Smart phones make smart referrals: The use of mobile phone technology in burn care – A retrospective case series
Introduction
Telemedicine, utilizing cell phone technology, plays an increasingly important role in the care of burns particularly in resource-limited settings. There have been a number of reports of the use of store and forward telemedicine, usually email with attached images, and real-time videoconference based telemedicine for burn wound assessment and management [1]. More recently concordance studies have validated the use of cellular phones for clinical photography of burn wounds [1], [2], [3]. The potential of mobile phones to facilitate burn telemedicine has been identified [3], [4], [5] but recent reviews do not report cellular phone or smartphone use [1], [4], [6]. In 2012, Wallace stated that ‘We anticipate case reports and series of the use of mobile phones for interactive burn assessment’ [1]. This has not occurred despite the ubiquity of cellular phones and ease and rapidity with which photographs can be taken and transmitted by email or instant messaging services like MMS (multimedia messaging service) or WhatsApp [3], [5], [7]. To date there have only been two cases reported of the assessment or management of burn wounds using mobile phones, one using the cell phone camera and email and the other, MMS [5], [7]. In another service, information and images, are sent over a secure Internet connection to a hospital server and the encrypted photographs are then sent from the server to the burn surgeon's smart phone for viewing using a specific application Teleburnsm [3], [8]. The use of phones to transmit images of burn wounds is not new with satellite phones used to do this in military settings in the 1990s [9], [10].
The Burns Unit at Inkosi Albert Luthuli Central Hospital in Durban, South Africa, is the tertiary referral hospital for the province of KwaZulu Natal with a population of roughly 10 million people. The unit employs a tiered referral policy, as suggested in the WHO document Guidelines for Essential Trauma Care [11]. We have reported that more than a third of our patients have been inappropriately referred to the unit [12] and a recent audit of referrals to our clinic revealed that a third of patients had healed by the time they were seen at the clinic and that another third had small area burns that could have been dealt with in the unit that referred the patient (unpublished results). That this is not a problem only in resource-poor settings was illustrated by a recent study from Denmark, with similar findings to ours [13]. Although a significant portion of such inappropriate referrals represent overtriage, undertriage is an even greater problem when patients with major burns are deprived of the specialized care that is only available in a burn centre. An important cause of inappropriate referrals is the difficulty that many first-line practitioners experience in estimating the extent of the burn, particularly in children, with estimations sometimes varying by a factor of two between observers [14], [15], [16], [17]. Telemedicine, including sending of images of the burn wounds to a burn specialist, has been suggested as a possible solution to this problem [13], [18].
For a number of years we have been using Smartphone images taken by our registrars during dressing changes for in-house assessment of burns when the senior surgeons were occupied in theatre and we found these to be reliable for planning management. From there it was a small step to request similar pictures from peripheral medical officers consulting us about their patients with burns. Adding photographs to the telephonic consultation allowed us to make management decisions about the patient before transfer to the burn unit. The aim of this paper is to describe our initial experience of the addition of burn wound photographs sent by smartphone for the assessment and management of burn wounds.
Section snippets
Methods
A pro-forma pre-admission form is used for all patients that are discussed with the burn surgeon on call for referral. This includes both acute and later referrals. The following information is collected: the referring doctor's name; the referral hospital; the patient's name, age and gender; the mechanism and circumstances of injury; vital signs and initial blood results; areas, percentage and depth of the burns; the presence of inhalation injury; initial management; the advice given to the
Results
During the study period, 119 patients were referred, discussed, and entered into the database. There were 66 children aged 16 years or younger, and 49 adults, with the age of four patients unknown. The male: female ratio was 1.6: 1. There were 45 scalds, 51 flame injuries, fourteen electrical burns, four chemical burns and one contact burn. The mechanism of injury was unknown in four patients. Six burns were sustained during an epileptic fit. Mean percentage of the total body surface area
Discussion
This is the first series reporting the use of cellular phones to transmit images and information for burn wound assessment and management. The main findings are that this is feasible and the addition of photographs to the routine telephonic referral altered the outcome in two thirds of referrals. Communication between cellular phones was directly via the cellular network for MMS and via the Internet for WhatsApp.
Telemedicine consultation enhanced by cellular phone-generated images changed the
Conclusion
Telemedicine has always been seen as adding extra steps to the routine workflow, expensive to establish and maintain, and requiring new competencies. Cell phones are ubiquitous, and health professionals use them to take and share photographs and information with family and colleagues either directly or via social media platforms like Facebook. They have now found an unintimidating and convenient way of practising inexpensive telemedicine. Pragmatic solutions to the legal, ethical and regulatory
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