Emergency department management of minor burn injuries in Ontario, Canada

Emergency department management of minor burn injuries in Ontario, Canada

Burns 30 (2004) 160–164 Emergency department management of minor burn injuries in Ontario, Canada M. Bezuhly a , M. Gomez b , J.S. Fish b,∗ b a Depa...

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Burns 30 (2004) 160–164

Emergency department management of minor burn injuries in Ontario, Canada M. Bezuhly a , M. Gomez b , J.S. Fish b,∗ b

a Department of Surgery, Division of Plastic Surgery, Dalhousie University, Halifax, NS, Canada Ross Tilley Burn Centre, Sunnybrook and Women’s College Health Sciences Centre, 2075 Bayview Avenue, Suite D704, Toronto, Ont., Canada M4N 3M5

Accepted 2 October 2003

Abstract Many thermal injuries are minor and can be effectively treated in a primary care setting. A cross-sectional survey was conducted to examine how emergency department physicians care for minor burns in the Canadian province of Ontario. Respondents were provided with a colour photograph of a patient with a minor burn and asked to comment about history, physical examination, investigations, treatment plan and follow-up care. A 37% response rate was attained (141/380). Of all respondents, 70% failed to record the burn extent, and 45% failed to discuss analgesia. No significant differences existed between emergency physicians in teaching and non-teaching hospitals (P > 0.05), with the exception that teaching hospital physicians referred significantly more to burn centres (P = 0.013). This suggests that educational interventions focussing on burn extent, pain control and referral criteria may be beneficial to emergency physicians. © 2003 Elsevier Ltd and ISBI. All rights reserved. Keywords: Minor burn injuries; Minor burn management; Emergency department

1. Introduction Each year, approximately 1.1 million Americans and 200,000 Canadians sustain a burn injury requiring medical attention [1,2]. The majority of these burns are minor and can be effectively treated in an ambulatory setting, such as the emergency department [3]. Very few research-based articles address the treatment of burns that can be managed on an outpatient basis [3,4]. The paucity of definitive research in minor burn care has significant implications. Without adherence to a standard protocol of care in the emergency setting, there is the potential for inconsistent or substandard management of minor burns. A lack of continuity of care of thermal injuries and delayed tertiary treatment is costly and increases the potential for permanent disability in severe cases [5]. A minor burn is not considered a complicated injury, and as such, it does not require the specialized treatment available in a tertiary centre. The skills and equipment necessary to treat a minor burn should be available in any primary care setting. Regardless of whether an individual seeks minor burn treatment in a teaching hospital in a major urban centre or a non-teaching ∗

Correspondence author. Tel.: +416-480-6703; fax: +416-480-6763. E-mail address: [email protected] (J.S. Fish).

0305-4179/$30.00 © 2003 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2003.10.006

hospital in a remote rural community, the quality of minor burn management should be identical across all potential care provider populations. The purpose of this study was to examine whether the treatment offered for minor burns is comparable across non-teaching hospital and teaching hospital emergency departments in the Canadian province of Ontario.

2. Methods A cross-sectional study in the form of a descriptive survey consisting of open-ended questions was used to gather data on current practices for treating outpatient burn wounds in Ontario emergency departments. Community hospital emergency physicians, and teaching hospital emergency physicians were identified by the Ontario Medical Association (OMA) emergency physician listing. In order to be included on the OMA listing, the physician must have practiced in an Ontario emergency department and must be a member in good standing of the OMA. The number of emergency physicians practicing in teaching hospitals was determined by counting the number of mailing addresses provided to hospitals defined as teaching hospitals by the Ontario Ministry of Health [6].

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The scenario-based survey tool provided respondents with the American Burn Association criteria for a minor burn and asked respondents to define their level of training and their practice setting. A color photograph of a patient with a minor burn injury was provided and respondents were asked to comment in point form or short sentences with respect to: (i) history, (ii) physical examination, (iii) investigations, (iv) treatment plan, and (v) follow-up (Appendix A). The simplified single page design was chosen to ensure compliance in the completion of the form. The wording of the questions was purposely left open-ended so as not to supply information in a checklist format to the respondents. The questionnaire (including a self-addressed and self-stamped return envelope) was distributed by mail to subjects in the study populations. No telephone follow-up was conducted. Completed surveys were collected and given an identifying number as they were received. The results of the survey were compared on a variable-byvariable basis against a scoring key derived from the American Burn Association’s general guidelines for minor burn care (Appendix B) [7]. A score of 1 was awarded if the respondent did mention of the given variable. A score of 0 was awarded if the respondent did not mention of the given variable. A Microsoft ExcelTM database was used to record questionnaire responses. Sample surveys were scored by an independent party in order to maintain consistency. Comparisons between the responses of emergency physicians from teaching hospitals and emergency physicians from community hospitals were made using the chi-square test of independence. A P < 0.05 was considered significant. This study received approval from the hospital’s ethics review committee. Confidentiality of participants was maintained throughout data collection and reporting.

3. Results Of the 380 surveys distributed, 141 were returned complete (response rate of 37%). An additional 12 surveys were returned incomplete (e.g., lack of demographic information, no responses). The response rate from teaching hospital physicians (53/123 = 43%) was higher than that from non-teaching hospital physicians (88/257 = 34%). 3.1. Level of training The majority of all respondents (45%) were general practitioners with postgraduate emergency medicine training. The remaining respondents were either general practitioners (26%) or Emergency Medicine certified by either the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada (29%). A significantly greater proportion of physicians practicing in teaching hospital emergency departments were certified in Emergency Medicine (47% teaching, 18% non-teaching, P < 0.01). A

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significantly larger number of general practitioners practiced in non-teaching hospital emergency departments than did in teaching hospitals (35 and 9%, respectively, P < 0.01). The majority of emergency department physicians in teaching hospitals had emergency medicine training (43% general practitioner with postgraduate emergency training, 47% Royal College or College of Family Physicians certification in Emergency Medicine). 3.2. History No significant differences existed between the non-teaching and teaching physician responses with regards to obtaining an accurate history (P > 0.05). All respondents would question the patient with regards to the mechanism of the burn. Approximately two-thirds of all respondents would ask about tetanus status (non-teaching: 72%, teaching: 58%), while 83% of those who completed the survey mention of comorbidities and associated injuries (non-teaching: 81%, teaching hospitals: 87%). 3.3. Physical examination On physical examination, burn wound depth was the component most consistently mentioned (total: 90%, non-teaching: 88%, teaching: 94%). Burn anatomic location was noted in 73% of surveys (non-teaching: 70%, teaching: 77%). Only 30% of all respondents made any mention of recording the extent of the burn injury (non-teaching: 28%, teaching: 36%). No significant differences existed between physicians in a non-teaching and teaching hospital setting (P > 0.05). 3.4. Laboratory investigations Of all respondents, 11% would order such laboratory investigations (e.g., haemoglobin, haematocrit, white blood count, glycemia, creatinine, etc.) for the patient depicted in the scenario (non-teaching: 11%, teaching: 9%). No significant differences existed between teaching and non-teaching hospital physicians in this regard (P > 0.05). 3.5. Treatment plan No significant differences existed between teaching and non-teaching emergency department physicians with regards to their treatment plan for the burn depicted in the scenario (P > 0.05) (Fig. 1). Approximately two-thirds of respondents would clean the wound (non-teaching: 60%, teaching hospital: 75%), while only about one-quarter of all physicians surveyed made any mention of debriding of the wound. Two physicians indicated the need to apply ice to the wound! Almost all respondents would use some type of dressing (97%) and topical antimicrobial (76%) on the wound. Only 55% of all respondents, however, made any

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100% 80% 60% 40% 20% 0% cleaning

total (N=141)

debridement

topical antimicrobial

dressing

non-teaching hospital (N=88)

analgesia

teaching hospital (N=53)

Fig. 1. Percentage of respondents who included given component in their treatment plan response no significant differences between non-teaching and teaching hospital populations (P > 0.05). Table 1 Percentage of respondents who mentioned of given component in their follow-up care response Practice setting

ED (%)

GP (%)

Plastic surgeon (%)

Burn centre∗ (%)

Follow-up in 24–48 h (%)

Total (N = 141) Non-teaching Hospital (N = 88) Teaching hospital (N = 53)

60 60 60

31 34 25

12 14 9

9 5 17

85 82 90

ED: emergency department, GP: general practitioner/family physician. ∗ Significant difference between non-teaching and teaching hospital populations (P = 0.013).

mention of questioning the patient with regards to pain or providing analgesia. 3.6. Follow-up The majority of respondents would ask the patient in the scenario to return to the emergency department for follow-up within 24–48 h after the initial visit (Table 1). In 31% of surveys, follow-up care was to be conducted by a general practitioner. Nevertheless, a considerable number of emergency physicians would still refer the patient to a plastic surgeon (12%) or burn centre (9%). No significant differences existed between emergency physicians in teaching and non-teaching hospitals (P > 0.05) with the exception of burn centre referral. Physicians in teaching hospitals referred on to burn centres significantly more often than did non-teaching hospital physicians (P = 0.013).

4. Discussion The results of this study, the first of its kind in Canada, mirror those of similar US surveys [8–10]. These studies demonstrated suboptimal documentation of diagnosis, treatment and follow-up care of minor burns seen in emergency departments. This survey has identified potential weaknesses in minor burn treatment, specifically in the recording of burn extent, the provision of analgesia and the

referral of minor burn cases to plastic surgeons and burn centres. The surface area involved in a burn is one of the single most important factors in determining whether or not it can be managed on an outpatient basis. The finding that less than a third of all respondents mention of burn extent in their survey response is therefore of considerable concern. Not only is assessment of the extent of the burn important in wound management, proper documentation has important implications from a medicolegal perspective as well. In more than 300 minor burn injury cases reported each year to the Ontario Workers’ Safety Insurance Board that receive compensation, burn extent and location are not specified and appropriate treatment and insurance coverage cannot be determined [11]. Analgesia should always be offered as even the smallest burns could be extremely painful. Proper pain control is essential to maintaining patient compliance. Minor burns require dressing changes every day, to every second day, and patients may be reticent to change their wound covering as often as they should because of the associated pain. In addition, poor pain control can deter individuals from mobilizing injured limbs, and returning to pre-burn levels of functioning [9]. Uncomplicated minor burns may be treated on an outpatient basis either in an emergency department or general practitioner’s office; as such, referral to a plastic surgeon for formal evaluation is redundant. Nevertheless, this study

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suggests that a considerable number of emergency physicians from both teaching and non-teaching centres would still refer on to a plastic surgeon or burn centre. Taken alone, this finding represents a potential misuse of health care resources. In light of the respondents’ poor replies with regards to analgesia provision and recording of burn extent, however, the referral to tertiary care providers may be entirely appropriate. When faced with a situation for which they are seemingly inadequately trained, emergency physicians correctly refer on to those who can provide the necessary care to their patients. Physicians in teaching hospitals referred on to burn centres significantly more often than did non-teaching hospital physicians. The explanation for this result is two-fold. Firstly, all provincial burn units are located in teaching centres, and teaching hospital emergency physicians are more likely to refer on to them on the basis of proximity. Secondly, the majority of burn centres hold organized outpatient clinics dedicated to emergency patient follow-up; comparable US studies indicate that triage of minor burns to outpatient clinics, when available, can result in considerable savings [12]. Such formal outpatient clinics are not available in community hospitals in the province. One of the major inherent limitations of the survey design was the fact that respondents were asked to develop a diagnosis and a treatment plan on the basis of a photograph. It is likely that the response of the physicians would be different if they were asked to assess the patient depicted in the survey photograph in person. For example, the photograph may have obviated the need for any mention of location. The second limitation of the survey is the fact that the respondents are asked to comment on broad categories. This naturally limits the ability to derive highly specific information from the responses. Based on the results of this survey, no significant differences exist between non-teaching and teaching emergency department physicians with regards to their management of minor burns, with the exception of referrals to burn centres. From these results, therefore, it would appear that primary burn care is comparable across non-teaching and teaching hospital emergency departments. Although Emergency Medicine accreditation in both the United States and Canada requires formal burn management training, further efforts should be made to make burn care a greater priority in continuing education [13–15]. In order to improve the diagnosis and treatment of minor burns, stronger educational and clinical ties should be established between burn centres and emergency departments. To this end, surgeons and clinical nurse specialists from burn centres should increase their roles as educators, supplying emergency physicians in their catchment’s areas, whenever possible, with information on the latest treatment regimens and referral policies. Specific emphasis should be placed on burn centre referral criteria, pain management, and proper documentation of burn injuries.

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The results of this survey reflect the emergency care delivered by numerous regional centres to some 4–5 million Ontarians. As the geographic arrangement of referral centres in our province is similar to that seen in many US and United Kingdom regions, we believe the results of this survey are generalizable. Burn centres have long recognized the need for pre-hospital care as outlined in the American Burn Association’s burn centre operation guidelines [16]. In an era of cost-containment, the unnecessary transport of minor burn injuries should and can be avoided if primary care providers are able to adequately assess and care for these injuries. This report investigates the role of the emergency department in the continuum of burn care and suggests a role for burn centres in clarifying referral criteria and standards of burn management.

Appendix A

Please answer each question in either sentence or point form. A 40-year-old healthy male with burn injury 8 h old. 1. Please comment on what you would elicit from the history. 2. Please comment on your observation and physical examination. 3. Please comment on investigations. 4. Please comment on your emergency room treatment plan. 5. Please comment on follow-up care. Thank you for your participation in this study. Please send your completed form in the enclosed, stamped envelope.

Appendix B Scoring key adapted from American Burn Association treatment criteria for minor burn from Peate, Outpatient management of burns [Am Fam Physician 1992;45:1321].

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B.1. Practice setting • 1 = Non-teaching hospital; • 2 = teaching hospital. B.2. Level of training • 1 = General practitioner; • 2 = general practitioner with postgraduate emergency medicine training; • 3 = Royal College certified emergency medicine. For next sections: • 0 = if component not included; • 1 = if component included. B.3. History Respondent mentions of: 1. Mechanism of injury (i.e. how it happened). 2. Tetanus status (others: Td, immunization). 3. Comorbidities and/or associated injuries (e.g., diabetes, inhalation, fractures). Maximum and ideal section scores = 3. B.4. Physical examination Respondent mentions of: 4. Anatomical location (i.e. lower limb, legs, where, location). 5. Extent (i.e. percentage total body surface area/TBSA). 6. Depth (i.e., first-, second-, third-degree, partial-, full-thickness). Maximum and ideal section scores = 3. B.5. Investigations Respondent mentions of: 7. Any investigation (e.g., CBC, electrolytes, ECG, urinalysis). Maximum section score = 1. Ideal section score = 0. B.6. Treatment plan Respondent mentions of: 8. Cleaning the wound (e.g., tap water, saline wash, NS irrigation). 9. Debridement (e.g., unroof blisters). 10. Topical antimicrobial (e.g., Polysporin®, Flamazine®, antibiotic ointment). 11. Dressing (e.g., non-restrictive, wet-to-dry, cling, Sofratulle®).

12. Analgesia (e.g., pain control, codeine, Tylenol®). Maximum and ideal section scores = 5. B.7. Follow-up care Respondent mentions of: 13. 14. 15. 16. 17.

Emergency department. Family/general practitioner. Plastic surgeon. Burn centre/surgeon. Follow-up in 24–48 h.

Maximum section score = 5. Ideal section score = 2 or 3 (score of 0 for #15 and #16). Maximum total score = 17. Ideal total score = 13 or 14 (score of 0 for #7, #15, #16). References [1] American Burn Association. Burn incidence and treatment in the US: 2000 fact sheet. http://www.ameriburn.org/pub/Burn%20Incidence %20Fact%20Sheet.htm. Accessed September 5, 2003. [2] Peters WJ. Forming an assessment and treatment plan for burn patients. Can J Diag 1991;12:81–4. [3] Mertens DM, Jenkins ME, Warden GD. Outpatient burn management. Nurs Clin North Am 1997;32:343–64. [4] Baxter CR, Waeckerle JF. Emergency treatment of burn injury. Ann Emerg Med 1988;17:1305–14. [5] Sheridan R, Weber J, Prelack K, Petras L, Lydon M, Tompkins R. Early burn center transfer shortens the length of hospitalization and reduces complications in children with serious burns injuries. J Burn Care Rehab 1999;20:347–50. [6] Ontario Ministry of Health. Burns in Ontario: final report; 1997. Project 1997-17. [7] Peate WF. Outpatient management of burns. Am Fam Physician 1992;45:1321–30. [8] Ulmer JF. Burn pain management: a guideline-based approach. J Burn Care Rehabil 1998;19:151–9. [9] Hermans MHE. Results of a survey on the use of different treatment options for partial and full thickness burns. Burns 1998;24:539–51. [10] Smith S, Duncan M, Mobley J, Kagan R. Emergency room management of minor burn injuries: a quality management evaluation. J Burn Care Rehabil 1997;18:76–80. [11] Holness J, Mastrilli A, Workers’ Safety Insurance Board of Ontario. Serious injuries program minutes; 2001 [Fish JS, personal communication]. [12] Brandt CP, Coffee T, Yurko L, Yowler CJ, Fratianne RB. Triage of minor burn wounds: avoiding the emergency department. J Burn Care Rehabil 2000;21:26–8. [13] Residency program accreditation and certification. Mississauga: College of Family Physicians of Canada; July 1997. [14] Objectives of training and specialty training requirements in emergency medicine. Ottawa: Royal College of Physicians and Surgeons of Canada; 1998. [15] Specialty requirements for residency training in emergency medicine. Graduate medical education directory for emergency medicine. American Board of Emergency Medicine; 1998. [16] American Burn Association. Hospital and prehospital resources for optimal care of patients with burn injury: guidelines for development and operation of burn centers. J Burn Rehabil 1990;11:98– 104.