Annals of Burns and Fire Disasters (ISSN 1592-9566) -
Pending Publications

NEW BURNS CENTRE IN PARMA HOSPITAL, WEST EMILIA HUB

Caleffi E., Bocchi A., Soncini I., Arena A.

Burns and Plastic Surgery Unit, Department of Surgery, Parma Hospital, Italy

SUMMARY. Parma Hospital is the Trauma Centre for SIAT (Trauma Patients Integrated Assistance System) in the West Emilia District in the regional trauma patient project. SIAT’s goal is to provide the quickest and most appropriate treatment in major trauma patients. Extensive burns are a multi-organ pathology, i.e. a major life-threatening trauma. Our burn patients are treated on the “Hub and Spoke” model: triage and immediate transfer from the Spoke (first- and second-level Centre) to the Hub (third-level centre, i.e. the Parma Hospital Burns Centre). Burn treatment requires pre-hospital care (timely assistance, airways security, steady life parameters, adequate central or peripheral access, fluid administration, maintenance of body temperature, transport) and adequate hospital treatment (fluid resuscitation, pain therapy, gastroduodenal ulceration prophylaxis, escharotomies, and topical wound care).

Organization of the Emilia-Romagna Trauma Centre

The Italian Regional Law on trauma patients (22 July 2002; resolution no. 1267) in the territory of Emilia-Romagna establishes that there are to be three SIATs (Trauma Patients Integrated Assistance Systems) (Fig. 1).



Fig. 1SIAT in Emilia-Romagna.

Fig. 1 - SIAT in Emilia-Romagna.


Each SIAT is a Hub and Spoke organization: in this model high-specialization sanitary services are united in Hub or Trauma Centres: trauma patients are sent to the Hub from the Spokes (peripheral territorial centres).

In this project Parma Hospital is the Hub of West Emilia.

In this protocol major traumas are treated quickly and with high-specialist performance. Major trauma is a life-threatening event with specific triage parameters (Tables Ia,b,c).



  Adults Children (<16 yr)
Breathing rate per min <10 to >30 <15 to >40
Cyanosis Yes Yes
Blood pressure (mm Hg) <90 <75 + child’s age (yr)
Consciousness level GCS<13 GCS<13
Table Ia - Triage parameters - vital parameters and consciousness levels




Deep wounds Head/neck, chest, abdomen, pelvis, axilla, groin
Amputation At wrist or ankle
Burn >20% TBSA, airways or head injury
Chest trauma Costal flap
Nerve lesion Limb paralysis
Limb fracture Two or more fractures of proximal bones
Table Ib - Triage parameters - trauma typology




Ejected from vehicle
Fatalities in same vehicle
Fall from height >5 metres
Pedestrian knocked down or run over
High-energy impact
Vehicle overturned
Burn or frostbite
<15 yr or >60 yr
Pregnancy, acute kidney failure, obesity
Table Ic - Triage parameters - trauma modality


If the transfer time is less than 30 minutes, the patient goes directly to the Trauma Centre; if longer, the patient goes to the nearest Spoke for immediate treatment until stable parameters are obtained and is then sent on to the Trauma Centre.

Major burns can be considered a major trauma. Table II presents the parameters for burn patient hospitalization as established by the American Burn Association.



Degree TBSA (percentage) Age (yr)
Second and third >10 <10& >50
Second and third >20 10-50
Second and third Face Eyes Ears Hands Feet Genitalia Perineum Major joints 
Third >5 Any age group
Other causes Electrical burn Chemical burn 
Associated injuries Inhalation injuryBurn injury in patients with previous medical conditions that could complicate management, prolong hospitalization, or affect mortalityPatients with burns and concomitant trauma (such as fractures) in whom the burn injury poses the greatest risk of morbidity or mortality
Table II - American Burn Association Burn Centre transfer criteria


Organization of Parma Burns Centre

Until November 2006 Parma Burns Centre had eight beds (four two-bed rooms without filters) and one balneotherapy room.

The new Burns Centre is in the new hospital building, where we have:

  • eight beds, four intensive care rooms for assisted- ventilation patients and four semi-intensive care double rooms
  • an operating room in the Burns Centre
  • a balneotherapy room with anaesthesiological support
  • an admittance room with balneotherapy facilities

This structure makes it possible to provide various forms of treatment:

  • clinical and surgical treatment for critical burn patients (if necessary, with assisted ventilation support)
  • scheduled surgical procedures
  • pain-free topical wound care provided with Burns Centre anaesthesiological support

Our procedures provide effective intensive care to the patient with reduced hospitalization time.

Epidemiological analysis

In the period 2001-2006, 539 patients (348 males and 191 females) were hospitalized in Parma Burns Centre.

The male:female ratio is illustrated in Fig. 1: there was a higher incidence of males in all age ranges. Fig. 2 shows that the age range between 15 and 44 years of age was most frequently involved. High-risk male work activity may be the reason for this, since in age ranges without work activity (below 9 and above 65 years of age), the male:female ratio was reduced: in this series we observed almost exclusively domestic accidents.

Since 2002 we have seen a higher overall incidence of patient admission to hospital (Fig. 1) and reduced hospitalization time (Fig. 3).



Fig. 1Male: female ratio. Higher incidence of burn injury in males.

Fig. 1 - Male: female ratio. Higher incidence of burn injury in males.




Fig. 2Working age range more frequently involved.

Fig. 2 - Working age range more frequently involved.




Fig. 3Reduced hospitalization time after 2002.

Fig. 3 - Reduced hospitalization time after 2002.


Conclusion

From 2002 on there has been a reduction in hospitalization time and a higher overall incidence of admission to hospital. Our preliminary reports indicate that improved intensive assistance effectively reduced hospitalization time (Fig. 4).



Fig. 4Reduced hospitalization time and higher incidence of admission to hospital after 2002.

Fig. 4 - Reduced hospitalization time and higher incidence of admission to hospital after 2002.


This first Italian Hub & Spoke system realized in the Emilia Romagna region has three independent SIATs with a principal Trauma Centre (Hub). The Hub accepts patients with major traumas and major burns from peripheral centres (Spoke).

This manner of organization has improved intensive immediate assistance in major burns and traumas.


RÉSUMÉ. L’Hôpital de Parme est le Centre des Traumatismes pour SIAT (Système d’Assistance Intégrée pour les Patients Traumatisés) dans la zone d’Emilia Occidentale dans le projet régional pour les patients traumatisés. Le but de SIAT est de fournir le traitement le plus rapide et le plus approprié aux patients gravement traumatisés. Les brûlures étendues constituent une pathologie multi-organique, c’est-à-dire un traumatisme de grandes proportions qui compromet la vie du patient. Nos patents brûlés sont traités selon le modèle “Hub and Spoke” (concentrateur et rayon): triage et transport immédiat du Spoke (centre de premier ou deuxième niveau) jusqu’au Hub (centre de troisième niveau, c’est-à-dire le Centre des Brûlés de l’Hôpital de Parme). Le traitement des brûlures nécessite les soins préhospitaliers (assistance précoce, sécurité des voies aériennes, paramètres vitaux stables, accès central ou périphérique adéquat, administration des fluides, maintenance de la température corporelle, transport) et le traitement hospitalier approprié (réanimation avec fluidothérapie, thérapie antidouleur, prophylaxie contre l’ulcération gastroduodénale, escharotomies et traitement local des lésions).


Bibliography

  1. Sheridan R.L.: Burns. Crit. Care Med., 30 (suppl.): S500-S514, 2002.
  2. Sistema Integrato di Assistenza ai Traumi dell’Emilia Occidentale - Linee guida per il trasferimento interospedaliero dei pazienti con trauma grave nel SIAT dell’Emilia Occidentale - Dipartimento Emergenza ed Urgenza, U.O. di 1° Anestesia, Rianimazione e Centrale Operativa, M. Mergoni.
  3. Linee guida dipartimentali per la gestione del paziente ustionato - Dipartimento di Emergenza ed Urgenza, S. Zucchelli.
  4. PAL, Assistenza ai grandi traumi - Dipartimento Emergenza ed Urgenza, U.O. di 1° Anestesia, Rianimazione e Centrale Operativa, M. Mergoni.

This paper was received on 16 July 2007.
Address correspondence to: Dr E. Califfi, Burns and Plastic Surgery Unit, Department of Surgery, Parma Hospital, Italy.
E-mail: mamaosoncia@hotmail.com