THE WINSTON CHURCHILL MEMORIAL TRUST OF AUSTRALIA YVONNE SINGER - 2007 Churchill Fellow THE JACK BROCKHOFF FOUNDATION CHURCHILL FELLOWSHIP Burns Surveillance, Prevention and Management I understand that the Churchill Trust may publish this Report, either in hard copy or on the internet or both, and consent to such publication. I indemnify the Churchill Trust against any loss, costs or damages it may suffer arising out of any claim or proceedings made against the Trust in respect of or arising out of the publication of any Report submitted to the Trust and which the Trust places on a website for access over the internet. I also warrant that my Final Report is original and does not infringe the copyright of any person, or contain anything which is, or the incorporation of which into the Final Report is, actionable for defamation, a breach of any privacy law or obligation, breach of confidence, contempt of court, passing-off or contravention of any other private right or of any law. Signed Dated Yvonne Singer 8 October 2008 1
INDEX Introduction 3 Executive Summary 4 Fellowship Programme 5 Burns Prevention 6 The role of burns services and ANZBA in burn prevention 6 Strategic planning 6 Applying Evidence 7 Fostering Partnerships 7 International Collaboration 7 Specific Burns Prevention Programs 8 Knowing the Target Audience 8 Measuring Outcomes 9 A Useful Acronym 9 National Burn Registries 9 Clinical Indicators 10 Data 10 User Friendliness 11 Verification 11 Burns Service Benchmarking 12 Recommendations 13 Dissemination & Implementation 13 Conclusion 14 2
Introduction In 2007, I was fortunate to receive the Jack Brockhoff Foundation, Winston Churchill Travelling Fellowship. The goals of the travelling fellowship were to further my knowledge, expertise and networking with regards to the development of state and national burns prevention programs and models; the development and application of national burns registries and benchmarking of clinical burns services with international colleagues. For the last 7 years I have been employed as the Care Coordinator of the Victorian Adult Burns Service at The Alfred Hospital in Melbourne Victoria. The core aspect of my role is to coordinate the clinical care of all patients within VABS, however during this time I have been actively involved in burns prevention activities on a local, state and national level. Furthermore, I have been responsible for the development of the Australian & New Zealand Burns Association National Burn Registry. This report summarises the key learnings from the fellowship and their relevance and application for Victorian Adult Burns Service (VABS), the Victorian Burns Prevention Partnership (VBPP) and the Australian & New Zealand Burns Association (ANZBA). I gratefully acknowledge the support of the Jack Brockhoff Foundation and the Winston Churchill Trust in making this possible. The opportunity has been invaluable for burns care in Australia. 3
Executive Summary Yvonne Singer Care Coordinator Victorian Adult Burns Service The Alfred Hospital Commercial Road Melbourne 3004 The goals of the travelling fellowship were to further knowledge, expertise and networking with regards to the development of state and national burns prevention programs and models; the development and application of national burns registries and benchmarking of clinical burns services with international colleagues. Highlights Travelling in May and June 2008, the organisations and places I visited were: 1. American Burns Association Conference, Chicago, Illinois. 2. American College of Surgeons, National Trauma Data Bank, Chicago, Illinois. 3. Weill Cornell Medical Centre, NY Presbyterian Hospital, New York 4. US Burn Prevention Foundation, Allentown, Pennsylvania 5. Le High County Burn Centre, Allentown, Pennsylvania 6. International Association of Fire Fighters, Washington, Virginia Recommendations ANZBA needs to embed prevention into its common vernacular. ANZBA and the VBPP need to develop a strategic plan that will strengthen their roles as key advocates in the prevention of burn injuries. Evidence should support prevention programs and their proposals. All efforts should be made to measure the effectiveness and outcomes of prevention initiatives. Research into burns injury prevention should be pursued. Partnerships should be fostered with key stake holders who can provide expertise, access and resources. In regards to the National Data Registry, ANZBA needs to develop indicators to benchmark clinical care and eventually outcomes, refine its minimum data set and prevention activities should inform the future evolution of the ANZBA NBR. ANZBA, the VBPP and VABS should pursue avenues now open for networking with international peers in the areas of burns prevention and data registries. Implementation & Dissemination Outcomes from the fellowship were presented recently at the ANZBA Annual Scientific Meeting in September 2008. Learnings and recommendations have been incorporated into the strategic plan of the ANZBA Burns Prevention Committee. Additionally these outcomes have already been integrated and actioned into the VBPP strategic plan. Learnings regarding National Burn Data Registries has already been fed back to the ANZBA National Burn Registry(NBR) Steering and Reference Committees and the Monash University Department of Epidemiological Medicine. It will help to shape the future evolution of the ANZBA NBR which is about to undergo a major overhaul. And finally, the burns service learnings have been and will continue to be disseminated through the VABS Burns Development Group as well as the ANZBA Nursing group. The outcomes from the fellowship should not be considered only in terms of what was learnt whilst I was overseas but also in terms of the relationships forged across the pond and the future potential of these relationships with regards to burns prevention and national data registries. 4
Fellowship Programme Travelling in April May and June 2008, the people, organisations and places I visited were: 1. American Burns Association Conference, Chicago, Illinois. Special thanks to Jimmy Parkes, chair of the ABA Burns Prevention Committee. 2. American College of Surgeons National Trauma Databank, Chicago, Illinois. With thanks to Chrystal Price (NTDB Coordinator) and Melanie Neal (NTDB Manager) 3. William Randolph Hearst Burns Center, Weill Cornell Medical Centre, NY Presbyterian Hospital, New York With thanks to Associate Professor Palmer Bessey, 4. US Burn Prevention Foundation, Allentown, Pennsylvania. With thanks to Dan Dillard, Executive Director. 5. LeHigh County Burn Center, Allentown, Pennsylvania. With thanks to Jackie Fenicle Nurse Unit Manager. 6. International Association of Fire Fighters, Washington, Virginia. With thanks to Patrick Morrison. 5
Burns Prevention In 2003, I established the established the Victorian Burns Prevention Partnership a collaboration between the Victorian state burn and fire services raising community awareness of burns prevention. These organisations are the Metropolitan Fire Brigade, Country Fire Authority, Royal Childrens Hospital and Alfred Hospital. Now firmly established, the VBPP is committed to further consolidating its role as a key advocate for the prevention of fire and burn injuries in Victoria. Moreover the VBPP has put forward their organisational framework as a template for fire and burns services across Australia and New Zealand to work collectively together in raising awareness of burn injuries and their prevention. The fellowship was invaluable in seeing how international fire and burns service peers work together on a national scale. The role of burns services and ANZBA in burns prevention Burns prevention is not the core business of tertiary services and organisations such as Burns services and ANZBA. However prevention should be embedded into the common vernacular. Prevention is palatable. It presents a kind and gentle face to an often devastating injury, a non threatening forum for the general public to glimpse the work of burns services, conceptually giving them a greater understanding and appreciation for what that is. Burns services possess a unique body of knowledge, expertise and facts. They are best poised to know the consequences of burn injuries almost better than anybody. This unique knowledge can provide invaluable insight and understanding into the mechanism, extent and consequence of injury that can produce a resonating and powerful voice to imbibe change and action in both the community and government that will make the country a safer place for all Australians. Strategic Planning To move forward ANZBA need to develop a strategic plan that will strengthen its role as a key national advocate in the prevention of burn injuries. Individually each burns service or in some cases states, have been working on burns prevention activities with limited success. Opportunity is now ripe to pool our resources and step up to the plate and work on a national level - and dare I say international level to maximise potential. Fortunately 2008 is the year that ANZBA spawned its Burns Prevention Committee. It is invaluably opportune that this fellowship came a few months beforehand, the benefits of which have begun to be reaped already at the recent ANZBA Annual Scientific Meeting in September 2008. The future is bright. ANZBA needs to determine a constitution to govern how it operates. Its strategic plan should have both long and short term goals with regards to specific burns prevention activities and what ANZBA wants to achieve as an organisation. Once this is identified, ANZBA needs to set an agenda for the next 3 to 5 years to guide our activities to meet these goals. This is a recipe for sustainability. 6
Applying Evidence As with the other realms of our work, ANZBA s work in burns prevention must be supported by scientific evidence and rigorous methodology. Health officials and policy-makers require this scientific framework as a basis for establishing priorities, and allocating resources. Data from the ANZBA National Burn Registry should inform and drive burns prevention efforts. It should also help prioritise them. Data should be used to identify and track immerging trends in injury and support, lever and justify burns awareness and prevention activities and proposals. ANZBA s data registry can also provide evidence to support changes in legislation that could reduce burns injury and assist in lobbying for change to engineering that can make Australian environments safer. It is equally important that burns prevention activities influence the future evolution of the ANZBA NBR. ANZBA should pursue research into burns injury prevention. It has access to potentially valuable & willing research candidates who can offer great insight into the mechanisms of specific types of burn injury along with the causative and contributing factors. This insight can greatly assist targeted prevention campaigns. Fostering partnerships ANZBA needs to foster strong partnerships and communication links between relevant sectors. Through fostering partnerships, in particular with government bodies, we can advocate and seek leverage for appropriate injury prevention legislation, policies and programs. Such organisations include Australasian Fire & Emergency Services Authority Council (AFAC), Australian Safety Council, Australian Injury Prevention Network, Department of Health and Ageing and the Department of Human Services. Historically, ANZBA has not embraced collaboration or affiliation with corporate industry. This fellow is an earnest advocate for change. Many corporate industries have a vested interest in burns prevention, it can reduce costs to a specific industry, provide good community exposure and offers financial gains. In turn they can assist with access to target audiences and resources to make prevention messages more robust. If this path is chosen, ANZBA must ensure the relationship is reciprocal not merely philanthropic - to ensure sustainability. And of course, the terms of this alliance needs be legally nutted out with a fine tooth comb. The ANZBA Burns Prevention Committee should establish a Steering Committee which extends invitations to key industry stakeholders who can provide access, expertise and resources. Those organisations who will embrace ANZBAs mission, projects and lobby for what it wants to achieve. These could include but not be limited to lawyers, gas and electrical company board members, AFAC, Worksafe, TAC. Such strategic relationships could greatly assist long term goals. International Collaboration ANZBA should go off shore and harness opportunities to work with and learn from our international peers. The fellowship was most beneficial in terms of opening international opportunities to collaborate and share ideas globally. The benefits would be mutually beneficial. The American Burns Association, the International Association of Fire Fighters and the US Burns Prevention Foundation were all committed to collaborate, share knowledge, resources and expertise with us. Opportunities discussed include sharing epidemiological trends in injury, 7
international prevention research projects and prevention campaigns. The US was most interested in the low incidence in fire fighter injuries and fatalities in Australia and New Zealand. There is no argument that research and campaigns on an international scale will be more effective. ANZBA should also consider collaboration with other peak international bodies such as the International Society of Burns Injuries, the European Burn Association and the British Burns Association. Specific Burns Prevention Programs It was invaluable spending time with the aforementioned organisations to see how they operate, how they collaborate, their views and experiences regarding successful sustainability and how they navigate their relationships with other organisations. It was also invaluable to see first hand specific burns prevention programs already established. The details regarding these specific programs are not detailed in this report but are available on request. Various aspects of these programs could be adapted and be useful in the Australian context. This has already been explored by the VBPP and facets are already being reviewed for incorporation into VBPPs current and future work. These specific programs include: Safety Lines The Great Escape Juvenile Firesetter s Intervention Program Stop, Drop Roll and Call First Responder Guide to Burn Injury Assessment & Treatment Moreover it was invaluable to see how these peak US bodies work together collaboratively in the development of a 3 year national scald prevention campaign. This template could be used to further national activities in Australia. Knowing the target audience It is important that ANZBA understands its target audiences in terms of changing trends of injury and the ANZBA National Burn Registry upgrade will greatly assist. ANZBA must also understand its target audience in terms of how to reach them, think outside the box, diversify its formats/mediums and meet the audience on their turf. An example of this is to use websites such as Facebook, My Space and You Tube to reach younger target audiences. Unfortunately the fellowship did not answer questions of how to connect with the isolated elderly regarding burns awareness. International peers face similar challenges and there was much discourse regarding this high risk group who en masse have poorer outcomes following burn injury. This group live in old houses and don t access usual prevention mediums such as attendance at community centres and are not part of the technologically savvy generation watching DVDs or using the internet. The concern is international and growing exponentially as the population expands globally and lives longer. We need to think of other ways to reach this high risk group. ANZBA is encouraged to look with interest at AFACs work with regards to changing legislation so fire safety education is compulsory in the curriculum of carers looking after the elderly in their homes. ANZBA should utilise established channels of communication to ensure scald safety is also on the curriculum. 8
ANZBA should be forward thinking and begin targeting the 50 60 year olds population, who are ageing and are technology savvy. Why wait until access to this audience could be relatively limited. Further more ANZBA should appreciate the changing dynamics of Australian families and consider educating the elderly on how to care for their grandchildren safely. For those challenges that there are no answers for yet a personal favorite is the misuse of flammable substances - ANZBA should delve more deeply into understanding the mechanism of injury through research. Measuring Outcomes Determining the effectiveness and outcomes of injury prevention strategies is as mind boggling as the works of Max Escher. It is nearly impossible to measure how many people did not get hurt who otherwise would have. Being able to measure the effectiveness of burns prevention measures provides leverage for future proposals. Health officials and policy-makers require this scientific framework as a basis for establishing priorities, and allocating resources. In regards to education, some measures include target audience saturation and pre and post knowledge testing. To digress historically, compulsory smoke alarms legislation has seen a reduction in burn injuries caused in house fires. Similarly, advances in engineering in the form of fuel injected cars have seen a reduction in flash injury caused by pouring petrol into the carburettor. These channels of injury prevention - legislation and engineering are powerful vehicles of change and should also be considered by ANZBA and the VBPP. More answers to the impasse of measuring outcomes needs to be found. A Useful Acronym Being fond of acronyms, a useful approach to prevention strategies that has been embedded in my mind was the four Es: Education: awareness Enforcement: legislation Engineering: change it Effectiveness: measure it National Burn Registries In 2003, I was given the task of developing the National Burn Registry on behalf of ANZBA. This challenging task was made easier through the enthusiasm and commitment of the ANZBA Board and its members. In 2007, the ANZBA NBR secured substantial funding from the Julian Burton Burn Trust and is now being managed by the Monash University Department of Epidemiological Medicine. It is about to undergo a major overhaul increasing and refining it data capturing capabilities. The Fellowship was helpful and timely to assist in the next stage of ANZBA NBR development. I was fortunate to spend several days with the team at the American College of Surgeons National Trauma Databank in Chicago as well as the American Burns Association NBR Committee. These are the key players and organisations who gather data on burns injuries across the United States. 9
Across the spectrum, it was equally beneficial to meet clinical registry users at the coalface at the Weill Cornell Medical Centre and Le High County Burns Centre. It was a valuable opportunity to network, share knowledge and experience with both ends of the continuum. It was heartening to note their experiences, challenges and frustrations were similar. In regards to minimum data sets, data integrity and data definitions it was highly beneficial to hear how they overcame them. At next years International Surgical Society Conference in Adelaide, the ACS NTDB team will visit Australia and there is already discussion regarding a visit to Victoria to visit ANZBA NBR and VSTORM to further share experience and expertise firsthand with international peers. Clinical Indicators The American Burns Association has already established Clinical Indicators for Burns Services. ANZBA is at the cusp of defining its own. The ABA Clinical Indicators have been tabled to the ANZBA NBR Steering and Reference Committee and are currently being reviewed for relevance and adaption to the Australian context. They include: Appropriateness of pre-hospital airway management Effectiveness of first 24 hours of fluid resuscitation Time from admission to Burns Surgeon evaluation Time to first excision & grafting Nutritional evaluation < 48 hours Therapy evaluation < 48hours Infectious complications Major complications categorised by organ system Ventilator days Re-intubation < 48 hours post extubation ICU days Graft take >80% Adequacy of nutritional supplementation Readmission for unexpected problems Incidence of ventilator acquired pneumonia Line sepsis rate Mortality Length of stay versus Total Body Surface area burnt Data There has been much discourse for several years within ANZBA of the components of the ANZBA NBR minimum dataset (MDS) and their definitions. The dialogue has once more been at the forefront of the ANZBA organisation as it is currently refining it MDS for the revamp of its registry. Knowledge gained from the ACS NTDB and the ABA NBR was a valuable contribution at the recent Steering and Reference Committee meetings at the ANZBA ASM. In addition, it was useful to explore experiences with peers relating to other aspects of data management including data integrity, collection, governance, consent, de-identification, and reports. 10
User Friendliness The ABA NBR is user friendly and this infrastructure is invaluable for ANZBA. The ABA NBR provides users an online feedback service which provides ease and timeliness for users to comment and ask questions regarding the registry. The chairman of the ABA NBR Committee publishes a section entitled Glimmers in the ABA publication each month. This serves to keep the registry at the forefront of the members mind. Furthermore, at each ASM, the ABA award a prize for the best paper presented that uses ABA NBR data. It is important to gather data but it is more important to use it. In time - once the current ANZBA NBR has been revised, ANZBA hopes to integrate such practices to encourage ownership by members and for them to realise the potential power of the registry. Verification It was also beneficial to spend time with the various organisations looking at burns centre verification. Verification is the process that assesses an organisation s ability and performance in its role in a regional burn system. The process is similar to that Australian hospitals undergo within the process of accreditation including patient care conferences; mortality/morbidity conferences; quality improvement; contribution to ABA NDR; educational requirements etc. However the focus is for the burns service alone not the entire organisation and provides standards for the operation of burn centers. Knowledge that could one day be applicable to the Australian setting. 11
Burns Service Benchmarking In Victoria, VABS and the Burns Unit at the Royal Children s Hospital has traditionally provided service to the Victorian public as isolated services from each other. There are moves within the Victorian community for these services to work cohesively in partnership under the umbrella of the Victorian Severe Burns Injury Service. As Victoria moves towards this conceptual framework, the fellowship was invaluable in visiting both the Weill Cornell Medical Centre, New York Presbyterian Hospital in New York City and the Le High Valley Burn Center in Pennsylvania. I met with key stakeholders with regards to how these burns services offer a state-wide service in regards to clinical service, research, education and prevention. The Weill Cornell Medical Centre treats approximately five times as many inpatients per year as the Victorian Adult Burns Service, whilst the Le High County Center inpatient numbers were comparative. Staffing numbers in both medical, nursing and allied health reflect this capacity in NY. Both units were stand alone units inclusive of intensive care beds and appropriately trained staff. The outpatient departments or Burn Recovery Centre was attached to the inpatient unit and was staffed by burns service rather than ambulatory care staff. Neither service provided a hospital in the home service but outpatient clinics ran 5 days per week. Last year the first burns nurse practitioner was endorsed in Australia yet these roles are part of the common vernacular in both of these US units. The evolution of these roles according to the different needs of these units were fascinating. The benefits to both organisations in both inpatient and outpatient settings was evident. Roles such as Physicians Assistants is another role unfamiliar to the Australian setting. To meet the human resource demands of attending burns wound care dressings, the Le High Valley Center used a Virtual Dressing Team composed of Licensed Practice Nurses (equivalent to a Division 2 Nurse in Australia) who provided the clinical power to attend the dressing whilst the Registered Nurse was involved with the wound assessment and decision making. This could be a useful approach at VABS. The recently designed unit at Le High had temperature and humidity controlled, positively ventilated single rooms with lifting machine hoists fitted into the ceilings and scales built into the beds. Antifungal paint was used on the walls, tiles were welded into the floor and there were no curtains or other material surfaces to collect dust. Perceptibly designed by burns clinicians, blinds were on both the inside and outside of the window glass and mirrors were strategically placed behind paintings for when the time was right. In regards to clinical practices the Victorian Adult Burns Service is similar with that of our international peers. Early excision and use of skin substitutes were similar. In the United States, there were many different wound care products including many silver preparations as well as enzymatic debriders not yet available in Australia. Discussion with various VABS clinicians and national peers has begun regarding the merits of exploring options for their TGA approved use in Australia. VABS is a leader in pain management practices and it was useful to share our practices. Having worked at the Victorian Adult Burns Service for 8 years it was noted anecdotally that staff who work in such environments have a similar sense of humour and it certainly helped to quell any home sickness. 12
Recommendations To summarize the key findings and recommendations from the fellowship: 1. ANZBA needs to embed prevention into the common vernacular. 2. ANZBA and the VBPP need to develop a strategic plan that will strengthen their roles as key advocates in the prevention of burn injuries. Evidence should support prevention programs and their proposals. Endeavour to measure effectiveness and outcomes. Pursue research into burns injury prevention Foster strong partnerships with key stake holders who can provide expertise, access and resources. 3. In regards to the National Data Registry, ANZBA needs to develop clinical indicators to benchmark clinical care and eventually outcomes, refine its minimum data set and prevention activities should inform the future evolution of the ANZBA NBR. 4. ANZBA, the VBPP and VABS should pursue avenues now open for networking with international peers in the areas of burns prevention and data registries. The information gained through this fellowship will assist ANZBA, VBPP and VABS in all of these pursuits. Dissemination and Implementation Outcomes from the fellowship were presented recently at the ANZBA Annual Scientific Meeting in September 2008. I presented a paper titled The Churchill Retrospective which provided a summary of this report to 250 delegates. Learnings regarding burns prevention have already been incorporated into the strategic plan of the ANZBA Burns Prevention Committee and recommendations have already been put in motion. Additionally these outcomes have already been integrated and actioned into the VBPP strategic plan. Already VBPP has already begun identifying and approaching strategic partners and structuring itself with the use of a Steering Committee. Furthermore, VBPP is adapting its current prevention programs to look ways to track its target audience saturation Learnings and networks regarding National Burn Data Registries has already been fed back to the ANZBA National Burn Registry(NBR) Steering and Reference Committee and the Monash University Department of Epidemiological Medicine at the recent ANZBA Annual Scientific Meeting. It will help to shape the future evolution of the ANZBA NBR. And finally, the burns service learnings have been and will continue to be disseminated through the VABS Burns Development Group as well as the ANZBA Nursing group. The outcomes from the fellowship should not be considered only in terms of what was learnt whilst I was overseas but also in terms of the networks forged across the pond and the future potential of these relationships with regards to burns prevention and national data registries. 13
Conclusion It is difficult to abridge two months of knowledge, experience and inspiration, but certainly retrospective wisdom has helped. This document has provided a summary of my learnings. Most importantly it is the application of this knowledge and the pursuit of new opportunities where the fruits of the fellowship will be seen. It is an exciting time for ANZBA at the moment with the rebirth of its National Burns Registry and the beginning of its burns prevention initiatives. The Churchill fellowship was an invaluable experience for the future development of these ventures. Furthermore on a state level, the experience was invaluable for the work of the Victorian Adult Burns Service and the Victorian Burns Prevention Partnership. I gratefully acknowledge the support of the Jack Brockhoff Foundation and the Winston Churchill Trust in making this possible. The opportunity has been invaluable for burns care in Australia. It would give me great pleasure to provide the Jack Brockhoff Foundation and the Churchill Trust an update of our progress in the future. 14