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Young A, Davies A, Tsang C, Kirkham J, Potokar T, Gibran N, Tyack Z, Meirte J, Harada T, Dheansa B, Dumville J, Metcalfe C, Ahuja R, Wood F, Gaskell S, Brookes S, Smailes S, Jeschke M, Cinar MA, Zia N, Moghazy A, Mathers J, Falder S, Edgar D, Blazeby JM. Establishment of a core outcome set for burn care research: development and international consensus. BMJ Med 2022; 1:e000183. [PMID: 36936572 PMCID: PMC9978679 DOI: 10.1136/bmjmed-2022-000183] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 05/24/2022] [Indexed: 11/03/2022]
Abstract
Objective To develop a core outcome set for international burn research. Design Development and international consensus, from April 2017 to November 2019. Methods Candidate outcomes were identified from systematic reviews and stakeholder interviews. Through a Delphi survey, international clinicians, researchers, and UK patients prioritised outcomes. Anonymised feedback aimed to achieve consensus. Pre-defined criteria for retaining outcomes were agreed. A consensus meeting with voting was held to finalise the core outcome set. Results Data source examination identified 1021 unique outcomes grouped into 88 candidate outcomes. Stakeholders in round 1 of the survey, included 668 health professionals from 77 countries (18% from low or low middle income countries) and 126 UK patients or carers. After round 1, one outcome was discarded, and 13 new outcomes added. After round 2, 69 items were discarded, leaving 31 outcomes for the consensus meeting. Outcome merging and voting, in two rounds, with prespecified thresholds agreed seven core outcomes: death, specified complications, ability to do daily tasks, wound healing, neuropathic pain and itch, psychological wellbeing, and return to school or work. Conclusions This core outcome set caters for global burn research, and future trials are recommended to include measures of these outcomes.
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Affiliation(s)
- Amber Young
- Centre for Surgical Research, Population Health Sciences, Bristol Biomedical Research Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Anna Davies
- Centre for Surgical Research, Population Health Sciences, Bristol Biomedical Research Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Carmen Tsang
- Centre for Surgical Research, Population Health Sciences, Bristol Biomedical Research Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jamie Kirkham
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Tom Potokar
- Centre for Global Burn Injury Policy and Research, Swansea University, Swansea, UK
| | - Nicole Gibran
- UW Medicine Regional Burn Center, Harborview Medical Center, UW Department of Surgery, University of Washington (UW), Seattle, WA, USA
| | - Zephanie Tyack
- Child Health Research Centre, Faculty of Medicine, Centre for Children’s Burns and Trauma Research, Queensland University of Technology, Brisbane, QLD, Australia
| | - Jill Meirte
- Department of Medicine and Health Sciences, University of Antwerp, Antwerpen, Belgium
| | - Teruichi Harada
- Seitokai Medical and Social Welfare Corporation, Teramoto Memorial Hospital, Kawachinagano, Osaka, Japan
| | - Baljit Dheansa
- Department of plastic surgery and burns, Queen Victoria Hospital, East Grinstead, UK
| | - Jo Dumville
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
- Division of Nursing, Midwifery, and Social Work, University of Manchester, Manchester, UK
| | - Chris Metcalfe
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Rajeev Ahuja
- Department of Burns & Plastic Surgery, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India
| | - Fiona Wood
- Burn service, University of Western Australia, Perth, WA, Australia
| | - Sarah Gaskell
- Paediatric Psychosocial Service, Royal Manchester Children's Hospital, Manchester, UK
| | - Sara Brookes
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Sarah Smailes
- Department of physiontherapy, Broomfield Hospital, Mid Essex Hospitals, Chelmsford, UK
| | - Marc Jeschke
- Department of Surgery and Plastic Surgery, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Murat Ali Cinar
- Department of Physical Therapy and Rehabilitation, Hasan Kalyoncu University, Gaziantep, Turkey
| | - Nukhba Zia
- Johns Hopkins International Injury Research Unit, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amr Moghazy
- Department of plastic surgery, Suez Canal University, Ismailia, Egypt
| | - Jonathan Mathers
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sian Falder
- Department of plastic surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Dale Edgar
- Adult Burns Unit, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Jane Mary Blazeby
- Centre for Surgical Research, Population Health Sciences, Bristol Biomedical Research Centre, Bristol Medical School, University of Bristol, Bristol, UK
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Smailes S, Spoors C, da Costa FM, Martin N, Barnes D. Early tracheostomy and active exercise programmes in adult intensive care patients with severe burns. Burns 2021; 48:1599-1605. [PMID: 34955297 DOI: 10.1016/j.burns.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/23/2021] [Accepted: 10/11/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND Tracheostomy is a strategy often employed in patients requiring prolonged intubation in ICU settings. Evidence suggests that earlier tracheostomy and early active exercise are associated with better patient centered outcomes. Severe burn patients often require prolonged ventilatory support due to their critical condition, complex sedation management and multiple operating room visits. It is still unclear the optimal timing for tracheostomy in this population. METHODS We conducted a service evaluation where we compared Early Tracheostomy (≤10 days) with Late Tracheostomy (>10 days) in 41 severely burned patients that required prolonged respiratory support. RESULTS Early Tracheostomy cohort was associated with fewer days of mechanical ventilation (16 vs 33, p = 0.001), shorter hospital length of stay (65 vs 88 days, p = 0.018), earlier first day of active exercise (day 8 vs day 25, p < 0.0001) and higher Functional Assessment for Burns scores upon discharge (32 vs 28, p = 0.016). CONCLUSION Early tracheostomy in patients with severe burns is associated with earlier active exercise, fewer days of ventilation, shorter length of hospital stay and better physical functional independence upon discharge from hospital.
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Affiliation(s)
- Sarah Smailes
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex CM1 7ET, United Kingdom.
| | - Catherine Spoors
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex CM1 7ET, United Kingdom
| | - Filipe Marques da Costa
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex CM1 7ET, United Kingdom
| | - Niall Martin
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex CM1 7ET, United Kingdom; Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Queen Mary University of London, United Kingdom
| | - David Barnes
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex CM1 7ET, United Kingdom
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Ward J, Phillips G, Radotra I, Smailes S, Dziewulski P, Zhang J, Martin N. Frailty: an independent predictor of burns mortality following in-patient admission. Burns 2018; 44:1895-1902. [DOI: 10.1016/j.burns.2018.09.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 06/11/2018] [Accepted: 09/13/2018] [Indexed: 01/26/2023]
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Deutsch C, Tan A, Smailes S, Dziewulski P. The diagnosis and management of inhalation injury: An evidence based approach. Burns 2018; 44:1040-1051. [DOI: 10.1016/j.burns.2017.11.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 10/03/2017] [Accepted: 11/20/2017] [Indexed: 10/28/2022]
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Win TS, Nizamoglu M, Maharaj R, Smailes S, El-Muttardi N, Dziewulski P. Relationship between multidisciplinary critical care and burn patients survival: A propensity-matched national cohort analysis. Burns 2017; 44:57-64. [PMID: 29169702 DOI: 10.1016/j.burns.2017.11.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 10/05/2017] [Accepted: 11/06/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aims of this study are: firstly, to investigate if admission to specialized burn critical care units leads to better clinical outcomes; secondly, to elucidate if the multidisciplinary critical care contributes to this superior outcome. METHODS A multi-centre cohort analysis of a prospectively collected national database of 1759 adult burn patients admitted to 13 critical care units in England and Wales between 2005 and 2011. Units were contacted via telephone to establish frequency and constitution of daily ward rounds. Critical care units were categorized into 3 settings: specialized burns critical care units, generalized critical care units and 'visiting' critical care units. Multivariate logistic regression analysis and propensity dose-response analysis were used to calculate risk adjusted mortality. RESULTS Multivariate logistic regression analysis shows that admission to a specialized burn critical care service is independently associated with significant survival benefit compared to generalized critical care unit (adjusted OR for in-hospital death 1.81, [95% CI, 1.24, 2.66]) and 'visiting' critical care services (adjusted OR for in-hospital death 2.24 [95% CI, 1.49, 3.38]). Further analysis using propensity dose-response analysis demonstrates that risk-adjusted in-hospital mortality rate decreased as the dose of multidisciplinary care increased, with an adjusted odds ratio of 1 (specialized burn critical care units), 1.81 (generalized critical care units) and 2.24 ('visiting' critical care units). CONCLUSIONS Admission to a specialized burn critical care service is independently associated with significant survival benefit. This is, at least in part, due to care being provided by a fully integrated multidisciplinary team.
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Affiliation(s)
- Thet Su Win
- St. Andrews Centre for Burns, Broomfield Hospital, Chelmsford CM1 7ET, UK
| | - Metin Nizamoglu
- St. Andrews Centre for Burns, Broomfield Hospital, Chelmsford CM1 7ET, UK.
| | - Ritesh Maharaj
- King's Health Partners, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Sarah Smailes
- St. Andrews Centre for Burns, Broomfield Hospital, Chelmsford CM1 7ET, UK
| | - Naguib El-Muttardi
- St. Andrews Centre for Burns, Broomfield Hospital, Chelmsford CM1 7ET, UK
| | - Peter Dziewulski
- St. Andrews Centre for Burns, Broomfield Hospital, Chelmsford CM1 7ET, UK
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Tan A, Smailes S, Friebel T, Magdum A, Frew Q, El-Muttardi N, Dziewulski P. Smoke inhalation increases intensive care requirements and morbidity in paediatric burns. Burns 2016; 42:1111-1115. [PMID: 27283733 DOI: 10.1016/j.burns.2016.02.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 02/10/2016] [Accepted: 02/11/2016] [Indexed: 11/26/2022]
Abstract
Burn survival has improved with advancements in fluid resuscitation, surgical wound management, wound dressings, access to antibiotics and nutritional support for burn patients. Despite these advancements, the presence of smoke inhalation injury in addition to a cutaneous burn still significantly increases morbidity and mortality. The pathophysiology of smoke inhalation has been well studied in animal models. Translation of this knowledge into effectiveness of clinical management and correlation with patient outcomes including the paediatric population, is still limited. We retrospectively reviewed our experience of 13 years of paediatric burns admitted to a regional burn's intensive care unit. We compared critical care requirements and patient outcomes between those with cutaneous burns only and those with concurrent smoke inhalation injury. Smoke inhalation increases critical care requirements and mortality in the paediatric burn population. Therefore, early critical care input in the management of these patients is advised.
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Affiliation(s)
- Alethea Tan
- St Andrew Burns Intensive Unit, Broomfield Hospital, Court Road, Chelmsford, CM1 7ET, United Kingdom; St Andrew Anglia Ruskin Research Unit, Faculty of Medical Sciences, 1-2 Bishop Hall Lane, CM11SQ, United Kingdom.
| | - Sarah Smailes
- St Andrew Burns Intensive Unit, Broomfield Hospital, Court Road, Chelmsford, CM1 7ET, United Kingdom.
| | - Thessa Friebel
- St Andrew Burns Intensive Unit, Broomfield Hospital, Court Road, Chelmsford, CM1 7ET, United Kingdom.
| | - Ashish Magdum
- St Andrew Burns Intensive Unit, Broomfield Hospital, Court Road, Chelmsford, CM1 7ET, United Kingdom.
| | - Quentin Frew
- St Andrew Burns Intensive Unit, Broomfield Hospital, Court Road, Chelmsford, CM1 7ET, United Kingdom; St Andrew Anglia Ruskin Research Unit, Faculty of Medical Sciences, 1-2 Bishop Hall Lane, CM11SQ, United Kingdom.
| | - Naguib El-Muttardi
- St Andrew Burns Intensive Unit, Broomfield Hospital, Court Road, Chelmsford, CM1 7ET, United Kingdom.
| | - Peter Dziewulski
- St Andrew Burns Intensive Unit, Broomfield Hospital, Court Road, Chelmsford, CM1 7ET, United Kingdom; St Andrew Anglia Ruskin Research Unit, Faculty of Medical Sciences, 1-2 Bishop Hall Lane, CM11SQ, United Kingdom.
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Roberts G, Thorburn G, Smailes S, Dziewulski P. Open access software tool for CUSUM analysis in burns - a freely available download for prospective outcome monitoring. Scars Burn Heal 2016; 2:2059513116642396. [PMID: 29799571 PMCID: PMC5965323 DOI: 10.1177/2059513116642396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Geoffrey Roberts
- St. Andrew's Plastics and Burns Unit, Broomfield Hospital, Chelmsford, UK
| | - Guy Thorburn
- St. Andrew's Plastics and Burns Unit, Broomfield Hospital, Chelmsford, UK
| | - Sarah Smailes
- St. Andrew's Plastics and Burns Unit, Broomfield Hospital, Chelmsford, UK
| | - Peter Dziewulski
- St. Andrew's Plastics and Burns Unit, Broomfield Hospital, Chelmsford, UK.,St. Andrew's Anglia Ruskin Burns and Plastic Surgery Research Unit, Anglia Ruskin University, Chelmsford, UK
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Maan ZN, Frew Q, Din AH, Unluer Z, Smailes S, Philp B, El-Muttardi N, Dziewulski P. Burns ITU admissions: length of stay in specific levels of care for adult and paediatric patients. Burns 2014; 40:1458-62. [PMID: 25155115 DOI: 10.1016/j.burns.2014.07.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 06/24/2014] [Accepted: 07/31/2014] [Indexed: 12/18/2022]
Abstract
Prediction of total length of stay (LOS) for burns patients based on the total burn surface area (TBSA) is well accepted. Total LOS is a poor measure of resource consumption. Our aim was to determine the LOS in specific levels of care to better inform resource allocation. We performed a retrospective review of LOS in intensive treatment unit (ITU), burns high dependency unit (HDU) and burns low dependency unit (LDU) for all patients requiring ITU admission in a regional burns service from 2003 to 2011. During this period, our unit has admitted 1312 paediatric and 1445 adult patients to our Burns ITU. In both groups, ITU comprised 20% of the total LOS (mean 0.23±0.02 [adult] and 0.22±0.02 [paediatric] days per %burn). In adults, 33% of LOS was in HDU (0.52±0.06 days per %burn) and 48% (0.68±0.06 days per %burn) in LDU, while in children, 15% of LOS was in HDU (0.19±0.03 days per %burn) and 65% in LDU (0.70±0.06 days per %burn). When considering Burns ITU admissions, resource allocation ought to be planned according to expected LOS in specific levels of care rather than total LOS. The largest proportion of stay is in low dependency, likely due to social issues.
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Affiliation(s)
- Zeshaan N Maan
- St Andrew's Centre for Plastic Surgery and Burns, CM1 7ET Chelmsford, Essex, United Kingdom; Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Quentin Frew
- St Andrew's Centre for Plastic Surgery and Burns, CM1 7ET Chelmsford, Essex, United Kingdom
| | - Asmat H Din
- St Andrew's Centre for Plastic Surgery and Burns, CM1 7ET Chelmsford, Essex, United Kingdom
| | - Zeynep Unluer
- St Andrew's Centre for Plastic Surgery and Burns, CM1 7ET Chelmsford, Essex, United Kingdom
| | - Sarah Smailes
- St Andrew's Centre for Plastic Surgery and Burns, CM1 7ET Chelmsford, Essex, United Kingdom
| | - Bruce Philp
- St Andrew's Centre for Plastic Surgery and Burns, CM1 7ET Chelmsford, Essex, United Kingdom
| | - Naguib El-Muttardi
- St Andrew's Centre for Plastic Surgery and Burns, CM1 7ET Chelmsford, Essex, United Kingdom
| | - Peter Dziewulski
- St Andrew's Centre for Plastic Surgery and Burns, CM1 7ET Chelmsford, Essex, United Kingdom.
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Masud D, Norton S, Smailes S, Shelley O, Philp B, Dziewulski P. The use of a frailty scoring system for burns in the elderly. Burns 2013; 39:30-6. [DOI: 10.1016/j.burns.2012.03.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Revised: 03/02/2012] [Accepted: 03/07/2012] [Indexed: 11/24/2022]
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Abstract
OBJECTIVE The use of tracheostomy in burns patients has been controversial. A retrospective study was conducted to assess the use, complications and outcome of tracheostomy in ventilated adult burns patients. METHODS Data was collected retrospectively regarding the extent of injury in each patient, the indication for tracheostomy, and outcome in terms of length of stay, days of mechanical ventilation, airway and pulmonary complications and survival. Patients were followed until discharge from the unit or death. RESULTS Comparing patients who received tracheostomy to those who had translaryngeal intubation showed similar age distribution and no significant difference in the total burn surface area (TBSA). The use of tracheostomy was significantly higher in patients with TBSA >60%. Inhalation injury was significantly higher and mean probability of survival (ABSI), significantly lower in patients receiving tracheostomy. Duration of mechanical ventilation, length of stay in HDU/ITU and the incidence of pulmonary sepsis were significantly higher in tracheostomy group patients. However, there was no significant difference in mortality between the two groups. CONCLUSION Burn survivors with TBSA >60% are more likely to undergo repeated surgery and have burns to the head and neck region, therefore increasing the requirement for tracheostomy. Tracheostomy is a safe procedure with minimal perioperative complications. Late complications in this patient group may be related to duration of intubation and mechanical ventilation and the presence of an airway burn. Tracheostomy was associated with a higher prevalence of chest infection. We suspect that the cause of this is multifactorial, possibly due to a higher incidence of inhalation injury, greater burn size and prolonged mechanical ventilation in this group.
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Smailes S. Predictors of discontinuation of mechanical ventilation and extubation in burn patients. Burns 2007. [DOI: 10.1016/j.burns.2006.10.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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