
Metaxa V, Lavrentieva A. End-of-life decisions in Burn Intensive Care Units - An International Survey. Burns 2014; 41:53-7. [PMID: 25017109 DOI: 10.1016/j.burns.2014.05.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 05/25/2014] [Accepted: 05/28/2014] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Burn victims and their families are faced with an unexpected, life changing injury, and they don't have the necessary time to adjust to the trauma. Even though there is extensive literature exploring the attitudes of intensive care physicians on forgoing life-sustaining treatment, little is known about end-of-life practices in specialised burn intensive care units (ICUs). The aim of this study was to evaluate physician beliefs, values, considerations and difficulties in end-of-life decisions in burn ICUs. METHODS Two hundred and fifty questionnaires were distributed via electronic mail to burn specialists, randomly selected from the directories of the 45(th) annual meeting of American Burn Association and the 15(th) European Burns Association Congresses. RESULTS A moral difference between withdrawing and withholding was stated by 73% of physicians, with withholding being viewed as more preferable (42% vs 37%). Primary reasons given by physicians for the decision to withhold/withdraw the treatment were the patient's medical condition/high probability of death (68%), unresponsiveness to therapy (68%), severity of burn (78%) and poor outcome in terms of quality of life (44%). Vasopressors (85%), blood products (68%) and renal replacement therapy (85%) were the common modalities withheld/withdrawn. Almost 50% involved the patients in the end-of-life decisions and 66% involved the family. CONCLUSIONS In this first international study on end-of-life attitudes, burn ICU physicians clearly distinguish between withhold and withdrawal decisions, with the majority preferring the former. In contrast to general ICUs, treatment limitation accounts only for the minority of the deaths.
Collapse
Affiliation(s)
- Victoria Metaxa
- Consultant in Critical Care and Major Trauma, Critical Care Units, King's College Hospital, London SE5 9RS, UK.
| | - Athina Lavrentieva
- Consultant in Critical Care Papanikolaou Hospital, Burn ICU, Thessaloniki, Greece.
| |
Collapse
|
10
|
den Hollander D, Albert M, Strand A, Hardcastle TC. Epidemiology and referral patterns of burns admitted to the Burns Centre at Inkosi Albert Luthuli Central Hospital, Durban. Burns 2014; 40:1201-8. [PMID: 24439933 DOI: 10.1016/j.burns.2013.12.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 12/10/2013] [Accepted: 12/17/2013] [Indexed: 10/25/2022]
Abstract
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.
Collapse
Affiliation(s)
- Daan den Hollander
- Regional Burns Centre, Inkosi Albert Luthuli Central Hospital, Durban, KwaZulu-Natal, Republic of South Africa; Level I Trauma Centre, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, Durban, KwaZulu-Natal, Republic of South Africa.
| | - Malin Albert
- Regional Burns Centre, Inkosi Albert Luthuli Central Hospital, Durban, KwaZulu-Natal, Republic of South Africa; Medical Students, Faculty of Medicine, Lund University, Lund, Sweden
| | - Anna Strand
- Regional Burns Centre, Inkosi Albert Luthuli Central Hospital, Durban, KwaZulu-Natal, Republic of South Africa; Medical Students, Faculty of Medicine, Lund University, Lund, Sweden
| | - Timothy C Hardcastle
- Level I Trauma Centre, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, Durban, KwaZulu-Natal, Republic of South Africa
| |
Collapse
|