JBUR-4531; No. of Pages 13 burns xxx (2015) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Smartphone applications in burns Paul Wurzer a,b,1,*, Daryousch Parvizi a,1, David B. Lumenta a, Michael Giretzlehner c, Ludwik K. Branski a,b, Celeste C. Finnerty b, David N. Herndon b, Alexandru Tuca a, Thomas Rappl a, Christian Smolle a, Lars P. Kamolz a a
Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria b Burns and Trauma Research, Acute Burn Surgery, and Reconstructive Burn Surgery, Shriners Hospitals for Children and The University of Texas Medical Branch, Galveston, TX, USA c Research Unit Medical-Informatics, RISC Software GmbH, Johannes Kepler University Linz, Hagenberg, Austria
article info
abstract
Article history:
Objective: Since the introduction of applications (apps) for smartphones, the popularity of
Accepted 12 November 2014
medical apps has been rising. The aim of this review was to demonstrate the current availability of apps related to burns on Google’s Android and Apple’s iOS store as well as to
Keywords:
include a review of their developers, features, and costs.
Total body surface area
Methods: A systematic online review of Google Play Store and Apple’s App Store was
Total fluid requirement
performed by using the following search terms: ‘‘burn,’’ ‘‘burns,’’ ‘‘thermal,’’ and the
Application
German word ‘‘Verbrennung.’’ All apps that were programmed for use as medical apps
Burns
for burns were included. The review was performed from 25 February until 1 March 2014. A
Apple
closer look at the free and paid calculation apps including a standardized patient was
Android
performed. Results: Four types of apps were identified: calculators, information apps, book/journal apps, and games. In Google Play Store, 31 apps were related to burns, of which 20 were calculation apps (eight for estimating the total body surface area (TBSA) and nine for total fluid requirement (TFR)). In Apple’s App Store, under the category of medicine, 39 apps were related to burns, of which 21 were calculation apps (19 for estimating the TBSA and 17 for calculating the TFR). In 19 out of 32 available calculation apps, our study showed a correlation of the calculated TFR compared to our standardized patient. Conclusion: The review demonstrated that many apps for medical burns are available in both common app stores. Even free available calculation apps may provide a more objective and reproducible procedure compared to manual/subjective estimations, although there is still a lack of data security especially in personal data entered in calculation apps. Further clinical studies including smartphone apps for burns should be performed. # 2014 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author at: Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, Graz 8036, Austria. Tel.: +43 6765448224. E-mail address: [email protected] (P. Wurzer). 1
These authors contributed equally to this work. http://dx.doi.org/10.1016/j.burns.2014.11.010 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
JBUR-4531; No. of Pages 13
2
burns xxx (2015) xxx–xxx
1.
Introduction
Since the introduction of smartphones by the ‘‘Stockholm Smartphone Team’’ [1] in 1997, the term smartphone has become common in our daily lives. Nowadays, a smartphone is synonymous with a device, which associates the properties of a mobile phone with the possibilities of a personal computer. Another historic milestone of the smartphone was the introduction of the first touch screen [1] on mobile devices in 2000. Heather Leonhard of the ‘‘Business Insider’’ expects that there will be 1.4 billion smartphone users worldwide at the end of 2014, indicating that nearly every fifth human being on the planet will possibly own one [2]. Most smartphones run on Google’s operating system Android (60%) followed by Apple’s iOS (40%) [2]. In 2008, both Apple and Google introduced their application (app) stores, which have made it easy for users to individualize their mobile devices. From 2008 until July 2011, 15 billion apps were downloaded from the Apple’s App Store [3]. Google Play Store, formerly Android Market from Google, hosts more than one million apps to date [4]. About half of these apps have become available in Apple’s App Store [3]. The widespread penetration of smartphones in the population has, of course, had an effect on the way in which we interact in our professional and private daily lives: smartphones are supposed to be used more often than personal computers, laptops, or even pen and paper. Even in daily clinical practice, electronic devices form an integral part of modern medicine. These devices may help guide patient care in hospitals, they may help find the right diagnosis, and they are sometimes helpful in therapeutic decision making. All these properties can be provided by different devices or they can be included in one system. Nowadays, custom-made apps for smartphones and their users are able to assume a majority, if not all, of these tasks. Therefore, modern app stores have special categories for medical/health-care apps. In the medical literature, a growing number of authors described the continuous rise in the popularity of smartphone apps [5–8]. Mosa et al. [5] described that most apps in medicine are used for disease diagnosis, medical calculations, or drug references. To enable special apps for every field of medicine, numerous different apps for almost every medical specialty have been made available. Most are free for download and some are to be purchased. In the treatment of burns, many different apps have been on offer ranging from first-aid leaflets, literature and papers, or games to calculation apps. The aim of this study was to review the offered apps applicable in the treatment of burns on Google’s Android and Apple’s iOS smartphones and to focus on the following parameters: costs (free/paid), developers, content, target groups (medical professionals/laypersons), and available interfaces (e.g., hospital information system/HIS). Furthermore, we compared all available calculation apps in a study based on a standardized patient model.
2.
Methods
2.1.
Ethics
A formal ethical review board approval was not required, because we did not use any personal or patient data.
2.2.
Design
A systematic review of the two provided app stores was performed from 25 February until 1 March 2014. The terms for research were defined: ‘‘burn,’’ ‘‘burns,’’ ‘‘thermal,’’ and the German word ‘‘Verbrennung.’’ At first, the terms were searched in Google Play Store (formerly Android Market) by using the following link: https://play.google.com/store/apps. As a second step, Apple’s App Store was browsed by using the following link: https://itunes.apple.com/en/genre/ios/ id36?mt=8. Using these home pages, we could easily access both stores. The information of all the listed apps was analyzed and individually graded based on their applicability in the treatment of burns. Apps concerning the treatment of other medical diseases containing such terms (e.g., burnout, etc.) were excluded. The following information was collected: medical link of the developer, available languages, type of app (information, calculator, etc.), and available interfaces between other devices. All available free and paid calculation apps underwent a trial by using a standardized patient: male, 25 years of age, with a height and weight of 175 cm and 75 kg, respectively, and 18% burned total body surface area (TBSA) (II–III8). The total fluid requirement (TFR) within the first 24 h for this standardized patient is 5400 ml, calculated with the Parkland formula (4 patient’s weight percentage burned TBSA (II–III8).
2.3.
Analysis and illustrations
For a descriptive analysis, we created spreadsheets using Excel 2008 (Microsoft, Richmond, VA, USA) and flowcharts using PowerPoint 2008 (Microsoft, Richmond, VA, USA) to illustrate the research process.
3.
Results
Detailed results of the available apps are described in Table 1 (for Google’s Android) and Table 2 (for Apple’s iOS). The research process is illustrated in two flowcharts (Figs. 1 and 2). In every store, we could identify four types of apps: calculators, information, books/journals, and games. Thirty-two calculator apps (13 for Android, 21 for iOS, and two of the same name in both stores) usually provide functionality both for estimating the TBSA and for calculating the TFR, whereas some apps only provide one of these features. Twenty-six information apps (15 for Android, 12 for iOS, and one of the same name in both stores) provide quick and easy-to-use first-aid guidelines and guidelines for treatment of burns. Three book and journal apps (one for Android, three for iOS, and one of the same name in both stores) are designed to provide more detailed information for the treatment of burns, usually developed for medical professionals. Most games (five; two for Android, and three for iOS) are quizzes, which provide an amusing way of obtaining more information about burns and learning firstaid procedures.
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
JBUR-4531; No. of Pages 13
Application
Price
Author
Journal of Wound Care#
Free
s
Med Tools# MedCalc 3000 Kidney#
0.74 3.73
s s
MedCalc 3000#
7.46
s
MediCalc Medical Calculator# MediForm medizinischer Rechner# BurnCare#
2.33
Society/ company
Type
Language
TBSA
TFR
B/L
EN
No
No
n.a.
Yes
No
No
M.P.
Yes Brooke, Semling, Evans, Modified Brooke, Slater, Parkland Parkland formula
Mosteller No
No No
No No
No M.P.
M.P.
No
No
No
M.P.
Parkland formula n.a.
No
No
No
M.P.
No
No
No
M.P.
2D patient model, Evans, Parkland, Carvajal No
No
No
No
M.P.
No
No
M.P.
BSA (Boyd, Dubois, Heycock, Mosteller) BSA (Dubois, Mosteller) 2D patient model, Lund and Browder chart, Parkland
No
No
No
M.P.
No
No
No
M.P.
No
No
No
M.P.
Rule of nines, Du Bois
No
No
No
M.P.
C
C EN
EN No
Yes Yes
C
EN
No
Yes
s
Foundation Internet Services CityJams
C
EN
No
Yes
1.99
s
Emorej
C
DE
No
Yes
Free
s
Pierre-Antoine Meley
C
EN
Yes
Yes
Calculate by QxMD#
Free
s
QxMD Medical Software Inc.
EN
Yes
Yes
Medfixation Medical Calculator#
2.01
s
Ryan Goodman
C
EN
Yes
Parkland formula, rule of nines Yes
Mediquation Medical Calculator#
3.73
s
Mediquations Inc
C
EN
Yes
Yes
Mersey Burns#
Free
s
Chris Seaton
C
EN
Yes
Yes
NurseCalcs Demo#
Free
s
Jonsap
C
EN
Yes
No
British Association of Plastic Reconstructive and Aesthetic Surgeons
Desinged for
Show closest burn center
Journal of Woundcare
C
Data interface
Guidelines described
MA Business & Leisure Darren Gates Foundation Internet Services
Used formulas
burns xxx (2015) xxx–xxx
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Table 1 – Details of all available burn apps in Google Play Store.
3
Price
Author
Society/ company
Type
TBSA
TFR
C
EN
Yes
Yes
C
EN
Yes
No
G
EN
No
G
EN
I
Used formulas
Data interface
Desinged for
Guidelines described
Show closest burn center
2D patient model, Parkland Size of mobile phones
No
No
No
M.P.
No
No
No
M.P.
No
n.a.
No
No
No
M.P.
No
No
n.a.
No
No
No
M.P.
EN
No
No
Yes
No
No
M.P.
I
EN
No
No
Parkland formula n.a.
No
No
No
L.P.
Parkland Formula#
Free
s
DTsEMT
Rapid Burn Assessor#
Free
s
RISC Software GmbH, Research Unit Medical Informatics
ABIM Exam Secrets Study Guide# Prognosis: Emergency Medicine# 10 Second EM#
37.34
s
Free
s
2.33
s
Mometrix Media LLC Medical Joyworks EM Gladiators
ABA 2013 Annual Meeting App#
Free
s
CrowdCompass Inc
AneIV - Anesthesia Aid# Atlanta Medical Center# Critical Care Paramedic (CCP)# Doctors Medical Center# ERres- Emergency Medicine# Frye Regional Medical Center# MEDGuide Emergency# MyATLS#
1.85 Free 2.16
s s s
I I I
EN EN EN
No No No
No No No
n.a. n.a. n.a.
Yes No No
No No No
No No No
M.P. L.P. M.P.
Free 2.23
s s
TomyLabs Tenet HelathCare ALFAJIRI MOBILE SOLUTIONS Tenet HelathCare Denali Apps, LLC
I I
EN EN
No No
No No
No Yes
No No
No No
L.P. M.P.
Free
s
Tenet HelathCare
I
EN
No
No
n.a. Rule of nines n.a.
No
No
No
L.P.
4.78 Free
s s
HUAN C.L.C American College of Surgeons
I I
EN EN
No No
No No
n.a. n.a.
Yes No
No No
No No
M.P. M.P.
Notfallmedizin pocket#
10.99
s
DE
No
No
n.a.
No
No
No
M.P.
Nursing Essentials# Pediatric EMS# PHTLS Pocket Companion# SMEDRIX 2.5#
5.97 3.73 1.49
s s s
Bo¨rm Bruckmeier Verlag GmbH Informed Publishing Informed Publishing Paul David Thomas
I I I
EN EN EN
No No No
No No No
n.a. n.a. n.a.
Yes No Yes
No No No
No No No
M.P. M.P. M.P.
10.06
s
Nougat
I
DE
No
Yes
n.a.
Yes
No
No
M.P.
Research Unit Medical Informatics, Johannes Kepler University Linz
American Burn Association
American College of Surgeons I
B/L: book or literature, C: calculator, G: game, I: information, M.P.: medical professional, L.P.: laypeople.
burns xxx (2015) xxx–xxx
Language
JBUR-4531; No. of Pages 13
4
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Table 1 (Continued ) Application
JBUR-4531; No. of Pages 13
Application
Price
Author
Language
TBSA
TFR
Used formulas
Data Desinged Guidelines Show for described closest interface burn center
Society/company
Type
Jones & Barlett Learning
B/L
EN
No
No
n.a
Yes
No
No
M.P.
B/L
EN
No
No
n.a
Yes
No
No
M.P.
B/L
EN
No
No
n.a
Yes
No
No
M.P.
C
EN
No
Yes
Parkland formula
Yes
No
No
M.P.
C C
EN EN
No Yes
Yes Yes
Parkland formula 2D patient model
No No
No No
No No
M.P. M.P.
No
No
No
M.P.
No No
No No
No No
M.P. M.P.
Tarascon Adult Emergency Pocketbook# Schwartz’s Manual of Surgery# Journal of Wound Care#
17.99 s USBMIS, Inc
EMS Pediatric Guide#
3.59
Burn Calc# Burn & Parkland Calculator# Lund–Browder Calculator#
Free 0.89
s MA Business & Leisure s Informed Publishing s D. Sparks s Patrick Campbell
0.89
s Shlose
C
EN
Yes
Yes
Rule Of Nines# TBSA of Burn Patients N3# BurnQQ2# Paramedic Parkland Formula# uBurn Medic#
0.89 0.89
s Rod Edwardson s Brian Donahower
C C
EN EN
Yes Yes
Yes Yes
2D patient model, Lund and Browder, Parkland Rule of nines Rule of nines
1.79 1.79
s Aoi Ogihara s Draken Design
C C
EN EN
Yes Yes
Yes Yes
Lund and Browder Rule of nines, Parkland
No No
No No
No No
M.P. M.P.
1.79
C
EN
Yes
Yes
Lund and Browder
Yes
Yes
Yes
M.P.
uBurn#
1.79
C
EN
Yes
Yes
Rule of nines, Parkland
Yes
No
No
M.P.
SARTech# BurnMed Pro#
2.69 4.49
s JAMB Innovations, LLC s JAMB Innovations, LLC s Adam Kusch s Johns Hopkins Mobile medicine
C EN
EN Yes
Yes No
No No
No No
No M.P.
M.P.
MBC Burn Care#
4.49
C
EN
No
Yes
Yes
Yes
M.P.
LiAo Burns Pro#
18.99 s Omesoft
C
ZH EN
Yes
No
No
No
M.P.
BurnCase 3D 2.0#
Free
Yes 2D patient model 3D Yes patient model Yes 2D patient model, Lund and Browder, Parkland Yes 2D patient model, Lund and Browder Yes 3D patient model, ABSI, Parkland
No
No
Yes
M.P.
BurnMed Lite#
Free
No
No
M.P.
LiAo Burns#
Free
No
No
No
59.99 s USBMIS, Inc Free
s Informed Italia s.r.l.
Journal of Woundcare
C
Euro-Mediterranean Council for Burns and Fire Disasters
s RISC Software GmbH, Research Unit Medical Informatics s Johns Hopkins Mobile medicine
Research Unit Medical Informatics, Johannes Kepler University Linz
C
EN
Yes
C
EN
Yes
No
s Omesoft
Third Military Medical University China
C
ZH EN
Yes
3D No patient model Yes 2D patient model, Lund and Browder
burns xxx (2015) xxx–xxx
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Table 2 – Details of all available burn apps in Apple’s App Store.
M.P.
5
Price
Author
Free
s Shlose
Free
uBurn LITE#
Free
Mersey Burns#
Free
s RISC Software GmbH, Research Unit Medical Informatics s JAMB Innovations, LLC s Chris Seaton
First Aid Information# Learning Dermatology Quiz# Burn Journey#
1.79 1.79 Free
Advanced Wound Treatment# ER-ICU Calc# First Aid & Care#
0.89
First Aid Tips!# Home First Aid (Chinese and English Only)# Vollsta¨ndiger Erste-Hilfe-Kurs fu¨r Notfa¨lle zuhause und unterwegs# Critical Care ACLS Guide# EMS ALS Guide# EMS BLS Guide# Health Bible A-Z# Choose a Dressing# MyALTS#
Type
Language
TBSA
TFR
EN
Yes
No
C
EN
Yes
C
EN
C
s motterSoft s Sylvester Renner
Guidelines Show Data Desinged described closest interface for burn center No
No
No
M.P.
No
2D patient model, Lund and Browder Size of mobile phones
No
No
No
M.P.
Yes
Yes
Rule of nines, Parkland
No
No
No
M.P.
EN
Yes
Yes
No
No
No
M.P.
G G
EN EN
No No
No No
2D patient model, Lund and Browder chart, Parkland n.a n.a
Yes No
No No
Yes No
L.P. M.P.
s Inidana University Health s USBMIS, Inc
G
EN
No
No
n.a
No
No
No
L.P.
I
EN
No
No
n.a
Yes
No
No
L.P.
I I
EN EN
No No
No No
Parkland formula n.a
Yes Yes
No No
No No
M.P. L.P.
0.89 1.79
s simpanddico Ilc s Egate IT Solutions Pvt Ltd s iTraveller s Redivideos
I I
EN EN ZH
No No
No No
n.a n.a
No No
No No
No No
L.P. L.P.
1.79
s Redivideous
I
DE, ES, FR,ZH, EN
No
No
n.a
Yes
No
No
L.P.
5.49 5.49 5.49 8.99 Free Free
s s s s s s
I I I I I I
EN EN EN EN EN EN
No No No No No No
No No No No No No
n.a n.a n.a n.a n.a n.a
Yes Yes Yes No Yes Yes
No No No No No No
No No No No No No
M.P. M.P. M.P. L.P. M.P. M.P.
0.89 0.89
C
Used formulas
Research Unit Medical Informatics, Johannes Kepler University Linz
British Association of Plastic Reconstructive and Aesthetic Surgeons
Informed Publishing Informed Publishing Informed Publishing Edward Choi Agent S MyALTS American College of Surgeons
B/L: book or literature, C: calculator, G: game, I: information, M.P.: medical professional, L.P.: laypeople.
burns xxx (2015) xxx–xxx
Lund–Browder–Parkland Calculator Light# Rapid Burn Assessor#
Society/company
JBUR-4531; No. of Pages 13
6
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Table 2 (Continued ) Application
JBUR-4531; No. of Pages 13 burns xxx (2015) xxx–xxx
7
Fig. 1 – Flowchart describing the review process in Google Play Store.
3.1.
Results of Google Play Store for Android
From more than 1,000,000 available apps, we identified 30 apps that might be helpful for the treatment of patients with burns (Fig. 1). Of these, 12 were free, 15 were available for 1 and 10 s, and three were available for >10 s. Three were available in German, while 27 were in the English language. Four were designed for users without a medical background. Of 13 calculation apps, eight help the user to estimate the TBSA or BSA. The calculation of the TFR was provided in nine of all calculation apps. All calculation apps were developed for medical professionals only. No calculation app in Google Play Store had an included three-dimensional (3D) patient model. No calculation app allowed an interface with another
electronic device for transferring data/information. The information of four apps showed a connection to a society or company: Journal of Wound Care# (Journal of Woundcare), ABA 2013 Annual Meeting App# (American Burn Association), MyATLS# (American College of Surgeons), and Rapid Burn Assessor# (RISC, Research Unit Medical Informatics, Johannes Kepler University Linz).
3.2.
Results of Apple’s App Store for iOS
To date, >450,000 apps are available in the App Store. We found 39 apps that were related to the treatment of burns (Fig. 2). Of these, 12 were free for download, while 24 were available for 1–10 s, and three for more than 10 s. Three apps
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
JBUR-4531; No. of Pages 13
8
burns xxx (2015) xxx–xxx
Fig. 2 – Flowchart describing the review process in Apple’s App Store.
(LiAo Burns#, LiAo Burns Pro#, Home First Aid (Chinese and English Only)#, and Vollsta¨ndiger Erste-Hilfe-Kurs fu¨r Notfa¨lle zuhause und unterwegs#) are available in languages other than English (Chinese, German, Hispanic, etc.). Only eight apps were designed for users without medical education, whereas the rest were designed for medical professionals. Of 21 calculation apps, 19 allowed the feature of estimating the TBSA or BSA. Eight apps were assigned to a society/company: Tarascon Adult Emergency Pocketbook# (Jones & Barlett Learning), Journal of Wound Care# (Journal of Woundcare), MBC Burn Care# (Euro-Mediterranean Council for Burns and Fire Disasters), BurnCase 3D 2.0# (RISC, Research Unit Medical Informatics, Johannes Kepler University Linz), LiAo Burns# (Third Military Medical University China), MyATLS# (American College of Surgeons), Rapid Burn Assessor# (RISC,
Research Unit Medical Informatics, Johannes Kepler University Linz), and Mersey Burns# (British Association of Plastic Reconstructive and Aesthetic Surgeons). Three calculation apps use a 3D patient model for estimating the TBSA or BSA (BurnMed Pro#, BurnMed Lite#, and BurnCase 3D 2.0#). The TFR could be calculated in 16 out of the 21 calculation apps. A data/information interface with personal computers or clinical staff was provided in three (BurnCase 3D 2.0#, MBC Burn Care#, and uBurn Medic#) of all calculation apps.
3.3.
Comparison of all free calculation apps
Twelve free calculation apps were included in the first step of our study (Table 3). In five apps, an estimation of the TBSA via the Mosteller formula (three), the Du Bois formula (two), or the
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
JBUR-4531; No. of Pages 13 burns xxx (2015) xxx–xxx
Lund and Browder chart (one) was possible. Eight apps provided a calculation of the TFR for the first 24 h, of which six calculated 5400 ml (Parkland formula), one 4025 ml, and one 6000 ml. The calculation of the burned TBSA in square centimeters was possible in two apps. Two provided an Abbreviated Burn Severity Index (ABSI) and one a Baux score. As we performed a closer investigation, we were required to register online with personal data in one (calculate by QxMD#) out of the 12 apps. A transfer of patient specific data was possible in one app (BurnCase 3D 2.0#), wherein the data will be sent via e-mail as a password-controlled ZIP file.
3.4.
Comparison of all paid calculation apps available
Twenty paid calculation apps were included in this step of our study (Table 4). With 14 apps, an estimation of the TBSA via the Mosteller formula (two), the Du Bois formula (two), the Lund and Browder chart (four), or the rule of nines (five) was possible. Four apps included a two-dimensional (2D) model providing a better overview. Eighteen apps offered a calculation of the TFR for the first 24 h (Fig. 3); thereof, 12 calculated 5400 ml, one 5388 ml, and four between 2700 ml and 4025 ml. In one app, the smallest burned TBSA to choose from was 20% and the computed TFR was 62 drops per minute (dpm) with no time limitation. The calculation of the burned TBSA in square centimeters was possible in six apps. The Paramedic Parkland Formula# app provided an ABSI. On closer investigation, the transfer of patient-specific data was possible with one app (Lund–Browder Calculator#), whereby the data were sent via text message. In five apps (SARTech#, Rule Of Nines#, uBurn#, uBurn Medic#, and BurnMed Pro#), a warning flashed during the start of the app with the message that the app is not a registered reliable medical tool.
4.
Discussion
We have supplied within this review an overview of apps for burns. The daily rising demand of medical apps for smartphones has a strong impact on finding the ‘‘right’’ app for orderly medical decisions. Van Velsen et al. [9] mentioned an app overload in the context of health care. In addition, we compared all free available calculation apps with a patient model. This comparison showed that 19 apps provide comparable and reliable results by the TFR calculation (Tables 3 and 4). Furthermore, our results are aimed at supporting medical professionals in identifying the app needed for daily decision making in burn diagnostics and treatment. Mosa et al. [5] demonstrated the existence of different types of medical apps, which we subdivided into four groups as previously mentioned. Most of the games are designed to teach first-aid procedures or obtain more information about burns by playing a quiz. Burn Journey#, an app developed especially for children, helps in understanding the importance of a dressing change in a burn. This app assisted in a playful manner to learn about an important setting in burns. Haze and Lynaugh [10] showed that a smartphone can also be a communication tool between patients and physicians. An interesting fact is
9
that three of these five apps were designed for medical professionals (ABIM Exam Secrets Study Guide#, Prognosis: Emergency Medicine#, and Learning Dermatology Quiz#), containing games dealing with the clinical treatment of patients. In our opinion, Internet search providers are the major competitors to journal and book apps, as they allow for a free and (even) faster access to medical articles for medical professionals and laypeople. As Wang et al. [11] stated, it is possible to gain accurate and useful information for healthand medical-related questions just by browsing the Internet in a systematic manner. Apps that simply provide information on burns are affordable and they provide quick information for wound coverage and first aid (basic life support and advanced trauma life support). First-aid apps are widely used by medical professionals, and not only in the treatment of burns. Lin et al. [12] described the top 10 apps for emergency departments and showed their positive impact on patient care. A rising demand of these apps could be observed and their benefit for educational use was proven by Waldmann and Weckbecker [13]. They described that medical students used their specially developed guideline app during waiting periods to improve their knowledge about the recent guidelines of primary care. Of course, in this special case, the app was developed and proven by the German College of General Practitioners. Further clinical studies including the widely used apps in emergency questions should be performed by, for example, societies to provide recommendations on their usability, data safety, and evidence. Medical calculator apps could provide a faster and safer treatment of patients in daily clinical practice [14–16]. For intensive and emergency physicians, a fast and adequate calculation program for fluid requirement and estimating the burned TBSA or BSA can be a useful companion. The most commonly used formulas for the estimation of burned surface in the apps are the rule of nines, the Lund and Browder chart, TBSA (Boyd, Dubois, Heycock, and Mosteller), and a 2D or 3D patient model. For calculating the TFR, most calculators use the Parkland formula. Only three apps provide the calculation of the ABSI, which has a strong impact for further clinical decisions. It is worth noting that all calculation apps are designed for medical professionals only. Not every app that helps in estimating the burned surface allows a calculation of the TFR; it is not clear why some developers do not support this feature. Our comparison showed a correlation of 19 apps by calculation of the TFR via the Parkland formula compared to our standardized patient (Fig. 3); despite one free app (calculate by QxMD#) using the Parkland formula as well, an overestimation of 600 ml for the first 24 h was the result. Seven apps (BurnQQ2#, EMS Pediatric Guide#, LiAo Burns#, LiAo Burns Pro#, Lund–Browder Calculator#, Med Tools#, and SARTech#) underestimated the TFR between 12 ml and 2700 ml. The great benefit of an app for estimating the burned surface and TFR is the precision and reproducibility. Estimating the total burned surface area in light of the fact that different burning depths, different body proportions, different ages, etc. may occur, it is still a challenge, even for experienced staff [17–24]. The consequence of the wrong estimated burned TBSA is a wrong TFR, with a possible fluid overload. An
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Application
TFR
Used formulas
BurnCare#
Yes
Yes
Calculate by QxMD#
Yes
Yes
Mersey Burns#
Yes
Yes
NurseCalcs Demo#
Yes
No
Parkland Formula#
Yes
Yes
Rapid Burn Assessor#
Yes
No
Burn Calc# BurnCase 3D 2.0#
No Yes
Yes Yes
BurnMed Lite# LiAo Burns#
Yes Yes
No Yes
2D patient model, Evans, Parkland, Carvajal Parkland formula, rule of nines 2D patient model, Lund and Browder chart, Parkland Rule of nines, Du Bois 2D patient model, Parkland Size of mobile phones Parkland formula 3D patient model, ABSI, Parkland 3D patient model 2D patient model, Lund and Browder
Lund–Browder–Parkland Calculator Light# uBurn LITE#
Yes
No
Yes
Yes
2D patient model, Lund and Browder Rule of nines, Parkland
TBSA (cm2)
BMI
Android
19210.00
24.00
Lund and Browder chart
18%
n.a.
5400 ml
Parkland
6 (80–90%)
43
Android
19000.00
24.50
Mosteller; Du Bois
18%
n.a.
6000 ml
Parkland
n.a.
n.a.
Android/iOS
n.a.
n.a.
18%
n.a.
5400 ml
Parkland
n.a.
n.a.
Android
19000.00
24.49
2D patient model, Lund and Browder chart Rule of nines, Du Bois
18%
n.a.
n.a.
n.a.
n.a.
n.a.
Android
n.a.
n.a.
2D patient model
18%
n.a.
5400 ml
Parkland
n.a.
n.a.
Android/iOS
1909.406
n.a.
Mosteller
18%
3446.13
n.a.
n.a.
n.a.
n.a.
iOS iOS
n.a. 19094.07
n.a. 24.49
n.a. Mosteller
18% 18%
n.a. 3437.29
5400 ml 5400 ml
Parkland Parkland
n.a. 5 (98%)
n.a. n.a.
iOS iOS
n.a. n.a.
n.a. n.a.
n.a. Lund and Browder chart
18% 18%
n.a. n.a.
n.a. 4025 ml
n.a. n.a.
n.a. n.a.
iOS
n.a.
n.a.
18%
n.a.
n.a.
n.a.
n.a.
iOS
n.a.
n.a.
Lund and Browder chart Rule of nines
n.a. TMMU Third Military Medical University n.a.
18%
n.a.
5400 ml
Parkland
n.a.
n.a.
Operating system
Formula for TBSA
II–III8 burn
Burned TBSA (cm2)
TFR first 24 h
Formula for TFR
ABSI
Baux
burns xxx (2015) xxx–xxx
TBSA
JBUR-4531; No. of Pages 13
10
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Table 3 – Comparison of the available free calculation apps.
JBUR-4531; No. of Pages 13
TBSA
TFR
Used formulas
Operating system
TBSA (cm2)
BMI
Med Tools# MedCalc 3000 Kidney#
Yes No
Yes Yes
Android Android
19094.07 n.a.
24.5 n.a.
Mosteller n.a.
18% 18%
n.a. n.a.
2700 ml 5400 ml
n.a. Parkland
n.a. n.a.
n.a. n.a.
MedCalc 3000# Medfixation Medical Calculator#
No Yes
Yes Yes
Mosteller Brooke, Semling, Evans, Modified Brooke, Slater, Parkland Parkland formula BSA (Boyd, Dubois, Heycock, Mosteller)
Android Android
19094.07 19200.00
24.49 24.5
18% 18%
n.a. n.a.
5400 ml 5400 ml
Parkland Parkland
n.a. n.a.
n.a. n.a.
MediCalc Medical Calculator# MediForm medizinischer Rechner# Mediquation Medical Calculator# Burn & Parkland Calculator# BurnMed Pro#
No
Yes
Parkland formula
Android
19100.00
24.5
n.a. Boyd, Dubois, Heycock, Mosteller n.a.
18%
n.a.
5400 ml
Parkland
n.a.
n.a.
No
Yes
n.a.
Android
19090.00
24.49
n.a.
18%
n.a.
5400 ml
n.a.
n.a.
n.a.
Yes
Yes
Android
19100.00
24.5
Dubois
18%
n.a.
5400 ml
Parkland
n.a.
n.a.
Yes
Yes
BSA (Dubois, Mosteller) 2D patient model
iOS
n.a.
n.a.
18%
n.a.
5400 ml
Parkland
n.a.
n.a.
Yes
No
3D patient model
iOS
n.a.
n.a.
18%
n.a.
n.a.
n.a.
n.a.
n.a.
BurnQQ2#
Yes
Yes
Lund and Browder
iOS
n.a.
n.a.
18%
n.a.
5388 ml
n.a.
n.a.
n.a.
EMS Pediatric Guide# LiAo Burns Pro#
No Yes
Yes Yes
Parkland formula 2D patient model, Lund and Browder
iOS iOS
n.a. n.a.
n.a. n.a.
2D patient model 3D patient model Lund and Browder Rule of nines 2D patient model, Lund and Browder
18% 18%
n.a. n.a.
3025 ml 4025 ml
n.a. n.a.
n.a. n.a.
Lund–Browder Calculator#
Yes
Yes
2D patient model, Lund and Browder, Parkland
iOS
n.a.
n.a.
18%
n.a.
2952 ml
n.a.
n.a.
MBC Burn Care#
No
Yes
iOS
n.a.
24.49
18%
3437.29
5400 ml
Parkland
6 (80–90%)
n.a.
Paramedic Parkland Formula# Rule Of Nines#
Yes
Yes
iOS
n.a.
n.a.
n.a.
20%
n.a.
62 dpm
Parkland
n.a.
n.a.
Yes
Yes
iOS
n.a.
n.a.
Rule of nines
18%
n.a.
5400 ml
Parkland
n.a.
n.a.
SARTech# TBSA of Burn Patients N3# uBurn Medic# uBurn#
Yes Yes
Yes Yes
Parkland and Palermo formula Rule of nines, Parkland Rule of nines Parkland formula 2D patient model Rule of nines
2D patient model, Lund and Browder chart n.a.
Parkland TMMU Third Military Medical University Parkland
iOS iOS
n.a. n.a.
n.a. n.a.
Rule of nines Rule of nines
18% 18%
n.a. n.a.
2880 ml 5400 ml
n.a. n.a.
n.a. n.a.
n.a. n.a.
Yes Yes
Yes Yes
Lund and Browder Rule of nines, Parkland
iOS iOS
n.a. n.a.
n.a. n.a.
Lund and Browder Rule of nines
18% 18%
n.a. n.a.
5400 ml 5400 ml
Parkland Parkland
n.a. n.a.
n.a. n.a.
Application
Formula for TBSA
II–III8 burn
Burned TBSA (cm2)
TFR first 24 h
Formula for TFR
ABSI
Baux
burns xxx (2015) xxx–xxx
11
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Table 4 – Comparison of the available paid calculation apps.
JBUR-4531; No. of Pages 13
12
burns xxx (2015) xxx–xxx
Fig. 3 – Overview of calculated TFR in milliliters compared to the standardized patient (dashed line).
individual an optimal fluid resuscitation in burned patients has strong impact at the outcome [25,26]. In smaller burns, a transfer to a burn unit is not always necessary and therefore an objective and accurate estimation of the burned TBSA is essential. The key to success is avoiding the subjective view at the burned TBSA and introducing a standardized objective procedure. We specially focused our evaluation on all free available calculation apps. The main reason why we validated the free apps was that we believe they are downloaded more often than those with a fee. Furthermore, to provide a validation of all calculation apps, we included the paid apps in our study. Up to now, only two calculating smartphone apps for burns underwent a clinical evaluation. This evaluation was performed by Morris et al. [15]; they compared uBurn# and MerseyBurns#. In addition, a digital interface between smartphone apps and the HIS would be very helpful in providing a transfer of patient’s specific data. Three apps of both stores provided this feature. The use of 3D programs for TBSA estimation in clinical practice could provide a fast and for the outcome essential tool [27–29]; therefore, an interface between apps and these tools has to be designed and optimized. When discussing interfaces for immediate transfer of patient-level data, we always have to comply with patient data protection laws. Certainly, the first level of a safe data collection is the device itself. Therefore, smartphone producers provide a safe access by key-locking
the devices through signs or simply fingerprints. Naturally, every smartphone user himself has to be responsible for the safety of locally stored data on his/her device. It is worth nothing that none of the apps that provided an estimation or calculation with personal data ensured a password-controlled access and further an encrypted data transfer. The key might be a password-controlled online database for these apps; this ought to enable an on-time data transfer between mobile devices and personal computers. Besides Apple and Android, the smartphone producer Blackberry, which supplies the United States Department of Defense with mobile devices, aims to provide such solutions [30]. A summary of an evaluation through the US Food and Drug Administration (FDA) is possible for every app with health contexts, and this could be performed by using a provided guidance called ‘‘Mobile Medical Applications – Guidance for Industry and Food and Drug Administration Staff’’ [31]. Further investigations for both smartphone producers and app designers are necessary to offer a balance between usability and security.
5.
Conclusion
Overall, there are some helpful apps available for burns in both app stores, although there is still a lack of data security especially for calculation apps. Many of them may provide
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
JBUR-4531; No. of Pages 13 burns xxx (2015) xxx–xxx
support in daily medical decisions and, of course, allow a continuous collection of data. Our study of free calculation apps showed that most of the calculated TFRs correlate. The benefit of an accurate and objective estimation of the burned TBSA and, furthermore, an optimized fluid resuscitation is uncontroversial. Further clinical studies including smartphone apps for burns will be necessary.
Conflict of interest statement N/A.
Funding We want to thank the Austrian Burn Treatment, Research and Prevention Study Group (ABUSG) for the funding of the paid calculation apps www.abusg.com.
references
[1] History Stockholm smartphone n.d. http://www. stockholmsmartphone.org/history/; 2010 [accessed 28.02.14]. [2] There will soon be one smartphone for every five people in the world. Bus Insid n.d. http://www.businessinsider.com/ 15-billion-smartphones-in-the-world-22013-2; 2013 [accessed 28.02.14]. [3] Pope S, Muller T. Apple’s app store downloads top 15 billion 2011; 2011, http://www.apple.com/pr/library/2011/07/ 07Apples-App-Store-Downloads-Top-15-Billion.html [accessed 28.02.14]. [4] Number of available Android applications – AppBrain n.d. http://www.appbrain.com/stats/number-of-android-apps; 2014 [accessed 28.02.14]. [5] Mosa ASM, Yoo I, Sheets L. A systematic review of healthcare applications for smartphones. BMC Med Inform Decis Mak 2012;12:67. [6] Popat R, Mohan AT, Branford OA. Current uses of smartphones and apps in orthopaedic surgery. Br J Hosp Med Lond Engl 2013;74:672–6. [7] Boulos MNK, Wheeler S, Tavares C, Jones R. How smartphones are changing the face of mobile and participatory healthcare: an overview, with example from eCAALYX. Biomed Eng Online 2011;10:24. [8] Donker T, Petrie K, Proudfoot J, Clarke J, Birch M-R, Christensen H. Smartphones for smarter delivery of mental health programs: a systematic review. J Med Internet Res 2013;15:e247. [9] Van Velsen L, Beaujean DJMA, van Gemert-Pijnen JEWC. Why mobile health app overload drives us crazy, and how to restore the sanity. BMC Med Inform Decis Mak 2013;13:23. [10] Haze KA, Lynaugh J. Building patient relationships: a smartphone application supporting communication between teenagers with asthma and the RN care coordinator. Comput Inform Nurs: CIN 2013;31:266–71. quiz 272–73. [11] Wang L, Wang J, Wang M, Li Y, Liang Y, Xu D. Using Internet search engines to obtain medical information: a comparative study. J Med Internet Res 2012;14:e74. [12] Lin M, Rezaie S, Husain I. Top 10 mobile apps in emergency medicine. Emerg Med J: EMJ 2014.
13
[13] Waldmann U-M, Weckbecker K. Smartphone application of primary care guidelines used in education of medical students. GMS Z Med Ausbild 2013;30. Doc6. [14] Flannigan C, McAloon J. Students prescribing emergency drug infusions utilising smartphones outperform consultants using BNFCs. Resuscitation 2011;82:1424–7. [15] Morris R, Javed M, Bodger O, Gorse SH, Williams D. A comparison of two smartphone applications and the validation of smartphone applications as tools for fluid calculation for burns resuscitation. Burns J Int Soc Burn Inj 2014;40(5):826–34. [16] Bierbrier R, Lo V, Wu RC. Evaluation of the accuracy of smartphone medical calculation apps. J Med Internet Res 2014;16:e32. [17] Livingston EH, Lee S. Percentage of burned body surface area determination in obese and nonobese patients. J Surg Res 2000;91:106–10. [18] Livingston EH, Lee S. Body surface area prediction in normal-weight and obese patients. Am J Physiol Endocrinol Metab 2001;281:E586–91. [19] Giretzlehner M, Dirnberger J, Owen R, Haller HL, Lumenta DB, Kamolz L-P. The determination of total burn surface area: how much difference? Burns J Int Soc Burn Inj 2013;39:1107–13. [20] Martin NAJ, Lundy JB, Rickard RF. Lack of precision of burn surface area calculation by UK Armed Forces medical personnel. Burns J Int Soc Burn Inj 2014;40:246–50. [21] Parvizi D, Kamolz L-P, Giretzlehner M, Haller HL, Trop M, Selig H, et al. The potential impact of wrong TBSA estimations on fluid resuscitation in patients suffering from burns: things to keep in mind. Burns J Int Soc Burn Inj 2014;40:241–5. [22] Giretzlehner M, Dirnberger J, Owen R, Haller HL, Lumenta DB, Kamolz L-P. The determination of total burn surface area: how big is the difference? Burns J Int Soc Burn Inj 2014;40:170–1. [23] Kamolz L-P, Parvizi D, Giretzlehner M, Lumenta DB. Burn surface area calculation: what do we need in future. Burns J Int Soc Burn Inj 2014;40:171–2. [24] Rickard RF, Martin NAJ, Lundy JB. Imprecision in TBSA calculation. Burns J Int Soc Burn Inj 2014;40:172–3. [25] Klein MB, Hayden D, Elson C, Nathens AB, Gamelli RL, Gibran NS, et al. The association between fluid administration and outcome following major burn: a multicenter study. Ann Surg 2007;245:622–8. [26] Kraft R, Herndon DN, Branski LK, Finnerty CC, Leonard KR, Jeschke MG. Optimized fluid management improves outcomes of pediatric burn patients. J Surg Res 2013;181:121–8. [27] Nichter LS, Bryant CA, Edlich RF. Efficacy of burned surface area estimates calculated from charts – the need for a computer-based model. J Trauma 1985;25:477–81. [28] Neuwalder JM, Sampson C, Breuing KH, Orgill DP. A review of computer-aided body surface area determination: SAGE II and EPRI’s 3D burn vision. J Burn Care Rehabil 2002;23:55– 9. discussion 54. [29] Haller HL, Dirnberger J, Giretzlehner M, Rodemund C, Kamolz L. Understanding burns: research project BurnCase 3D – overcome the limits of existing methods in burns documentation. Burns J Int Soc Burn Inj 2009;35:311–7. [30] BlackBerry’s next move may be a phone that keeps you healthy. Huffington Post 2014. http://www.huffingtonpost. com/2014/04/15/blackberry-collaborating-nanthealthsmartphone_n_5154514.html; 2014 [accessed 20.04.14]. [31] Bakul P. Mobile medical applications – guidance for Industry and Food and Drug Administration Staff 2013; 2013, http://www.fda.gov/downloads/MedicalDevices/./ UCM263366.pdf [accessed 20.04.14].
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Smartphone applications in burns Paul Wurzer a,b,1,*, Daryousch Parvizi a,1, David B. Lumenta a, Michael Giretzlehner c, Ludwik K. Branski a,b, Celeste C. Finnerty b, David N. Herndon b, Alexandru Tuca a, Thomas Rappl a, Christian Smolle a, Lars P. Kamolz a a
Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria b Burns and Trauma Research, Acute Burn Surgery, and Reconstructive Burn Surgery, Shriners Hospitals for Children and The University of Texas Medical Branch, Galveston, TX, USA c Research Unit Medical-Informatics, RISC Software GmbH, Johannes Kepler University Linz, Hagenberg, Austria
article info
abstract
Article history:
Objective: Since the introduction of applications (apps) for smartphones, the popularity of
Accepted 12 November 2014
medical apps has been rising. The aim of this review was to demonstrate the current availability of apps related to burns on Google’s Android and Apple’s iOS store as well as to
Keywords:
include a review of their developers, features, and costs.
Total body surface area
Methods: A systematic online review of Google Play Store and Apple’s App Store was
Total fluid requirement
performed by using the following search terms: ‘‘burn,’’ ‘‘burns,’’ ‘‘thermal,’’ and the
Application
German word ‘‘Verbrennung.’’ All apps that were programmed for use as medical apps
Burns
for burns were included. The review was performed from 25 February until 1 March 2014. A
Apple
closer look at the free and paid calculation apps including a standardized patient was
Android
performed. Results: Four types of apps were identified: calculators, information apps, book/journal apps, and games. In Google Play Store, 31 apps were related to burns, of which 20 were calculation apps (eight for estimating the total body surface area (TBSA) and nine for total fluid requirement (TFR)). In Apple’s App Store, under the category of medicine, 39 apps were related to burns, of which 21 were calculation apps (19 for estimating the TBSA and 17 for calculating the TFR). In 19 out of 32 available calculation apps, our study showed a correlation of the calculated TFR compared to our standardized patient. Conclusion: The review demonstrated that many apps for medical burns are available in both common app stores. Even free available calculation apps may provide a more objective and reproducible procedure compared to manual/subjective estimations, although there is still a lack of data security especially in personal data entered in calculation apps. Further clinical studies including smartphone apps for burns should be performed. # 2014 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author at: Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, Graz 8036, Austria. Tel.: +43 6765448224. E-mail address: [email protected] (P. Wurzer). 1
These authors contributed equally to this work. http://dx.doi.org/10.1016/j.burns.2014.11.010 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
JBUR-4531; No. of Pages 13
2
burns xxx (2015) xxx–xxx
1.
Introduction
Since the introduction of smartphones by the ‘‘Stockholm Smartphone Team’’ [1] in 1997, the term smartphone has become common in our daily lives. Nowadays, a smartphone is synonymous with a device, which associates the properties of a mobile phone with the possibilities of a personal computer. Another historic milestone of the smartphone was the introduction of the first touch screen [1] on mobile devices in 2000. Heather Leonhard of the ‘‘Business Insider’’ expects that there will be 1.4 billion smartphone users worldwide at the end of 2014, indicating that nearly every fifth human being on the planet will possibly own one [2]. Most smartphones run on Google’s operating system Android (60%) followed by Apple’s iOS (40%) [2]. In 2008, both Apple and Google introduced their application (app) stores, which have made it easy for users to individualize their mobile devices. From 2008 until July 2011, 15 billion apps were downloaded from the Apple’s App Store [3]. Google Play Store, formerly Android Market from Google, hosts more than one million apps to date [4]. About half of these apps have become available in Apple’s App Store [3]. The widespread penetration of smartphones in the population has, of course, had an effect on the way in which we interact in our professional and private daily lives: smartphones are supposed to be used more often than personal computers, laptops, or even pen and paper. Even in daily clinical practice, electronic devices form an integral part of modern medicine. These devices may help guide patient care in hospitals, they may help find the right diagnosis, and they are sometimes helpful in therapeutic decision making. All these properties can be provided by different devices or they can be included in one system. Nowadays, custom-made apps for smartphones and their users are able to assume a majority, if not all, of these tasks. Therefore, modern app stores have special categories for medical/health-care apps. In the medical literature, a growing number of authors described the continuous rise in the popularity of smartphone apps [5–8]. Mosa et al. [5] described that most apps in medicine are used for disease diagnosis, medical calculations, or drug references. To enable special apps for every field of medicine, numerous different apps for almost every medical specialty have been made available. Most are free for download and some are to be purchased. In the treatment of burns, many different apps have been on offer ranging from first-aid leaflets, literature and papers, or games to calculation apps. The aim of this study was to review the offered apps applicable in the treatment of burns on Google’s Android and Apple’s iOS smartphones and to focus on the following parameters: costs (free/paid), developers, content, target groups (medical professionals/laypersons), and available interfaces (e.g., hospital information system/HIS). Furthermore, we compared all available calculation apps in a study based on a standardized patient model.
2.
Methods
2.1.
Ethics
A formal ethical review board approval was not required, because we did not use any personal or patient data.
2.2.
Design
A systematic review of the two provided app stores was performed from 25 February until 1 March 2014. The terms for research were defined: ‘‘burn,’’ ‘‘burns,’’ ‘‘thermal,’’ and the German word ‘‘Verbrennung.’’ At first, the terms were searched in Google Play Store (formerly Android Market) by using the following link: https://play.google.com/store/apps. As a second step, Apple’s App Store was browsed by using the following link: https://itunes.apple.com/en/genre/ios/ id36?mt=8. Using these home pages, we could easily access both stores. The information of all the listed apps was analyzed and individually graded based on their applicability in the treatment of burns. Apps concerning the treatment of other medical diseases containing such terms (e.g., burnout, etc.) were excluded. The following information was collected: medical link of the developer, available languages, type of app (information, calculator, etc.), and available interfaces between other devices. All available free and paid calculation apps underwent a trial by using a standardized patient: male, 25 years of age, with a height and weight of 175 cm and 75 kg, respectively, and 18% burned total body surface area (TBSA) (II–III8). The total fluid requirement (TFR) within the first 24 h for this standardized patient is 5400 ml, calculated with the Parkland formula (4 patient’s weight percentage burned TBSA (II–III8).
2.3.
Analysis and illustrations
For a descriptive analysis, we created spreadsheets using Excel 2008 (Microsoft, Richmond, VA, USA) and flowcharts using PowerPoint 2008 (Microsoft, Richmond, VA, USA) to illustrate the research process.
3.
Results
Detailed results of the available apps are described in Table 1 (for Google’s Android) and Table 2 (for Apple’s iOS). The research process is illustrated in two flowcharts (Figs. 1 and 2). In every store, we could identify four types of apps: calculators, information, books/journals, and games. Thirty-two calculator apps (13 for Android, 21 for iOS, and two of the same name in both stores) usually provide functionality both for estimating the TBSA and for calculating the TFR, whereas some apps only provide one of these features. Twenty-six information apps (15 for Android, 12 for iOS, and one of the same name in both stores) provide quick and easy-to-use first-aid guidelines and guidelines for treatment of burns. Three book and journal apps (one for Android, three for iOS, and one of the same name in both stores) are designed to provide more detailed information for the treatment of burns, usually developed for medical professionals. Most games (five; two for Android, and three for iOS) are quizzes, which provide an amusing way of obtaining more information about burns and learning firstaid procedures.
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
JBUR-4531; No. of Pages 13
Application
Price
Author
Journal of Wound Care#
Free
s
Med Tools# MedCalc 3000 Kidney#
0.74 3.73
s s
MedCalc 3000#
7.46
s
MediCalc Medical Calculator# MediForm medizinischer Rechner# BurnCare#
2.33
Society/ company
Type
Language
TBSA
TFR
B/L
EN
No
No
n.a.
Yes
No
No
M.P.
Yes Brooke, Semling, Evans, Modified Brooke, Slater, Parkland Parkland formula
Mosteller No
No No
No No
No M.P.
M.P.
No
No
No
M.P.
Parkland formula n.a.
No
No
No
M.P.
No
No
No
M.P.
2D patient model, Evans, Parkland, Carvajal No
No
No
No
M.P.
No
No
M.P.
BSA (Boyd, Dubois, Heycock, Mosteller) BSA (Dubois, Mosteller) 2D patient model, Lund and Browder chart, Parkland
No
No
No
M.P.
No
No
No
M.P.
No
No
No
M.P.
Rule of nines, Du Bois
No
No
No
M.P.
C
C EN
EN No
Yes Yes
C
EN
No
Yes
s
Foundation Internet Services CityJams
C
EN
No
Yes
1.99
s
Emorej
C
DE
No
Yes
Free
s
Pierre-Antoine Meley
C
EN
Yes
Yes
Calculate by QxMD#
Free
s
QxMD Medical Software Inc.
EN
Yes
Yes
Medfixation Medical Calculator#
2.01
s
Ryan Goodman
C
EN
Yes
Parkland formula, rule of nines Yes
Mediquation Medical Calculator#
3.73
s
Mediquations Inc
C
EN
Yes
Yes
Mersey Burns#
Free
s
Chris Seaton
C
EN
Yes
Yes
NurseCalcs Demo#
Free
s
Jonsap
C
EN
Yes
No
British Association of Plastic Reconstructive and Aesthetic Surgeons
Desinged for
Show closest burn center
Journal of Woundcare
C
Data interface
Guidelines described
MA Business & Leisure Darren Gates Foundation Internet Services
Used formulas
burns xxx (2015) xxx–xxx
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Table 1 – Details of all available burn apps in Google Play Store.
3
Price
Author
Society/ company
Type
TBSA
TFR
C
EN
Yes
Yes
C
EN
Yes
No
G
EN
No
G
EN
I
Used formulas
Data interface
Desinged for
Guidelines described
Show closest burn center
2D patient model, Parkland Size of mobile phones
No
No
No
M.P.
No
No
No
M.P.
No
n.a.
No
No
No
M.P.
No
No
n.a.
No
No
No
M.P.
EN
No
No
Yes
No
No
M.P.
I
EN
No
No
Parkland formula n.a.
No
No
No
L.P.
Parkland Formula#
Free
s
DTsEMT
Rapid Burn Assessor#
Free
s
RISC Software GmbH, Research Unit Medical Informatics
ABIM Exam Secrets Study Guide# Prognosis: Emergency Medicine# 10 Second EM#
37.34
s
Free
s
2.33
s
Mometrix Media LLC Medical Joyworks EM Gladiators
ABA 2013 Annual Meeting App#
Free
s
CrowdCompass Inc
AneIV - Anesthesia Aid# Atlanta Medical Center# Critical Care Paramedic (CCP)# Doctors Medical Center# ERres- Emergency Medicine# Frye Regional Medical Center# MEDGuide Emergency# MyATLS#
1.85 Free 2.16
s s s
I I I
EN EN EN
No No No
No No No
n.a. n.a. n.a.
Yes No No
No No No
No No No
M.P. L.P. M.P.
Free 2.23
s s
TomyLabs Tenet HelathCare ALFAJIRI MOBILE SOLUTIONS Tenet HelathCare Denali Apps, LLC
I I
EN EN
No No
No No
No Yes
No No
No No
L.P. M.P.
Free
s
Tenet HelathCare
I
EN
No
No
n.a. Rule of nines n.a.
No
No
No
L.P.
4.78 Free
s s
HUAN C.L.C American College of Surgeons
I I
EN EN
No No
No No
n.a. n.a.
Yes No
No No
No No
M.P. M.P.
Notfallmedizin pocket#
10.99
s
DE
No
No
n.a.
No
No
No
M.P.
Nursing Essentials# Pediatric EMS# PHTLS Pocket Companion# SMEDRIX 2.5#
5.97 3.73 1.49
s s s
Bo¨rm Bruckmeier Verlag GmbH Informed Publishing Informed Publishing Paul David Thomas
I I I
EN EN EN
No No No
No No No
n.a. n.a. n.a.
Yes No Yes
No No No
No No No
M.P. M.P. M.P.
10.06
s
Nougat
I
DE
No
Yes
n.a.
Yes
No
No
M.P.
Research Unit Medical Informatics, Johannes Kepler University Linz
American Burn Association
American College of Surgeons I
B/L: book or literature, C: calculator, G: game, I: information, M.P.: medical professional, L.P.: laypeople.
burns xxx (2015) xxx–xxx
Language
JBUR-4531; No. of Pages 13
4
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Table 1 (Continued ) Application
JBUR-4531; No. of Pages 13
Application
Price
Author
Language
TBSA
TFR
Used formulas
Data Desinged Guidelines Show for described closest interface burn center
Society/company
Type
Jones & Barlett Learning
B/L
EN
No
No
n.a
Yes
No
No
M.P.
B/L
EN
No
No
n.a
Yes
No
No
M.P.
B/L
EN
No
No
n.a
Yes
No
No
M.P.
C
EN
No
Yes
Parkland formula
Yes
No
No
M.P.
C C
EN EN
No Yes
Yes Yes
Parkland formula 2D patient model
No No
No No
No No
M.P. M.P.
No
No
No
M.P.
No No
No No
No No
M.P. M.P.
Tarascon Adult Emergency Pocketbook# Schwartz’s Manual of Surgery# Journal of Wound Care#
17.99 s USBMIS, Inc
EMS Pediatric Guide#
3.59
Burn Calc# Burn & Parkland Calculator# Lund–Browder Calculator#
Free 0.89
s MA Business & Leisure s Informed Publishing s D. Sparks s Patrick Campbell
0.89
s Shlose
C
EN
Yes
Yes
Rule Of Nines# TBSA of Burn Patients N3# BurnQQ2# Paramedic Parkland Formula# uBurn Medic#
0.89 0.89
s Rod Edwardson s Brian Donahower
C C
EN EN
Yes Yes
Yes Yes
2D patient model, Lund and Browder, Parkland Rule of nines Rule of nines
1.79 1.79
s Aoi Ogihara s Draken Design
C C
EN EN
Yes Yes
Yes Yes
Lund and Browder Rule of nines, Parkland
No No
No No
No No
M.P. M.P.
1.79
C
EN
Yes
Yes
Lund and Browder
Yes
Yes
Yes
M.P.
uBurn#
1.79
C
EN
Yes
Yes
Rule of nines, Parkland
Yes
No
No
M.P.
SARTech# BurnMed Pro#
2.69 4.49
s JAMB Innovations, LLC s JAMB Innovations, LLC s Adam Kusch s Johns Hopkins Mobile medicine
C EN
EN Yes
Yes No
No No
No No
No M.P.
M.P.
MBC Burn Care#
4.49
C
EN
No
Yes
Yes
Yes
M.P.
LiAo Burns Pro#
18.99 s Omesoft
C
ZH EN
Yes
No
No
No
M.P.
BurnCase 3D 2.0#
Free
Yes 2D patient model 3D Yes patient model Yes 2D patient model, Lund and Browder, Parkland Yes 2D patient model, Lund and Browder Yes 3D patient model, ABSI, Parkland
No
No
Yes
M.P.
BurnMed Lite#
Free
No
No
M.P.
LiAo Burns#
Free
No
No
No
59.99 s USBMIS, Inc Free
s Informed Italia s.r.l.
Journal of Woundcare
C
Euro-Mediterranean Council for Burns and Fire Disasters
s RISC Software GmbH, Research Unit Medical Informatics s Johns Hopkins Mobile medicine
Research Unit Medical Informatics, Johannes Kepler University Linz
C
EN
Yes
C
EN
Yes
No
s Omesoft
Third Military Medical University China
C
ZH EN
Yes
3D No patient model Yes 2D patient model, Lund and Browder
burns xxx (2015) xxx–xxx
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Table 2 – Details of all available burn apps in Apple’s App Store.
M.P.
5
Price
Author
Free
s Shlose
Free
uBurn LITE#
Free
Mersey Burns#
Free
s RISC Software GmbH, Research Unit Medical Informatics s JAMB Innovations, LLC s Chris Seaton
First Aid Information# Learning Dermatology Quiz# Burn Journey#
1.79 1.79 Free
Advanced Wound Treatment# ER-ICU Calc# First Aid & Care#
0.89
First Aid Tips!# Home First Aid (Chinese and English Only)# Vollsta¨ndiger Erste-Hilfe-Kurs fu¨r Notfa¨lle zuhause und unterwegs# Critical Care ACLS Guide# EMS ALS Guide# EMS BLS Guide# Health Bible A-Z# Choose a Dressing# MyALTS#
Type
Language
TBSA
TFR
EN
Yes
No
C
EN
Yes
C
EN
C
s motterSoft s Sylvester Renner
Guidelines Show Data Desinged described closest interface for burn center No
No
No
M.P.
No
2D patient model, Lund and Browder Size of mobile phones
No
No
No
M.P.
Yes
Yes
Rule of nines, Parkland
No
No
No
M.P.
EN
Yes
Yes
No
No
No
M.P.
G G
EN EN
No No
No No
2D patient model, Lund and Browder chart, Parkland n.a n.a
Yes No
No No
Yes No
L.P. M.P.
s Inidana University Health s USBMIS, Inc
G
EN
No
No
n.a
No
No
No
L.P.
I
EN
No
No
n.a
Yes
No
No
L.P.
I I
EN EN
No No
No No
Parkland formula n.a
Yes Yes
No No
No No
M.P. L.P.
0.89 1.79
s simpanddico Ilc s Egate IT Solutions Pvt Ltd s iTraveller s Redivideos
I I
EN EN ZH
No No
No No
n.a n.a
No No
No No
No No
L.P. L.P.
1.79
s Redivideous
I
DE, ES, FR,ZH, EN
No
No
n.a
Yes
No
No
L.P.
5.49 5.49 5.49 8.99 Free Free
s s s s s s
I I I I I I
EN EN EN EN EN EN
No No No No No No
No No No No No No
n.a n.a n.a n.a n.a n.a
Yes Yes Yes No Yes Yes
No No No No No No
No No No No No No
M.P. M.P. M.P. L.P. M.P. M.P.
0.89 0.89
C
Used formulas
Research Unit Medical Informatics, Johannes Kepler University Linz
British Association of Plastic Reconstructive and Aesthetic Surgeons
Informed Publishing Informed Publishing Informed Publishing Edward Choi Agent S MyALTS American College of Surgeons
B/L: book or literature, C: calculator, G: game, I: information, M.P.: medical professional, L.P.: laypeople.
burns xxx (2015) xxx–xxx
Lund–Browder–Parkland Calculator Light# Rapid Burn Assessor#
Society/company
JBUR-4531; No. of Pages 13
6
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Table 2 (Continued ) Application
JBUR-4531; No. of Pages 13 burns xxx (2015) xxx–xxx
7
Fig. 1 – Flowchart describing the review process in Google Play Store.
3.1.
Results of Google Play Store for Android
From more than 1,000,000 available apps, we identified 30 apps that might be helpful for the treatment of patients with burns (Fig. 1). Of these, 12 were free, 15 were available for 1 and 10 s, and three were available for >10 s. Three were available in German, while 27 were in the English language. Four were designed for users without a medical background. Of 13 calculation apps, eight help the user to estimate the TBSA or BSA. The calculation of the TFR was provided in nine of all calculation apps. All calculation apps were developed for medical professionals only. No calculation app in Google Play Store had an included three-dimensional (3D) patient model. No calculation app allowed an interface with another
electronic device for transferring data/information. The information of four apps showed a connection to a society or company: Journal of Wound Care# (Journal of Woundcare), ABA 2013 Annual Meeting App# (American Burn Association), MyATLS# (American College of Surgeons), and Rapid Burn Assessor# (RISC, Research Unit Medical Informatics, Johannes Kepler University Linz).
3.2.
Results of Apple’s App Store for iOS
To date, >450,000 apps are available in the App Store. We found 39 apps that were related to the treatment of burns (Fig. 2). Of these, 12 were free for download, while 24 were available for 1–10 s, and three for more than 10 s. Three apps
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
JBUR-4531; No. of Pages 13
8
burns xxx (2015) xxx–xxx
Fig. 2 – Flowchart describing the review process in Apple’s App Store.
(LiAo Burns#, LiAo Burns Pro#, Home First Aid (Chinese and English Only)#, and Vollsta¨ndiger Erste-Hilfe-Kurs fu¨r Notfa¨lle zuhause und unterwegs#) are available in languages other than English (Chinese, German, Hispanic, etc.). Only eight apps were designed for users without medical education, whereas the rest were designed for medical professionals. Of 21 calculation apps, 19 allowed the feature of estimating the TBSA or BSA. Eight apps were assigned to a society/company: Tarascon Adult Emergency Pocketbook# (Jones & Barlett Learning), Journal of Wound Care# (Journal of Woundcare), MBC Burn Care# (Euro-Mediterranean Council for Burns and Fire Disasters), BurnCase 3D 2.0# (RISC, Research Unit Medical Informatics, Johannes Kepler University Linz), LiAo Burns# (Third Military Medical University China), MyATLS# (American College of Surgeons), Rapid Burn Assessor# (RISC,
Research Unit Medical Informatics, Johannes Kepler University Linz), and Mersey Burns# (British Association of Plastic Reconstructive and Aesthetic Surgeons). Three calculation apps use a 3D patient model for estimating the TBSA or BSA (BurnMed Pro#, BurnMed Lite#, and BurnCase 3D 2.0#). The TFR could be calculated in 16 out of the 21 calculation apps. A data/information interface with personal computers or clinical staff was provided in three (BurnCase 3D 2.0#, MBC Burn Care#, and uBurn Medic#) of all calculation apps.
3.3.
Comparison of all free calculation apps
Twelve free calculation apps were included in the first step of our study (Table 3). In five apps, an estimation of the TBSA via the Mosteller formula (three), the Du Bois formula (two), or the
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
JBUR-4531; No. of Pages 13 burns xxx (2015) xxx–xxx
Lund and Browder chart (one) was possible. Eight apps provided a calculation of the TFR for the first 24 h, of which six calculated 5400 ml (Parkland formula), one 4025 ml, and one 6000 ml. The calculation of the burned TBSA in square centimeters was possible in two apps. Two provided an Abbreviated Burn Severity Index (ABSI) and one a Baux score. As we performed a closer investigation, we were required to register online with personal data in one (calculate by QxMD#) out of the 12 apps. A transfer of patient specific data was possible in one app (BurnCase 3D 2.0#), wherein the data will be sent via e-mail as a password-controlled ZIP file.
3.4.
Comparison of all paid calculation apps available
Twenty paid calculation apps were included in this step of our study (Table 4). With 14 apps, an estimation of the TBSA via the Mosteller formula (two), the Du Bois formula (two), the Lund and Browder chart (four), or the rule of nines (five) was possible. Four apps included a two-dimensional (2D) model providing a better overview. Eighteen apps offered a calculation of the TFR for the first 24 h (Fig. 3); thereof, 12 calculated 5400 ml, one 5388 ml, and four between 2700 ml and 4025 ml. In one app, the smallest burned TBSA to choose from was 20% and the computed TFR was 62 drops per minute (dpm) with no time limitation. The calculation of the burned TBSA in square centimeters was possible in six apps. The Paramedic Parkland Formula# app provided an ABSI. On closer investigation, the transfer of patient-specific data was possible with one app (Lund–Browder Calculator#), whereby the data were sent via text message. In five apps (SARTech#, Rule Of Nines#, uBurn#, uBurn Medic#, and BurnMed Pro#), a warning flashed during the start of the app with the message that the app is not a registered reliable medical tool.
4.
Discussion
We have supplied within this review an overview of apps for burns. The daily rising demand of medical apps for smartphones has a strong impact on finding the ‘‘right’’ app for orderly medical decisions. Van Velsen et al. [9] mentioned an app overload in the context of health care. In addition, we compared all free available calculation apps with a patient model. This comparison showed that 19 apps provide comparable and reliable results by the TFR calculation (Tables 3 and 4). Furthermore, our results are aimed at supporting medical professionals in identifying the app needed for daily decision making in burn diagnostics and treatment. Mosa et al. [5] demonstrated the existence of different types of medical apps, which we subdivided into four groups as previously mentioned. Most of the games are designed to teach first-aid procedures or obtain more information about burns by playing a quiz. Burn Journey#, an app developed especially for children, helps in understanding the importance of a dressing change in a burn. This app assisted in a playful manner to learn about an important setting in burns. Haze and Lynaugh [10] showed that a smartphone can also be a communication tool between patients and physicians. An interesting fact is
9
that three of these five apps were designed for medical professionals (ABIM Exam Secrets Study Guide#, Prognosis: Emergency Medicine#, and Learning Dermatology Quiz#), containing games dealing with the clinical treatment of patients. In our opinion, Internet search providers are the major competitors to journal and book apps, as they allow for a free and (even) faster access to medical articles for medical professionals and laypeople. As Wang et al. [11] stated, it is possible to gain accurate and useful information for healthand medical-related questions just by browsing the Internet in a systematic manner. Apps that simply provide information on burns are affordable and they provide quick information for wound coverage and first aid (basic life support and advanced trauma life support). First-aid apps are widely used by medical professionals, and not only in the treatment of burns. Lin et al. [12] described the top 10 apps for emergency departments and showed their positive impact on patient care. A rising demand of these apps could be observed and their benefit for educational use was proven by Waldmann and Weckbecker [13]. They described that medical students used their specially developed guideline app during waiting periods to improve their knowledge about the recent guidelines of primary care. Of course, in this special case, the app was developed and proven by the German College of General Practitioners. Further clinical studies including the widely used apps in emergency questions should be performed by, for example, societies to provide recommendations on their usability, data safety, and evidence. Medical calculator apps could provide a faster and safer treatment of patients in daily clinical practice [14–16]. For intensive and emergency physicians, a fast and adequate calculation program for fluid requirement and estimating the burned TBSA or BSA can be a useful companion. The most commonly used formulas for the estimation of burned surface in the apps are the rule of nines, the Lund and Browder chart, TBSA (Boyd, Dubois, Heycock, and Mosteller), and a 2D or 3D patient model. For calculating the TFR, most calculators use the Parkland formula. Only three apps provide the calculation of the ABSI, which has a strong impact for further clinical decisions. It is worth noting that all calculation apps are designed for medical professionals only. Not every app that helps in estimating the burned surface allows a calculation of the TFR; it is not clear why some developers do not support this feature. Our comparison showed a correlation of 19 apps by calculation of the TFR via the Parkland formula compared to our standardized patient (Fig. 3); despite one free app (calculate by QxMD#) using the Parkland formula as well, an overestimation of 600 ml for the first 24 h was the result. Seven apps (BurnQQ2#, EMS Pediatric Guide#, LiAo Burns#, LiAo Burns Pro#, Lund–Browder Calculator#, Med Tools#, and SARTech#) underestimated the TFR between 12 ml and 2700 ml. The great benefit of an app for estimating the burned surface and TFR is the precision and reproducibility. Estimating the total burned surface area in light of the fact that different burning depths, different body proportions, different ages, etc. may occur, it is still a challenge, even for experienced staff [17–24]. The consequence of the wrong estimated burned TBSA is a wrong TFR, with a possible fluid overload. An
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Application
TFR
Used formulas
BurnCare#
Yes
Yes
Calculate by QxMD#
Yes
Yes
Mersey Burns#
Yes
Yes
NurseCalcs Demo#
Yes
No
Parkland Formula#
Yes
Yes
Rapid Burn Assessor#
Yes
No
Burn Calc# BurnCase 3D 2.0#
No Yes
Yes Yes
BurnMed Lite# LiAo Burns#
Yes Yes
No Yes
2D patient model, Evans, Parkland, Carvajal Parkland formula, rule of nines 2D patient model, Lund and Browder chart, Parkland Rule of nines, Du Bois 2D patient model, Parkland Size of mobile phones Parkland formula 3D patient model, ABSI, Parkland 3D patient model 2D patient model, Lund and Browder
Lund–Browder–Parkland Calculator Light# uBurn LITE#
Yes
No
Yes
Yes
2D patient model, Lund and Browder Rule of nines, Parkland
TBSA (cm2)
BMI
Android
19210.00
24.00
Lund and Browder chart
18%
n.a.
5400 ml
Parkland
6 (80–90%)
43
Android
19000.00
24.50
Mosteller; Du Bois
18%
n.a.
6000 ml
Parkland
n.a.
n.a.
Android/iOS
n.a.
n.a.
18%
n.a.
5400 ml
Parkland
n.a.
n.a.
Android
19000.00
24.49
2D patient model, Lund and Browder chart Rule of nines, Du Bois
18%
n.a.
n.a.
n.a.
n.a.
n.a.
Android
n.a.
n.a.
2D patient model
18%
n.a.
5400 ml
Parkland
n.a.
n.a.
Android/iOS
1909.406
n.a.
Mosteller
18%
3446.13
n.a.
n.a.
n.a.
n.a.
iOS iOS
n.a. 19094.07
n.a. 24.49
n.a. Mosteller
18% 18%
n.a. 3437.29
5400 ml 5400 ml
Parkland Parkland
n.a. 5 (98%)
n.a. n.a.
iOS iOS
n.a. n.a.
n.a. n.a.
n.a. Lund and Browder chart
18% 18%
n.a. n.a.
n.a. 4025 ml
n.a. n.a.
n.a. n.a.
iOS
n.a.
n.a.
18%
n.a.
n.a.
n.a.
n.a.
iOS
n.a.
n.a.
Lund and Browder chart Rule of nines
n.a. TMMU Third Military Medical University n.a.
18%
n.a.
5400 ml
Parkland
n.a.
n.a.
Operating system
Formula for TBSA
II–III8 burn
Burned TBSA (cm2)
TFR first 24 h
Formula for TFR
ABSI
Baux
burns xxx (2015) xxx–xxx
TBSA
JBUR-4531; No. of Pages 13
10
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Table 3 – Comparison of the available free calculation apps.
JBUR-4531; No. of Pages 13
TBSA
TFR
Used formulas
Operating system
TBSA (cm2)
BMI
Med Tools# MedCalc 3000 Kidney#
Yes No
Yes Yes
Android Android
19094.07 n.a.
24.5 n.a.
Mosteller n.a.
18% 18%
n.a. n.a.
2700 ml 5400 ml
n.a. Parkland
n.a. n.a.
n.a. n.a.
MedCalc 3000# Medfixation Medical Calculator#
No Yes
Yes Yes
Mosteller Brooke, Semling, Evans, Modified Brooke, Slater, Parkland Parkland formula BSA (Boyd, Dubois, Heycock, Mosteller)
Android Android
19094.07 19200.00
24.49 24.5
18% 18%
n.a. n.a.
5400 ml 5400 ml
Parkland Parkland
n.a. n.a.
n.a. n.a.
MediCalc Medical Calculator# MediForm medizinischer Rechner# Mediquation Medical Calculator# Burn & Parkland Calculator# BurnMed Pro#
No
Yes
Parkland formula
Android
19100.00
24.5
n.a. Boyd, Dubois, Heycock, Mosteller n.a.
18%
n.a.
5400 ml
Parkland
n.a.
n.a.
No
Yes
n.a.
Android
19090.00
24.49
n.a.
18%
n.a.
5400 ml
n.a.
n.a.
n.a.
Yes
Yes
Android
19100.00
24.5
Dubois
18%
n.a.
5400 ml
Parkland
n.a.
n.a.
Yes
Yes
BSA (Dubois, Mosteller) 2D patient model
iOS
n.a.
n.a.
18%
n.a.
5400 ml
Parkland
n.a.
n.a.
Yes
No
3D patient model
iOS
n.a.
n.a.
18%
n.a.
n.a.
n.a.
n.a.
n.a.
BurnQQ2#
Yes
Yes
Lund and Browder
iOS
n.a.
n.a.
18%
n.a.
5388 ml
n.a.
n.a.
n.a.
EMS Pediatric Guide# LiAo Burns Pro#
No Yes
Yes Yes
Parkland formula 2D patient model, Lund and Browder
iOS iOS
n.a. n.a.
n.a. n.a.
2D patient model 3D patient model Lund and Browder Rule of nines 2D patient model, Lund and Browder
18% 18%
n.a. n.a.
3025 ml 4025 ml
n.a. n.a.
n.a. n.a.
Lund–Browder Calculator#
Yes
Yes
2D patient model, Lund and Browder, Parkland
iOS
n.a.
n.a.
18%
n.a.
2952 ml
n.a.
n.a.
MBC Burn Care#
No
Yes
iOS
n.a.
24.49
18%
3437.29
5400 ml
Parkland
6 (80–90%)
n.a.
Paramedic Parkland Formula# Rule Of Nines#
Yes
Yes
iOS
n.a.
n.a.
n.a.
20%
n.a.
62 dpm
Parkland
n.a.
n.a.
Yes
Yes
iOS
n.a.
n.a.
Rule of nines
18%
n.a.
5400 ml
Parkland
n.a.
n.a.
SARTech# TBSA of Burn Patients N3# uBurn Medic# uBurn#
Yes Yes
Yes Yes
Parkland and Palermo formula Rule of nines, Parkland Rule of nines Parkland formula 2D patient model Rule of nines
2D patient model, Lund and Browder chart n.a.
Parkland TMMU Third Military Medical University Parkland
iOS iOS
n.a. n.a.
n.a. n.a.
Rule of nines Rule of nines
18% 18%
n.a. n.a.
2880 ml 5400 ml
n.a. n.a.
n.a. n.a.
n.a. n.a.
Yes Yes
Yes Yes
Lund and Browder Rule of nines, Parkland
iOS iOS
n.a. n.a.
n.a. n.a.
Lund and Browder Rule of nines
18% 18%
n.a. n.a.
5400 ml 5400 ml
Parkland Parkland
n.a. n.a.
n.a. n.a.
Application
Formula for TBSA
II–III8 burn
Burned TBSA (cm2)
TFR first 24 h
Formula for TFR
ABSI
Baux
burns xxx (2015) xxx–xxx
11
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
Table 4 – Comparison of the available paid calculation apps.
JBUR-4531; No. of Pages 13
12
burns xxx (2015) xxx–xxx
Fig. 3 – Overview of calculated TFR in milliliters compared to the standardized patient (dashed line).
individual an optimal fluid resuscitation in burned patients has strong impact at the outcome [25,26]. In smaller burns, a transfer to a burn unit is not always necessary and therefore an objective and accurate estimation of the burned TBSA is essential. The key to success is avoiding the subjective view at the burned TBSA and introducing a standardized objective procedure. We specially focused our evaluation on all free available calculation apps. The main reason why we validated the free apps was that we believe they are downloaded more often than those with a fee. Furthermore, to provide a validation of all calculation apps, we included the paid apps in our study. Up to now, only two calculating smartphone apps for burns underwent a clinical evaluation. This evaluation was performed by Morris et al. [15]; they compared uBurn# and MerseyBurns#. In addition, a digital interface between smartphone apps and the HIS would be very helpful in providing a transfer of patient’s specific data. Three apps of both stores provided this feature. The use of 3D programs for TBSA estimation in clinical practice could provide a fast and for the outcome essential tool [27–29]; therefore, an interface between apps and these tools has to be designed and optimized. When discussing interfaces for immediate transfer of patient-level data, we always have to comply with patient data protection laws. Certainly, the first level of a safe data collection is the device itself. Therefore, smartphone producers provide a safe access by key-locking
the devices through signs or simply fingerprints. Naturally, every smartphone user himself has to be responsible for the safety of locally stored data on his/her device. It is worth nothing that none of the apps that provided an estimation or calculation with personal data ensured a password-controlled access and further an encrypted data transfer. The key might be a password-controlled online database for these apps; this ought to enable an on-time data transfer between mobile devices and personal computers. Besides Apple and Android, the smartphone producer Blackberry, which supplies the United States Department of Defense with mobile devices, aims to provide such solutions [30]. A summary of an evaluation through the US Food and Drug Administration (FDA) is possible for every app with health contexts, and this could be performed by using a provided guidance called ‘‘Mobile Medical Applications – Guidance for Industry and Food and Drug Administration Staff’’ [31]. Further investigations for both smartphone producers and app designers are necessary to offer a balance between usability and security.
5.
Conclusion
Overall, there are some helpful apps available for burns in both app stores, although there is still a lack of data security especially for calculation apps. Many of them may provide
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
JBUR-4531; No. of Pages 13 burns xxx (2015) xxx–xxx
support in daily medical decisions and, of course, allow a continuous collection of data. Our study of free calculation apps showed that most of the calculated TFRs correlate. The benefit of an accurate and objective estimation of the burned TBSA and, furthermore, an optimized fluid resuscitation is uncontroversial. Further clinical studies including smartphone apps for burns will be necessary.
Conflict of interest statement N/A.
Funding We want to thank the Austrian Burn Treatment, Research and Prevention Study Group (ABUSG) for the funding of the paid calculation apps www.abusg.com.
references
[1] History Stockholm smartphone n.d. http://www. stockholmsmartphone.org/history/; 2010 [accessed 28.02.14]. [2] There will soon be one smartphone for every five people in the world. Bus Insid n.d. http://www.businessinsider.com/ 15-billion-smartphones-in-the-world-22013-2; 2013 [accessed 28.02.14]. [3] Pope S, Muller T. Apple’s app store downloads top 15 billion 2011; 2011, http://www.apple.com/pr/library/2011/07/ 07Apples-App-Store-Downloads-Top-15-Billion.html [accessed 28.02.14]. [4] Number of available Android applications – AppBrain n.d. http://www.appbrain.com/stats/number-of-android-apps; 2014 [accessed 28.02.14]. [5] Mosa ASM, Yoo I, Sheets L. A systematic review of healthcare applications for smartphones. BMC Med Inform Decis Mak 2012;12:67. [6] Popat R, Mohan AT, Branford OA. Current uses of smartphones and apps in orthopaedic surgery. Br J Hosp Med Lond Engl 2013;74:672–6. [7] Boulos MNK, Wheeler S, Tavares C, Jones R. How smartphones are changing the face of mobile and participatory healthcare: an overview, with example from eCAALYX. Biomed Eng Online 2011;10:24. [8] Donker T, Petrie K, Proudfoot J, Clarke J, Birch M-R, Christensen H. Smartphones for smarter delivery of mental health programs: a systematic review. J Med Internet Res 2013;15:e247. [9] Van Velsen L, Beaujean DJMA, van Gemert-Pijnen JEWC. Why mobile health app overload drives us crazy, and how to restore the sanity. BMC Med Inform Decis Mak 2013;13:23. [10] Haze KA, Lynaugh J. Building patient relationships: a smartphone application supporting communication between teenagers with asthma and the RN care coordinator. Comput Inform Nurs: CIN 2013;31:266–71. quiz 272–73. [11] Wang L, Wang J, Wang M, Li Y, Liang Y, Xu D. Using Internet search engines to obtain medical information: a comparative study. J Med Internet Res 2012;14:e74. [12] Lin M, Rezaie S, Husain I. Top 10 mobile apps in emergency medicine. Emerg Med J: EMJ 2014.
13
[13] Waldmann U-M, Weckbecker K. Smartphone application of primary care guidelines used in education of medical students. GMS Z Med Ausbild 2013;30. Doc6. [14] Flannigan C, McAloon J. Students prescribing emergency drug infusions utilising smartphones outperform consultants using BNFCs. Resuscitation 2011;82:1424–7. [15] Morris R, Javed M, Bodger O, Gorse SH, Williams D. A comparison of two smartphone applications and the validation of smartphone applications as tools for fluid calculation for burns resuscitation. Burns J Int Soc Burn Inj 2014;40(5):826–34. [16] Bierbrier R, Lo V, Wu RC. Evaluation of the accuracy of smartphone medical calculation apps. J Med Internet Res 2014;16:e32. [17] Livingston EH, Lee S. Percentage of burned body surface area determination in obese and nonobese patients. J Surg Res 2000;91:106–10. [18] Livingston EH, Lee S. Body surface area prediction in normal-weight and obese patients. Am J Physiol Endocrinol Metab 2001;281:E586–91. [19] Giretzlehner M, Dirnberger J, Owen R, Haller HL, Lumenta DB, Kamolz L-P. The determination of total burn surface area: how much difference? Burns J Int Soc Burn Inj 2013;39:1107–13. [20] Martin NAJ, Lundy JB, Rickard RF. Lack of precision of burn surface area calculation by UK Armed Forces medical personnel. Burns J Int Soc Burn Inj 2014;40:246–50. [21] Parvizi D, Kamolz L-P, Giretzlehner M, Haller HL, Trop M, Selig H, et al. The potential impact of wrong TBSA estimations on fluid resuscitation in patients suffering from burns: things to keep in mind. Burns J Int Soc Burn Inj 2014;40:241–5. [22] Giretzlehner M, Dirnberger J, Owen R, Haller HL, Lumenta DB, Kamolz L-P. The determination of total burn surface area: how big is the difference? Burns J Int Soc Burn Inj 2014;40:170–1. [23] Kamolz L-P, Parvizi D, Giretzlehner M, Lumenta DB. Burn surface area calculation: what do we need in future. Burns J Int Soc Burn Inj 2014;40:171–2. [24] Rickard RF, Martin NAJ, Lundy JB. Imprecision in TBSA calculation. Burns J Int Soc Burn Inj 2014;40:172–3. [25] Klein MB, Hayden D, Elson C, Nathens AB, Gamelli RL, Gibran NS, et al. The association between fluid administration and outcome following major burn: a multicenter study. Ann Surg 2007;245:622–8. [26] Kraft R, Herndon DN, Branski LK, Finnerty CC, Leonard KR, Jeschke MG. Optimized fluid management improves outcomes of pediatric burn patients. J Surg Res 2013;181:121–8. [27] Nichter LS, Bryant CA, Edlich RF. Efficacy of burned surface area estimates calculated from charts – the need for a computer-based model. J Trauma 1985;25:477–81. [28] Neuwalder JM, Sampson C, Breuing KH, Orgill DP. A review of computer-aided body surface area determination: SAGE II and EPRI’s 3D burn vision. J Burn Care Rehabil 2002;23:55– 9. discussion 54. [29] Haller HL, Dirnberger J, Giretzlehner M, Rodemund C, Kamolz L. Understanding burns: research project BurnCase 3D – overcome the limits of existing methods in burns documentation. Burns J Int Soc Burn Inj 2009;35:311–7. [30] BlackBerry’s next move may be a phone that keeps you healthy. Huffington Post 2014. http://www.huffingtonpost. com/2014/04/15/blackberry-collaborating-nanthealthsmartphone_n_5154514.html; 2014 [accessed 20.04.14]. [31] Bakul P. Mobile medical applications – guidance for Industry and Food and Drug Administration Staff 2013; 2013, http://www.fda.gov/downloads/MedicalDevices/./ UCM263366.pdf [accessed 20.04.14].
Please cite this article in press as: Wurzer P, et al. Smartphone applications in burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2014.11.010
