The SILKIE (Skin graftIng Low friKtIon Environment) study: a non-randomised proof-of-concept and feasibility study on the impact of low-friction nursing environment on skin grafting success rates in adult and paediatric burns.

OBJECTIVES: To evaluate the impact of low-friction (LF) bedding on graft loss in an acute burn care setting, and to examine the feasibility and costs of using LF bedding compared with standard care. DESIGN: Proof of concept before and after study with feasibility of delivering the intervention. SETTING: Three burns services within two UK hospital trusts. PARTICIPANTS: Inclusion criteria were patients older than 4 weeks, who received a skin graft after burn injury and were admitted overnight. The comparator cohort were eligible patients admitted in a 12-month period before the intervention. INTERVENTION: Introduction of LF sheets and pillowcases during a 15-month period. OUTCOME MEASURES: For proof of concept, the LF and comparator cohorts were compared in terms of number of regrafting operations (primary), percentage graft loss, hospital length of stay (LoS) and LoS cost (secondary). Feasibility outcomes were practicality and safety of using LF bedding. RESULTS: 131 patients were eligible for the LF cohort and 90 patients for the comparator cohort. Although the primary outcome of the proportion needing regrafting was halved in the LF cohort, the confidence interval (CI) crossed 1 (OR (95% CI): 0.56 (0.16 to 1.88)). Partial graft loss (any loss) was significantly reduced in the LF cohort (OR (95% CI): 0.27 (0.14, 0.51)). Inpatient LoS was no different between the two cohorts (difference in median days (95% CI): 0 (-2 to 1)), and the estimated difference in LoS cost was £-1139 (-4829 to 2551). Practical issues were easily resolved, and no safety incidents occurred while patients were nursed on LF bedding. CONCLUSIONS: LF bedding is safe to use in burned patients with skin grafts and we have shown proof of concept for the intervention. Further economic modelling is required to see if an appropriately powered randomised control trial would be worthwhile or if roll out across the National Health Service is justified. TRIAL REGISTRATION NUMBER: ISRCTN82599687.

Variations in guideline use and practice relating to diagnosis and management of infection in paediatric burns services in England and Wales: A national survey.

BACKGROUND: Wound infection causes morbidity and mortality in burns. UK National Burns Care Standards state that guidance should be used to diagnose and treat burn wound infection. However, surveys of senior staff about standard operating procedures or guidance in UK burns services indicate that they are infrequently available (Papini et al., 1995; Lymperopoulos et al., 2015). Staff may have differing views and experiences of guidance use according to their role. This survey investigated the extent to which guidance is available, and current practices used for diagnosis and treatment of burn wound infection, both within and between paediatric burns services. METHODS: Staff from paediatric burns services in England and Wales were individually interviewed by two nurses about guidance and practices around antibiotic prophylaxis, diagnosis and management of burn wound infection and toxic shock syndrome, and antibiotic use. In each service staff from three categories were interviewed: lead consultant/burns specialist nurse, junior doctor/senior nurse, ward based nurse. Data were subjected to content analysis and reliably coded by two researchers using a coding frame. Guidance documents were also requested. RESULTS: Thirteen services took part. Staff in fewer than half of services reported that they had guidance for antibiotic prophylaxis, diagnosis, and management of burn wound infection. In nine services at least one staff member reported that they had guidance for antibiotic use. Guidance was available for diagnosis and management of toxic shock syndrome in ten services, and staff in five were consistently aware of it. One service routinely used antibiotic prophylaxis, but had no written guidance for it. In five services where at least one member of staff reported that they had guidance for diagnosing infection, at least one interviewed staff member was unaware of it. Swabbing practice varied between and within services, with 10 staff across six services cleaning before swabbing, and four staff in three services cleaning after swabbing. CONCLUSIONS: Staff from fewer than half of burns services report that they have guidance for diagnosing and managing burn wound infection, and there is variation between and within services relating to staff awareness of available guidance. There are some consistencies in practice; the majority of services do not use antibiotic prophylaxis, and there is consistent prescribing for suspected infection and tests used for infection diagnosis. Swabbing practices are less consistent. This survey indicates a need for evidence-based guidelines to be developed in order to meet national burns care standards, and for staff to be made aware of them and trained in their use. Guidelines do not need to replace clinical judgement and should be developed with the involvement of those who will implement them.