Epidemiology of children admitted to the Dutch burn centres. Changes in referral influence admittance rates in burn centres

Background

In the Beverwijk Burn Centre a remarkable rise has been noted in the number of paediatric admissions since 2000. To investigate if this is a national trend and, if so, what may have caused it, a retrospective epidemiological study has been undertaken.

Materials and methods

The databases of the three Dutch burn centres were combined. Data on the population at risk for admission in a burn centre and data on burns related hospital admissions were added. Two age groups, 0–4 years and 5–17 years and two time periods, 1995–1999 and 2000–2007, were compared.

Results

The mean number of paediatric admissions in the Dutch burn centres per year increased by 44.0% and 44.3% for the younger children (0–4 years) and the older children (5–17 years), respectively, whereas the number of paediatric burn admissions in other hospitals in the Netherlands decreased. The percentage of children that was referred from other hospitals increased in both age groups, and for the younger children this was significant.

Conclusion

There has been a shift in paediatric burn care towards a greater volume of admissions in specialized burn care of especially young children with less severe burns. A possible explanation for the increased number of referred children may be the introduction of the EMSB course in 1998, since EMSB guidelines dictate stricter and generally accepted referral criteria.     

Adherence to the emergency management of severe burns referral criteria in burn patients admitted to a hospital with or without a specialized burn center

BackgroundThe primary aim was to determine to what extent referral and admission of burn patients to a hospital with or without a burn center was in line with the EMSB referral criteria.MethodsThis was a retrospective, multicenter cohort study. Burn patients admitted from 2014 to 2018 to a hospital in the Southwest Netherland trauma region and Network Emergency Care Brabant were included in this study. Outcome measures were the adherence to the EMSB referral criteria.ResultsA total of 1790 patients were included, of whom 951 patients were primarily presented to a non-burn center. Of these patients, 666 (70.0%) were managed according to the referral criteria; 263 (27.7%) were appropriately not referred, 403 (42.4%) were appropriately referred. Twenty (2.1%) were overtransferred, and 265 (27.9%) undertransferred. In 1213 patients treated at a burn center 1119 (92.3%) met the referral criteria. Adherence was lowest for electrical (N = 4; 14.3%) and chemical burns (N = 16; 42.1%), and was highest in ‘children ≥5% total body surface area (TBSA) burned’ (N = 109; 83.2%).ConclusionThe overall adherence to the referral criteria of patients presented to a non-burn center was fairly high. However, approximately 25% was not transferred to a burn center while meeting the criteria. Most improvement for individual criteria can be achieved in patients with electrical and chemical burns.     

Impact of trauma societies on the clinical care of polytrauma patients

Introduction

Trauma societies have an influence on the management and outcome of polytrauma. Its contributions include setting up standard definitions, trauma registries, evidence-based medicine guidelines, and the creation of educational tools such as specific courses of trauma care and decision-making.

Methods

Literature and web-based search of definitions and available information.

Results

The history of and accomplishments of trauma societies in the above-mentioned domains are reviewed, including the major trauma registries (Major Trauma Outcome Study, National Trauma Data Bank, The American Pediatric Surgical Association, the American Burn Association trauma, and the German Trauma Society trauma registries). Several learned societies in the field of trauma have created recommendations and/or guidelines concerning polytrauma (the Eastern Association for the Surgery of Trauma, The Society of Critical Care Medicine, and the German Trauma Society, Brain Trauma Foundation, and the Essential Trauma Care (EsTC) Guidelines). Several practical, hands-on courses and scoring systems for improving the quality of management of polytrauma patients have been founded and implemented in the past 35?years, including the Advanced Trauma Life Support (ATLS^?) Course of the American College of Surgeons, the Definitive Surgical Trauma Care (DSTC^TM) Course, the National Trauma Management Course (NTMC^TM Course,) the Advanced Trauma Operative Management (ATOM) Course, and the European Trauma Course (ETC).

Conclusions

Trauma and emergency care societies have made an elaborate, substantial contribution by developing trauma registries and creating specific guidelines courses on trauma care and decision-making.     

Effect of training in the Emergency Management of Severe Burns on the knowledge and performance of emergency care workers as measured by an online simulated burn incident

Objective

To determine the value of training for the Emergency Management of Severe Burns (EMSB) for medical and nursing staff working in emergency care as measured by their performance in a simulated burn incident online program.

Methods

An Internet-based questionnaire, which included a simulated burn incident, was developed. All of the medical and nursing staff in hospital emergency departments and ambulance services in the Netherlands were invited to complete this questionnaire. The effect of EMSB training on the individual's knowledge of and performance in the emergency management of a burn victim was evaluated because some of the respondents had participated in EMSB training, whereas others had not.

Results

Of the 280 responses received, 198 questionnaires were included in the analysis. The analyzed questionnaires were submitted by nurses (43%), ambulance workers (33%), and physicians (23%). Only 14% of the people in the study had participated in EMSB training, whereas 78% had received other or additional life support training and 22% of respondents had no additional life support training.Medical and nursing staff who had participated in EMSB training performed better in the following subjects: mentioning hypothermia as a focus of attention (70% versus 53%, p = 0.085), correct use of hand size (70% versus 36%, p = 0.001) and use of the correct hand percentage in the estimation of total body surface area (TBSA, 82% versus 57%, p = 0.015), suspicion of no airway obstruction in an outdoor trauma (93% versus 63%, p = 0.002) and referral of functional area burns to a burn center (22% versus 8%, p = 0.04). However, both groups overestimated the TBSA (34% of the total group overestimated ≥20%) and did not know the correct formula for fluid resuscitation (87% of the total group).

Conclusion

There is some evidence that medical staff members who have participated in EMSB training have a better knowledge of emergency management and are more effective in the management of a simulated burn case. However, both individuals who had participated in EMSB as well as those who had not participated in EMSB needed additional training in EMSB.     

Introduction of the certificate in transplant coordination in the United Kingdom

Training for transplant coordinators is not mandatory in the United Kingdom, although the United Kingdom Transplant Coordinators Association has provided informal courses since 1988. The authors of this article were responsible for the development of an accredited training program for transplant coordinators in the United Kingdom. Accredited by the University of Central England, the course modules have been run and managed by the Association since 1996. The course consists of 3 modules: Introduction to Transplant Coordination; Interpersonal and Professional Skills for Transplant Coordinators, and Introduction to Research Methods for Transplant Coordinators. Between 1996 and 1999, 64 transplant coordinators (60% of transplant coordinators currently in post) in the United Kingdom have undertaken at least 1 module. The Association feels that the accredited training program means one step further on the road to professional recognition of transplant coordinators in the United Kingdom.     

Experiences in organizing Advanced Burn Life Support (ABLS) provider courses in Japan

The ABLS course sponsored by the ABA has not yet been made available in Japan, although it is strongly desired. During the 3 years between 2006 and 2008, authorized ABLS provider courses were given once a year in Japan as part of preparations to reach an agreement between the ABA and the JSBI for the continuation of ABLS provider courses in Japan. These courses were provided as one of the programs available at the annual meeting of the JSBI. Nine Japanese registered ABLS instructors (including some candidates) acted as lecturers. Two national faculty members and one course coordinator, acting as ABA observers, participated in the first and second courses. In total, 64 physicians (37 emergency physicians, 20 plastic surgeons, 4 intensivists and 3 general surgeons) attended the courses. Course management and instructor behavior were reviewed by the ABA observers and the 64 physicians in attendance using questionnaires. The ABA observers rated the courses as “outstanding” in every aspect (course faculty, facilities, course organization, course conduct, and adherence to ABLS philosophies). The pre-course planning, course conduct, and course evaluations were professional and adhered to the highest educational standards. However, several areas of the ABLS course content may require revision to accommodate differences in standard medical treatment between the United States and Japan. Two percent of the physicians rated the courses as easy, 59% rated the course as moderate, 22% rated the course as slightly difficult, and 6% rated the course as difficult. The courses were generally evaluated as very good by 28% of the physicians and good by 56%. The major opinion regarding the organization of the course in Japan was that the course should have undergone appropriate curriculum changes to accommodate societal differences (including the translation of the course into Japanese) as well as modifications to the disaster management and patient transport sections. Regarding the organization of future ABLS courses in Japan, the active involvement of the JSBI is inevitable. Several areas of the ABLS course content may need to be revised to accommodate differences in standard medical treatment between the United States and Japan. A joint effort between the ABA and the JSBI regarding appropriate curriculum changes to accommodate societal differences as well as modifications to some sections would increase the applicability of the course in Japan.     

Addressing sexual function in adult burns victims: A multidisciplinary survey of current practice in UK burn units

BackgroundBurn injury was shown to affect a patient’s sexuality. Cultural and social inhibitions may mean this topic is often overlooked.AimsTo assess current opinion and management strategies amongst UK burns care teams in relation to addressing sexual function after burn injuries.MethodAn online questionnaire was circulated to all members of the British Burn Association.ResultsThe majority of UK burn care professionals reported that sexual function after burn injury was an important (79% of respondents) and unaddressed problem (85% of respondents) in current clinical practice. However, over 90% of professionals reported that they ‘never’ or ‘only occasionally’ ask patients about their sexual function concerns. Multiple different management strategies are employed by UK burns centers, with a number of respondents indicating no designated individual responsible for leading care in this area.ConclusionsCurrently no standardized method is in common use to address sexual function concerns of adult burns victims. The authors suggest this topic may be included in future information leaflets for patients and in burns awareness courses for medical professionals.     

Smoke inhalation injury: diagnosis and respiratory management

Smoke inhalation is a significant comorbid factor following major thermal injury. Smoke exposure is only a trigger for the sequence of events responsible for the development of inhalation injury. Noxious chemicals generated by incomplete combustion injure the exposed bronchoepithelium and stimulate the release of chemical mediators that cause a progressive inflammatory process. Airway inflammation and pulmonary edema impair gas exchange and increase the susceptibility to pulmonary infection. Earlier diagnosis and treatment of inhalation injury is an important element to improve the clinical course of severe burn patients. The American Burn Association, however, recently concluded that there are insufficient data to support a treatment standard for the diagnosis of inhalation injury. At present, the diagnosis of inhalation injury is supported by the combination of history, physical examination, bronchoscopy, and laboratory findings For accurate diagnosis of inhalation injury, helical CT scanning and examination to detect activated leukocytes in bronchoalveolar lavage fluid may be warranted. In the respiratory management of inhalation injury, repeated removal of pseudomembrane by fiberoptic bronchoscopy and the use of adequate PEEP to avoid airway obstruction are essential. High-frequency percussive ventilation can be a suitable mode of ventilation for inhalation injury.     

Retrospective analysis of the Bangour Burn Unit.

The Bangour Burn Unit was opened in 1968 having been built using existing buildings modified in a relatively inexpensive way. The buildings were unsophisticated because the Unit was designed to be temporary before an eventual move into a new regional plastic surgery unit elsewhere. An analysis of some salient observations over the 22-year period of its lifetime is discussed.     

European Burns Association guidelines for the management of burn mass casualty incidents within a European response plan

BackgroundA European response plan to burn mass casualty incidents has been jointly developed by the European Commission and the European Burn Association. Upon request for assistance by an affected country, the plan outlines a mechanism for coordinated international assistance, aiming to alleviate the burden of care in the affected country and to offer adequate specialized care to all patients who can benefit from it. To that aim, Burn Assessment Teams are deployed to assess and triage patients. Their transportation priority recommendations are used to distribute outnumbering burn casualties to foreign burn centers. Following an appropriate medical evacuation, these casualties receive specialized care in those facilities.MethodsThe European Burns Association’s disaster committee developed medical-organizational guidelines to support this European plan. The experts identified fields of interest, defined questions to be addressed, performed relevant literature searches, and added their expertise in burn disaster preparedness and response. Due to the lack of high-level evidence in the available literature, recommendations and specially designed implementation tools were provided from expert opinion. The European Burns Association officially endorsed the draft recommendations in 2019, and the final full text was approved by the EBA executive committee in 2022.RecommendationsThe resulting 46 recommendations address four fields. Field 1 underlines the need for national preparedness plans and the necessary core items within such plans, including coordination and integration with an international response. Field 2 describes Burn Assessment Teams' roles, composition, training requirements, and reporting goals. Field 3 addresses the goals of specialized in-hospital triage, appropriate severity criteria, and their effects on priorities and triage. Finally, field 4 covers medical evacuations, including their timing and organization, the composition of evacuation teams and their assets, preparation, and the principles of en route care.     

Clinical outcome analysis of male and female genital burn injuries: a 15-year experience at a level-1 burn center

Objectives: The American Burn Association classifies a burn to the genitalia as a major injury. Isolated burns to the penis, scrotum or vulva are rare as a result of protection provided by the thighs and abdomen. Thus, burned genitalia represent an ominous sign of a more extensive total body surface area burn. Methods: A retrospective analysis of consecutive patients admitted to a Level‐1 Burn Unit with a burn involving the genitalia from January 1995 to December 2009 comprised the study population. Results: A total of 393 patients of 5878 patients (6.7%) admitted to the Burn Unit suffered a burn involving the genitalia, including 253 males (64.4%) and 140 females (35.6%). The median total body surface area was 12% (range 1–100%), the most common cause of genital burn was scald (n = 246, 62.9%) and median length of stay was 9 days (range 1–472 days). A total of 269 patients (68.4%) were discharged to home from the hospital, and in‐hospital mortality was 20.9%. Conclusions: The typical profile for those sustaining a genital burn include younger patients (≤30 years‐of‐age), sustaining a median total body surface area burn of 12% from a scald injury, with extensive genitalia involvement. Length of stay for genital burns is usually extended and, as a result of concomitant injuries, is associated with a 20% in‐hospital death rate.     

Evaluation of infrastructure, equipment and training of 28 burn units/burn centers in Germany, Austria and Switzerland

Treatment of burn patients requires special training and skills, and an adequate infrastructure. In the United States, burn center referral criteria and requirements of burn centers are defined by the American Burn Association (ABA) in the Guidelines for the Operation of Burn Centers, and in Germany, by the German Society for Burn Treatment (DGV). The European Burn centers in Austria and the German-speaking part of Switzerland share the standards in the setting of the German-speaking Association for Burn Therapy (DAV) with some modifications. The aim of this study was to evaluate the current infrastructure of burn centers in the three German-speaking countries with respect to the existing guidelines. Therefore, guidelines for burn center referral criteria and burn center requirements were compared between the USA (ABA) and Germany (DGV). In addition, a questionnaire was sent to all burn centers in Germany, Austria and the German-speaking part of Switzerland, in order to collect current information regarding the architectural and medical infrastructure, available equipment and care-providing personnel. The comparison of guidelines for the USA and Germany revealed similar burn center referral criteria for both countries. With respect to burn center requirements, both the USA and Germany have similar requirements, albeit with different focus points. In Germany, the main focus lies on the infrastructural requirements for burn centers, while in the US, the main focus lies on the requirements for medical and nursing personnel. Critical review of the responses from the burn centers of German-speaking countries revealed that the biggest infrastructural differences among centers were observed in burn units providing pediatric care, as compared to adult burn centers. In summary, the DGV guidelines for German-speaking countries reflect an overall adoption of the ABA guidelines, and the burn centers included in this study met those requirements. As a result of the positive experience and effective treatment of burn patients in German-speaking countries, we recommend an adoption of the ABA guidelines to those countries and societies that are in need of appropriate standards of burn care.     

Schmerztherapie bei Verbrennungen

Burn injuries represent a severe form of acute pain. In spite of improvements in wound treatment and pain regimens during recent years, the management of burn pain still remains a common problem and a tremendous challenge for clinical staff. An efficient pain treatment plan contributes to a fast and uneventful course and is an important part of the therapeutic management by plastic surgeons, anesthesiologists, psychologists and physiotherapists. Extensive pharmacokinetic alterations, additional neuropathic components and multiple dressing changes or therapeutic procedures need a flexible and dynamic pain strategy. A standardized continuous pain assessment and documentation are a cornerstone of burn pain control. In addition to pharmacological methods non-pharmacological procedures can play an important role and should be started early during burn patient therapy.     

Pain in the patient with burns

Thermal injury can be one of the most painful and disfiguringforms of trauma, as it affects the skin, the largest and mostvisible organ. The National Burn Care Review (British Burn Association,2001) determined that as many as 500,000 people suffer a burninjury each year in the UK. Most are minor. Around 13,000 people,of which 45% are children, are admitted to hospital; only asmall proportion have severe injuries requiring resuscitation. Burns anaesthesia and, when required, intensive care can forma significant part of the anaesthetic workload in the hospitalwith a burn centre. An appreciation of analgesia managementrelated to the pathophysiology of the burn is also important,and the role of the anaesthetist in supporting analgesia forburn patients is crucial. The generalist anaesthetist cannotescape entirely, as patients with burns present initially atlocal hospitals; the early management of pain can have a significantimpact on the pain experience thereafter.     

Creation of a standardized burn course for Low Income Countries: Meeting local needs

IntroductionStandardized courses for the care of the burn patient have historically been developed in High Income Countries (HIC). These courses do not necessarily reflect the challenges and needs of Low Income Countries (LIC) and some components may not be relevant there (i.e. use of ventilators in a country that has no or very limited number of ventilators). We are developing a Burn Management Course for East Africa. This course was created and trialed in a LIC and subsequently a formal manual and course curriculum created. Recently the first iteration of the course was undertaken in a major regional burn centre in East Africa. We present participant feedback on the course content, and potential future directions for course development.Objective(1) To evaluate the ability of a standardized burn course for LIC to meet the needs of the participants. (2) To explore characteristics of burn care and needs related to delivery of burn care in LIC.Methods21 students participated in a multidisciplinary burn management course. They were asked to complete an anonymous questionnaire at the end of the course.ResultsThere were 11 nurses, 6 doctors, a physiotherapist, occupational therapist, and a dietician. 15 worked in either the adult or pediatric burn units, the other six worked in emergency, ICU or the operating room. The majority of respondents (56%) had less than 3 years of experience working with burn patients. Overall agreement that the course met their objectives was rated as 4.6 out of 5. As well the students agreement that they had a better understanding of burn injury was rated as 4.8/5.55.6% indicated that scalds were the most commonly seen injury followed by 27.8% responding that flames were the most common.Some responses to the question of top difficulties facing the caregivers were similar to HIC: staffing shortages, bed shortages, and finding useable donor site in large burns. Other responses highlighted the challenges these care givers face: poverty stricken patients, not enough appropriate food available, and deficiencies in infection control practices.ConclusionIt is possible to create a course that translates knowledge from a HIC setting to meet the needs of the end-user in a LIC setting.     

烧伤整形患者心理问题分析及心理干预的研究进展

烧伤是由热力因素造成的组织损伤，其不仅可使患者受到生理性损害，烧伤带来的痛苦和外形 遭到的破坏还会使患者出现负性情绪。虽然临床可以通过整形手术来改善患者外貌美观度，但沉重的心理 负担会对其身体健康和治疗依从性造成严重影响，进而影响整形手术的顺利进行及术后康复，因此临床需 要对烧伤整形患者做好心理干预，以缓解其心理障碍，促进术后康复。本文对烧伤整形患者存在的心理问 题进行分析，并对其心理干预的研究进展进行总结，以期为烧伤整形心理护理研究提供理论依据。     

Burn contractures of the extremities

Burn contractures are common after deep burns of the limbs. When rehabilitation fails to restore joint function and normal range of motion, surgical contracture release should be performed. Different plastic surgery techniques can be used, from Z-plasty to skin grafts, artificial dermis and flaps. Surgery can also be used in case of esthetic concerns. Available surgical techniques and indications are presented.     

The utility of the functional independence measure (FIM) in discharge planning for burn patients

Determining burn patients' need for inpatient rehabilitation at discharge is difficult and an objective clinical indicator might aid in this decision. The functional independence measure (FIM) is a validated outcome measure that predicts the need for rehabilitation services. This study evaluated the utility of the FIM score for discharge planning in burn patients. A retrospective chart review and FIM score determination was performed on all major burn patients discharged from a regional adult burn centre between July 1, 1999 and June 30, 2000. From 164 adult burn patients discharged, 37 met the American Burn Association criteria for major burns. One patient had insufficient data. Therefore, 36 patients were studied (mean age 47.3 +/- 17.4 years, and mean body area burned 27.4 +/- 12.9%). All 17 patients with FIM scores greater than 110 were discharged home, and patients with FIM score of 110 or lower were discharged to another institution (rehabilitation hospital n = 14, other acute care hospital n = 4, or a nursing home n = 1) p < 0.0001. A discharge FIM score of 110 or lower was strongly associated with the need for inpatient rehabilitation, while a FIM score greater than 110 indicates the patient is independent enough to manage at home. Further prospective studies will be necessary to validate these findings.     

转化医学理念促进我国烧伤医学的发展

This article endeavours to reiterate the advances in six vital aspects of burn injury,i.e.shock/ischemiahypoxia,infection/sepsis,inhalation injury,regenerative medicine/tissue engineering and wound rep...     

中药外敷配合骶管封闭治疗腰椎间盘突出症疗效观察

目的观察中药外敷配合骶管封闭治疗腰椎间盘突出症的疗效。方法回顾性分析中药外敷配合骶管封闭治疗腰椎间盘突出症267例,以10天为一疗程,观察两个疗程,治疗后采用疼痛视觉模拟评分(VAS)和日本矫形外科学会(JOA)腰椎疾患治疗成绩评分表评定疗效。结果患者治疗后疼痛症状减轻,腰椎功能改善明显,其中治愈92例(34.45%)、显效104例(38.95%)、有效42例(15.73%)、无效29例(10.86%)。结论中药外敷配合骶管封闭治疗腰椎间盘突出症安全、简单而有效,是治疗腰椎间盘突出症的有效方法。