burns 38 (2012) 438–443

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Are parents in the UK equipped to provide adequate burns first aid? Hamish E. Graham a,*, Sarah E. Bache a,b, Preetha Muthayya a,b, Julie Baker b, David R. Ralston a,b a b

Department of Burns and Plastic Surgery, Northern General Hospital, Herries Road, Sheffield, South Yorkshire, S5 7AU, United Kingdom Burns Unit, Sheffield Children’s Hospital, Western Bank, Sheffield, South Yorkshire, S10 2TH, United Kingdom

article info

abstract

Article history:

Aim: Simple first aid following a burn injury has been shown to improve outcome. With this in

Received 28 February 2011

mind, a prospective study was conducted to evaluate the knowledge of burns first aid amongst

Received in revised form

parents in South Yorkshire, United Kingdom. This information was used to identify which

25 August 2011

aspects of burn first aid need to be highlighted in an education campaign and who the target

Accepted 25 August 2011

audience should be. A simple mnemonic is suggested to assist parental education on the topic. Methods: Parents attending outpatient clinics at Sheffield Children’s Hospital were interviewed and asked about the first aid they would provide for a child with a large scald.

Keywords:

Removal of hot clothes and jewellery; application of cold water for 10–20 min; obtaining

Burns

medical advice; and covering the burn with a plastic film or clean cloth were all considered

Scalds

to be ideal responses. Variations in responses in relation to the age and ethnicity of the

Thermal injury

parent were noted.

First aid

Results: One hundred and eighty eight parents were included in the questionnaire. Of these,

Pre-hospital care

81% (n = 152) were white British and 20% (n = 36) were from other ethnic groups. Only 10%

Public health

(n = 18) of all respondent would give all the ideal first aid steps. Less than 40% (n = 73) of parents

Patient education

questioned would remove hot clothes and jewellery. There was no significant difference in

Emergency care

responses between ethnic groups when assessing knowledge of the need to remove hot

Wounds

soaked clothing. Although 73% (n = 137) of parents would run the burn under cool water, only

Injuries

35% (n = 66) would cool the burn for an adequate length of time. White British parents were

Thermal

significantly more likely to run cool water over the burn, and to continue this for the

Water

recommended 10–20 min. Whilst 88% (n = 165) of parents would seek medical attention, this

Cold

was significantly less in parents under 20 years old. Finally, 92% (n = 173) of parents would

Cooling

protect the wound with appropriate dressings, but of note, 26% (n = 9) of parents from minority

Dressing

ethnic groups would potentially impair burn healing by using inappropriate dressings and topical agents including butter, milk, cooking oil and toothpaste. Conclusions: The questionnaire findings highlighted the need for improved parental awareness of burns first aid. This was across all ethnic groups and ages questioned. In particular, knowledge of appropriate cooling times and the use of inappropriate dressings were highlighted as areas for concern. Ideal burns first aid measures were summarised with the mnemonic STOP–Strip clothes, turn on the tap for 10 min, organise help, put on plastic film. This mnemonic is to be used in a pilot educational campaign in the Sheffield area, with possible expansion nationwide. # 2011 Elsevier Ltd and ISBI. All rights reserved.

* Corresponding author: Tel.: +44 7779871938. E-mail address: [email protected] (H.E. Graham). 0305-4179/$36.00 # 2011 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2011.08.016

burns 38 (2012) 438–443

1.

Background

First aid is the emergency care given before regular medical aid can be obtained [1]. People without formal medical training and with scarce resources will often be required to practice first aid. Whilst administering first aid, the care provider may face significant psychological and environmental stress. Therefore, any intervention should be simple, effective, universally accessible and taught in a memorable, logical sequence. First aid should not hinder later wound assessment or management [2]. Burn first aid advice varies between nations and between organisations within the same nation [3– 6], leading to confusion amongst the public [7]. Cultural beliefs and superstition may contribute to further confusion. In clinical practice, lack of clarity and knowledge of burns first aid in the community results in children presenting with toothpaste and other domestic products applied to their burns [8,9]. It has been well established that burn first aid awareness is poor internationally [10–14]. However, education programmes have been shown to improve compliance [15]. To date, there has been no stepwise analysis examining which specific areas of burn first aid people have difficulty with and whether that differs amongst ethnicities within the same country. The Sheffield Childrens’ Hospital Burns Unit (SCHBU), located in Sheffield, South Yorkshire, United Kingdom (UK), provides care for any child with burns up to 30% Total Body Surface Area (TBSA). Alongside other units in the region, SCHBU serves a population of 5.3 million in the Yorkshire and Humber area (population 5.3 million, 18.5% under 16 years [16]). It was noted that a minority of patients arriving at the unit had received optimal community based first aid. In particular, there was a widely held belief in certain communities that applying water to the burn was wrong. This belief, and the use of inappropriate topical agents, appeared to be more common among ethnic minority groups. Hot clothes were often removed only following the arrival of paramedics. The burns unit runs a comprehensive education package for patients and relatives of patients. This covers burn prevention, first aid and post injury support. Those running the courses also reported very poor levels of baseline first aid knowledge amongst participants. There has been evidence to suggest some UK burn centres see a disproportionately high number of patients from minority ethnic groups, particularly of Asian origin [17]. This finding has been disputed by a number of authors previously [18,19] and the question has yet to be answered definitively. Burns amongst some UK ethnic minorities have been suggested to have a different pattern of causation [9]. Poor general burn first aid amongst British Asian burn victims has been observed in previous studies [9,17]. No recent studies have defined evidence based first aid criteria and analysed their knowledge by ethnic groups within the same community. Over 91% of Sheffield residents describe themselves as white [16]. The majority of the remaining people describe themselves as Asian (approximately 5%) with Chinese, Black and mixed ethnicities making up the remainder equally [16].

439

It was believed that a widespread education campaign might benefit parents and children in the area. The current study was designed to identify the level of burn first aid knowledge across parents in South Yorkshire. Secondary aims were to examine differences in first aid knowledge between different ages and ethnic groups. This paper describes a prospective questionnaire of parents in South Yorkshire and highlights the paucity of burns first aid awareness amongst the public in general. A lack of good burn first aid knowledge amongst UK ethnic minorities is highlighted. An evidence based teaching mnemonic for English speaking groups is suggested as a tool to improve understanding amongst parents. Translated material is presented to help address the generally poor burn first aid amongst all UK parents, including resident ethnic minorities (Figs. 1 and 2).

2.

Methods

2.1.

Participants

Parents in the waiting room of Sheffield Children’s Hospital outpatient department were approached between January 2009 and April 2009 and asked to complete a structured interview on burns first aid. Parents attending the burn clinic, or whose child had previously been treated on a burn unit were excluded from the study.

2.2.

Demographics

Parents who agreed to take part in the study were asked to state their age group (<20 years, 20–30 years, 31–40 years, and >40 years); their ethnic origin; and whether or not they were born in the UK.

2.3.

Scripted scenario

The same data collector read aloud a scripted scenario, which described finding a 2-year-old child, who had just pulled a saucepan of boiling water over himself. It was made clear the child sustained a large scald. Parents were then asked to write or say (if unable to write English) the first three things they would do on discovering the child. For additional clarification they were then asked to complete a second page with specific questions on whether they would remove clothing; put anything on the burn; and if they would, what they would use and for how long. The scenario and questionnaire were designed by the authors after a review of evidence in literature [2,20–25] and agreement by the authors on what ideal burns first aid should be. This was put before a local ethics committee who amended and approved the questionnaires before allowing them to be used in the hospital waiting areas. Questionnaires were anonymous and no responder identifying features were collected. Answers were compared to first aid standards set following a review of the available literature, namely: 1) Remove hot clothes and jewellery [2,20,23,24] 2) Run under cold water for 10–20 min or until discussed with emergency medical service [21,23,24]

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burns 38 (2012) 438–443

3) Seek help from healthcare professionals [23,24] 4) Dress the wound with plastic food wrap or clean cloth [22,23,24]. This was later summarised by the STOP mnemonic–Strip clothes, turn on the tap for 10 min, organise help, put on some plastic film, for educational purposes.

2.4.

White British Other Total

Age <20

20–30

31–40

>40

Total

3 2 5

28 8 36

73 19 92

48 6 54

152 35 187

Data analysis

The data were entered into Microsoft Excel and one-tailed chisquared tests were used to compare groups for statistically significant differences. Statistical testing was carried out at the 5% significance level ( p < 0.05). The minority ethnic groups in the sample were grouped together to improve the reliability of statistical analysis. Due to the small sample size, detailed analysis by age within ethnic groups was not undertaken.

3.

Results

3.1.

Demographics

difference in the rates of compliance with the complete package STOP principles (11%) when compared to the other ethnicities (3%) ( p = 0.05). Compliance rates were also similar across all ages (20% <20 years, 3% 20–30 years, 5% 31–40 years, 17% >40 years) ( p = 0.05).

3.3.

Stripping clothes

Over 60% (114/188) of all respondents failed to mention that they would remove the child’s clothes following a scald. There was no difference in the rates of stripping hot soaked clothes between the different ethnicities or age groups questioned ( p = 0.05).

One hundred and eighty nine parents responded. One parent did not state their age or ethnicity: they were therefore excluded from all further analysis (n = 188). One further parent did not specify their age: they were therefore excluded from any further analysis by age (n = 187 for analysis by age). The modal age range was 30–40 years. One hundred and fifty-two parents (80%) were white British. Thirty-six parents (20%) from thirteen other ethnic groups also responded. There was no significant difference in age between the groups surveyed ( p < 0.05). Results of demographic data are summarised in Table 1.

3.2.

Table 1 – Demographic data for parents who completed the questionnaire, divided into age groups and ethnicity (white British vs. other ethnic groups).

Application of full STOP package

Results for all questions are summarised in Table 2. Only 10% (18/188) of all respondents would strip clothing, turn on the tap, organise help and put on appropriate dressings (i.e. apply the full STOP package). White British respondents showed no

3.4.

Turning on the cool water

It was shown that although 73% (137/188) of parents questioned stated that they would cool the burn under running water, significant differences were demonstrated between white British and other ethnicity parents. White British parents were significantly more likely to state that they would cool the burn under running water than parents (76%) from other ethnicities (58%) ( p = 0.05). When comparing knowledge of the correct duration (10–20 min) of cooling, White British parents were again significantly more likely to cool for an adequate length of time (39%) than parents of other ethnicities (19%) ( p = 0.05). Of note, although white parents were in general more likely to cool for the correct 10–20 min, if parents who cooled using incorrect methods (e.g. direct application of ice) were excluded, no significant difference between both ethnic groups was found (39% of White respondents vs. 19% of Other Ethnicities

Table 2 – Summary of correct results given by all parents, and divided into age and ethnic groups. Ethnic group

Total

White Other Total

152 (81%) 36 (19%) 188

Full STOP package of care

Strip clothes

Turn on cold tap (any duration)

Run cold water greater than 10 min

Organise help

Protect wound according to STOP

17 (11%) 1 (3%) 18 (10%)

59 (39%) 14 (19%) 73 (39%)

116 (76%) 21 (58%) 137 (73%)

59 (39%) 7 (19%) 66 (35%)

133 (88%) 32 (89%) 165 (88%)

147 (97%) 26 (72%) 173 (92%)

Age

Total

Full STOP package of care

Strip clothes

Turn on cold tap (any duration)

Run cold water greater than 10 min

Organise help

Protect wound according to STOP

<20 20–30 31–40 >40 Total

5 36 92 54 187a

1 (20%) 3 (8%) 5 (5%) 9 (17%) 18 (10%)

3 (60%) 14 (39%) 38 (41%) 18 (33%) 73 (39%)

4 (80%) 25 (69%) 62 (67%) 46 (85%) 137 (73%)

2 (40%) 11(31%) 28(30%) 25(46%) 66 (35%)

2 (40%) 34 (94%) 80 (87%) 48 (89%) 164 (88%)

3 (60%) 34 (94%) 82 (89%) 54 (100%) 173

a

One parent did not specify their age, they were therefore excluded from any further analysis by age (n = 187 for analysis by age).

burns 38 (2012) 438–443

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Fig. 1 – Summary poster for Burn First Aid including, from left to right, translations into Somali, Urdu and Arabic.

Fig. 2 – Summary poster for Burn First Aid including, from left to right, translations into Punjabi, Polish and Slovak.

p = 0.05). In other words those ethnic minority parents who knew to cool a burn with running water and not ice were just as likely to know the correct duration as their white British counterparts. No difference between duration of cooling was shown across different age groups (<20 years 33%, 20–30 years 31%, 30–40 years 30%, >40 years 46% p = 0.05).

were suggested by ethnic minority parents (27% White respondents 42% of Other Ethnicities) ( p = 0.01). Inappropriate answers included butter, milk, antiseptic or other creams, ointment, cooking oil and toothpaste.

3.5.

Discussion

Organising help

Eighty eight percent (165/188) of parents stated that they would seek medical help. No difference was shown between different ethnic groups (88% of White respondents vs. 89% of Other Ethnicities p = 0.05). Statistically significant differences between age groups and likelihood of seeking medical assistance were demonstrated (<20 years 40%, 20–30 years 94%, 30–40 years 89%, >40 years 100% p = 0.05) with the under20 year age group being less likely to state that they would seek assistance.

3.6.

4.

Protecting the burn with plastic cover or clean sheet

Although (92%) 173/188 of parents overall stated they would cover the burn with a clean dry cloth or plastic film, there was a significant difference between ethnic groups. Significantly greater rates of application of inappropriate topical agents

This study was carried out following a series of admissions where scalded children were kept in their hot soaked clothes and were not cooled properly while awaiting paramedics. There is a significant body of literature on burn care following hospital admission, examining dressings, surgery, nutrition, outcome and medical management. There have also been notable improvements in burn prevention in the community, following campaigns for flame retardant furniture and clothing [7], capped temperature water thermostats [26] and accident prevention and awareness education programmes [26,27]. In contrast, burn first aid has not been significantly developed since the famous ‘‘Stop, Drop and Roll’’ television campaign of the 1970s. Furthermore, poor burn first aid care is a serious global concern [10,14,15,20,27,28] particularly in lower- and middle-income countries [10,29]. In more developed countries the cost of minor scalds in children is conservatively estimated at between £1500 [30] and £4000

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burns 38 (2012) 438–443

[31] per case. This poses a significant socioeconomic burden to communities. The standards set for community burn first aid were a balance between the most recent evidence suggesting that 20 min cooling may be more efficacious than 10 min and the need to avoid hypothermia in children and to get help early. It is hoped that in the UK, from 10 min, the responder would be able to be guided by the emergency services over the phone or in person. In the current study, 90% of parents surveyed did not think of all the steps to burns first aid. This was despite being in a comparatively calm setting with time to think. Particularly concerning was the lack of knowledge that clothes should be stripped, with 61% of parents omitting to state that they would do this. Several parents remarked that they thought that this would further damage the skin. Whilst others would apply inappropriate domestic products. These findings are similar to previous studies in the UK and abroad [9,11–14,17,20,32]. Although parents were more aware of the need to cool the burn this was often vague. Seventy percent of parents questioned stated that they would leave the child under the cold water for inappropriate lengths of time. While shorter times may lead to unnecessary burn advancement, at the other end of the spectrum, some parents would risk hypothermia, having stated they would cool for up to an hour. Rates of cooling with tap water were significantly lower amongst ethnic minority groups: over 40% would use ice or not cool at all. Less than 20% of ethnic minority respondents would turn on the tap and cool for 10–20 min. This highlights the need to emphasise this stage in first aid particularly among these groups. Parents under 20 years would organise medical help less frequently than other age groups in this survey. Due to the small sample size, although statistically significant, this would need further data or compelling arguments to support singling out the parents less than 20 years for education. In all other aspects of the STOP package, there was found to be no difference between the answers given by different age groups. When considering target groups for education, it is worth bearing in mind that scalds are a common injury in preschool children and they commonly occur in the house [26]. New mothers are most likely to be 25–34 years old, although, 25% of births are to mothers under 25 years of age [33]. By working with prenatal services, health visitors, sure start and the agencies that deliver compulsory first aid training for registered child carers (e.g. St. John’s Ambulance) the parents of the most frequently scalded demographic could be educated. Almost 30% of ethnic minority respondents would have dressed the wound using household products other than plastic food wrap or a clean cloth. Suggested dressings ranged from using cocktails including water, milk and washing up liquid together, through to, applying toothpaste or petroleum jelly alone. This was significantly different to the eight percent of white British responses who would have used inappropriate dressings. Delivering health protection advice with general medical practitioners and asylum seeker medical services in South Yorkshire could help reduce the incidence of inappropriate burn dressing amongst ethnic minorities.

Several limitations of the current study are acknowledged. By selecting parents in hospital waiting rooms the sampling may have introduced some bias. The parents would have been a self-selecting group who were aware of and able to access local children’s hospital services. Furthermore, parents were able to think more clearly and more logically in a relatively calm waiting room than in the stressful environment portrayed in the scenario. It can be argued that the lack of visual triggers in the questionnaire reduced the accuracy of the results. For instance seeing the hot soaked clothes parents may intuitively remove them. However, the data collected reflects pre-hospital first aid practices seen in burnt children at our unit. Children arriving at the emergency department still in burnt or hot soaked clothes are not uncommon. This is possibly because stripping jewellery and clothing is not prioritised when giving burns first aid advice. Removal of jewellery and clothes is the fifth piece of advice given on the Red Cross guide to burns first aid [34] and the fourth on the St John’s Ambulance website [6]. A number of parents stated they would not remove clothes for fear of damaging the burnt skin. Excluding those parents with significant experience of burns may have excluded some of the most burn care aware parents. It is standard practice in SCHBU to educate all parents whose children present to the unit on burn prevention and first aid. The level of burns first aid education parents had received was not explored for the purposes of this study. This would be difficult to quantify without asking personal questions, which did not receive ethics committee approval. This study is the first prospective study of burns first aid knowledge among parents who have no previous contact with a burns service. It shows that poor burn first aid knowledge is prevalent among the community in general, throughout age groups and across ethnicities. The results of this paper will be passed onto the main first aid providers locally through British Red Cross, St. John’s ambulance and the local council. Groups not anticipated to attend first aid training will also be targeted via community health care teams. The STOP educational campaign designed from these findings highlights each of the four evidence-based steps in good burn first aid. A pilot of the STOP education campaign is planned in Sheffield, with possible expansion across Britain if it is found to be helpful. A further analysis of different ethnic groups may be useful in order to target specific groups for education. A more widespread investigation of these issues would enable comment on whether this is a national or regional problem.

5.

Conclusions

Less than 10% of parents questioned would treat a serious scald in a 2-year-old by stripping their clothes, turning on the tap for 10 min, organising help and putting on a plastic film dressing. Appropriate burn cooling and dressing are a particular problem amongst ethnic minority parents in Yorkshire. The STOP mnemonic may be a useful aid to help with the education of parents, and will be used in a pilot educational campaign in the local area, with possible expansion nationwide.

burns 38 (2012) 438–443

Acknowledgements We would like to thank Brigitte Garcia de Jager, Statistics Tutor, Maths and Statistics Help (MASH), Learning and Teaching Services, University of Sheffield, The Octagon Centre M15-17, Western Bank, Sheffield S10 2TQ, United Kingdom (Tel.: +44 0114 222 1745) for the statistical support. http://web.anglia.ac.uk/numbers/index.html. Bio measurement Calculation Sheet by Toby Carter & Dawn Hawkins (www.biomeasurement.net).

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