Burn Service Research Articles

739 A 14 Year Experience of Pediatric Complex Skin Disorders in a Burn Unit

IntroductionComplex skin disorders including Stevens-Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN), Ritter's Disease (Staph Scalded Skin Syndrome), and Erythema Multiforme are uncommon, but result in significant injury to pediatric patients. Skin necrosis and desquamation occurs, which in some cases affects mucosa. Gynecologic, ophthalmologic, and dermatological complications also occur. The purpose of this work is to describe epidemiology and management trends in these cases.MethodsRecords were reviewed for all pediatric patients with skin disorders from 2006 - 2019 to evaluate trends in occurrence, age, length of stay, survivability, types of consultants, causative agent, and wound care strategies.ResultsOne-hundred percent of pediatric patients were transferred from other hospitals for definitive management by the burn service. The incidence in pediatric patients was 21% compared to 79% in adults. Males were most often affected at 67% compared to 33% in females. The age range was 2-17 years, with an average of 9.2 years. The type most frequently seen was SJS/TEN at 60% of the cases. The total body surface affected ranged from 10-95%. Management of wounds commonly required operative management for dressing changes in children with large body surface area involvement, in addition to ophthalmologic and gynecologic procedures in patients with mucosal involvement. In the subset of patients with SJS / TEN, 100% had ophthalmology consults and 50% were seen by gynecology. The average hospital length of stay was 11.3 days. All children survived.ConclusionsComplex skin disorders in pediatric patients require a multidisciplinary team approach to care and wound management and benefit from burn service care. Early transfer is beneficial in order to definitively diagnose the specific disorder and prioritize strategies in care such as nutrition, wound care, and psychosocial support.

85 Changes in Burn Surgery Operative Volume and Metrics Due to COVID-19

IntroductionDue to COVID-19, hospitals have had to undergo drastic changes to operating room (OR) policy to mitigate the spread of the disease. Elective surgeries were cancelled, and some ORs were repurposed to help withstand a surge of COVID-19 patients. Given these unprecedented measures, we aim to look at the changes in operative volume and metrics of the burn surgery service at our institution.MethodsAn IRB-approved single-institution retrospective review was conducted by querying our institutional OR database. We obtained case lists and OR metrics for the months of March to May for 2019, 2020, and 2021, which correspond with pre-COVID, early COVID (period without elective cases), and late COVID (period with resumed elective cases). Inclusion criteria were cases related to burns. These cases were then divided into the following groups: excision only, grafting only, excision and grafting, laser scar procedures, secondary reconstruction without grafting or flaps, secondary reconstruction with grafting, and secondary reconstruction with flaps. Types of cases and operative metrics were compared amongst the three time periods.ResultsThe total number of cases performed by the entire hospital during 2019, 2020, and 2021 was 2375, 1184, and 2265 respectively. During those times, the burn surgery service performed 174, 124, and 212 total cases (138, 103, and 114 burn related cases) respectively. Compared to the hospital, the burn service had a smaller decrease in volume during early COVID (28.7% vs. 50.1%) and exceeded pre-pandemic volumes during late COVID (+21.8% vs. -4.6%). There was a significant increase in excision and grafting cases in early and late COVID periods (41, 84, 74 respectively; p < .0001 and p < .002). There was a significant decrease in laser scar procedures that persisted even during late COVID (69, 0, 14 respectively; p < .0001). The projected and actual lengths of cases significantly increased and persisted into late COVID (p < .01). The average length pre-COVID and late COVID were 109.9 ± 78.5 and 138.2 ± 79.2 minutes.ConclusionsCOVID-19 related OR closures lead to an expected decrease in the number of overall cases and elective cases. However, there was no significant decline in the number of burn specific cases performed. The elective cases were largely replaced with excision and grafting cases and this shift has persisted even after elective cases have resumed. This change is also reflected in increased operative times.

758 Constant evolution: Early experiences treating COVID-19 in a burn center

IntroductionThe COVID-19 pandemic came as an unexpected challenge to many healthcare systems around the world. Many centers struggled to provide COVID-19 ICU-level care while also maintaining adequate care for non-COVID-19-related conditions, especially in critical care specialty units like trauma and burn. We present a case series of our early experiences treating COVID-19 in a burn center.MethodsWe present a case.ResultsSee Table 1. Though one case was admitted prior to initiation of universal testing, routine infection-control protocols limited exposure to personnel and prevented transmission to staff. In May 2020, we implemented the use of N95 mask and eye protection during all aerosolizing procedures, N95 mask use in all ORs, and universal surgical mask use in all rooms regardless of COVID-19 status. An in-house risk-stratification system was used to screen patients based on symptoms and exposure. Burn-center admissions were screened at a lower threshold than throughout the institution given the unique nature of burn injury. Eventually, because of increasing community spread, all admissions to the hospital were universally screened with RT-PCR prior to admission. To minimize exposure to non-COVID patients and Burn Center staff, COVID-19 positive burn admissions were assessed on a case-by-case basis. High acuity patients were admitted to the Burn Center and followed by the COVID consult team. Lower acuity patients were admitted to the Burn Center but were treated on the medical COVID unit and followed by the burn consult service.ConclusionsThe COVID 19 pandemic has strained healthcare systems worldwide. Development and implementation of universal screening, testing, infection-control precautions, and triage strategies are critical elements of burn care during the COVID-19 pandemic. As we prepare for future surges due to more transmissible variants, implementation of standard protocols enables continued provision of quality care, preservation of the healthcare workforce, and efficient use of resources.

Quality of life in paediatric burn patients with non-severe burns

BackgroundBurns are common worldwide, and the vast majority are non-severe burns of less than 20% of the total body surface area (TBSA). In Australia, paediatric burns account for a third of all burn admissions, thus understanding the quality-of-life outcomes after a non-severe burn in children is important. MethodsThis retrospective cohort study describes a paediatric cohort from Western Australia with non-severe burns occurring between 2018 and 2020 and characterises the child’s quality-of-life outcomes which is measured using the Paediatric quality of life survey (PedsQL). The PedsQL included a parent-report and child-report assessment, each with a physical function domain and a psychosocial function domain which comprised of an emotional, a social and a school category. ResultsData collected from 249 patients; 50.6% were male, 45.6% were toddlers. The most common cause was scald (48.19%), the majority had burns smaller than 5% TBSA (91.97%), and most included visible areas such as head, neck or hands (77.51%). The parent-report PedsQL scores were significantly different for both physical and psychosocial domains between the different age groups (p = 0.002, p = 0.001, respectively) and for burn cause (p = 0.004, p = 0.005, respectively). For child-reported scores we found evidence of an effect of burn cause across both domains that did not reach a statistical significance (p = 0.076, p = 0.078, respectively). The psychosocial functions in both the parent-report and the self-report were significantly different for the socioeconomic status groups (p = 0.015, p = 0.032, respectively). Quality of life scores were critically low in 16.46% of paediatric burn patients at three months after burn. ConclusionParent-reported and child-reported psychosocial function was significantly poorer in higher socioeconomic groups, for older children and for those with flame burns. About 16% of patients had scores below the critical cut off. These data provide insight into the quality-of-life outcomes of paediatric patients with non-severe burns, allowing future studies to investigate burn prevention strategies and services to help paediatric burn patients in their recovery.

757 A Patient Inclusion Criteria Algorithm for New Burn Centers Seeking to Implement a Burn Registry

IntroductionData submissions to the NBR are based upon the standardized medical definitions and generalized guidance on patient inclusion criteria found in the ABA Burn Care Quality Data Dictionary. The guidance is complex, often leading to confusion in determining proper patient identification. This is most problematic for new burn centers seeking to implement a burn registry. Therefore, at our burn center, we designed and implemented an algorithm based on a thorough literature review and ABA guidance to improve the accuracy and efficiency of patient identification.MethodsA review of the literature was conducted using the PubMed database. In addition, utilizing the ABA’s multitude of resources including, the Burn Care & Quality Platform (BCQP) Data Dictionary 2020 version 1.1 patient inclusion criteria statements, a BCQP Q&A session on admission information, and Quality & Registry Community discussion boards, the following algorithm was developed by the compilation and simplification of the definitions provided for burn and non-burn injury patient inclusion criteria.ResultsA thorough literature review produced no articles that address NBR inclusion criteria. According to these documents, all patients admitted to the hospital for treatment of an acute burn or soft tissue wound should be included in the burn registry; however, a BCQP Q&A session expressed the Burn Service must provide medical care in order for a patient to be included in the registry. Furthermore, the BCQP Data Dictionary outlines patient inclusion based on a hospital length of stay >24 hours, a surgical operation, or expire at a hospital facility for registry inclusion. Observation patients and non-burn patient consults are excluded from the NBR. The ABA community discussion board revealed many centers only count and track non-burn injury admissions to the burn center service line. The compilation of information resulted in the development of a standardized algorithm defining a patient for registry inclusion.ConclusionsA comprehensive review of the ABA resource documents was compiled to clarify the patient inclusion criteria for data submission to the NBR. The BCQP Data Dictionary 2020 version 1.1 patient inclusion criteria statements, the collaborative Ameriburn communities, and the BCQP Q&A session influenced the design of the clarification algorithm for patient identification to assist burn centers seeking to accurately and most efficiently implement a burn registry. Further research should be conducted on the utilization of the algorithm in comparison to other burn centers.

591 Transition to an Advanced Practice Provider led burn service: process and lessons learned

IntroductionBurn is not a required rotation for general surgery residency training. Additionally, mandates on resident work hours have created a deficiency in resident support for many burn programs across the country. Subsequently, the need to transition to an Advanced Practice Provider (APP) service was identified. At our institution, a medium volume (~250 admissions/year) burn center, we created an APP service and evaluated the evolution and lessons learned during the transition.MethodsTimeline of recruitment of APPs was reviewed along with the recruitment process, onboarding process and orientation process. Exit interviews were conducted with all APPs who resigned to delineate strengths and weakness of the APP program. Functionality of the institution’s APP recruiter, manager and Lead Burn APP (LAPP) were reviewed as well.ResultsBetween 2014 and 2021 the daytime burn APP service expanded from two to six APPs and the Night House Officer (NHO) APP service was created and expanded to four APPs. Based on thorough review of the APP program, key changes were made including improvements in team communication, daily nurse-driven rounds, the 90-day focused professional performance evaluation (FPPE), enhanced and structured education, and critical care exposure.The need for a LAPP was identified and designated in 2019. The LAPP is responsible for making an equitable schedule, execution of new APP orientation, organizing the 90 day FPPE and ongoing professional performance evaluation (OPPE), monthly APP peer review and APP meetings, coordinating OR coverage, and functioning as an APP advocate at division leadership. The LAPP enacted changes to the existing hiring/onboarding process as described below.All APPs are now recruited through an APP recruiter who discusses the hospital contract and salary as well as organizes the logistics of the interview, formalizes the offer, and aids with the transition to credentialing. All new APPs are given a hospital onboarding checklist, that includes hospital orientation, APP boot camp, simulation and electronic health record training classes. In addition they are given a clinical orientation checklist, which includes BLS/ABLS/ACLS/ATLS certification, exposure to various phases of patient care, tracking of quantitative patient care metrics, participation in monthly burn APP peer review and burn triage simulation. There are subtle differences with the NHO APP clinical checklist. After 90 days of employment a new employee FPPE is held with the LAPP and burn director. This allows for direction of areas to focus on, comprehensive feedback, and discussion about increasing autonomy.ConclusionsThrough a focused process, APPs can play an integral role in the daily functioning of a burn center. We believe that a similar effective and financially sound model can be created for similar sized units.

40 Evaluation of a Multidisciplinary Approach to Pressure Injury Prevention Among Patients in a Burn Center

IntroductionCompromised skin integrity in tandem with the prolonged length of stay necessitated by patients in a burn center has the capacity to result in an increased incidence of hospital acquired pressure ulcers (HAPUs). A HAPU increases the cost of a hospital stay by approximately $43,000. Many interventions exist to reduce their occurrence; however, interventions have been largely compartmentalized by discipline. One burn center’s dramatic increase in HAPUs from 2018 to 2019 led to further evaluation of prevention efforts. Upon detecting a 117% increase of HAPUs and a threefold increase in cost for specialty bed rental, a multidisciplinary approach to pressure injury prevention was employed. The frequency of multidisciplinary patient rounds was increased from once to twice daily, and involved discussions regarding functional status, mobility, and nutrition. The practice of ordering specialty beds was modified to require three-part approval by the Medical Director of Burn Services, Nursing Director, and a burn therapy supervisor. The purpose of this QI project was to examine the implementation of the multidisciplinary approach to pressure injury prevention among patients in a burn center and to identify trends in HAPUs and specialty bed expenses.MethodsThis was a retrospective review of patients admitted to a Burn Center between January 1, 2018 and June 30, 2021. Preexisting pressure ulcers were identified upon admission and were not regarded as HAPUs. Patients were grouped by year of their admission date.ResultsA total of 941 patients were admitted for inpatient care in 2020, six HAPUs (1.35%) were identified for this population. As compared to the prior year, this revealed a 53% decrease in incidence of HAPUs. The specialty bed rental cost from 2019 to 2020 was reduced by $110,181.76 (68%). *Data provided for 2021 is from 01/01/2021 to 06/30/2021ConclusionsFollowing implementation of a multidisciplinary approach to pressure injury prevention, we were able to reduce the incidence of HAPUs and dramatically reduce the expense associated with specialty bed rental. This supports an effort to identify additional practices which may increase quality while decreasing cost.

The CARe Burn Scale-Adult Form: Identifying the Responsiveness and Minimal Important Difference (MID) Values of a Patient Reported Outcome Measure (PROM) to Assess Quality of Life for Adults with a Burn Injury.

The CARe Burn Scales are a suite of burn-specific PROMs for adults, children, young people, and parents affected by burns. This study aimed to determine the responsiveness and minimal important difference (MID) values of the Adult Form for use in adult burn care and research. Participants were recruited by 11 UK Burn Services. They completed online or paper versions of the CARe Burn Scale -Adult Form and a set of appropriate comparison validated measures and anchor questions at baseline (T1, up to 4 weeks post-burn), 3 months (T2), and 6 months post-burn (T3). A total of 269 participants took part at baseline and 226 (84%) were retained at the 6-month follow-up. Spearman's correlation analysis and effect sizes based on Cohen's d thresholds were reported and MID values calculated. MID values were created for all subscales and ranged from 4-15. The CARe Burn Scale-Adult Form is responsive to change over time and can therefore be used to reliably inform the management of adults' burn injury treatment and recovery. It is freely available for clinical and research use.

Burn Care Specialists' Views Toward End-of-Life Decision-Making in Patients With Severe Burn Injury: Findings From an Online Survey in Australia and New Zealand.

Burn care clinicians are required to make critical decisions regarding the withholding and withdrawal of treatment in patients with severe and potentially non-survivable burn injuries. Little is known about how Australian and New Zealand burn care specialists approach decision-making for these patients. This study aimed to understand clinician beliefs, values, considerations, and difficulties regarding palliative and end-of-life (EoL) care discussions and decision-making following severe burn injury in Australian and New Zealand burn services. An online survey collected respondent and institutional demographic data as well as information about training and involvement in palliative care/EoL decision-making discussions from nurses, surgeons, and intensivists in Australian and New Zealand hospitals with specialist burn services. Twenty-nine burns nurses, 26 burns surgeons, and 15 intensivists completed the survey. Respondents were predominantly female (64%) and had a median of 15 years of experience in treating burn patients. All respondents received little training in EoL decision-making during their undergraduate education; intensivists reported receiving more on-the-job training. Specialist clinicians differed on who they felt should contribute to EoL discussions. Ninety percent of respondents reported injury severity as a key factor in their decision-making to withhold or withdraw treatment, but less than half reported considering age in their decision-making. Approximately two-thirds indicated a high probability of death or a poor predicted quality of life influenced their decision-making. The three cohorts of clinicians had similar views toward certain aspects of EoL decision-making. Qualitative research could provide detailed insights into the varying perspectives held by clinicians.

Treatment Decisions in Patients With Potentially Nonsurvivable Burn Injury in Australia and New Zealand: A Registry-Based Study.

Whilst burn-related mortality is rare in high-income countries, there are unique features related to prognostication that make examination of decision-making practices important to explore. Compared to other kinds of trauma, burn patients (even those with nonsurvivable injuries) may be relatively stable after injury initially. Complications or patient comorbidity may make it clear later in the clinical trajectory that ongoing treatment is futile. Burn care clinicians are therefore required to make decisions regarding the withholding or withdrawal of treatment in patients with potentially nonsurvivable burn injury. There is yet to be a comprehensive investigation of treatment decision practices following burn injury in Australia and New Zealand. Data for patients admitted to specialist burn services between July 2009 and June 2020 were obtained from the Burns Registry of Australia and New Zealand. Patients were grouped according to treatment decision: palliative management, active treatment withdrawn, and active treatment until death. Predictors of treatment initiation and withholding or withdrawing treatment within 24 hours were assessed using multilevel mixed-effects logistic regression. Descriptive comparisons between treatment groups were made. Of the 32,186 patients meeting study inclusion criteria, 327 (1.0%) died prior to discharge. Fifty-six patients were treated initially with palliative intent and 227 patients had active treatment initiated and later withdrawn. Increasing age and burn size reduced the odds of having active treatment initiated. We demonstrate differences in demographic and injury severity characteristics as well as end of life decision-making timing between different treatment pathways pursued for patients who die in-hospital. Our next step into the decision-making process is to gain a greater understanding of the clinician's perspective (eg, through surveys and/or interviews).

Variation in burn wound management approaches for paediatric burn patients in Australia and New Zealand.

To date, no large-scale exploration of the profile of, and variance among paediatric patients who underwent a burn wound management procedure in theatre exists in an Australian and New Zealand context. This study aims to provide a profile of paediatric burn patients who underwent a burn wound management procedure in theatre during an acute admission and highlight specific areas of practice where there is variation between burn services that may affect treatment efficacy and efficiency. We performed a retrospective review of all paediatric patients (ages <16 years) who sustained a burn injury between July 2016 and June 2019 and underwent a burn wound management procedure in theatre, using data from the Burns Registry Australia New Zealand. The number of patients across burn services decreased as TBSA increased. Deep dermal burns represented the majority of cases across services. There was significant variation in time from injury to admission and the proportion of patients who received skin grafts across services. Significant differences in the patient profile and clinical practices were observed among burn services. A greater understanding of the factors underlying the variations at each particular service will also be helpful.

Burn Lessons Learned From the Whakaari White Island Volcanic Eruption.

New Zealand's most active volcano, Whakaari White Island was a common tourist attraction prior to its eruption on December 9, 2019. At the time of the eruption, there were 47 people on the island from 3 tour groups. Thirty-nine people survived the initial eruption and were extracted. Thirty-one entered into the New Zealand National Burn Service across four hospitals. The median age of the patients treated at the National Burn Centre was 45.5 years (range: 14-67 years) and median TBSA burn was 49.5% (range: 9%-90%). The 3-month survival of this eruptive event was 55%, which subsequently fell to an overall rate of 53% following one late death of an early survivor after repatriation home. Of the patients who survived the initial eruption for long enough to be admitted to the National Burn Service, the overall survival rate was 71% at 3 months. We describe 12 lessons we have learnt from our management of the survivors. The key surgical lessons among these are: 1) The injuring mechanism combined ballistic trauma, thermal and acidic burn components, with the acid component being the most problematic and urgent for management; 2) Volcanic ash burns result in ongoing burn depth progression, deep underlying tissue damage and significant metabolic instability; 3) Early skin grafting was not successful in many cases; 4) Reconstructive strategy needed adjusting to cope with the high operative demand and limited donor sites in all patients; 5) Protect yourself from potential dangers with additional personal protective equipment in an unfamiliar setting.

“Burns Behind Bars”: A 10-year review and cost analysis of burn injuries in prison inmates presenting to a regional burns centre, and the role of the burns outreach service

IntroductionFrom 85348 inmates in England and Wales, over 26,000 incidents of assault and 40,000 of self-harm were reported from within prisons in 2016. This study focuses primarily on burn injuries in prison, determining the predominant aetiology as well as clinical outcomes of these injuries. MethodsData was retrieved retrospectively and a case series performed, including all burns referred from regional prisons to our centre from 2007 to 2017 and comprising patient demographics, mechanism of injury, total body surface area affected, management, and outcome. Cost analysis of care was conducted using a previously published framework. Results18 cases from three regional prisons were recorded, with 67% from a single prison. Referrals rose exponentially over time, with 44% occurring in 2017. 94% were scald burns, and 56% secondary to assault, primarily through the use of kettles and mostly targeting the face and trunk. The mean TBSA of burn was 2.89% (<1–8%), and 80% received first aid. 72.2% were admitted to hospital for an average of 4 days. All burns were managed nonoperatively with dressings and underwent on average 2 outpatient reviews (1–8). DiscussionThe disproportionate spread of referrals across the prisons correlates partly with the respective populations, but may also represent contrasting medical provisions. The recurring method of assault reflects the relative ease of access to hot water as a harmful agent, predominantly presenting with scalds affecting more critical areas, and with concurrent physical trauma in nearly half of cases which presents management challenges. ConclusionTargeted education is recommended to reduce the incidence and ensure adequate management of burns in prison, referrals for which are demonstrably rising. Accordingly, the Burns Outreach team can provide training to in-house prison health staff and review referrals to specialist Burns services, aiming to ensure equitable care while alleviating costs associated with transfer to and management in hospital.

RSTNCOVID Burns: A multi-centre service evaluation and stakeholder survey of the impact of COVID-19 on burns care in England, Wales and Northern Ireland

As the UK entered the first wave of the COVID-19 pandemic, the National Health Service published consensus guidance to the UK burns services advising changes to the acute management of burns to allow the continuation of safe care while protecting limited hospital resources. We aimed to describe the demographics of burns service users, changes to clinical pathways and experiences of the burns team during the first wave of the COVID-19 pandemic.All burns services in the UK were invited to participate in a national collaborative, trainee-led study supported by the Reconstructive Surgery Trials Network. The study consisted of (1) a service evaluation of patients receiving burns treatment during the COVID-19 pandemic; (2) a multidisciplinary team survey. Analyses were descriptive and narrative depending on data types.Collaborators from 18 sites contributed data from burns MDT surveys and 512 patients. Patient demographics were consistent with typical burns patterns in the UK. The delayed presentation occurred in 20% of cases, with 24 patients developing complications. MDT surveys indicated substantial adaptations and challenges as a result of the pandemic. Access to theatres and critical care were limited, yet a comprehensive acute burns service was maintained. Telemedicine was utilised heavily to reduce patient footfall.Adaptations in the provision of burns care, including greater outpatient care and telemedicine, have emerged out of necessity with reported success. The impact of reduced scar therapy and psychological interventions for burns patients during the pandemic requires longer-term follow-up. Lessons from the UK experience can be used to strategise for future pandemics.

Burns in India: a call for health policy action

Burns in India: a call for health policy action

Impact of COVID-19 and containment measures on burn care: A qualitative exploratory study

BackgroundBurn care in India is limited by multiple constraints. The COVID-19 pandemic and the containment measures restricted access to non-COVID emergency conditions, including burns. The aim of this study was to explore the impact of the pandemic on burn care in India. MethodsUsing the qualitative exploratory methods, we conducted in-depth interviews (IDI) with plastic and general surgeons representing burn units from across India. Participants were selected purposively to ensure representation and diversity and the sample size was guided by thematic saturation. Thematic analysis was undertaken adopting an inductive coding using NVivo 12 Pro. Results19 participants from diverse geographic locations and provider types were interviewed. Three major emerging themes were, change in patient and burn injury characteristics; health system barriers, adaptation, and challenges; and lessons and emerging recommendations for policy and practice. There was change in patient load, risk factors, and distribution of burns. The emergency services were intermittently disrupted, the routine and surgical services were rationally curtailed, follow-up and rehabilitation services were most affected. Measures like telemedicine and decentralising burn services emerged as the most important lesson. ConclusionsThe ongoing pandemic has compounded the challenges for burns care in India. Urgent action is required to prioritise targeted prevention, emergency transport, decentralise service delivery, and harnessing technology for ensuring resilience in burns services.

Testing the Responsiveness of and Defining Minimal Important Difference (MID) Values for the CARe Burn Scales: Patient-Reported Outcome Measures to Assess Quality of Life for Children and Young People Affected by Burn Injuries, and Their Parents/Caregivers

The CARe Burn Scales are a portfolio of burn-specific PROMs for people affected by burns, including a Child Form (for children &lt; 8 years (parent-proxy)), a Young Person Form (for young people aged 8–17 years), an Adult Form, and a Parent Form (for parents/carers of children aged 0–17 years). This study aimed to determine the responsiveness and minimal important difference (MID) values of the three scales developed for use in paediatric burn services and research. Participants were recruited by 15 UK Burn Services. Participants completed the appropriate CARe Burn Scale and a set of appropriate comparison validated measures, at three time points: 4 weeks (T1), 3 months (T2) and 6 months (T3) post-burn injury. Spearman’s correlation analysis and effect sizes based on Cohen’s d thresholds were reported and MID values were calculated. At baseline, 250 participants completed the Child Form, 69 completed the Young Person Form, and 320 completed the Parent Form. A total of 85–92% of participants were retained at follow up. The tested CARe Burn Scales were all responsive to change over time. MID values were created for all subscales and ranged from 2 to 11 for the Child Form, 3 to 14 for the Young Person Form and 3 to 10 for the Parent Form. The CARe Burn Scales for children, young people and parents are responsive to change over time. The scales are freely available for clinical and research use.

Comparison of the international Burn Injury Database nurse dependency tool with the Safer Nursing Care Tool: Observational study.

Safe and effective nurse staffing is widely recognised as an important issue to ensure quality patient care and reduce mortality. There are many nurse dependency tools described in the literature but no gold standard tool that can be used in all specialities. In burn care there are even fewer burn specific tools and none reported for use in the UK to date. The international Burn Injury Database contains routinely collected information about burn injuries, including nurse dependency data which so far has not been reported in the literature. This study aimed to confirm whether the international Burn Injury Database nurse dependency tool can be used to measure nurse dependency in burn services. Over a two week period, nurses in three burn services scored the nurse dependency of their burn injured patients daily using the international Burn Injury Database Nurse Dependency Tool and the Safer Nursing Care Tool. Additionally all the participating nurses were asked to score three fictional case studies using the same two tools to assess inter-rater reliability. There was a statistically significant positive correlation between the international Burn Injury Database Nurse Dependency Tool and the Safer Nursing Care Tool scores (ρ=0.87, 95% CI=0.82-0.90). The case study scores showed a similar correlation pattern as the daily comparison recordings. The inter-rater reliability between the participants was comparable for both the international Burn Injury Database Nurse Dependency Tool (α =0.74, CI=0.71-0.77) and the Safer Nursing Care Tool (α =0.79, CI=0.76-0.81). Psychological support variable had the weakest correlation with the nurse dependency tools and the lowest agreement between nurses. This is the first report in the literature of the international Burn Injury Database Nurse Dependency Tool, the results of which suggest that it does measure aspects of nurse dependency and thus could be a valuable tool in the battle to ensure safe staffing. The good inter-rater reliability between the nurses, regardless of the nurse dependency tool used, should give confidence to nurses and managers using the dependency data to influence staffing.

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.

1237 Optimising Outpatient Care After Paediatric Burns: The Development of a Chatbot To Identify Complications And Provide Clinical Advice

Abstract Aim More than 6000 children require specialist care from one of fourteen regional burns services in England and Wales each year. Families often have to travel long distances and may not have access to specialist care with restricted services due to Covid-19. This quality improvement project aimed to: Method We conducted a national service evaluation of children’s burns services in England and Wales. We then conducted a PRISMA compliant systematic review up to September 2020 to identify studies reporting chatbot use to deliver outpatient care. A chatbot was then developed using Dialogflow to identify complications and provide advice to families. Results Across England and Wales, 11 children’s burns services reported outpatient practice: six services follow up all children at three months, three have variable follow-up and two discharge all patients. Our systematic review identified 10 studies reporting chatbot use although none were used following burns. A frame-based system-focused chatbot was developed in conjunction with expert burns surgeons and patient representatives. Conclusions Chatbots are effective and acceptable alternatives for in-person follow up. We demonstrate national variation in the provision of outpatient paediatric burn care and have developed a chatbot that can address clinical concerns and provide reassurance to patients and family members. Future studies will determine the acceptability and safety of this chatbot.