Publications

Work at the Centre for Global Burn Injury Policy & Research has been collated into various forms of publications including informative posters, presentations, articles, and papers. We are able to share some of these with our community and those interested in global health, specifically burn care. 

 

Highlights Report 2019/2020

Read about the key work being carried out by the Centre from 2019-2020 and looking ahead to 2021. 

Highlights Report 19/20

 

 

Practical  Guide to Quality Improvement for Burn Care

This guide is an educational tool, which provides a practical 8 step framework for quality improvement in burn care in low-resourced settings. This has been developed together with nurses from Ethiopia and Malawi, who were participants of our QI course for nurses.

Read below or download the pdf. Share with others using this link: Guide to QI for burn care

A Practical Guide to Quality Improvement for Burn Care

 

 

Improving hand hygiene in a low-resource setting: A nurse-led quality improvement project

Authors: Patricia Kamanga, Patricia Ngala, Caitlin Hebron

Abstract: Hand hygiene is a simple but often ignored practice in health care systems worldwide, but it is integral for nosocomial infection prevention, with many hospital-acquired infections being linked to inadequate hand hygiene practice. At the burns unit in Kamuzu Central Hospital, 50% of patients were found to have acquired pseudomonas infections: one of the contributing factors being inadequate hand hygiene. This quality improvement project was part of a course for nurses to introduce change for patient benefit, with the aim of increasing the baseline figures for hand hygiene practices and hand hygiene facilities from 37% and 22%, respectively (baseline collected in November 2019). Using robust, standard quality improvement processes, measures were put in place such as checklists to observe hand hygiene compliance and facilities, appointment of a hand hygiene committee who monitored and sustained activities of the project, procurement and distribution of handrub and placement of hand-washing buckets and soap at strategic points. The project saw an increase in availability of hand-washing facilities to 95.6% and hand hygiene practices increase to >80% within 6 months. The project demonstrates that low cost interventions, led by nurses, can make a real difference to practice in resource poor countries. 

Published in: International Wound Journal 2021 https://doi.org/10.1111/iwj.13647

(https://onlinelibrary.wiley.com/doi/10.1111/iwj.13647)

Parental acceptance and willingness to pay for a newly designed kitchen rack to reduce paediatric burns

Authors: Gerelmaa Gunsmaa, Aiko Shono, Patricia Price, Masahide Kondo, Caitlin Hebron, Tom Potokar, Masao Ichikawa

Abstract: The majority of pediatric burns in Mongolia occur within the home, particularly in the spaces dedicated to cooking. This makes home environment modification a priority for injury prevention. Many of these injuries are caused by electric appliances used in traditional tent-like dwellings (called a ger). In the present study, we designed and provided a context appropriate kitchen rack to 50 households with children aged 0–3 years living in gers and investigated parental views on the acceptability of the rack and willingness-to-pay (WTP) through face-to-face structured individual and group interviews and the contingent valuation method. We used the DCchoice package of R to estimate the median WTP and its 95% confidence interval by the household income, previous experience of childhood burn injury, and the number of children in the household. There was a total of 89 children aged <5 years in the 50 households, with a total of 59 burn experiences since birth including 29 treated at inpatient facilities. The median WTP was MNT 106,000 (about USD 37). The WTP appeared to be higher for the households with a higher income, more severe child burn experiences, and a greater number of children in the household. In the group interviews conducted after 4–6 weeks of routine use, the participants indicated that the use of the rack had resulted in a less stressful cooking environment, and the kitchen rack was described as a positive contribution to the reduction of risk to their young children. Whilst there were some suggestions for minor modifications, the rack was well accepted as a means of child burn prevention by the parents of infants and toddlers in Mongolia.

Published in: Burns 2021 https://doi.org/10.1016/j.burns.2021.05.008 (https://www.sciencedirect.com/science/article/pii/S0305417921001303)

Investigating burn cases, knowledge, attitudes and practices to burn care and prevention in Ethiopia: a community-survey

Authors: Baye Denekew, Caitlin Hebron, Abeba Mekonnen, Mihret Ayele, Kassahun Negash, Muluken Desalegne, Patricia Price, Tom Potokar

Abstract: Background: Burn injuries are thought to be preventable but are still a prevalent global health problem, especially in low- and middle- income countries, including Ethiopia. According to the 2016 Ethiopian Demographic and Health Survey report, burn injuries represent 8.7% of all significant injuries in Ethiopia. Such injuries result in catastrophic consequences for patients; to reduce this burden of injury, we need to ensure that future community-based burn prevention and treatment interventions are effective, available and evidence based. The main objective of this study was to assess the magnitude and causes of burn injuries as well as the knowledge, attitude and practice towards burns of community members to create an evidence base for improving basic burn care services focusing on prevention. Methods: This cross sectional study was conducted in three districts (Dembiya, Limu Genet and Tula) found in Amhara, Oromia and Southern Nations, Nationalities, and People’s Region (SNNPR) regional states. 651 households were selected using multi-stage cluster sampling method. Results: The survey team asked households if anyone in the selected household had experienced a burn injury within the past 12 months; 3.5% of these households reported a burn injury (using WHO definition), which was equivalent to 0.7% of all individuals from the surveyed households. Of the individuals who experienced a burn, the majority were female (14 of 23, 60.9%) and children under five (14 of 23, 60.9%); households with a separate ‘house’ for cooking had an 85.9% reduction in their chances of experiencing a burn injury. The main causes of burn injuries were heat, flame and hot liquid water (89.7%) and all 23 burn injuries occurred at home. A significant number of community members still used traditional practices to treat a burn injury, like applying dough and oil. Conclusions: This research highlights the importance of improving community awareness and knowledge on burn prevention methods, with recognition that women and children are high risk groups. The research also demonstrates the need to develop the capacity of health facilities at all levels, through appropriate training and resources, to enable them to provide quality health care service to the community.

Published in: Journal of Global Health Reports 2021;5:e2021050. doi:10.29392/001c.24353 (https://www.joghr.org/article/24353-investigating-burn-cases-knowledge-attitudes-and-practices-to-burn-care-and-prevention-in-ethiopia-a-community-survey)

Quality improvement training for burn care in low-and middle-income countries: A pilot course for nurses

Authors: Maria Holden, Edna Ogada, Caitlin Hebron, Patricia Price, Tom Potokar

Abstract: Background: There is an urgent need to empower practitioners to undertake quality improvement (QI) projects in burn services in low-middle income countries (LMICs). We piloted a course aimed to equip nurses working in these environments with the knowledge and skills to undertake such projects. Methods: Eight nurses from five burns services across Malawi and Ethiopia took part in this pilot course, which was evaluated using a range of methods, including interviews and focus group discussions. Results: Course evaluations reported that interactive activities were successful in supporting participants to devise QI projects. Appropriate online platforms were integral to creating a community of practice and maintaining engagement. Facilitators to a successful QI project were active individuals, supportive leadership, collaboration, effective knowledge sharing and demonstrable advantages of any proposed change. Barriers included: staff attitudes, poor leadership, negative culture towards training, resource limitations, staff rotation and poor access to information to guide practice. Conclusions: The course demonstrated that by bringing nurses together, through interactive teaching and online forums, a supportive community of practice can be created. Future work will include investigating ways to scale up access to the course so staff can be supported to initiate and lead quality improvement in LMIC burn services.

Published in: Burns, 2021. https://doi.org/10.1016/j.burns.2021.01.016 (https://www.sciencedirect.com/science/article/pii/S0305417921000838)

A simplified fluid resuscitation formula for burns in mass casualty scenarios: Analysis of the consensus recommendation from the WHO Emergency Medical Teams Technical Working Group on Burns

Authors: Thomas Leclerc, Tom Potokar, Amy Hughes, Ian Norton, Calin Alexandru, Josef Haik, Naiem Moiemen, Stian Kreken Almeland

Abstract: Introduction Burn fluid resuscitation guidelines have not specifically addressed mass casualty with resource limited situations, except for oral rehydration for burns below 40% total body surface area (TBSA). The World Health Organization Technical Working Group on Burns (TWGB) recommends an initial fluid rate of 100 mL/kg/24 h, either orally or intravenously, beyond 20% TBSA burned. We aimed to compare this formula with current guidelines. Methods: The TWGB formula was numerically compared with 2–4 mL/kg/%TBSA for adults and the Galveston formula for children. Results: In adults, the TWGB formula estimated fluid volumes within the range of current guidelines for burns between 25 and 50% TBSA, and a maximal 20 mL/kg/24 h difference in the 20–25% and the 50–60% TBSA ranges. In children, estimated resuscitation volumes between 20 and 60% TBSA approximated estimations by the Galveston formula, but only partially compensated for maintenance fluids. Beyond 60% TBSA, the TWGB formula underestimated fluid to be given in all age groups. Conclusion: The TWGB formula for mass burn casualties may enable appropriate fluid resuscitation for most salvageable burned patients in disasters. This simple formula is easy to implement. It should simplify patient management including transfers, reduce the risk of early complications, and thereby optimize disaster response, provided that tailored resuscitation is given whenever specialized care becomes available.

Published in:  Burns, 2021. https://doi.org/10.1016/j.burns.2021.01.016 (https://www.sciencedirect.com//article/pii/S0305417921000231)

The cost of inpatient burn management in Nepal

Authors: Narayan Poudel, Patricia Price, Julia Lowin, Rojina Shilpakar, Kiran Nakarmi, Tom Potokar

Abstract: The management of burns is costly and complex with inpatient burns accounting for a high proportion of the costs associated with burn care. We conducted a study to estimate the cost of inpatient burn management in Nepal. Our objectives were to identify the resource and cost components of the inpatient burn care pathways and to estimate direct and overhead costs in two specialist burn units in tertiary hospitals in Nepal.

Published in:  Burns, 2021. https://doi.org/10.1016/j.burns.2021.01.016 (https://www.sciencedirect.com/science/article/pii/S0305417921000231)

 

 

A Structured Review to Assess the Current Status of Cost-Based Burns Research in Nepal

AUTHORS: Julia L. Lowin, Ak Narayan Poudel, Patricia E. Price, Tom S. Potokar

ABSTRACT: The management of burns is costly and complex. The problem is compounded in low and middle income countries (LMICs) where the incidence of burn injuries is high but infrastructure and funding for management and prevention is limited. Cost of illness studies allows for quantification of the costs associated with public health problems. Without cost quantification, focus and allocation of funding is challenging. The authors explored the availability of cost-focused burns research data in a target LMIC. The focus of their research was Nepal. A structured literature review including published papers, Ministry of Health (MOH) and World Health Organization (WHO) statistics was conducted to identify cost of illness studies or evidence relating to burn-related resource and costs. Gaps in the evidence base were highlighted. Research methodologies from other LMICs were reviewed. We found 32 papers related to burn injury in Nepal, one key MOH document and one relevant WHO data source. Most research focused on the epidemiology and etiology of burns in Nepal. Of the papers, only 14 reported any type of burn-related resource use and only 1 paper directly reported (limited) cost data. No studies attempted an overall quantification of the cost of burns. MOH statistics provided no additional insight into costs. Our study found an almost complete lack of cost-focused burns research in Nepal. Primary research is needed to quantify the cost of burns in Nepal. Initial focus could usefully be on the cost of care in tertiary hospitals. A full cost of burns for Nepal remains some way off.

PUBLISHED IN:Julia L Lowin, MSc, Ak Narayan Poudel, PhD, Patricia E Price, PhD, Tom S Potokar, FRCS (Plast), A Structured Review to Assess the Current Status of Cost-Based Burns Research in Nepal, Journal of Burn Care & Research, , iraa125, https://doi.org/10.1093/jbcr/iraa125

Recommendations for burns care in mass casualty incidents: WHO Emergency Medical Teams Technical Working Group on Burns (WHO TWGB) 2017-2020

AUTHORS: Amy Hughes, Stian Kreken Almeland, Thomas Leclerc, Takayuki Ogura, Minoru Hayashi, Jody-Ann Mills, Ian Norton, & Tom Potokar.

ABSTRACT: Health and logistical needs in emergencies have been well recognised. The last 7 years has witnessed improved professionalisation and standardisation of care for disaster affected communities – led by the World Health Organisation Emergency Medical Team (EMT) initiative.

Mass casualty incidents (MCIs) resulting in burn injuries present unique challenges. Burn management benefits from specialist skills, expert knowledge, and timely availability of specialist resources. With burn MCIs occurring globally, and wide variance in existing burn care capacity, the need to strengthen burn care capability is evident. Although some high-income countries have well-established disaster management plans, including burn specific plans, many do not – the majority of countries where burn mass casualty events occur are without such established plans. Developing globally relevant recommendations is a first step in addressing this deficit and increasing preparedness to deal with such disasters.

Global burn experts were invited to a succession of Technical Working Group on burns (TWGB) meetings to:

1) review literature on burn care in MCIs; and

2) define and agree on recommendations for burn care in MCIs.

The resulting 21 recommendations provide a framework to guide national and international specialist burn teams and health facilities to support delivery of safe care and improved outcomes to burn patients in MCIs.

PUBLISHED IN: Burns, 2020. https://doi.org/10.1016/j.burns.2020.07.001.
(http://www.sciencedirect.com/science/article/pii/S0305417920304599)

 

 

A comprehensive, integrated approach to quality improvement and capacity building in burn care and prevention in low and middle-income countries: An overview

AUTHORS: T. Potokar, R. Bendell, S. Chamania, S. Falder, R. Nnabuko, P.E. Price

ABSTRACT: Consistent evidence has emerged over many years that the mortality and morbidity outcomes for burn patients in low and middle-income countries (LMICs) lag behind those in more resource rich countries. Interburns is a charity that was set up with the aim of working to reduce the disparity in the number of cases of burns as well as the outcomes for patients in LMICs. This paper provides an overview of a cyclical framework for quality improvement in burn care for use in LMICs that has been developed using an iterative process over the last 10 years. Each phase of the process is outlined together with a description of the tools used to conduct a gap analysis within the service, which is then used to frame a programme of capacity enhancement. Recent externally reviewed projects have demonstrated sustained improvement with the use of this comprehensive and integrated approach over a three-year cycle. This overview paper will be supported by further publications that present these results in detail.

PUBLISHED IN: T. Potokar, R. Bendell, S. Chamania, S. Falder, R. Nnabuko, P.E. Price, ‘A comprehensive, integrated approach to quality improvement and capacity building in burn care and prevention in low and middle-income countries: An overview’, Burns (in press; available online 11 June 2020) https://www.sciencedirect.com/science/article/pii/S0305417920304149?via%3Dihub

Burns in Nepal: a participatory, community survey of burn cases and knowledge, attitudes and practices to burn care and prevention in three rural municipalities.

AUTHORS: Kamal Phuyal, Edna Adhiambo Ogada , Richard Bendell, Patricia E. Price, Tom Potokar

ABSTRACT: Objectives As part of an ongoing, long-term project to co-create burn prevention strategies in Nepal, we collected baseline data to share and discuss with the local community, use as a basis for a co-created prevention strategy and then monitor changes over time. This paper reports on the method and outcomes of the baseline survey and demonstrates how the data are presented back to the community. Design a community-based survey. Setting Community based in three rural municipalities in Nepal. Participants 1305 households were approached: the head of 1279 households participated, giving a response rate of 98%. In 90.3% of cases, the head of the household was male. Results We found that 2.7% (CI 1.8 to 3.7) of 1279 households, from three representative municipalities, reported at least one serious burn in the previous 12 months: a serious burn was defined as one requiring medical attention and/or inability to work or do normal activities for 24 hours. While only 4 paediatric and 10 adult cases in the previous 12 months reached hospital care, the impact on the lives of those involved was profound. Only one patient was referred on from primary to secondary/ tertiary care; the average length of hospital stay for those presenting directly to secondary/tertiary care was 21 days. A range of first aid behaviours were used, many of which are appropriate for the local context while a few may be potentially harmful (e.g., the use of dung). Conclusion. The participatory approach used in this study ensured a high response rate. We have demonstrated that infographics can link the pathway for each of the cases observed from initial incident to final location of care.

PUBLISHED IN: Phuyal K, Ogada EA, Bendell R, et al, ‘Burns in Nepal: a participatory, community survey of burn cases and knowledge, attitudes and practices to burn care and prevention in three rural municipalities’, BMJ Open (2020) ;10:e033071. doi: 10.1136/bmjopen-2019-033071

Finding the Best Way to Deliver Online Educational Content in Low-Resource Settings: Qualitative Survey Study

AUTHOR: Lucy Kynge 

ABSTRACT: The reach of internet and mobile phone coverage has grown rapidly in low- and middle-income countries (LMICs). The potential for sharing knowledge with health care workers in low-resource settings to improve working practice is real, but barriers exist that limit access to online information. Burns affect more than 11 million people each year, but health care workers in low-resource settings receive little or no training in treating burn patients. Interburns’ training programs are tailor-made to improve the quality of burn care in Asia, Africa, and the Middle East; the challenge is to understand the best way of delivering these resources digitally toward improved treatment and care of burn patients.

PUBLISHED IN: Kynge L, ‘Finding the Best Way to Deliver Online Educational Content in Low-Resource Settings: Qualitative Survey Study’, JMIR Med Educ 2020;6(1):e16946. URL: https://mededu.jmir.org/2020/1/e16946. DOI:10.2196/16946. PMID: 32452810

Estimating the cost impact of dressing choice in the context of a mass burns casualty event

AUTHORS: Lowin J, Winfield T, Price P, Anderson P, Potokar T

ABSTRACT: Mass casualty burn events (MCBs) require intense and complex management. Silver-infused longer use dressings might help optimise management of burns in an MCB setting. We developed a model estimating the impact of dressing choice in the context of an MCB. The model was developed in Excel in collaboration with experienced emergency response clinicians. The model compares use of silver-infused dressings with use of traditional dressings in patients with partial thickness burns covering 30% of their body. Costs were estimated from a UK perspective as a proxy for a funded emergency response team and limited to cost of dressings, bandages, padding, and analgesia and staff time. Expected patient costs and resource use were summarised over an acute 2-week intervention period and extrapolated to estimate possible timesaving’s in a hypothetical MCB. Per patient costs were estimated at £2,002 (silver) and £1,124 (traditional) (a daily additional spend of £63). Per patient staff, time was estimated at 864 minutes (silver) and 1,200 minutes (traditional) (a daily time saving of 24 minutes). Multiplying up to a possible MCB population of 20 could result in a saving equivalent to 9 staff shifts over the 2-week intervention period. The model was sensitive to type of silver dressing, frequency of dressing change and staff costs. We found increased costs through use of silver dressings but timesavings that might help optimise burns management in an MCB. Exploring the balance between costs and staff time might help future MCB response preparation.

PUBLISHED IN: Lowin J., Winfield T., Price P., Anderson P., Potokar T., ‘Estimating the cost impact of dressing choice in the context of a mass burns casualty event’, Annals of Burns and Fire Disasters, vol. XXXII n. 3, (2019), pp. 222-226. https://cronfa.swan.ac.uk/Record/cronfa53529http://www.medbc.com/annals/review/vol_32/num_3/v32n3content.htm

Review of the epidemiology of burn injuries in Ethiopia; implications for study design and prevention

AUTHORS: Edna Adhiambo Ogada, Abiye Hailu Gebreab, Thomas Stephen Potokar

ABSTRACT: Background: 90% of burn deaths occur in lower resource settings, where prevention programs are uncommon. Efficient planning and resource allocation for prevention requires consistent and reliable data. Published research on burn epidemiology from these settings is limited in scope and rigor and often not replicable. Objective: The objective of the review was; to examine the literature to determine what information exists on the epidemiology of burn injuries in Ethiopia; to assess its utility and suitability for planning interventions for burn prevention. Methods: Taking a public health approach in which burn injuries fall within the broader field of injury, a broad key term search was performed in Safety Lit and MEDLINE. We reviewed the literature on burn epidemiology in Ethiopia, to assess its utility and suitability for planning interventions for burn prevention. Results: Our search strategy yielded more information than burn specific search strategies. We identified 23 studies drawn from observational and primarily hospital-based, cross sectional studies. They offer a preliminary evidence base that can be used to make recommendations for future surveillance, risk factor exploration and prevention initiatives. Conclusion: We conclude that the low rate of burn cases identified from observational studies; the challenge of defining and coding injury in the field; recall bias; mean case series data from tertiary units are more efficient and sustainable for monitoring burn epidemiology in Ethiopia. We recommend the establishment of a national trauma registry or WHO’s Global Burn Registry (GBR) to gather data in Ethiopia and countries in comparable settings. Community studies, provide the best avenue to gauge knowledge, attitudes and practices relevant to injury prevention, first aid and health seeking behaviour. This critical preliminary synthesis on burn epidemiology frames future national research and policy on burn surveillance and prevention.

PUBLISHED IN: Edna Adhiambo Ogada, Abiye Hailu Gebreab, Thomas Stephen Potokar, ‘Review of the epidemiology of burn injuries in Ethiopia; implications for study design and prevention’, Burns Open 3 (2019), pp. 75–82. https://doi.org/10.1016/j.burnso.2019.05.002.

Developing and implementing a community led burn prevention programme and first aid programme in three rural municipalities in Nepal.

AUTHORS: Edna Adhiambo Ogada, Kamal Phuyal, Richard Bendell, Patricia Price, Tom Potokar

ABSTRACT: A poster to summaries the work carried out in Nepal. The poster highlights the geographic regions of the community survey into burn incidence and treatment, the main objectives and methods, proposed interventions, and the barriers and facilitators to the prevention propositions. It showcases how the CGBIPR uses implementation science to study knowledge, attitudes and practices surrounding burns and design effective community prevention programmes.

PRESENTED AT: Phuyal, Kamal; Ogada, Edna (presenter); Bendell, Richard; Price, Patricia and Potokar, Thomas, ‘Developing and implementing a community-led burn prevention and first aid programme in three rural municipalities in Nepal’, presented at Global Implementation Conference, Glasgow, 16-17 September 2019.

Implementation and Improvement Science: A course for nurses working in burns units in Malawi and Ethiopia

AUTHOR: Maria Holden (nee Beard)

ABSTRACT: A poster detailing the course aims and summary for the Implementation & Improvement Science workshop. The workshop was designed for nurses working in low to middle income countries in burn care settings and this pilot took place with nurses from five hospitals in Malawi and Ethiopia. The aim of this course was to improve the burn care in these areas by training nurses in quality improvement processes to be applied on their own wards.

PRESENTED AT: Beard, Maria (presenter); Ogada, Edna, ‘Implementation and Improvement Science: A course for nurses working in burns units in Malawi and Ethiopia’, presented at International Nurses Day is Nurses: A Voice to Lead – Health for All Event at University of Nottingham, Nottingham, 2019.

Advanced Burn Care Report 

AUTHOR: Caitlin Hebron 

ABSTRACT: A report on the Advanced Burn Care training that took place in Addis Ababa, Ethiopia (March 2020). The report details each day of the training, the topics covered, and the issues currently faced. This course was designed to enhance burn care through education and knowledge share to those working in burn units in low resource settings.

PRESENTED AT: Disseminated online. 

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