A holistic exploration of paediatric partial thickness burn care in the outpatient setting

Abstract

Introduction: Countless children sustain painful burn injuries every year, many requiring hospital treatment. Treatment can involve painful wound care procedures, possible surgical intervention and the risk of lifelong scarring which can have a multi-faceted effect on the child and their family. The current focus of research into paediatric burns lies predominantly with severe burn injuries which generally denote long hospital stays and worse outcomes (functionally, cosmetically and psychosocially). However in high-income countries, the majority of children sustain small partial thickness burns which are treated in the outpatient setting with specialized dressings. Thesis aim: The aim of this study was to provide a holistic and comprehensive exploration of pediatric partial thickness burn care. The first phase was to determine the most effective silver dressing for reduced wound re-epithelialization time and pain during dressing changes, establish the reliability of a new wound measurement tool, assess the scar outcome of study participants and complete a cost effective analysis of silver dressings. The second phase was to provide an exploration of parent experiences in the outpatient setting. Phase 1 Methodology and Results: RCT: Ninety-six children (0-15 years) with ≤10% total body surface area partial thickness burn injuries were recruited for a randomised controlled trial and received either 1) ActicoatTM; 2) ActicoatTM with MepitelTM; or 3) Mepilex AgTM dressings changed every 3-5 days until full re-epithelialization or skin grafting occurred. When adjusted for burn depth, Acticoat™ significantly increased the expected days to full re-epithelialization by 40% (p < 0.01) and Acticoat™ with Mepitel™ significantly increased days to full re-epithelialization by 33% (p = <0.01) when compared to Mepilex Ag™. Pain scores were also significantly lower at dressing changes in children who received Mepilex Ag and Acticoat with Mepitel compared to Acticoat alone. 3D photography reliability: Burn wound re-epithelialisation was measured at each dressing change using digital planimetry (Visitrak™ system) and stereophotogrammetry (3D photography). Wound surface area measurements were complete for 75 participants at the first dressing change. Level of agreement between wound surface area measurements was excellent (ICC 0.96, 95% CI 0.93, 0.97). Visitrak™ tracings could not be completed in ii 19 participants with 16 aged less than two years. 3D photography could not be completed for one participant. Barriers to completing Visitrak™ tracings were: excessive movement, pain, young age or wound location. Cost-analysis: This study was trial based economic evaluation conducted from a healthcare provider perspective. Costs directly related to the management of partial thickness burn injuries ≤10% TBSA were collected from March 2013-July 2014 and for a one year post re-epithelialization time horizon. Incremental cost effectiveness ratios were estimated and dominance probabilities calculated. Costs (dressing, labor, analgesics, scar management) were considerably lower in the Mepilex Ag™ group (median AUD$94.45) compared to the Acticoat™ (median $244.90) and Acticoat™ with Mepitel™ (median $196.66) interventions. There was a 99% and 97% probability that Mepilex Ag™ dominated (cheaper and more effective than) Acticoat™ and Acticoat™ with Mepitel™, respectively. Scar assessment: An assessment of forty-three children participants’ skin appearance was conducted at 3 and 6 months post re-epithelialization for children who presented for follow-ups or sent a photo. Days to re-epithelialization was a significant predictor of skin/scar quality at 3 and 6 months (p<0.01). Patient-rated color and observer-rated vascularity and pigmentation POSAS scores were comparable at 3 months (color vs. vascularity 0.88, p<0.001; color vs. pigmentation 0.64, p<0.001), but patients scored higher than the observer at 6 months (color vs. vascularity 0.57, p<0.05; color vs. pigmentation 0.15, p = 0.60). Burn depth was significantly correlated with skin thickness (r=0.51, p<0.01). Hypopigmentation of the burn site was present in 25.8% of children who re-epithelialized in ≤2 weeks. Phase 2 Methodology and Results: This study was a qualitative design using purposive sampling. Ten parents of children aged 0 to 5 years with an acute partial thickness burn injury ≤10% TBSA who were referred for outpatient treatment were interviewed. Semi-structured interviews were conducted on the day of their child’s discharge from the service. Interviews were transcribed verbatim and analysed using an inductive thematic analysis method. Themes identified included; going into the unknown, facilitation and resilience. Discussion: This body of work has provided a comprehensive and holistic overview of pediatric partial thickness burn care. Outcomes from this study have resulted in the development of a new and more cost-effective dressing protocol for pediatric burn care, which has been implemented Queensland-wide and introduced interstate and in New Zealand. 3D photography is now being utilized as a non-invasive alternative to digital planimetry when completing wound surface area measurements. It has also provided a greater knowledge of challenges and outcomes faced by this population of children and their families, which can be used to inform future clinical practice so that the burn treatment experience includes faster wound re-epithelialization, less pain and reductions in parental stress.