Evaluation of pathways for initial management of small paediatric scalds

to achieve clinical and cost effective care and improved patient experience

Chief Investigator	Institution	Dates	Funding Stream	Amount
Dr Amber Young	University Hospitals Bristol NHS Foundation Trust	Apr 2014 - Sep 2014	RCF Autumn 2013	£19,476

Summary

This grant freed up consultant and research nurse time, in order to write and submit an outline grant application to the NIHR Health Services and Delivery Research (HS&DR) Programme at the end of January 2015, for the Scaldcare (now entitled 'OSTRICH': optimising treatment and care pathways in children) project. It also funded related travel expenses for meetings; visits to other centres; patient travel, patient and public involvement.

Lay summary for the OSTRICH  grant application

Hot liquid scalds are common. 40,000 children with burns are seen in UK A&E's each year; 92% are less than 10 years and approximately three quarters are due to scalds. Most scalds happen to young children due to hot drinks. Scalds are usually small in area, but still significant in terms of pain and potential to cause permanent scarring. Distress during and after treatment can be considerable for children and parents, causing great parental anxiety and guilt during both the healing period and also in the long term if permanent scarring occurs.

Scalds can be treated in 4 different ways. Burns need to be cleaned to remove dead skin and reduce infection risk. Some doctors choose expensive dressings that remain in place until healing. These require a thorough wound cleaning which is painful and are usually applied with an anaesthetic. Other doctors use less expensive dressings which can be applied without anaesthetic but need regular changing which is painful.

Burn teams feel differently about treatment. Some services do not use anaesthetics because of safety issues in young children. Others use anaesthesia because it allows more thorough wound cleaning and it avoids sedation risks. Others have difficulty getting theatre time to allow an anaesthetic. Some hospitals do not believe in using expensive dressings on small scalds because there is no evidence to show that this cost reduces permanent scarring. Using an anaesthetic and applying a dressing which remains until healing appears more expensive in the short term, but dressings that require changing, avoid anaesthesia and appear cheaper, may have hidden longer term costs. More frequent changes will require more nurse time and may cause more pain to the child with family inconvenience. The initially more expensive treatment route might be better value for money if outcomes are better.

We know that care and costs for scalds vary. Scarring after small burns also varies. We do not know how these are related, which type of care parents prefer, and what importance they place on different aspects of care or scarring. Without evidence, variations in care will remain. Treatment needs to be informed by research evidence of cost, outcomes and family experience; only in this way will all children receive the best quality care.

Information relating to different treatment and outcomes from burns hospitals are kept on two existing databases. We will use these to examine outcomes and costs after different pathways. We will also talk to parents to understand their views and preferences for their child's treatment and outcomes within 3 weeks of the injury and also at 2 to 4 years after injury if their child has scarring.

Several parents of children with scalds have agreed to form a Parent Advisory Group. They have made suggestions about study design and will bring parent views to all study aspects and information. We will discuss questions for interviews, our findings and how to publicise them. Parents will be given vouchers for each meeting they attend. They will be provided with the INVOLVE Public Information Pack booklets and offered training about being involved. Two members of the group will also attend the study Steering Group meetings.

The study results will be used to provide recommendations on best practice for the NHS to ensure that all children receive best care based on evidence and not simply according to different services' preferences and where they receive care.

Work carried out

Work complete with grant application submitted to NIHR HS&DR funding stream end of January 2015 for a two year grant to look at the cost and clinical effectiveness of different care pathways for managing small area scalds in young children.

In order to submit the application, the following work was undertaken and completed:

• Develop a research team comprising statistician, qualitative researcher, health economist, surgeon, nursing professor, professor of psychology, chair of the national burn injury database.
• Undertake PPI work to assess the need for the work and the views of parents on the study methodology.
• Collect national burn database data and analyse with statistical input for variation in skin grafting rates with different acute management at burn services across England and Wales.
• Link the above to HES a to validate the burn database data.
• Undertake a survey of care in the 14 services across England and Wales and link these to grafting rates.
• Understand quality of life measures.
• Write and submit the grant application ('OSTRICH': optimising treatment and care pathways in children).

Impact

The study results will be used to provide recommendations on best practice for the NHS to ensure that all children receive best care based on evidence and not simply according to different services' preferences and where they receive care.

Other outcomes

• Team developed for grant application including methodologists, senior nursing, surgical
• PPI work undertaken to ascertain need for the research and input into methodology
• Outline grant application made to the NIHR HS&DR funding stream end of January 2015
• Survey of clinical practice at all 14 burn care services in England and Wales
• Analysis of HES and National Burn Database (iBID) data to understand the skin grafting rates for children fulfilling the inclusion criteria
• Understanding gained as to methodology to compare HES and iBID data

Outputs

Description	Status	Date	Further details
The safety of general anaesthesia in paediatric patients undergoing the application of Biobrane® for small scalds Warwicker, Sarah J. et al. Burns , Volume 41 , Issue 6 , 1221 - 1226	Published	Sep-15	https://doi.org/10.1016/j.burns.2015.02.007
Lack of a standardised UK care pathway resulting in national variations in management and outcomes of paediatric small area scalds Trevatt, Alexander E.J. et al. Burns , Volume 42 , Issue 6 , 1241 - 1256	Published	Sep-16	https://doi.org/10.1016/j.burns.2016.04.001