Annals of the Royal College of Surgeons of England (1991) vol. 73, 329-331
Assessment of burn in jury in the accident and emergency department: a review of 100 referrals to a regional burns unit J Hamish E Laing
BSc FRCS
Senior House Officer in Plastic Surgery
Brian D G Morgan
FRCS
Consultant in Plastic and Reconstructive Surgery
Roy Sanders
BSc FRCS
Consultant in Plastic and Reconstructive Surgery
North West Thames Regional Burns Unit, Mount Vernon Hospital, Northwood, Middlesex
Key words: Burn trauma; Assessment; Accident & Emergency department, Trauma
Accurate assessment of the extent of thermal injury in the accident and emergency (A&E) department is essential if appropriate resuscitation and referral to a specialist unit is to occur. However, review of 100 referrals to a regional burns unit confirms that assessment is often inaccurate, and usually undertaken by no one more senior than a casualty officer, leading to suboptimal treatment and referral. Severe thermal injury should be assessed by a team of senior doctors, according to the major trauma protocol, and casualty officers should receive better training in the assessment of less extensive burns.
Thermal injury represents one of the most severe forms of trauma that a patient may suffer, and a favourable outcome is enhanced by treatment in a specialist centre. The importance of the initial assessment and resuscitation in the A&E department cannot be overemphasised, particularly if the patient must travel a considerable distance to reach the nearest available burns unit. While many centres have their own protocol for fluid resuscitation, all depend upon an accurate assessment of the nature of the burn, its extent and severity. Many of these protocols are based upon the Muir and Barclay formula (1). A retrospective review of 100 admissions to a regional Present appointment and correspondence to: J H E Laing BSc FRCS, Research Registrar, RAFT Department of Research in Plastic Surgery, Mount Vernon Hospital NHS Trust, Northwood, Middlesex HA6 2RN
team
burns unit was undertaken. The assessment of burn extent by the referring doctor was compared with that of the burns unit team.
Patients and methods The hospital A study was made at the North West Thames Regional Burns Unit, Mount Vernon Hospital, of patients admitted between March 1989 and February 1990. The majority of patients were referred from accident and emergency departments within the Region, but 7% were extra-Regional referrals.
Patients The medical records of 127 consecutive admissions to the Regional Burns Unit were examined. Data were obtained of the grade and specialty of the referring doctor, the assessment of the nature and extent of the burn injury and the initial assessment of the patient by the Burns Unit team upon arrival. Two patients for whom no referral letter was available were excluded, as were 18 patients in whom no attempt at assessment of extent had been made in the referring hospital. Patients in our own A&E department are usually assessed there by the Burns Unit Team and seven such patients were also excluded from this study. The records of 100 patients were therefore included in the study. No comparison of the assessment of the depth
330
H E Laing et al.
of burn was possible, since it was uncommon for the referring doctor to have remarked upon this.
CHART FOR ESTIMATING SEVERITY OF BURN WOUND NAME
AGE._
Data analysis The referral letters and casualty cards of the patients were reviewed as were the Burns Unit admission notes and charts. The most senior doctor to see the patient in the A&E department was deemed to be the assessor, and their grade and specialty recorded, with their estimation of the extent of burn injury. The assessment of burn extent in the referring hospital was then compared with that made on the patient's arrival at the Regional Burns Unit. The error between the two figures was calculated, and the mean error for each grade of referring doctor derived. The range of error was recorded, and whether the referring estimate was an over- or underestimate of burn extent.
DATE_
NUMBER -WARD ADMISSION WEIGHT___
LUND AND ROWDE CHARTS
WA
Wa
~
T 1H
3*-V ARM AFFEC:TED w G
~
Results
~ 1~~~~ 1~~~~
NEC
RGHTLAR ~LEFT LEG TOTAL BURN
RELATiV PERCENAGE OF BODY SURFACE AREA AFFECTED BY GROWTH AREA 15 5 10 ~~~AGEG0 1 LA-lbOF HEAD 18% 16½ 15½ 4% B-½,/ OF ONE THIGH 23/io 3Ti' 4 4½/ 4½b 3 . 313½ IC-½ 0FONELEG ,~~~~~~1 -2½/ -212½ 123/
Of 127 patients whose notes were reviewed, 27 were excluded (no letter, 2; no assessment of extent, 18; seen in our A&E department, 7). Thus the data from 100 referrals were studied.
'9½,
ADULT
J3k14
143/7 31½ .-
Grade of assessor
The most senior doctor to see the patient in the casualty department was recorded, and the results are summarised in Table I. It is clear that the majority (63%) had been seen by the casualty officer only. Plastic surgical trainees had seen all patients referred from hospitals with a plastic surgery unit (but no burns unit). Less than 10% of referrals had been seen by a more senior casualty doctor (registrar, senior registrar or consultant) despite their increasing presence in A&E departments. Where another opinion had been sought from hospital junior staff, it was usual to call the registrar (or senior registrar) in either orthopaedics or general surgery, according to local policy. Paediatric juniors had been asked to see some (but not all) burnt children.
Figure 1. Lund and Browder age related charts for estimation of burn extent. (By kind permission Smith and Nephew Pharmaceuticals Ltd.)
Quality of assessment The estimated extent of surface area burnt made by the referring doctor was compared with that made by the Burns Unit team on arrival. In our unit all admissions are assessed by two clinicians using Lund and Browder charts (Fig. 1), which are modified for the patient's age. Depth of burn is also assessed and simple erythema excluded. The average error is shown in Table II, by grade of assessor. Casualty officers and hospital SHOs all performed poorly, with no significant difference between the Table II. Degree of error in estimation of burn extent in the A&E department, when related to burns unit assess-
Table I. Grade of the most senior assessor in the A&E department for 100 referrals to a Regional Burns Unit
ment
Specialtylgrade
Specialty/grade
A&E SHO Ortho/surgical Reg/SR Plastic surgery SHO/Registrar A&E Registrar/SR Paediatric SHO/Registrar A&E Consultant Others
Patients assessed 63 12 9 6 4 3 3
A&E SHO Paediatric SHO/Registrar Ortho/surgical SHO Ortho/surgical Registrar/SR A&E Registrar/SR A&E Consultant Plastic surgery SHO/Registrar
Mean
error
133 117 100 60 40 8 7
(%)
Range 0-1100 100-150 50-150 0-200 0-150 0-15 0-17
Assessment of burn injury PATIENTS 14
12 10
UNDER-ESTIMATED
OVER-ESTIMATED
8 6 4
2~j 0
-99
-49
to -50
-20
to
-19 to -10
-9 to 0
0
0 to .9
10 to
19
X0
to 49
50 100
*00
to
to #99
99
lo
199
>100
ERROR (%) =ALL OTHERS Figure 2. Under- and overestimation of burn extent by referring doctor. _ A&E HO
surgical specialties. While duty surgical/orthopaedic registrars were better assessors than the SHOs, there was still a mean error of 60%. Casualty consultants and local junior plastic surgeons performed equally well, and the small variance between their assessment and ours probably reflects the degree of error inherent in visual chart assessment. Errors were analysed for over- and underestimation. These results are summarised in Fig. 2. Over 85% of patients were overestimated, the worst by over 1000%! This led to gross overtreatment and fluid overload.
Discussion Thermal injury is common, with over 10 000 patients requiring hospital treatment in England and Wales each year, and resulting in over 600 deaths (2,3). A favourable outcome in burn injury is dependent upon effective and appropriate fluid resuscitation within the first 36 h, the identification and treatment of other injuries and the prompt referral to a specialised unit, where a multidisciplinary approach may be provided in an optimal environment (1). The estimate of fluid loss and hence the calculation of fluid requirement is dependent upon an accurate assessment of the extent and depth of the burn injury and the weight of the patient. The development of hypovolaemia in association with myoglobinaemia readily precipitates acute renal failure, which substantially worsens the prognosis of patients suffering burn trauma. Similarly, overhydration resulting in pulmonary oedema may exacerbate any tendency towards adult respiratory distress syndrome (ARDS) with consequent worsening of outcome (4).
These data show that the assessment of burn extent in A&E departments is often inaccurate, and that initial resuscitation could, therefore, be considerably improved. The majority of the patients (63%) were seen in the A&E department only by the casualty officer, who may have only recently completed preregistration training, and may never before have seen a severe burn injury (5,6). Recent evidence for the management of major trauma shows that better care is provided by a 'trauma team',
331
comprising senior surgeons and anaesthetists (7). The severity of burn injury is such that it would seem appropriate for it to be included in the criteria for immediate experienced care, even if there are no other associated injuries. Relatively small burns may be significant at the extremes of age, and the training of casualty officers in their accurate assessment and care should be improved. Assessment might be enhanced if Lund and Browder charts were completed for each patient, and the importance of excluding simple erythema reiterated. The high incidence of error and the great inaccuracy of assessment of extent of burns highlights the paucity of teaching of the management of this common and serious injury in medical school curricula. Regional units might ensure that referring hospitals are aware of their referral and resuscitation policy and of the importance of the initial management in the A&E department. The increasing prevalence of multiresistant pathogens, financial constraints and shortage of skilled nursing staff, result in frequent temporary closure of Regional Burns Units. Patients are often required to travel considerable distances to reach a specialised unit. Appropriate assessment, resuscitation and referral is critical if a favourable outcome is to be achieved, and resources used to best effect. Errors of the degree found in this study seem unacceptable. Since major burns are potentially lethal, perhaps greater attention should be given to them in undergraduate education. We are grateful to Smith and Nephew Pharmaceuticals Ltd for permission to reproduce the Lund and Browder chart. Pads of preprinted charts for use in A&E departments may be obtained from them (Telephone 04023-49333).
References 1 Muir IFK, Barclay TL, Settle JAD eds. Treatment of burns shock. Burns and their Treatment. 3rd Edition. Sevenoaks: Butterworths, 1987:14-54. 2 Department of Health and Social Security. Hospital inpatient enquiry series MB4, 87/1. May 1987. London: OPCS. 3 OPCS. Mortality Statistics: Cause. Series DH2, No 14. London: HMSO, 1987. 4 Petroff PA, Pruitt BA. Pulmonary disease in the burn patient. In: Artz CP, Moncrief JA, Pruitt BA eds. Burns-A Team Approach. Philadelphia PA: WB Saunders, 1979:95106. 5 Yates DW, Wakeford R. The training of junior doctors for accident and emergency work: a case for urgent treatment? Injury 1983;14:456-60. 6 Griffiths GD, Jenkinson LR, Francis DA, Henderson JJ. Burns management and junior staff-what do they know? Burns 1989;15:47-8. 7 Royal College of Surgeons of England. Report of the Working Party on the Management of Patients with Major Injuries. London, November 1988:22-5.
Received 26 February 1991
Assessment of burn in jury in the accident and emergency department: a review of 100 referrals to a regional burns unit J Hamish E Laing
BSc FRCS
Senior House Officer in Plastic Surgery
Brian D G Morgan
FRCS
Consultant in Plastic and Reconstructive Surgery
Roy Sanders
BSc FRCS
Consultant in Plastic and Reconstructive Surgery
North West Thames Regional Burns Unit, Mount Vernon Hospital, Northwood, Middlesex
Key words: Burn trauma; Assessment; Accident & Emergency department, Trauma
Accurate assessment of the extent of thermal injury in the accident and emergency (A&E) department is essential if appropriate resuscitation and referral to a specialist unit is to occur. However, review of 100 referrals to a regional burns unit confirms that assessment is often inaccurate, and usually undertaken by no one more senior than a casualty officer, leading to suboptimal treatment and referral. Severe thermal injury should be assessed by a team of senior doctors, according to the major trauma protocol, and casualty officers should receive better training in the assessment of less extensive burns.
Thermal injury represents one of the most severe forms of trauma that a patient may suffer, and a favourable outcome is enhanced by treatment in a specialist centre. The importance of the initial assessment and resuscitation in the A&E department cannot be overemphasised, particularly if the patient must travel a considerable distance to reach the nearest available burns unit. While many centres have their own protocol for fluid resuscitation, all depend upon an accurate assessment of the nature of the burn, its extent and severity. Many of these protocols are based upon the Muir and Barclay formula (1). A retrospective review of 100 admissions to a regional Present appointment and correspondence to: J H E Laing BSc FRCS, Research Registrar, RAFT Department of Research in Plastic Surgery, Mount Vernon Hospital NHS Trust, Northwood, Middlesex HA6 2RN
team
burns unit was undertaken. The assessment of burn extent by the referring doctor was compared with that of the burns unit team.
Patients and methods The hospital A study was made at the North West Thames Regional Burns Unit, Mount Vernon Hospital, of patients admitted between March 1989 and February 1990. The majority of patients were referred from accident and emergency departments within the Region, but 7% were extra-Regional referrals.
Patients The medical records of 127 consecutive admissions to the Regional Burns Unit were examined. Data were obtained of the grade and specialty of the referring doctor, the assessment of the nature and extent of the burn injury and the initial assessment of the patient by the Burns Unit team upon arrival. Two patients for whom no referral letter was available were excluded, as were 18 patients in whom no attempt at assessment of extent had been made in the referring hospital. Patients in our own A&E department are usually assessed there by the Burns Unit Team and seven such patients were also excluded from this study. The records of 100 patients were therefore included in the study. No comparison of the assessment of the depth
330
H E Laing et al.
of burn was possible, since it was uncommon for the referring doctor to have remarked upon this.
CHART FOR ESTIMATING SEVERITY OF BURN WOUND NAME
AGE._
Data analysis The referral letters and casualty cards of the patients were reviewed as were the Burns Unit admission notes and charts. The most senior doctor to see the patient in the A&E department was deemed to be the assessor, and their grade and specialty recorded, with their estimation of the extent of burn injury. The assessment of burn extent in the referring hospital was then compared with that made on the patient's arrival at the Regional Burns Unit. The error between the two figures was calculated, and the mean error for each grade of referring doctor derived. The range of error was recorded, and whether the referring estimate was an over- or underestimate of burn extent.
DATE_
NUMBER -WARD ADMISSION WEIGHT___
LUND AND ROWDE CHARTS
WA
Wa
~
T 1H
3*-V ARM AFFEC:TED w G
~
Results
~ 1~~~~ 1~~~~
NEC
RGHTLAR ~LEFT LEG TOTAL BURN
RELATiV PERCENAGE OF BODY SURFACE AREA AFFECTED BY GROWTH AREA 15 5 10 ~~~AGEG0 1 LA-lbOF HEAD 18% 16½ 15½ 4% B-½,/ OF ONE THIGH 23/io 3Ti' 4 4½/ 4½b 3 . 313½ IC-½ 0FONELEG ,~~~~~~1 -2½/ -212½ 123/
Of 127 patients whose notes were reviewed, 27 were excluded (no letter, 2; no assessment of extent, 18; seen in our A&E department, 7). Thus the data from 100 referrals were studied.
'9½,
ADULT
J3k14
143/7 31½ .-
Grade of assessor
The most senior doctor to see the patient in the casualty department was recorded, and the results are summarised in Table I. It is clear that the majority (63%) had been seen by the casualty officer only. Plastic surgical trainees had seen all patients referred from hospitals with a plastic surgery unit (but no burns unit). Less than 10% of referrals had been seen by a more senior casualty doctor (registrar, senior registrar or consultant) despite their increasing presence in A&E departments. Where another opinion had been sought from hospital junior staff, it was usual to call the registrar (or senior registrar) in either orthopaedics or general surgery, according to local policy. Paediatric juniors had been asked to see some (but not all) burnt children.
Figure 1. Lund and Browder age related charts for estimation of burn extent. (By kind permission Smith and Nephew Pharmaceuticals Ltd.)
Quality of assessment The estimated extent of surface area burnt made by the referring doctor was compared with that made by the Burns Unit team on arrival. In our unit all admissions are assessed by two clinicians using Lund and Browder charts (Fig. 1), which are modified for the patient's age. Depth of burn is also assessed and simple erythema excluded. The average error is shown in Table II, by grade of assessor. Casualty officers and hospital SHOs all performed poorly, with no significant difference between the Table II. Degree of error in estimation of burn extent in the A&E department, when related to burns unit assess-
Table I. Grade of the most senior assessor in the A&E department for 100 referrals to a Regional Burns Unit
ment
Specialtylgrade
Specialty/grade
A&E SHO Ortho/surgical Reg/SR Plastic surgery SHO/Registrar A&E Registrar/SR Paediatric SHO/Registrar A&E Consultant Others
Patients assessed 63 12 9 6 4 3 3
A&E SHO Paediatric SHO/Registrar Ortho/surgical SHO Ortho/surgical Registrar/SR A&E Registrar/SR A&E Consultant Plastic surgery SHO/Registrar
Mean
error
133 117 100 60 40 8 7
(%)
Range 0-1100 100-150 50-150 0-200 0-150 0-15 0-17
Assessment of burn injury PATIENTS 14
12 10
UNDER-ESTIMATED
OVER-ESTIMATED
8 6 4
2~j 0
-99
-49
to -50
-20
to
-19 to -10
-9 to 0
0
0 to .9
10 to
19
X0
to 49
50 100
*00
to
to #99
99
lo
199
>100
ERROR (%) =ALL OTHERS Figure 2. Under- and overestimation of burn extent by referring doctor. _ A&E HO
surgical specialties. While duty surgical/orthopaedic registrars were better assessors than the SHOs, there was still a mean error of 60%. Casualty consultants and local junior plastic surgeons performed equally well, and the small variance between their assessment and ours probably reflects the degree of error inherent in visual chart assessment. Errors were analysed for over- and underestimation. These results are summarised in Fig. 2. Over 85% of patients were overestimated, the worst by over 1000%! This led to gross overtreatment and fluid overload.
Discussion Thermal injury is common, with over 10 000 patients requiring hospital treatment in England and Wales each year, and resulting in over 600 deaths (2,3). A favourable outcome in burn injury is dependent upon effective and appropriate fluid resuscitation within the first 36 h, the identification and treatment of other injuries and the prompt referral to a specialised unit, where a multidisciplinary approach may be provided in an optimal environment (1). The estimate of fluid loss and hence the calculation of fluid requirement is dependent upon an accurate assessment of the extent and depth of the burn injury and the weight of the patient. The development of hypovolaemia in association with myoglobinaemia readily precipitates acute renal failure, which substantially worsens the prognosis of patients suffering burn trauma. Similarly, overhydration resulting in pulmonary oedema may exacerbate any tendency towards adult respiratory distress syndrome (ARDS) with consequent worsening of outcome (4).
These data show that the assessment of burn extent in A&E departments is often inaccurate, and that initial resuscitation could, therefore, be considerably improved. The majority of the patients (63%) were seen in the A&E department only by the casualty officer, who may have only recently completed preregistration training, and may never before have seen a severe burn injury (5,6). Recent evidence for the management of major trauma shows that better care is provided by a 'trauma team',
331
comprising senior surgeons and anaesthetists (7). The severity of burn injury is such that it would seem appropriate for it to be included in the criteria for immediate experienced care, even if there are no other associated injuries. Relatively small burns may be significant at the extremes of age, and the training of casualty officers in their accurate assessment and care should be improved. Assessment might be enhanced if Lund and Browder charts were completed for each patient, and the importance of excluding simple erythema reiterated. The high incidence of error and the great inaccuracy of assessment of extent of burns highlights the paucity of teaching of the management of this common and serious injury in medical school curricula. Regional units might ensure that referring hospitals are aware of their referral and resuscitation policy and of the importance of the initial management in the A&E department. The increasing prevalence of multiresistant pathogens, financial constraints and shortage of skilled nursing staff, result in frequent temporary closure of Regional Burns Units. Patients are often required to travel considerable distances to reach a specialised unit. Appropriate assessment, resuscitation and referral is critical if a favourable outcome is to be achieved, and resources used to best effect. Errors of the degree found in this study seem unacceptable. Since major burns are potentially lethal, perhaps greater attention should be given to them in undergraduate education. We are grateful to Smith and Nephew Pharmaceuticals Ltd for permission to reproduce the Lund and Browder chart. Pads of preprinted charts for use in A&E departments may be obtained from them (Telephone 04023-49333).
References 1 Muir IFK, Barclay TL, Settle JAD eds. Treatment of burns shock. Burns and their Treatment. 3rd Edition. Sevenoaks: Butterworths, 1987:14-54. 2 Department of Health and Social Security. Hospital inpatient enquiry series MB4, 87/1. May 1987. London: OPCS. 3 OPCS. Mortality Statistics: Cause. Series DH2, No 14. London: HMSO, 1987. 4 Petroff PA, Pruitt BA. Pulmonary disease in the burn patient. In: Artz CP, Moncrief JA, Pruitt BA eds. Burns-A Team Approach. Philadelphia PA: WB Saunders, 1979:95106. 5 Yates DW, Wakeford R. The training of junior doctors for accident and emergency work: a case for urgent treatment? Injury 1983;14:456-60. 6 Griffiths GD, Jenkinson LR, Francis DA, Henderson JJ. Burns management and junior staff-what do they know? Burns 1989;15:47-8. 7 Royal College of Surgeons of England. Report of the Working Party on the Management of Patients with Major Injuries. London, November 1988:22-5.
Received 26 February 1991
