Early Debridement versus Delayed Debridement in Paediatric Burns and the implications on outcomes

Dr Bronwyn Griffin1, Dr Hamseera  Dave2, Dr  Harry Jin3, Prof Roy Kimble4

1Centre For Children’s Burns And Trauma Research, South Brisbane, Australia, 2Mater Public Hospital, South Brisbane, Australia, 3Royal Brisbane and Women’s Hospital, Herston, Australia, 4Queensland Children’s Hospital, South Brisbane, Australia

Abstract:

Background:

It has been well defined in literature that early excision and grafting for larger burns effectively reduces morbidity, mortality and hospital length of stay for adult burns however little evidence supports the best option for paediatric burns.  This study aims to determine if there is indeed similar advantages in the paediatric population with burns ≥5% total burn surface area (TBSA).

Methods: Patients with superficial or deeper burns that cover ≥5% TBSA from 1st January 2013 to 31st December 2017 were extracted from the Queensland Paediatric Burns Registry and included in data analysis. Cox Regression was utilised to define the risk of delayed days to re-epithelialisation for those not going to theatre within 48 hours of injury.

Results: In total 343 patients were included in analysis,  n=143 patients were taken to theatre at some point and n=49 patients were taken to theatre within 48 hours of injury. Median time to theatre was 66.63 hours (SD=98.87) for all patients and for those within 48 hours, median time to theatre was 15.45 hours (SD=13.67). After adjusting for depth and TBSA%, there was a 33% reduced time to re-epithelialisation for those patients who went to theatre within 48 hours compared to those who didn’t, although not statistically significant (p=0.079), this finding remains clinically relevant.

Discussion: Following these results, additional analysis will be performed to examine the interactions of debridement within 48hours of burn injury and the risk of grafting to further inform the debate of early or delayed debridement in paediatric burns.


Biography:

Dr Griffin has over 10 years’ experience Nursing in paediatric emergency departments across Australia before she first embarked on her PhD with the Centre of Children’s Burns and Trauma Research in 2009. Now Dr Griffin is a Senior Research Fellow based at the Queensland Children’s Hospital where her work supports the integrated spectrum of paediatric burn and trauma care from injury prevention/public health, first aid, acute care and quality of life outcomes.

In her spare time Bronwyn wrangles three school aged children, whom have had no choice but to grow up with a love the bush, books, beaches and baking.

Exploration of patients’ views towards the implementation of an Allied Health led TeleBurns model of care

Ms Amber Jones1, Mr Perry Judd2, Ms Michelle Cottrell2, Ms Anita Plaza2, Ms Andrea Mc Kittrick1, Dr Angela  Chang3, Dr Clare Burns4

1Occupational Therapy Department, Royal Brisbane & Women’s Hospital, Herston, Australia, 2Physiotherapy Department, Royal Brisbane & Women’s Hospital, Herston, Australia, 3Centre for Allied Health Research, Royal Brisbane & Women’s Hospital, Herston, Australia, 4Speech Pathology Department, Royal Brisbane & Women’s Hospital, Herston, Australia

Abstract:

Background: Upwards of one-third of patients are discharged from the Royal Brisbane and Women’s Hospital (RBWH) Burns Outpatient Clinic due to non-attendance. This study aimed to explore patients’ perceptions of accessing Allied Health services via telehealth, as an alternative intervention model.

Methods: Surveys were distributed to patients receiving Allied Health services within the clinic over a four-week period. The survey evaluated five key areas including: patient demographics, burn injury management, travel arrangements, barriers to service access, and attitudes towards telehealth. Descriptive statistics were used to analyse responses.

Results: 48 patients completed the survey. 72.9% (n=35) patients resided outside MNHSS, travelling an average of 279 kilometres to RBWH. Almost 30% (n=14) of patients reported that they had missed or rescheduled a previous appointment. Finding a carpark (40%), taking time off work (32%) and travel expenses (18%) were identified as the biggest barriers to attending appointments. Whilst only three patients had previously used telehealth, almost 70% (n=33) were agreeable to telehealth as an alternative intervention model. 94% (n=45) reported they have access to an internet-enabled device, of which 87% (n=39) patients would accept a home-based telehealth appointment if appropriate.

Discussion: Survey results demonstrate that many patients find it difficult to access their clinic appointments. A high proportion of patients are willing to attend a telehealth appointment at their local facility or at home using their personal device.

Conclusion: These results justify the consideration of an Allied Health TeleBurns Clinic as a substitution model for patients managed through the RBWH Burns Outpatient Clinic.


Biography:

Amber Jones is the Occupational Therapy Burns Team Leader at the Royal Brisbane and Women’s Hospital Professor Stuart Pegg Adult Burn Centre. In her 15 years working in burn care, Amber has contributed to clinical research, and presented at several national and international burns conferences and workshops. In 2012, she undertook a tour of American burn centers, and gained valuable insight into burn rehabilitation practices for adults and paediatrics within a number of different treatment/funding models. In 2015, Amber was deployed to Cairns Hospital following the Ravenshoe mass casualty, to lead the occupational therapy response locally, and train the local therapists. She has also established an educational support and mentorship role with an occupational therapist who is setting up a therapy service within a burn centre in Nepal.

Is Biodegradable Temporising Matrix a new-age hero of dermal scaffolds and wound closure? The experience in a quaternary paediatric hospital.

Dr Alicia Miers1,2,3, Dr Aoife Rice1,2,3, Ms Kristen Storey1,2,3, Dr  Yun Phua1, Professor  Roy Kimble1,2,3,4

1Queensland Children’s Hospital, South Brisbane, Australia, 2University of Queensland, St Lucia, Australia, 3Pegg Leditschke Children’s Burns Centre, Queensland Children’s Hospital, Brisbane, Australia, 4Queensland University of Technology, Brisbane, Australia

Abstract:

Novosorb™ Biodegradable Temporising Matrix (BTM) provides a fully synthetic dermal scaffold for tissue repair, and contributes to stable, durable and flexible wound closure (Cheshire et al. 2016).

Retrospective chart review revealed nine children where BTM was used between October 2018 and May 2019 at Queensland Children’s Hospital. A majority of patients were managed through the Pegg Leditschke Children’s Burns Centre.

The injuries and conditions included in this series all resulted in full thickness skin defects prompting operative intervention for surgical debridement, dressings, application of BTM and 7 out of 9 patients required skin grafting. In a total of 9 patients, BTM was used on 27 sites. Conditions requiring wound management where BTM was used included electrical injuries resulting in full thickness burns, scar contracture releases, lower limb ulceration in the context of ataxia telangiectasia, excision of an epidermal naevus on the posterior neck, and skin necrosis arterial thrombus as well as necrosis complicating sclerotherapy of a venous malformation of the scalp.

At the time of submission, BTM had incorporated well into the sites of all patients within three to five weeks. In small areas, BTM did not require grafting. Two patients had an unexpected return to theatre for bleeding and there was one graft failure in the context of pseudomonas infection requiring re-grafting.

Reports of BTM use in the Australian context are limited and this case series aims to reflect on the experience in our hospital and highlight the versatility and durability of BTM in the management of complex wounds.

Reference List

Cheshire, PA, Herson, MR, Cleland, H & Akbarzadeh, S 2016, Artificial dermal templates: A comparative study of NovoSorb™ Biodegradable Temporising Matrix (BTM) and Integra ® Dermal Regeneration Template (DRT), 03054179


Biography:

Dr Alicia Miers is a Registrar with the Paediatric Surgery, Urology, Burns and Trauma Unit at Queensland Children’s Hospital.

V.C.S. Project – INTRODUCING DIGITAL SOLUTIONS FOR CLININCAL MANAGEMENT AND QUALITY IMPROVEMENT

Mr Graeme McLeod1, Professor Fiona Wood1, A/Professior Dale Edgar1

1Fiona Stanely Hospital -WA Department Of Health , Palmyra Dc, Australia, 2Fiona Wood Foundation, Palmyra Dc, Australia

Abstract:

BACKGROUND

Quality of Life surveys (QOLs) provide clinicians with an objective measure of physical and mental patient progress since injury.  In WA the State Adult Burns Unit (SABU) QOLs are typically completed online during consult; this ensures results are collected securely and linked to the patient’s record.

To arm clinicians with information pertinent to the patient, completion of QOLs is best prior to consult, however the combination of the typical clinician workload and time-constrained patients often impedes this, resulting in clinicians needing to revisit or rebook the patient to address any issues raised.

METHOD

SABU together with WA Health ICT piloted The Virtual Clinic System (VCS), a WA Health solution that integrates with current hospital applications. VCS enables staff to invite patients, via SMS/Email, to complete encrypted QOLs on their mobile/PC. Further it allows staff to monitor progress of completion and send reminders. Once completed VCS automatically matches the survey back inside the Health Network.

RESULTS

  • ~ 40% increase—surveys completed prior to appointments
  • Average rating—9/10 from 15 patients (random)
  • Minimum reduction—6 minutes per appointment

Subsequently VCS has been adopted as BAU and results continue to show a positive increase in completed QOLs, in particular a substantial increase is noted for rural and remote patients

DISCUSSION

VCS is an exemplar of a digital solution that can safely be used to expedite clinical care and provide the right intervention at the right time.  Additionally patient experience is positively boosted by focusing on improving time efficiencies and reducing unnecessary appointments.


Biography:

Graeme has been working in the State Adult Burns Unit since May 2015, as an MDT Officer, and also as a member of the Digital Innovation Team with the Fiona Wood Foundation.  Graeme’s role has supported the introduction of innovative quality improvement solutions to improve the efficiencies of the Unit, the Hospital and the Department.

Respiratory muscle strength training (RMST): an adjunctive method to facilitate swallow and pulmonary rehabilitation in patients with severe deconditioning and tissue loss

Dr Nicola Clayton1,2,3,4,5, Ms Katina Skylas3,6, Ms Caroline  Place3,7, Miss Rosemarie Giannone2,7, Dr Frank  Li2,7, Ms Caroline Nicholls2,8, Mrs Cheryl Brownlow2,8, Dr Rosalba  Cross3, Dr Justine O’Hara2, Dr Andrea  Issler-Fisher2,9, Dr Mark Kol3, Prof Peter Maitz2,9

1Speech Pathology Department, Concord Repatriation General Hospital, Sydney, Australia, 2Burns Unit, Concord Repatriation General Hospital, Sydney, Australia, 3Intensive Care Unit, Concord Repatriation General Hospital, Sydney, Australia, 4School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia, 5Faculty of Heatlh Sciences, University of Sydney, Sydney, Australia, 6Department of Nursing, Concord Repatriation General Hospital, Sydney, Australia, 7Physiotherapy Department, Concord Repatriation General Hospital, Sydney, Australia, 8Department of Nutrition & Dietetics, Concord Repatriation General Hospital, Sydney, Australia, 9Faculty of Medicine, Concord Repatriation General Hospital, Sydney , Australia

Abstract:

Background: Severe deconditioning due to critical illness frequently manifests as debilitation of pulmonary musculature, resulting in impaired respiratory and swallow function. Evidence indicates that respiratory muscle strength training (RMST) can improve cough and swallowing outcomes in certain populations, however this method of rehabilitation, specifically Expiratory Muscle Strength Training (EMST), has not been previously examined in critical care or severe burn injury.

Aim: To examine the effect of RMST on cough and swallow function in patients with marked deconditioning post severe tissue loss.

Methods: Two male patients receiving treatment within Concord Burns Unit, (19-year-old with 80%TBSA burns and 45-year-old with Group-A Strep Myositis necessitating quadruple amputation), both experienced prolonged intensive care and mechanical ventilation. Routine intensive dysphagia rehabilitation was applied, however chronic aspiration and poor secretion clearance remained considerable issues. RMST was employed using EMST150 and Threshold-IMT devices. Peak expiratory flow (PEF) and anthropometry measures were obtained prior to commencing RMST and continually monitored throughout treatment. Swallow function was assessed via endoscopy and recorded using the Functional Oral Intake Scale (FOIS), Penetration-Aspiration Scale (PAS), Yale Pharyngeal Residue and New Zealand Secretion Rating Scales.

Results: Baseline PEF scores were recorded at 240 and 90L/min. Baseline scores of PAS-8 and FOIS-1 indicated profound swallowing impairment. Preliminary results indicate improvements in cough and swallow function, progression in tracheostomy weaning and transition to oral intake. Full results are pending following treatment program completion.

Conclusion: RMST should be considered as a potential treatment option to improve swallow and pulmonary function in those patients with profound deconditioning.


Biography:

Dr Nicola Clayton is a Clinical Specialist Speech Pathologist employed at Concord Repatriation General Hospital for the past 19 years. She is recognised nationally and internationally for her clinical expertise and research in the assessment and treatment of complex swallowing disorders post burn injury and has presented and published widely in this field.

Evaluation of service delivery provided through a scar management triage clinic

Ms Claire Toose1, Ms Amy Hickey1, Ms Stephanie Wicks1, Dr Sonia Tran1

1The Children’s Hospital at Westmead, Westmead, Australia

Abstract:

For over ten years, The Children’s Hospital at Westmead has conducted a weekly scar management triage clinic, staffed by the dedicated Burns Registrar and a Burns Physiotherapist. This clinic aims to provide an efficient triage process to determine the need for ongoing scar management in children with identified risk factors for hypertrophic scarring at time of wound closure and discharge from the acute Burns service. The aim of this initiative is to reduce the number of healed wounds requiring “one more check” in the acute burns clinics by diverting them to a clinic specifically designed to assess their ongoing scar management needs. Referral criteria include: patients healing at 14-21 days post burn injury who have not already been commenced on active scar management treatment by the clinic Burns Physiotherapist; patients referred from peripheral hospitals for specialist review; and patients healed in ≤ 14 days post burn with identified risk factors for hypertrophic scarring or a wound showing signs that warrant further monitoring for scarring. Patients who receive skin grafting or have scar management interventions initiated while being managed in the acute burns clinic are excluded from this clinic and managed via the regular consultant clinic scar management pathway.

This project aims to evaluate the effectiveness of this clinic as a triage service and optimise the current service delivery model. Data has been gathered on all patients presenting to the clinic over a two year period, from January 2017 to January 2019. Retrospective analysis of this data will be presented evaluating trends in the types of patients accessing the service, attendance and non-attendance of patients, the proportion of patients discharged following initial consultation, and the proportion of patients requiring ongoing management based on the initial presentation to the clinic. Information gained from the retrospective review will inform the refinement of referral criteria and development of an educational strategy to optimise effectiveness of this service delivery initiative.


Biography:

Claire is a Senior Physiotherapist at The Children’s Hospital at Westmead, working in both the inpatient and outpatient setting with children following burn injury, trauma and reconstructive surgery. Alongside her clinical work she is also  very involved in research, project work, education and training.

Improving Burn Team Resilience

Carl Horsley2, Miss Yvonne Singer1

1Victorian Adult Burns Service, The Alfred, , , 2Critical Care Complex, Middlemore Hospital, ,

Abstract:

Modern acute burn care has the hallmarks of a complex adaptive system. Patient care on any day is in a state of flux, influenced by multiple inter-related factors. These include the variability of patients and their injuries, the skill set and relationships of the clinical team on shift, the acuity and workload, and team and organizational culture.

Burn care therefore sits at the junction of urgency and complexity, requiring burn teams to make time critical decisions in the setting of uncertainty. Risks and hazards abound, and staff are constantly responding to the needs to the patients and the wider system, balancing competing goals and priorities.

Therefore, patient safety, rather than being the natural state of our systems, is something that burns teams must create together every day. However, this daily work, and how it is achieved, remains largely unseen and unvalued by current patient safety efforts which are instead focussed on responding to adverse outcomes and near misses.

Steeped in Safety-II principles, this presentation will examine how our people and teams are the key resource required to navigate the complexity of the burn care we provide. It will explore how to build “team resilience”, the capacity of the team to constantly adjust performance to achieve their goals, even when the unexpected happens. It will share proactive strategies to help build diverse, adaptable teams that can respond flexibly to dynamic work demands, and progress the new aim of safety: that “as much as possible goes right”.


Biography:

Bio to come

Handheld Indirect Calorimetry in the Burns Unit: a feasibility study

Ms Caroline Nicholls1, Mrs Cheryl Brownlow1, Dr Nicola Clayton1,2,3, Ms Christine Parker1, Prof Peter Maitz1,3

1Concord General Repatriation Hospital, Concord, Australia, 2University of Queensland, St Lucia, Australia, 3University of Sydney, Camperdown, Australia

Abstract:

Background:

Given the limitations of existing predictive equations, indirect calorimetry (IC) is considered the gold standard for assessing energy requirements following burn injury. Historically, the equipment has been cumbersome, costly and requires time for calibration, warm up and cleaning. More recently, handheld bedside units have become available making these assessments more accessible and efficient. This study aims to investigate the efficacy of implementing regular use of the handheld calorimeter (FitMate®) into regular dietetic practice in the Burns Unit and how the results compare with the predictive equations currently in use.

Method:

As part of an on-going study, the FitMate® will be used to measure energy requirements for all patients ≥75 years. All patients ≥18 years with burn injuries ≥10%TBSA will also be added to the cohort. The IC will be run with the aim for 10 mins of steady state (defined as less than 10% coefficient of variation in VO2).

FitMate® results will then be compared with the current practice of predictive equations. Staff and patients will be surveyed regarding their perceptions of the FitMate® test, specifically the time taken, patient comfort during the IC and their willingness to repeat the test. Any barriers to IC will be recorded and explored.

Results and Conclusions:

Preliminary results indicate that clinical application of the FitMate® is a feasible tool to assess energy requirements and potentially enhance individualised nutrition care for patients following burn injury. Further detailed analysis will be explored and discussed.


Biography:

Caroline Nicholls has worked as a clinical dietitian for over 20 years and has an interest in nutrition support. She has been the dietitian at the Concord Hospital Burns unit since 2003 and was involved in establishing the Australasian Burns Nutrition Interest Group.  She was an author of the Nutritional Management chapter of the Burn Trauma Rehabilitation: Allied Health Practice Guidelines, a collaboration between the Australian & New Zealand Burn Association and Joanna Briggs Institute.

Pressure garment therapy in children across the ages: less is more

Mrs Kristen  Storey1, Mrs Tamsin Mahoney1, Professor Roy Kimble1,2

1Queensland Children’s Hospital, South Brisbane, Australia, 2Centre for Children’s Burns and Trauma Research, South Brisbane, Australia

Abstract:

Introduction

Pressure garment therapy and silicone gel are common interventions utilised by burns therapists in the prevention and management of hypertrophic scars (Often combined), despite limited clinical evidence to support the efficacy of either treatment modality. Additionally, the challenges with pressure garment prescription including patient adherence, burden and cost of treatment, and inability to quantify or standardise pressure (mmHg) applied to the scar are recognised.

A randomised controlled trial is currently being conducted at our centre exploring the effectiveness of topical silicone gel and pressure garment therapy for burn scar prevention and management in children.

Preliminary results presented at ANZBA 2018 revealed:

–              There is no benefit to using combined interventions (i.e. silicone gel and pressure garment therapy) in reducing scar height.

–              Combined interventions resulted in increased adverse events and reduced adherence to treatment.

The purpose of this review was to establish if there has been a reduction in pressure garment therapy prescription following this RCT.

Method

A cost analysis of custom-made pressure garment expenditure 4 months prior to, and 4 months post the trial was conducted to explore changes to pressure garment prescription.

Results

The cost analysis to date has revealed custom-made pressure garment expenditure:

–              Pre trial: $77,608.32

–              Post trial: $38, 532.52

Discussion

There has been a reduction in pressure garment prescription following the trial as demonstrated in the cost reduction to the unit, despite an increase in burns admissions annually. This shift in practice has resulted in significant reductions in consumable expenditure and therapist time within our Burns Centre.


Biography:

Bio to come

Movement and Mobility protocols after surgical management of burn injuries: An audit of current practice at the Royal Brisbane and Women’s Hospital

Ms Anita Plaza1, Ms Phillipa  Ault1, Ms Marnie Macfie1, Mrs Brooke Mulliss1, Ms Catherine Sharpe1, Mrs Joanne  Alexander1, Mrs Charlotte Jackson1, Ms Jacinta Weber1, Ms Catherine Anderson1, Ms Gemma Allinson1, Ms Michelle Cottrell1

1Royal Brisbane And Women’s Hospital, Australia

Abstract:

Despite growing evidence for the benefits of early mobilisation, there are no clear mobilisation guidelines for the various surgical interventions used in burn management.  Early mobilisation, within 3 days, is recommended after split skin graft (SSG) procedures, however, there are no mobility recommendations for other skin substitutes.

The aim of this project was therefore to conduct an audit of the current mobility practices post burn surgery at the Professor Stuart Pegg Adult Burn Centre, Royal Brisbane and Women’s Hospital (RBWH).

Methods: A retrospective chart audit was conducted and included all patients who were admitted to the RBWH, required surgery for management of a burn injury between 1st July 2017 and 31st December 2018, and survived to hospital discharge.  Patient demographics, burn surgery specific data, ROM and mobility commencement timeframes, patient outcome data, rehabilitation requirements and complication rates were collected.

Results: 480 patients with 662 surgical procedures were included in this audit.  Mean age 39 years (range 14-84), mean %TBSA 6.4% (range 0.1-86) and mean hospital length of stay (LOS) 12 days (range 1-300).  Meshed SSGs were the most frequently performed surgical procedures (64.4%, n=426) with allograft used in 10.7% (n=71) and other skin substitutes used in 7.3% (n=48) of cases.  The mean time to commencement of ROM for meshed SSGs was 3.5 days (range 0-14) with the mean start time of full weight-bearing mobilisation (FWBMob) being 2.4 days (range 0 to 20).  For widely meshed grafts (4:1) with allograft overlay, the mean time to commence ROM was 4.3 days (range: 3-13) and FWBMob was 6 days (range 4-21).  For Biodegradable Temporising Matrix (BTM).BTM, mean ROM commencement after application was 7.6 days (range 6-15 days) and the mean time to FWBMob was 11.3 days (range 6-28 days).  For Biobrane, mean ROM commencement was 3.4 days (range 1-7) and mean time to FWBMob was 5.2 days (range 1-10).  The relationships between early mobilisation and patient outcomes, hospital complications, LOS and rehabilitation requirements will also be explored.

Conclusion: Outcomes from this audit may positively influence patient outcomes post burn injury by contributing to the reduction of complications associated with bed rest and immobilisation.


Biography:

Phillipa Ault is a physiotherapist working at the Royal Brisbane and Women’s Hospital.  She has over 5 years experience working in the area and has published previously on the effectiveness of scar massage for hypertrophic scarring.

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About ANZBA

ANZBA is a not for profit organisation and the peak body for health professionals responsible for the care of the burn injured in Australia and New Zealand. ANZBA encourages higher standards of care through education, performance monitoring and research.

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