Question Title

* 1. WG Draft Recommendation 1:

Estimation of burn severity during the scene response should focus solely on Total Burn Surface Area (TBSA) estimation.

Remarks:

1. TBSA estimation must remain a dynamic process with consideration given toother survivability factors.
2. Following  a mass casualty incident a rapid assessment and triage of bruns severity is required and may be performed by a first response team inexperienced in burns care.



Additional Notes
Following a mass casualty incident (MCI), a rapid assessment and triage of burns severity is required. This assessment may be performed by a first response team inexperienced in burns care and in often insecure volatile environments. Access to resources in the early phase of response may also be limited.

TBSA estimation must remain a dynamic process – with consideration given to other survivability factors – through on-going evaluation from the first receiving health facility onwards. TBSA estimation and depth estimation is prone to errors in the field and thus the priority is estimating gross numbers/% of patients/burn injured and ensuring timely transfer of patients from the scene to the first receiving health facility.

Depth of a burn will change over time and can be difficult to assess even by burns specialists in the first 24 hours. Thus to simplify assessment and triage in the first phase of response the WG recommend that only TBSA is estimated. 
 
In the presence of a suspected inhalational injury and other traumatic injuries, the patient should be triaged according to the conventional ‘ABCDE” approach independent of severity of burn (e.g. potential airway compromise from inhalation injury = P1/Red).
 

Question Title

* 2.
WG Draft Recommendation 2:

The tool the EMT healthcare workers are most familiar with should be used to determine TBSA on scene. However, should guidance be required, the Rule of Nines TBSA estimation is recommended.

Remarks
1. The TBSA estimation tool utilised on scene should reflect the tool most familiar to the healthcare worker

2.  On arrival at a health facility, additional tools and/or specialists may be available to re-assess the TBSA estimation

Additional Notes:
This is likely to reduce error. Each of the tools (Table 1, WG Document, Page 4) have their own merits, and variation in accuracy is accountable to expertise, experience and patients body type. If guidance is required, use of the Rule of Nines is recommended. This method is simple, applicable across a variety of contexts and is a commonly used burn estimation tool used in the pre-hospital environment.

Modern technology has greatly increased the options available to clinicians and strengthened accuracy of  TBSA assessment. However, resources enabling the use of such devices are likely to be very limited in low and middle-income countries particularly during the early phases of response. TBSA is integral to many fluid regime formulas thus a difference in TBSA estimation over a certain percentage (in one study 16.5% difference5) can have significant implications to fluid management and over-resuscitation in particular.

Paediatric burns are routinely difficult to assess. A recent retrospective study of 123 paediatric burns patients by Face and Dalton in 2017 demonstrated that approximately 40% of cases received an initial overestimation of TBSA by the early referring hospital. The study concluded that significant differences were observed between the TBSA assessment of referring hospitals and a specialist burns unit – a difference which impacts on the decision to transfer to higher specialist facilities. Consideration should therefore be given to the dynamic process of TBSA assessment and the regular re-evaluation required by skilled healthcare workers.
 

Question Title

* 3. WG Draft Recommendation 3

Conventional triage systems should be utilised on scene to determine life-threatening trauma injuries. The following categories and associated colours are recommended for on scene burn injury (TBSA) triage.

Colour  % TBSA Notes
Green < 20  
Yellow 20-40  
Red > 40 Inhalational injury; extensive facial burns; circumferential chest wall burns = P1/Red irrespective of TBSA


Remarks

1. Triage is a dynamic process and as such regular re-assessment and re-categorisation is advised

2. Life threatening trauma injuries should be identified as part of a primary triage process in the first phase of response.

3. A secondary phase of triage is recommended to determine burn severity (TBSA). If an additional triage process is not undertaken patients with burn injuries are at risk of being categorised as 'green' (walking wounded)

4. Suspected inhalational injuries (and extensive burns to face/airway' soot in nose; potential breathing compromise from circumferential chest wall burn) should be triaged as a P1/red irrespective of TBSA and other injuries. 

Additional Notes:
The triage system recommended above  is to support on scene decision-making in a MCI burn incident. When determining % TBSA and triage category, consideration was given to likely resources and expertise  available.

Based on discussions amongst the expertise of the WG, and reflective of to the dynamic process of triage and TBSA estimation, it was deemed inappropriate to assign any patient to the ‘non-survivable’ (black) triage category on scene.
Mortality from burns is multifactorial. Context, in addition to other survivability factors such as age, sex, burn size, burn depth and presence or absence of inhalational injury influence mortality. The relationship between TBSA and survival is well known, and was first noted in 1902.  However, further studies demonstrated that percentage of TBSA burned, patient age and the presence of inhalational injury are the primary determinants of mortality. 

Question Title

* 4. WG Draft Recommendation 4

The 'non-survivable' triage category (black) should not be implemented on scene


Remarks
1. Allocation of patients to this triage category on scene is not recommended.

2. Due to the dynamic nature of TBSA estimation and potential TBSA estimation error, decision making regarding survivability of a burn injury should only be undertaken at the health facility and under experienced guidance following further TBSA assessment.


3. Consideration should also be given to other factors impacting on survivability including: patient age; co-morbidities; context; and resource availability

4. The term considered most appropriate which is reflective of context and culture should be used to describe this category of patient.


Additional Notes
Context and culturally appropriate terminology for triage category ‘Black’ was discussed in detail. The terms considered were:

1.     Expectant

2.     Palliative

3.     Non-survivable injury/ies

Non-survivable’ injury was considered the most appropriate terminology amongst working group experts and previous survey contributors, deemed also to provide the most clarity. If national guidelines / decision tools regarding management of patients with non-survivable injuries exist, these should be implemented according to local culture and attitudes.

Emphasis was placed on highlighting the need to ensure patients allocated into this category continue to receive treatment for palliation. Treatment considerations included the following:
1.     Basic airway management
2.     Analgesia
3.     Simple dressings
4.     Oral fluids
5.     Catheter
6.     Vector Control interventions (e.g. mosquito net)

In addition, mental health and bereavement support is recommended for the family of the patient to support the individual in dying with dignity.

Question Title

* 5. WG Draft Recommendation 5

Re-triage should be a dynamic process occurring at a minimum of three stages of an MCI burn incident and be undertaken by experienced healthcare workers at the first receiving health facility onwards. Additional factors impacting survivability and TBSA estimation should be considered during arrival and definitive triage. 

Re-triage stages:
1. On Scene

2. On arrival at first health facility
3. Definitive after scrub/wound cleaning by experienced burns healthcare workers.


Remarks:
1. Higher acuity burn care resources can be appropriately allocated following re-triage of patients at the first receiving health facility

2. Patients categorised as 'non-surviviable' following re-triage should not be transferred to higher specialist centres but managed at the local health facility with additional expertise as available to ensure patient dignity and family support


Additional Notes
The dynamic process of re-triage should focus on:
a)     depth of burn;
b)     age of patient;
c)     current context;
d)     resource availability;
e)     systems infrastructure (availability of specialist burns bed and capacity at national burns centres); and
f)      accessibility to skilled burn care clinicians.

The process of re-triage (arrival triage and definitive triage) helps mitigate for the over-utilisation and inappropriate use of higher specialist resources. Early transfer of patients prior to definitive triage can be detrimental to the patient and risk misuse of high acuity resources.


Consideration should be given to the system infrastructure impact locally and regionally (for example bed availability; existing patient demands; resource capacity) following a MCI with a high volume of burn patients. All countries should be supported in Burn MCI planning as part of their general mass casualty response plans.

Question Title

* 6.
WG Draft Recommendation 6

In the event of a MCI resulting in burn injuries, patients should not receive intravenous fluid at the scene unless a concurrent trauma injury requiring fluid resuscitation. 

Oral fluid can be encouraged as appropriate

Remarks
1. Fluid replacement therapy is recommended once the patient has arrived at the initial health facility.


2. Volume of intravenous fluid titrated should be according to patient clinical need and following a re-evaluation of TBSA.

3. If the patient is likely to be delayed at scene for greater than 6 hours prior to transfer to the first receiving health facility, intravenous fluids should be considered.

4. National guidelines for fluid management of burns patients in a mass casualty incident should be respected and used as appropriate and at the direction of the treating team.

5. If a patient is administered a high volume of fluid due to deteriorating clinical course, early advanced airway intervention should be considered.

6. If a patient is transferred from the first receiving facility to a higher specialist centre, re-assessment of fluid status and on-going fluid management should be undertaken. Use of local fluid formula or Parkland formula from this stage is likely. 

Additional Notes:
The volume of intravenous fluid titrated should be according to patient clinical need, and following a re-evaluation of TBSA - TBSA is an integral part of almost every resuscitation formula. Unlike trauma injuries resulting in massive haemorrhage and where early ‘fluid’* (*in recent years packed red cells and clotting agents rather than saline or equivalent) is required to preserve life, the fluid shifts resulting from burn injuries is far slower thus giving time for appropriate delayed fluid management.

There is clear evidence demonstrating the need for intravenous fluids as part of the management of a seriously (partial and full thickness) burned patient, with complications such as haemoglobinuria and myoglobinura from renal failure secondary to burns injuries being avoidable with early administration of fluids. However, broad evidence also exists detailing the complications of excessive fluid administration in patients with burn injuries. Reported complications include abdominal compartment syndrome, pulmonary oedema, interstitial tissue leakage, airway compromise, and acute respiratory distress syndrome amongst others.  Fluid creep is a well recognised term used for excessive fluid resuscitation in the first 24 hours after  a burn and increases the chances of developing many of the complications listed above.
Complications such as those listed above affecting just one individual will impact on resource and skill requirement for the patients on-going management – a scenario which would be amplified significantly in a mass casualty situation where multiple burns patients are at risk of developing resource intense complications if  context inappropriate fluid regimes are used.

In addition, inaccurate TBSA assessment, most likely to occur in the early response phase, and the resultant fluid formula based on this assessment can be detrimental to p

Question Title

* 7. WG Draft Recommendation 6a

On arrival at the health facility, the following fluid regimes are recommended:

% TBSA Fluid regime recommended
< 20 Oral fluids to thirst. No intravenous fluids required
20 - 40 Support with Oral Rehydration Solution as soon as is practicable at a volume of 100mls/kg/24 hours
> 40 100mls/kg/24 hours intravenous fluid. Calculate fluid regime up to a maximum of 50% TBSA to avoid giving too much fluid to the patient. For example: a patient with estimated 60% TBSA should still only receive 100mls/kg/24 hours for a 50% TBSA burn

Remarks:
1. Little evidence exists detailing the impact of minimal fluid administration in the early phase of response to a burn 
casualty and whether this would cause harm or be of benefit especially in the context of a mass casualty incident. 

2. Complications of aggressive intravenous fluid resuscitation are well documented

3. Logistical challenges should be taken into account - if intravenous fluid is provided per 'normal regime' to 50 patients with an average 40% TBSA in the pre-hospital phase, and each litre of fluid weighs 1kg, the overall weight of transporting the required fluid volume will be huge. 

4. The use of enteral fluids should be considered in the event of an MCI.


Additional Notes
There are a number of recognised guidelines and formula for fluid management in burns care, primarily focused on care of the individual burns patient. Little evidence however exists detailing the impact of minimal fluid administration in the early phase of response to a burn casualty and whether this would cause harm or be of benefit especially in the event of a mass casualty incident. A recent 2017 review on ‘The Care of Thermally Injured Patients in Operational, Austere and Mass Casualty Situations’ identified that due to the challenges of austere environments, fluid resuscitation can be delayed or restricted in burns up to 40% TBSA providing the patient is expedited quickly to a treatment facility.

Many counties vary on their recommendations on the patients meeting the ‘requires fluid status’ with some categorising those with 20% burns (adult) and 15% burns (child) compared to others categorising those with 15% burns (adult) and 10% burn (child).


Question Title

* 8. WG Draft Recommendation 6b

Volume of fluid administered to patients should be calculated from time of arrival at first health facility and not time of burn

Remarks

Please see previous question


Question Title

* 9. WG Draft Recommendation 6c

Fluid status of the patient should be assessed regularly (urine output, capillary refill time; heart rate; respiratory rate) and fluid regime adjusted accordingly.

Additional Notes
Use of oral fluids
The use of enteral (oral) fluids should also be considered in the event of a mass casualty burns incident. This is particularly pertinent for contexts where resources such as access to intravenous fluids may initially be limited. The first documented ‘successful’ use of enteral fluids in the management of burns ranging from 19-80% was in 1944.Chilled isotonic sodium lactate orally was used at a rate of 100-150ml/kg/24 hours resulting in the successful resuscitation of 4 children (23-80% TBSA) and 5 adults (19-41% TBSA).This example was followed in the 1960’s by Sorensen who sought a simple and efficient way to treat mass casualties due to thermal nuclear warfare. Sorensen calculated the amount of oral fluid (any liquid containing 5gm salt  tablet per litre) according to body weight rather than TBSA and days since burn. The result was 80% of his patients with burns as great as 45% TBSA requiring no intravenous support.However at that time little quantitative data existed on how  burn shock affects internal uptake of oral fluid.

Michell and Oliveira, in their study determining whether fluid could be absorbed by the intestine in the early period after a burn, recognised that in the resuscitation of burns using the Parkland formula ‘a 50% TBSA burn in a 70Kg patient would require 7L of IV fluid in the first 8 hours and that this volume is within the capacity of the normal small intestine. Their porcine model study comparing intravenous fluid and oral fluid absorption demonstrated that enteral absorption from oral administration was slightly lower than for intravenous fluid absorption. The authors suggested also that due to the likely insufficiency of enteral absorption at a high injury level, internal absorption from enteral feeding would be adequate for burns up to 40% TBSA. The suggested fluid for enteral resuscitation is Oral Rehydration Solution (ORS). This work was supported by a randomised clinical trial in 2014/15 at a Burns Unit in Egypt whereby patients suffering greater than 15% TBSA were allocated randomly to either the control intravenous group or the study oral group. The intravenous control group received intravenous fluid as per the Parkland Formula and the oral study group received oral fluids as per Sorensons formula but using ORS. Although a number of limitations to the study (and exclusions including inhalational injury and patient co-morbidities) and a small trial number, the authors summarised that for all assessed parameters there were no major significant differences between the study group and the control group.
 

Question Title

* 10. WG Draft Recommendation 7

Potable/drinking water can be used to cool and clean burn wounds.


Remarks
1. Immediate first aid can be defined as triage with basic decontamination of the burn wound and include cooling, cleaning and applying a simple clean dressing to the burn wound.

2. Traditional practices for burn care such as the use of toothpaste, animal ointment, grass and fish sauce are not recommended.

3. EMTs are advised that the team should be proficient in water purification techniques. 
 

Question Title

* 11. WG Draft Recommendation 8a

The following on scene management of burn wounds is recommended:

1. Cool burn wound if less than 3 hours since injury with (running) potable water if available (avoid hypothermia)

2. Provide pain relief to patient

3. Remove debris / irritant from the wound and clean as thoroughly as possible with drinking water (and as tolerated)

4. Cover burn wound with a light clean dressing or plastic wrap

5. Avoid local traditions such as the use of eggs, butter, toothpaste or similar on the burn

Question Title

* 12. WG Draft Recommendation 8b

On arrival at the first health facility, the following burn care is recommended:

1.     Avoid extensive cooling of burns to mitigate risk of hypothermia

2.     Provide analgesia to patient

3.     Thoroughly clean the wound, re-estimate TBSA and change triage category according to findings

4.     Confirm tetanus status

5.     Determine appropriate dressing (daily change versus 5 day change)

6.     Consider limb positioning/splinting for high risk injury

 

Patients with <20% TBSA.

7.     Consider early discharge with out-patient follow up if <20% and superficial or non-critical areas

 

Patients with >20% TBSA and/or deep or critical areas

8.     Patients with TBSA considered >20% and/or deep or critical areas should be reviewed by an experienced burn clinician.

9.     Such patients are likely to require on-going in-patient care; scrub; analgesia and regular review

10.  Ensure comprehensive documentation of TBSA and depth of burn in addition to any other factors.

11.  For those patients undergoing surgical scrub, definitive triage can be undertaken and decisions regarding transfer of patient to a high specialist centre.
 

Question Title

* 13. WG Draft Recommendation 9

Depending on availability, cost implications, resource requirement (e.g. staffing) and normal practice, consider the type of dressing to be applied:

  •  Daily dressing
  • 5 day dressing

Remarks

1. Developments in dressing technology have resulted in there now being a number of dressings available that are designed to be left in place for 5-7 days as opposed to more traditional daily or alternate day dressings. 

2. Two options for dressings should be considered - the dressings routinely used at the health facility and/or the more specialist dressings likely to be externally sourced and more costly.

3. In a mass casualty context, availability of staff to regularly change dressings and dressing availability are likely to be compromised. 

4. The use of open dressings was not deemed appropriate for modern burn care except for burns afflicting the face or perineum.

5. Consideration needs to be given to the logistical impact to a Burns Specialist Cell of bringing in the required number of dressings - in particular packaging weight and volume; clinical waste disposal requirements and local transportation need. 

Additional Notes
The type of dressing used depends on a number of factors:
a)     Clinical state of wound
b)     Availability of different dressing type
c)     Staffing levels
d)     Ability of patient to return for follow up if an outpatient
e)     Cost
f)      Point of application (pre hospital/first response phase versus health facility phase)

Silver preparations for burns are often used to help prevent infection and promote healing. However evidence of their clinical and cost effectiveness remains controversial. In low and middle-income countries, access to silver based dressings and availability of funding to support their use is likely to be restricted. This limitation will be magnified in the event of a high number of patients requiring burn care at any one time.


Question Title

* 14. WG Draft Recommendation 10

Surgical Intervention capacity for the care of burns patients at the first receiving health facility should include escharotomy and scrub. If additional expertise is supported via a Burns Specialist Cell additional interventions can be undertaken(early excision and grafting)

Remarks
1. Surgical care can be implemented at the first receiving health facility. 

2. Procedures that local surgical teams are unfamiliar or inexperienced in should be supported by clinical expertise from a Burns Specialist Cell in addition to the provision of written procedural guidance and checklists. 

3. Excision and grafting procedures must be performed by surgeons skills in burns care and/or by surgeons supported by clinical expertise.

4. If early excision and grafting is undertaken at the first receiving health facility the patients care should continue at that facility and no transfer of the patient undertaken unless clinical course deteriorates. 

5. As a life saving intervention, escharotomies and/or fasciotomites were deemed to be an important part of the initial management and stabilisation approach to burn patients arriving at the first receiving health facility. 

6. TBSA estimation and depth re-assessment should be performed following wound scrub to help guide definitive triage and aid decision regarding transfer. 

7. Patients with >20% TBSA after scrub are recommended for referral and transfer to a more specialist facility

8. Patients with < 20% TBSA requiring on-going surgical care should remain at the first receiving health facility thus supporting rationing of resources by ensuring capacity of specialist health facilities is preserved for the more complex and extensive burns. 

9. Paediatric burns >20% TBSA (determined after definitive triage); inhalational; and specific chemical burns should be triaged to and managed in a specialist burns facility when possible. 

Additional Notes
As part of strategies for burns care, the definition of early versus late burns management was also considered with agreement within the WG that full thickness burns should ideally be managed within the first week (early excision) and partial thickness burns beyond week one (late excision) to permit healing of those areas that might heal with dressings alone. Following discussions within the working group, it was considered appropriate for a local surgical team in a non-specialist centre to perform scrub and excision on TBSA of up to 20% in adults and 10% in children. However, a staged approach to this intervention is advised and where possible supported by burn expertise. Skilled burn surgeons (supporting a local facility or at a specialist facility) would be required to undertake excision in patients with >20% TBSA (adult) and 10% TBSA (children)

Question Title

* 15. WG Draft Recommendation 11

When indicated, rehabilitation including active and passive exercises and functional retraining should commence at the earliest phase of care, once vital functions are stable and considering contraindications*. 

Remarks

1. Pain can reduce participation and performance in rehabilitation, therefore adequate analgesia is essential and should be administered for maximum effect during rehabilitation interventions.

2. Dressings may need to be debulked to facilitation movement.

3. Encourage participation in and independence with self-care as soon as possible.

4. *Precautions to consider include related trauma, wound breakdown/graft frailty, k-wires, low blood pressure, or infection.

Additional Notes
The hypermetabolic response from severe burns, coupled with prolonged bed-rest make patients vulnerable to deconditioning and secondary complications. Rehabilitation facilitates supports the cardiorespiratory system, reduces oedema, prevents pressure areas and contractures, as well as readying the patient for discharge. This is especially critical in the context of limited inpatient bed availability characteristic of MCI.

Question Title

* 16. WG Draft Recommendation 12

Position the burnt/grafted skin in end-range, using splints when indicated, to prevent contracture and manage oedema

Remarks
1. Splinting can be used post-skin grafting to immobilise the limb. The typical regime post-skin graft is continually for five to seven days, followed by night-wear, but this should be at the surgeon’s discretion.

2. Splints may be applied in theatre while the patient is under anaesthesia, or during post-operative recovery, to minimise discomfort.

3.  Indication for splinting is based on the severity and position of the burn, and the patient’s ability to move actively. Splinting should be carefully considered for young children and sedated patients.

4. Splinting should be considered for conservatively managed wounds that do not heal within two weeks, as the risk of scaring increases.

5. Thermoplastic is the ideal splinting material as it can be remoulded over time and can achieve good conformality, but alternative materials, such as plaster of paris and PVC piping may also be considered in more resource-scare settings. Innovative resources can also be used for mouth and neck splints.

6. Document up-to-date splinting regimes clearly and use photographs or pictures to illustrate ideal positioning.

7. Splint fit and skin integrity should be checked regularly, especially in hot climates.

8. Patients and family members/carers should be educated on splinting and positioning regimes before discharge as the risk of contracture may persist for 12-18 months.

Additional Notes
Burn contractures can develop rapidly (within hours). Splinting and positioning are essential for elongating tissues during wound healing and to maximise functional outcomes. Oedema post burn insult can be aggravated by limb dependency and can restrict wound healing and movement, as well as exacerbate pain. Elevated positioning facilitates lymphatic drainage and, along with massage and compression, can be used to effectively manage oedema.


 

Question Title

* 17. WG Draft Recommendation 13


Compression therapy and massage should be used to minimise scarring and manage oedema


Remarks
1. Compressional can be achieved with bandaging, tubular elastic stockings, and pressure garments. Which is used should be determined by the wound healing/skin integrity.

2. Application should avoid any sheering of the skin, using application rings if necessary.

3. While customised compression garments may not be available in resource-scarce settings, compression should achieve a pressure between 24 and 40mmHG.

4. Compression bandages or garments should be worn 23 hours a day, until scar maturation, irrespective of weather.

5. When using compression therapy, regular monitoring is especially important for those with reduced sensation or compromised vascularisation.

6. As patients with severe burns will continue to use compression and massage well beyond discharge, education in correct use/technique is critical. Encouraging participation during inpatient stay to improve chances of continuity. 

Additional Notes

In the context of moderate and severe burns, compression therapy can improve the appearance of scars, making them flatter and softer, and can reduce some of the discomfort of immature scars, such as blood rush and itching. Scar massage similarly works to soften scars and can improve skin movement and reduce hypersensitivity.

 

Question Title

* 18. WG Draft Recommendation 14

The Burns Specialist Teams (BST) should be composed of the following personnel:

Team Leader x 1 (non clinical role)
Burns specialist surgeons x 2 (> 5 years burns experience and general trauma)
Anaesthetist x 2 (> 5 years burns experience)
Nurses x 5 (with burns/paeds experience)
Medical Logistician x 1(experience in WASH and waste management for burns)
General logistician x 1
Physiotherpist / rehab specialist x 2 (> 3 years burns experience)

Remarks
1. Globally a total of 5 - 10 Burn Specialist Teams in recommended, inclusive of international and national. 

2. The main function of a BST will be to provide additional specialist capacity to support triage and early and on-going management of patients suffering burn injuries in the context of a mass casualty incident and/or humanitarian emergency.


3. National and International BSTs are recommended to be composed of the same number and skill mix of personnel. 

4. A Burns Forward Assessment Team (BAT) personnel are recommended to be drawn from a BST

5. BST are most likely to be co-lacted within an existing health facility or supported by an Emergency Medical Team (EMT) Type 2 or Type 3.

6. BSTs should have capacity to deploy for a minimum of 6-8 weeks in order to support the continuity of care for burn patients. 

7.In terms of capacity, the predominant responsibility of the BST is to support the expertise, resources and decision-making in the care of burns patients.


Question Title

* 19. WG Draft Recommendation 14a

A forward burns assessment team (BAT)  is recommended to be composed of the following expertise:

Team Leader x 1
Burns Specialist Surgeon x 1

Burns experienced Anaesthetist x 1
Burns experienced Nurse x 1
Logistician x 1

Remarks
1. The main role of BATs is to support assessment of the situation; provide a comprehensive check on resource availability; support the co-ordination mechanisms in place regarding transfer of patients from scene to health facility;and determine the need for further BSTs.


2. BATs should deploy within 6-12 hours after a request from the affected local health authority or country

3. BAT are recommended to be self sufficient in equipment; consumables; communication tools; food and habitat (i.e. for their own needs and in order to perform their function) for a minimum of 3 days. 




Question Title

* 20. WG Draft Recommendation 15

All BST personnel should have completed generic EMT training prior to being eligible to join BST

Additional Notes
In terms of capacity, the predominant responsibility of the BST is to support the expertise, resources and decision-making in the care of burns patients. In particular, capacity building of specialist services and resources for existing facilities is recommended, acting in a ‘force multiplier’ role. The resource and time commitments required for optimal care of burns patients is extensive and where many local health facilities may struggle. EMTs Type 2 and 3 are not required as part of classification and capacity to provide specialist burns services thus the role of the specialist cell is crucial in supporting optimal patient care.

The main role of a BST has been recognised as capacity building particularly for an existing health facility, and thus a BST would not necessarily be the best skill set to deploy to the scene of a mass casualty incident but rather be part of the initial receiving health facilities. It may be preferable to keep national healthcare staff and expertise in their existing place of work where familiarity resides rather than re-distribute personnel to support other facilities – a role that could be supported by a BST.  Resource allocation is recommended to be determined on a case by case basis dependent on local context and resources, BST availability and type of incident.


Question Title

* 21. WG Draft Recommendation 16

All BST personnel should complete specialised training in burns care specifically focusing on mass casualty burn incidents. 
 

Additional Notes
All BST team members should have completed EMT generic training prior to undertaking specialist training for a burns cell.30 In particular, all members should complete the training focusing on adaptation of clinical care according to context and the team focused training. Successful completion of this training is recommended as a pre-requisite for selection to a BST.

The target audience for burns specialist training are practising clinicians (as opposed the healthcare workers who are no longer clinically active). Utilisation should be made of existing courses globally. If courses are developed to meet the required learning outcomes, these should be regionally accessible and the training material open access, modulised and economically viable.

Question Title

* 22.
WG Draft Recommendation 17

Burn Specialist Teams are expected to be self-sufficient for their own needs and for the equipment and consumables required for the surgical and burns care capacity they will provide.

Additional Notes
A knowledge of existing facilities and resources in the receiving health facilities is useful when a BST is deciding on infrastructural support equipment to deploy with. Some of this knowledge may be supplied by the Burns Forward Assessment Team, in addition to identifying additional resources that may be required. Although self-sufficiency of BSTs is required, they are not expected to be self-sufficient in the same manner as EMTs 1-3 as they are most likely to integrate with an existing facility. However BSTs should adapt their equipment and infrastructural support according to local availability and re-supply. Emphasis should be on equipment to support an MCI incident. The following specific infrastructural support equipment is recommended to augment and potentially replenish local resources:

1.     Warming equipment (for example warming blanket; IV fluid warmer)
2.     Simple steam autoclave
3.     Headtorch/lamp
4.     Ambient heater

If required, further infrastructural equipment (such as a ward module) can be deployed to strengthen capacity of the BST through a logistical support module.



Question Title

* 23.
WG Draft Recommendation 18

Following a burns MCI, antibiotics should not be given prophylactically to burns patients unless specifically clinically indicated

Additional Notes
BSTs should aim to augment the laboratory equipment available locally. Information about locally available equipment can be communicated by the BAT. The following equipment is likely to be present in a local receiving health facility:

1.     Haemacue
2.     Basic Electrolytes
3.     Blood Sugar Testing equipment
4.     Urinalysis
5.     Malaria Screening Rapid Diagnostic Test (RDT)

 
In addition, BSTs should consider deploying with a Post Exposure Prophylaxis (PEP). Tetanus should be provided by the local receiving health facility. Tetanus availability and supply should be determined by the Burns Forward Assessment Team when possible.



 

Question Title

* 24.
WG Draft Recommendation 19

BST should have the capability to support the clinical management of burns patients resulting from a CBRN incident once decontamination has occurred. However BSTs are not expected to deliver on-scene care nor be required to be specifically trained or skilled in CBRN scene management or scene decontamination.

Additional Notes
BSTs should have the capability to support the required clinical care of CBRN patients suffering burns. This would include non thermal burns such as chemical and nuclear (radiation). BSTs are not however expected to contribute to on-scene management of the CBRN incident nor scene decontamination of patients but support the arrival and on-going care of such patients at the first receiving health facility. Team members should have a good awareness and basic training in CBRN but do not require specialist higher-level training.

Specific knowledge on the following types of CBRN related burn injuries is recommended:
o   Chemical burns (for example ammonia; mustard gas; hydrochloric acid; phosphorus)
o   Radiation burns
 
 

Question Title

* 25.
WG Draft Recommendation 20

All countries should have a mass burns plan; ideally as a sub-plan under its national trauma plan.

Remarks

1. Health facilities are recommended to include a Burns MCI as part of their Mass Casualty Plans and exercise these plans using desktop scenarios when able.

2. To ensure an effective response from BSTs, co-ordination should be centralised and engage all relevant stakeholders. Burns Forward Assessment Teams have an important role in supporting and guiding early co-ordination efforts especially in guiding countries in receiving international BSTs.

3. A clear and concise communication pathway should exist between the transferring and receiving health facilities to optimise patient care and resource allocation.

Additional Notes
Focus of co-ordination should include strategies to decompress specialist centres and harness additional resources where availableConsideration should be given to the support and use of local and regional trauma teams (not burn specialised) in augmenting some of the clinical work required. Guidance on how to scrub can be provided by BAT and/or BSTs. The integration of such teams is likely in the event of a mixed blast incident.

All BSTs are recommended to exercise an effective and economical supply chain – an example is a stock rotation approach whereby stock is sourced from a local health facility (BST host country) and if not used, returned to the health facility for use within 3 months of expiry. Replenishment of specialist team stock with expiry date >12/18 months then re-drawn from local health facility. This system helps minimise wastage.
 
 

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