Burn Injuries explained by Krissie Stiles

Last month on the blog we shared a rare insight to a day in the working life of Krissie Stiles, a Burn Care Advisor. In this next blog Krissie explains about burn injuries and her role within the local community.

At what point would a child be transferred from Accident and Emergency to a Specialist Burns Unit?

There are national and local criteria for referral to a specialist burn service. The cause of injury quite often gives an indication of the likely severity of the burn:

• Deep dermal and full thickness burns may require surgery and specialist treatment to enable these wounds to heal;
• Electrical and chemical injuries can potentially cause internal injuries and can affect the function of organs other than skin, these tend to be deep and may lead to loss of limbs;
• Inhalational injury causes destruction of the lungs and can alter the process by which air and oxygen are transported to blood and requires support in a critical care environment;
• Burns alongside any other injuries can be life changing and require support from a multidisciplinary burns and trauma teams.

Certain parts of the body are functionally and aesthetically important to all of us, so burns to faces, hands, genitals, feet, joints, scalps and ears will require referral to the burns team, who are aware of the potential consequences of such injuries.

Any burn that causes skin loss over 1% total body surface area (equal to the surface covered by one palm with fingers) in a child and over 3% in an adult must be referred to a specialist burn unit.

There are many other criteria for referral to a specialist burn service, but referring clinicians are often advised just to pick up the phone and call for specialist advice. The benefits provided by this phone call allow immediate support and advice to be given to the referring clinician, expediting appropriate care to be delivered to the patient.

What is the clinician process you go through with a child coming into a specialist burns unit?

Early assessment of the depth and size of the injury is needed as it is often indicative of the severity of the burn. Pain relief is administered before any wound review is carried out as exposure of the wound is often unpleasant and wound cleansing can be painful. Prompt clinical assessment by the burns specialist nurse, doctor and physiotherapist will then lead to a decision on whether the child’s wounds need surgery or whether they could be managed with dressings on an out-patient basis. Once cleaned, the physiotherapist will assess the available range of movement in the affected area and advise on any appropriate exercises to be carried out during the healing process. The wound is then dressed with secure bandages and advice on monitoring for signs of infection, appropriate pain management and diet to support wound healing is then given to the child/child’s parents. Often the patients will be expected to return for their change of dressing every 3^rd day until the wound has healed.

A burn is for life! What are the rehabilitation processes you undertake in the Burns Unit, both from a physical and psychological aspect?

Rehabilitation of the child begins at the time of injury and every intervention from that point onwards is aimed at encouraging wound healing, mobility and psychological health. The burns team is a large team comprising of specialist nurses, doctors, physiotherapists, occupational therapists, dieticians, pharmacists, psychologists and play specialists, who work together to deliver a holistic package of care to the children and their families.

Whilst the surgeons and anaesthetists, alongside the theatre team look after the surgical management of the wounds, the pharmacists monitor any required medications and their potential side-effects, the dieticians advise on the most balanced diet to speed up wound healing and support nutrient intake. The physiotherapists and occupational therapists work with the child and parents to ensure that daily exercise and activity regimes are adhered to; the psychology team and play specialists look after the psychosocial aspects of health of the whole family, and the nursing team offer ongoing support and care over a 24 hour period in the absence of other burn team members.

Children are able to utilise computer technology, like Wiii or Play Station games, to encourage their physical rehabilitation. Simple activities that stimulate movement are encouraged. For example, for hand rehabilitation many stretches and exercises are available to extend and flex the many joints in the hand; fine pincer movement is practiced by attempting to pick up small objects with fingers. Any facial burns will lead to a rehabilitation regime that involves funny faces being pulled to prevent thickening of the healing skin.

Psychologists and play specialists work together with children and their families to support the emotional aspects of dealing with the reality and consequences of the burn injury. The support of the psychology team is available long after the burn injury has healed, as the families and patients attempt to return to their lives and their places in society.

What should parents/carers be aware of if their child is burned or scalded?

It is an incredibly emotional and stressful situation when a burn injury happens, especially when a child is involved. The essential aspect of care at this point is to remove any clothing, jewellery and nappies away from the affected area, commence cooling with luke warm water (e.g in the shower) and continue this for at least 20 minutes, loosely cover the wound with domestic cling film or a clean non-fluffy cloth, and then seek medical advice by calling the GP or NHS 111 service. This simple first aid measure will reduce the severity of the burn injury and will be the difference between the need for surgery and minimal scarring.

The layers of the skin blister and lift when damaged by the burn injury. It can be scary to observe the swift reddening and blistering of the damaged skin, which can often lift off with the removal of clothing and during first aid. However, non-removal of clothing will retain heat and cause further damage, which may lead to the child needing surgery and skin grafts. The lack of appropriate and timely cooling will have the same effect. So stick to the burns first aid motto: Cool, Call, Cover.

Burns are very painful injuries. Whilst cooling and covering the wound will go some way towards alleviating the discomfort of the injury, simple pain relief medication (like Paracetamol or Ibuprofen) should be given to the child at home.

If further medical assessment is needed, the parents will be advised to take the child to the local minor injuries unit or emergency department, who will assess and if necessary refer to the specialist burn service. It is not possible to attend the burn service directly.

Krissie, you wear numerous hats please can you briefly explain each one?

As the Burn Specialist Nurse, I have completed post-registration burns and plastics training, Critical Care  nurse training  and earned the “Outstanding Patient Care Award”. I have developed a Burns Referral Form which is still in use today to collect comprehensive referral information and offer appropriate management advice to the referring non-specialist clinicians. I work as part of the burns intensive care team, looking after the most severely injured and sickest patients on our unit.

As the Burn Care Advisor, I attempt to bridge the gap between the Fire & Rescue, Ambulance, HEMS, Trauma and specialist burn services by facilitating Burns Management Study Days for non-specialist clinicians. I often present at national and international conferences and write for publication. I take the lead on the regional publicity campaigns for the annual National Burn Awareness Day and am proud to be part of the team awarded the “Innovation in Care Award” for the Burn Care Advisory role.

As the Lead Nurse for London and South East of England Burn Network, I lead a team of senior nurses on projects to develop evidence-based burn referral, transfer and wound care practice guidelines, which have become the standard of care across the London and South East region.

As the British Burn Association’s (BBA) Executive Committee Member, I was part of a team who developed The Burns Game (www.burnsgame.com) as an educational resource for non-specialist clinicians and have pioneered the BBA Pre-Hospital Specialist Interest Group to support the pre-hospital needs of patients with burn injuries and clinicians involved in their care.

How are you involved in burn and scald prevention education in the local community?

I lead the promotion and local publicity campaign for the annual National Burn Awareness Day every October across the South East region and the catchment area of the QVH. This often means working with the fantastic Photographic Department team at QVH to create visual materials to support the day, including a “First Aid For Burns Cool, Call, Cover” You Tube video, which has received over one thousand views so far. In the months preceding the day, I liaise with colleagues at the regional Fire & Rescue Services, Ambulance Services and referring emergency departments to enlist their support of the National Burn Awareness Day, by promoting this via social media as well as burn prevention messages and leaflets offered to their local communities and patients. I also work closely with the Communication team at QVH to ensure the appropriate first aid and burn prevention messages are available on QVH website, Twitter and Facebook pages. For the last 3 years I have submitted an article to my local parish magazine highlighting the importance of appropriate burns first aid and prevention.

I am most proud of our achievements during 2016’s National Burn Awareness Day as a Trust. This was the most successful collaboration between West Sussex Fire & Rescue Service, Kent, Surrey and Sussex Air Ambulance, South East Coast Ambulance Service, NHS England and QVH in raising the #BeBurnsAware, #CoolCallCover and #NationalBurnAwarenessDay message across the South East region.

As the Lead Nurse for London and South East of England Burn Network (LSEBN), what do you feel the benefits are in having a Burns Care Network?

Networks allow the specialist burn services to coordinate and standardise their approach to patient care. A Network approach means regular meetings for the multidisciplinary teams from every service within the LSEBN, sharing of information and highlighting areas for improvement across every discipline.

Appointment of the LSEBN psychosocial, physiotherapy and nursing leads has offered a consistent voice representative of their colleagues from the Network services.

The recent appointment of the Patient and Public Representatives to the Network team has brought an invaluable sense of balance, reflection and purpose to our Network projects.

You’re involved in the National Burn Awareness Day in October, what do you think are the key messages people should take away from National Burn Awareness day?

The best first aider is already present at the scene – it is you. Only 39% of all adults and 48% of all children with a burn injury receive appropriate first aid at the scene. What you do, or don’t do, can make a real difference to a burn survivor’s outcome and quality of life.

Twenty minutes can seem like a life time when its your own child, who is distressed and in pain. Applying the luke warm running water for the full twenty minutes will relieve the pain, reduce the swelling, prevent further heat damage to the skin, improve healing and reduce the likelihood of scarring. Can you afford to not do it?

British Burn Association advises ‘Cool, Call, Cover’ as steps to initial management of a burn injury. REMOVE any clothing, nappies or jewellery near the burned area

COOL under running tap water for at least 20 minutes

COVER the wound with loose strips of cling film

CALL your GP or NHS 111 for medical advice, in an emergency dial 999

Immediate application of cool running water to a burn injury is best; however first aid is still beneficial within 3 hours of injury.