M.E. van Baar

Accuracy of burn size assessment prior to arrival in Dutch Burn centres and its consequences in children: A nationwide evaluation §

BACKGROUND Total body surface area (TBSA) burned, expressed as percentage is one of the most important aspects of the initial care of a burn victim. It determines whether transfer to a burn centre is necessary as well as the need for, and amount of, intravenous fluid resuscitation. Numerous studies, however, have highlighted inaccuracies in TBSA assessment. Therefore, the differences in burn size estimates between referrers and burn centres in children and its consequences in terms of transfer and intravenous fluid resuscitation were investigated. METHODS This study involved two time periods from January 2002 until March 2004 and January 2007 until August 2008. All referred children admitted to a Dutch Burn centre within 24h post burn were eligible. Data were obtained from patient records retrospectively and in part prospectively. RESULTS A total of 323 and 299 children were included in periods 1 and 2, respectively. Referring physicians overestimated burn size with a factor two (mean difference: 6% TBSA ± 5.5). About one in five children was referred to a burn centre without fulfilling the criteria for referral with regard to burn size (assessed by burn specialists) special localisation or inhalation trauma. Proportions of children receiving intravenous fluid resuscitation regardless of indication increased from 33% to 49% (p<0.01). The received volumes tended to be higher than necessary. CONCLUSIONS Referring physicians overestimate burn size in children admitted to Dutch burn centres. This has little negative consequences, however, in terms of unindicated transfers to a burn centre or unnecessary fluid resuscitation.

Health-related quality of life in preschool children in five health conditions.

ObjectiveTo test the responsiveness of the Infant/Toddler Quality of Life Questionnaire (ITQOL) to five health conditions. In addition, to evaluate the impact of the child’s age and gender on the ITQOL domain scores.MethodsObservational study of 494 Dutch preschool-aged children with five clinical conditions and 410 healthy preschool children randomly sampled from the general population. The clinical conditions included neurofibromatosis type 1, wheezing illness, bronchiolitis, functional abdominal complaints, and burns. Health-related quality of life (HRQoL) was assessed by a mailed parent-completed ITQOL. Mean ITQOL scale scores for all conditions were compared with scores obtained from the reference sample. The effect of patient’s age and gender on ITQOL scores was assessed using multi-variable regression analysis.ResultsIn all health conditions, substantially lower scores were found for several ITQOL scales. The conditions had a variable effect on the type of ITQOL domains and a different magnitude of effect. Scores for ‘physical functioning’, ‘bodily pain’, and ‘general health perceptions’ showed the greatest range. Parental impact scales were equally affected by all conditions. In addition to disease type, the child’s age and gender had an impact on HRQoL.ConclusionsThe five health conditions (each with a distinct clinical profile) affected the ITQOL scales differently. These results indicate that the ITQOL is sensitive to specific characteristics and symptom expression of the childhood health conditions investigated. This insight into the sensitivity of the ITQOL to health conditions with different symptom expression may help in the interpretation of HRQoL results in future applications.

Epidemiology and trends in severe burns in the Netherlands

INTRODUCTION The aim of this study was to characterize the epidemiology of severe burns in the Netherlands, including trends in burn centre admissions, non burn centre admissions and differences by age. METHODS Patients with burn-related primary admission in a Dutch centre from 1995 to 2011 were included. Nationwide prospectively collected data were used from three separate historical databases and the uniform Dutch Burn Repository R3 (2009 onwards). General hospital data were derived from the National Hospital Discharge Register. Age and gender-adjusted rates were calculated by direct standardization, using the 2005 population as the reference standard. RESULTS The annual number of admitted patients increased from 430 in 1995 to 747 in 2011, incidence rates increased from 2.72 to 4.66 per 100,000. Incidence rates were high in young children, aged 0-4 years and doubled from 10.26 to 22.96 per 100,000. Incidence rates in persons from 5 up to 59 increased as well, in older adults (60 years and older) admission rates were stable. Overall burn centre mortality rate was 4.1%, and significantly decreased over time. There was a trend towards admissions of less extensive burns, median total burned surface area (TBSA) decreased from 8% to 4%. Length of stay and length of stay per percent TBSA decreased over time as well. CONCLUSIONS Data on 9031 patients admitted in a 17-year period showed an increasing incidence rate of burn-related burn centre admissions, with a decreasing TBSA and decreasing in-burn centre mortality. These data are important for prevention and establishment of required burn care capacity.

Epidemiology of children admitted to the Dutch burn centres. Changes in referral influence admittance rates in burn centres

BACKGROUND In the Beverwijk Burn Centre a remarkable rise has been noted in the number of paediatric admissions since 2000. To investigate if this is a national trend and, if so, what may have caused it, a retrospective epidemiological study has been undertaken. MATERIALS AND METHODS The databases of the three Dutch burn centres were combined. Data on the population at risk for admission in a burn centre and data on burns related hospital admissions were added. Two age groups, 0-4 years and 5-17 years and two time periods, 1995-1999 and 2000-2007, were compared. RESULTS The mean number of paediatric admissions in the Dutch burn centres per year increased by 44.0% and 44.3% for the younger children (0-4 years) and the older children (5-17 years), respectively, whereas the number of paediatric burn admissions in other hospitals in the Netherlands decreased. The percentage of children that was referred from other hospitals increased in both age groups, and for the younger children this was significant. CONCLUSION There has been a shift in paediatric burn care towards a greater volume of admissions in specialized burn care of especially young children with less severe burns. A possible explanation for the increased number of referred children may be the introduction of the EMSB course in 1998, since EMSB guidelines dictate stricter and generally accepted referral criteria.

Reconstructive surgery after burns: a 10-year follow-up study.

BACKGROUND There is minimal insight into the prevalence of reconstructive surgery after burns. The objective of this study was to analyse the prevalence, predictors, indications, techniques and medical costs of reconstructive surgery after burns. METHODS A retrospective cohort study was conducted in the three Dutch burn centres. Patients with acute burns, admitted from January 1998 until December 2001, were included. Data on patient and injury characteristics and reconstructive surgery details were collected in a 10-year follow-up period. RESULTS In 13.0% (n=229/1768) of the patients with burns, reconstructive surgery was performed during the 10-year follow-up period. Mean number of reconstructive procedure per patient were 3.6 (range 1-25). Frequently reconstructed locations were hands and head/neck. The most important indication was scar contracture and the most applied technique was release plus random flaps/skin grafting. Mean medical costs of reconstructive surgery per patient over 10-years were €8342. CONCLUSIONS With this study we elucidated the reconstructive needs of patients after burns. The data presented can be used as reference in future studies that aim to improve scar quality of burns and decrease the need for reconstructive surgery.

Reduction in skin grafting after the introduction of hydrofiber dressings in partial thickness burns: A comparison between a hydrofiber and silver sulphadiazine

AIM/PURPOSE The aim of this study was to compare clinical outcome of children with scald burns treated with a hydrofiber dressing (Aquacel(®), Convatec Inc.) with the former standard of care with silver sulfadiazine (Flammazine(®); Solvay Pharmaceuticals), considering surgical intervention and length of stay (LOS). METHODS A retrospective study of all consecutive children from zero to four years with primary scald burns up to 10% admitted to the Burn Centre of the Maasstad Hospital Rotterdam between January 1987 and January 2010 were reviewed. For data collection a prospective computerized database was used. For comparison the study period was divided into two periods representing the period before and after the introduction of the hydrofiber dressing (HFD), respectively 1987-1999 (period 1) and 1999-2010 (period 2). RESULTS Over the whole study period 27.3% of 502 patients treated with silver sulfadiazine (Ag-SD) underwent surgery, while before the introduction of HFD 30.5% of 338 Ag-SD treated patients were operated upon. After the introduction of the HFD 20.7% of 164 patients treated with Ag-SD eventually underwent skin grafting, a significant difference with the 11.6% of 302 patients whose wounds were dressed with HFD (p<0.01). CONCLUSIONS Compared to silver sulfadiazine treatment a reduced number of surgical interventions was observed in mixed partial thickness scald burns up to 10% TBSA burned in children aged 0-4 years after the introduction of hydrofiber dressings. The mode of treatment with this wound dressing also limited hospital length of stay.

Effectiveness of Cerium Nitrate-Silver Sulfadiazine in the Treatment of Facial Burns: A Multicenter, Randomized, Controlled Trial

Background: The face is a very frequent site of burn injuries. This multicenter, randomized, controlled trial thus investigates the effectiveness of cerium nitrate–silver sulfadiazine in the treatment of facial burns compared with silver sulfadiazine. Methods: Adult patients with acute facial burns admitted to Dutch burn centers were randomized to treatment with either cerium nitrate–silver sulfadiazine or silver sulfadiazine. Primary outcome was need for surgery and time to wound healing. Aesthetic and functional outcome was assessed at 3, 6, and 12 months after burn. Results: From March of 2006 until January of 2009, 179 patients were randomized and 154 could be included. The two groups of patients (cerium nitrate–silver sulfadiazine group, n = 78; silver sulfadiazine group, n = 76), were comparable regarding sex, age, percentage total body surface area burned, and cause. During admission, four patients died, leaving 77 and 73 patients for primary analyses, respectively. Surgery was required in 13 (16.9 percent) compared with 15 patients (20.5 percent) (p = 0.57; odds ratio, 0.8; 95 percent CI, 0.3 to 1.8), respectively. Median time to wound healing was 11.0 days in the cerium nitrate–silver sulfadiazine group (interquartile range, 7.0 to 15.0) and 9.0 days for silver sulfadiazine group (interquartile range, 5.0 to 15.75) (p = 0.17). There were no significant differences in functional and aesthetic outcome. Conclusions: No differences were found in effectiveness of both treatments. The vast majority of facial burns do not require surgery, and treatment with cerium nitrate–silver sulfadiazine and silver sulfadiazine leads to satisfactory outcome, both aesthetically and functionally. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Early management in children with burns: Cooling, wound care and pain management

INTRODUCTION Early management in burns, i.e. prior to admission in a burn center, is essential for an optimal process and outcome of burn care. Several publications have reported suboptimal early management, including low levels of pain medication after trauma, especially in children. The aim of this study was to evaluate the current practice in the Netherlands and factors related to early management in pediatric burns, i.e. cooling, wound covering and pain management. To study possible change and improvement over time, two study periods were compared. METHODS This study involved two periods; January 2002-March 2004 (period 1) and January 2007-August 2008 (period 2). All children (0-15 years of age) with acute burns admitted within 24h after burn to one of the three Dutch Burn centers with a formal referral were eligible. Data were obtained from patient records, both retrospectively and prospectively. RESULTS A total of 323 and 299 children were included in periods 1 and 2, respectively. The vast majority of children in both study periods had been cooled before admission (>90%). Over time, wound covering increased significantly (from 64% to 89%) as well as pain treatment (from 68% to 79%). Predominantly paracetamol and morphine were used. Referral from ambulance services (OR=41.4, 95%CI=16.6-103.0) or general practitioners (OR=59.7, 95%CI=25.1-141.8) were strong independent predictors for not receiving pre-burn center pain medication. On the other hand, flame burns (OR=0.2, 95%CI=0.1-0.5) and more extensive burns (TBSA 5-10%: OR=0.4, 95%CI=-0.2 to 0.8; TBSA≥10%: OR=0.2, 95%CI=0.1-0.4) were independent predictors of receiving pain medication. CONCLUSION Referring physicians of children with burns were overall well informed: they cool the wound after burns and cover it before transport to prevent hypothermia and reduce the pain. Additional studies should be conducted to clarify the duration and temperature for cooling to be effective. Furthermore, there is room and a need for improvement regarding early pain management.

Clinical outcome of patients with self-inflicted burns

INTRODUCTION Patients with self-inflicted burns (SIB) are thought to have a longer length of stay compared to patients with accidental burns. However, other predictors for a longer length of stay are often not taken into account, e.g. percentage of the body surface area burned, age or comorbidities. Therefore, we wanted to study the outcome of patients with SIB at our burn center. METHODS A retrospective, observational study was conducted. All adult patients with acute burns admitted to the burn center of the Martini Hospital Groningen, between January 1, 2009 and December 31, 2013 were included. Data on characteristics of the patient, injury, and outcome (LOS, mortality, discharge destination) were collected. In patients with SIB, suicide attempts (SA) were distinguished from self-harm without the intention to die (non-suicidal self-injury, NSSI). To evaluate differences in outcome, each patient with SIB was matched on variables and total score of the Abbreviated Burn Severity Index (ABSI) to a patient with accidental burns (AB). RESULTS In total 29 admissions (21 SA and 8 NSSI) were due to SIB and 528 due to accidents. Overall, when compared to AB, there were significant differences with respect to mortality and LOS for SA and/or NSSI. Mortality was higher in the SA group, while the LOS was higher in both the SA and NSSI groups compared to the AB group. However, after matching on ABSI, no statistical significant differences between the SA and SA-match or the NSSI and NSSI-match group were found. CONCLUSION With the right and timely treatment, differences in mortality rate or length of stay in hospital could all be explained by the severity of the burn and the intention of the patient.

Return to work after specialised burn care: A two-year prospective follow-up study of the prevalence, predictors and related costs

BACKGROUND Burn injuries may cause long-term disability and work absence, and therefore result in high healthcare and productivity costs. Up to now, detailed information on return to work (RTW) and productivity costs after burns is lacking. AIMS The aim of this study was to accurately assess RTW after burn injuries, to identify predictors of absenteeism and to calculate healthcare and productivity costs from a societal perspective. METHODS A prospective cohort study was conducted in the burn centre of Rotterdam, the Netherlands, including all admitted working-age patients from 1 August 2011 to 31 July 2012. At 3, 12 and 24 months post-burn, patients were sent a questionnaire: including the Work and Medical Consumption questionnaire for the assessment of work absence and medical consumption and the EQ-5D-3L plus a cognitive dimension to assess post-burn and pre-burn quality of life (QOL). Cost analyses were from a societal perspective according the micro-costing method and the friction cost method was applied for the calculation of productivity loss. Univariate logistic regression was used to identify predictors of absenteeism at three months. RESULTS A total of 104 patients were included in the study with a mean total body surface area (TBSA) burned of 8% (median 4%). 66 respondents were pre-employed, at 3 months 70% was back at work, at 12 months 92% and 8% had not returned to work at time of final follow-up at 24 months. Predictors of absenteeism at 3 months were: TBSA, length of stay, ICU-admission and surgery. Mean costs related to loss in productivity were €11.916 [95% CI 8.930-14.902] and accounted for 30% of total costs in pre-employed respondents in the first two years. CONCLUSION This two-year follow-up study demonstrates that burn injuries cause substantial and prolonged productivity loss amongst burn survivors with mixed burn severity. This absenteeism contributes to already high societal costs of burn injuries. Predictors of absenteeism found in this study were primarily fixed patient and treatment related factors, future studies should focus on modifiable factors, in order to improve RTW outcomes. Also, more attention in the rehabilitation trajectory is needed to optimally support RTW in burn survivors.