November 21, 2016
Leticia Ryan, M.D.
Too often, says pediatric emergency medicine specialist Leticia Ryan, patients transported to the Johns Hopkins Pediatric Burn Center arrive with burns somewhat different than those described by the referring hospital. And more often than not, Ryan and her colleagues found in a recent study of 164 children transferred from 30 referring facilities, those burn assessments overstate the size and severity of the burn.
Indeed, the quality improvement study found that the initial estimated total body surface area, or TBSA, of burns reported by referring facilities was high in 86.7 percent of cases and low in 6.7 percent. Such discrepancies, Ryan adds, may influence mode of transport and trigger inappropriately aggressive fluid management and other interventions with potential for patient harm.
“Prior to the patient’s arrival, we may make treatment recommendations based on an initial description that proves to differ from our own description,” says Ryan. “So if there’s a big difference in the number representing the amount of skin involved and the total burn surface area, that could lead to too little or too much fluid being given, which could affect the quality of care and the healing of the burn.”
It’s not that providers at referring hospitals aren’t doing their best to assess burns, Ryan explains, but estimating the size of burns can be difficult to do, and not all providers use the same instruments or techniques in measuring burns. While the gold-standard Lund and Browder chart, a fairly detailed diagram with percentage surface areas of different parts of the body, is most often used, some referring hospitals rely on the Rule of Nines chart, which splits the body into 11 areas of 9 percent. Some providers wrap cling film around the burn and then remove it and measure it, others may rely on computer algorithms, and some simply eyeball the burn.
“The standards for assessing burns are loose, and providers are using different systems and tools,” says Ryan. “Part of it is human nature.”
To optimize the care of these patients, Ryan and her colleagues are reaching out to referring hospitals in the state to help everyone get on the same page in evaluating burns. They are also conducting workshops on the tools used by the Johns Hopkins Pediatric Burn Center.
“So we’re all communicating and doing our best to share our approach for these patients,” says Ryan. “Ultimately, we’ll see if we’re getting closer to more consistent estimates.”
The quality improvement study was a collaboration of the Division of Pediatric Emergency Medicine, the Pediatric Transport Service, and the Pediatric Trauma and Burn Program at the Johns Hopkins Children’s Center.