Differences in Burn Wound Size Estimation Between Points of Referral and The Burn Unit

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Drs Samuel Adesina Ademola and Chinsunum Peace Isamah share insights from their paper, “Differences in burn wound size estimation between points of referral and the burn unit: A major burn center experience from southwestern Nigeria.” Read the full paper here.

Transcript

Samuel Adesina Ademola, MBBS, FWACS, FACS:

I am Samuel Ademola. I'm a plastic surgeon at the University College Hospital in Ibadan, Nigeria. I also lecture at the College of Medicine of the University of Ibadan.

Chinsunum Peace Isamah, MBBS, MWACS:

I'm Dr. Chinsunum Isamah. I'm a senior registrar in Plastic and Reconstructive Surgery at University College Hospital Ibadan, where this study was done.

Ademola:

Maybe one other thing, as you'll notice in the paper, is that Dr. Isamah is the corresponding author while I'm the first author on the paper. The overview of the paper is that we tried to compare whether there are differences or the differences in the estimation of burn wound size between referral centers, where we have people who are non-burn surgeons who refer patients to us, their estimate of the burn wound size to compare it with what we have at our burn center. So that's basically what the paper is about.

And the reason for doing that is that we notice that when we receive patients or we receive referrals, there are actually some differences in the estimates of burn wound size between the people who refer the patients and what we come up with when we review the patients at the burn center. We were not sure of the magnitude of these differences. We are not sure of whether these things have significant effect on patient management or whether it would have great effect on decision making. But there are a number of things why we think it's important to know the magnitude of the difference.

The first reason is because the way patients arrive at the hospital in our practice is such that patients do not come to the hospital immediately. They have these injuries. Sometimes they would have gone to some other centers and they would've received some management for 24 hours, sometimes 48 hours before coming to our practice, to our burn center. And therefore we thought that it's important for us to know if what management they have received would've been, particularly the resuscitation, would've been the same that they're supposed to receive if they come to the burn center.

Also because the manner of accessing consumables and treatment in our practice setting is that of out of pocket payment—it’s largely out of pocket payment—some of the patients may not be able to receive consumables for wound dressings immediately, and therefore, when they arrive at a practice setting or at a burn center, what we do is that we rely on the estimates that have been put in place or written in their referral notes until we are able to actually have the available resources to change their wound dressings and re-estimate what the wound size is. And also we felt, well, could there have been situations where we really have unnecessary referrals to our centers?

So because of all these things, we thought, let us look at the magnitude of difference that we have between the referral centers and the burn centers and see whether there are things that we need to modify or interventions we need to put in place so that these patients will have adequate management.

Isamah:

Yes. And that is something that we found from this study. Some of the findings were surprising. For instance, about a third of the patients we received during this time period had no burn size estimation. And that is important because management of the burn wound, both in terms of decision making like Dr. Ademola has said and subsequent improvement depends significantly or remarkably on burn size estimation. So when we are receiving about a third of our patients without burn size estimation, that was quite remarkable and surprising. The other thing we felt too about the surprising trend was that over two-thirds of these patients who had no burn size estimation were actually children. So it brings to the fore that perhaps there is some problem with the burn size estimation in children adding up with the appropriate formula to use or exactly how to use it. So this could also be something that one should look at, because to two-thirds is really remarkable in terms of proportion,.

We also found that about two-thirds of these patients that had their burn size estimated by the referral centers had discrepancies. So, yes, we anticipated that there will be some burn size discrepancies, but not as much as two-thirds of these patients, with about 40% having their burn size overestimated and about 22% having their burn size underestimated. And this is really huge. And we also, in keeping with the trend of those that didn't have their burn size estimated, we found that children were more likely to have their burn size overestimated. And this really shows that there is a problem with burn size estimation in children from referral sources.

Yes. Thank you. So from what we've found, we've been able to identify some areas of further research. For instance, we intend to incorporate education as continuous medical education into the different activities through the regional medical associations where our patients are referred from. And when that is done with the mind of the appropriate meters for burn size estimation, the need for every patient to have their burn size estimated, and the implication of burn size estimation in burn management and [inaudible], we’ll be able to do a follow-up study looking at the impact of this educational intervention in this area. So this is actually one area of further research that, from the outcome of this study and the proposed intervention targeting the referral sources, we also want to evaluate further if this had been able to solve part of this problem.

And the other area we see, the other area we see is to be able to use this going forward because this is a retrospective study. So we're not able to evaluate the impact of these discrepancies in terms of patient outcome, in terms of fluid resuscitation, those who did actually received too much fluid because of the overestimation or those who received too little because of the underestimation. And then if this had any impact in terms of morbidity or the mortality. So going forward, another area of research is actually to see if these discrepancies that occur from referral sources to the burn center also impact the patient management decisions and outcome at the referral facilities, and then at the definitive facility.

Ademola:

I think we have captured basically things that we think we should do, but we need also to say that it's as part of planning intervention, we actually intend to see, to explore the reasons why we have these discrepancies. That might help us in carrying out the intervention that we propose to carry out. And of course, as Dr. Isamah mentioned, we will then be able to evaluate the effect of intervention down the line. Thank you.