Burn Referral Research Articles

Pediatric Burn Referrals: Comparisons of Apples and Oranges.

Pediatric Burn Referrals: Comparisons of Apples and Oranges.

Enzymatic Debridement (Nexobrid) on Burned Hands: Retrospective Review from a Burn Referral Center in Spain.

In deep burns, the gold standard of treatment is surgical debridement and coverage, but in hands, this may lead to poor aesthetic and functional results due to the complexity of this anatomical area. Enzymatic debridement (Nexobrid) allows for the preservation of the dermal remnant and reduces the number of skin grafts when compared with surgical excision. The study aimed to analyze the patients with intermediate second-degree or deeper burns in hands who required surgical treatment after Nexobrid and those who avoided it. A descriptive retrospective study of all patients who underwent Nexobrid following hand burns between May 2015 and April 2020 treated in Vall d'Hebrón University Hospital was conducted. After the enzymatic debridement, the burn unit team determined if the burn required conservative treatment or surgery, based on the characteristics of the wound bed. A total of 202 hands were collected. Most hands included in this study had deep second-degree burns (122; 60.4%). Almost half of the hands underwent surgery (99; 49%), and most had deep second-degree burns (61; 61.62%). During follow-up, 24 hands required surgery for sequelae (11.88%) and 62 did not undergo follow-up (30.69%). In the group that needed sequelae surgery, 21 needed surgery after Nexobrid and three of them were healed with conservative treatment after Nexobrid (P < 0.001). Nexobrid decreases the number of surgical procedures in deep burns of the hand because more conservative attitudes are adopted. Also, it seems to reduce the need of surgery due to burn sequelae.

Implementation evaluation of tiered tele-triage pathways for burn center consultations and transfers.

Early transfer to specialized centers improves trauma and burn outcomes; however, overtriage can result in unnecessary burdens to patients, providers, and health systems. Our institution developed novel burn triage pathways in 2016 to improve resource allocation. We evaluated the implementation of these pathways, analyzing trends in adoption, resource optimization, and pathway reliability after implementation. Triage pathways consist of transfer nurses (RNs) triaging calls based on review of burn images and clinical history: green pathway for direct outpatient referral, blue pathway for discussion with the on-call provider, red pathway for confirmation of transfer as requested by referring provider, and black pathway for the rapid transfer of severe burns. We used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to evaluate implementation. These pathways affected all acute burn referrals to our center from January 2017 to December 2019 (reach). Outcomes of interest were pathway assignment over time (adoption), changes to burn provider call volume (effectiveness), and the concordance of pathway assignment with final disposition (implementation reliability). Transfer RNs triaged 5,272 burn referrals between 2017 and 2019. By January 2018, >98% of referrals were assigned a pathway. In 2018-2019, green pathway calls triaged by RNs reduced calls to burn providers by a mean of 40 (SD, 11) per month. Patients in green/blue pathways were less likely to be transferred, with >85% receiving only outpatient follow-up ( p < 0.001). Use of the lower acuity pathways increased over time, with a concordant decrease in use of the higher acuity pathways. Younger adults, patients referred from Level III to Level V trauma centers and nontrauma hospitals, and patients referred by APPs were less likely to be triaged to higher acuity pathways. Implementation of highly adopted, reliable triage pathways can optimize existing clinical resources by task-shifting triage of lower acuity burns to nursing teams. Prognostic and Epidemiological; Level III.

Cohort analysis of 50% lethal area (LA50) and associating factors in burn patients based on quality improvements and health policies

Burn injuries are among the common traumatic injuries, which can be accompanied with lifelong morbidity and mortality. The Lethal Area Fifty Percent (LA50) index is another reliable outcome measurement tool that assesses the standard of medical care at burn centers. It is widely used as a benchmark for assessing the quality of burn care and is considered the percentage at which 50% of burn patients are expected to die because of burn-related injuries. We aimed to determine and compare the LA50 in burn patients admitted to Shiraz Burn Referral Centers in 2018–2021 and 2011–2018 with regard to improving the quality of special care and infection control in the new hospital. We conducted a retrospective cohort analysis on patients admitted to Amir al-Momenin Burn Injury Hospital in Shiraz, Fars, Southern Iran. Data were retrospectively gathered from March 2011 to January 2022, and subsequently analyzed with standard statistical analysis, and also multivariate and probability analysis. A total of 7382 patients with acute burns injuries were identified. Among them, 4852 (65.7%) patients were men, and the median age was 27 years [Q1–Q3 7–40; range 1–98]. Most of the patients were in the pediatric and early adulthood age range, with 76.2% being younger than 40 years old. The median TBSA was 24% [IQR 14, 43], and the median duration of hospitalization was 11 [IQR 11] days. Most injuries were secondary to flame and fire (33.5%; n = 2472). The mortality rate in our study was 19.0% (n = 1403). We evaluated our patients based on two main time intervals: March 2011 till February 2018 (n = 3409; 46.2%), and March 2018 to January 2022 (n = 3973; 53.8%). Based on multivariate analysis, the second interval of our study was significantly correlated with a more female patients, higher age, lower TBSA, less burn injuries due to scald, contact, but more frequent fire and flame injuries, and also lower mortality rate. Factors correlated with higher mortality included male gender, older age, shorter hospitalization duration, higher TBSA, etiology of fire and flame, and accidental burn injuries. A Baux score of 76.5 had a sensitivity of 81.1%, specificity of 87.3%, accuracy of 86.1% in predicting mortality among our patients. The mortality probability for the study intervals were 20.67% (SD 33.0%) for 2011–2018, and 17.02% (SD 29.9%) for 2018–2022 (P < 0.001). The LA50 was 52.15 ± 2 for all patients. This ammount was 50 ± 2% in 2011–2018, and 54 ± 2 in 2018–2022 (P < 0.001). The mean LA50 values showed significant improvements following significant modifications in our critical care for burn victims, including augmented intensive care unit capacity, prompt relocation of inhalation burn cases to the intensive care unit, establishing a well-trained multidisciplinary team, and improved infection control. To improve outcomes for burn patients in developing countries, major changes should be made in the management of burn patients and LA50 is a reliable assessment tool for evaluating the how these changes affect patient’s outcomes.

Clinical decision-support for acute burn referral and triage at specialized centres – Contribution from routine and digital health tools

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.

The impact of COVID-19 on burn referrals received via telemedicine

BackgroundBurn referrals make up a significant proportion of the referrals received by the on-call Plastics surgery team at University Hospital Plymouth (UHP). UHP is a burns facility that takes referrals that are< 10% total body surface area (TBSA) in adults and< 5% in children. Since switching to a telemedicine service in 2018, this has had the benefit of not needing to see the patient face-to-face. It allows for direct advice given over the phone enabling immediate treatment to be administered. In addition it prevents unnecessary referrals. The COVID-19 pandemic has meant that more people are spending time at home and this study aims to see if this has had an impact on the number of referrals received. MethodsData was collected retrospectively over 2 years 2019 and 2020 from MDSAS telemedicine service. The outcome of each referral was recorded as advice given, seen in outpatients or patient admitted. The total for each year was calculated and compared. Also recorded was the age of the patient, the referring unit, the type of burn and the TBSA. ResultsA 19.3% increase in referrals received during the year of 2020. The most common age group for a burn referral was the 0–5 years age group; the number of referrals increased by 8.4% in this age group in the year of lockdown. Scalds and contact burns remained the highest mechanism of injury. TBSA of 0.5% was the most common TBSA over both years. Over 47% of referrals travelled from over 30 miles away. The majority of referrals were either seen in outpatients or given advice only. Burn referrals were most commonly over-estimated, 23.2% of burn referrals in 2019 and 20.9% in 2020 were over estimated by> 1% TBSA. 5.5% of referrals were under-estimated. ConclusionThere was an increase in the number of referrals during COVID-19. Overall there were a very low number of inappropriate referrals. The telemedicine system has impacted positively in time efficiency especially during COVID-19. It has meant that advice can be given without seeing the patient directly leading to both benefits for the patient and the department.

P59 How COVID-19 influenced UK Burns Services: a national multicentred audit

IntroductionCOVID-19 has affected national guidelines and availability of resources, resulting in different approaches to treating burns. This project aimed to identify changes to burns management in the UK during the “first wave” of COVID-19, and how the lessons learned can be applied to the current “second wave”.MethodsBetween 11th July-15th September, 18 burns services across the UK completed a MDT survey and contributed data on service evaluation. The MDT survey captured perspectives of multiple stakeholders and included changes to burns services, disruptions to supply chain, and service improvements resulting from COVID-19. Service evaluation data was collected retrospectively and prospectively on patients who received inpatient/outpatient treatment during COVID-19. Patients in the retrospective cohort were first seen by burns services between 6th-30th April (coinciding with the UK’s COVID-19 peak), and the prospective cohort were first seen between 30th April-15th September. Each cohort consisted of 10-20 patients per burns service. Service evaluation covered key areas of burns aetiology, referral pathway changes, patient presentation delays to tertiary services, patient management decisions, and outpatient dressing clinic management. Data from the MDT survey and the service evaluation were analysed by descriptive statistics and thematic analysis.ResultsThe changes to burns services include delays in burn referrals, increase in conservative management, and increased use of telemedicine.ConclusionAcross the UK, safe and effective burns care continued to be delivered despite difficulties from the pandemic. We hope the learning points identified in this study will be of use during the “second wave” of the pandemic.

Let's Escape Didactics: Virtual Escape Room as a Didactic Modality in Residency.

The virtual escape room is a didactic activity for emergency medicine residents (interns, junior residents, senior residents). Residency programs are employing a wide variety of active learning techniques to engage their learners, including large-group discussion, small-group activities, team-based learning, gamification, problem-based learning, role-playing and case studies. In recent years, educators have drawn their attention to educational escape rooms, a new type of learning activity that utilizes collaborative learning activities to foster creating thinking, communication, teamwork and leadership.1-3 There have been a number of cases in medicine, 4,5 but there have been limited works published on the use of virtual educational escape rooms in residency education.Unfortunately, the COVID pandemic has made participation in an escape room more difficult. In lieu of social distancing during the COVID pandemic, participation in a virtual escape room is an effective and flexible learning modality for resident didactics that appears to promote participant satisfaction, competency, learning, and engagement. By the end of the activity, learners should be able to:Identify the hazardous chemicals associated with house firesClassify burn injury according to depth, extent and severity based on established standardsRecall the actions to take in response to fire emergencies (R.A.C.E. and P.A.S.S. acronyms)Recall key laboratory features of cyanide and carbon monoxide poisoningsIdentify appropriate management strategies for smoke inhalation injuriesRecite the treatment for cyanide and carbon monoxide poisoningsDescribe the management of the burn injuriesCommunicate and collaborate as a team to arrive at solutions of problemsDisplay task-switching and leadership skills during exerciseEvaluate virtual escape room experience. Emergent care of burns, a popular and shared topic in both Emergency Medicine and Family Medicine literature, was chosen and educational objectives were developed. The website Deck.Toys was utilized to formulate the escape room along with puzzles around the educational objectives. Students congregated remotely on Zoom, and after instructions, were separated into teams to solve content-specific puzzles in order to escape the room. Teams which solve all the puzzles in the allotted time were considered to have successfully escaped the room. After the allotted time, the faculty led debriefing, and topic discussion occurred. Sixty-three participants composed of residents (24 emergency [EM], 29 family medicine [FM], 4 combined emergency and family medicine [EM/FM]), advanced practice practitioner trainees (2 EM), and faculty member participants (4 FMP) partook in the virtual escape room experience. At the end of the activity, a 17-item survey using Likert-scale questions was embedded in order to obtain feedback regarding satisfaction, engagement, learning, and medical competency in communication, collaboration, task-switching, and leadership skills. Eighteen out of 63 participants filled out the survey. This was the first virtual escape room experience for 94% of the respondents. A majority (88.9%) of respondents enjoyed the virtual escape room, finding it fun, interesting, engaging, and interactive. None of the respondents preferred traditional didactics over the virtual escape room activity, and 72% were either just as or equally as satisfied with virtual compared to in-person escape rooms. Nearly all respondents agreed that the activity encouraged collaboration, communication skills, task-switching, and leadership skills (94.4%, 88.9%, 72.2%, 72.2%, respectively). Participation in a virtual escape room is an effective and flexible learning modality for resident didactics that appears to promote learner satisfaction and engagement. The escape room also promoted important competencies encouraged during residency, such as interpersonal and communication skills and practice-based learning and improvement, and is an effective addition to virtual learning tools. Small group activity, team-building exercise, remote learning, virtual learning, educational games, gamification, medical education, escape room, millennials, student engagement, adult learning theory, emergency medicine residents, family medicine residents, chemicals in house fires, smoke inhalation injuries, burn classification, burn injury management, carbon monoxide poisoning, cyanide poisoning, R.A.C.E. acronym, P.A.S.S. acronym, fluid resuscitation in burn patients, burn referrals.

745 Pediatric Burn Transfers: A 10 Year Analysis of Adherence to ABA Transfer Criteria

Abstract Introduction Severe burn injuries require complex care at certified burn centres to minimize morbidity and mortality. The ABA Burn Centre Referral Criteria was developed to aid clinicians in determining which patients warrant transfer as physician comfort with the management of pediatric burns, accurate estimation of TBSA, and burn depth varies. We hypothesize that pediatric patients are often transferred despite not meeting referral criteria. The aim of this study was to review pediatric patients with burn injuries that were transferred to the provincial burn centre over the past 10 years to better understand the reasons for the transfer. Methods A 10-year retrospective review from January 2008 to December 2018 was performed using the provincial Burn Registry. Pediatric burn patients under 18 years old who were transferred for burn care were identified and their demographics, burn characteristics, and the basis for transfer was analyzed against the ABA Burn Referral Criteria. Results A total of 130 pediatric burn patients were transferred from 42 different hospitals of varying trauma levels. Patients on average were 5 years old, predominantly male (59%), and scalds were the most common etiology (53%). Most patients were transferred by a fixed-wing ambulance (54%) and the average transport time was 1.5 days after the initial injury. All children met 1 or more ABA Referral Criteria for transfer. The most common reasons for transfer were for a TBSA greater than 10% (42.2%), burn to the hand (27.7%) or perineum (11.5%), 3° burn depth (12.3%), or significant pre-existing medical disorders (9.2%). Conclusions Over the past 10 years, all pediatric burn patients met ABA Burn Centre Referral Criteria based on TBSA, burn depth and burn location alone. This study is limited in that we were not able to capture all pediatric burn patients to identify those that warranted a referral but were not transferred. Applicability of Research to Practice The results indicate that burn-related transfers to the provincial burn centre were appropriate. The dissemination of this information to the referring centres may serve to reinforce these positive referral patterns. Furthermore, this audit provides insight into the geographic origins of pediatric burn referrals in the province to help direct burn prevention and physician education efforts, as well as resources for initial burn care and post-discharge rehabilitation services.

Factors related to pediatric unintentional burns: The comparison of logistic regression and data mining algorithms

Background: Burn injuries are one of the traumas seen in all parts of the world and children are usually one of the vulnerable groups. The aim of this study was to determine the factors related to unintentional burns in children, using data mining algorithms. Methods: In this hospital-based case-control study conducted in Kermanshah province, Iran, data were collected over a period of 15 months. Children under the age of 15 years old who were referred to the burn ward of Imam Khomeini Hospital, the only burn referral in Kermanshah province, were included as cases. For the control group, children who were admitted to Dr. Mohammad Kermanshahi Hospital, the only specialist and subspecialist pediatric center in this province, were included. Frequency matching was performed for age and sex. Support vector machine (SVM), artificial neural network (ANN), random forest (RF), and logistic regression (LR) were employed to determine the factors related to burns in children. Results: The mean age of children with burn injuries was 4.29 ± 3.51 years and 58% of them were boys. The ANN algorithm had better performance than other algorithms. Body mass index (BMI), socioeconomic status, hours without a watchful, mother’s age, mother’s education, household size, father’s job, father’s age, having more than one watchful, and petroleum storage were the most important factors related to pediatric burns. Conclusion: The majority of the burn-related variables were related to individuals’ social welfare status and their environments. Lessening the effects of these factors could reduce the incidence of pediatric burns.

20 Bringing Burn Referral Criteria into the 21st Century: A Structured Expert Consensus Project to Update and Refine Recommendations for Transfer and Consultation

20 Bringing Burn Referral Criteria into the 21st Century: A Structured Expert Consensus Project to Update and Refine Recommendations for Transfer and Consultation

T5 Multi-regional Utilization of a Mobile Device App for Triage and Transfer of Burn Patients

Technology and telehealth have the potential to optimize burn care in areas limited by geographic distance from a burn center. Patients may be inappropriately transferred long distances to a burn center for wounds that could otherwise be treated locally; incurring significant costs and burden to the health care system, patients, and providers. This study reports a multi-center, multi-regional experience of institutions using a mobile device application (Burn App) to facilitate triage of burn patients by allowing referring providers to send encrypted photos via a mobile device. A retrospective review was conducted on referals from January 2016 to April 2017 at three regional burn centers that utilize the same third party Burn App. Burn centers studied are located in the Western(WE), Northeast(NE), and Southern (SR) regions. Data on numbers of admissions, consults, referral facilities, type of wounds, disposition, and distance in miles (mi) from burn center were recorded. Totaling the three centers, 1785 consults were placed thru the Burn App from 294 different referring facilities. 3972 total individual users are registered for the app. Catchment area utilized at each burn center was: WE, 87 referral sites, average distance 491 mi (range 5–977 mi); NE, 132 referral sites, average distance 122 mi (range 3–240); SR, 75 referral sites, average distance 108 mi (range 0.2–216 mi). Disposition of patients at each burn center included: WE, 84 (54%) follow up in burn clinic (BC), 40 (26%) direct admission to burn unit (BU), 29 (18%) no follow up required. NE, 509 (44%) follow up in BC, 324 (28%) direct admission to BU, 315 (27%) no follow up required; SR, 404 (83%) follow up in BC, 80 (16%) direct admission to BU, with all requiring follow up. Top three consult diagnoses were scald/flame burns, and frostbite (see Figure 1). Ultilization and catchement areas of the Burn App varied greatly amongst centers highlighting the need for technology assistance. The majority of Burn App consults at all centers were triaged as outpatient burn referrals, potentially avoiding costly transfers. Unique injury demographics were noted, such as high incidence of scald burns for NE and SR, and frostbite at WE. Utilization of a Burn App appears to be a useful tool in the triage of burn patients over long distances, regardless of regional differences in injury pattern.

Assessing guidelines for burn referrals in a resource-constrained setting: Demographic and clinical factors associated with inter-facility transfer

AimThe aim was to assess demographic and clinical factors associated with inter-facility referrals for patients with burns in a resource-constrained setting. MethodsThis was a cross-sectional case review of patients presenting with a burn at the trauma unit at the Red Cross War Memorial Children’s Hospital (RXH) in Cape Town, South Africa. ResultsSix hundred and eleven—(71%) children were referred to the burns or the intensive care unit and 253 children were treated and discharged from the trauma unit. Of those admitted as inpatients 94% fulfilled at least one of the criteria for referral and 80% of those treated and discharged fulfilled the criteria for referral. ConclusionsAlmost three out of four children evaluated at the trauma unit were referred to the burns unit for further management. However, a large number of patients were treated and discharged from the trauma unit despite being eligible for referral.

Creation of a Pediatric Burn Clinic

Pediatric burns are a major source of morbidity and healthcare expenditure in the United States. Options and availability for outpatient pediatric burn treatment can be limited, potentially leading to high medical costs and delay in proper treatment. In our local community, there was no adequate, cost-effective outpatient treatment for patients with pediatric burn. In 2007, clinicians who specialize in pediatric burn care developed an outpatient pediatric burn clinic. The treatment team consisted of a pediatric nurse practitioner and four pediatric surgeons from the local children's hospital. Since opening, over 1,200 patients have been treated on a strictly outpatient basis. Kurt Lewin's three-stage model of change provided a conceptual model. The constructs include unfreeze the model pattern of burn referrals, change the pattern, and then work through a refreezing process. The burn clinic filled a need in the community by providing cost-effective outpatient specialty treatment for patients with pediatric burns. The future includes continuing ongoing marketing to the referring pediatric groups and outlying emergency department providers, expansion of staff to meet the growing needs of the community, and burn prevention community outreach.

Optimization of burn referrals

IntroductionCorrect estimation of the severity of burns is important to obtain the right treatment of the patient and to avoid over- and undertriage. In this study we aimed to assess how often the guidelines for referral of burn injured patients are met at the national burn centre (NBC), Denmark. MethodsWe included burn patients referred to the NBC in a three-months period. Patient records were systematically analyzed and compared with the national guidelines for referral of burn injured patients. ResultsA total of 97 burn injured patients were transferred for treatment at the NBC and the most common reason for referral was partial thickness burn exceeding 3% estimated area of burn (55% of the patients) while facial burns (32%) and inhalational injury (25%) were other common reasons. We found that 29 (30%) of the referrals were considered potentially unnecessary according to the guidelines. The overtriage was highest among patients suffering of burns due to scalding and these were mostly children below 2 years of age. ConclusionAn overtriage of referred burn injured patient was found and 30% of the referred patients were treated as outpatients. A telemedicine solution may be useful in the evaluation of burn injured patients before transfer.

Use of telemedicine and telephone consultation in decision-making and follow-up of burn patients: Initial experience from two burn units

Objective This study investigated the use of telemedicine in decision-making and follow-up of burn patients. Methods The Konya Burn Unit was established in July 2003, and up to December 2009, 187 patients were admitted to this unit, all of them were consulted—via audiovisual transmission of data (telemedicine)—to the same burn surgeon at the Ankara Burn Referral Center of our hospital network. Three basic systems are currently used: live interactive video, store-and-forward images, and telephone. The demographic data and burn criteria of the patients were investigated. Changes in the number of televisits and patient management were analyzed. Results During the 66-month timeframe, 525 televisits were performed on 187 patients. There were 126 males (67.4%) and 61 females (32.6%). The mean total burn surface area (percentage of total burn surface area burned) was 23.3 ± 17.8% (range, 3–95%). Nine of the 187 patients (4.8%) died owing to multiorgan failure and sepsis. As a result of these televisits, 21 patients (11.2%) were transferred to our referral center. The number of dead and transferred patients decreased during the study. Conclusions Telemedicine is appropriate and cost-effective for treatment and follow-up of patients in burn units with personnel with limited experience.

Improving accuracy of burn referrals through the use of an internet-based burns chart

A study was performed to compare the efficacy of an internet-based burns assessment form in communicating burns referral data with conventional phone and fax data transfer. An internet-based data collection form was developed in consultation with the multidisciplinary team at our centre with the aim of efficient data collection whilst minimising the time burden on the referring clinician. Through our website, an interactive Lund and Browder chart, is readily accessible which allows the user to mark on the chart itself the areas that have been injured. The ‘Burnschart’ system was incorporated into the referral process at Concord Hospital from January to June 2009 in addition to the conventional referral system. A review was conducted comparing a group of patients prior to and post implementation of the online referral system. The study population consisted of two groups of 25 patients that had been referred using Burnschart (group 1), or the conventional referring system (group 2). A significant difference between the two groups of 2.71% in the mean TBSA estimation error was found when comparing the two groups (p < 0.05). These results indicate that a simple web-based program to assist in accurately conveying summary data of site, size and severity of burn injury may be a useful tool in improving quality of communication between referring and receiving clinicians.

A cohort study of acute plastic surgery trauma and burn referrals using telemedicine

A store-and-forward telemedicine system was used to supplement normal telephone referrals to the plastic surgery unit at the Queen Victoria Hospital (QVH). During a 12-week prospective study, 11 units (8 hospitals and 3 minor injury units) with the telemedicine system and 10 units (8 hospitals and 2 minor injury units) without it regularly made referrals (at least 10) to the QVH. There were 389 referrals from the telemedicine-equipped units and 607 telephone referrals from the non-telemedicine units. The telemedicine system was used for 246 of the 389 referrals (63%) made from telemedicine-equipped units. There was a significant difference in the management of patients when the telemedicine system was available, with more patients booked directly into day surgery and fewer attending for assessment. The burns unit and the day surgery unit demonstrated a significantly improved accuracy of triage. Telemedicine could have a valuable role to play in the triage and planning of acute plastic surgery referrals.

Changing Pattern of Adult Burn Referrals to a Regional Burns Centre

The National Burn Care Review prompted us to review trends in adult acute admissions to our unit with the intention to implement the guidelines of referral set down in the report. We had recently also adopted a more open admissions policy in keeping with these recommendations. This was achieved by a retrospective casenote analysis with the years 1981, 1991, and 2001 used as reference snapshot years to outline trends. The results showed an increase in the number of patients, a decrease in the depth and extent of burns, a decrease in the number of inpatient days and crude mortality rate. There was also a slight decrease in the age of patients.

Can Burn Centers Evacuate in Response to Disasters?

On August 29, 2005, the Gulf Coast was hit by Hurricane Katrina, a category 4 storm. The storm was responsible for more than 1000 deaths and the displacement of hundreds of thousands of people. Hospitals in the city of New Orleans evacuated because of the complete collapse of infrastructure. This event influenced the decisions and actions taken to protect patients, families, and staff of a 30-bed pediatric burn center in the projected path of a second catastrophic hurricane 3 weeks later. Approximately 80 hours before projected landfall, the local government announced that a mandatory evacuation of the community surrounding the burn center would occur. A coordinated decision was made by administration, nursing, and medical staff to cancel upcoming clinics and elective surgery and to evacuate all 14 inpatients, 52 outpatients, and 66 guardians to other facilities. The evacuation plan was successfully completed in 32 hours. The eye wall of the hurricane passed 65 miles east of the burn center. No significant damage to the physical plant was noted. Repopulation of the hospital by patients and acceptance of new acute burn referrals began approximately 40 hours after the local government permitted the population to return to the area. No morbidity or mortality was attributed to the evacuation. Emergent evacuation of threatened burn centers can be safely accomplished with adequate prior planning of evacuation sites, and modes of transportation. An established communication command center plays a key role in this process.