Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)

Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital

Document Title:
and Emergency Department (ED) Setting: EMS and Self-Presenting
Emergency Departments’ Arrivals
Document Ref.
Protocol/Burns/1.0 Version 1.0
Number:

Approval Date: 7 December 2017 Effective Date: 10 December 2017

Document
DOH Policy and Standards Department
Owner/Control

Applies to The entire healthcare sector of Abu Dhabi.

Document
Classification Public

Governing Theme Integrated Continuum of Care: Care Coordination

 Ambulance Clinical practice Guidelines 2015.

 HAAD Circular on Treatment of Emergency Cases For non UAE Nationals
Related Laws, (HSS-33/2007).
Policies,  HAAD Standard for Emergency Departments In the Emirate of Abu
Standards, Dhabi
Circulars,  HAAD Standard for Minimum Preparedness for Common Medical
Guidelines Emergencies In Inpatient Care Setting, Outpatient Care Setting,
Ambulance Services and Interfacility Patient Transfer
(HAAD/EMS/SD/0.9)

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

Contents

ABBREVIATIONS .................................................................................................................... 4
1. Introduction................................................................................................................... 5
2. Main Objective .............................................................................................................. 5
3. Sub-Objectives ............................................................................................................... 5
4. Scope ............................................................................................................................. 5
5. Definitions ..................................................................................................................... 6
6. Triage for EMS-Driven Burns Emergencies ..................................................................... 7
7. Triage for Self-Presenting Burns Cases ........................................................................... 7
8. Enforcement and Compliance ...................................................................................... 9
9. Appendices ................................................................................................................. 10

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

ABOUT DEPARTMENT OF HEALTH ABU DHABI (DOH)

The Department of Health (DOH) previously known as the Health Authority Abu Dhabi
(HAAD) is the regulative body of the Health System in the Emirate of Abu Dhabi and seeks
excellence in Health for the community by regulating and monitoring the health status of
the population. DOH shapes the regulatory framework for the health system, inspects
against regulations, enforces regulations, and encourages the adoption of best practices
and performance targets by all health service providers. DOH also drives programmes to
increase awareness and adoption of healthy living standards among the residents of the
Emirate of Abu Dhabi in addition to regulating scope of services, premiums and
reimbursement rates of the health system in the Emirate of Abu Dhabi.
The Health System of the Emirate of Abu Dhabi is comprehensive, encompasses the full
spectrum of health services and is accessible to all residents of Abu Dhabi. The health
system encompasses, providers, professionals, patients, insurers and the regulator.
Providers of health services include public and private services and the system is financed
through mandatory health insurance (with the exception to Thiqa) and has three main
sources of financing: Employers or Sponsors, the Government and Individuals. The Health
Insurance scheme places responsibilities on any Insurer, Broker, Third Party Administrator,
Health Provider, Employer, Sponsor (including educational establishments), Limited Income
Investors and Insured Persons to participate in the Health Insurance Scheme.

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

ABBREVIATIONS
 CASMEET: The necessary information and reporting mechanism that EMS or ED staff are
required follow in order to pass concise and reliable information to the receiving
facilities (see Appendix 4 for details).
 ED: Emergency Department.
 EMS: Emergency Medical Services.
 ESL1: Emergency Severity Level 1.
 TBSA: Total Body Surface Area.

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

1. Introduction
One of the priorities of the Department of Health (DOH) is to achieve an integrated patient-
centric model of care, where the right care of time critical emergencies is coordinated and
delivered in the right place, by the right expertise, at the right time without interruption,
unless clinically justified, and irrespective of healthcare insurance coverage.

This Protocol focuses on burns emergencies and seeks to ensure that:

• No burns emergency case is rejected irrespective of healthcare insurance coverage.

• EMS take burns emergency cases to a facility capable of dealing with the specific
type and level of emergency.
• Facilities that are not designated to dealing with the specific type and level of self-
presented burns emergencies transfer patients to designated facilities as quickly as
possible.
• EDs designated to dealing with the specific type and level of self-presented
emergencies keep and treat them.

This protocol was developed in consultation with the DOH (previously HAAD) - led Burns
Taskforce, under the Multi-stakeholder platform to drive integration of care. For a list of
member organisation and their representatives, refer to Appendix 1.

2. Main Objective
The main objective of this document is to define the triage process that EMS and healthcare
facilities must follow for burns emergencies for both EMS-driven and self-presenting arrivals.

3. Sub-Objectives
The above objective is achieved through the fulfilment of the following sub-objectives:

3.1 Define Burns and Wounds Assessment Criteria applied by EDs, to govern burn
patients’ flow to the appropriate level of care ( Appendix 2).
3.2 Define Burns Unit admission criteria ( Appendix 3).
3.3 Define Paediatric Emergency Service admission criteria for burns ( Appendix 3).
3.4 Specify the required data and reporting mechanism to be followed when
conveying patient information to the receiving facility ( Appendix 4).
3.5 List of designation criteria for Specialised Burn Services ( Appendix 5).
3.6 List of currently designated facilities with Specialised Burn Services ( Appendix 6).

4. Scope
This Protocol applies to all healthcare facilities within the Emirate of Abu Dhabi and
Emergency Medical Services.

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

5. Definitions
5.1 Specialised Burn Services: Burns Centres and Burns Units.
5.2 Burns Centres: a facility that cares for the highest level of injury complexity and
offers a separately staffed, geographically discrete ward. The facility is skilled to the
ICU level of critical care and has immediate operating theatre access.1
5.3 Burns Unit: a facility that deals with the moderate level of injury complexity, with
its separately staffed, discrete ward. These facilities are up to the HDU level of
critical care and operating theatre access suitable for the case mix
5.4 Emergency Department (ED): every facility that complies with DOH’s definition as
per HAAD’s Standard for Emergency Departments.2
5.5 Emergency Medical Services: ambulances deployed though the emergency
number 999.
5.6 First-degree burn: superficial burn.
5.7 Second-degree burn (2a): partial thickness/dermal burn.
5.8 Second-degree burn (2b): deep dermal burn.
5.9 Third-degree burn: full thickness of burn affecting 40% TBSA or more.
5.10 Paediatric Emergency Services: any ED that can deal with ESL1 paediatric
emergencies.3
5.11 Urgent Care Centre: every facility that complies with DOH’s definition as per
HAAD’s Standard for Emergency Departments.4

1
At the time of publication of this Protocol, there were no facilities in Abu Dhabi that meet the Burn Centre
designation Criteria.
2
HAAD Standard for Emergency Departments in the Emirate of Abu Dhabi (2017).
3 For details, refer to HAAD’s “Triage Protocol for Paediatric emergencies and their Referrals in Pre-Hospital
and Emergency Department (ED) Setting: EMS and Self-Presenting Emergency Departments’ Arrivals.
4
Ibid.

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

6. Triage for EMS-Driven Burns Emergencies

EMS conduct triage as per Ambulance Field Triage Criteria5 to establish the type of burn
injuries and the necessary level of care. Irrespective of burn type, all burns emergencies
will be first transported to the closest ED to be stabilised:

6.1 EMS contact the closest ED to alert them about the incoming emergency.
6.2 EMS communicate the patient’s data to the closest ED as per CASMEET (Appendix
4).
The receiving facility should assess patients for potential transfer to the Burns Unit (
Appendix 3). Those who need to be admitted to a designated facility with specialised
burns services will be transferred after stabilisation.

6.3 The referring ED should contact the closest designated Burns Unit to alert them
about the incoming burns emergency:
6.4 Time limit: interfacility transfer must be carried out by an ambulance (either
internal or external) that complies with DOH’s (previously HAAD’s) relevant
Standard6 within four hours of emergency arrival to the ED.
6.5 Unconditional acceptance: the receiving designated Burns Unit will accept the
patient irrespective of bed availability or insurance cover.
6.6 Data exchange: the referring ED carries out a clinical handover to the designated
Burns Unit to exchange all the necessary data (Appendix 4).
6.7 Ambulance Transfer: interfacility transfer must be carried out with an ambulance
service that complies with HAAD’s Ambulance related Standard.7

7. Triage for Self-Presenting Burns Cases

Any self-presenting patient with burns that arrives to any Urgent Care Centre or ED will
be stabilised using the respective facility burns protocol regardless of the severity of the
burn:

7.1 Self-presenting patients who need to be admitted to a Burns Unit ( Appendix 3) will
be transferred after stabilisation.
7.2 The referring Urgent Care Centre or ED should contact the closest designated Burns
Unit to alert them about the incoming burns emergency:
 Ambulance Transfer: inter-facility transfer must be carried out with an
ambulance service that complies with HAAD’s Ambulance related Standard.8
 Data exchange: the referring Urgent Care Centre or ED carries out a clinical
handover to the Burns Unit to exchange all the necessary data (Appendix 4).

5
As per Ambulance Clinical practice Guidelines 2015
6
HAAD Standard for Minimum Preparedness for Common Medical Emergencies In Inpatient Care Setting,
Outpatient Care Setting, Ambulance Services and Interfacility Patient Transfer
7
Ibid.
8
Ibid.

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

 Time limit: interfacility transfer must be carried out by an ambulance (either

internal or external) that complies with DOH’s (previously HAAD’s) relevant
Standard9 within four hours of emergency arrival to the ED.
 Unconditional acceptance: The receiving Burns Unit will accept the patient
irrespective of bed availability or insurance cover.10

9
Ibid.
10
HAAD Circular on Treatment of Emergency Cases For non UAE Nationals (HSS-33/2007).

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

8. Enforcement and Compliance

DOH will enforce the compliance of all concerned stakeholders with this Protocol to ensure
that:
• No burns emergency case is rejected irrespective of healthcare insurance coverage.
• EMS take burns emergency cases to a facility capable of dealing with the specific
type and level of emergency.
• Facilities that are not designated to dealing with the specific type and level of self-
presented burns emergencies transfer patients to designated facilities as quickly as
possible.
• EDs designated to dealing with the specific type and level of self-presented
emergencies keep and treat them.

DOH may impose sanctions in relation to any breach of requirements under this Protocol
in accordance with Chapter IX, HAAD Policy on Complaints, Investigations, Regulatory
Action and Sanctions, The Healthcare Regulator Policy Manual Version 1.0.

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

9. Appendices
9.1 Appendix 1
Burns Task Force Members and Experts
Member Organisation
Dr. Maitha Al Darei Abu Dhabi Police Ambulance
Khaled Mohammed Al Kaabi Abu Dhabi Police Ambulance
Mahmoud Mohammed Al Baloushi Abu Dhabi Police Ambulance
Mohammed Naser Al Bahri Abu Dhabi Police Ambulance
Dr. Mazin Alsaidi ADNOC
Bunna Eng Tusitala Al Mafraq Hospital
Dr Zaka Khan Al Noor Hospital
Dr. Fawad Khan Al Noor Hospital
Dr. Charles F Stanford Burjeel Hospital (VPS)
Dr. Howard S. Podolsky Cambridge Medical and Rehabilitation Centre
Jose Lopez Cleveland Clinic Abu Dhabi (CCAD)
Dr. Hatem Abueida Daman
Dr. Wafa Al Mahri Daman
Mr. Mohammed Abu Jubara Daman
Dr Muqdad Al Hammadi Al Mafraq Hospital
Dr. Ayman Adel Ahmad National Ambulance
Michelle Navalta National Ambulance
Dr. Merezban Katrak NMC Hospital
Ruth Taylor SEHA Corporate
Dr. Saleh Fares Zayed Military Hospital

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

9.2 Appendix 2
Burns Assessment Criteria to be applied by ED
√ Yes
Assessment Findings Initial
X No
Primary Survey
A: Airway Maintenance with Cervical Spine Control
B: Breathing and Ventilation
- Administer 100% Oxygen
- Expose the chest and ensure chest expansion is
adequate and bilaterally equal – consider
escharotomy in full thickness chest burns
- Consider early intubation in signs of inhalation
injury
- Record Respiratory Rate and SPO2
C: Circulation with Hemorrhage Control
- Inspect for obvious signs of bleeding
- Monitor and record peripheral pulses for rate,
strength (strong/weak) and rhythm in all burned
limbs
- Assess capillary refill
- Record Heart Rate and Blood Pressure
- Monitor circulation of peripheries if a
circumferential burn is present
- Elevate limb
- - Consider escharotomy for patients with
compromised circulation in circumferential burns
D: Disability: Neurological Status
- Evaluate level of consciousness:
- A – Alert
- V – Response to Vocal stimuli
- P – Responds to Painful stimuli
- U – Unresponsive
- Examine pupils response to light for reaction and
size
- - Assess for restlessness and altered level of
consciousness, which can indicate hypoxemia /
Carbon Monoxide Poisoning
E: Exposure with Environmental Control
- Remove all clothing and jewelry near burned areas
- Provide Burn First Aid: cool burn with tepid water
for half hour, apply cling wrap/sterile non-
adherent dressing
- Keep patient warm (minimum room temp 24°C)
- - Record patients temperature
F: Fluid Resuscitation

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

√ Yes
Assessment Findings Initial
X No
- Fluid resuscitation is required for paediatric burns
of ≥10% and
- Adult burns of ≥15%
- Estimate total body surface area burned,
according to guideline
- Insert 2 large bore (16-18 gauge) peripheral IV
Cannulas preferably through unburned tissue
(avoid burned tissue if possible)
- Collect bloods simultaneously for essential base
line bloods: CBC, Electrolytes, PT PTT, cross match-
for every major burn patient
- Obtain patients’ body weight in kilograms

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

Burns Wound Assessment (First, Second or Third Degree) to be applied by ED

REGION % PT FT
Head:
Neck:
Ant. Trunk:
Post. Trunk:
Right Arm:
Left Arm:
Buttocks:
Genitalia:
Right Leg:
Left Leg

PARKLAND FORMULA FLUID

CALCULATION:
Time of Burn:
Time of Arrival:
Weight (Kgs):
Total % Burn:
4mls/Kg X Percentage Burn
Fluid Volume
1st 8 hours:
Maintenance Fluid:
Fluid Volume
Next 16 hours:
Maintenance Fluid:
REGION
RELATIVE PERCENTAGE OF BODY SURFACE AREA AFFECTED BY GROWTH
AREA AGE 0 1 5 10 15 ADULT
A = 1/2 of Head 9 1/2 8 1/2 6 1/2 5 1/2 4 1/2 3 1/2
B = 1/2 of One 2 3/4 3 1/4 4 4 1/4 4 1/2 4 3/4
Thigh
C = 1/2 of One 2 1/2 2 1/2 2 3/4 3 3 1/4 3 1/2
Leg
Children less than 30Kg require maintenance fluids in addition to resuscitation fluid. The
infusion rate shall be guided by the urine output, not by the formula.

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

Burn Wound Depth Assessment Table

DEPTH COLOUR BLISTERS CAPILLARY REFILL SENSATION HEALING
First degree Red No Present Present Yes
(Superficial)
Second degree Pale Pink Small Present Painful Yes, 7-
(2a) (Partial 10 days
Thickness/
Dermal Burn)
Second degree Blotchy +/- Absent Absent Prolonge
(2b) (Deep Red d
Dermal)
Third degree White No Absent Absent No
(Full Thickness)

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

9.3 Appendix 3
Burns Unit Admission Criteria

 All patients with circumferential burns involving extremities or chest.

 All patients with partial thickness burns sustained to special areas like the face, ears,
neck, genitalia, perineum, hands and feet.
 Patients with a burn injury of Full Thickness affecting more than 1% TBSA.
 All patients with a Chemical / Electrical burn.
 All patients with a burn associated inhalation injury.
 All burn injury patients with a pre-existing medical disorder which could complicate
the management of the injury and prolong recovery e.g. diabetes.
 Any burn injury with concomitant trauma whereby the burn injury poses the
greatest risk of morbidity and mortality.
 Patient’s that require specialised wound care resulting from specific skin diseases
can request consultation through the head of Plastic Surgery or Consultant on Call.
Should a patient require admission to the Burn Unit this will be at the discretion of
the Consultant and Burn Unit Manager.

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

9.4 Appendix 4

CASMEET: The necessary information and reporting mechanism that EMS or ED staff are
required follow in order to pass concise and reliable information to the receiving facilities
(CASMEET).
 C – Call sign and CAD number
 A – Age of patient
 S – Sex of patient
 M– Mechanism of Injury or Mode of illness
 E – Examination, AVPU / GCS, RR, HR, BP & SPO2 (where possible)
 E – Estimated time of arrival
 T – Treatment given
 Trauma Level if available.

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

9.5 Appendix 5
Designation Criteria of Specialised Burn Services

Burn Centre: Such facility cares for the highest level of injury complexity and offers a
separately staffed, geographically discrete ward. The facility is skilled to the ICU level of
critical care and has immediate operating theatre access:
 Designated standalone ward for paediatric or adult admissions
 Cubicle accommodation with environment control
 Designated burns nursing and other health professionals with training and
experience
 Immediate access to a dedicated burn theatre (<25 metres)
 Educated burn anaesthetic input with nominated lead consultant
 Intensive care provided by intensivists in BC critical care beds OR in a suitably
equipped, adjacent (<50 metres) ICU or PICU
 Consultant burn surgeon on-call rota
 Full range of support services and specialties
 Care provision for complex, large skin area injuries

Burn Unit: This facility deals with the moderate to severe level of injury complexity, with its
separately staffed, discrete ward. These facilities are up to the HDU level of critical care
and operating theatre access suitable for the case mix:
 Designated stand-alone ward for paediatrics OR adult admissions
 Cubicle accommodation of adequate size
 Designated burns nursing and other health professionals with training and
experience
 Access to operating theater (<50 metres) with fixed burn lists each week
 Intensive care access as for any surgical patient either paediatric or adult
 Plastic surgeon on-call rota
 Single, named consultant lead for the burn service
 General hospital level support services and specialties
 Care provision for complex, small skin area injuries

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Triage Protocol for Burns Emergencies and their Referrals in Pre-Hospital and Emergency Department (ED)
Setting: EMS and Self-Presenting Emergency Departments’ Arrivals

9.6 Appendix 6
List of Currently Designated Facilities with Specialised Burns Services
Burns Centres None at the time of publishing
Burns Units Mafraq Hospital

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