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Abstract

Background:

Early intervention by specialized burn surgeons is crucial in preventing wound progression and complications of deep burns. However, limited access to specialist burn centers remains a challenge. Telemedicine offers a potential solution by providing timely and high-quality access to burn experts. The study aims to compare the diagnostic accuracy of telemedicine for diagnosing burn depth by surgeons working in the field of burns.

Method:

This cross-sectional study included 15 actively practicing surgeons specializing in burn surgery, including general surgeons, burn surgery fellows, and plastic surgeons. The surgeons’ work experience and areas of expertise were documented. The study presented 13 images of partial-thickness burn ulcers on patients’ extremities and trunk, requiring participants to diagnose burn depth and assess the necessity of grafts.

Results:

Among the 15 participating surgeons, complete responses were obtained from 11 individuals, comprising 3 general surgeons, 4 burn surgery fellows, and 4 plastic surgeons. For deep burns, no significant difference in diagnostic accuracy was observed between general surgeons and burn surgery fellows (p = 0.152) or between burn surgery fellows and plastic surgeons (p = 0.193). However, plastic surgeons demonstrated significantly higher accuracy compared to general surgeons (p = 0.020). Regarding superficial burns, there were no statistically significant differences in diagnostic accuracy between general surgeons and burn surgery fellows (p = 0.567), but both general surgeons (p = 0.011) and burn surgery fellows (p = 0.043) exhibited significantly higher diagnostic accuracy than plastic surgeons. Furthermore, the analysis indicated that work experience did not significantly impact the accuracy of burn depth estimation.

Conclusion:

The study’s results confirm the reliability of utilizing photographs to evaluate superficial burns, but underscore the limitations in both validity and reliability when it comes to determining burn depth. In addition, the findings highlight that general surgeons exhibit greater proficiency in identifying superficial burns, whereas plastic surgeons demonstrate higher accuracy in diagnosing deep burns.

Introduction

Burn injuries pose a significant public health problem, particularly in developing countries, where mortality rates can be up to ten times higher than in high-income countries.^1,2 Access to specialized burn centers is often limited in these regions, resulting in delayed diagnoses and subsequent delays in treatment.^3,4

The diagnosis of burn depth is crucial in determining the appropriate treatment approach, required for preventing long-term disabilities, decreasing mortality rates, and also minimizing the economic impact on both individuals and society.^5–8 Two treatment strategies are utilized: conservative treatment for superficial burn injuries and surgical intervention with skin graft for deep burn injuries to facilitate healing. Although the surgeon’s decision to perform skin graft should be made as soon as possible to improve the patient’s prognosis, inaccurate assessments of burn depth can lead to unnecessary interventions.^9,10 Nonetheless, differentiating between superficial and deep burns poses a significant challenge, particularly in cases involving partial-thickness injuries. This distinction is significantly important as the deep partial-thickness injuries necessitates more intricate and specific treatment approaches.^6,11

Telemedicine has become an increasingly valuable tool in the diagnosis and management of different diseases.^10,12–14 In the field of burn care, telemedicine has proven to be effective in enhancing diagnostic precision, minimizing unwarranted referrals, enabling remote consultations, and promoting earlier intervention and treatment. It should be also mentioned that telemedicine has emerged as a potential solution for providing timely and cost-effective access to burn experts.^15–19

One specific telemedicine tool that has been utilized in burn care is photography.^20,21 Photographs of burn wounds provide an objective record of the injury that can be shared with health care professionals for diagnosis and management planning. This approach allows for a more accurate and efficient assessment of the wound and can potentially improve patient outcomes by enabling timely intervention and monitoring of the burn injury.^22–26

In recent years, there has been an increasing amount of literature on using photos in telemedicine. For instance, Boissin et al. (2015) conducted comprehensive research on using photos to assess the size and depth of burns in patients with dark-skin types, and their results led to correct diagnoses two-thirds of the time.²⁷ Study of using cellular phones for burn assessment by Hollander et al. (2017) show the importance of photographs in burn assessment. Burn evaluation with photographs prevents unnecessary or delayed admission to referral centers in almost two-thirds of the cases.²⁸

A recent study conducted by Blom et al. (2017) involved the use of smartphones and tablets to diagnose the size and depth of burns by viewing photos. It was determined that this method was suitable for diagnosing burn size; however, it did not yield accurate results for assessing burn depth.²⁹ Data from the Basaran et al. (2021) study also indicate that there was agreement between the photographs sent over WhatsApp and the face-to-face examination in terms of burn evaluation.³⁰

To assess the accuracy of using photographs in burn diagnosis, Hop et al. (2014) compared the reliability and validity of photos for assessing the size and depth of burns. They concluded that photos provide an accurate method for assessing burn size; however, it remains challenging for evaluating burn depth.²³ Surveys such as that conducted by Wearn et al. (2018) have compared the accuracy of different methods for assessing burn depth. On days 0 and 3, the accuracy of burn depth evaluation using photos was 62.5% and 71.6%, respectively.³¹ In view of these findings more attention needs to be paid to addressing burn depth in telemedicine.

Although previous studies have explored the accuracy of diagnosing burn depth using photographs, they have often lacked a specific focus on considering the expertise and training of the individuals making the assessments. By comparing the proficiency of surgeons specializing in burn care (general surgeons, burn surgery fellows, and plastic surgeons), we provide valuable insights into how different specialties perform in assessing burn depth through telemedicine.

In a previous study,³² the authors investigated the accuracy of burn depth assessment by a group of qualified surgeons. The findings indicated that for partial-thickness burns, the accuracy of identifying deep burns from photographs was relatively low, whereas the accuracy of identifying superficial burns was high. In the present study, we extend the analysis to compare the diagnostic accuracy of the three distinct groups of surgeons involved in the study_ general surgeons, burn surgery fellows, and plastic surgeons. The study places particular emphasis on the challenging task of identifying partial-thickness burns, which can prove difficult even for experienced clinicians.

Material and Methods

In this cross-sectional study a total of 15 surgeons, including plastic surgeons, general surgeons, and burn surgery fellows, were selected through convenience sampling provided they had a minimum of two years’ experience in the field of burn treatment.

The number of participants required for the study was calculated using a sample size estimation formula. The objective was to achieve a 90% confidence level with a confidence interval of 0.08, considering an 80% accuracy rate found in similar studies, in order to estimate the success ratio accurately.

The study utilized 13 standardized images of partial-thickness burn ulcers on the extremities and trunk, captured in the first 24 h after the burn and before any interventions, at the Shiraz Burn Accident Center in 2017–2018 (Fig. 1).

FIG. 1.

Examples of cases featured in the study: (a) Superficial burn (b) Superficial burn (c) Deep burn (graft required).

Prior to obtaining any medical images, patients were required to provide informed consent, explicitly authorizing the utilization of their images for diagnostic or clinical purposes. The consent procedure adhered to the guidelines and regulations mandated by the relevant human subjects committee to ensure the research’s ethical conduct. Approval for the study was granted by the Human Subjects Committee at Shiraz University of Medical Sciences, allowing and required explicit consent from all 13 patients before initiating the study. This allowed the photographic documentation to be obtained while maintaining compliance with ethical guidelines and regulations.

All images were captured using a standardized setting and the same digital camera (Canon EOS 1300D 18-15 mm DC III Digital Camera). The guidelines set forth by the American Telemedicine Association for image acquisition were the focus of our efforts. This encompassed the use of a high-quality camera for documentary of medical images while upholding strict patient privacy safeguards throughout the image acquisition process. Furthermore, standardized image capture techniques were implemented to mitigate distortions or artifacts that might adversely affect the diagnostic precision of the images.

Images were displayed on a full HD (High Definition) computer screen. The display resolution was set at 1920 × 1080 pixels, equivalent to full HD. Microsoft Photos software was used for examining the photos which allowed users to zoom in and pan across the images to explore specific areas of interest. However, it’s important to note that adjusting the color scale or using any tools was not a feature available to users (Table 1).

Table 1.

Features of Burn Photos Used in the Study

	Burn depth (deep/superficial)	Location (extremity/trunk)	Skin color	Burn degree	Graft required
Pic 1	Deep	Extremity	White to red	Partial thickness	Yes
Pic 2	Superficial	Trunk	Pink to red + blister	Partial thickness	No
Pic 3	Deep	Trunk	White to red	Partial thickness	Yes
Pic 4	Deep	Trunk	White to red + blister	Partial thickness	Yes
Pic 5	Superficial	Extremity	Pink to red	Partial thickness	No
Pic 6	Superficial	Extremity	Pink to red	Partial thickness	No
Pic 7	Deep	Extremity	White to red + blister	Partial thickness	Yes
Pic 8	Deep	Trunk	White to red	Partial thickness	Yes
Pic 9	Superficial	Trunk	Pink to red	Partial thickness	No
Pic 10	Superficial	Trunk	Pink to red + blister	Partial thickness	No
Pic 11	Superficial	Extremity	Pink-to-red + blister	Partial thickness	No
Pic 12	Superficial	Extremity	Pink to red	Partial thickness	No
Pic 13	Deep	Extremity	White to red + blister	Partial thickness	Yes

The participating surgeons were asked to diagnose the burn depth using relevant forms. Their diagnostic accuracy was subsequently assessed by comparing it to the diagnoses documented in the patients’ medical records, which had been initially confirmed by independent experts through clinical examination upon admission and then final treatment as the gold standard for validity assessments. The need for grafting was decided from the identification of deep burns. In this study, deep burns were categorized as those requiring grafting. Therefore, if a burn was identified as deep, it was assumed to necessitate grafting.

The diagnostic results were analyzed, using SPSS version 20 software, employing independent t-tests and chi-square tests. In addition, General Linear Model and Repeated Measurement ANOVA were used to examine the impact of work experience on diagnosis accuracy. A statistically significant p < 0.05 was considered significant.

Results

Among the 15 surgeons involved in the study, 11 surgeons provided complete responses to all questions. Subsequently, data analysis was carried out based on their responses. Of the 11 participants, 3 were general surgeons, 4 were plastic surgeons, and 4 were burn surgery fellows.

The average diagnostic accuracy of deep burns for general surgeons was 17.21% ± 5.99% for example (95% CI for mean: 2.33–32.09%), for burn surgery fellows was 27.42% ± 13.29% (95% CI for mean: 6.29–48.55%), and for plastic surgeons was 38.46% ± 21.88% (95% CI for mean: 3.68–73.24%). There was no statistically significant difference between the average diagnostic accuracy of deep burns for general surgeons and burn surgery fellows $(p = 0.152)$ or burn surgery fellows and plastic surgeons $(p = 0.193)$ . However, the average diagnostic accuracy of deep burns for plastic surgeons was significantly higher than for general surgeons $(p = 0.020)$ .

The average diagnostic accuracy of superficial burns for general surgeons was 85.32% ± 22.98% (95% CI for mean: 77.77–92.88%), for burn surgery fellows was 82.23% ± 26.74% (95% CI for mean: 74.78–89.67%), and for plastic surgeons was 70.42% ± 31.69% (95% CI for mean: 61.60–79.24%). There was no statistically significant difference between the average diagnostic accuracy of superficial burns for general surgeons and burn surgery fellows $(p = 0.567)$ . However, the average diagnostic accuracy of superficial burns for general surgeons $(p = 0.011)$ and burn surgery fellows $(p = 0.043)$ was significantly higher than for plastic surgeons (Table 2).

Table 2.

The Average Diagnostic Accuracy of Specialists by Type of Burn and Expertise

Diagnostic accuracy of burn type	General surgeons	Burn surgery fellows	Plastic surgeons
Deep burns	17.21% ± 5.99%	27.42% ± 13.29%	38.46% ± 21.88%
Superficial burns	85.32 ± 22.98	82.23 ± 26.74	70.42 ± 31.69

The average working experience of general surgeons in burn field was 7.66 ± 2.51 years (range: 5–10 years, median = 8), burn surgery fellows was 11.25 ± 2.50 years (range: 10–15 years, median = 10), and plastic surgeons was 4.50 ± 3.78 years (range: 2–10 years, median = 3).

Among the participants, one general surgeon and three plastic surgeons had less than 5 years of experience, whereas two general surgeons, three burn surgery fellows, and one plastic surgeon had work experience between 6 and 10 years. Only one burn surgery fellow had more than 10 years of experience (Table 3).

Table 3.

Work Experience

Work experience	General surgeons	Burn surgery fellows	Plastic surgeons
Less than 5 years (x ≤ 5)	1	0	3
Between 5 and 10 years (5 < x ≤ 10)	2	3	1
More than 10 years (x > 10)	0	1	0

General Linear Model and Repeated Measures ANOVA were used to explore the effect of work experience on diagnostic accuracy. According to the results, work experience did not have a noticeable impact on burn accuracy estimation. This applies to overall accuracy $(p = 0.189)$ , as well as accuracy regarding superficial burns $(p = 0.192)$ and deep burns $(p = 0.098)$ .

Discussion

The study’s results indicated that although the average diagnostic accuracy for deep burns was generally low among all specialists, plastic surgeons demonstrated significantly higher accuracy than general surgeons in diagnosing deep burns. In contrast, general surgeons demonstrated a greater proficiency in identifying superficial burns compared to plastic surgeons. One potential explanation for these differences in accuracy between specialties could be because of the limited exposure of plastic surgeons to acute-phase burn patients. During the early stages of burns, general surgeons typically evaluate and treat patients and work out resuscitation requirements, whereas plastic surgeons become involved only after stabilization when assessing the need for grafts.

The study results are consistent with those of Blom et al. (2017) who investigated the accuracy of acute burns diagnosis using burn photographs by burns specialists from South Africa and Sweden, as well as emergency medicine specialists from South Africa. This study found that there was no significant difference in the diagnosis of total body surface area (TBSA) levels among the three participant groups, and TBSA was diagnosed with high accuracy. Despite the challenges faced by all specialists in accurately assessing burn depth, South African burn specialists stood out by consistently providing the most accurate depth assessments, which are crucial when considering the need for surgery—a domain where burn specialists play a more prominent role.²⁹

The reliability and validity of using photographs to evaluate burn size and depth were also assessed by Hop et al. (2014) with participation from burn experts and referring physicians. Their results demonstrated that burn experts could reliably and validly assess burn size, whereas referring physicians could not. However, the photographic assessment of burn depth was found to be neither reliable nor valid for any of the surgeons. Furthermore, the indication for surgery could not be validly assessed based only on burn photographs, and alternative clinical elements might be needed.²³ The results of Hop et al. agree with the conclusions of our study, which found that assessing burn depth through photographs proved to be neither reliable nor valid, suggesting the potential need for alternative clinical elements.

These results reflect those of Wearn et al. (2018) who compared the accuracy of different methods (thermal imaging, laser Doppler imaging, photography, and clinical evaluation) for assessing burn depth in 16 burn patients. Four burn surgeons were shown digital photos of the burn areas on days 0 and 3, and they were asked to classify the areas as deep or superficial. Their study results demonstrate that photographic evaluation has significantly lower accuracy on days 0 and 3 compared to laser Doppler imaging and clinical evaluation.³¹

However, our outcome is contrary to that of Boissin et al. (2015), who studied patients with dark-skin types and achieved accurate diagnoses of burn size and depth in over two-thirds of the cases. In their study, patient characteristics influenced burn size diagnosis, but not burn depth. The Boissin’s study also revealed similar diagnoses of burn size and depth among South African burn surgeons and emergency care clinicians compared with emergency physicians and burn surgeons from other countries. Although South African clinicians achieved the highest accuracy in assessing burn depth, overall medical expertise and clinicians’ country of origin did not show statistically significant differences. This outcome can be attributed to the extensive pool of respondents and the diversity in their clinical backgrounds.²⁷ One possible explanation for the difference between two studies could be that the respondents in our study were limited to burn surgeons with nearly identical clinical backgrounds, potentially reducing the diversity. The accuracy of burn depth assessment in their results was similar to our study, but only in cases of superficial burns, whereas diagnosing deep partial-thickness burns proved to be particularly challenging.

In contrast to our findings Basaran et al. (2021) showed that burn image evaluation through WhatsApp and face-to-face examination resulted in agreement in terms of burn depth and percentage of TBSA. This differs from the findings presented here, which show a significant difference in assessing burn depth through image or clinical examination. The observed increase in agreement in their study could be attributed to limiting the sample to outpatient clinics and not including patients admitted to the emergency room.³⁰

Another important finding in our study was the underestimation of burn depth by surgeons which subsequently led to inadequate surgical intervention. Because of the variability in most burn injuries, early excision and grafting within one week postburn were uncommon practices, as they could lead to excessive excision. Live assessment studies have demonstrated that the validity of burn depth assessment is higher when conducted several days postburn, and this likely applies to photographic assessments of burn depth as well. Therefore, surgeons might have been hesitant to exclusively base their surgical intervention decisions on the initial photographic observation of the burn injury.^33,34 This issue may also have been partly caused by the difficulty of distinguishing between superficial-partial and deep-partial thickness burns, which is particularly challenging and crucial. Although agreement regarding the need for grafting would likely be higher in patients with larger burn sizes and larger full-thickness burns, accurately differentiating between these types of burns remains a critical issue in burn care.^11,35,36

Another finding that stands out from the results reported earlier is that work experience alone did not significantly impact the accuracy of burn depth estimation. However, in previous research that included both burn nurses and doctors, experience was considered an important determining factor.²⁴ This finding suggests that, in addition to work experience, other factors such as training and exposure to burn cases may also play a crucial role in the accurate detection of burn depth.

The most important result from this study was that telemedicine can be a useful tool for identifying superficial burns, as general surgeons and burn fellows demonstrated higher accuracy in diagnosis. However, for deep burns, plastic surgeons may be more accurate in providing diagnoses. Nevertheless, it should be noted that the accuracy of diagnosing deep burns from photographs is generally low and unreliable. In addition, it is important to know that decisions regarding conservative versus surgical treatment cannot be reliably evaluated using only photographs. Clinical assessment factors such as sensitivity, tissue retraction, hair adhesion, bleeding, or scarification may impact clinical diagnosis.

Conclusion

This study set out to evaluate the diagnostic accuracy of different types of burns among surgeons using standardized images. The findings suggest that while plastic surgeons demonstrate higher accuracy in diagnosing deep burns compared with general surgeons, the latter exhibit greater proficiency in identifying superficial burns. The second finding was that relying only on photographs to assess burn injuries does not provide sufficient information to determine the depth of the burn and make an informed decision on whether surgical intervention or conservative treatment is necessary. The research has also shown that the accuracy of burn depth assessment was not significantly affected by work experience. The current study is limited by the fact that it was restricted to partial-thickness burn ulcers, which can be challenging even for experienced clinicians. Further research using alternative telemedicine modalities, such as conducting live video consultations while physically examining the wound and assessing other relevant features, is recommended for future studies. This approach has the potential to lead to better outcomes in terms of assessing burn depth.

Confirmation Statement

All authors confirm that this research is supported by Shiraz University of Medical Sciences, an institution primarily involved in education and research.

Footnotes

Authors’ Contributions

H.S. and A.A.M. contributed to the study conception and design. Material preparation, data collection, and analysis were performed by H.S., F.S., and S.R. The first draft of the article was written by F.S. and H.S. All authors commented on previous versions of the article and read and approved the final article.

Author Disclosure Statement

The authors declare that they have no related conflicts of interest to this work.

Funding Information

The authors declare that there was no direct or indirect financial support by extramural sources for the study or related studies.

Abbreviations Used

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Telemedicine in Burn Care: Assessing Surgeons' Proficiency

Abstract

Background:

Method:

Results:

Conclusion:

Introduction

Material and Methods

Results

Discussion

Conclusion

Confirmation Statement

Footnotes

Authors’ Contributions

Author Disclosure Statement

Funding Information

Abbreviations Used

References