The development of the Delivery Assessment Tool (DAT) to facilitate quality improvement in burns services in low-middle income countries

Implementation science is a useful tool to consider ways in which we can introduce improvements to burn services in low-and-middle income countries (LMICs), where the majority of the burden of burn injury is now experienced. This paper outlines the development of the Delivery Assessment Tool (DAT), a method for facilitating quality improvement in burn services in LMICs. We used a participatory approach that ensured that local clinicians and experts were fully involved in piloting the tool. The DAT is based on internationally agreed operational standards for burn care service delivery and has undergone an iterative process of improvement and refinement through an initial three-year project in Nepal and Bangladesh. The DAT, a 50-item tool organised into 10 subsections, is used to assess a service through a participatory focus group discussion with a mixed, multidisciplinary team of staff working at the burn service, typically 6-10 participants. This usually lasts 2-3 h. The staff in the unit then select priority areas for quality improvement programmes that are within their control to achieve, which starts a cycle of audit and review. The final version of the tool was used in a further three-year project to evaluate 11 hospitals in Nepal and Bangladesh. Education and training are key components of this work; both were provided by Interburns as part of on-going support for the clinical teams. At the end of the project a>19% improvement in scores was demonstrated using the final version of the DAT in both Nepal and Bangladesh; this achievement is remarkable given the continued difficulties in service provision where patient numbers far outstrip the resources available to care for them. As a result of this work, we have made a digital version of the tool available free of charge.

A comprehensive, integrated approach to quality improvement and capacity building in burn care and prevention in low and middle-income countries: An overview

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Quality improvement requires a comprehensive integrated approach.

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Clinical standards are a vital first step in improving outcomes for LMICs.

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Capacity building needs a range of educational courses from basic to advanced.

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Evaluation tools are needed to measure progress.

Consistent evidence has emerged over many years that the mortality and morbidity outcomes for burn patients in low and middle-income countries (LMICs) lag behind those in more resource rich countries. Interburns is a charity that was set up with the aim of working to reduce the disparity in the number of cases of burns as well as the outcomes for patients in LMICs. This paper provides an overview of a cyclical framework for quality improvement in burn care for use in LMICs that has been developed using an iterative process over the last 10 years. Each phase of the process is outlined together with a description of the tools used to conduct a gap analysis within the service, which is then used to frame a programme of capacity enhancement. Recent externally reviewed projects have demonstrated sustained improvement with the use of this comprehensive and integrated approach over a three-year cycle. This overview paper will be supported by further publications that present these results in detail.

Estimating the cost impact of dressing choice in the context of a mass burns casualty event

Mass casualty burn events (MCBs) require intense and complex management. Silver-infused longer use dressings might help optimise management of burns in an MCB setting. We developed a model estimating the impact of dressing choice in the context of an MCB. The model was developed in Excel in collaboration with experienced emergency response clinicians. The model compares use of silver-infused dressings with use of traditional dressings in patients with partial thickness burns covering 30% of their body. Costs were estimated from a UK perspective as a proxy for a funded emergency response team and limited to cost of dressings, bandages, padding, analgesia and staff time. Expected patient costs and resource use were summarised over an acute 2-week intervention period and extrapolated to estimate possible time savings in a hypothetical MCB. Per patient costs were estimated at £2,002 (silver) and £1,124 (traditional) (a daily additional spend of £63). Per patient staff time was estimated at 864 minutes (silver) and 1,200 minutes (traditional) (a daily time saving of 24 minutes). Multiplying up to a possible MCB population of 20 could result in a saving equivalent to 9 staff shifts over the 2-week intervention period. The model was sensitive to type of silver dressing, frequency of dressing change and staff costs. We found increased costs through use of silver dressings but time savings that might help optimise burns management in an MCB. Exploring the balance between costs and staff time might help future MCB response preparation.

Where to from here? A quality improvement project investigating burns treatment and rehabilitation practices in India

Objective

To describe the capacity of the Indian healthcare system in providing appropriate and effective burns treatment and rehabilitation services.

Results

Health professionals involved in burns treatment or rehabilitation at seven hospitals from four states in India were invited to participate in consultative meetings. Existing treatment and rehabilitation strategies, barriers and enablers to patient flow across the continuum of care and details on inpatient and outpatient rehabilitation were discussed during the meetings. Seventeen health professionals from various clinical backgrounds were involved in the consultation process. Key themes highlighted (a) a lack of awareness on burn first aid at the community level, (b) a lack of human resource to treat burn injuries in hospital settings, (c) a gap in burn care training for medical staff, (d) poor hospital infrastructure and (e) a variation in treatment practices and rehabilitation services available between hospitals. A number of opportunities exist to improve burns treatment and rehabilitation in India. Improvements would most effectively be achieved through promoting multidisciplinary care across a number of facilities and service providers. Further research is required to develop context-specific burn care models, determining how these can be integrated into the Indian healthcare system.

Paediatric injuries due to home treadmill use: an emerging problem

INTRODUCTION

The use of home exercise equipment is increasing and treadmills are becoming more popular. This has brought with it an emerging but preventable problem. We present our experience, highlight the importance and promote public awareness of this type of injury. To our knowledge this has not been reported previously in the UK.

METHODS

A retrospective review was conducted of the medical records at two regional burn units of children who sustained treadmill-related injuries between July 2003 and July 2009. Data on patient demographics, mechanism of injury, management, surgical intervention and outcome were recorded.

RESULTS

Twenty-nine children (15 boys, 14 girls) sustained treadmill-related injuries. The mean age was 3.8 years (range: 1-13 years). All injuries occurred at home and the majority of children trapped their hand under the running belt when an adult was using the machine. Most of the injuries were to the upper limb (97%) with less than 1% of the total body surface area burnt. More than two-thirds of patients had deep burns and 17 (58%) required surgical intervention. Five patients developed hypertrophic scars. All patients achieved a good functional outcome.

CONCLUSIONS

Treadmills can pose a significant danger to children. These injuries are preventable. Regulatory authorities, manufacturers and parents should take steps to prevent this emerging health problem.

Foot burns: Epidemiology and management

This is a retrospective study of the epidemiology and management of isolated foot burns presenting to the Welsh Centre for Burns from January 1998 to December 2002. A total of 289 were treated of which 233 were included in this study. Approximately 40% were in the paediatric age group and the gender distribution varied dramatically for adults and children. In the adult group the male:female ratio was 3.5:1, however in the paediatric group the male:female ratio was more equal (1.6:1). Scald burns (65%) formed the largest group in children and scald (35%) and chemical burns (32%) in adults. Foot burns have a complication rate of 18% and prolonged hospital stay. Complications include hypertrophic scarring, graft loss/delayed healing and wound infection. Although isolated foot burns represent a small body surface area, over half require treatment as in patients to allow for initial aggressive conservative management of elevation and regular wound cleansing to avoid complications. This study suggests a protocol for the initial acute management of foot burns. This protocol states immediate referral of all foot burns to a burn centre, admission of these burns for 24-48 h for elevation, regular wound cleansing with change of dressings and prophylactic antibiotics.

Neonatal accessory digits: a survey of practice amongst paediatricians and hand surgeons in the United Kingdom

AIM

To describe the management of neonatal accessory digits, comparing views of paediatricians with those of hand surgeons, giving particular emphasis to the form of partial, ulnar duplication of the little finger (ulnar or postaxial polydactyly type B) which has a narrow pedicle.

METHODS

Postal questionnaire of management preference using three photographs of ulnar accessory digits of varying complexity.

RESULTS

The response rate was 64% in 234 paediatricians and 25% in 260 surgeons. All respondents would intervene in cases of ulnar polydactyly type B with a narrow pedicle: 79% of paediatricians but only 67% of hand surgeons would recommend referral of these cases for specialist assessment, the remainder advocating ligation by the paediatrician in the nursery. Paediatricians and neonatologists working in regional centres or with an on-site specialist service were more likely to refer. There was almost unanimous agreement on the management of the most complex case, but no general consensus on that of the simplest form.

CONCLUSION

There is uncertainty and inequality in initial treatment decisions for infants with all but the most complex of accessory digits. Despite published evidence that ligation gives satisfactory results, most respondents in this survey advocate specialist referral, with evidence that the availability of specialist services influences decision making.

The use of ADCON-T/N after repair of zone II flexor tendons

This double-blinded randomised clinical trial investigated whether application of ADCON-T/N to zone II tendon repairs improved their outcome. Fifty-nine patients were randomised into control or ADCON-T/N treated groups and all followed an early mobilisation regime following tendon repair. Tendon rupture rates were comparable between the control and ADCON-T/N treated patients. At six months follow-up, the ADCON-T/N treated group had better proximal interphalangeal motion.

Isolated buttock burns: epidemiology and management

This is a retrospective study of the epidemiology and management of isolated buttock burns presenting to the Welsh Regional Burns Centre from January 1996 to December 1999. A total of 36 cases have been treated of which 31 are included in this study. Approximately, 50% are in the paediatric age group and the sex distribution is equal for both adults and children. Contact burns form the largest group, and in children resulted in superficial burns requiring dressings only. The adult population is more likely to sustain deeper burns that require skin grafting, and approximately 50% will have a contributing premorbid condition. Despite difficulties in dressing and positioning of the patients, grafting of full thickness burns is appropriate without recourse to faecal diversion.

Gunshot injuries of the head of the pancreas: conservative approach

This study is comprised of 48 patients with gunshot injuries of the head of the pancreas, many of which were high velocity injuries. The purpose of this study was to evaluate our management policy for these injuries based on our recent wide experience. Patients with grade II and III injuries underwent conservative surgery, with 0% and 21% postoperative mortality, respectively, directly related to the pancreatic injury. For patients in whom the duodenum was involved, pyloric exclusion was applied depending on the grade of the duodenal injury. We concluded that moderate gunshot injuries of the head of the pancreas (grade II) can be safely treated by débridement and suture repair, with or without drainage. Severe (grade IV) injuries warrant a pancreaticoduodenectomy. Most grade III injuries can be treated by débridement and drainage unless an associated severe duodenal injury is present, in which case resection may be indicated.

Diaphragmatic herniation after penetrating trauma

A study was made of 45 patients with diaphragmatic herniation after penetrating trauma. In 29 the diagnosis was established during the first admission (early presentation) and in 16 during a subsequent admission (delayed presentation). The mortality rate in the early presentation group was 3 per cent compared with 25 per cent in the delayed presentation group. The presence of gangrenous or perforated abdominal viscus in the chest cavity was the single most common and severe aggravating factor. The need for diagnosis of diaphragmatic herniation during the initial admission is emphasized. As isolated diaphragmatic injuries provide few helpful clinical features to aid diagnosis, appropriate investigations and good follow-up are of paramount importance in preventing late herniation of intra-abdominal viscera through a penetrating diaphragmatic injury.

Distal pancreatectomy for gunshot injuries of the distal pancreas

This study comprised 57 patients with gunshot injury of the distal pancreas. There were 16 grade II, 29 grade III and 12 grade IV pancreatic injuries. The intraoperative mortality rate was 12 per cent. Patients with the most severe grade II injuries and all those with grade III and IV injuries had distal pancreatectomy and splenectomy, with a 14 per cent fistula formation rate and 2.3 per cent postoperative mortality rate directly related to the pancreatic injury. The remaining patients with grade II injuries were managed by debridement and drainage; there were no fistulas or deaths. The method of closure of the pancreatic resection margin is unrelated to fistula formation, and identification of the duct for ligation is unnecessary. Liberal use of distal pancreatectomy with splenectomy for gunshot injuries of the distal pancreas is suggested.

Penetrating injuries of the axillary artery

This is a retrospective study of 32 patients with penetrating injury of the axillary artery. There was an overall mortality of 6% entirely accounted for by associated injuries. Pre-operative angiography was used in 12 of these patients either to confirm the presence of an injury or to define its location. Twelve patients underwent lateral arteriorrhaphy or an end-to-end anastomosis and 19 patients had an interposition graft. No immediate problems were experienced with polytetrafluoroethylene grafts compared with autogenous vein grafts. There were 14 patients with a concomitant venous injury; 13 were repaired and only transient arm oedema was experienced. Eleven patients had a brachial plexus injury and, of these, nine underwent a secondary nerve repair with a poor outcome. Axillary artery injury has a good prognosis with a morbidity related mainly to associated nerve injury and a mortality accounted for by injuries to other body systems.

Penetrating injuries of the brachial artery

This is a retrospective study of 72 patients with non-iatrogenic penetrating injuries of the brachial artery treated between 1991 and 1993. The mechanism of injury was stabbing in 39 per cent, a bullet in 51 per cent, pellets in 4 per cent and a dog bite in 6 per cent. We believe that angiography is rarely indicated, as in all our patients the diagnosis was made on clinical grounds. The proximity of the injury to neurovascular bundles was a poor predictor of arterial injury. One month after discharge 95 per cent of the patients had palpable distal pulses. Long-term morbidity is mainly attributed to associated nerve injuries.

Penetrating injuries of the femoral artery

This is a retrospective study of 106 patients with penetrating injuries to the femoral artery. The cause of injury was gunshot in 82 per cent, stabbing in 13 per cent and pellets in 5 per cent. We believe that angiography is unnecessary in patients with 'hard' signs of vascular injury: 97 patients underwent immediate exploration with positive findings. The presence of 'soft' signs alone mandates angiography as five of 12 patients with suspected injury were saved a negative exploration. Proximity of injury was a poor predictor of arterial injury. There were four amputations. Ligation of the femoral vein is not reliably associated with amputation but it was an aggravating factor in the setting of severe arterial disruption and delay to surgery.

[Comparison of amoxicillin and amoxiclav in the therapy of respiratory infections]

Randomly hospitalized patients with respiratory tract infections admitted to three pulmonary departments of the Golnik Institute for Pulmonary Diseases and Tuberculosis were enrolled in an open, comparative clinical study of Amoksiklav and Amoxicillin. A group of 26 patients with a mean age of 64.5 years presenting with pneumonia (13), exacerbation of chronic bronchitis (12) and bronchiectasis (1) were given Amoskilav, while another 20 patients with a mean age of 61.4 years presenting with pneumonia (9), exacerbation of chronic bronchitis (5), bronchiectasis (5) and sinusitis (1) received Amoxicillin. The efficacy of treatment was assessed by bacteriological findings of respiratory tract specimens, sputum and blood leucocytosis, macroscopic purulence of sputum and the presence of fever. The bacteriological findings are shown in detail. Leucocytosis and macroscopic purulence of sputum significantly improved on Amoksiklav therapy (p less than 0.05) while with Amoxicillin there was no significant improvement. With respect to the presence of fever, there was no significant difference between Amoksiklav and Amoxicillin. The overall clinical and bacteriological response was very good and good in 88.5% of patients treated with Amoksiklav compared to 75% of those receiving Amoxicillin. Additionally, 1000 pathogenic strains were tested for their response to Amoksiklav and Amoxicillin. Amoksiklav proved superior against strains of Branhamella catarrhalis, E. coli, coagulase-negative staphylococci and K. pneumoniae (p less than 0.01).