Current Anaesthesia & Critical Care (2002) 13, 83^ 86 2002 Published by Elsevier Science Ltd.cdoi:10.1054/cacc.402, available online at http://www.idealibrary.com onFOCUS ON: BURNS AND PLASTICSOrganization of burns servicesS. J. SquiresMcIndoe Burns Centre, QueenVictoria Hospital NHS Trust, East Grinstead, West Sussex RH19 3DZ, UK KEYWORDS Summary In commonwith many aspects of acute health careinthe United Kingdom, burns, critical care burns care is currently undergoing signi¢cant review and recon¢guration. Anaesthesia peri-operative care, and Critical Care provision form an integral part of burns care and are thus part of this resuscitation anaesthesia change. Bringing burns critical care in line with modern general adult and paediatric in- tensive care is highly desirable, but will need to be achieved with minimal disruption to continuity of service and with careful attention to sta¡ retention. National,College and Association Guidelines for service provision and training should inform the strategy for recon¢guring local burns services and be applied appropriately to ensure that change, once achieved, is for the better.Where possible these guidelines should be appliedlocally to optimize the anaesthetic and critical care of burned patients in advance of wider ser- vice recon¢guration. 2002 Published by Elsevier Science Ltd. cHISTORYAND BACKGROUND largely made on historical grounds, and the units devel- oped locally with plastic surgery, according to localThe care of patients with burn injuries underwent need and desire, and largely independent of onemajor changes during the last century. The most rapid another. This has resulted in a heterogeneous group ofdevelopments in burn care have come at times of con- facilities, bearing little resemblance to one another, with£ict, with major advances in burn surgery coming during some occupying separate sites, and some developingthe Second World War. Up until that time, patients with within district general hospitals or within large teachingburns a¡ecting more than one-third of the total body hospital groups. They also di¡er markedly in termssurface area (TBSA) were not expected to survive,1 of style, working practices, activity levels and sta⁄ngwhereas, by the 1990s, patients with massive injuries of pro¢le.190% TBSA might eventually return to the community, al- Although burns care in Britain had led the way in inno-beit after a long and involved hospital stay. vation, by the end of the 20th century it had fallen behind Since the 1950s developments in the understanding of in comparison with the best services elsewhere in the£uid resuscitation, the pathophysiology and medical western world. Furthermore, burns services did not ¢ttreatment of burns, the availability and use of antibiotics, easily with modern NHS aspirations for equity of access,dressing materials and techniques, and the early excision standards of care, particularly critical care, and theand closure of the burn wound, have all led to steady im- process of health commissioning. These issues combinedprovements in prognosis. to stimulate a desire for change.3 During the same period signi¢cant advances inanaesthesia and intensive care have enabled seriouslyburnt patients to survive for prolonged periods,with respiratory, cardiovascular and renal support, and THE NATIONAL BURN CARE REVIEWto undergo the repeated and protracted surgical epi- (NBCR)sodes needed to achieve closure and healing of the burn In 1998 the British Burns Association received supportwound. from the Department of Health for a complete review The concept of the burns team became recognized of burns care in the UK. In 2001 The National Burn Careand the ¢rst purpose built burns units were established Review Committee published its report.2 This extensiveduring the1960s.2 The choice of sites for these units was document reviews current services, argues for change, and makes recommendations under eight headings whichCorrespondence to: SJS.Tel.: +44 - 01342- 410 210 are summarized below.0953-7112/02/$ - see front matter
84 CURRENT ANAESTHESIA & CRITICAL CARESummary of NBCR recommendations rescued and resuscitated by the ¢re or ambulance ser- vice and may arrive at hospital in-extremis. Patients requiring resuscitation will usually have this(1) Uniform clinical management and referral guidelines (see provided, or commenced, in A&E before being referred below): Based on complexity of injury rather than onto the burns specialist unit. Guidelines for resuscita- simply on extent of body surface area a¡ected.(2) In-patient provision for burn injuries to be provided by tion, and criteria for referral will normally be dissemi- nated by burns units to their ‘feeder’ district general specialists. hospitals. This enables the burns teams to in£uence the(3) A new structure for burns care services: Strati¢cation condition of patients arriving in their units, and is largely into Burns Facilities, Units or Centres. These are e¡ective. It is now unusual for patients to be inadequately de¢ned according to facilities, specialist sta¡ and resuscitated and early renal failure, due to hypovolaemia, supporting services available on-site and determine is rare. Burns are relatively common at the extremes of the complexity of injury admitted, with facilites age, and for both small children and elderly adults, even a caring for non-complex injuries and centres for the most complex. limited injury may require admission. Severe major inju- ries are rare but these patients, in order to survive, will(4) Critical care provision: Discussed further below. need prolonged intensive and high dependency care, re-(5) Continuing care as part of a burn service: Physical and peated surgical episodes to excise the wound and pro- psychological rehabilitation. Outreach teams. vide both temporary and permanent skin cover, and(6) A national network of services: Involving primary care, prolonged rehabilitation. A&E departments, and specialized burns services,(7) Research and development: Into dependency scoring, care pathways and outcome measures.(8) Improved data gathering and analysis: Further Table 1 Proposed national guidelines for burn injury development of the British Burn Injury Database referral (BIBID). Complex injury F refer to local specialist burns service The review calls for immediate implementation in Age Below 5 or over 60 yearssome areas, particularly in the establishment of suitable Site Face, hands, perineum, feet Flexureservices for the severely burned child. Paediatric inten- Circumferential to limb, torso or necksive care unit (PICU) services have developed in major, Any inhalation Excluding pure carbon monoxidelargely teaching, centres, and are rarely co-sited with injury poisoningburns services.This situation has forced burns specialists Mechanism Chemical 45% total body surfaceto either care for major paediatric burns in units lacking area (TBSA)in accredited PICU facilities and expertise, or to transfer Ionizing radiationpatients to PICUs where burns expertise is not available. High-pressure steamNeither situation is acceptable, or comfortable for the High-tension electricalclinicians concerned. Suspicion of non-accidental injury The NBCR report is currently being adopted for imple- (adult or paediatric)mentation by the Department of Health.The identi¢cation Size Paediatric 45% TBSA Adult 410% TBSAand development of services to be designated as burns Pre-existing Systemic or debilitating conditions‘Centres’, ‘Units’ or ‘Facilities’, if to be followed as recom- illnessmended, will require care, time and resource if valuable Associated Head injuryspecialist sta¡ are to be retained and new sta¡ recruited. injuriesAs has been seen in general ITU, allocation of ¢nance for Fractures or crush injuriesbed expansion has not necessarily brought with it the spe- Penetrating injuriescialist nursing sta¡ who remain our most valuable resource. Non-complex F refer to local plastic surgery service Size of skin Paediatric; 2^5% TBSA injuryCURRENT BURNS CARE; GENERAL Adult: 5^10% TBSACONSIDERATIONS Other injuries F often suitable for A&E or community careRelatively trivial burn injuries may never present for Non-acute F may require referral in the post acute phasemedical care while signi¢cant minor injuries may be man- Wound Wound unhealed at14 days post-burnaged in the primary care setting. More severe burns will healinggenerally arrive at accident and emergency departments Complications Local or systemic sepsiseither as ambulatory patients or via the ambulance ser- Rehabilitation Complicated scarringvice. The most seriously burned patients may have been
ORGANIZATION OF BURNS SERVICES 85 Around 25/100 000 population require hospital admis- surgical, anaesthetic, therapist and ¢nancial resource.sion for burns annually. Two-thirds of these patients are The care of these patients is very demanding on the sta¡admitted to hospitals with specialist burns services and who become, in themselves, a rare specialist resource.represent a broad spectrum of severity. Patients who The NBCR seeks to set standards of care and facilitiesare initially cared for in the community or admitted to which will bring burns critical care closer in location andgeneral hospitals may be referred late to specialist standards to general ICUs. Achieving this will be particu-services with complications or poor healing. The NCBR larly demanding for the burned child for whom at pre-has outlined national referral guidelines to bring some sent it is di⁄cult to identify the ideal arrangementuniformity to referral practices in the NHS. These are anywhere in the UK, where a burns unit is co-sited withsummarised in abbreviated form inTable 1. a fully accredited PICU. Good communication between specialist burns ser- In the meantime consultant sessions for burns anaes-vices and local accident and emergency departments is thetists/intensivists should be adequate to provide theessential. Standardized referral documentation can be best 24 -h cover currently feasible for burned patientsprovided which can then be faxed to the receiving unit requiring critical care. Every e¡ort must be made toprior to transfer. Telemedicine links, being developed in provide appropriately trained nursing support to burnsome areas, may prove to be valuable, enabling specia- wards or, as proposed in the NBCR, achieve mutuallists to give advice on the treatment of cases that may support and co-operation with a co-sited adult ITU. Out-not require immediate transfer. Education, such as the reach capabilities should be developed by the burns ser-‘Emergency Management of Severe Burns’ (EMSB) course vices to support professionals in general wards and ITUscan be o¡ered by the specialist burns sta¡. when, for whatever reason, patients cannot be trans- The emergence of multiresistant bacterial strains, and ferred to the specialist unit.the virtual inevitability of contamination of the burn pa-tient demands aggressive infection control measures,and a continued degree of physical and procedural se- ANAESTHESIA FOR BURN INJURIESparation of burns beds and sta¡ from the wider generalhospital population. Provision Anaesthetists may be involved at all stages of acute burns care. Most patients will enter the hospital system via theBURNS CRITICAL CARE PROVISION accident and emergency department. Initial resuscitation may involve assessing and securing the threatened air-Critical care for burned patients is delivered mainly with- way, initiation of arti¢cial ventilation, analgesia and seda-in burn units, mainly by burn anaesthetists/intensivists, tion, establishing adequate venous access and invasiveworking with specialist burns nurses who may also occa- monitoring. Major cases, referred to specialist services,sionally hold a recognized intensive care quali¢cation. may require stabilization for, and care during transfer.This situation obviously £ies in the face of recommended Anaesthetists are likely to be called upon to managepractice for critical care. It has arisen as a result of the these procedures, and within the general hospital set-development of burns care separate from adult and pae- ting, they will represent the normal extent of anaes-diatric ICUs, which are also physically separated, often thetic involvement.by great distances, from the burns wards. Patients with major complex injuries will only survive Due to the relative rarity of major burns requiring in- with excision of the burn wound at the earliest possibletensive care, burns units which admit these patients are stage. The most extensive wounds will require very pro-unlikely to achieve the levels of throughput of even the tracted and repeated surgical procedures and dressingsmallest general intensive care units. This makes recruit- changes at a time when they may be highly dependent onment and retention of intensive care nurses very di⁄cult support of both the respiratory and cardiovascular sys-in a competitive market. It also means that anaesthetist/ tems.These patients comprise some of the most compro-intensivists working exclusively in these units will ¢nd it mised patients to undergo planned surgery, as it may notdi⁄cult to remain current in the more general aspects of be possible to improve their condition without it.ICU work. Proposed transfer of burns patients to gener- Later during their recovery period, patients will needal adult or paediatric ICUs may be met with reluctance as revision of scarred areas, and reconstructive proceduresspecialist burns nursing and surgical skills may not be during which time they may have developed contrac-available at the ICU location. tures which threaten safe airway management. The most severely injured patients will require ICU At the specialist burns unit, anaesthetists will bestays measured in weeks rather than days, with a high involved inincidence of contamination with multi-resistant organ-isms, multiple surgical interventions, and frequent dres- K receiving and stabilising patients,sing changes which are hugely demanding on nursing, K management of high dependency and intensive care,
86 CURRENT ANAESTHESIA & CRITICAL CARE Table 2 RCA & ABRA guidance for the provision of burns anaesthesia services (2001)Fsummary Incorporating NBCR recommendations (1) Emergency anaesthetic assessment and treatment may be required in any hospital with an A&E department. Guidelines should be available for immediate care and transfer (2) Burns centres provide care for complex injuries with large TBSA; Burns Units provide care for complex injuries with small TBSA;Burn facilities provide care for non-complex injuries (3) The responsibility for critical care of burned patients should be shared between burns anaesthetists/intensivists, and burns surgeons. (4) The critical care of burned patients is an integral part of burns anaesthesia services. Specialist departments need to provide protocols, sta¡ training, and rapid availability of resources (5) Provision of beds for burnintensive care must be adequate.With su⁄cient workload these willbein a Burns ICUwithin a Burns centre.With lesser workloads they will be in general ITU or paediatric intensive care unit (PICU) (6) Critical care beds for burns patients need to be in close proximity to an operating theatre and other support facilities (7) Major burn anaesthesia should only take place in a Burns Centre or Burns Unit with full consultant cover (8) Paediatric burn cases require special facilities and sta⁄ngK anaesthesia thorough training in all aspects of anaesthesia for burns,K peri-operative care. plastic and reconstructive surgery. The Association of Burns and Reconstructive Anaesthetists (ABRA) (for- As in most acute clinical areas, delivery of the best merly the Plastic Surgery and Burns Anaesthetistscare is by a well led multidisciplinary team comprising FPSBA) have identi¢ed key areas of training and com-nursing, medical, therapist, technical, and supporting petence for anaesthetists.5 Most of the anaesthetic skillssta¡. Burns surgeons, anaesthetists and nurses will need required are generic, however, the unique nature of theto co-operate closely, and for the initial stages of surgery, patients and the demands they make on acute health ser-will need access to a dedicated operating theatre for long vices, make specialist experience essential.periods, and be able to mobilize large theatre teams at It is important that, despite limited training opportu-relatively short notice.These logistical requirements are nities in some areas, as many anaesthetic Specialist Re-challenging to deliver with the limited resources. Com- gistrars as possible are exposed to the care of majorbined with the high elective and emergency demands burns.With current limitations on trainee doctors hoursbeing made on UK operating theatres the need for a being introduced through the ‘New Deal’, and the rela-dedicated burns theatre is clear. This is also likely to re- tively small number of the most severe injuries, it is con-duce the infection control risk to the general hospital po- sidered that a 6 month attachment to a departmentpulation posed by severe burns cases. providing a burns anaesthetic service is the realistic mini- The Royal College of Anaesthetists and the Associa- mum to achieve training aims.tion of Burns and Reconstructive Anaesthetists has re-cently drafted ‘Guidance for the Provision of BurnsAnaesthesia Services’.4 This incorporates NBCR recom-mendations and is summarized inTable 2. REFERENCES 1. National Burn Care review. Committee Report. 2001.Training 2. Sutherland A. Organisation of burn care facilities. In: Settle JAD (ed). Principles and Practice of Burns Management. New York:All anaesthetists will need, on completion of training, to Churchill Livingstone, 1996; 43–49.be competent in the assessment and early management 3. Judkins K. Burns treatment in the 21st century: a challenge forof burns injuries which might present to the general hos- British anaesthesia. Anaesthesia 1999; 54(12): 1131–1135. 4. Guidance on the Provision of Burns Anaesthesia Services.pital A&E department. A further group may be required, Association of Burns and Reconstructive Anaesthetists, 2000.as consultants, to provide sessions in plastic surgery with 5. Plastic Surgery and Burns TrainingFContent and Minimumoccasional burns surgery.Those anaesthetists working as Caseload. Association of Burns and Reconstructive Anaesthetists,consultants in burns centres will need to have received a 2000.