Development of a value-based healthcare burns core set for adult burn care.

BACKGROUND: Value-based healthcare (VBHC) is increasingly implemented in healthcare worldwide. Transparent measurement of the outcomes most important and relevant to patients is essential in VBHC, which is supported by a core set of most important quality indicators and outcomes. Therefore, the aim of this study was to develop a VBHC-burns core set for adult burn patients. METHODS: A three-round modified national Delphi study, including 44 outcomes and 24 quality indicators, was conducted to reach consensus among Dutch patients, burn care professionals and researchers. Items were rated on a nine-point Likert scale and selected if ≥ 70% in each group considered an item 'important'. Subsequently, instruments quantifying selected outcomes were identified based on a literature review and were chosen in a consensus meeting using recommendations from the Dutch consensus-based standard set and the Dutch Centre of Expertise on Health Disparities. Time assessment points were chosen to reflect the burn care and patient recovery process. Finally, the initial core set was evaluated in practice, leading to the adapted VBHC-burns core set. RESULTS: Twenty-seven patients, 63 burn care professionals and 23 researchers participated. Ten outcomes and four quality indicators were selected in the Delphi study, including the outcomes pain, wound healing, physical activity, self-care, independence, return to work, depression, itching, scar flexibility and return to school. Quality indicators included shared decision-making (SDM), the number of patients receiving aftercare, determination of burn depth, and assessment of active range of motion. After evaluation of its use in clinical practice, the core set included all items except SDM, which are assessed by 9 patient-reported outcome instruments or measured in clinical care. Assessment time points included are at discharge, 2 weeks, 3 months, 12 months after discharge and annually afterwards. CONCLUSION: A VBHC-burns core set was developed, consisting of outcomes and quality indicators that are important to burn patients and burn care professionals. The VBHC-burns core set is now systemically monitored and analysed in Dutch burn care to improve care and patient relevant outcomes. As improving burn care and patient relevant outcomes is important worldwide, the developed VBHC-burns core set could be inspiring for other countries.

Multidisciplinary staff perceived barriers and enablers to early mobilization of patients with burns in the ICU.

BACKGROUND: Complex challenges face clinicians managing critically ill patients with burns, particularly in the context of enhancing outcomes after a stay in ICU. Compounding this, a dearth of research explores the specific and modifiable factors that impact early mobilization in the ICU environment. AIM: To explore the barriers and enablers of early functional mobilization for patients with burns in the ICU from a multidisciplinary perspective. DESIGN: A qualitative phenomenological study. METHODS: Semi-structured interviews supplemented by online questionnaires conducted with 12 multidisciplinary clinicians (four doctors, three nurses and five physical therapists) who previously managed burn patients at a quaternary level ICU. Data were thematically analysed. RESULTS: Four main themes: patient, ICU clinicians, the workplace and the physical therapist were identified as impacting on early mobilization. Subthemes identified barriers or enablers to mobilization but all were strongly influenced by overarching theme of the clinician's "emotional filter." Barriers included high levels of pain, heavy sedation and low levels of clinician exposure to treating patients with burns. Enablers included higher levels of clinician's experience and knowledge about burn management and benefits of early mobilization; increased coordinated staff resources when undertaking mobilization; and, open communication and positive culture towards early mobilization across the multidisciplinary team. CONCLUSION: Patient, clinician and workplace barriers and enablers were identified to influencing the likelihood of achieving early mobilization of patients with burns in the ICU. Emotional support for staff through multidisciplinary collaboration and development of structured burns training program were key recommendations to address barriers and strengthen enablers to early mobilization of patients with burns in the ICU.

Olfactory dysfunction at six months after coronavirus disease 2019 infection.

OBJECTIVE: This study aimed to assess olfactory dysfunction in patients at six months after confirmed coronavirus disease 2019 infection. METHODS: Coronavirus disease 2019 positive patients were assessed six months following diagnosis. Patient data were recoded as part of the adapted International Severe Acute Respiratory and Emerging Infection Consortium Protocol. Olfactory dysfunction was assessed using the University of Pennsylvania Smell Identification Test. RESULTS: Fifty-six patients were included. At six months after coronavirus disease 2019 diagnosis, 64.3 per cent of patients (n = 36) were normosmic, 28.6 per cent (n = 16) had mild to moderate microsmia and 7 per cent (n = 4) had severe microsmia or anosmia. There was a statistically significant association between older age and olfactory dysfunction. Hospital or intensive care unit admission did not lead to worse olfactory outcomes compared to those managed in the out-patient setting. CONCLUSION: At six months after coronavirus disease 2019 diagnosis, approximately two-thirds of patients will be normosmic. This study is the first to describe six-month outcomes for post-coronavirus disease 2019 patients in terms of olfactory dysfunction.

Longitudinal recovery following distal radial fractures managed with volar plate fixation.

AIMS: To synthesise the literature and perform a meta-analysis detailing the longitudinal recovery in the first two years following a distal radius fracture (DRF) managed with volar plate fixation. MATERIALS AND METHODS: Three databases were searched to identify relevant articles. Following eligibility screening and quality assessment, data were extracted and outcomes were assimilated at the post-operative time points of interest. A state-of-the-art longitudinal mixed-effects meta-analysis model was employed to analyse the data. RESULTS: The search identified 5698 articles, of which 46 study reports met the selection criteria. High levels of disability and impairment were reported in the immediate post-operative period with subsequently a rapid initial improvement followed by more gradual improvement for up to one year. The results highlight that the period associated with the greatest physical recovery is in the first three months and suggest that the endpoint of treatment outcomes is best measured at one year post-surgery. CONCLUSION: Clinically meaningful improvements in outcomes can be expected for 12 months, after which progress plateaus and reaches normal values. This paper adopted a novel approach to meta-analyses in that the research question was of a longitudinal nature, which required a unique method of statistical analysis. Cite this article: Bone Joint J 2017;99-B:1665-76.

Alternate electrode placement for whole body and segmental bioimpedance spectroscopy.

Bioimpedance spectroscopy (BIS) is frequently used to monitor body fluid and body composition in healthy and clinical populations. BIS guidelines state that there should be no skin lesions at the site of electrodes, and if lesions are present, electrode positions should be changed. However, alternate electrode positions are yet to be reported. This study aimed to determine if ventral electrode placements were suitable alternatives for whole body and segmental BIS measurements. Three alternate electrode placements were assessed for whole body BIS using a combination of ventral hand and foot electrode placements. An alternate position was assessed for upper and lower body segmental BIS. The results demonstrated that for whole body BIS, if drive and sense electrodes on the hand are moved to ventral positions, but foot electrodes remain in standard positions, then whole body BIS variables were comparable to standard electrode positioning (percentage difference range = 0.01 to 1.65%, p = 0.211-0.937). The alternate electrode placement for upper limb segmental BIS, results in BIS variables that are comparable to that of the standard positioning (percentage difference range = 0.24-3.51%, p = 0.393-0.604). The alternate lower limb electrode position significantly altered all resistance and predicted BIS variables for whole body and lower limb segmental BIS (percentage difference range = 1.06-12.09%, p < 0.001). If wounds are present on the hands and/or wrist, then the alternate electrode position described in this study is valid, for whole body and upper limb segmental BIS.

Towards more efficient burn care: Identifying factors associated with good quality of life post-burn.

BACKGROUND: As minor burn patients constitute the vast majority of a developed nation case-mix, streamlining care for this group can promote efficiency from a service-wide perspective. This study tested the hypothesis that a predictive nomogram model that estimates likelihood of good long-term quality of life (QoL) post-burn is a valid way to optimise patient selection and risk management when applying a streamlined model of care. METHOD: A sample of 224 burn patients managed by the Burn Service of Western Australia who provided both short and long-term outcomes was used to estimate the probability of achieving a good QoL defined as 150 out of a possible 160 points on the Burn Specific Health Scale-Brief (BSHS-B) at least six months from injury. A multivariate logistic regression analysis produced a predictive model provisioned as a nomogram for clinical application. A second, independent cohort of consecutive patients (n=106) was used to validate the predictive merit of the nomogram. RESULTS AND DISCUSSION: Male gender (p=0.02), conservative management (p=0.03), upper limb burn (p=0.04) and high BSHS-B score within one month of burn (p<0.001) were significant predictors of good outcome at six months and beyond. A Receiver Operating Curve (ROC) analysis demonstrated excellent (90%) accuracy overall. At 80% probability of good outcome, the false positive risk was 14%. The nomogram was validated by running a second ROC analysis of the model in an independent cohort. The analysis confirmed high (86%) overall accuracy of the model, the risk of false positive was reduced to 10% at a lower (70%) probability. This affirms the stability of the nomogram model in different patient groups over time. An investigation of the effect of missing data on sample selection determined that a greater proportion of younger patients with smaller TBSA burns were excluded due to loss to follow up. CONCLUSION: For clinicians managing comparable burn populations, the BSWA burns nomogram is an effective tool to assist the selection of patients to a streamlined care pathway with the aim of improving efficiency of service delivery.

A modified Vancouver Scar Scale linked with TBSA (mVSS-TBSA): Inter-rater reliability of an innovative burn scar assessment method.

BACKGROUND: Current scar assessment methods do not capture variation in scar outcome across the burn scar surface area. A new method (mVSS-TBSA) using a modified Vancouver Scar Scale (mVSS) linked with %TBSA was devised and inter-rater reliability was assessed. METHOD: Three raters performed scar assessments on thirty patients with burn scars using the mVSS-TBSA. Scoring on pigmentation, vascularity, pliability and height was undertaken for the 'best' and 'worst' areas of each scar. Raters allocated the total body surface area of the scar (%TBSA) to three mVSS categories (<5, 5-10, >10). Intra-class correlation coefficient (ICC) and weighted kappa statistic (kw) were used to assess inter-rater reliability. The data were also analysed for clinically relevant misclassifications between pairs of raters. RESULTS: Total mVSS scores showed 'fair to good' agreement (ICC 0.65-0.73) in the 'best' area of the scar while there was 'excellent' agreement in the 'worst' scar area (ICC 0.85-0.88). The kw of the individual mVSS components ranged from 0.44 to 0.84 and 0.02 to 0.86 for 'best' and 'worst' scar areas, respectively. Determination of scar %TBSA had 'excellent' reliability (ICC 0.91-0.96). Allocation of scar %TBSA to severity category <5 mVSS demonstrated 'good to excellent' reliability (ICC 0.63-0.80) and 'fair to good' reliability (ICC 0.42-0.74) for 5-10 mVSS category. However, misclassifications were observed for the total mVSS score in the 'worst' scar area and the allocation of scar %TBSA in the <5 mVSS category. CONCLUSION: Inter-rater reliability of mVSS scores depends on the severity of the scar area being assessed. The mVSS-TBSA method of allocation of scar %TBSA to two broad mVSS categories, namely <5 and ≥5 mVSS, has 'good to excellent' reliability. The mVSS-TBSA has demonstrated utility for both clinical and research purposes; however, there is potential to misclassify scar outcome in some cases.

Burn-injured adults with long term functional impairments demonstrate the same response to resistance training as uninjured controls.

OBJECTIVE: The catabolic response associated with major burn injuries results in loss of lean body mass (LBM) and prolonged muscle weakness. Exercise training improves LBM and muscle strength in burn-injured children in the acute post injury phase, yet it is unknown whether adults will experience the same benefits when exercise training is implemented at least two years post injury. PROCEDURES: Nine burn-injured participants (%TBSA=42±18.38; time since injury=6.56±3.68 years) and 9 matched controls participated in a 12-week interval training and resistance exercise programme. Muscle strength was assessed via isokinetic dynamometry and LBM was determined via dual energy X-ray absorptiometry. Both measures were administered prior to and following the exercise programme. RESULTS: There was no significant difference in LBM or strength between the two groups at baseline. Following the exercise programme, both groups displayed significant improvements in LBM and in hip, shoulder and elbow muscle strength. There was no significant difference in muscle strength or LBM, between the groups, following the exercise training. CONCLUSION: A combined exercise training programme was able to improve muscle strength and lean body mass in adults with burn injury. There was no difference between the two groups in their response to the exercise programme, therefore general exercise prescription principles may be applied directly to the burns population.

Exercise training to improve health related quality of life in long term survivors of major burn injury: a matched controlled study.

OBJECTIVE: Patients often experience reduced health-related quality of life (HRQOL) following burn injury. Exercise training has been demonstrated to improve HRQOL in a number of clinical populations, yet it is unknown whether exercise can improve HRQOL in burns patients. PROCEDURES: Nine burn-injured participants (42±18.38%TBSA: 6.56±3.68 years after injury) and 9 matched controls participated in a 12-week exercise programme. HRQOL was assessed via the Burn Specific Health Scale-Brief (BSHS-B) and the Medical Outcomes Study 36-Item Short Form (SF-36). Activity limitation was measured using the quick Disabilities of the Arm, Shoulder and Hand (QuickDASH). RESULTS: The burns group had decreased HRQOL compared to the controls at baseline, as reported by the BSHS-B (t (16)=3.51, p=0.003) and some domains of the SF-36 including role physical (t (16)=3.79, p=0.002). Burned participants reported decreased activity levels compared to the controls as measured by the QuickDASH (t (16)=2.19, p=0.044). Exercise training improved SF-36 scores in both burn (t (8)=3.77, p=0.005) and control groups (t (8)=2.71, p=0.027). Following training there was no difference between the groups on the SF-36 or QuickDASH. CONCLUSION: Exercise training improves HRQOL and activity limitations in burn-injured patients to a level that is equivalent to that of their uninjured counterparts.

The effect of exercise training on pulmonary function and aerobic capacity in adults with burn.

PURPOSE: Pulmonary function (PF) is compromised in some individuals following burn, which may result in impaired aerobic capacity. Exercise training improves PF and exercise capacity in children recovering from burns, yet it is unknown if adults will demonstrate the same response. PROCEDURES: 9 burn injured participants (%TBSA 42 ±18.38, 6.56 years ±3.68 post injury) and 9 matched controls participated in a 12-week goal directed interval training and resistance exercise programme. PF was measured using spirometry, and a graded exercise test quantified peak oxygen consumption (Vo(2peak)), both prior to and following the exercise training. The Canadian Occupational Performance Measure assessed the participant's goal attainment. RESULTS: Burn injured participants had significantly lower PF (FEV(1)/FVC ratio) than the healthy controls both prior to and following the exercise intervention (F(1,16)=8.93, p=0.009). Exercise training did not improve PF in either group, however both groups had a significant improvement in their Vo(2peak), maximal minute ventilation, and work achieved on a graded exercise test (F(1,16)=19.325, p<0.001), (F(1,16)=51.417, p<0.001) and (F(1,16)=36.938, p<0.001), respectively, following the exercise training. All participants achieved their occupational performance goals. CONCLUSION: Although the exercise training did not alter PF, both aerobic capacity and occupational performance were improved.

An assessment of burn injury hospitalisations of adolescents and young adults in Western Australia, 1983-2008.

BACKGROUND: This study presents a 26-year epidemiological assessment of burn injury hospitalisations for people 15-29 years of age in Western Australia. METHODS: Linked hospital morbidity and death data for all persons hospitalised with an index burn injury in Western Australia for the period 1983-2008 were analyzed. Annual age-specific incidence rates were estimated. Poisson regression analyses were used to estimate temporal trends in hospital admissions. RESULTS: There were 6404 burn hospital admissions of which 76% were male. Males had hospitalisation rates 3.0 times that of females (95%CI: 2.8-3.2) and Aboriginal people had rates 2.3 times (95%CI: 2.1-2.5) that of non-Aboriginal persons. Hospitalisations for burn injury declined by 42% (95%CI: 35-47) for males and 21% (95%CI: 6-33) for females. Hospitalisations declined by 53% (95%CI: 35-63) for Aboriginal people, and by 35% (95%CI: 29-41) for non-Aboriginal people. Significant reductions were observed for flame and electrical burn hospitalisations. The major causes of burns in males were exposure to controlled fires and ignition of inflammable materials, with scalds the predominant cause of burn in females. CONCLUSIONS: Downward trends in burn injury hospitalisations for both males and females 15-29 years of age were observed; however, males and Aboriginal persons have significantly elevated hospitalisation rates.

The QuickDASH is an appropriate tool for measuring the quality of recovery after upper limb burn injury.

BACKGROUND: Upper limb (UL) burns commonly result in significant dysfunction. The measurement of disability is vital to assess recovery after burn injury. The QuickDASH questionnaire was developed to evaluate UL disorders. The aim of this study was to evaluate its validity, repeatability and responsiveness for burn patients. METHODS: In 2006, 85 patients with UL burns were recruited at Royal Perth Hospital. Each completed both QuickDASH and Burns Specific Health Scale-Brief (BSHS-B) at regular intervals after their burn. Further, 67 patients repeated the questionnaire 1 day after completing it at discharge. RESULTS: Validity-Criterion validity was demonstrated between QuickDASH and BSHS-B through good correlations (r(2)=-0.79 to -0.89). Construct validity was demonstrated using burn severity markers. QuickDASH scores significantly differed when grouped according to major burn, full thickness burn, surgery and need for hospital admission. Repeatability-QuickDASH showed excellent repeatability (ICC=0.93). Responsiveness-Effect size of QuickDASH was demonstrated to be greater than BSHS-B at all measurement points. CONCLUSIONS: This longitudinal study confirms the validity, repeatability and responsiveness of the QuickDASH outcome measure in patients with upper limb burns. It supports the use of the QuickDASH in this population to help assess change in functional level.