Stream Overview

Recommendations

Identify and Treat the Cause
1 Take a history and perform a physical examination of the burned skin. Level of Evidence
5


Address patient-centered Concerns
2 Provide ongoing support and education that is appropriate for the age, developmental, cognitive, and psychological status of the patient, family, and/or caregivers throughout all phases of recovery. Level of Evidence
5
3 Enable the patient to identify the functional implications of his/her individual scar and contribute to planning future needs. Level of Evidence
5
4 Ensure adequate pain management using a combination of medications and non-pharmacological techniques to allow for optimum function. Level of Evidence
5
5 Discuss with the patient and encourage return to work as soon as possible. Level of Evidence
5


Provide Local Wound Care
6 Determine depth and extent of burn area or stage wound healing on an ongoing basis. Level of Evidence
5
7 Prepare the wound using appropriate burn care principles, including minimizing edema, and cover the wound with an appropriate dressing. Level of Evidence
5
8 Consult appropriate Professionals, including a Dietitian to ensure appropriate nutrition Level of Evidence
3b
9 Implement scar management techniques. Level of Evidence
5
10 Provide post burn wound care. Level of Evidence
5


Provide Organizational Support
11 Empower an interprofessional burn team ensuring involvement of appropriate professionals, e.g., Dietitian, OT, PT, and provide education and support. Level of Evidence
5


Background

Burns are often categorized as first-, second-, or third-degree burns. All burns should be quickly treated to reduce the temperature of the burned area and reduce damage to the skin and underlying tissue. Burns can cause potential fatal complications such as shock, infection, electrolyte imbalance and respiratory distress. Burns can also result in severe psychological and emotional distress due to scarring and deformity. When tissues are burned, fluid leaks into them from the blood vessels, causing swelling and pain. Older people and young children are particularly vulnerable to burns.

A systematic literature search for clinical practice guidelines on surgical wounds was completed using the Medline, CINAHL, and Embase databases and 46 guideline clearinghouses. A librarian was involved in identifying the appropriate keywords and search strategies to ensure that all guidelines on the topic were found.

307 burns clinical practice guidelines were found in the English literature from 2002 until May 2007. Many of these published articles were excluded due to a variety of reasons. They were: not specifically addressing surgical wounds, articles, review papers, not CPGs, supplemental documents of a guideline and quick reference guides.

Of the identified papers, 8 guidelines were appraised by a minimum of three reviewers using the AGREE instrument (http://www.agreecollaboration.org/instrument/). The AGREE instrument has six domains: scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, and editorial independence. It is not recommended that the scores obtained for the domains be aggregated. Instead the guidelines that received the highest scores for most of the domains and particularly for rigour of development were ranked highest and their recommendations will be reported throughout this Acute Wounds - Burns stream.

The most highly ranked guidelines were Samson’s Wound-Healing Technologies: Low-Level Laser and Vacuum-Assisted Closure (2004); Jacob’s “Practice Management Guidelines for Nutritional Support of the Trauma Patient (2004); Simon’s “OT/PT Forum. Occupational Therapy and Physiotherapy for the Patient with Burns: Principles and Management Guidelines (2003); Alsbjorn’s Guidelines for the Management of Partial-thickness Burns in a General Hospital or Community Setting – Recommendations of a European Working Party (2006).

The following figure indicates the AGREE domain scores for these burns guidelines.

The following recommendations are intended to help busy clinicians provide excellent care. They are based on the high ranking guidelines that are referenced. Since each of the guidelines addresses a very specific topic, our recommendations are expressed in general terms to make them more useful to burn practitioners generally. Clinicians needing specifics are advised to review the appropriate guideline.

References

High Ranking Guidelines
1 Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Samson DJ, Lefevre F, Aronson N. Wound-Healing Technologies: Low-Level Laser and Vacuum-Assisted Closure. Agency for Health Care Research and Quality. December 2004.
In this guideline the evidence on low-level laser therapy or vacuum-assisted closure (VAC) on wound-healing outcomes is systematically reviewed. These wound-healing technologies were assessed based on the incidence of complete wound closure, time to complete closure and adverse effects. Many factors influencing wound healing are indicated, such as poor nutrition, metabolic derangements, drugs, tissue hypoxia, infection and dry wound bed. VAC treatment was suggested to be used not for complete wound healing, but to advance the wound to a stage where wound healing is possible. These results and evidence comparing low-level laser therapy and VAC were limited due to poor trial quality. On going RCTs with greater sample sizes, group comparability and well defined primary outcomes may provide better evidence on outcomes of interest.
2 Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Jacobs DG, Jacobs DO, Kudsk KA, Moore FA, Oswanski MF, Poole GV, Sacks GS, ‘Tres‘ Scherer III LR, Sinclair KE. Practice Management Guidelines for Nutritional Support of the Trauma Patient. Journal of Trauma 57.3 (2004): 660-79.
This guideline provides principles of nutritional support such as route, timing, site of nutritional support, macronutrient formation, and monitoring and type of nutritional support for the treatment of trauma patients.
3 Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Simons M, King S, and Edgar D. Occupational Therapy and Physiotherapy for the Patient with Burns: Principles and Management Guidelines. Journal of Burn Care & Rehabilitation 24.5 (2003): 323-335.
This guideline provides key principles of respiratory management, edema management, splinting and positioning, physical function, scar management, and psychosocial and mutual elements such as work safety, education, pain management, and professional development in addressing patient needs as burns patients. Although it was developed for OT and PT practitioners, its usefulness is more universal. Levels of evidence were not reported.
4 Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Alsbjorn B, Gilbert P, Hartmann B, Kazmierski M, Monstrey S, Palao R, Roberto MA, Trier AV, Voinchet V. Guidelines for the Management of Partial-Thickness Burns in a General Hospital Or Community Setting-Recommendations of a European Working Party. Burns 33 (2007): 155-160.
This guideline provides key areas that need to be included in the treatment algorithm for burns, specifically the management of partial-thickness burns. They are: diagnosis and referral, wound preparation, wound covering and post-wound care, useful for all practitioners. The recommendations are based on consensus statements and expert opinion from burns specialists. The levels of evidence for the recommendations are not reported.


Enablers for practice

Coming Soon...