Friday 28 September 2018
Registration & Coffee
Session 1: Organisation of Burn Centre Care
Organisation of burn care in China
Jun Wu, China
Follow up of patients/home integrated care
Fredrik Huss, Sweden
Burn care is far from over when the intensive care period is over. The following, often, lengthy hospital stays are stressful for both patients and wards. But do the patients always need to stay in the hospital? Everything we do, should be in the best interest of the individual patient. However, the common clinical situation with high demands on efficiency and throughput often conflicts this. What measures can be done to maintain high efficiency and throughput but still ensure patient-centered qualitative care?
Flexibility, thinking outside the box along with tools like telemedicine, anaesthesia nurse-led sedations, nitrous oxide, lidocaine gel, etc open alternative possibilities of care. We review different ways and models to build an effective outpatient clinic that gives the patients quality in their care.
Ass. Prof., Director of Uppsala Burn Center, Dept. of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
mHealth for diagnostic and treatment support regarding acute burn patients. A means to reduce morbidity and promote health equity
Lucie Laflamme, Sweden
Smartphones’ versatility and vast availability alongside wireless networks’ ever-increasing outreach have pave the way to digital approaches in health technologies that can help prevent, diagnose, or treat illness. One untapped domain of application of health apps is that of diagnostic and treatment support to front line clinicians, an area where the need is immense globally and the potential for cost-saving tremendous. This definitely applies to burn injuries, which are an important global health issue.
This presentation concerns an image-based consultation platform for the diagnostic and treatment of acute burn injuries. It was developed in the context of a research project taking place in the Western Cape, South Africa, a project that involves researchers and clinical experts from several medical fields (i.e., medical technology, emergency medicine, surgery, public health, epidemiology). Once the rationale of the project and its overarching aim are exposed, the main results from some of the formative evaluations conducted thus far (mainly studies on remote diagnostic accuracy and user acceptance) are highlighted. The potential for real-time computer-based burns diagnostic using deep learning solutions is also touched upon, considering the research team’s most recent development work.
Image-based diagnostic support for burn care through mHealth has the potential to increase significantly the readiness of healthcare services to deal with such a wide-ranging global population health threat. Beyond the potential to ultimately improve patient management options and outcomes, secondary potential benefits like less referrals, reduced costs and time saved are likely and so is the reduction of professional isolation. This, in turn, can contribute to more equitable systems in global health care through large-scale support into resource poor settings.
Professor, Karolinska Institutet, Department of Public Health Sciences, Stockholm, Sweden
Interactive parallel workshops 1
Lunch & poster presentations
Session 2: Education
Implementation of guidelines
Nadia Depetris, Italy
The appropriate management of the burn patients remains a major challenge. A multidisciplinary approach, the implementation of locally adapted treatment algorithms and the adherence to evidence-based guidelines are the key to improve the quality of the treatment after severe burn injury.
The European Burns Association (EBA) guidelines reflect the current medical knowledge in the field of burn care and summarise the evidence concerning burn mortality, morbidity, and patient-reported outcomes. They represent an educational aid to improve and standardize the care of the severe burns across Europe and beyond.
The EBA guidelines were developed by a multidisciplinary team, including surgeons, intensivists, anesthesiologists, and professionals allied to medicine all around Europe on behalf of EBA. The team members took into account the fundamental principles of the guideline developing methods, identifying the main clinical questions, searching for evidence, and making judgments and recommendations using a consensus process among the team and finally sharing them with the European burn care community.
The EBA Practice Guidelines for Burn Care – Version 4 2017 were released at the 17th EBA Congress in Barcelona in September 2017. They aim at assisting professionals who provide care to severe burn patients from the time of injury to wound closure and full reintegration of burn patients to everyday life.
The EBA Practice Guidelines for Burn Care – Version 4 2017 can be downloaded in their entirety as PDF-files from the EBA homepage.
The EBA Practice Guidelines will be reassessed every two years by a designated EBA multidisciplinary team. The team will adapt the previously released recommendations to new scientific evidence if indicated and address further uncovered clinical areas.
Physician, Città della Salute e della Scienza, Turin, Italy
Stian Almeland, Norway
Paul van Zuijlen, the Netherlands
Scars have a long-term impact on patient well-being. The usage of high-quality scar evaluation tools have become indispensable to improve the efficacy of scar management. Nowadays instruments are broadly used that enable an objective evaluation of scar color, stiffness and contraction. But these instruments do not account for an expert opinion or even more importantly, the opinion of the patient.
In 2002 our group developed an outcome measure for scar quality in patients with burn scars called the Patient and Observer Scar Assessment Scale (POSAS). The POSAS was developed mainly because we felt that the available scar scales were lacking the patient perspective. Moreover available scales clearly contained errors in design and structure.
The POSAS consists of two scales, the Patient Scale and the Observer Scale, each containing six items. The patient scores six items: pain, pruritus, color, thickness, surface roughness, and pliability. The observer – mostly health-care professionals – scores six items: vascularization, pigmentation, thickness, relief, pliability, and surface area. All included items are scored on the same 10-point scale, in which a score of 1 is given when the scar characteristic is comparable to ‘normal skin’ and a score of 10 reflects the ‘worst imaginable scar’. But the POSAS is not perfect and needs
In 2017 we started ‘project POSAS 3.0’. We initiated a study is to improve the POSAS with involvement of many patients and health-care professionals in the field, and we will test its quality in an international setting. More specifically, this project aims to investigate content validity which will likely lead to a new version of the POSAS, and subsequently, assess item quality, differential item functioning (DIF), reliability, measurement error and interpretability of the new version of the scale.
Paul van Zuijlen
Professor, Director of the Burn Center of the Red Cross Hospital, Beverwijk, The Netherlands
Session 3: Research in scar management
Use of stem cells
Juan Barret, Spain
Use of dermal substitutes
Esther Middelkoop, the Netherlands
Dermal substitutes have now been used for reconstructive wound treatment in scar revision since several decades. Although improved scar quality is reached with this treatment, still scar formation is present.
Use of cellular skin constructs could represent a further improvement in quality of wound healing.
We tested the feasibility to use fetal dermal cells in a collagen based dermal substitute in an experimental acute wound treatment. In several consecutive studies, we found that both adult allogeneic cells and fetal cells gave rise to a higher inflammatory response than autologous dermal cells. Also, scar quality was better when using autologous fibroblasts in a dermal substitute compared to the other treatment modalities. Furthermore, autologous keratinocytes seeded in a collagen carrier were successfully applied to acute wounds and improved wound healing aspects.
These studies paved the way for application of full skin constructs in acute wound treatment.
Prof. skin regeneration and wound healing, Association of Dutch Burn Centres
Sonia Gaucher, France
Use of autologous fat grafting
Mariëlle Jaspers, The Netherlands
Nowadays, patients normally survive severe trauma such as burns and necrotizing fasciitis. Large skin defects can be closed but the scars remain. The resulting scars often become adherent to underlying structures, as not only the skin but also the subcutaneous tissue may be destroyed due to the injury. This causes scar stiffness, pain, and sometimes friction and a limited range of motion. Autologous fat grafting (AFG) provides the possibility to reconstruct a functional sliding layer underneath the scar. AFG is becoming increasingly popular for scar treatment although large studies using validated evaluation tools were lacking until recently. We objectified the effectiveness of single treatment autologous fat grafting on scar pliability using validated scar measurement tools and a comprehensive scar evaluation protocol. The results of this clinical study will be discussed as well as developments in this interesting field of medicine. Current data could be expanded by future research into functional improvement and studying the patient’s mobility after AFG. Especially when several AFG treatments are performed over larger scar surface areas, it would be of interest to investigate the effect on quality of life. In addition, more and more measurement tools are becoming available to study the presence and development of the fat graft after treatment. This appraisal may provide an update and food for thought regarding the set-up of future studies on AFG.
Burn Center Rode Kruis Ziekenhuis, Beverwijk, The Netherlands
The chance to change is now
René Boender, The Netherlands
“The world is changing; are you changing, too?” is the title and question of a lecture that will be given by international marketing & media maver and bestseller author
René Boender during our summit!
The world is his playground
René Boender is as brain-agent involved in precious and exiting projects around the globe. He is the author of the bestsellers Great to Cool, Generation Z & the 4th industrial revolution and Cool is Hot. René believes that everything’s stands with the (honest)power of communication.
Also in the BURN CARE.
He is a fountain of energy and inspiration and knows how to strike the social media cord as Twitter, Facebook or Instagram. He is founder of the ISP (Inspirational Selling Point), the 3″12″ Eternity rule and more, are real eye openers and for many the starting point to change. He knows how to reach out and touch the ‘marketears’ around the globe.
Yes, you are also a marketEAR..
His storytelling capabilities are energetic, enthusiastic and most of all: creative. René is this generation’s advocate of creative thinking in burn care as well ! And a well-versed advisor to the world’s top companies of how to make the most of the tools that are now available. René
is also a great believer in women in business and important positions: “If you present something to a man, they will talk about it,” he asserts, “if you ask a woman, they will DO.” In his opinion, “(Wo)men make the world! – and the new ROI! Return on Involvement….
It’s a wonderfully stimulating and entertaining presentation and it is his hope, stimulating you create more contact points about the great opportunities in BURN CARE. Please take a look:http://www.youtube.com/watch?v=DXvtqDZ9taM&sns=em
René is described as a “Brand Booster, Brain Agent and Trend Teller,”
Ted Turner of CNN says of him “even more significantly, all of them call him “Visionary”!
Welcome reception City Hall
Saturday 29 September 2018
Session 5: Resuscitation and ICU care
Can Ince, The Netherlands
Acute kidney injury
Folke Sjöberg, Sweden
Acute kidney injury (AKI) is a common and a significant complication after burn, with an incidence and mortality of approximately 30% and 80%, respectively, depending on which criteria that are used (AKI/RIFLE). The AKI criteria most commonly used are based on: Improving Global Outcomes (KDIGO) consensus guidelines, which defines stages (3 staged) and severity of AKI based on changes of serum creatinine and urine output (UOP). They comprise a broad clinical condition including many etiologies, making definition and diagnosis in burn care challenging. Burn-related AKI when examined closely appears to occur continuously after the burn and parallel other organ failures most of being manifest within 14 days after the burn. Its aetiology still is largely unknown. The factors found most important for the development of AKI in the burn populations are TBSA % and age. Diagnosis may be difficult to establish, especially early after burn as UOP and biochemical markers can be either affected by the fluid resuscitation or relatively normal even with significant renal injury. A sensitive and specific biomarker for the early diagnosis of AKI is still lacking. Renal clearance of the most important biomarkers, i.e., Creatinine, Cystatin C or tracers such as Iohexol/Inulin may vary intra –, and inter individually, which further complicates the diagnosis. Further kidney injury may occur at different levels of the nephron depending on aetiology and time. For treatment, the reversal of the underlying cause is the first intervention and there are findings that modern early wound closure may be beneficial. Furthermore, the advent of renal replacement therapy has significantly improved the mortality of burn patients with AKI. However the timing of dialysis intervention or whether using intermittent or continuous dialysis/filtration does appear to significantly affect outcome. And as of yet, no beneficial pharmacologic agents have been identified, despite multiple investigations. The renal prognosis after AKI due to burns is most often benign; however, this is still debated.
Director, the Burn Center at Linköping University Hospital,
Optimal resuscitation in burn patients
Dr. M. Legrand, France
Early mobilisation in ICU patients: effects on outcome
Dale W. Edgar, Australia
Since the 1980’s, >98% patients survived their burn in WA, with only the most severely injured, or premorbidly compromised, patients succumbing to their injury (Duke et al., 2011). Post-burn mortality in a modern burn facility is an obsolete outcome measure. Thus, the vast majority of patients are candidates for rehabilitation, with a focus on reducing the morbidity due to post-burn scarring. Adult burn survivors in WA demonstrated that rehabilitation involving routine early ambulation and strength gaining exercise therapy, were beneficial to burn patient outcomes. The clinical studies to date in WA have shown that functional mobility and balance were improved significantly at three and six months post-burn, when post-operative ambulation was achieved by three days.
Further, early analysis of a randomised, controlled acute burn patient trial, demonstrates that muscle strength was up to 58% greater in patients undergoing resistance strength training, compared to controls. These results are promising and add to the emerging science supporting the body of knowledge that early exercise therapy strategies are applicable in any environment, in various patient populations, without significant cost. However, the parameters of exercise prescription for burn patients are not straightforward. Thus, the current interpretations of our research findings and data, will be presented for discussion.
Associate Professor, Head of Burn Injury Research Node, The University of Notre Dame Australia (UNDA)
Session 6: Non-medical strategies in acute burn care
The benefit of 3D scanners in Designing and Developing Pressure Garments
Peter Moortgat, Belgium
Pressure garments are commonly used in the treatment of hypertrophic and deformed scars. These garments need to be continuously worn so that adequate pressure can be applied to the hypertrophic scar, this to increase the rate of scar maturation, prevent contracture formation, and enhance cosmetic appearance without impairing circulation. Thus, pressure monitoring, patient compliance and comfort sensation are crucial in pressure garment therapy. To optimise the effectiveness of pressure garments, an accurate measurement of body dimensions is crucial. In making custom-made garments, direct measurement tools such as flexible measuring tape are used. The tension of a measuring tape and the curvatures of corresponding landmarks can influence the results, which lead to poor repeatability and large variances. Currently, the inaccurate body dimensions due to the lack of suitable measuring equipment in hospitals result in re-measurements and repeated adjustments for pressure garment fitting, thus adversely affecting the efficacy of the pressure therapy treatment.
More recently, apart from direct measurement methods, indirect methods such as multi-camera photogrammetric systems based on two-dimensional (2D) images or 3D scanners for body measuring have been developed and used in different medical applications such as monitoring facial shape, skin wound, teeth abrasion, etc… Various studies have shown that the 3D image analysis methods are able to obtain results that are close to direct measurements. However, a standardised measuring position is required together with a fixed distance between 3D scanner and body and the results can be influenced by movement, light, viewing angle and the number of registered images.
Daniel Daly, Belgium
Daniel Daly in cooperation with Mieke Anthonissen & Eric Van den Kerckhove, Faculty of Movement and Rehabilitation Sciences, KU Leuven, Belgium
Due to the development of comprehensive burn centers with advanced in treatment there has been an increased focus on the functional outcome of burns and the need for extensive rehabilitation. Complications after burns include deconditioning, muscle weakness, hypertrophic scarring, pain, itching, and psychological and social impairments.
Subsequently, physiotherapy plays a crucial role in the treatment and rehabilitation process of burn patients including joint mobilization, positioning, splinting, massage therapy, pressure and silicone therapy, exercise therapy and cardiopulmonary training. Various studies have shown positive effects of exercise therapy in children with burns. In adults, however few randomized controlled trials are available. This presentation will concentrate on exercise therapy in water for burn patients particularly for adults.
Aquatic exercise provides several therapeutic benefits as compared to land-based exercise. Buoyancy and hydrostatic pressure counteract gravity and create an environment with low joint loading and variation in muscle resistance during movement. This might provide a more effective and attractive medium to develop physical fitness in several patient groups returning from long periods of inactivity or even bed rest. Our own work has also shown that a short 3-week aquatic intervention significantly increased handgrip strength. There was also a significant improvement in redness and POSAS vascularity score over time. This was nevertheless not different from a group receiving passive water massage, although there was a temporary increase in redness and vascularity during the intervention in the passive treatment.
This presentation will concentrate on practical aspects of aquatic interventions in water for these patients in typical swimming facilities. It will include inclusion and exclusion criteria and deal with other questions e.g. use of equipment such as aquacycles, aqua jogging and the advantages of swimming itself.
Professor Emeritus, Kinesiology and Rehabilitation Sciences, Leuven, Belgium
Joachim Suss, Germany
Many patients suffer from heavy burn injuries each year, with hospitalisation. Burn wounds are painful during surgical intervention and physical therapy afterwards. Painful procedures often lead to an implementation of pain memory. Pain, anxiety and discomfort are very high. Today common alleviation is through heavy doses of analgesics taking into account well-known side effects. We propose to use modern of-the-shelf Virtual Reality (VR) systems to reduce doses of analgesics and as a drug-free, less pain and anxiety inducing physical therapy approach for patients.
VR has been studied for more than 15 years to improve therapy for different patient groups. Pain alleviation during wound care is one of the first and most successful areas of application. Through the technological advance and especially with the market-success of gaming consoles, today we find VR-systems on the market, which are ready-to-use in clinical settings. Together with these systems comes a variety of movement-based games that are appropriate for main points of treating burned patients. Different films and games can be used before and during dressing and physical therapy.
The use of VR systems during wound care demonstrated that patients with severe burn injuries have about 35-40 percent less pain without high doses of analgesics. There is also a reduction of discomfort during wound dressing and reduction of anxiety levels. VR can also help to get back in social contacts with family, school and friends. The cooperation of the patient may be enhanced.
Discussion / Conclusion
Modern VR systems have a high technical standard and are easy to use, which makes them available to everyday clinical practice. Furthermore patients can be equipped with the systems to use them at home for on-going rehabilitation. By means of achievements or high-
Head of Unit Pediatric surgery, Catholic Childrens Hospital Wilhelmstift, Ahrensburg, Germany
Extracopereal shock wave therapy
Jorge Aguilera, Spain
Shock waves are high-amplitude acoustic waves characterized by a rapid alternation of positive and negative pressures. Although its first clinical application was in the treatment of urolithiasis, its use has been extended in orthopedics (tendinopathies, fasciitis, pseudoarthrosis, etc.) and in wound healing. In relation to wound healing, Extracorporeal Shock Waves Therapy (ESWT) are commonly used in the treatment of burns, yet what scientific evidence exists in burned patients?
In acute burns, there is existing preclinical evidence based on studies using rats or mices. They have shown that ESWT decreases the expression of proinflammatory cytokines, chemokines and metalloproteins, increases angiogenesis and induces vasodilation, increases leukocyte migration and accelerates the healing of burns. At the clinical level, the evidence is limited, but it has supported the fact that ESWT increases the perfusion of the burned area measured with LDI, accelerates re-epithelialization of superficial dermal burns and decreases the number of surgeries expected in deep dermal burns.
Regarding its use in the treatment of post-burn scars, at the preclinical level, a study performed with human fibroblasts in vitro has shown that ESWT regulates the expression of molecules related to hypertrophic scarring and reduces the migration of these fibroblasts. Clinically, the existing evidence is little, but it seems to improve the appearance and symptomatology of the scars (pain and pruritus).
Although ESWT could be a useful tool in the treatment of burned patients, there is not enough evidence and more studies are needed to consolidate this knowledge and specify many aspects that we still do not know, such as how much energy should be applied? how many sessions are necessary? what is the best moment to perform the treatment?
Interactive parallel workshops 2
Recuperate Medical | Natural Fibrin Matrix and Tissue Recovery
11:30-11:35 Henry Kuper, RN, CRNA, Recuperate Medical
Welcome and Introduction
11:35-11:45 Dr. Dirk de Korte, Manager Product & Process Development, Sanquin Bloodbank
Characteristics of Plasma components in FITRIX
11:45-12:00 Drs. Ivo van der Bijl, PhD, Blood Cell Research, Sanquin Research
PRP, mechanism, applications in woundhealing
12:00-12:15 Dr. Moniek de Maat, associate professor dept hematology, Erasmus University Rotterdam
Role of Fibrinogen in Tissue Recovery
12:15-12:30 Dr. Annebeth de Vries, sugeon. Burncentre Red Crosshospital. Beverwijk
The use of Fitrix for skin graft fixation in children with burns to avert sedation and pain: a prospective cohort study
Lunch & poster presentations
Session 7: Measurement (of outcomes) in Burn Care
The Burn centres Outcome Registry the Netherlands (BORN): development and first experiences
Tsjitske Haanstra, The Netherlands
Routine measurement and registration of health outcomes after burns enables professionals to make data-informed clinical decisions, track and benchmark outcomes and demonstrate the value of burn care to payers and fellow providers. Furthermore, datasets with routinely measured outcomes may serve as an alternative for comparative effectiveness research. The Dutch Burns Centres in Groningen, Rotterdam and Beverwijk initiated a uniform outcomes registry together with the Dutch Burns Foundation. Outcomes data will be used for 1. the benefit of the individual patient by providing real time measurement feedback 2. quality assessment and benchmarking 3. research purposes.
A modified Delphi study amongst a multidisciplinary group of experts informed the development of an outcome measurement trajectory for adult patients with burns. This trajectory consists of a set of patient- and practitioner reported outcome measures, and a set of time-points for assessment. Patient experts were consulted to give their feedback on the measurement trajectory. A state-of-the-art electronic measurement system including real-time feedback for patient and practitioner was developed and implemented within the electronic medical records in the participating centers. Outcomes data will be enriched with patient, injury, process and treatment related variables from the Dutch Burn Repository R3 in order to capture the complete patient journey and be able to take case-mix into account in data analysis. Currently, both qualitative and quantitative methods (e.g. user data) are used to evaluate the first experiences of patients and professionals with the system.
Results of the Delphi study showed a range of physical, psychological and social outcomes essential for adult burns patients. This project is one of the largest data projects in the area of burns. As routine outcome measurement and value based healthcare is on the agenda of many national and international healthcare societies we would like to share and discuss the pearls and pitfalls experienced so far.
Coordinator of the Burns centres Outcomes Registry the Netherlands (BORN), The Dutch Burns Foundation and the Association of Dutch Burns Centres,
Cost analysis - How I do it
Suzanne Polinder, the Netherlands
Cost analysis in burns
Ken Dunn, United Kingdom
No clinician in healthcare would deny that finance is an important area, but it is really the subject of discussion at clinical meetings or areas of research undertaken by clinicians. The value of such work is that it brings vitally important understanding to the problems and consequences associated with change. These changes can be in many areas: staffing, consumables, the introduction of new techniques, service resizing, service closure.
The work undertaken in Manchester, UK has focused on answering questions concerning the cost of burn care and on modelling change. The process initiated in 2007 was to establish a financial baseline against which changes could be evaluated. The many steps in this process will be coming to a conclusion in the near future and already allow a far more profound understanding of the consequences of changes in burn care. These developments fall into 4 key areas, each 1 of which will be presented separately:
- The financial consequences of change in terms of service funding.
- An understanding of the epidemiology of burn care demand and the geographical areas of high demand.
- The financial consequences of service reorganisation and the requirements for resilience in such planning.
- The financial consequences of introducing changes in clinical practice and evaluating its impact on service activity and funding.
Consultant Burn and Plastic Surgeon
Session 8: Scar management/Reconstructive surgery I and II
Perforator based flaps
Paul van Zuijlen, the Netherlands
Juan Barret, Spain
Jyrki Vuola, Finland
Reconstruction in children
Clemens Schiestl, Switzerland