Audit Tool: Burn

Facility name Deder General Hospital

Department/unit Emergency and Critical Care
Audit Topic Burn patient management in the emergency room
Aim To Improve the quality of clinical care provided to burn patients
Objectives To ensure burn victims presenting to the emergency are evaluated appropriately
To ensure burn victims presenting to the emergency are investigated appropriately
To ensure burn victims presenting to the emergency are treated appropriately
To ensure burn victims presenting to the emergency are disposed appropriately
Period of Audit June 2016E.C
Inclusion criteria All moderate and severe burns (patients with burn injuries fulfilling admission criteria either to ward or burn
unit) patients aged 14 and above treated in the emergency department with-in the study period
Exclusion criteria (where applicable) Patients who sustained their burn injury >24 hrs. before arrival to the ED
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual
patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply
to the individ- ual patient
Perfor
Data Actua -
No Standards/criteria Source l manc Remar
and perfor e k
verifica- -
Target

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agains
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tion manc t
e targe
t
1 IDENTIFICATION INFORMA- 100 100 67 100 89%
TION IS RECORDED FOR A % % % %
PATIENT PRESENTING WITH
BURN

1.1 Name Yes Yes Yes

1.2 Age Patient Yes Yes Yes

ED
1.3 Sex Admissio Yes Yes Yes
n Note
1.4 Date of visit Yes Yes Yes

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1.5 Time of visit Yes No Yes

1.6 MRN Yes No Yes

2 APPROPRIATE EVALUATION 100 31 30 88 89%

 AND MANAGEMENT FOR % % % %
ACUTE LIFE THREATENING
INJURIES IS DONE A
PATIENT PRESENTING
WITH BURN
2.1 Decontamination is done if the NA NA NA
patient has chemical burn
2.2 Evaluation of airway
patency is done (airway is
clear/patent or presence of Yes Yes NA
secretion, presence of
foreign body or injury to the
face or presence of soot inside
nostrils is evaluated)
2.3 If patient has secretion NA NA NA
secretions are suctioned out
2.4 If foreign body is present it is NA NA NA
removed
2.5 Airway management is done
(Oral airway or insertion or Triangula
supraglottic device placement te Patient NA Yes NA
or endotracheal intubation or ED
surgical airway) if airway Admission
patency is compromised Note,
2.6 Evaluation of cervical Order
stability is done for patient Sheet, Yes Yes NA
with GCS score of 15 and Pro-
concomitant other physical cedure
trauma is identified Note,
2.7 Cervical collar is secured for Medicatio
cervi- cal injury for patient n Sheet NA NA NA
with concomi- tant physical and Vital
trauma Sign
Sheet
2.8 Appropriate breathing Yes NA Yes
evaluation is conducted
Oxygen saturation measured 1 1 1

Respiratory rate counted 1 1 1

Respiratory movement 1 1 1
symmetry assessed
Chest is auscultated 1 1 1

2.9 Oxygen is provided using

nasal prong or face mask for NA NA NA
patient with SpO2 < 90%
2.10 Ventilation is provided using
me- chanical ventilator for NA NA NA
patient who have evidence of
severe inhalational burn

2.11 Appropriate interventions are

done for other
suspected/identified trau- ma

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on the respiratory system
(Chest tubes for concomitant NA NA NA
pneumo- thorax and/or
hemothorax, needle
thoracostomy done for
tension pneumothorax
patients)
2.12 Blood pressure is measured Yes Yes Yes

2.13 Pulse rate is counted Yes Yes Yes

2.14 IV line is secured:

Peripheral percutaneous
Intravenous access/ Yes Yes Yes
Intraosseous access/ Triangula
Venous cut down/ Central te Patient
venous access established ED
2.15 Immediate fluid resuscitation Admission
with Ringer’s Lactate is Note, Yes NA NA
started if the patient is in Order
shock state Sheet,
Pro-
2.16 GCS is calculated, pupillary cedure
size and reaction are
Note, Yes Yes Yes
checked, motor preference
Medicatio
is checked and RBS is
n Sheet
measured
and Vital
2.17 Dextrose is given if patient is Sign NA NA NA
hypo- glycemic Sheet
2.18 Log-roll is done Yes Yes Yes

2.19 Total burn surface area is

calculated using either rule of 9
and Lund and Browder’s chart No No No
for adults and pal- mar
surface method for pediatric
patients
2.20 Assessment for presence of NA NA
eshcar at any site is done
2.21 If eshcar is present, NA NA NA
eshcarotomy is done
2.22 Patient is evaluated for
presence of compartment Yes Yes Yes
syndrome if circum- ferential
burn is diagnosed on distal
extremities
2.23 Bed side ultrasound is done
(FAST/ eFAST) for patient NA NA NA
with concomi- tant physical
trauma
3 DETAILED HISTORY AND 100 100 100 71% 90%
PHYSICAL EXAMINATION % % %
PERFORMED FOR A PATIENT
PRESENTING WITH BURN

3.1 Detailed history of the burn

inci- dent is recorded
(Duration of burn, the type of
burn experienced by the
patient; if the burn occurred Yes Yes No
in
closed or open area; other
materials that were burned
during the inci- dent; if it was
electrical burn, the voltage Patient’s
ED
of line and entry site)
Admissio
3.2 Patient’s current complaint is n Note Yes Yes Yes
recorded
3.3 Past medical and surgical Yes Yes Yes
history is taken
3.4 History of food or medication Yes Yes Yes
allergy is taken
3.5 Current medications patient is Yes Yes Yes
on medications are identified
3.6 Time of last meal the patient Yes Yes Yes
took is identified
3.7 Vital signs are retaken (Time Yes Yes No
specified)
Blood pressure 0 0 1
Patient’
Pulse rate s Vital 0 0 1
Sign
Respiratory rate Sheet 0 0 1

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Oxygen saturation(SpO2) 0 0 1

Temperature 0 0 1
 Pain score 0 0 0

3.8 Head to toe physical Yes Yes No

examination is performed
Detailed report of burned
areas with full description of Patient’s 1 1 1
size, depth and local ED

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complications is written Admissio
Pulse rate counted n Note 1 1 1

Respiratory rate is counted 1 1 1

Oxygen saturation(SpO2) 1 1 1
measured
Temperature measured 0 1 0

4 RELEVANT INVESTIGATION 100 0 0 100 33%

ARE DONE FOR A PATIENT % %
PRESENTING WITH BURN
4.1 Baseline CBC, RFT and serum Triangulat No No Yes
elec- trolytes (Na, K) are e Patient
determined ED
4.2 ECG is done for electrical burn Admission No NA NA
patient Note with
investigatio
4.3 Other investigations as per n papers
indica- tion are done and/ or No No Yes
investiga-
tion
summa- ry
5 APPROPRIATE DIAGNOSIS 100 40 80 100 73%
IS MADE FOR A PATIENT % % % %
PRE- SENTING WITH
BURN
5.1 Primary diagnosis is written Triangulat Yes Yes Yes
e the
5.2 Severity of burn injury is history Yes Yes Yes
and P/E
identified findings
5.3 TBSA is calculated with the No No Yes
diagnosis
5.4 All degrees of burn the patient on Patient No Yes Yes
sustained are specified ED
5.5 Diagnosis of additional admission
observed conditions and Note with
complications is made ED No Yes Yes
admis-
sion
Order
Sheet
6 APPROPRIATE 100 71 67 56 65%
TREATMENT IS % % % %
PROVIDED FOR A
PATIENT PRESENTING
WITH BURN
6.1 Wound care is done Yes Yes Yes
regardless of the severity
of burn injury
6.2 Tetanus prophylaxis is Triangula
provided for the patient whose te NA No No
tetanus immuni- zation Patient’s
status is not up-to-date ED
6.3 Patients with partial thickness Admissio
n Note
burn with ED
>10% or full thickness burn Order
>2%, patients with burns to Sheet
the face, major joints, with
perineum or hands, patients Yes Yes Yes
Medicatio
with high voltage electri- cal n Sheet
burns or lightening or
patients with chemical burns
are kept in the emergency
until admission/referral is
facilitated
6.4 For severe burn patient
(TBSA > 20% for adults or >
10% for chil- dren except for
1st degree burns, burns NA NA NA
complicated by trauma or
inhalational injury, chemical
burn and high-voltage
electrical burn) appropriate
monitoring is done
Order is written to put patient NA NA NA
on cardiac monitor
BP measured every 1hr NA NA NA

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PR measured every 1hr NA NA NA

RR is measured every 1hr NA NA NA

Patient is put on continuous Triangula NA NA NA

 oxygen saturation monitor te
and finding recorded every 1 Patient’s
hr. ED
Admissio
Temperature is recorded every n Note NA NA NA
1 hr with ED
Urine output is measured every Order 1 NA NA
Sheet
1hr

258
with
Pain score is determined every Medicatio NA NA NA
4hrs n Sheet
6.5 For non-critical burn patient, NA Yes Yes
ap- propriate monitoring is
done
BP measured every 4hrs. 0 1 1

PR measured every 4hrs. 0 1 1

RR measured every 4hrs. 0 1 1

Urine output is measured every 0 1 1

4hrs.
Pain score is determined every 0 1 1
4hrs.
6.6 Parkland formula is used for
cal- culation of fluid
resuscitation if the patient NA No No
presents within 24 hours of
burn incident (except for
electrical burn patients)
6.7 Appropriate fluid loss
estimation and replacement is Yes NA NA
made for electri- cal burn
patient
Loss is estimated using urine 0 0 0
output
Urine out put is measured 0 0 0
every one hour

Fluid loss is replaced based on 0 0 0

urine output with Ringers Triangula
lactate te
Patient’s
6.8 Standing dose analgesia is ED Yes Yes Yes
provided Admissio
6.9 Topical agents are ordered n Note No No No
to be used during wound with ED
care Order
6.10 Temperature target is
determined and means of Sheet
with No Yes No
preventing hypother- mia is
planned/ordered Medicatio
n Sheet
6.11 Patient is monitored for
additional observed conditions Yes Yes Yes
and complica- tions of burn
Urine color, urinalysis, and Triangula
serum creatinine for patient te
with high voltage burn progress 0 1 NA
(rhabdomyolysis) note with
investigati
on papers
Airway condition for patient
with suspected inhalational NA NA NA
injury and facial and neck Progre
burn ss note
Signs and symptoms of
compart- ment syndrome for NA 1 1
patient with circumferential
burn injuries
6.12 Consultation to the burn unit Triangula
is made (Time of consultation te
spec- ified) Patient’s
ED
Admissio
n Note NA NA NA
with ED
Order
Sheet
with
Consulta-
tion
Sheet
7 APPROPRIATE PATIENT DIS- 100 100 100%
POSITION IS DONE FOR A % %
PATIENT PRESENTING WITH
BURN

7.1 For patient with partial Triangula NA NA Yes

thickness burn >10% or full te
thickness burn Patient’s
>2%, patient with burns to the ED
face, major joints, perineum Admissio
or hands, patient with high n Note
voltage electrical burns or with ED
lightening or patient with Order
chemical burns; patient is Sheet
admitted or referred to burn with
unit Transfer/r
e- ferral
sheet

259
8 IDENTIFICATION OF 100 100 100%
CARE PROVIDER IS % %
DOCUMENTED FOR A
PATIENT PRESENTING
WITH BURN
8.1 Name and signature of the
phy- sician is clearly ED
documented on all ED admis- Yes Yes Yes
admission history and P/E sion
sheets History
sheet
8.2 Name and Signature of the
physi- cian is clearly ED
progress Yes Yes Yes
documented on all ED
progress notes note
sheet
8.3 Name and signature of the
physi- cian is clearly ED Yes Yes Yes
documented on all ED order order
sheets sheet
8.4 Name and signature of the
nurse is clearly documented ED Yes Yes Yes
on all ED medication medica-
sheets tion sheet
9 PATIENT DIAGNOSED WITH 2% Triangula NA NA NA
BURN DIED WHILE BEING te
MANAGED IN THE EMER- admissio
GENCY WITHIN 24HOURS n note
OF ADMISSION TO ED with
progress
note and
discharg
e note.
Total standards met per chart 80%
Percentage