Improving burn care across the nation

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Yvonne Singer from the Australian and New Zealand Burns Association presents two tools that are useful for clinicians dealing with burns patients: the BRANZ and BQIP.

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Burn injury can have devastating consequences. Each year there are approximately 50,000 burn related hospital admissions in Australia, and more than 3500 people will require admission to one of the 17 specialist burn centres throughout Australia and New Zealand. Apart from the devastating effects of the physical injury itself, burn injuries can result in significant personal and familial stress, long term unemployment and disability. Care must be evidence based to minimise these adverse consequences of injury.
Unfortunately however, the evidence base for burn management is lacking, and there is significant variation in the treatment of burn injuries across Australia and New Zealand. This means that patients with similar injuries can receive very different treatment according to which unit they are managed in; and we do not have a good understanding of the consequences of these differences, and their effect on patients’ quality of life.
Recognising the significant impact of burn injuries and the variations in treatments and patient outcomes, our region’s peak body for burn care clinicians, the Australian and New Zealand Burn Association (ANZBA) in collaboration with Monash University Department of Epidemiology and Preventive Medicine developed the Burn Registry of Australia & New Zealand (BRANZ) in 2009. The overall aim of BRANZ, a population based clinical quality registry, is to improve the standard of care for burn injured patients in Australia and New Zealand. This will be achieved by

• Collecting demographic details regarding burn injury.


• Measuring and benchmarking significant clinical processes and procedures, and linking them with patient outcomes.


• Monitoring compliance with evidenced based quality indicators.

With 4 years of BRANZ data available, there is evidence of considerable variation in the management of burn injury between the Australian and New Zealand burn units. There is also evidence of significant variation in outcomes that are not explained by differences in injury severity or patient risk factors alone.
ANZBA established the Burn Quality Improvement Program (BQIP) in 2013. The aim of the BQIP is to use the BRANZ data to understand the effects of treatment variation on patient outcomes to determine best clinical practices. Multiple factors influence the different practices; these include a lack of an evidence base, geographical isolation, different training pathways and health care systems, as well as clinician and patient preferences. The BRANZ provides data to analyse the effects of different practices, and the BQIP provides a framework to address differences to ensure all patients receive best practice care.
Burn care is centralised in Australia and New Zealand with 17 designated burn units providing specialist burn care. These centres manage nearly all cases of major burn injury, which allows the BRANZ to collect standardised population based data.
It is timely to reflect on the significant achievements of both the BRANZ and the BQIP in improving burn care and patient outcomes across Australia and New Zealand.
The Burn Registry of Australia & New Zealand
The BRANZ is a Clinical Quality Registry (CQR) managed by Monash University Department of Epidemiology and Preventive Medicine (DEPM), in accordance with the Australian Commission on Safety and Quality in Health Care Operating principles and technical standards for Australian clinical quality registries. BRANZ collects data on all patients admitted with a burn injury to the identified 17 burn centres for more than 24 hours, or cases with a length of stay of less than 24 hours who either had a surgical procedure and was discharged, or succumbed to their injury.
As a CQR, the BRANZ collects specific clinical and service activity data as well as patient outcomes. This provides an opportunity to link care and processes with risk adjusted outcomes to help determine best practices. For example, BRANZ can improve understanding of the relationship between different surgical treatments and scarring outcomes associated with the use of new bioengineered skin substitutes..
Additionally, embedded into BRANZ are clinical quality indicators related to structure and processes which allow surveillance of burn unit performance and provide a quantitative basis to drive improvements in care and processes. The quality indicators are clinically relevant and evidenced based, and provide useful comparisons for benchmarking.
An example of one of the nutritional Quality Indicators and burn unit performance is illustrated in Figure2. Hypermetabolism is a consequence of severe burn injury and the early provision of adequate nutrition is critical to quality burn management. The commencement of enteral nutrition within 24 hours is associated with a reduction in rates of paralytic ileus, attenuation of the catabolic response and prevention of malnutrition.The Quality Indicator is “Was Enteral feeding commenced in less than 24 hours of admission for burns adults >20% Total Body Surface Area (TBSA) and children >10% TBSA.” The data illustrates significant variation in practice between units, with compliance of different units with best practice varying between 35% and 100% of eligible patients. This is where BQIP comes in to provide a framework for burn units to improve performance.
The BQIP
The primary aims of the BQIP are to improve the quality of burn care and patient outcomes. BRANZ data is used by the BQIP to provide:

1. Risk adjusted Burn Centre Specific Quality Indicator reports: each unit will be provided an annual report and by request, to benchmark individual performance against comparative bi-national QI data and yet to be developed Standards of Care.


2. Analysis of variances in treatment and outcomes: the BRANZ data will be analysed by the BQIP Research Fellow so that the impact of practice variations on outcomes can be distinguished.


3. Standards of Care: Standards of Care for the BRANZ Quality Indicators will be developed.


4. Best Practice Guidelines: best practice guidelines will be developed.

The BQIP provides burn units:

1. Educational opportunities: web conferencing will provide education on subjects such as the Quality Improvement cycle and change management to provide knowledge and skills to facilitate changes to improve care.


2. Audit tools: With the assistance of the Joanna Briggs Institute, develop a suite of on line audit tools for the QIs to assist in the identification of barriers which can then be acted on to improve performance.


3. An on-line learning community: a secure web portal will be developed for BQIP to facilitate peer to peer learning where clinicians can ask questions of each other to crowd source solutions.


4. Development of local BQIP champions: BQIP champions in each of the 17 burn units will integrate the BQIP into local quality improvement programs.


5. Showcase high performers and best practices: Burn Units who perform well in relation to specific quality indicators will be invited to share their practices via interactive presentation at Scientific Meetings, forums, online education sessions and through publication. Similarly, Burn Units will be invited to share their local successes and challenges in using the Quality Indicator to drive improvements to care via the on-line classroom.


6. Project support: assistance is available to units to analyse their data, navigate the Quality Improvement cycle and support through the change management process.


7. Address variance in practice: The BRANZ & BQIP Steering Committee will lead discussions within the Australian & New Zealand burn community regarding the impact of data and develop recommendations for practice change.

Where are we now?….
The last two years has been productive for the BRANZ and the BQIP. The Quality Indicators and data items have undergone a major review and are currently undergoing interpretation. Additional QIs have been added, including QIs related to infection control practices and the management of psychosocial needs. These changes will be reflected in the BRANZ by 2016. There are several publications currently in press which examine long-term outcomes, outpatient presentations and the relationship between first aid practices and surgical requirements and hospital length of stay.
As BRANZ and BQIP continue to grow, resource implications are increasingly significant and need to be addressed to ensure the program’s sustainable future. ANZBA has been exploring long term sustainable funding opportunities.
Once Standards of Care have been developed, it is anticipated that BQIP will be integrated into the future ANZBA verification program. Verification is the next step in the process of the BRANZ and the BQIP and will make burn units accountable for their performance and integrate BQIP into local processes to improve safety and quality. This program will also facilitate multicentre morbidity and mortality meetings.
Conclusion
Access to data is a powerful driver of health care quality improvement provided it is timely, reliable and meaningful, and presented in a manner that can be understood.Clinical quality registries such as BRANZ provide significant advantages of a coordinated, national, approach to tracking outcomes of care, especially for relatively small medical sub specialties such as burns.
ANZBA’s highest priority is to promote the safest care and best outcomes for patients. The BRANZ and the BQIP are welcome and useful tools for ANZBA to achieve this.
Who gets burnt in Australia?
The fifth annual report from the Burn Registry of Australia and New Zealand was made publicly available via the ANZBA website (www.anzba.org.au) in June 2015. Data was presented for 2656 burns patients treated at 15 burn units over the 12-month period from 1st July 2013 to 30th June 2014.
In summary, 64% of cases overall were adults, with males accounting for 68% of all cases. Children aged 12 to 24 months accounted for 34% of paediatric cases (Figure 2) while 20 to 29 year olds accounted for 25% of adult cases (Figure 3). Flame (32%) and scald burns (38%) were the primary cause of burn injury for all age groups. Scald burns were the predominant cause for paediatric patients accounting for 56 % of all burns followed by contact burns (19%). For children 11 to 15 years of age and adults 16 to 79 years of age, flame burn was the predominant cause. In the over 80 year age group, scalding was the predominant cause of burn. Nearly all burns were considered unintentional (96%).
Data from the BRANZ is used by ANZBA as well as other key stakeholders to increase community awareness regarding the prevention of burn injury as well as influence changes to legislation and product design that can minimise the incidence of burn injury. BRANZ data has recently been used by the Australian Competition and Consumer Commission in the revision of their hot water bottle safety messages, the revision of the children’s nightwear standards and the development of burn awareness information leaflets available via the ANZBA website.