Burns care undergoes overhaul
NEW CARE protocol includes use of new synthetic dressing and grafting method, leading to benefits like less pain, fewer infections and surgeries.
Imagine the pain when the plaster covering a wound is ripped off.
Now imagine the pain – and agony – when a large area of burnt skin is repeatedly cleaned, the dead skin cut off to prevent bacteria from growing and causing infection, and dressed.
Mindful of the pain and suffering that burns injuries cause, the Singapore General Hospital ( SGH) Burns Centre introduced changes to the way such wounds are treated. The new set of protocols provide for prompt treatment, the use of a new synthetic dressing for less serious or extensive burns, and a new grafting technique for major or deep burns.
A study in 2016 comparing serious burns apatients treated with the new burns care protocol between 2014 and 2016, and those in the year before, found that the former group stayed a shorter period in hospital (an average of 13 days versus 17), underwent fewer operations (1.96 versus 2.29), experienced fewer complications (the serious infection rate dropped 70 per cent) and fewer deaths ( 0.5 per cent versus 2.7 per cent).
“This means more patients returned home safer and faster,” said Dr Chong Si Jack, Consultant, Department of Plastics, Reconstruction and Aesthetic Surgery, SGH.
Dr Chong, who was instrumental in making the changes, said that standardising the care for burns patients meant everyone involved had a clear idea of what to do and at what point of the patient’s recovery.
“Burns patients often require care from a multi- disciplinary team, and could go through months, even years, of treatment and rehabilitation. Adopting a standard set of steps in treating burns patients allows us to tighten the processes and allocate resources more efficiently,” he said. The medical team includes plastic surgeons; intensive care, renal and infectious disease doctors; as well as specialist nurses and therapists, dietitians, pharmacists and social workers.
Burns patients who visit the A& E and are assessed to have second- degree burns – or burns that didn’t penetrate beyond the outer skin or epidermis – are treated with a type of dressing known as artificial or substitute skin. Unlike conventional dressings, the substitute skin combines a layer of nylon interweaved with collagen. It sticks better, helps to lower the frequency of dressing changes and length of hospital stay, and offers better pain relief.
According to Dr Chong, burns wounds are dynamic and will worsen or deepen within two to three days if infected, so using a skin substitute to cover the wounds early is crucial.
Patients with deeper and more severe or third- degree burns (covering more than 40 per cent of the body) will have the burnt and dead tissue cut away before undergoing a skin graft .
Thin layers of the patient’s own skin, supplemented by donated skin, have to be used to cover the burnt areas to promote skin recovery and regeneration. But in badly burnt patients, the amount of skin available for grafting can be very limited. Donated skin, meanwhile, is also limited and expensive. Donated skin has to be replaced frequently as it faces rejection after some weeks.
To overcome this, SGH adopted a new grafting technique where very small squares of the patient’s own skin ( 3mm x 3mm) are placed onto 5cm x 5cm squares of donated skin. These micrografts are then used to cover burns wounds.
“Like little seeds placed neatly in a rice feed”, the micrografts are able to stay on for around three weeks, allowing the tissues underneath to recover. The donated skin – unlikely to be a match with the patient’s own skin – is rejected, but the tiny pieces of the patient’s own skin remains.
“The micrografts allow donated skin to be maximised, and are an important resource, because when we have large, extensive areas of burnt skin of more than 40 per cent, we don’t have much to use, so every little bit counts,” said Dr Chong.
“The micrografts are lifesaving but, unfortunately, they are not nice looking,” said Dr Chong. The healed skin are discoloured and mottled.
• This story was first published in Singapore Health, Nov - Dec 2018 issue