Burncare across Western Australia: How the Coronavirus Pandemic has shaped practice in 2020
We speak to Jeremy Rawlins, Burns Surgeon and President of the Australian & New Zealand Burn Association about how the COVID-19 pandemic has shaped the delivery of burncare across Western Australia, and some of the long-lasting benefits that have come from working ‘Covid safe.’
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Hello, my name is Ruth Timmins from Smith & Nephew and welcome to our podcast today. Today, we'll be discussing burn care across Western Australia, how the Coronavirus has shaped practice in 2020, with our special guest, Jeremy Rawlins, who's a specialist burn surgeon from Fiona Stanley Hospital in Perth, in Western Australia. He's also the president of the Australia and New Zealand Burn Association. So welcome, Jeremy, and thank you for joining us today.
Thank you very much indeed, Ruth.
It's great to have you with us so I guess, Jeremy, 2020 has been an extraordinary year for health care and how we interact with the COVID world. What are some of the things that have impacted your practice this year?
Well, as you say, Ruth, it has been an extraordinary year and really, none of us could've predicted what has happened this year but as you say, I think the COVID world and the Coronavirus pandemic has really forced us to think a little bit differently in health care and burn surgery and plastic surgery is no different. We've really had to be creative and really sort of make sure what we're doing is right for now but also right for the future as well.
And one of the things that we get used to in burns is very much the ebb and flow of burn injury so we have times when things are quiet and times when things are busy and I suppose for the most extreme version of being busy is when we have disasters. Bali bombings, Ashmore Reef disasters and so forth and we've learnt over the years, particularly here in Perth that when things are tough, when things are bad, you've got to keep continuing to do your normal things, your normal practice in burns but just more of it.
And that sounds very simple but actually, there's a bit of planning that is required to do that and whilst the COVID world has not necessarily been a disaster in terms of a sudden increase in the number of patients that we're seeing in Western Australia, we had to put systems in place that meant that we could work a bit like a disaster situation so not necessarily changing the sorts of surgery that we do or the various things that we do but actually making sure that given the very changing circumstances that COVID pandemic brought to us, we could respond to that.
And I think that one of the things that we have always done really, really well in Western Australia because of our geography is telehealth and that is being really able to provide what we would believe to be and what we wish to be a quick, equitable burn care across Western Australia independent of whether you live in Perth, Freemantle, Connemara, wherever it may be. And so we've always relied very heavily on the fact that we utilise video conferencing, email, photographs and so forth to deal with our patients across Western Australia.
And what the Coronavirus pandemic did very, very quickly when we were starting to see numbers here in Western Australia is it drove us to doing more in terms of our telehealth and so we've got the technology in place and a bit like that disaster situation, do what you do but do more of it. We were able to very rapidly increase the amount of teleconferencing and telemedicine that we were doing, not just with those patients that were having burns who are traditionally seen by that means in rural and remote patients but actually pretty much all of our patients in Western Australia.
If we could see them via Health Call, the equivalent for Facetime, Skype, those sorts of means then that was gonna be safer for our patients and keeping them out of hospitals, safer for us in terms of our staff. And generally, would prove beneficial in terms of making sure that we still could provide really good guidance for our burns patients but doing so in a safe way, particularly when patients didn't necessarily want to come to a hospital. They were rightly doing the right thing in trying to stay home. So that's been I think one of the ways in which our practice has had to change a bit in the COVID world that we're living in but I think in some regards, quite a positive way.
I think some of the other ways in which we've changed and again, I'd like to think that these are positive changes that we can utilise moving forwards irrespective of whether we have ongoing issues with coronavirus or other pandemic-type things and that's really sort of thinking about how we work as sort of specialists, how we work as teams meaning that we try and keep our self and not spread ourselves around across too many hospitals but sort of concentrating our efforts in one hospital at a time, for example.
And making sure that we weren't having lots of people unnecessarily dragged around on a burns ward round when actually we could be a lot more sensible about who was coming on that round and again, utilising Microsoft Teams, health choices and so forth such that we could utilise those people's skills and their expertise but doing so safely via remote video and so forth
And I suppose that the other thing that we've noticed change in this sort of COVID world that we're living in is a change in the patterns of burns and so it would be wrong of me to make sweeping statements about the whole of Australia and what was experienced with the Coronavirus pandemic because, of course, things have been very different in different parts of Australia. But one of the things that we noticed here in Western Australia is that as more time was spent in the kitchen, for example, we were seeing more of those smaller cooking-related injuries both in adults and in children.
And then potentially a delay in presentation and then the potential problems of those patients having delayed presentation which was actually quite different to what some of my colleagues in Melbourne, for example, are seeing, particularly in the paediatric service where there were quite a large number of major burns so real differences across the country and across the regions but I think that the take-home message was that, yes, Coronavirus came onto us very, very quickly and I think we've been able to respond by changing and adapting our practices, hopefully, for the better and, hopefully, for the long-term that we can make these changes as and when.
That's really interesting, isn't it, how things - you know we can take some positives from a very difficult situation I guess into the future. The burn units in WA have always been great proponents of nanocrystalline silver in burns. Has 2020 posed any particular issues with respect to infection control?
Well, yes, in many, many ways. Again, we have really sort of put our heads together and thought about infection control. It's been an opportunity to look at what we do and as you say, historically, we've been huge users of ACTICOAT™ nanocrystalline silver across our burn service and that's across the whole of Western Australia. But I think the whole issue of a pandemic and the requirements for better isolation, better hand washing, the use of masks, infection prevention and so forth has been so key that we've really had to look at our prevention of burn wound infection alongside the difficulties of dealing with a worldwide pandemic that is airborne. And so absolutely, we've looked at what we do.
I think again, going back to the first question. Do what you do normally, just more of it and I think what we have realised, particularly when we were having to deal with more patients remotely, was that from the word go the message to our GPs, to our emergency departments, to our patients, our patients carers across the state was you've got to get patients first and foremost, good first aid.
So there's 20 minutes of cool running water, but everyone needs to be in ACTICOAT™. Because we need those patients in ACTICOAT™ to minimise burn wound colonisation, minimise burn wound infection, because when things were bad, we didn't necessarily have the predictability of being able to get people into clinic.
You know, very, very quickly because of issues with getting people into hospital with the last thing we want is patients getting infections we're potentially gonna need that ACTICOAT™ on for a little bit longer. So the real priority was making sure that patients were safe wherever they were in the state. And a massive part of that of course, is ACTICOAT™. So these patients don't get infections. So that was a big thing.
And we said, we really had to make sure that that communication was strong with all our colleagues in other parts of Perth, but also in Perth as well. And other parts of Western Australia, but also that that message was consistent to all the different people that were looking after our patients, whether that be here in the metropolitan area or elsewhere in the state. And in line with that, we were able to look after those patients, as I said, some of those patients never needed to come to Perth. And they healed fine. Those that did need to come to our burn services here in Perth.
We dealt with much like we would when we're not dealing with a pandemic minimising the use of anti-microbials if we don't need anti-microbials, we don't use them. And those patients that did move on and need surgery they got a single dose prophylaxis and exactly that, is it a single dose, no ongoing antibiotics as prophylaxis beyond their trip to theatre.
So those were the key things with regards to using ACTICOAT ™and really minimising the amount of, you know, antibiotics we're using and really trying to think hard about minimising inappropriate use of antibiotics. But as I alluded to earlier on one of the things that's been really interesting, is you tell people, and what I mean by people are healthcare workers, patients, and their relatives that you've got to cover your face, and you've got to wash your hands and they do that. And what's been very interesting is the reduction in some of the infections that you might expect within a hospital over a period of time because of potential issues with hand hygiene, hand hygiene has been good and that's only good for our burns patients.
And obviously we will reap the benefits of, of people washing their hands better and not spreading around other viruses, other bacteria and indeed coronavirus. So it's again, exciting times in terms of people's overall education about avoiding infections and whether that infection is a burn wound infection, or whether that's avoiding Coronavirus, it doesn't really matter as long as there is they're doing safe things that's only a good for the patients, for our services and society.
Yes. And you mentioned the importance of preventing infection there. So I just wonder if you could expand a bit more on the role of ACTICOAT™ as part of your protocol, perhaps, especially in the context of anti-microbial stewardship. Could you expand a little bit more on that?
Yeah. So as I mentioned, the patients go into ACTICOAT™ as soon as we possibly can get them into ACTICOAT™ following their burn and they get 48 hours of ACTICOAT™ and then we start obviously changing the recipe, so to speak in terms of their dressings, are we moving towards something that's gonna try and hydrate a burn wound? Are we trying to dry something out? Are we trying to prepare someone for an operation? And then of course, some of those patients will progress to an operation.
And as I alluded to, we do not use a lot of prophylactic antibiotics we're minimising antibiotics, and obviously we're keeping our patients in a clean environment. But when you're dealing with big burns, of course, inevitably patients will develop some degree of colonisation of their wounds or indeed infections. And one of the things that has been really, really useful, particularly in the pseudomonas infections that we sometimes see in a donor sites is not reaching for the antibiotic, but actually putting the patients back in ACTICOAT™, particularly on those donor sites, even if it's only for 24, 48 hours can rapidly eradicate that pseudomonas all over that donor site and minimise the need for us to ever touch an antibiotic.
And the same is true for areas that we're concerned about. Again, post-surgery that we're concerned about infections in debrided burn wounds, wounds that have been debrided and skin grafted. Again, a period of time back in ACTICOAT™ with that concentrated silver dressing has really you know, been very, very beneficial and minimised a progression of that infection and B actually dealt with it. So that's been very much our pattern of looking after patients and really trying our best to, to minimise the morbidity of infection.
So clearly efficiency is important. It sounds like your unit strive for efficiency, managing patients across your enormous state and doing everything you can to do to prevent infection and burn wound progression. Are there other areas where you've shown efficiency?
Yeah. I think in surgery and in burns, we have learnt that we just have to be more efficient. Surgery is so expensive on resource. It's so expensive with respect to time and, we really do have to be more efficient at what we do. And I think we've had the luxury here in Perth to really be able to look at our efficiencies really from the point that those patients get burned, from the point that they attend our emergency department and really working out when is the best time for these patients to come and see us in our clinics, if they're an ambulant burn so that we're not wasting time, we're not unnecessarily doing dressings where we're not going to reap benefits.
And so we've worked out that if you get a burn on a Monday, as much as everyone would like us and think that it's best to see the patient on Tuesday, we're actually better off seeing the patient on the Wednesday and the reason being A, we know the patient's safe, they've got a silver dressing in place. If we see them too early, we can't really make that assessment as to right, you're gonna need an operation. You're likely to heal with dressings. So that's one efficiency that we've made. So, we've moved our review appointments to a point that is near a 48 hours as opposed to 24 hours so that we can better determine what is going to be the outcome for this patient.
And we know that that that's fine and safe because the ACTICOAT™ will be in place for those couple of days. Those couple of days that we find are important. And then working from that, we can very accurately predict how many patients we're gonna see through our walk-in clinics every day. And with that, we realised that when those patients come to our clinic and we make a diagnosis so that patient required operation that needs to be done similarly on a daily basis. So rather than make a diagnosis and say, right, yes, you need a skin graft, but unfortunately can't do you for a week. We've actually moved away from, well, why don't we do the operation when you need it?
And so we've moved to an environment where we have an operating theatre every single morning, so that we have got a progression of patients coming through. Some would say timed to perfection in terms of when they're going to need an operation, and we operate on them when they need their surgery as opposed to convenience throughout the week where you might only have two operating theatres a week. So we're lucky, we have an operating theatre every morning. It means that patients are not waiting around for days and days and days to have their surgery. Most of these patients are done as outpatients but, of course, the bigger injuries, those are admitted to the wards.
But again, we have that luxury of a daily burns list so that those big injuries can be done first up as well and the smaller injuries sort of are fitted around them. And so this really has allowed us to be efficient in terms of our hospital stay and really making sure that we utilise that very, very important resource, that theatre list very, very, very well. One of the other things that we have spent a bit of time doing is actually looking at what we do in the operating theatre and we can predict when we see someone in the clinic or on the ward what operation they're gonna need. They're either going to need a cell-based treatment such as ReCell™. They're gonna need skin grafts, they're gonna need a combination of those two things, they may need a local flap, whatever it is.
So we spend a lot of time actually writing out and making sure that our theatre teams know as precisely as they can do what we're gonna do in theatre and this means that they're ready. They're ready with just the right number of dressings, the right sort of dressings, the right sort of donor-site dressing, the right sort of kit for us to do our debridements and reconstruction and so we're not throwing away nearly so much precious dressings, precious resource that perhaps we were before we were really sort of concentrating on what we would need for each and every case. And so that's really important, particularly, of course, we are in a very remote part of the world here.
Historically, we've relied on quite a lot of air freight and shipping and so forth. That is clearly not what it used to be now that we live in this COVID world so we're having to be a little bit more proactive in terms of thinking about what sort of delays there may be in procuring dressings, dermal substitutes, whatever it may be. So us being really, really efficient in theatre has kind of been a good thing because we needed to be because of potential lack of access to some of these dressings and so forth.
So, yeah, efficiency is really, really important as you can tell and I suppose that that's just scraping the surface really. There's lots of areas in which we're just striving for more and more efficiency and making sure that every single day that our patients either spend in the hospital or have to have a dressing on that they're gaining something, they're making progress towards wound closure or making progress towards going home. And that's a very positive thing for patients.
So what about surgery, Jeremy? What has 2020 delivered with respect to the burn surgery you're doing in Perth?
Well, I mean as I alluded to earlier on, the burns have varied in terms of how many we've had through 2020. During our lockdown period, we were quiet. As I mentioned, there were a few small injuries associated with people cooking, for example, at home and then as things got busy following the easing of our lockdowns, we were really busy.
And I think people were celebrating their newfound freedom so lots of young people celebrating with alcohol, of course, and drugs sometimes, barbecues and firepits often and, of course, those combinations result in nasty burns, burns that require inpatient care. And really that whole process of prevention of the infection, oedema control, fluid resuscitation that's cautious and really ensures that we don't over-resuscitate people so that, again, our hospital stay for these patients with maybe a 20% burn is as speedy and as efficient as possible.
What we want is surgery that, as I mentioned, is timed to perfection so ideally at 48-72 hours if they need an operation. And so that operation is then possible because we've optimised them for a perfect time and I think the sorts of surgeries that we've really been able to finesse and get better and better at over the last year or so is some of the techniques that are evolving in terms of minimising scars.
So its dermal sparing techniques so we use lots of dermabrasion, VERSAJET ™, really techniques that help clean and remove debris but also doing so without cutting away unnecessary dermis. That dermis is, of course, is so important for the final outcome. We use, as I'm sure you're aware, lots of cell-based therapy so ReCell™, non-cultured autologous skin cell suspensions and also, increasingly, some of the dermal matrices.
And one of the things that we've really sort of noticed is that those techniques that we use are possible when we are efficient with respect to our management of those patients in a very efficient way. So I think that's particularly important with respect to surgery. I think you can't do all these innovative things if you've got a patient who is infected. You can't do these things if you've got a patient who has got a colonised wound that's all oedematous so the surgery is complex but you can only do that complex surgery if that patient is set for success by doing all those efficient things that I've talked about.
So it's that early management of the patient from wherever they are in a state. As I said, the use of the ACTICOAT™ dressings, oedema control, our physio therapists are all over these patients from the word go. And then being efficient with the theatre space that we have such that we can do the innovative things and really minimise scarring, maximise the outcomes for our patients.
Well, thank you so much, Jeremy, for sharing your perspectives and your expertise, particularly in light of the COVID situation that we've been going through, and, you know, it's been really interesting to hear how you've adapted and perhaps some positives have come from the situation even though it's been very difficult and challenging, so thank you so much. We do appreciate your time. Don't forget to tune into our next podcast and we'll see you soon.
Thank you, Jeremy.
Thanks very much.
Act on infection with ACTICOAT™ dressings and the power of nanocrystalline silver. Find out how they can help infection protocols and antimicrobial stewardship. The right product at the right time for the right patient. For more information, contact your local Smith & Nephew representative or email us at firstname.lastname@example.org.
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RCS(Plast) FRACS(Plast) Consultant in Burns & Plastic, Reconstructive, Aesthetic Surgery President, Australian & New Zealand Burn Association
Jeremy Rawlins is a Specialist Plastic Surgeon from Perth Western Australia. He is Head of the Plastic Surgery Department at Royal Perth Hospital where he has an interest in complex trauma and reconstructive microsurgery. He is Burns Consultant at the State Adult Burns Unit, Fiona Stanley Hospital where he provides acute and reconstructive burn surgery and complex wound & scar management. Jeremy has been involved in the development of the Burns Unit in Moshi, Tanzania for the past 10years. He is currently President of the Australia and New Zealand Burn Association (ANZBA).