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Chapter 16. Outpatient Burn Care
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Chapter 17
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Telemedicine
LaurenB.Nosanov andAmaliaCochran
Effective prevention efforts have resulted globally in a lower
incidence of burn injury. An unforeseen consequence of this
success in the United States is an overall decrease in centers
providing regionalized burn care, with only 70 American
Burn Association (ABA) verified centers in the United
States as of 2020 [1–3]. Remaining centers have developed
progressively larger catchment areas, often necessitating air
transport when interfacility transfers are needed [4–7].
Disparities in access to specialized burn care persist nationally, particularly in rural regions [3, 8]. Global access is sparse
and is a major challenge as 90% of burns occur in developing
or underdeveloped countries, with the majority of those
burned being children [1]. Telemedicine has become one of
the major modes used to bridge these gaps at a local, locoregional, regional, national, and international level [9, 10].
The Institute of Medicine defines telemedicine as “the use
of electronic information and communications technologies
to provide and support health care when distance separates
L. B. Nosanov
Department of Surgery, University of Wisconsin,
Madison, WI, USA
A. Cochran (*)
Department of Surgery, University of Florida, Gainesville, FL, USA
e-mail: amalia.cochran@surgery.u.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. O. Lee (ed.), Essential Burn Care for Non-Burn Specialists,
https://doi.org/10.1007/978-3-031-28898-2_17
365
366
L. B. Nosanov and A. Cochran
participants” [11]. Earlier forms of telemedicine technologies
were asynchronous, consisting of storing and forwarding
images and communications. While this approach remains
popular, synchronous interactive platforms have become
more widely used. Associated technologies are numerous and
include a variety of modalities including web-based platforms, proprietary communication systems, encrypted text,
and video messaging services such as WhatsApp, Facebook
Portal, FaceTime, and Skype, non-encrypted texting from
personal phones, and publicly and privately available burnspecific applications for mobile devices such as Burn App
and Teleburn App [12–17]. Standard digital cameras and
smartphones provide adequate image resolution for accurate
diagnosis and clinical decision-making [18].
The medical community has long appreciated the value of
telemedicine, citing diminished unnecessary travel, increased
cost savings, availability of specialty services, improved rates
of post-operative follow-up, expediency of “real time” communication, and teleconferencing and education across large
distances and even across national borders [12, 19]. The benefits of telemedicine have been established in studies of multiple surgical subspecialties, with application to both adult
and pediatric patient populations [20, 21]. Telemedicine is a
crucial tool for triage and management in the setting of natural disasters and can be used during triage, resuscitation, and
evacuation from military settings in remote front-line austere
environments [1].
Within burn care, telemedicine has been used for over
20years. Current technology allows for provider-to-provider
consultation as well as direct patient-provider communication. A 2012 survey of ABA burn center directors showed
that 84% were using at least one form of telemedicine as a
part of their practice [22]. Patient portals enable outpatient
consultation, post-operative or post-discharge monitoring,
guidance and troubleshooting of home wound care, longterm scar monitoring, rehabilitative care, and ongoing psychosocial support that draws on the multidisciplinary
resources provided by burn centers [12, 20, 23, 24].
Chapter 17. Telemedicine
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367
Widespread adoption of telemedicine for burn care has
been slow, due in part to a dearth of high-level evidence supporting efficacy, patient satisfaction, cost effectiveness, and
safety. Initially, Massman etal. published a small case series
out of Regions Hospital Burn Center, finding that telemedicine follow-up improved access to rural and underserved
areas and diminished travel time and costs [25]. A subsequent
publication from the same group evaluated a larger cohort of
patients with similar findings [26]. The body of supporting
literature has since grown, as demonstrated in a 2012 systematic review by Wallace etal. [18]. The authors identified 24
studies, eight of which assessed technical feasibility and clinical validation, seven of which looked at clinical decisionmaking in acute burn care, and nine that focused on outpatient
care. Although some have expressed concern as to burn provider capacity to accurately evaluate burn injuries by photographic images alone, data show that addition of a visual
component to consultation improves estimation of burn total
body surface area (TBSA) [1, 18, 20, 23, 27].
With the diminishing prevalence of burn injuries, nonspecialist providers are experiencing less exposure to burns
both in training and in practice. Misestimation of burn size
and severity can lead to both under-triage and over-triage,
which can be ameliorated by utilization of telemedicine [4, 13,
28, 29]. Lack of familiarity most often leads to overestimation
of burn size and underestimation of burn depth [3]. A recent
systematic review on burn size estimation by Pham et al.
found that TBSA burn miscalculations between 5 and 339%
were reported within the 26 articles evaluated [28]. It has
been demonstrated elsewhere that overestimation of burn
TBSA occurs in up to 70% of patients transferred to burn
centers [5, 30]. One retrospective analysis of all burn patients
transferred by air to a regional burn center found that referring physicians’ analyses of burn size differed from burn
center measures by 9% TBSA, comprising 75% of the total
burn size [7]. There are numerous, significant consequences of
burn size misestimation including unnecessary healthcare
costs, misappropriation of limited resources, and delay in pro-
368
L. B. Nosanov and A. Cochran
viding appropriate patient care. Further, burn TBSA overestimation is linked with over-resuscitation, which in turn
results in increased morbidity and mortality from complications such as abdominal compartment syndrome [18, 28, 29].
Lack of familiarity with inhalation injury is similarly a
major source of avoidable morbidity as well as cost. Although
there is a risk of underappreciation of airway edema and
potential for airway loss, the tendency is toward overestimation of this risk. Romanowski et al. showed that more than
one-third of intubations in patients transferred to burn centers could be considered unnecessary, in that many patients
were extubated within 24h of arrival to the burn center [31].
Similarly, Wibbenmeyer et al. found that while only 5% of
patients were intubated in a pre-hospital or pre-transfer setting, nearly two-thirds were extubated within 24h of transfer
[30]. Kashefi etal. reported a 14.5% rate of intubation among
over-triaged patients which they attributed to potential overdiagnosis of inhalation injury or airway compromise [6].
Recent updated burn center referral criteria aid in
identifying patients with injuries who benefit from telehealth
consultation for triage (Table 1 7. 1 ) [32]. These include fullthickness burns greater than 5% TBSA, adults older than 55,
children with burns greater than 10% TBSA, chemical burns,
inhalation injury, high-voltage and lightening electrical
injuries, and those with injury due to frostbite. Patients with
epidermal skin sloughing disorders such as Stevens-Johnson
syndrome (SJS), toxic epidermal necrolysis (TEN), and necrotizing soft tissue infection (NSTI) are also recommended
for transfer given that they benefit from nursing expertise
and multidisciplinary support more readily available at a
burn center. Beyond this, patients who benefit from burn
center consultation include full-thickness burns of any size,
children with burns smaller than 10% TBSA, and low-voltage
electrical injuries. Referring providers caring for patients not
in need of transfer can acquire guidance as to initial management including wound dressing choice and can establish a
plan for follow-up with either local providers, burn center
outpatient clinics, or burn center telemedicine [20, 33].
Chapter 17. Telemedicine
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369
b, c
Outpatient burn center
referral recommended
• Full- thickness burns <5%
c
potentially deep burns of
Telemedicine consultation
recommended
a, b
TBSA
<10% TBSA
any size
(continued)
• Not specifically indicated
burns to the face without
inhalation injury
burns involving the face, hands,
genitalia, feet, perineum, or over any
• Full thickness >5% TBSA • Recommended for all
Patient transfer potentially indicated
T . Recommendations for burn center transfer and consultation [with permission from Oxford University
Press]
Thermal
burns
• Partial thickness >10% TBSA • Partial- thickness burns
• Any deep partial- or full-thickness
joints
• All patients with true inhalation injury • Recommended for flash
Inhalation
injury
comorbidities such as COPD may
benefit from burn center admission
• Patients smoking on oxygen with other
L. B. Nosanov and A. Cochran
370
b, c
Outpatient burn center
referral recommended
c
Telemedicine consultation
recommended
a, b
• Same thresholds as adults
a burn center should occur
within 7days of injury
• Outpatient consultation at
potentially deep burns
of any size
adults
• Same thresholds as other
potentially deep burns
of any size
• Recommended for all
Patient transfer potentially indicated
T . (continued)
center admission unless they have
thermal burns meeting above criteria
• Facial flash burns do not need burn
• Same %TBSA thresholds as adults • Recommended for all
Pediatrics
(≤16years)
partial thickness burns may benefit
from burn center admission due to
dressing change, rehabilitation, or
parent/caregiver needs
• Children with <10%TBSA full or
adults
• Same %TBSA thresholds as other
Older adults
(≥55years)
patients may particularly benefit
• Older adult (>55years) burn
from the multi- disciplinary team
resources available at a burn center
Chapter 17. Telemedicine
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371
b, c
injuries should receive, at
minimum, one follow-up
Outpatient burn center
referral recommended
• Not specifically indicated
• Low voltage electrical
c
available
• Recommended if
Telemedicine consultation
recommended
a, b
visit to a burn center to
available
screen for delayed symptom
onset and vision problems
• Not specifically indicated
(continued)
available
for in a burn center
• All chemical injuries should be cared
Patient transfer potentially indicated
• All high voltage electrical injuries • Recommended if
Chemical
injuries
Electrical
injuries
• Lightning injury
Cold injury • Grades II–IV frostbite • Recommended if
from the multidisciplinary team
resources available in a burn center
• All cold injured patients may benefit
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