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Burns and Scalds Assessment Template: standardising clinical assessment of childhood burns in the emergency department
  1. Kirsty Hepburn1,
  2. Verity Bennett2,
  3. Alison Mary Kemp2,
  4. Linda Irene Hollen3,
  5. Diane Nuttall2,
  6. Zoe Roberts4,
  7. David Farrell4,
  8. Stephen Mullen5
  1. 1 Medical School, Cardiff University, Cardiff, South Glamorgan, UK
  2. 2 Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
  3. 3 Centre for Academic Child Health, University of Bristol Faculty of Medicine and Dentistry, Bristol, UK
  4. 4 Paediatric Emergency Department, Cardiff and Vale University Health Board, Cardiff, UK
  5. 5 Paediatric Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
  1. Correspondence to Dr Stephen Mullen, Paediatric Emergency Department, Royal Belfast Hospital for Sick Children, Belfast BT12 6BA, UK; stephenm.mullen{at}belfasttrust.hscni.net

Abstract

Objectives The Burns and Scalds Assessment Template (BaSAT) is an evidence-based proforma coproduced by researchers and ED staff with the aim of (1) standardising the assessment of children attending ED with a burn, (2) improving documentation and (3) screening for child maltreatment. This study aimed to test whether the BaSAT improved documentation of clinical, contributory and causal factors of children’s burns.

Methods A retrospective before-and-after study compared the extent to which information was recorded for 37 data fields after the BaSAT was introduced in one paediatric ED. Pre-BaSAT, a convenience sample of 50 patient records of children who had a burn was obtained from the hospital electronic database of 2007. The post-BaSAT sample included 50 randomly selected case notes from 2016/2017 that were part of another research project. Fisher's exact test and Mann-Whitney U tests were conducted to test for statistical significance.

Results Pre-BaSAT, documentation of key data fields was poor. Post-BaSAT, this varied less between patients, and median completeness significantly (p<0.001) increased from 44% (IQR 4%–94%) to 96% (IQR 94%–100%). Information on ‘screening for maltreatment, referrals to social care and outcome’ was poorly recorded pre-BaSAT (median of 4% completed fields) and showed the greatest overall improvement (to 95%, p<0.001). Documentation of domestic violence at home and child’s ethnicity improved significantly (p<0.001) post-BaSAT; however, these were still not recorded in 36% and 56% of cases, respectively.

Conclusion Introduction of the BaSAT significantly improved and standardised the key clinical data routinely recorded for children attending ED with a burn.

  • burns
  • paediatrics
  • paediatric emergency med
  • paediatric injury
  • paediatrics, non accidental injury

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Key messages

What is already known on this subject

  • An estimated 40 000 children present to EDs in England and Wales with a burn or scald every year.

  • The Burns and Scalds Assessment Template (BaSAT), a proforma used in 13 paediatric EDs and minor injury units in the UK, has informed numerous epidemiological research studies to date.

  • Whether the BaSAT improves the quality and standardisation of clinical notes has not been quantified.

What this study adds

  • In this uncontrolled before-and-after sutdy at a paediatric ED, we saw a significant improvement in clinical documentation for children attending emergency care with a burn.

  • Greatest improvement was seen in ‘screening for maltreatment, referrals to social care and outcome’, where the median percentage of documented fields per child improved from 4% pre-BaSAT to 95% post-BaSAT.

  • While the results of this study would support the use of the BaSAT in paediatric EDs, given this was a single-centre study with a 9-year time period between data points, further research is recommended to validate these findings.

Introduction and background

A standardised proforma, the Burns and Scalds Assessment Template (BaSAT) (online supplementary appendix 1) was developed by a burns research team and emergency physicians for children who present with a burn to the ED. The template was initially designed for a research project collating epidemiological data on childhood burns.1 2 It has undergone multiple revisions, responding to the advancing literature in burns injury, as well as the clinical needs of the ED physicians. The BaSAT was developed with input from authors of this paper to the exclusion of the lead investigators (KH, VB and SM).

Supplemental material

The BaSAT is evidence-based and developed as a multifunctional template. It acts as a clinical record, replacing the ED flimsy, and provides a structured approach to the history and examination of the patient and focuses on salient points relating to safeguarding in childhood burns. To date, the BaSAT has been used in over 4000 children who have attended emergency care. These epidemiological1 2 data have contributed to primary burn prevention strategies.3 4

The BaSAT is currently active in 13 ED and minor injury units in England and Wales. As a research tool, the validity of the template is acknowledged.1 2 4–6 However, the clinical utility of the BaSAT has not previously been quantified.

This study aimed to evaluate the BaSAT as a clinical proforma, assessing its impact on the documentation.

Methods

We performed a retrospective before-and-after study at the University Hospital of Wales, paediatric ED (PED). This tertiary PED manages over 32 000 attendances per year. Over a 12-month time period, a convenience sample of 50 patient records of children who had a burn was obtained from the hospital electronic database of 2007, prior to the introduction of the BaSAT in 2008. BaSAT V.6 was incorporated into routine clinical records from 2014. The pre-BaSAT data were extracted by a single researcher (KH, medical student). KH was independent of the research team and extracted data on a bespoke form, recording only what was documented in the notes. KH was unaware of the hypothesis of this project.

The post-BaSAT sample included 50 randomly selected case notes from 2016/2017 (KH was attached to the ED at this time). The post-BaSAT data were obtained by DN from cases on REDCap as part of another research project.

The BaSAT comprises 52 data fields. The patient’s hospital number, name, postcode and date of birth were excluded from analyses as these fields are routinely recorded in the notes using hospital patient identification labels. Fields dependent on the completion of other fields were also excluded. The remaining 37 fields were divided into four sections; ‘patient and clinician details’, ‘history of the injury’, ‘characteristic of the injury’ and ‘screening for maltreatment, referrals to social care and outcome’ (eg, discharge and follow-up).

There were no patient and public involvement in this research project.

Analysis

Fisher’s exact tests were used to compare proportions of completed fields in the two different years using STATA V.15.7 To adjust for multiple testing, we used a Bonferroni-corrected p value of 0.001. Median percentage changes for the four subsections and overall were analysed with Mann-Whitney U tests.

Results

Pre-BaSAT, a median of 44% (IQR 4%–94%) of the 37 data fields was recorded per child. Patient and clinician details were the best recorded fields, with a median of 94% of fields recorded, whereas only 4% of information in the screening for maltreatment, referrals to social care and outcome category was recorded (figure 1). Pattern of injury, whether the family had an active or previous social worker, ethnicity and presence of domestic violence were not recorded in any of the 50 cases pre-BaSAT (figure 2).

Figure 1

Median percentage completion of information within patient notes preintroduction and postintroduction of the BaSAT by category. Error bars denote IQR. BaSAT, Burns and Scalds Assessment Template.

Figure 2

Percentage of records in which each of the 37 data fields was recorded preintroduction and postintroduction of the BaSAT. Significant (p<0.01) improvement of completion of data fields is denoted by *. BaSAT, Burns and Scalds Assessment Template. TBSA, total body surface area.

The recording of type of burn injury was similar for the two time points (contact burn 40% vs 46%, scald 54% vs 46%, other 6% vs 8% for 2007 and 2016, respectively). The child’s age, gender, date and time of assessment, type of injury, explanation and burn agent were recorded in 100% of cases in both (figure 2).

Post-BaSAT, the median percentage of the 37 data items recorded for each child increased significantly (p<0.001) to 96% (IQR 94%–100%) (table 1).

Table 1

Comparison of precompletion and postcompletion of data fields following implementation of the BaSAT

Screening for maltreatment, referrals to social care and outcome saw the greatest improvement between years (4% prescreening, 95% postscreening; p<0.001), followed by ‘characteristics of injury’ (24% prescreening, 100% postscreening; p=0.008) and ‘history of injury’ (66% prescreening, 100% postscreening; p=0.02). There was no improvement in patient and clinician details (94% prescreening, 98% postscreening; p=0.52) as it was already high to start with. (figure 1). The overall variance within the four categories post-BaSAT was reduced as shown by the narrowing of the interquartile range (figure 1).

Pattern of injury and total body surface area were recorded in substantially more cases in 2016 than in 2007, increasing from 0% to 94% (p<0.001) and from 16% to 100% (p<0.001), respectively (figure 2). Whether the parents/carers conducted any first aid increased from 66% preintroduction to 100% postintroduction (p<0.001). Ethnicity and domestic violence remained poorly documented post-BaSAT, being documented in only 44% and 64% of cases, respectively (figure 2).

Discussion

Postimplementation of the BaSAT, a statistically significant improvement in clinical documentation for children who attended PED with a burn, was noted. This was most notable in areas concerned with child maltreatment.

These results are valuable but potentially limited by the small sample size at a single institution. The datasets were 9 years apart and chosen due to the ongoing development of the BaSAT. The unit was involved in codeveloping the BaSAT and participated in other branches of burns research. Furthermore, within the time period, a paediatric emergency consultant was appointed. These factors may have a benefit on education and training, with the potential to influence any improvement in documentation. There is the potential for measurement bias, given that data extraction was undertaken by different personnel at different times. Of note, there were no changes to information technology systems and the records remained handwritten at both time points. A strength of the study is that we only assessed what was documented in the ED notes at both time points, allowing for a direct comparison to be made. We did not assess other documentations, that is, inpatient notes, as the BaSAT was designed for an ED setting.

An estimated 10% of burns arise from child maltreatment,8 yet these are under-recognised in children presenting to the ED. In the post-BaSAT cohort, significant improvement in recording screening for maltreatment, referrals to social care and outcome, and increases the potential for early recognition and referral of these cases for safeguarding assessment. It is important to acknowledge the areas which remained poorly completed, in particular, domestic violence. Our research team hypothesise that clinicians may feel uncomfortable asking these questions in acute cases involving an unwell children or where both parents are present. Further studies are required to explore how to improve screening for domestic violence in the ED setting.

Prompt burns first aid has the potential to reduce the size and depth of the wound. The results demonstrated improved documentation of home first aid after implementation of the BaSAT. The BaSAT may prompt the clinician to enquire if adequate first aid was performed and, if not, to cool the burn in ED within the 3-hour recommended window.11

We believe the BaSAT prompts better documentation as the depth of questions asked allows the clinician to gain a greater appreciation of the intricacies of the case, which may be lost if one simply added a few open-ended questions to the standard documentation. We would recommend further studies in other units that use the BaSAT to ascertain if similar results are identified in departments that have not been involved in the production of this template as we believe the BaSAT has the potential to prompt thorough clinical assessment, ensure that safeguarding risks are considered, monitor local trends in the causes of childhood burns and inform injury prevention.

References

Footnotes

  • Twitter @VerityBennett3

  • Contributors KH, VB and SM drafted the manuscript with editorial input from all authors. The research idea was conceived and developed by AK and SM. LIH, KH and VB undertook the statistical analysis. KH led the data collection with assistance from DN, ZR and DF. All authors read and approved the final manuscript.

  • Funding This study was funded by Health and Care Research Wales (516832) and the Scar Free Foundation (505345).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval (Wales REC 3 13/WA/0003) and approval from the Confidentiality Advisory Group (CAG 1-06(PR7)/2013) were obtained to enable data collection from case notes for research with waived consent. This project was registered with the hospital audit team.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Data are held on a project database and are available upon reasonable request.

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