Exploring misclassification of injury intent: A burn register study.

INTRODUCTION: Burn registers are an important source of surveillance data on injury intent. These data are considered essential to inform prevention activities. In South Asia, intentional burn injuries are thought to disproportionately affect women. Assessment of injury intent is difficult because it is influenced by personal, family, social, and legal sensitivities. This can introduce misclassification into data, and bias analyses. We conducted a descriptive, hypothesis generating study to explore misclassification of injury intent using data from a newly digitised single centre burn register in south India. METHODS: Data from 1st February 2016 to 28th February 2022 were analysed. All patients in the data set were included in the study (n = 1930). Demographic and clinical characteristics for patients are described for each classification of injury intent. All data cleaning and analyses were completed using RStudio. RESULTS: Injury intent data were missing for 12.6% of cases. It was the most commonly missing variable in the data set. "Accidental" injuries had a similar distribution over time, age, and total body surface area (TBSA) for males and females. "Homicidal" injuries were more common in females. Injuries reported as "Suicidal" affected men and women equally. A decrease in reporting of "Suicidal" injuries in females corresponded to an increase in high TBSA injuries classified as 'Other' or with missing data. Overwriting of injury intent was present in 1.5% of cases. The overwritten group had a greater proportion of females (62.1% vs. 48.5%) and higher median TBSA (77.5% vs. 27.5%) compared to the group where intent was not overwritten. CONCLUSION: Our findings indicate that some subgroups, such as females with high TBSA burns, appear to be more likely to be misclassified and should be the focus of future research. They also highlight that quality of surveillance data could be improved by recording of clinical impression, change in patient reported intent, and use of a common data element for intent to standardise data collection. We also recommend that injury intent is recorded as a unique variable and should not be mixed with other elements of injury causation (e.g. mechanism). Although this is a single centre study, the methods will be of interest to those who utilise routinely collected data and wish to reduce misclassification of this important variable.

Monodigital Double Cross-Finger Flaps-A Novel Approach for Coverage of Large Volar Defects.

INTRODUCTION: A single cross-finger flap can only address digital defects of a limited size, and larger defects often require distant flaps such as abdominal or groin flaps that are cumbersome to perform and sometimes bulky. Two cross-finger flaps harvested from the same donor digit could offer a simple and effective solution for many such defects. In this study, we describe the technique of monodigital double cross-finger flaps and its clinical applicability, with evaluation of donor and recipient site morbidity. METHODS AND MATERIALS: A total of 10 subjects with large volar defects were included in the study. The demographic data, etiology, defect size, flap donor, and recipient sites were tabulated prior to surgery. Each subject was assessed for postoperative complications at the donor and recipient site and followed up for 6-12 months to document any flap or donor site morbidities. RESULTS: The subjects included 9 males and 1 female subjects, with an average age of 35.6 years (21-67 years). Most patients had posttraumatic defects, with 3 cases of full thickness burns and one with postsurgical tissue necrosis. All defects were volar, with 4 on the little finger, 3, 2, and 1 in the ring, index and middle fingers, respectively. No major postoperative complications were noted in any case. All flaps survived well with good contour, and donor fingers achieved near-normal range of flexion with only minimal restriction (10-15°) at the distal interphalangeal joint that did not result in any overall functional disability. CONCLUSIONS: Monodigital double cross-finger flap technique offers a simple and effective solution for reconstruction of large digital defects that are not amenable for closure by a classical cross-finger flap, and is a good alternative for other procedures, providing supple soft tissue coverage and no significant morbidity at the donor digit provided that there is preservation of a small skin bridge across the proximal interphalangeal joint.

Development of an electronic burns register: Digitisation of routinely collected hospital data for global burns surveillance.

INTRODUCTION: Burn registers provide important data that can track injury trends and evaluate services. Burn registers are concentrated in high-income countries, but most burn injuries occur in low- and middle-income countries where surveillance data are limited. Injury surveillance guidance recommends utilisation of existing routinely collected data where data quality is adequate, but there is a lack of guidance on how to achieve this. Our aim was to develop a rigorous and reproducible method to establish an electronic burn register from existing routinely collected data that can be implemented in low resource settings. METHODS: Data quality of handwritten routinely collected records (register books) from a tertiary government hospital burn unit in Mysore, India was assessed prior to digitisation. Process mapping was conducted for burn patient presentations. Register and casualty records were compared to assess the case ascertainment rate. Register books from February 2016 to February 2022 were scanned and anonymised. Scans were quality checked and stored securely. An online data entry form was developed. All data underwent double verification. RESULTS: Process mapping suggested data were reliable, and case ascertainment was 95%. 1930 presentations were recorded in the registers, representing 0.84% of hospital all-cause admissions. 388 pages were scanned with 4.4% requiring rescanning due to quality problems. Two-step verification estimated there to be errors remaining in 0.06% of fields following data entry. CONCLUSION: We have described, using the example of a newly established electronic register in India, methods to assess the suitability and reliability of existing routinely collected data for surveillance purposes, to digitise handwritten data, and to quantify error during the digitisation process. The methods are likely to be of particular interest to burn units in countries with no active national burns register. We strongly recommend mobilisation of resources for digitisation of existing high quality routinely collected data as an important step towards developing burn surveillance systems in low resource settings.

Terminology and methods used to differentiate injury intent of hospital burn patients in South Asia: Results from a systematic scoping review.

INTRODUCTION: A key component in the classification of all injury types is to differentiate whether the injury was deliberately inflicted and by whom, commonly known as "intent" in the surveillance literature. These data guide patient care and inform surveillance strategies. South Asia is believed to have the greatest number of intentional burn injuries, but national surveillance data is not disaggregated by injury intent. Scientific literature can be used for injury surveillance where national data collection does not exist. In order to synthesise research findings, it is essential to assess the potential impact of misclassification bias. We therefore conducted a systematic scoping review to understand terminology and methods used to differentiate injury intent of hospital burn patients in South Asia. METHODS: We followed the methods in our registered protocol (https://doi.org/10.17605/OSF.IO/DCYNQ). Studies met defined population, concept, context, and study design criteria. The databases Embase, MEDLINE, CINAHL, PsycInfo, and PakMediNet were searched. Two reviewers independently screened results. Data were extracted in a standardised manner and verified. The rigour of the method used to differentiate injury intent was appraised. RESULTS: 1435 articles were screened. Of these, 89 met our inclusion criteria. Most articles were from India and Pakistan, and used an observational study design. There were 14 stem terms used in the articles. The most common was "cause". There were 40 classifier terms. The most common were "accident", "suicide", and "homicide". Few articles defined these terms. The method used to differentiate injury intent was only described explicitly in 17% of articles and the rigour of the methods used were low. Where methods of differentiation were described, they appear to be based on patient or family report rather than multidisciplinary assessment. CONCLUSION: The heterogeneity in terms, lack of definitions, and limited investigation of injury intent means this variable is likely to be prone to misclassification bias. We strongly recommend that the global burn community unites to develop a common data element, including definitions and methods of assessment, for the concept of burn injury intent to enable more reliable data collection practices and interstudy comparisons.

Terminology and methods used to differentiate injury intent of hospital burn patients in South Asia: a systematic scoping review protocol.

BACKGROUND: The greatest proportion of burn injuries globally occur in South Asia, where there are also high numbers of intentional burns. Burn injury prevention efforts are hampered by poor surveillance data on injury intent. There is a plethora of local routinely collected data in the research literature from South Asia that could be used for epidemiological purposes, but it is not known whether the definitions and methods of differentiation of injury intent are sufficiently homogenous to allow valid study comparisons. METHODS: We will conduct a systematic scoping review to understand terminology and methods used to differentiate injury intent of hospital burn patients in South Asia. The objectives of the study are to: determine the breadth of terminology and common terms used for burn injury intent; to determine if definitions are comparable across studies where the same term is used; and to appraise the rigour of methods used to differentiate burn injury intent and suitability for comparison across studies. The databases Embase, MEDLINE, CINAHL, PsycINFO, and PakMediNet will be searched. Screening and data extraction will be completed independently by two reviewers. To be included, the article must be as follows: peer reviewed, primary research, study cutaneous burns, based on hospital patients from a country in South Asia, and use intent terminology or discuss a method of differentiation of injury intent. Results will be restricted to English language studies. No date restrictions will be applied. A plain language summary and terminology section are included for non-specialist readers. DISCUSSION: Results will be used to inform stakeholder work to develop standardised terminology and methods for burn injury intent in South Asia. They will be published open access in peer-reviewed journals wherever possible. SYSTEMATIC REVIEW REGISTRATION: This review has been registered with the Open Science Framework ( https://doi.org/10.17605/OSF.IO/DCYNQ ).

Establishing Self-Harm Registers: The Role of Process Mapping to Improve Quality of Surveillance Data Globally.

Self-harm registers (SHRs) are an essential means of monitoring rates of self-harm and evaluating preventative interventions, but few SHRs exist in countries with the highest burden of suicides and self-harm. Current international guidance on establishing SHRs recommends data collection from emergency departments, but this does not adequately consider differences in the provision of emergency care globally. We aim to demonstrate that process mapping can be used prior to the implementation of an SHR to understand differing hospital systems. This information can be used to determine the method by which patients meeting the SHR inclusion criteria can be most reliably identified, and how to mitigate hospital processes that may introduce selection bias into these data. We illustrate this by sharing in detail the experiences from a government hospital and non-profit hospital in south India. We followed a five-phase process mapping approach developed for healthcare settings during 2019-2020. Emergency care provided in the government hospital was accessed through casualty department triage. The non-profit hospital had an emergency department. Both hospitals had open access outpatient departments. SHR inclusion criteria overlapped with conditions requiring Indian medicolegal registration. Medicolegal registers are the most likely single point to record patients meeting the SHR inclusion criteria from multiple emergency care areas in India (e.g., emergency department/casualty, outpatients, other hospital areas), but should be cross-checked against registers of presentations to the emergency department/casualty to capture less-sick patients and misclassified cases. Process mapping is an easily reproducible method that can be used prior to the implementation of an SHR to understand differing hospital systems. This information is pivotal to choosing which hospital record systems should be used for identifying patients and to proactively reduce bias in SHR data. The method is equally applicable in low-, middle- and high-income countries.