Current Anaesthesia & Critical Care (2002) 13, 83^86�c 2002 Publishedby Elsevier Science Ltd.doi:10.1054/cacc.402, available online at http://www.idealibrary.com on

FOCUSON:BURNSANDPLASTICS

Organization of burns servicesS. J. Squires

McIndoe Burns Centre,QueenVictoria Hospital NHS Trust, East Grinstead,West Sussex RH19 3DZ,UK

KEYWORDSburns, critical careperi-operative care,resuscitation anaesthesia

Summary Incommonwithmanyaspectsof acutehealthcareintheUnitedKingdom,burns care is currently undergoing signi¢cant review and recon¢guration. Anaesthesiaand Critical Care provision form an integral part of burns care and are thus part of thischange.Bringing burns critical care in line withmodern general adult and paediatric in-tensive care is highly desirable, but will need to be achievedwithminimal disruption tocontinuity of service andwith careful attention to sta¡ retention.National,College andAssociation Guidelines for service provision and training should informthe strategy forrecon¢guring local burns services and be applied appropriately to ensure that change,once achieved, is for thebetter.Wherepossibletheseguidelines shouldbe appliedlocallyto optimize the anaesthetic and critical care of burnedpatients in advance of wider ser-vice recon¢guration.�c 2002 Publishedby Elsevier Science Ltd.

HISTORYANDBACKGROUNDThe care of patients with burn injuries underwentmajor changes during the last century. The most rapiddevelopments in burn care have come at times of con-£ict, withmajor advances in burn surgery coming duringthe SecondWorldWar.Up until that time, patients withburns a¡ecting more than one-third of the total bodysurface area (TBSA) were not expected to survive,1

whereas, by the 1990s, patients with massive injuries of90% TBSAmight eventually return to the community, al-beit after a long and involved hospital stay.Since the 1950s developments in the understanding of

£uid resuscitation, the pathophysiology and medicaltreatment of burns, the availability anduse of antibiotics,dressingmaterials and techniques, and the early excisionand closure of the burnwound, have all led to steady im-provements in prognosis.During the same period signi¢cant advances in

anaesthesia and intensive care have enabled seriouslyburnt patients to survive for prolonged periods,with respiratory, cardiovascular and renal support, andto undergo the repeated and protracted surgical epi-sodes needed to achieve closure and healing of the burnwound.The concept of the burns team became recognized

and the ¢rst purpose built burns units were establishedduring the1960s.2 The choice of sites for these units was

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largely made on historical grounds, and the units devel-oped locally with plastic surgery, according to localneed and desire, and largely independent of oneanother. This has resulted in a heterogeneous group offacilities, bearing little resemblance to one another, withsome occupying separate sites, and some developingwithin district general hospitals or within large teachinghospital groups. They also di¡er markedly in termsof style, working practices, activity levels and sta⁄ngpro¢le.1

Althoughburns care in Britain had led theway in inno-vation, by the endof the 20th century ithad fallenbehindin comparison with the best services elsewhere in thewestern world. Furthermore, burns services did not ¢teasily withmodern NHS aspirations for equity of access,standards of care, particularly critical care, and theprocess of health commissioning.These issues combinedto stimulate a desire for change.3

THENATIONALBURNCAREREVIEW(NBCR)In 1998 the British Burns Association received supportfrom the Department of Health for a complete reviewof burns care in the UK. In 2001The National Burn CareReview Committee published its report.2 This extensivedocument reviews current services, argues for change,andmakesrecommendationsunder eightheadings whichare summarizedbelow.

Table 1 Proposed national guidelines for burn injuryreferral

Complex injuryFrefer to local specialist burns serviceAge Below 5 orover 60 yearsSite Face, hands, perineum, feet

FlexureCircumferential to limb, torso orneck

Anyinhalationinjury

Excludingpure carbonmonoxidepoisoning

Mechanism Chemical45% totalbody surfacearea (TBSA)Ionizing radiationHigh-pressure steamHigh-tension electricalSuspicion of non-accidental injury(adultor paediatric)

Size Paediatric45% TBSAAdult410% TBSA

Pre-existingillness

Systemicordebilitatingconditions

Associatedinjuries

Headinjury

Fractures orcrush injuriesPenetrating injuries

Non-complexF refer to local plastic surgery serviceSize of skininjury

Paediatric; 2^5% TBSA

Adult: 5^10% TBSA

Other injuriesF often suitable for A&E orcommunity care

Non-acuteFmayrequire referral in the post acute phaseWoundhealing

Woundunhealed at14 dayspost-burn

Complications Local or systemic sepsisRehabilitation Complicated scarring

84 CURRENT ANAESTHESIA & CRITICALCARE

Summary of NBCR recommendations

(1) Uniform clinical management and referral guidelines (seebelow): Based on complexity of injury rather thansimply on extent of body surface area a¡ected.

(2) In-patient provision for burn injuries to be provided byspecialists.

(3) A new structure for burns care services: Strati¢cationinto Burns Facilities, Units or Centres. These arede¢ned according to facilities, specialist sta¡ andsupporting services available on-site and determinethe complexity of injury admitted, with facilitescaring for non-complex injuries and centres for themost complex.

(4) Criticalcare provision: Discussed further below.(5) Continuing care as part of a burn service: Physical and

psychological rehabilitation.Outreach teams.(6) A national network of services: Involving primary care,

A&E departments, and specialized burns services,(7) Research and development: Into dependency scoring,

care pathways and outcomemeasures.(8) Improved data gathering and analysis: Further

development of the British Burn Injury Database(BIBID).

The review calls for immediate implementation insome areas, particularly in the establishment of suitableservices for the severely burned child. Paediatric inten-sive care unit (PICU) services have developed in major,largely teaching, centres, and are rarely co-sited withburns services.This situation has forcedburns specialiststo either care for major paediatric burns in units lackingin accredited PICU facilities and expertise, or to transferpatients to PICUswhereburns expertise is not available.Neither situation is acceptable, or comfortable for theclinicians concerned.The NBCR report is currently being adopted for imple-

mentationby theDepartmentof Health.The identi¢cationand development of services to be designated as burns‘Centres’, ‘Units’ or ‘Facilities’, if to be followed as recom-mended, will require care, time and resource if valuablespecialist sta¡ are to be retained and new sta¡ recruited.As has been seen in general ITU, allocation of ¢nance forbed expansion has not necessarily broughtwith it the spe-cialistnursing sta¡whoremainourmostvaluableresource.

CURRENTBURNSCARE; GENERALCONSIDERATIONSRelatively trivial burn injuries may never present formedical carewhile signi¢cantminor injuriesmaybeman-aged in the primary care setting.More severe burns willgenerally arrive at accident and emergency departmentseither as ambulatory patients or via the ambulance ser-vice.The most seriously burned patients may have been

rescued and resuscitated by the ¢re or ambulance ser-vice andmay arrive at hospital in-extremis.Patients requiring resuscitation will usually have this

provided, or commenced, in A&E before being referredonto the burns specialist unit. Guidelines for resuscita-tion, and criteria for referral will normally be dissemi-nated by burns units to their ‘feeder’ district generalhospitals. This enables the burns teams to in£uence thecondition of patients arriving in their units, and is largelye¡ective. It is nowunusual for patients to be inadequatelyresuscitated andearlyrenal failure, due to hypovolaemia,is rare. Burns are relatively common at the extremes ofage, and for both small children and elderly adults, even alimited injury may require admission. Severe major inju-ries are rare but these patients, in order to survive, willneed prolonged intensive and high dependency care, re-peated surgical episodes to excise the wound and pro-vide both temporary and permanent skin cover, andprolonged rehabilitation.

ORGANIZATIONOFBURNSSERVICES 85

Around 25/100 000 population require hospital admis-sion for burns annually. Two-thirds of these patients areadmitted to hospitals with specialist burns services andrepresent a broad spectrum of severity. Patients whoare initially cared for in the community or admitted togeneral hospitals may be referred late to specialistservices with complications or poor healing.The NCBRhas outlined national referral guidelines to bring someuniformity to referral practices in the NHS. These aresummarised in abbreviated form inTable1.Good communication between specialist burns ser-

vices and local accident and emergency departments isessential. Standardized referral documentation can beprovided which can then be faxed to the receiving unitprior to transfer. Telemedicine links, being developed insome areas, may prove to be valuable, enabling specia-lists to give advice on the treatment of cases that maynot require immediate transfer. Education, such as the‘EmergencyManagementof SevereBurns’ (EMSB) coursecan be o¡ered by the specialist burns sta¡.The emergence ofmultiresistant bacterial strains, and

the virtual inevitability of contamination of the burn pa-tient demands aggressive infection control measures,and a continued degree of physical and procedural se-paration of burns beds and sta¡ from the wider generalhospital population.

BURNSCRITICALCAREPROVISIONCritical care for burnedpatients is deliveredmainlywith-in burn units, mainly by burn anaesthetists/intensivists,working with specialist burns nurseswhomay also occa-sionally hold a recognized intensive care quali¢cation.This situation obviously £ies in the face of recommendedpractice for critical care. It has arisen as a result of thedevelopment of burns care separate from adult and pae-diatric ICUs, which are also physically separated, oftenby great distances, from the burns wards.Due to the relative rarity of major burns requiring in-

tensive care, burns units which admit these patients areunlikely to achieve the levels of throughput of even thesmallest general intensive care units.This makes recruit-ment andretention of intensive care nurses very di⁄cultin a competitivemarket. It alsomeans that anaesthetist/intensivists working exclusively in these units will ¢nd itdi⁄cult to remain current in themore general aspects ofICUwork. Proposed transfer of burns patients to gener-al adultor paediatric ICUsmaybemetwith reluctance asspecialist burns nursing and surgical skills may not beavailable at the ICU location.The most severely injured patients will require ICU

stays measured in weeks rather than days, with a highincidence of contamination with multi-resistant organ-isms, multiple surgical interventions, and frequent dres-sing changes which are hugely demanding on nursing,

surgical, anaesthetic, therapist and ¢nancial resource.The care of these patients is very demanding on the sta¡who become, in themselves, a rare specialist resource.TheNBCR seeks to set standards of care and facilities

whichwill bring burns critical care closer in location andstandards to general ICUs. Achieving thiswill be particu-larly demanding for the burned child for whom at pre-sent it is di⁄cult to identify the ideal arrangementanywhere in the UK, where a burns unit is co-sitedwitha fully accredited PICU.In the meantime consultant sessions for burns anaes-

thetists/intensivists should be adequate to provide thebest 24-h cover currently feasible for burned patientsrequiring critical care. Every e¡ort must be made toprovide appropriately trained nursing support to burnwards or, as proposed in the NBCR, achieve mutualsupport andco-operationwith a co-sited adult ITU.Out-reach capabilities should be developed by the burns ser-vices to support professionals in general wards and ITUswhen, for whatever reason, patients cannot be trans-ferred to the specialist unit.

ANAESTHESIAFORBURNINJURIES

Provision

Anaesthetistsmaybe involved at all stages of acuteburnscare.Most patients will enter the hospital systemvia theaccident and emergency department. Initial resuscitationmay involve assessing and securing the threatened air-way, initiation of arti¢cial ventilation, analgesia and seda-tion, establishing adequate venous access and invasivemonitoring. Major cases, referred to specialist services,may require stabilization for, and care during transfer.Anaesthetists are likely to be called upon to managethese procedures, and within the general hospital set-ting, they will represent the normal extent of anaes-thetic involvement.Patients with major complex injuries will only survive

with excision of the burn wound at the earliest possiblestage.The most extensive wounds will require very pro-tracted and repeated surgical procedures and dressingchanges at a timewhen theymay be highly dependent onsupport of both the respiratory and cardiovascular sys-tems.Thesepatients comprise some of themost compro-mised patients to undergo planned surgery, as itmay notbe possible to improve their conditionwithout it.Later during their recovery period, patients will need

revision of scarred areas, and reconstructive proceduresduring which time they may have developed contrac-tures which threaten safe airwaymanagement.At the specialist burns unit, anaesthetists will be

involved in

K receiving and stabilising patients,K management of high dependency and intensive care,

Table 2 RCA&ABRAguidance for the provision of burns anaesthesia services (2001)Fsummary

Incorporating NBCR recommendations

(1) Emergency anaesthetic assessment and treatment may be required in any hospital with an A&E department.Guidelinesshould be available for immediate care and transfer

(2) Burns centres provide care for complex injuries with largeTBSA; Burns Units provide care for complex injuries with smallTBSA;Burn facilities provide care fornon-complex injuries

(3) The responsibility for critical care of burned patients should be shared between burns anaesthetists/intensivists, and burnssurgeons.

(4) The critical care of burned patients is an integral part of burns anaesthesia services. Specialist departments need to provideprotocols, sta¡ training, andrapid availabilityof resources

(5) Provisionof beds forburnintensivecaremustbeadequate.Withsu⁄cientworkloadthesewillbeina Burns ICUwithina Burnscentre.With lesser workloads theywill be in general ITUor paediatric intensive care unit (PICU)

(6) Critical care beds for burnspatients need to be in close proximity to anoperating theatre and other support facilities(7) Major burn anaesthesia should only take place in a Burns Centre or Burns Unitwith full consultantcover(8) Paediatric burn cases require special facilities and sta⁄ng

86 CURRENT ANAESTHESIA & CRITICALCARE

K anaesthesiaK peri-operative care.

As in most acute clinical areas, delivery of the bestcare is by a well led multidisciplinary team comprisingnursing, medical, therapist, technical, and supportingsta¡. Burns surgeons, anaesthetists and nurses will needto co-operate closely, and for the initial stages of surgery,will need access to a dedicatedoperating theatre for longperiods, and be able to mobilize large theatre teams atrelatively short notice.These logistical requirements arechallenging to deliver with the limited resources. Com-bined with the high elective and emergency demandsbeing made on UK operating theatres the need for adedicated burns theatre is clear.This is also likely to re-duce the infection controlrisk to thegeneralhospital po-pulation posed by severe burns cases.The Royal College of Anaesthetists and the Associa-

tion of Burns and Reconstructive Anaesthetists has re-cently drafted ‘Guidance for the Provision of BurnsAnaesthesia Services’.4 This incorporates NBCR recom-mendations and is summarized inTable 2.

Training

All anaesthetists will need, on completion of training, tobe competent in the assessment and early managementof burns injurieswhichmightpresent to the general hos-pital A&Edepartment. A furthergroupmayberequired,as consultants, to provide sessions in plastic surgery withoccasionalburns surgery.Those anaesthetistsworking asconsultants in burns centres will need to have received a

thorough training in all aspects of anaesthesia for burns,plastic and reconstructive surgery. The Association ofBurns and Reconstructive Anaesthetists (ABRA) (for-merly the Plastic Surgery and Burns AnaesthetistsFPSBA) have identi¢ed key areas of training and com-petence for anaesthetists.5 Most of the anaesthetic skillsrequired are generic, however, the unique nature of thepatients and the demands theymake on acute health ser-vices, make specialist experience essential.It is important that, despite limited training opportu-

nities in some areas, as many anaesthetic Specialist Re-gistrars as possible are exposed to the care of majorburns.With current limitations on trainee doctors hoursbeing introduced through the ‘New Deal’, and the rela-tively small number of themost severe injuries, it is con-sidered that a 6 month attachment to a departmentproviding a burns anaesthetic service is therealisticmini-mum to achieve training aims.

REFERENCES

1. National Burn Care review. Committee Report. 2001.

2. Sutherland A. Organisation of burn care facilities. In: Settle JAD

(ed). Principles and Practice of Burns Management. New York:

Churchill Livingstone, 1996; 43–49.

3. Judkins K. Burns treatment in the 21st century: a challenge for

British anaesthesia. Anaesthesia 1999; 54(12): 1131–1135.

4. Guidance on the Provision of Burns Anaesthesia Services.

Association of Burns and Reconstructive Anaesthetists, 2000.

5. Plastic Surgery and Burns TrainingFContent and Minimum

Caseload. Association of Burns and Reconstructive Anaesthetists,

2000.