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burns 41 (2015) 638–647

J.A. Dunne* ST4 Plastic Surgery, St George’s Hospital, Blackshaw Road, London SW17 0QT, UK

Owen Bodger University of Swansea, Singleton Park, Swansea SA2 8PP, United Kingdom

J.M. Rawlins Plastic, Reconstructive and Burns Surgeon, Royal Perth Hospital, 197 Wellington Street, Perth, WA 6000, Australia

Sarah Hemington Gorse David Williams Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea SA6 6NL, United Kingdom

*Corresponding author. Tel.: +44 7870987503 E-mail address: [email protected] (J.A. Dunne)

*Corresponding author. Tel.: +44 07949450866 E-mail address: [email protected] (R. Morris)

http://dx.doi.org/10.1016/j.burns.2014.12.019 0305-4179/# 2015 Published by Elsevier Ltd and ISBI.

http://dx.doi.org/10.1016/j.burns.2015.01.019 0305-4179/# 2015 Elsevier Ltd and ISBI. All rights reserved.

Response to Letter to the Editor

Letter to the Editor

Patient confidentiality and new technologies in burn care

Cost-effective outpatient burn-care for minor burns

We agree with the general concerns raised by Dunne and Rawlins [1] regarding data confidentiality and the use of smartphone cameras in the clinical environment. The apps which we evaluated [2] are simple calculators, requiring input data of age, body weight, burn surface area and time of injury. They do not use any patient identifiable data or take photographs of the patient, and the results of the calculations are not stored or transmitted in any form. We have no interests in promoting either app, but note that both apps studied present less of a threat to patient confidentiality than a handwritten Lund and Browder chart.

Dear Sir,

Funding Nil.

Conflict of interest Nil.

references

[1] Dunne JA, Rawlins JM. Patient confidentiality and new technologies in burn care. Burns 2015;41:638–9. [2] Morris R, Javed M, Bodger O, Hemington Gorse S, Williams D. A comparison of two smartphone applications and the validation of smartphone applications as tools for fluid calculation for burns resuscitation. Burns 2014;40: 826–34.

Rhys Morris* Muhammad Javed Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea SA6 6NL, United Kingdom

Burn care is known to be expensive. Nowadays, research on burn-related costs is becoming a current subject of debate and a wide variety of methodological approaches and cost prices are found in the literature. The mean total healthcare cost per burn patient in high-income countries is calculated as $88,218 (range $704–$717,306; median $44,024) [1]. According to ‘American Burn Association, National Repository 2013 report’ the estimated number of burns receiving medical treatment is 450,000 and only 40,000 of these cases are hospitalized [2]. These data suggest that majority of burn cases are treated as outpatients and I think that cost-effective outpatient management should be a current issue in modern burn-care approach. This letter intends to discuss the factors which may influence the cost-effectiveness of outpatient burn-care. The goal of outpatient management in burn trauma is to provide the best environment for spontaneous healing in order to prevent scarring and allow normal functions. Infections must be avoided at all costs because it will change the depth of burn and increase scarring with functional losses [3]. In the light of these principles, I think that the primary factor which may influence the cost-effectiveness of outpatient burn-care is the appropriateness of initial treatment for minor burns. Superficial burn wounds result in less damage when compared to deeper ones, hence cautious attempts for protecting the burn wound from deepening should be started in the initial treatment. Immediate cooling of the burn wound with tap water, water-soaked gauze or hydrogel reduces the surface temperature as well as the state of dehydration of a burned zone. By cooling, pain and damage due to perilesional vasodilatation are reduced as well [4,5]. Analgesia with nonsteroid anti inflammatory agents, oral rehydration and appropriate elevation of the affected extremity are other initial therapies which may protect the wound from deepening [6]. Successful management in the acute phase lowers the number of future wound dressings and debridements,

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shortens the estimated period of outpatient treatment and results in satisfactory functional and esthetic results. Appropriateness of local wound care after the acute phase is the other factor that could influence the cost-effectiveness. During the wound care period following the acute phase, clinicians should continue to their attempts for lowering the number of painful wound dressings. In addition, they should focus on prevention of infection and enhancement of wound healing within a comfortable and cost-effective wound dressing. There are many alternate wound dressing methods for outpatient burn-care: Silversulfodiazine (SSD) is one of the topical antimicrobial agents which is widely used in outpatient wound care all around the world, it has been the mainstay of topical antimicrobial therapy for several decades since Fox developed it in 1960s [7]. It is a cheap, easy to find and easy to apply topical antimicrobial agent in every type of burn care. So, it is the most frequently used proflactic agent in burn patients. SSD is applied daily or a twice daily basis. It is wellknown that its penetration into the eschar is poor. In superficial dermal burns, pseudoeschar forms after several days of application, it is easily lifted from the wound but, it is hard for the inexperienced eyes to distinguish it from the real eschar [8]. The use of some other alternate wound dressings in the treatment of minor burns has been explored: According to a clinical study in 1990, compared with those in the SSDtreated group, burns in patients treated with hydrocolloid dressings healed faster, showed better appearance after healing and better repigmentation, required fewer and less elaborate dressing changes, and were less costly to treat [9]. Currently, several nano-technology and nano-crystalline silver dressings are commonly used in outpatient burn-care all around the world. Studies on silver dressings suggest that they are less costly to treat when compared to SSD [10]. In fact, management of the burn wound is a dynamic process. Clinicians in outpatient services should repeatedly reassess the wound with regard to wound bed factors and patient-related factors and they should modify the use of wound dressings throughout the outpatient treatment. The route of the treatment should be designed uniquely for every individual minor burn patient according to his/her age, sex, nutritional status, associated diseases and/or trauma and social status. The site, depth, width and infectious status of the burn wound should also be considered. For cost-effective decisions about the wound care, an experienced and educated outpatient service team is necessary. It seems that experienced ‘outpatient burn teams’ are the other most important factors for a cost-effective outpatient burn-care. I think that outpatient burn care at burn-centers which already have efficient materials, supplies, personnel, etc. should be the cost-effective treatment of choice. But in some world-regions, it is not a realistic and cost-effective approach to expect the burn-center teams to take the responsibility of minor burns alone. Because, high numbers of burn patients live in the countryside in those regions and it may be an expensive solution to transport them to burn-centers for minor burns. In addition, the numbers and localizations of burn-centers are not sufficient in some low-middle income countries yet. In such countries, if selected clinicians are educated and

assigned to specialized ‘outpatient burn-wound care services’ at local health-care centers, and if these local teams are affiliated with the nearest burn-centers (may be by the help of telemedicine [11]), qualified outpatient burn-care could be managed with more acceptable costs. I think that new research and discussions on the factors which influence cost-effectiveness of outpatient burn-care will improve the costs of outpatient burn facilities all around the world. But, it should be emphasized that a qualified and unpainful outpatient burn-care which achieves good functional and aesthetic results is not the ‘cost’ but the ‘effectiveness’ of burn-care. No concessions about the quality of treatment are acceptable when building up a standard costsaving approach for outpatient burn care.

references

[1] Hop MJ, Polinder S, Vlies CH, Middle koop E, Baar ME. Costs of burn care: a systematic review. Wound Rep Reg 2014;22:436–50. [2] American Burn Association National Burn Repository report; 2013. [3] Walson GD. Management of outpatient burns. Can Fam Physician 1986;32:805–8. [4] Arturson G. Forty years in burns research – the postburn inflammatory response. Burns 2000;26:599–604. [5] Jandera V, Hudson DA, de Wet PM, Innes PM, Rode H. Cooling the burn wound: evaluation of different modalities. Burns 2000;26:265–70. [6] Lloyd ECO, Rodgers BC. Out patient burns: prevention and care. Am Fam Physician 2012;85:25–32. [7] Fox Jr CL. Silver sulfodiazine – a new topical therapy for pseudomonas in burns. Therapy of pseudomonas in burns. Arch Surg 1968;96:184–8. [8] Bessey PQ. Wound care. In: Herndon DN, editor. Total burn care. Philadelphia: Saunders; 2007. p. 127–35. Chapter 11. [9] Wyatt D, McGowan DN, Najarian MP. Comparison of a hydrocolloid dressing and silver sulfadiazine cream in the outpatient management of second-degree burns. J Trauma 1990;30:857–65. [10] Gravante G, Carusa R, Sorge R, Nicoli F, Gentile P, Cervelli V. Nanocrystalline silver: a systematic review of randomized trials conducted on burn patients and evidence-based assessment of potential advantages over older silver formulations. Ann Plast Surg 2009;63:201–5. [11] Turk E, Karagulle E, Aydogan C, Oguz H, Tarim A, Karakayali H, et al. Use of telemedicine and telephone consultation in decision-making and follow-up of burn patients:initial experience from two burn units. Burns 2011;37:415–9.

Ayse Ebru Abali* Burn Center, Baskent University Burn and Fire Disasters Institute, Ankara, Turkey *Correspondence to: Baskent Universitesi Hastanesi, 5. Sok. Poliklinikler, Genel Cerrahi, 53.Sok No: 48, 06490, Bahc¸elievler, Ankara, Turkey. Tel.: +90 5427230031 E-mail address: [email protected] (A.E. Abali) http://dx.doi.org/10.1016/j.burns.2014.11.015 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.

Cost-effective outpatient burn-care for minor burns.

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