American Telemedicine Association Guidelines for Teleburn

Optimizing an Outpatient mHealth Intervention for Children with Burns: A Convergent Mixed-Methods Study

Burn injury is one of the most common traumatic injuries in childhood. Fortunately, 90% of pediatric burns may be treated in the outpatient setting after appropriate burn triage. Patients with burns face significant geographic disparities in accessing expert burn care due to regionalized care. To aid patients and their families during acute outpatient burn recovery, we developed a smartphone app, Telemedicine Optimized Burn Intervention (TOBI). With this app, we aimed to increase access to care by allowing secure, streamlined communication between patients and burn providers, including messaging and wound image transfer. The purpose of this study was to systematically evaluate user feedback to optimize the patient and provider experience. TOBI was evaluated using a convergent mixed-methods approach consisting of qualitative semi-structured interviews and quantitative measurements of app usability via the mHealth App Usability Questionnaire. Participants included 15 caregivers of pediatric patients with burns who used TOBI during treatment and ten burn providers. Users found TOBI to be a highly usable application in terms of usefulness, ease of use, satisfaction, and functionality. Qualitative data provided insight into user experience, satisfaction and preferences, difficulty navigating, usability and acceptability, and potential improvements. Although most users were highly satisfied, improvements were needed to optimize the burn app. We systematically made these improvements before we released TOBI for routine patient use. This study uncovered helpful recommendations for app improvements that can be generalized to other mobile health apps to increase their appeal and adoption.

Best Practices for the Provision of Virtual Care: A Systematic Review of Current Guidelines

Background: Telemedicine has emerged as a feasible adjunct to in-person care in multiple clinical contexts, and its role has expanded in the context of the COVID-19 pandemic. However, there exists a general paucity of information surrounding best practice recommendations for conducting specialty or disease-specific virtual care. The purpose of this study was to systematically review existing best practice guidelines for conducting telemedicine encounters. Methods: A systematic review of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) of existing guidelines for the provision of virtual care was performed. Data were synthesized using the Synthesis Without Meta-Analysis (SWiM) guideline, and the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE II) tool was used to evaluate the quality of evidence. Results: A total of 60 guidelines for virtual care encounters were included; 52% of these were published in the context of the COVID-19 pandemic. The majority (95%) of provider guidelines specified a type of virtual encounter to which their guidelines applied. Of included guidelines, 65% provided guidance regarding confidentiality/security, 58% discussed technology/setup, and 56% commented on patient consent. Thirty-one guidelines also provided guidance to patients or caregivers. Overall guideline quality was poor. Discussion: General best practices for successful telemedicine encounters include ensuring confidentiality and consent, preparation before a visit, and clear patient communication. Future studies should aim to objectively assess the efficacy of existing clinician practices and guidelines on patient attitudes and outcomes to further optimize the provision of virtual care for specific patient populations.

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.

Acute Management of Thermal Hand Burns in Adults: A 10-Year Review of the Literature

INTRODUCTION

Advances in the evidence base of acute thermal hand burns help to guide the management of these common injuries. The aim of this literature review was to evaluate recent evidence in the field over 10 years.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols methodology was used as a guide for this literature review. PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar were searched for English language articles related to hand burns published between 2009 and 2018 inclusive, and the Cochrane Library was reviewed. Exclusion criteria were as follows: participants younger than 18 years, scar or contracture management, rehabilitation, outcomes assessment, late reconstruction, and electrical or chemical burns.

RESULTS

An initial search retrieved 6493 articles, which was narrowed to 403 full-text articles that were reviewed independently by 3 of the authors and categorized. Of 202 included articles, there were 8 randomized controlled trials and 2 systematic reviews. Six evidence-based guidelines were reviewed. Referral of hand burns to specialist centers, use of telemedicine, early excision and grafting, and immediate static splintage have been recommended. Enzymatic debridement results in earlier intervention, more accurate burn assessment, preservation of vital tissue, and fewer skin grafts, and ideally requires regional anesthesia. Guidance on escharotomy emphasizes indication, technique and adequate intervention, and potential for enzymatic debridement. Inclusion of topical negative pressure, dermal regenerative templates, acellular dermal matrices, and noncellular skin substitutes in management has helped improve scar and functional outcomes.

DISCUSSION

The results of this literature review demonstrate that multiple national and international societies have published burns guidelines during the decade studied, with aspects directly relevant to hand burns, including the International Society for Burn Injuries guidelines. There are opportunities for evidence-based quality improvement across the field of hand burns in many centers.

CONCLUSIONS

More than 200 articles globally in 10 years outline advances in the understanding of acute management of thermal hand burns. Incorporating the evidence base into practice may facilitate optimization of triage referral pathways and acute management for hand burns.

Expert Outpatient Burn Care in the Home Through Mobile Health Technology

Access to care for pediatric burns remsains a major public health problem in the United States. Telemedicine has an opportunity to improve access to care, but current models are expensive and inefficient. They have developed and pilot-tested the TeleBurn App, a novel smartphone application, to treat partial thickness burns while outpatient. The app allows the provision of expert clinical burn care directly in the patient's home through text and image messaging, video conferencing, and instructional videos. They retrospectively reviewed clinical outcomes and usability in pediatric partial thickness burn patients treated using the TeleBurn App compared with standard therapy alone. Standard therapy is considered to be face-to-face delivery of care. Burn wound care was provided to 32 patients via the app and 35 patients with standard therapy. Most (74%) patients offered the app, used it as their primary source of follow-up care. This group had no wound infections or unexpected returns to clinic or hospital. Both TeleBurn App and standard therapy groups had similar burn severity, age, and burn mechanism. Mean healing time was shorter in the app group (mean ± standard deviation: 11.6 ± 4.7 days versus standard therapy: 14.3 ± 5.4 [P = .03]) with fewer clinical encounters (0.93 ± 0.6 vs standard therapy: 3.3 ± 1.0 [P = .001]). Adherence with completion of therapy in patients using the app was 80 vs 64 per cent with standard therapy. They describe a functional, scalable mobile health application in clinical use in a pediatric burn program. Further prospective, randomized studies may validate this mobile health platform, improving access to expert burn care for a vulnerable population.

[Telemedicine and initial medical regulation of severe burns]

The evaluation of the patient and his burned body surface is one of the fundamental prerequisites for his care on site as well as for the initiation of his care journey. New tools such as the E-burn application and telemedicine improve this assessment and remote medical assistance management by reducing the risk of under-sorting or over-sorting. Telemedicine limits inappropriate secondary inter-hospital transfers and the resulting increased mortality. It is carried out according to standards that ensure safety and confidentiality for the patient and caregivers.

Prospective observational study comparing burn surgeons' estimations of wound healing after skin grafting to photo-assisted methods

INTRODUCTION

Appropriate graft healing after split-thickness skin graft and early recognition of complications (graft loss) are critical to burn patient management. Larger mesh ratio expansions and Meek micrografting may pose a greater challenge in estimating the percentage of wound healing. This study looks at the reliability of photograph assessments and the concordance of bedside evaluation to photograph assessments of wound healing after skin grafting.

METHODS

Three assessment methods for percentage of wound healing after skin Grafting were assessed: (1) clinicians' bedside rating, (2) clinician assessment of high-definition photographs, and (3) digital image analysis through color subtraction using Adobe Photoshop. We compared each method using a mixed-effects model on absolute agreement using intra-class correlation (ICC) and Bland Altman (BA) plots.

RESULTS

Fourteen burn patients were enrolled with 38 grafted wounds (100 sites). Bedside assessments had a mean ICC of 0.64 (compared to digital image analysis) and 0.69 (compared to photo assessment), with a wide range on BA-plots. Inter-rater reliability of photo assessment was excellent (0.96) among six clinicians. Repeated photo-assisted assessments had good intra-rater reliability (ICC: photo assessment: 0.88; digital analysis: 0.97).

CONCLUSIONS

Bedside wound healing assessments show variability; photograph documentation of sequential wound progression could supplement active clinical management or studies for more reliable assessments.

Formulating Telemedicine Strategies in Isfahan University of Medical Sciences

INTRODUCTION

The use of telemedicine technology can lead to an equitable distribution of specialized care. There are numerous influencing factors which should be identified for successful implementation and efficacy of telemedicine. The aim of this study was to evaluate current situation and internal and external environment of Isfahan University of Medical Sciences (IUMS) and prepare telemedicine development strategies for IUMS.

METHODS

This study was an applied cross-sectional mixed method study which was conducted between July 2014 to November 2016 and in five phases in IUMS. a) Evaluating Internal and external factors (IFE & EFE); b) Formulating goals; c) Identifying and prioritizing strategic problems; d) Setting objectives; and e) formulating the strategies to develop telemedicine in IUMS. The research sample included 147 of IUMS inner customers and stakeholders in the first phase (census) and 14 in the second phase (Purposive sampling based on more work experience). In the first phase, to analyze obtained data of two researcher-made questionnaires, measures of central tendency and dispersion (frequency, percent and mean) were calculated using SPSS. To evaluate internal and external factors and formulating strategies was used TOWS matrix. And finally, to select optimal strategies for telemedicine developing quantitative strategic planning matrix was used.

RESULTS

The final score of internal and external factors evaluation was 2.67 and 2.68, respectively. According to the strategic position and action evaluation (SPACE), telemedicine strategic planning in IUMS was in aggressive posture. Because the numbers were closer to 2.5 can be concluded that based on internal factors the organization was in moderate to strong and based on external factors was in a moderate level and neither have a serious positive feature for use the opportunities outside the organization and suffered a serious threat from the outside of organization. Finally, we formulated 14 strategies to develop telemedicine in IUMS as followings: 5 SO, 2 ST, 5 WO, and 2 WT strategies.

CONCLUSION

Telemedicine development in IUMS is located in poor aggressive posture. Therefore, IUMS can develop telemedicine and subsequently, in this study, strategies were developed to preserve and retain healthcare workers, practical studies, data confidentiality and security programs, and other issues.