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CHAPTER31 Outpatient management ofminor burns
Follow- up
Follow- up arrangements vary depending on physician, institution, and patient preferences. However, intervals should be selected to ensure that
adverse events, including conversion to deeper injuries, are promptly
identied and rectied. Shorter intervals are preferred initially (commonly
2– 3days after the initial dressing then 3– 7- day intervals), becoming longer
if healing is satisfactory. Multidisciplinary clinics involving physiotherapists, occupational therapists and psychologists should be established to
reduce patient inconvenience. Telemedicine may be appropriate for some
patients. Outreach clinics may also reduce patient transportation costs
and are an important way of following patients up.
Further reading
Hartford CE, Kealey GP. Care of outpatient burns. In Herndon DN, (ed.) Total burn care, 3rd edn.
Edinburgh:W.B. Saunders, 2007; pp. 67– 80.
ISBI. Care of out patient burns. 2014. Available from http:// www.worldburn.org/ documents/
burncare.pdf (accessed 2 July 2014).
Warner PM, Coee TL, Yowler CJ. Outpatient burn management. Surgical Clinics of North America
2014;94:879– 92.
Reference
Wasiak J, Cleland H, Campbell F, Spinks A. Dressings for supercial and partial thickness burns.
Cochrane Database Syst Rev. 2013;28(3):CD002106.
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Chapter32
293
Remote assessment
ofburns
Introduction to remote assessment of burns 294
Organization of burn care in England and Wales 295
Telemedicine 296
Further reading 298
References 298
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CHAPTER32 Remote assessment ofburns
Introduction toremote assessment
ofburns
Approximately 130,000 people with burn injuries visit Emergency
Departments in the UK each year.1 Of these approximately 12,000 are admitted to hospital. Around 6,000 children aged 0– 15years are admitted to
hospital with burns (which equates to approximately 16 babies and children
each day). Of these an average of 250 suer a major burn (>10% total
body surface area (TBSA) requiring uid resuscitation.2 The majority of
cases referred to specialized burns services are not severe. However, even
so, such injuries require specialized care to achieve good outcomes, reduce
long- term scarring, and prevent other ongoing problems.
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ORGANIZATION OFBURN CARE INENGLAND AND WALES
Organization ofburn care inEngland
and Wales
In England and Wales burn care is organized using a tiered model of care2
where the most severely injured are cared for in ‘Burns Centres’ and those
requiring less intensive clinical support being cared for in either a ‘Burns
Unit’ or a ‘Burns Facility’. This endeavours to provide a balance between
easy access and care provided closer to home for the majority of patients
with a smaller number of highly specialized centres for the smaller proportion of patients with more severe injuries.
There are four Adult Burns centres in England and Wales for Adults
(Queen Elizabeth Hospital in Birmingham, Morriston Hospital in Swansea,
Broomseld Hospital in Chelmsford and Chelsea and Westminster Hospital
in London) and four Childrens Burns centre (Birmingham Childrens
Hospital, Queens Medical Centre in Nottingham, Frenchay Hospital in
Bristol and Broomseld Hospital in Chelmsford). This inevitably means a
small subsection of patients with severe injuries potentially may need to
travel long distances for management of their injuries.
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CHAPTER32 Remote assessment ofburns
Telemedicine
The World Health Organization (WHO) denes telemedicine (from
the Greek prex ‘tele’ meaning ‘at a distance’ and the Latin ‘meden’
meaning ‘healing’) as ‘the delivery of health care services, where distance
is a critical factor, by all health care professionals using information and
communication technologies for the exchange of information for the
diagnosis, treatment and prevention of disease and injuries, research and
evaluation, and for the continuing education of health care providers in
the interests of advancing the health of individuals and their communities.’
Telemedicine is not a new branch of medicine or an activity aiming to
replace health care workers and face- to- face consultations. Historically, it
has been performed in a variety of ways, eg. postal services, telegraph, telephone, radio transmission, and initial video recording.
There are two main areas where it can be utilized eectively. Firstly,
where there is no alternative, eg. in emergency situations in remote locations where medical care would be dicult or impossible to reach the
patient in time. Secondly, where it improves the access to health service
avoiding or reducing travel for patients or clinicians.
Modes oftelemedicine
There are a number of dierent modes of telemedicine.
• Store and forward or pre- recorded telemedicine (asynchronous).
Information is acquired and stored in some format prior to being sent
by appropriate means for expert consultation
• Realtime or video conference. There is no delay between the
information being collected, transmitted, and displayed, and interactive
communication between clinicians is possible
• Hybrid telemedicine. This involves is a combination of real- time and
store and forward telemedicine techniques
• Mobile or cellular telemedicine. Portable devices with inbuilt camera
(smartphones, laptops, tablets) capture digital images and computing
and networking features allow digital interaction
• Integration model. Integration of electronic devices and software allows
capturing, transferring, storage, measurement and delivery of follow- up
Medicolegal issues associated withtelemedicine
There have been many medicolegal and ethical concerns raised in regards
to telemedicine including:
• The licensure
• Responsibilities and potential liabilities of the health professional
• Continuity of care
• Duty to maintain the condentiality of patient records
• Informed consent
• Data security
• Jurisdictional problems associated with cross- border consultations
• Reimbursement of care provided by using a telemedicine service
2
3
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Telemedicine inburns assessment and management
The severity of burn injuries is determined by the percentage of the TBSA
injured and the depth of the burn. The injured body surface and depth of
the burn wound are assessed mainly by visual inspection.
Over the past 40years survival from burns injuries5 has improved dramatically. Incidence has also decreased by more than half. However as
incidence has decreased so has most physicians familiarity with burns assessment and treatment. Accuracy of burns assessment has been shown to
be vastly increased when seen by a specialist and simple SAF telemedicine
has been shown to be an eective method of assessment.
vances in smart device technology have increased the potential to make this
technology more accessible and cheaper but the informatics governance
implications have lagged behind the technology.
Cost- eectiveness
There has been little evidence clearly demonstrating the cost- eectiveness
of telemedicine in the assessment of burns injuries especially in developed
countries. However, various projects have shown its clear advantage in both
assessment and subsequent management, prevention of inappropriate or
unnecessary referrals, and costly transfers to burns units.
Conclusion
8
Telemedicine has proved already to be a useful tool in Burns triage and is
just beginning to be used more widely in trauma care, including plastic surgery, burns, neurosurgery, and orthopaedics. With work patterns changing
and increasing super specialization within medicine, telemedicine may prove
critical in helping to permit continued access to essential expertise.
TELEMEDICINE
3, 6
Recent ad-
3,5,7,8
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CHAPTER32 Remote assessment ofburns
Further reading
Claquinto- Cilliers MGC. Telemedicine, mobile phones and burn wound assessment:a valid resource
for South Africa? Wound Healing Southern Africa 2013;6:56– 9.
Sae J, Edelman L, Theurer L, Morris S, Cochran AJ. Telemedicine evaluation of acute burns is ac-
curate and cost- eective. Trauma, Injury, Infection and Critical care 2009;67:358– 65.
Shokrollahi K, Sayed M, Dickson W, Potokar T. Mobile phones for the assessment of bur ns:we have
the technology. Emergency Medicine Journal 2007;24:753– 5.
Wallace DL, Jones SM, Milroy C, Pickford MA. Telemedicine for acute plastic surgical trauma and
burns. Plastic and Reconstructive Aesthetic Surgery 2008;61:31– 6.
Martin N, Lundy J, Rickard R. Lack of precision of burn surface area calculation by UK Armed Forces
medical personnel. J Burns 2013.
Virendra Deo Sinha, Rahul Hath Tiwari, Rashim Kataria. Telemedicine in neurosurgical emergency:
Indian perspective. Asain J Neurosurg. 2012;7(2):75–7.
Egol KA, Helfet DL, Koval KJ. Ecacy of telemedicine in the initial management of orthopaedic
trauma. Am J Orthop (Belle Mead NJ) 2003;32(7):356–60.
References
1. NHS, Hospital Episode Statistics 2011 to 2012.
2. National Burn Care Review Committee Report, Standards and Strategy for Burn Care: A review
of burn care in the British Isles, British Burn Association, February 2001.
3. Claquinto-Cilliers MGC. Telemedicine, mobile phones and burn wound assessment: A
valid resource for South Africa? Claquinto-Cilliers MGC Wound Healing Southern Africa
2013;6(2):56–9.
4. Tsuchihashi Y, Okada Y, Ogushi Y, Mazaki T, Tsutsumi Y, Sawai T. The current status of
medicolegal issues surrounding telepathology and telecytology in Japan. J Telemed Telecare
2000;6(suppl 1):143–5.
5. Sae J, Edelman L, Theurer L, Morris S. Telemedicine evaluation of acute burns is accurate and
cost-eective. Cochran A J Trauma, Injury, Infection and Critical care. 2009;67(2):358–65.
6. Shokrollahi K, Sayed M, Dickson W, Potoker T. Mobile phones for the assessment of Burns: we
have the technology. Emerg. Med J 2007;24:753–5.
7. Wallace DL, Jones SM, Milroy C, Pickford MA. Telemedicine for acute plastic surgical trauma and
burns. Plast Reconstr Aesthet Surg. 2008;61(1):31–6.
8. Wallace D, Hussain A, Khan N, Wilson Y. A systematic review of the evidence for telemedicine
in burn care: with a UK perspective. Burns 2012;38:465–80.
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Chapter33
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Cost ofburn care
Introduction to cost of burn care 300
Acute care cost 300
Rehabilitation cost 301
Cost containment 302
Further reading 302
References 302
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CHAPTER33 Cost ofburn care
Introduction tocost ofburn care
The burden of burn injury, however trivial it may seem, is devastating physically, psychologically, and also nancially. Health economists nd it dicult
to quantify the costs of acute care and almost impossible to dene the cost
of the needed adjustment after recovery. Burns patients often require longterm therapy and outpatient hospital care, and, frequently, re- admission for
reconstructive surgery.
Calculating the cost of burn care is important for reimbursement, resource allocation and achieving eciency by prudent cost analysis. Realistic
cost estimates of burn care require robust data collection and a reliable
informatics infrastructure.
Acute care cost
Stang, operating theatre, intensive care, wound dressings, and the emerging new expensive technologies including skin substitutes are the most expensive categories in burns care. The operating theatre costs between £18
and £50 per minute depending on case complexity.1 The rst 2days after
admission to the burns or the critical care unit cost the most (equivalent of
£6,650day 1, £4,100day 2, and £3,000day 3). This is a reection of the
cost incurred till the patient is resuscitated and stabilized.2 Skin substitutes
including cultured cells technologies and cadaveric skin costs on average
£5.50/ cm2 area covered. Mathew Klein3 estimated the overall average cost
of a paediatric burns to be £5,500, but costs will vary depending on country
and healthcare systems. The severity of the burn— extent and depth—
were the only two factors associated with a greater costs. One per cent
of TBSA grafted increased the cost by £1,600 in one study.3 On the other
hand, it is estimated that the cost of acute care for a massive burn in the
UK ranges from £500,000 to £1,000,000, excluding the rehabilitation costs,
costs of social re- integration, and opportunity costs to society.
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REHABILITATION COST
Rehabilitation cost
The latest iteration of the UK burn care standards require o- site rehabilitation outside the acute care facility, yet the availability of rehabilitation
facilities have yet to catch up with the standards, and commissioning of
these facilities is not streamlined. The cost of rehabilitation includes loss of
productive manpower, earnings, opportunities, and also the cost of social
care and benets. The impact of burns on the patient ’s family and carer
has to be also taken into account. The long- term impact of the burn on
the quality of life has been widely reported. However, there is very little
related to the cost impact, and those funding rehabilitation are focusing increasingly on outcome measures. The World Health Organization’s Global
Disease Burden project has included re as one of 107 major diseases. The
disability- adjusted life years (DALYs) was used as a single measure for combined morbidity and mortality of a certain disease. The estimated DALYs
per 100,000 population in Japan in 2004 for ame burns were 16years, 28
for the USA, 209 in the Russian Federation, 461 in India, and 14 in the UK.
However, the source data need more rening to produce a standardized
comparative risk assessment tool.
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