Clinical decision-support for acute burn referral and triage at specialized centres – Contribution from routine and digital health tools

ABSTRACT

Background

Specialized care is crucial for severe burn injuries whereas minor burns should be handled at point-of-care. Misdiagnosis is common which leads to overburdening the system and to a lack of treatment for others due to resources shortage.

Objectives

The overarching aim was to evaluate four decision-support tools for diagnosis, referral, and triage of acute burns injuries in South Africa and Sweden: referral criteria, mortality prediction scores, image-based remote consultation and automated diagnosis.

Methods

Study I retrospectively assessed adherence to referral criteria of 1165 patients admitted to the paediatric burns centre of the Western Cape of South Africa. Study II assessed mortality prediction of 372 patients admitted to the adults burns centre by evaluating an existing score (ABSI), and by using logistic regression. In study III, an online survey was used to assess the diagnostic accuracy of burn experts’ image-based estimations using their smartphone or tablet. In study IV, two deep-learning algorithms were developed using 1105 acute burn images in order to identify the burn, and to classify burn depth.

Results

Adherence to referral criteria was of 93.4%, and the age and severity criteria were associated with patient care. In adults, the ABSI score was a good predictor of mortality which affected a fifth of the patients and which was associated with gender, burn size and referral status. Experts were able to diagnose burn size, and burn depth using handheld devices. Finally, both a wound identifier and a depth classifier algorithm could be developed with relatively high accuracy.

Conclusions

Altogether the findings inform on the use of four tools along the care trajectory of patients with acute burns by assisting with the diagnosis, referral and triage from point-of-care to burns centres. This will assist with reducing inequities by improving access to the most appropriate care for patients.

KEYWORDS:

• Clinical decision-making
• injuries
• computer-assisted diagnosis
• emergency service
• accident prevention

RESPONSIBLE EDITOR

Julia Schröders

RESPONSIBLE EDITOR

Julia Schröders

Acknowledgments

I would like to thank my supervisors for all their guidance and support through the whole PhD process: Professor Lucie Laflamme, Professor Lee Wallis and Professor Johan Lundin. I would like to express gratitude to all my coauthors, and in particular to Dr Nikki Allorto, Dr Wayne Kleintjies, Professor Heinz Rode, Dr Lisa Blom, and Dr Anders Klingberg. I would also like to thank all the clinicians, patients and participants who partook in all the stages of the studies from planning to participation and for sharing their experiences. Finally, I would like to thank Dr Mahilde Sengoelge for her constant support and language editing.

Ethics

Ethical approvals were obtained from the University of Cape Town (South Africa) Health Research Ethics Committee (452/2015), the Stellenbosch University Health Research Ethics Committee (N16/10/125, N16/09/107, N13/02/24), the University of Kwa-Zulu Natal Ethics Committee (BCA 106/14) and the Uppsala Ethics Committee (Dnr 2016/279).

Paper context

Access to specialised care is costly and limited, especially in resource-scarce settings. Accurate diagnosis, triage and referral are all essential in order to maximise the benefits for both the patients and the healthcare system. This work focused on four clinical tools that are likely to assist, either at admission to burns centres for the triage of patients, or using the latest modern technologies to assist with diagnosis at point-of-care.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/16549716.2022.2067389.

Additional information

Funding

The research was partly funded by the Swedish Research Council [grant number 2016-01819] and the South African Sweden University Forum.