Annals of Burns and Fire Disasters - vol. XVI - n. 2 - June 2003
BURNET PROJECT: TELEMEDICINE IN BURNS CENTRES IN THE EURO-MEDITERRANEAN AREA - European Union initiative – Pilot project
M. Masellis, MD., S.W.A. Gunn, FRCSC
Mediterranean Council for Burns and Fire Disasters
SUMMARY. The BurNet project is a pilot project of the Eumedis initiative. The Eumedis (EUro MEDiterranean Information Society initiative) is part of the MEDA programme of the EU and aims at developing the Information Society in the Mediterranean area. In the health care sector, the objective of Eumedis is: the deployment of network-based solutions to interconnect - using user-friendly and affordable solutions - the actors at all levels of the “health care system” of the Euro-Mediterranean region. The BurNet project aims to interconnect the Mediterranean Burn Centres (B.C.s) through an information network both to standardize courses of action in the field of prevention, treatment, and functional and psychological rehabilitation of burn patients and to co-ordinate interactions between B.C.s and emergency rooms in peripheral hospitals using training/information activities to optimize first aid provided to burn patients before referral to a B.C. Shared procedure protocols for the prevention, care, and rehabilitation of patients, both at individual and mass level, will help create an international specialized database and a Web-based teleconsultation system.
The Eumedis (EUro MEDiterranean Information Society) initiative is part of the European Union’s MEDA programme and aims at developing the Information Society in the Mediterranean area. The objective of the programme, which was approved by the European Commission on 22 February 1999, is to increase the rate of general economic development through the modernization of strategic sectors and to stimulate the most active areas in the Mediterranean countries, by promoting regional pilot-projects applied in five strategic sectors:
The programme will set out to create:
In the health care sector, the objective of Eumedis is:the deployment of network-based solutions to interconnect - using user-friendly and affordable solutions - the actors at all levels of the “health care system” of the Euro-Mediterranean region.
The ultimate aim of the interconnection should be the creation of co-operative working procedures capable of reinforcing the effectiveness and the quality of the work of the chosen actors through the sharing of localized scientific resources and findings (these methods include measures to foster exchange of experiences, multi-country training in public health, creation of specialized regional databases, and organization of epidemiological surveillance groups) and the implementation of computerized solutions for telediagnosis and workshops aiming at network-supported co-ordination of policies in the treatment of major diseases.
The projects funded in this sector link professionals from primary care structures, research institutes in large hospitals, health care administration, and individual doctors through information services based on specialized databases and accessible, comparatively affordable and user-friendly technology, with the implementation of computerized solutions to support service functions directed to patients and individuals on matters like prevention, post-hospitalization support and awareness.
The BurNet Project: Outline
The project deals with burns. It aims to interconnect the Mediterranean Burns Centres (B.C.s) through an information network both to standardize courses of action in the field of prevention, treatment and functional and psychological rehabilitation of burn patients and to co-ordinate interactions between B.C.s and emergency rooms in peripheral hospitals using training/information activities to optimize first aid provided to burn patients before referral to a B.C.
Shared procedure protocols for prevention, care and rehabilitation of patients, both at individual and mass level, will help to create an international specialized database and a web-based teleconsultation system.
A web-portal will be developed with the aim of interconnecting and involving all health-care providers and emergency workers involved in rescuing burn victims, transferring them or giving their contribution to fighting against fire disasters, when they often come into contact with burn victims. Some pages of the BurNet web portal will be specially designed for these people, with discussion groups, mailing lists, the opportunity to publish articles and personal experiences, and online training courses.
In the event of mass burns, the network will make it possible to co-ordinate emergency actions between the various B.C.s and between the Centres, peripheral hospitals, and similar operational units, with the aim of optimizing the procedures to be implemented at the various stages of disaster management.
The establishment of a Burns Centre linking network aims at the following general objectives:
The BurNet Project: Needs and benefits
All surveys of patients with extensive burn injuries transferred to Burns Centres agree that prognosis is dependent on three basic factors: the time-lag between the accident and fluid resuscitation, the quality of treatment, and the type of monitoring throughout the disease.
The time-lag can undoubtedly be affected by several factors, such as the locality where the accident has occurred (for example, a place not far from a hospital or a health-care facility is different from a place where emergency care can be provided only by a general practitioner), the distance from a big city, the characteristics of the route to a Burns Centre, the site of the accident, such as a crowded discotheque or a disaster area, the arrival of the burn victim in a specialized unit within three hours of the accident (an essential factor for the patient’s prognosis), etc.
The transfer of patients must therefore be rapid, well-planned and well-co-ordinated. Emergency corps, ambulance staff, and voluntary rescuers must be adequately trained to provide first aid to the burn victim, who needs highly specialized care.
Immediate first aid. When a burn accident occurs in a remote place, care is generally inadequate. General practitioners may not remember, or may not be familiar with, the physiopathology of burn injury and consequently underestimate the relationship between the extent of the injury and the degree of severity of the ensuing hypovolaemic shock. They are not always able to evaluate the extent and depth of skin thermal damage or the patient’s condition. As a result, on arrival in a suitable health-care facility the patient may not have received appropriate local or general emergency treatment.
This also applies to first-aid stations, hospital emergency departments, and anyone who comes in contact with a burn patient: diagnosis and treatment in cases of minor injuries, or pre-hospital care before referral to a B.C., can be erroneous or inadequate. In such cases physicians should be provided with standard questionnaire-like forms and with clear instructions on immediate treatment. This could be of much help in an emergency case. The form, which is tantamount to the patient’s documentation, will contain the victim’s personal data, when and how the accident took place, the cause of the thermal injury, a list of antidotes to be used for the immediate treatment of chemical burns, the resuscitation procedures to perform in case of cardiac arrest due to electric shock, etc. Instructions will also be provided on how to evaluate the extent and depth of burns and the degree of severity related to the patient’s age and general health. Fluid resuscitation therapy will be outlined, both qualitatively and quantitatively, in order to reduce the damage due to hypovolaemic shock. Information will be given on how to treat the burned areas. Finally, mention will be made of where and how to refer the patient in order to continue specific therapy, and to provide appropriate transport.
The arrival in non-specialized, peripheral hospitals of patients with extensive burn injuries requires appropriate management of their condition. Guidance protocols can be of help to doctors, indicating specific therapies and laboratory tests as preliminary procedures to more appropriate management.
Other forms will deal with indications for monitoring of vital signs (urine volume, haemodynamic tests, etc.) and for the continuation of general and local treatment. Finally, the assessment criteria for referral to a B.C. will be listed. B.C.s will also be provided with information on what to do in the event of mass burn disasters.
In specialized units such as B.C.s, the life prognosis and functional and psychological recovery of a patient with extensive burns are closely related to resuscitation therapy, the monitoring of the later stages of the disease, and surgical and rehabilitation indications. These factors are often affected by the lack of advanced scientific knowledge and the ensuing technological innovation, because many health care providers cannot participate - e.g. for economic reasons - in medical congresses, symposia, seminars, or workshops, and sometimes have difficult access to updated scientific periodicals.
Most importantly, it can be difficult, if not impossible, for these persons to seek the advice of more advanced Centres. The Centres themselves often have difficulty in exchanging information on medical, surgical, and rehabilitation procedures: low-cost technological tools may not be available, or Centres may often be reluctant to reveal their own data if no immediate access to those of other Centres is available.
The online connection of different specialized Centres can give rise to a new collaborative spirit, to a new, specialized pool of health-care providers.
Furthermore, the creation of a database collecting all the patients’ medical records (family history, prognosis, therapies, and rehabilitation procedures) can be a valid statistical tool to standardize - as far as possible - the analysis of medical data and treatment protocols in the different Centres. The online network will be ideal for teleconsultation and diagnosis and for comparing therapies not only between the Centres but also between them and peripheral hospitals. An inexpensive, easily accessible, and practical tool will be available to encourage participation in forums and discussion groups, publication of articles and reports, access to journals, work meeting proceedings, etc.
Prevention campaign: these data can also be used in prevention campaigns. In many countries prevention and first aid are still defective. These gaps should be filled, starting from basic education at schools, a necessary step to reach unambiguous social awareness, especially in countries where the positive impact of education and training on societal development has not yet been felt.
Medical knowledge must therefore be conveyed to the public through simple and comprehensible instructions. Anybody may happen to provide first aid to a burn victim: at home, at the workplace, walking the streets.
A successful result can be obtained only by launching educational and awareness campaigns on first aid, fire preparedness, and the prevention of burn-causing accidents (fire, electric shock, chemicals handling, vapours, etc.).
Such campaigns can bring to light the potential role that the general population can play in the event of fires. It would be sufficient to disseminate a few simple rules to give enormous help to experts and make their job easier.
More detailed and specialized rules and methodologies should be made available to rescuers, emergency corps, and paramedical staff, in order to facilitate the management of patients in B.C.s.
Online training and refresher courses: in addition to the information campaigns conducted by specialists, the Internet can prove a highly popular, low-cost tool which can rapidly reach anybody, from schools to workplaces, from hospital departments to emergency rooms, from fire stations to voluntary workers - the project envisages online training and refresher courses for anybody involved in the burn care sector.
Moreover, using the Partnership approach to create a network of all players involved in as many countries as possible, we can ensure the sharing of consistent objectives, working methodologies, and high-quality procedures.
The Scientific Partners gave a powerful contribution to the identification of issues and needs during the preparation of the Project. Each of them highlighted the gaps in the treatment and prevention of burns in their respective countries.
These gaps turned out to be quite common, and the need therefore arose to create a “powerful” co-ordination system in this field throughout the Euro-Mediterranean area. Starting from the mutual exchange of medical and educational methodologies, some common guidelines could be established and used as proven and practical intervention tools, which could also be delivered to emergency corps and the general population as far as first aid and prevention are concerned.
Given these shared problems and the common will to solve them, the natural outcome of the context analysis was therefore a set of clear and self-evident guidelines. Similarly, it was obvious that the Web appeared to the Partners to be a simple, quick, economical, and practical tool which could be used to involve all people working in this field.
The BurNet Project: Purposes
The BurNet project intends, as its specific purpose, to considerably improve the care and emergency capabilities of health-care and other personnel in each of the countries involved in the Project. Burn patients suffer from conditions which make them considerably different from other types of patients. They require immediate treatment (within three hours after the accident) and specialized care. The initial purpose is therefore to improve the first-aid capabilities of persons who reach the scene of the accident and are the first to come into contact with a burn patient. Whoever these people may be - a member of the family, a colleague, a passer-by, a nurse, a doctor, or a fireman - they must be adequately trained and ready to take immediate, responsible, and effective action. Secondly, during the transfer of the patient to a B.C., which must take place as efficiently as possible, the patient must receive initial specialized treatment by paramedical staff. If the patient is taken to a first-aid station or an emergency room, doctors must be ready to make the appropriate diagnoses and to provide adequate treatment which should follow the protocols adopted at Burns Centres. Furthermore, if the patient is later to be referred to a B.C. because of particularly serious conditions, the care-givers who have first come into contact with the patient must take adequate action to facilitate subsequent treatment. As far as the co-ordination of the B.C.s is concerned, the project aims at a gradual and steady improvement of their internal organizational ability (e.g. in the event of a fire disaster) and of treatment standards provided to burn patients, who are to be considered the ultimate beneficiaries of the project. The exchange of information at international level, the medical and scientific training of care-givers, the awareness campaigns addressed to the public, and the hoped-for consequences of the adoption of shared and standardized operational guidelines will have a positive impact on the development of scientific and operational expertise in the medical sector of Euro-Mediterranean countries. Training activities, awareness campaigns, and the dissemination of the Project’s results are also intended to raise the level of knowledge in the field of first aid and fire prevention.
BurNet Project: Consortium
The constitution of the Consortium has been drawn up according to the indications of the guidelines of the MEDA Programme-Eumedis Initiative published in 1999 by the European Commission. The guidelines indicate the list of countries eligible for the project (Table I). The participation of 17 B.C.s permits a complete geographical distribution of the partners in the Mediterranean area (Fig. 1). Countries not included may participate as Associate Countries and help towards the success of the Project. Each of the other B.C.s in the countries participating in the Project may ask an official Partner to be included as an Associate Partner, participate in its development, and become a user.
The first operational phases (WP1, WP2, WP3) will be based on the study and development of the hardware and software architecture aimed at establishing a Network of all Mediterranean Burns Centres through IT connections that will facilitate contacts and the exchange of different experiences. These tools will enable the scientific community operating in the field of burns treatment to mutually enrich their knowledge and enhance their skills and capabilities.
These technological activities will be based on the analysis of the scientific contribution made by the B.C.s involved in the Project and will help define and develop information tools such as a “technological kit” (Internet-connected PC with clinical data acquisition and input devices), which will be used by all the B.C.s, a Web Portal, and a tool for the online collection of burn patients: a Data Collection Tool (DCT) to use as a computer Data Base of medical records.
The Scientific Partners will thus have an easy, low-cost tool to communicate with each other and initiate web-based diagnostic procedures. They will follow a training course on how to use the DCT supplied by the Technological Partner, so as to be able to create an archive of burn patient records to be used also for statistical and epidemiological purposes.
The objective is the scientific growth of the health-care sector. The implementation of the BurNet network, using such a simple, popular, and inexpensive tool as the Internet, makes this exchange even more feasible and enhances its effectiveness.
The technological features of the web portal will be updated, modified, and enhanced. Efforts will be made on a regular basis to enrich the scientific content of the web portal and the research carried out within the framework of the BurNet project.
The purpose of the expansion of the web portal will also be to adjust it according to the various needs and proposals of the people involved in the field of burns care (doctors, emergency workers, paramedical staff, voluntary workers, teachers, etc.).
Moreover, further modification to the DCT or to the portal could be made on the basis of new epidemiological studies that would for example require the collection of new data.
The creation of a specialized web portal and a database for Teleconsultation (WP4) will enable health-care providers, emergency corps, burns centre staff, and others to have access to the most recent updates in the field, improving their knowledge in order to tackle more effectively the problems of burns victims, who are the ultimate beneficiaries of the project. In addition, the DCT will prove a valid statistical tool to be used in the standardization of data analysis and treatment protocols of the various Centres.
Shared action protocols in the field of burn care will be created that will be produced and endorsed by all participants (WP4).
There will be several themes to analyse and discuss through the portal by all Scientific Partners which will be the basis for the creation of a common medical language in the burns sector and of various online training courses for different profession categories.
These topics will concern the following areas:
A web-based tool offers a great saving of time and money when medical protocols and guidelines have to be decided upon. The conventional way of doing this is to hold a conference or a seminar, and this may often take a long time. On the other hand, using an online discussion group (an e-group), common guidelines could be obtained more rapidly, and these can be followed by all Euro-Mediterranean countries.
The inexpensive, easily accessible, and practical web-based connection will provide the opportunity to stimulate international debate and foster a new collaborative spirit.
The BurNet web portal will include several pages dedicated to involvement of all people who give their contribution to fighting against burns and fire disasters and often come into contact with burn victims (e.g. firemen, voluntary workers, first-aid station and emergency room personnel, hospitals lacking a burns unit, law enforcement agencies, paramedical staff, general practitioners, etc.).
In these pages they can find spaces for discussion and contacts and specialized online training courses.
upon by all Partners, will be put on line, in pages targeted at various professionals.
The online training has also an indirect goal, which is to promote and foster the use and the knowledge of new IT-based methodologies, especially in countries and organizations that have not yet taken full advantage of them.
The purpose of the campaigns, which will be mainly conducted in schools and will include the distribution of teaching and informative materials, is to make the public aware of the importance of fire prevention and to provide training in basic first aid in case of burn accidents.
To this purpose, there will be wide dissemination of the activities and results of the BurNet project.
The activities carried out through the BurNet web portal will be prevalently medical and scientific, but they may prove of great relevance to society as a whole and in particular to countries that lag behind in the field of prevention and health-care in comparison with some other European countries. It is therefore of paramount importance that these activities be disseminated and publicized widely, also through conventional mass media.
The use of media that publish common medical protocols in specialized periodicals will give even more prominence to the partnership created by the BurNet Pilot Project and its activities, with the ultimate aim of stimulating public interest and encouraging other organizations, not necessarily operating in the health-care sector, to join the Project, thus ensuring the sustainability of the project itself.
The organization of Work Meetings will give added value to the goals of the Project, enhancing its appeal to the public through the media. The conferences will also give the opportunity to take stock of the work carried out thus far.
The exchange of information that the BurNet network will implement will also help to develop the integrative activity of real-time verification and monitoring (WP0), in which each Partner will engage in the evaluation of the different activities in terms of their actual implementation, their compliance with the time-line, and their being in line with the general and particular aims of the projects that are being jointly pursued by all participants.
The activities of the BurNet Project began on 1 July 2003 and will conclude on 30 June 2005.
The Portal will be divided into several sections, covering the overall project, technical tools supporting exchange of know-how, online training courses, and teleconsultation.
The first page will allow the user to choose a language (English, French, or Arabic) and will offer access to a summary page with links to all functions available, including a module for online registration. Based on the user’s category, the registration process will limit access to certain functions (for example, during the Project, only doctors from Partner countries will have access to teleconsultation).
The sections of the portal include the following: general introduction to the BurNet Project, description of Partners, links to other institutions and projects, news and events, teleconsultation, scientific themes of the project (Fig. 3).
The effort made to standardize educational, informative and training tools at different social and professional levels and in such different countries will have far-reaching social and cultural consequences.
There are gaps in the level of public awareness of health-care, social and prevention issues in many Mediterranean countries. These gaps can be bridged with activities aimed at redressing the balance.
The BurNet Project was conceived for this reason, since it may enable the Euro-Mediterranean people to share comments on common issues, exchange their opinions, and reach better standards in terms of scientific knowledge, social awareness and cultural activities in all countries.
The involvement of schools, which at first may appear to be very far away from such specialized issues, can be the priming for further mass improvement, stimulating the interest of young people in this sector and increasing computer literacy all over the Euro-Mediterranean area.
Similarly, the large-scale dissemination of the results of the Project, performed through the media, will involve the general public and raise their awareness of such issues as fire prevention and first aid, engendering reflections on common themes.
BurNet wants to develop a network which links various other Burn Centres on the Web, not included initially in the Project, giving more prominence to their activities and putting them in a wider international context.
The activities of the web portal will result in standardized methodologies, enhanced training programmes and more powerful awareness campaigns (action in this sector has long been taken by the Mediterranean Council for Burns and Fire Disasters) and more effective dissemination of research results.
After the establishment of this Web-based network, the mutual exchange of information will commence thanks to the IT tools envisaged by the Project, and will continue as no additional costs are expected.
The success of the Project will be validated by other health facilities that ask to join the network. Also the other institutions and organizations involved in the Project as target groups (emergency corps, voluntary workers, schools, etc.) are expected to take more and more interest in the activities of the web portal.
The activities that are carried out through the portal and the Database are the following: online exchange of know-how, input of medical records in the Database (of high statistical relevance), teleconsultation, future drawing-up of other common protocols, future creation of other training modules.
The above-mentioned activities do not need considerable financial resources to be carried out: their costs are limited to the charges for the connection to the Internet through a phone line, which could be paid by the Partners, as they realize the potential benefits of the Project.
The online exchange of information and methodologies will enable all the persons operating in the sector of burn care to enjoy continuous information, thus expanding and updating their own knowledge using a low-cost tool. Conventional opportunities for training and updating are generally very time-consuming and expensive because of the necessity of travelling to reach the venues of conference, medical congresses, symposia, seminars and forums. Updated medical journals and scientific periodicals are also expensive.
The Web-based network will host pages with articles and publications and give the opportunity to its users of taking part in discussion groups, forums and mailing lists. An ample archive will be available, with updated scientific information, case studies, conference proceedings: surfing will be the only thing the actors have to do.
The training modules envisaged in the project will also be accessible online, in specific pages and with different content according to the end user, who can be health-care providers, emergency workers, ordinary citizens, or students.
Access to these courses will always be immediate. Their content will be updated and expanded thanks to the financial resources of the promoter of the Project and the technical advice of the Technological Partners.
Training plays a key role in the Project’s sustainability, since it allows all concerned to expand their knowledge and improve their skills.
Online training courses can also raise the rate of computer literate participants in each country.
RESUME. Le projet BurNet est un projet pilote de l’initiative Eumedis. L’initiative Eumedis (