In view of standardization: Comparison and analysis of initial management of severely burned patients in Germany, Austria and Switzerland

burns 41 (2015) 33–38

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In view of standardization: Comparison and analysis of initial management of severely burned patients in Germany, Austria and Switzerland Matthias Mu¨nzberg a,1, Benjamin Ziegler b,1, Sebastian Fischer b, Christoph Georg Wo¨lfl a, Paul Alfred Gru¨tzner a, Thomas Kremer b, Ulrich Kneser b, Christoph Hirche b,* a

Department for Trauma- and Orthopaedic Surgery, BG Trauma Center Ludwigshafen/Rhine, Ludwig-Guttmann-Str. 13, D–67071 Ludwigshafen, Germany b Department of Hand, Plastic and Reconstructive Surgery—Burn Center, BG Trauma Center Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D–67071 Ludwigshafen, Germany

article info

abstract

Article history:

Introduction: Initial treatment of severely injured patients in German speaking trauma

Accepted 22 August 2014

centers follows precise sequences. Several guidelines and training courses ensure a constant quality in providing evidence-based treatment for these patients.

Keywords:

Similar standards, algorithms and guidelines for the treatment of severely burned patients

Burn

are lacking. This raises the question about the current standard of care for burn victims in

Trauma management

German speaking burn centers. In order to achieve standardization, as a first step this study

Structured patient care

surveys principles of burn room organization and management in these burn centers.

Standard operating procedures

Material and methods: A questionnaire including 40 questions regarding burn room organization, personnel structure and qualification, infrastructural conditions and quality management was developed and sent to 21 level one burn centers in Germany, Austria and Switzerland. Results: The rate of returned questionnaires was 81%. The analysis revealed varying personnel and infrastructural conditions in participating burn centers. Indications for admission to the burn room and admission procedures itself are different throughout surveyed hospitals. Individual standard operating procedure (SOP) for burn trauma admissions was available in most burn centers and nearly all participants register their burn trauma cases using an in-house burn register. Conclusion: The survey suggests a lack of standardization in personnel structure, infrastructure and treatment approach for the initial clinical care of severely burned patients in burn centers across the German speaking countries. Further evaluation of existing protocols and international standards in burn care is inevitable to develop standardized guidelines for burn care and to improve quality of care. # 2014 Elsevier Ltd and ISBI. All rights reserved.

* Corresponding author at: Research group ‘‘Trauma meets Burns’’, Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG-Trauma Center Ludwigshafen/Rhine, University of Heidelberg, Department of Hand and Plastic Surgery, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany. Tel.: +49 621 6810 2944. E-mail address: [email protected] (C. Hirche). 1

Equally contributing authors. http://dx.doi.org/10.1016/j.burns.2014.08.021 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.

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1.

burns 41 (2015) 33–38

Introduction

In emergency departments clinical management of severely injured patients who are suffering from life-threatening injuries is still a challenging task today. Diagnostic procedures and therapeutic interventions are critical in terms of time. To face these needs, several guidelines and standardized priorityorientated algorithms in the trauma bay are available. Guidelines regarding the preclinical treatment as well as the trauma bay phase are published as ‘‘Whitebook Medical Care of the Severely Injured’’ [1] and as ‘‘Guideline on Treatment of Patients with Severe and Multiple Injuries’’ [2]. These guidelines provide recommendations with the highest level of evidence available. Several evidence-based educational tools are accessible for health care providers. The worldwide most prevalent training course for the treatment of severely injured patients during the trauma bay phase is Advanced Trauma Life Support1 (ATLS1) [3]. Special attention is paid on a structured survey of the patient following the ABCDE scheme. All major information on patient status and injuries are repeated loud on handover of the patient by the admitting emergency physician, during the trauma bay phase and as well on the handover to the ICU respectively the operating team. A loss of information can be minimized and a continuous focus on life-threatening problems is maintained after implementation of this approach. The training is well established throughout the world by now, and mandatory requirement for trauma care in trauma centers in some European countries [4]. An additional training course for health care practitioners is Prehospital Trauma Life Support1 (PHTLS1). This training transfers the principles of ATLS1 to the preclinical care of severely injured patients offering a quick and structured survey of the patient, priority-orientated treatment and prompt transport to an adequate trauma hospital [5]. Although the case load is low, the complex pathophysiology of burned patients and the consecutive burn disease also demand a high degree of expertise in primary hospital care of these patients. Due to the specific needs of severely burned patients in terms of fluid resuscitation, airway management and prevention of hypothermia [6] clinical management of these patients has to focus further, aspects in contrast to the treatment of severely injured patients. Nevertheless other primary life-threatening systemic conditions have to be, ruled out in burn trauma patients as well. Because of these reasons it is questionable to which extend the ATLS1 approach is also suitable for severely burned patients or whether burn-specific programs like Advanced Burn Life Support (ABLS1) are additionally necessary. A comparable standardized approach for the management of severely burned patients is lacking in the German speaking countries showing the need for further research to evaluate the current status in initial clinical care of burned patients. This may allow development of standardized treatment algorithms for severe burn trauma during the preclinical phase and in the burn room, a trauma room specific for treatment of severely burned patients which is equipped with a powerful room temperature regulation unit and conditions to perform minor surgical procedures, e.g. escharotomy. In

view of standardization, an evaluation of the current status in burn treatment was carried out in this study to survey principles of burn room organization and management in burn trauma centers in Germany, Austria and Switzerland.

2.

Material and methods

A questionnaire was developed and sent to all 21 level one burn trauma centers in Germany, Austria and Switzerland. The questionnaire surveyed structural data of the burn center including personnel structure, qualification level and organizational measures of the burn unit. Additional statistical data were collected. Criteria for admission to the burn room, its leading structure and available staff and in particular the presence and supervision of an attending physician were evaluated. Furthermore, the performance of a team-time-out, the option of ethical rounds, designation and identification of the trauma room team leader and the treatment of patients with concomitant injuries were focused. In addition, the use and reference of standard operating procedures (SOP) were evaluated. Last, the questionnaire surveyed if the center refers to an internal register for documentation and analysis of care of severely burned patients The questionnaire contained 33 multiple-choice questions and seven open questions. Partially multiple answers were allowed. The referred topics are listed in detail in Table 1. The included burn trauma centers were initially contacted by mail with the option to mail back the completed form. Afterwards, the centers were contacted by phone to discuss and reveal remaining uncertainties. In addition, the form was available for web-based download and to be send back via email.

3.

Results

The return rate of questionnaires was 81% (17 out of 21). Fifteen centers from Germany, one from Austria and one from Switzerland successfully participated in the survey. All returned questionnaires were answered completely and could be included in the study. The reasons for declining participation of the survey were a missing response to the inquiry in two cases and refusal of providing the asked information for reasons of data protection by two burn centers. Criteria for admission of patients to the burn room varied in the evaluated centers. Five centers (30%) admit all patients with thermal injuries to the burn room while other centers admit only patients with an average minimal affected total body surface area (TBSA) of 10% (range 5–15%). Additional criteria were the presence of concomitant injuries (n = 12; 71%), medical sedation applied preclinically (n = 11; 65%), assumption of an inhalation trauma (n = 12; 71%), other known severe illnesses (n = 9; 53%) and cardiopulmonary instability (n = 12; 71%). Reasons for admission to the burn room are displayed in Fig. 1. Patients with concomitant injuries were admitted to the regular trauma room in 14 (82%) and to the burn room in three (18%) centers. Admission requests were accepted by the plastic surgery department in seven (41%) burn centers, by the

burns 41 (2015) 33–38

Table 1 – Detailed parameters which were surveyed in the developed questionnaire. Topic Structural data

Statistical data for 2012

Organization of burn room

Quality management

Questions Number of intensive burn care beds Count of attending physicians, fellows, residents Medical department leading the burn unit Number of patients treated Mean total body surface area (TBSA) of treated patients Mean length of stay on ICU Mean mortality Indication for submission to the burn room Qualification and department of staff accepting admission of patients Staff present in the burn room Performance of team-time-out Designation and identification of the team leader Department leading the burn room Availability of ethical council at time of admission Availability and kind of standard operating procedures Performance of standardized data assessment at admission Treatment of patients with concomitant injuries Responsibility of trauma room organization Recording of in-house burn register Parameters recorded in burn register if available Evaluation of assessed data Availability of interdisciplinary quality management Transfer of statistical data to the German Speaking Association for Burn Treatment

department of trauma surgery in one (6%), by either plastic surgeons or anesthesiologists in eight (47%) centers and by trauma surgeons or anesthesiologists in one (6%) burn center. Acceptance of admission was either given by resident physicians on their own (n = 2; 12%), in agreement with a

consultant physician (n = 13; 76%) or by nurses (n = 2; 12%). The burn room in the participating burn centers were declared to be staffed by attending plastic surgeons (n = 5; 29%), fellows certified by the board of plastic surgery (n = 4; 24%) and resident physicians of plastic surgery (n = 15; 88%). Presence of trauma surgeons was declared in one (6%) case for attending physicians, five (29%) for fellows certified by the board of orthopedics and traumatology and four (24%) for resident physicians. In addition, in nearly all burn centers anesthesiologists were regular attending the burn room (n = 3; 18% attending physicians, n = 9; 53% fellows and n = 4; 24% resident physicians). In 12 (71%) centers, a mean number of 1.5 nurses of the burn intensive care unit and in 11 (65%) a mean number of 1.2 respiratory/anesthesiologist nurses were attending the burn room. In centers without an attending physician always present in the burn room, the fellow or attending physician was called in cases with burns exceeding 15–30% TBSA or if a tracheotomy was necessary. 16 (94%) evaluated burn centers reported to have a designated team leader in the burn room. This burn leader was marked and easily recognizable by special clothing in one center (6%). The burn room was managed by plastic surgeons in nine (53%), by anesthesiologists in six (35%) and by trauma surgeons in two (12%) cases. A team-time-out in the burn room was performed in five (29%) centers and the option for ethical rounds at the time of admission existed in eight (47%) centers. Of the surveyed burn trauma centers 16 (94%) reported the availability and performance of SOPs for admission and treatment of severely burned patients. All of these SOPs were individually developed by the particular burn centers and were based on ATLS1 in ten centers (63%). One center (6%) mentioned Advanced Burn Life Support (ABLS1) as model for the development of their own SOPs. An in-house burn register was used in 15 burn centers (88%) which included preclinical data (n = 12; 80%), the affected TBSA at the time of admission (n = 14; 93%), length of stay at intensive care unit (n = 14; 93%), days of mechanical ventilation (n = 14; 93%), special intensive care interventions (n = 9; 60%), length of hospital stay (n = 13; 87%), number of operations (n = 13; 87%), topical wound treatment (n = 8; 53%), assessment of multiple resistant germs (n = 10; 67%), mortality (n = 15; 100%) and clinical outcome in the form of functional scores (n = 5; 33%). Regular evaluation of the assessed data was reported by 16 (94%) participating burn centers. In eight (47%) responding centers, the evaluation was carried out in the context of a periodical quality circle. All replying burn centers (100%) participated in the annual statistical investigation of the German Speaking Association for Burn Treatment. Results are shown in detail in Table 2.

4.

Fig. 1 – Other reasons for admission to the burn room mentioned by the participating burn centers showed as percentage of all centers.

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Discussion

The initial clinical management of severely burned patients remains challenging and requires a structured approach. Lessons can be learned from the successful implementation of ATLS1 for the treatment of severely injured patients. However, we have to realize, that there is still room for improvements regarding guidelines and extension courses for the initial burn

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Table 2 – Results of the survey in detail. Displayed is the absolute number of naming with percentage of all participating centers in brackets. Questions Leading of burn unit By plastic surgeons By anesthesiologists By trauma surgeons Criteria for admission TBSA of at least Concomitant injuries Sedation by emergency physician Assumption of inhalation trauma Known severe illnesses Cardiopulmonary instability Acceptance of admission by Plastic surgery department Department of trauma surgery Plastic surgeons or anesthesiologists Trauma surgeons or anesthesiologists Consultant physicians Resident physicians Nurses Attendance of plastic surgeons in burn room Attending physicians Fellows Resident physicians Attendance of trauma surgeons in burn room Attending physicians Fellows Resident physicians Attendance of anesthesiologists in burn room Attending physicians Fellows Resident physicians Attendance of nurses in burn room From burn unit Anesthesiologist nurses Management of burn room by Plastic surgeons Trauma surgeons Anesthesiologists Designation of team leader Performance of a team-time-out Availability of ethical council at admission Availability of SOPs Based on ATLS1 Recording of in-house burn register Preclinical data Affected TBSA Length of stay at ICU Mechanical ventilation Special intensive care interventions Length of hospital stay Number of operations Topical wound treatment Assessment of multiple resistant germs Mortality Clinical outcome by functional scores Regular evaluation of assessed data Performance of regular quality circle Participating in annual statistical investigation of the German Speaking Association for Burn Treatment

Results n (%) 10 (59%) 5 (29%) 2 (12%) 5 to 15%TBSA (mean 10%) 12 (73%) 11 (65%) 13 (76%) 9 (53%) 12 (71%) 7 (41%) 1 (6%) 8 (47%) 1 (6%) 13 (76%) 2 (12%) 2 (12%) 5 (29%) 4 (24%) 15 (88%) 1 (6%) 5 (29%) 4 (24%) 3 (18%) 9 (53%) 4 (24%) 12 (71%) 11 (65%) 9 (53%) 2 (12%) 6 (35%) 16 (94%) 5 (29%) 8 (47%) 16 (94%) 10 (63%) 15 (88%) 12 (80%) 14 (93%) 14 (93%) 14 (93%) 9 (60%) 13 (87%) 13 (87%) 8 (53%) 10 (67%) 15 (100%) 5 (33%) 16 (94%) 8 (47%) 17 (100%)

room treatment. As a first step, this investigation reveals the current state of burn care and shows a wide inhomogeneity for major burn treatment. Most concordance could be shown in quality management and data recording. The variations were most apparent in personnel setting in the burn room and concerning indications for admission to the burn room. Our findings show as well lack of standardized infrastructure and management in burn rooms. In contrast, the presence and qualification of surgeons, anesthesiologists, other medical specialists and nurses in the trauma room is defined precisely depending on the role of the trauma center as local, regional or supra-regional center and indication for admission to hospitals of these different levels of care are determined [1]. Although a trauma leader is demanded for trauma centers by the German Society for Trauma Surgery, only one of the investigated burn centers has a designated burn leader who is easily identifiable by the burn room team and by external health care providers. Fig. 2 illustrates the difficulties to identify the team leader at time of admission of a patient to a common burn room. Driscoll et al. and Bouillon et al. showed that the designation of a team leader is crucial for optimizing communication and decision-making in the trauma room [7,8]. The profession of this team leader does not affect the outcome of trauma patients showing that the trauma room can be managed by any specialty such as surgeons or emergency physicians [9,10]. The standardized performance of a team-time-out in the burn room is reported by 29% of the evaluated centers. Despite little evidence and limited experiences recent research showed positive effects of performing a team-time-out on team communication and patient safety [11,12]. Most centers indicated to use a self-developed SOP, which is declared to be based on ATLS1 in most cases. In the past years, research showed that therapy and clinical outcome can be improved when treatment guidelines are applied in severely injured patients [13]. ATLS1 in specific was shown to improve the knowledge of participants on trauma management as well as their clinical skills and organization. Participants reported an improved self-confidence while managing crucial situations [14]. Although a comparison of data before and after introduction of ATLS1 in the Netherlands showed a significant mortality reduction during the first hours after trauma [15], there is still no clear evidence that ATLS1 impacts the long-term outcome of severely injured patients [16]. To transfer these improvements to the care of severely burned patients, a collaboration of the American College of Surgeons (ACS) and the American Burn Association (ABA) resulted in Advanced Burn Life Support (ABLS1), an educational program that incorporates some elements of the established ATLS1 program with focus on burns. The ABLS1 program suggests an approach for specific treatment after burn in the first 24 h period. ABLS1 tries to help health care providers to assess the severity of the injury, to determine the transfer of the patient into a regional burn center and to provide appropriate treatment of the burn victim. The course is structured in a certified 8-hour course addressing physicians, nurses and paramedics [17]. The ABLS1 program, initially limited to the United States, was successfully adapted to the

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Fig. 2 – Scenery during arrival of the preclinical team in a common burn room, a trauma room specific for treatment of severely burned patients which is equipped with a powerful room temperature regulation unit and conditions to perform minor surgical procedures e.g. escharotomy. The staff is wearing a cap, a face mask and a water repellent overall making the team leader hard to identify.

local health care system of Japan and Italy [18,19]. Another competing educational program is the Emergency Management of Severe Burns (EMSB1) course [20]. Originally introduced by the Australian and New Zealand Burn Association in 1996 to provide a more effective approach to the severely burned patient, it has been distributed to more countries around the world by now [21,22]. The effectiveness of this training on knowledge and capability in managing burn incidents by nurses as well as by physicians was approved by online simulation testing in the Netherlands [23]. Although evidence relating improvements of burn patient care through introduction of ABLS1 or EMSB1 is missing by now, a set of guidelines for the treatment of these patients should be discussed for the German speaking countries. Further investigations are required to evaluate the present individual SOPs in the surveyed burn centers as a basis to establish a generally accepted guideline. In addition, the documentation and registration of burn victims has to be improved in order to provide an adequate data set for quality management and scientific analysis. The German Trauma Society established a central trauma register in 1993. Nowadays, over 800 clinics are participating and over 80% of all patients suffering from a severe injury are included in this register. As a consequence, a high level of evidence has been achieved in a medical field where randomized control studies are hardly to arrange [24,25]. Although most burn centers also describe a register with varying parameters to record their burn trauma cases a comparable register is missing. Since 1991 patients admitted

to burn trauma centers participating in the German Speaking Association for Burn Treatment are recorded with protocol of their admission data, circumstances of trauma and mortality [26]. Further information on patient treatment and outcome is missing in the resent version of the register. These data should be recorded and analyzed in a central register as a first step to establish a standardize treatment strategies for severely burned patients. Second, this documentation is required to re-evaluate the quality of burn care in the German speaking area after introducing new standards of burn patient care. A comparable burn register that already records these necessary data is the Dutch Burn Repository R3 that has been established in the Netherlands in 2009. It is able to provide the required information to evaluate treatment quality and measure a longitudinal trend in the outcome of burns [27]. Beside regular re-evaluation through inter-clinical analysis, a center associated quality management should be available. In this way, clinical structure and operational sequences can be compared with predefined goals, and further need for improvements can be detected [28]. Our findings suggest that 47% of the surveyed centers already use a quality management, but increasing prevalence to all burn trauma centers is necessary.

5.

Conclusion

Initial hospital burn care is characterized by inconsistent organization and patient treatment as well as a lack of

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standardized approaches. Major focus is set on burn room organization, human resources and standardized operating procedures. Further research is necessary to review existing individual protocols and standards in order to define a standardized and validated regime for burn care. Implementation of prevalent protocols, guidelines and training courses for general trauma treatment like ATLS1 enhanced by burn specific courses like ABLS1 with respect to the local health care structure have to be pursued. To provide a sufficient data set for an evidence based approach and a longitudinal measure of treatment quality, an improved system of registration of burn cases has to be established.

Conflict of interest statement On behalf of all authors, I wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome.

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