Summary Article

Clinical Guidelines in the Management of Burn

Injury: A Review and Recommendations From the
Organization and Delivery of Burn Care Committee
Kevin Foster, MD, MBA

DEFINITION AND PURPOSE OF have access to a plethora of electronic information.

CLINICAL GUIDELINES As such, they often have opinions and expectations
based on this electronic access. These expectations
A clinical guideline (CG) is best defined as “sys- may or may not be reasonable depending upon the
tematically developed statements to assist health clinical situation. CGs provide appropriate informa-
care professional and patient decision making tion to patients and families, assisting in tempering
about appropriate health care for specific clinical reasonable expectations for care. Likewise, CGs pro-
circumstances.”1 vide support for clinicians when discussing clinical
A closer examination of this definition is warranted. care with patients and their families.
CGs are “systemically developed.” The statements Finally, CGs provide support for “appropriate
and recommendations within a CG must be evidence health care for specific clinical circumstances.” CGs
based. Evidence-based statements are derived from are not meant to be global or general statements
appropriately conducted and well-analyzed studies regarding clinical care. Rather, CGs provide infor-
demonstrating improved clinical outcomes for par- mation for very specific clinical situations.
ticular interventions. The evidence-based statements As crucial as it is to understand the purpose of
in CGs are obtained from a comprehensive search CGs, it is also important to understand what CGs
of the available literature, classification of this litera- are not meant to do. CGs are not meant to replace
ture into levels of evidence (eg, level I, level II, level clinical decision making by healthcare profession-
III), and development of a CG based on the depth als. Likewise, CGs are not meant to be the only tool
and breadth of this evidence. A limitation inherent in used to guide clinicians in clinical care. In addition,
this process is the availability of high-level studies on the existence of a CG for a specific clinical situation
which to make effective statements for use in CGs. does not preclude deviating from its recommenda-
Second, CGs are meant to “assist health care pro- tions depending on medical circumstances and the
fessional . . . decision making.” As discussed below, experience and judgment of the health care profes-
CGs are not meant to replace clinical decision mak- sionals involved.
ing on the part of physicians and nurses and other
health care professionals. Rather, CGs are developed
and implemented to provide the best current avail- ADVANTAGES AND DISADVANTAGES
able information to the key decision makers. This OF CLINICAL GUIDELINES
information on best practices and interventions The advantages of CGs include the following:
leading to optimal outcomes facilitates making the
appropriate clinical decisions. •• Template on which to base clinical decisions
Similarly, CGs are meant, in part, to “assist . . . •• Latest evidence-based studies that have an
patient decision making.” Patients and families impact on patient outcomes
•• Evaluate effectiveness of newest therapies
•• Information accessible to all health care profes-
From the Arizona Burn Center, Phoenix. sionals as well as patients and families
Address correspondence to Kevin Foster, MD, MBA, Department •• Ability to change care plans based on new
of Surgery, Arizona Burn Center, Maricopa Integrated Health information
Systems, 2601 E. Roosevelt, Phoenix, Arizona 85008.
Copyright © 2014 by the American Burn Association •• Ensure that details of care are not missed or
1559-047X/2014 forgotten
DOI: 10.1097/BCR.0000000000000088 •• Promote equality of care across populations
271
 Journal of Burn Care & Research
272   Foster et al July/August 2014

The disadvantages (real and perceived) of CGs These criteria can be modified in step F, depending
include the following: on the results of the literature search. In addition, the
health care professional stakeholders who will either
•• Initial hesitation to change clinical practice
use or be affected by the CG must be identified.
•• Effort to develop CG using evidence-based
studies B. Choose a working group
•• Continual review and modification of existing The driving force behind the project is the CG devel-
CGs opment working group and its chair. The purpose of this
•• Must have investment by all key stakeholders group is to work its way through the steps listed below.
•• Perception that CGs stifle independent thought The number and specialty of the group members are
and action by health care professionals variable. The number should be low enough to allow
work to proceed efficiently but high enough to divide
up the work load. The individuals in the group should
PROCESS OF CLINICAL
be stakeholders in CG use (ie, they will ultimately be
GUIDELEINE DEVELOPMENT AND
IMPLEMENTATION using the CG in clinical practice). This is an important
point. One of the keys to successful implementation of
The process of CG development and implementa- change at any level is to involve those affected by the
tion is illustrated in Figure 1. A few specific points in change. This is particularly crucial in medicine where
this process warrant discussion.1 individual care practices are often thought to be invio-
A. Decide whether a clinical guideline is desirable late by those using them. Ultimately, practitioners must
and/or necessary for a given clinical situation believe in the CG or it will be unsuccessful.
Not all clinical situations require or are amena- Most individuals approach guideline develop-
ble to CG use. CGs are particularly useful when a ment with a fair amount of reluctance. This is often
particular outcome is desired. The questions to be because the CG is too broad in scope or because the
asked here are what positive outcome is wanted and/ expectations for the CG are too high. These pitfalls
or what adverse outcome is to be avoided. So the must be avoided. Ultimately, the CG must be fea-
process of CG development really begins at the end, sible and team members must want to use it or it
with defining the goal of the CG. An example of this simply will not be successfully implemented.
would be deciding that a CG for nutritional support C. State the objective(s) of the clinical guideline
is warranted for patients in the burn intensive care In step 1, the overall goal of the CG was defined in
unit (ICU). The desired outcome would be rapid an effort to determine whether a CG was wanted and
implementation and continuous provision of enteral feasible. In this step, the specific clinical objectives of
nutritional support that meets the patients’ needs. the CG must be defined.
When developing a CG, it is important to identify Establishing goals should maximize patient bene-
specifically the population to whom the CG will apply. fit, minimized potential harm, potentiate cost-effec-
A very useful and convenient way of specifying the pop- tiveness, and fit appropriately within the constraints
ulation is to identify inclusion and exclusion criteria. of existing health care systems. Remember, a key
aspect of CG development is statement of desire
Determine need for CG clinical goals and working backward from there.
Once the goals are defined, specific question(s)
Select working group regarding these goals must be developed. This is
crucial to keep the working group focused and on
Define objective of CG
task. These questions form the framework of the evi-
dence-based literature search. And the answers form
Literature and best practice Look for existing CG &
search evaluate
the framework for the CG and recommendations.
D. Search for existing clinical guidelines
Compose CG It may not be necessary to construct a CG de
novo, if an appropriate CG already exists and is in use
Implement CG
by other health care professionals. A search of the lit-
Review CG
erature and Internet-based resources can often yield
positive results in this regard. If an existing CG is
Figure 1.  Process of clinical guideline (CG) development found, it must be analyzed for content, completeness,
and implementation. and applicability for the current clinical situation.
Journal of Burn Care & Research
Volume 35, Number 4 Foster et al   273

E. Search the literature for evidence-based studies Table 1. Classes of evidence

and best practices
Class of
Searching the scientific literature for evidence- Evidence Description
based studies on which to base the CG is a difficult
Class I Evidence from properly designed and conducted
task in and of itself. However, other than composing
randomized controlled trial(s)
the CG itself, this step is probably the most impor-
Class II-1 Evidence from properly designed and conducted
tant in CG development. The search must be com- controlled trial(s) without randomization
prehensive and thorough. Several steps are involved: Class II-2 Evidence from properly designed and conducted
•• Based on the objective(s), develop and list the cohort or case-control trial(s)
Class II-3 Evidence from multiple case series
clinical questions that must be answered for the
Class III Opinions of respected authorities or expert
CG. This is one responsibility of the working
committees; evidence from descriptive studies
group.
•• Perform a search for each question or group of
related questions
easily compared. It also allows other stakeholders to
° The search must be systematic rapidly assess the quality of a study without having to
° Define databases to be used appraise every single study. Finally, it allows CG users
to see a summary of the evidence on which the CG
° Define search terms to be used was based. An evidence table would typically contain
° Define other limitations and filters to the the following elements:
search such as publication date
•• Name and date of study
° Refine search to reach a workable number of •• Study type
publications to be reviewed
•• Population studied
•• Interventions and randomization
•• Critically appraise and rank the literature
•• Results
° Designate a hierarchy system for classes of •• Notes
evidence (Table 1) •• Level of evidence
° List strengths and weaknesses of each study

° Designate a level of evidence for each study F. Develop the clinical guideline, establish recom-
° Define criteria for accepting and rejecting mendations, and draft a document
evidence The questions posed in step C now have answers
based on the search performed in step E. These
Evidence is generally ranked in terms of the qual-
answers to the questions should now be formulated
ity of the studies performed to generate conclusions.
as recommendations based on the level of evidence.
There are numerous ranking systems. A commonly
Recommendations can be made as follows:
used ranking system is the U.S. Preventive Services
Task Force system.2 This is demonstrated Table 1. •• Level 1 recommendation: The recommenda-
Levels of evidence can briefly described as follows: tion is convincingly justifiable based on the
available scientific information alone. This rec-
•• Class I: This is evidence obtained from at least
ommendation is usually based on class I data.
one well-conducted, randomized, controlled
However, the recommendation may be based
clinical trial.
on strong class II data, especially if the issue
•• Class II: This is evidence usually obtained non-
does not lend itself to study in a randomized
randomized controlled trials or from cohort or
clinical trial. Conversely, low quality or contra-
case-control trials or from multiple case series
dictory class I data may not support a level 1
studies.
recommendation.
•• Class III: This is evidence largely obtained
•• Level 2 recommendation: The recommenda-
from either expert authorities and/or expert
tion is reasonably justifiable by available scien-
committees and based on clinical experience or
tific evidence and strongly supported by expert
descriptive studies
opinion. This recommendation is usually sup-
In critically appraising and ranking the obtained liter- ported by class II evidence or a preponderance
ature, it may be helpful to construct an evidence table of class III evidence.
for each study. This allows details of the study as well •• Level 3 recommendation: The recommendation
as strengths and weaknesses to be documented and is supported by available data, but adequate
 Journal of Burn Care & Research
274   Foster et al July/August 2014

scientific evidence is lacking. This recommen- Internet-based presentations and distribution by

dation is generally supported by class III data. electronic means. However, the presentation should
This type of recommendation is useful for edu- also include a live presentation(s). These processes
cational purposes and, particularly, for guiding allow the stakeholders to review the CG, ask ques-
future clinical research. tions, make suggestions, and modify the CG. The
objectives of this process include ensuring that all
At this point in time it is helpful to review the
pertinent data have been collected, that the rec-
population to whom the CG will apply and verify
ommendations are supported by the data, and that
utility and suitability. Re-examination of the inclu-
where data are lacking, the recommendations are
sion and exclusion criteria and modification is also
supported by expert opinion that reflects stakehold-
appropriate.
ers’ views. Ultimately, the goal is to familiarize the
Likewise, re-examination of the target health care
stakeholders with the CG and to win stakeholders’
setting and personnel involved should be performed.
support. Once the presentation process is complete,
Additional tools and resources, including educa-
the working group revises the CG and completes the
tion, should be identified and obtained. A search
development process. The CG is then made available
for potential barriers to implementation should be
to stakeholders, preferably through publication in an
made and potential interventions to increase success
appropriate journal and through electronic means.
discussed.
Finally, when all of the above has been accom- H. Implement the CG
plished, a CG document should be drafted. CG The key to implementation is education of all
documents can take many forms from a simple sin- stakeholders, including physicians, nurses, residents
gle-page flow diagram to lengthy, multiple-page nar- in training, therapists, and all other health care per-
ratives. Regardless, in order to facilitate transparency, sonnel involved. Education includes making the CG
easy understanding, and participation, a CG should widely and easily available in multiple formats, mak-
have the following elements: ing sure the CG is available during bedside patient
care and providing intensive coaching during actual
•• Title and date
patient care.
•• Working-group members
The actual application of a CG to clinical care may
•• Statement of the problem with the list specific
take one of several formats. A critical pathway or care
questions: The questions will come from step
map is a timeline of the patient’s expected clinical
C, and represent the focus of the CG.
course based on a particular disease process or clini-
•• Literature search process: As previously stated,
cal situation. Health care professional interventions
this will include databases, search terms, limita-
are made based on the timeline of expected events.
tions, and so on.
Another format of implementation is the clinical
•• Recommendations: This is the heart of the CG.
management protocol (CMP). A CMP is similar to
Recommendations may be narrative statements,
a critical pathway but differs in the decision-making
flow diagrams, algorithms, or a combination.
process. Decision making in a CMP is based on algo-
•• Scientific rationale or discussion: This is a
rithms. CMPs lend themselves to problem-related or
review of the literature and justification of the
disease-related situations.
recommendations based on this literature. This
Once stakeholders are educated, the CG should be
is often a lengthy section.
implemented in a small number of patients initially.
•• Ares for future clinical study (ie, unanswered
As the comfort level of the stakeholder’s increases,
questions): These unanswered questions or
the CG should be implemented widely throughout
unresolved issues form the basis of further
an individual unit or institution. Finally, the CG
clinical research and/or quality improvement
should be implemented in multiple institutions.
projects.
•• Summary statement I. Make provisions for evaluation and modification
•• References of the CG
•• Evidence tables The goals of each CG are to maximize the qual-
ity of care, improve clinical outcomes, and increase
G. Present the clinical guideline to stakeholders cost-effectiveness. It is unlikely that a new CG will
Once the CG has been completed to the satisfac- be comprehensively effective in these ways without
tion of the working group, including drafting of review and modification. Review and modification
the written document, it is presented to the wider occur at several different levels and with several dif-
group of stakeholders. This process can include ferent methodologies.
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Volume 35, Number 4 Foster et al   275

First, the CG must be examined to see whether the Table 2. Institute of Medicine standards for developing
recommendations are being followed and whether trustworthy PMGs3
actual practice patterns have changed. If not, the •  Establish a transparent process
reasons must be determined. It may be that the CG •  Manage conflict of interest
recommendations are not feasible or that stakehold- •  Use a multidisciplinary guideline development group
ers are not truly knowledgeable or that the necessary •  Guideline systematic review interaction
resources have not been supplied. •  Clearly describe summary of evidence and differences of
Second, if the CG recommendations are being fol- opinion
lowed appropriately, it must be determined whether •  Clearly articulate the recommendations and how they
should be used
this is resulting in actual improvement in patient care
•  Allow for external review from other experts and stakeholders
and better outcomes. Outcomes before and after CG
•  Keep guidelines up to date
implementation must be tracked, documented, and
compared. This process lends itself well for quality PMGs, practice management guideline.
improvement initiatives.
Finally, the CG must be reviewed on a timely basis effort, the GRADE approach has been adopted by
to ensure that the recommendations continue to be numerous organizations, including the Centers for
supported by new and developing evidence and liter- Disease Control, American College of Chest Physi-
ature. The timeline for this analysis really depends on cians, the Infectious Disease Society of American,
the nature of the clinical situation and the rapidty of and the East Association of the Surgery of Trauma.3
change in the literature. A good rule of thumb is to GRADE methodology is becoming the most widely
review a CG annually for changes in evidence. How- used basis for evaluating evidence and making rec-
ever, considering the complexity of the development ommendations in the CG development process.
and implementation process, this may not be reason- The details of GRADE methodology can be
able and a longer timeline may be more effective. found on its website ([Link].
org). Details were also published in a six-part series
J. GRADE Methodology
in 2008.3 A 20-part update is in the process of
1. Introduction to GRADE methodology
being published. Eighteen parts of this have been
Recognizing their benefit, many organizations published.3
have developed CGs to address specific problems in A brief description of the application of GRADE
specific disciplines. Currently, the National Guide- methodology as described by the Eastern Association
line Clearinghouse lists over 2500 of these CGs in its for the Surgery of Trauma (EAST) follows here.3
database.3 However, the process of CG development
varies considerably depending on the organization.3 Table 3. Advantages of the GRADE methodology4
A decade ago, there were more than 100 systems •  C lear separation between quality of evidence and strength
used to develop CGs.3 As result of this variability the of recommendations
quality of CGs and the value of the recommendations •  Explicit and comprehensive criteria for downgrading or
therein were inconsistent and sometimes even con- upgrading quality of evidence
tradictory across CGs. Specific problems identified •  Explicit consideration of the relative importance of various
in some of these CGs included: inadequate evalua- outcomes to patients
tion of evidence, lack of multidisciplinary approach, •  Explicit acknowledgement of values and preferences
conflict of interest, and lack of transparency.3 The assumed when making recommendation
•  Transparent process of moving from evidence to
Institute of Medicine has made recommendations for
recommendations
development of trustworthy CGs, shown in Table 2.5
•  Explicit advise to make recommendations about the most
In response to this inconsistency in CGs, the appropriate course of action, even when very little evidence
Grades of Recommendation, Assessment, Develop- is available
ment, and Evaluation (GRADE) working group was •  Grading the strength only for recommendations about the
convened in 2000 to develop a standardized method diagnostic or therapeutic course of action, but not about
of CG development concentrating on two specific prognosis or etiology
processes: 1) rating the quality of evidence in the •  Clear and pragmatic interpretation of “strong” and “weak”
literature and 2) making effective recommendations recommendations
based on this evidence and other factors.4 This group •  Balance between simplicity and methodological
has continued to modify and improve this standard- comprehensiveness
ized approach. The advantages of GRADE meth- GRADE, Grades of Recommendation, Assessment, Development, and
odology are shown in Table 3.6 As a result of this Evaluation.
 Journal of Burn Care & Research
276   Foster et al July/August 2014

Table 4. Outcome classification for VTE prophylaxis in as 1) critical, 2) important but not critical, or 3) not
burn patients1 important.6 This is done with a numerical ranking
Outcome Type Rank Outcome
system with a rating scale of 1 to 9. An example is
shown in Table 4.3
Critical 9 Mortality
outcomes 4. Systematically obtain pertinent literature
8 Respiratory insufficiency A comprehensive literature search using large
7 Post-thrombotic syndrome databases and appropriate terminology and/or key
Important 6 Bleeding complications words to identify pertinent literature is performed.
outcomes Resources such as the Cochrane Collaboration
5 Need for transfusion should be utilized. Citations from pertinent manu-
4 Need for systemic anticoagulation scripts can also be utilized. If appropriate, smaller
Limited 3 Cost
studies can be combined into a meta-analysis.
important
outcomes 5. Grade the quality of existing evidence in the
2 literature
1 The next step in GRADE methodology is grading
VTE, venous thromboembolism. the evidence into one of four categories: high, moder-
ate, low, or very low. The qualifications, descriptions,
2. Ask a precise question and examples are shown in Table 5.3,6 Usually in
The GRADE approach begins with asking a precise GRADE methodology studies are grouped together
question focusing on the diagnosis and/or treatment as much as possibly, with each group addressing a
of a disease process, but not on prognosis or etiology.6 specific PICO question.
This clinical question should have four components In addition, there are additional factors that may
in a “PICO” format: patient Population, Interven- decrease the quality of evidence, particularly ran-
tion (diagnostic or therapeutic), alternative interven- domized controlled clinical trials. There are five
tion (Comparison), and Outcome(s) of interest.3 For factors that may decrease the quality of evidence
instance, a clinical question could be: “In patients with and three that may increase. These are shown in
thermal injury (P) should venous thromboembolism Table 6.7 Each grouping of evidence for a specific
(VTE) prophylaxis with low molecular heparin (I) be PICO question should be evaluated for these seven
administered compared to no VTE prophylaxis (C) to factors.4 GRADE methodology for modification of a
prevent VTE (O)?” One clinical question may lead to study is shown in Table 7.3,7
multiple different PICO questions.
6. Make recommendations
3. Define the importance of outcomes The final step in GRADE methodology is to make
GRADE methodology requires that making rec- recommendations for clinical practice based on the
ommendations include qualifying various outcomes evaluation of available evidence. It should be noted

Table 5. GRADE methodology levels for rating the quality of evidence1,4

Quality Level Definition Explanation Example

High (A) Very confident that the true effect Further research is very unlikely to Randomized trials without
lies close to estimate of effect change confidence in estimate limitationsWell-performed
of effect observational trials
Moderate (B) Moderate effect; true effect is likely Further research is likely to have an Randomized trials with serious
close to estimate of effect but important impact on confidence in limitationsWell-performed
may be substantially different estimate of effect and may change it observational trials yielding
large effects
Low (C) Limited confidence; true effect Further research is very likely to have an Randomized trials with very serious
may be substantially different important impact on confidence in limitationsObservational trials
from estimate of effect the estimate of effect and is likely to without special strengths or
change the estimate important limitations
Very low (D) Little confidence; true effect likely Any estimate of effect is very uncertain All others
substantially different from
estimate of effect

GRADE, Grades of Recommendation, Assessment, Development, and Evaluation.

Journal of Burn Care & Research
Volume 35, Number 4 Foster et al   277

Table 6. Factors affecting quality of evidence5 this process is frequent review and modification of
Factors that may decrease quality of evidence the CGs.
•  Study limitations
•  Inconsistency of results
EXAMPLES OF EXISTING CLINICAL
•  Indirectness of evidence
•  Imprecision
GUIDELINES
•  Publication bias Before considering burn CGs specifically, examina-
Factors that may increase the quality of evidence tion other organizations’ CGs is waranted. Described
•  Large magnitude of effect below are CGs of the EAST and CGs from the
•  Plausible confounding, reducing demonstrated effect
National Comprehensive Cancer Network (NCCN).
•  Dose response gradient
Also described below are CGs somewhat broader in
scope from the American College of Physicians and the
that often the composers of the recommendations Agency for Healthcare Research and Quality and algo-
(guideline developers) are often different than the rithms from the Western Trauma Association (WTA).
systematic reviewers of evidence. One of the ben-
efits of GRADE methodology is that only one of Clinical Guidelines From the Eastern
two recommendations can be made: 1) strong or Association for the Surgery of Trauma
2) weak/conditional. The definitions of strong and Table 9 demonstrates a list of the current CGs in use
weak/conditional recommendations as they apply to by the EAST.8 EAST uses the term practice man-
each group of stakeholders are shown in Table 8.3 agement guideline (PMG) instead of CG, and this
The final recommendation of strong or weak/con- terminology will be used in this section. Column 1
ditional is based on the level of evidence and these lists the name of the CG as well as the citation if
definitions for stakeholders as well as other factors the guideline has been published in a peer-reviewed
such as risk: benefit ratio, patient preferences, and journal. Column lists the date of publication of the
patient and institutional values. PMG. Publication in this context may refer to pub-
K. Summary lication in a peer-reviewed journal or publication by
CGs when properly developed and implemented the organization responsible for the PMG, in this
maximize patient care, optimize clinical outcomes, case, EAST.
utilize resources appropriately, and promote cost- As can be seen in column 1, most of the EAST
effective care. CGs are not meant to be mandates PMGs concentrate on specific clinical situations.
from above, imposing managed care onto health However, the scope of these PMGs can vary from
care professionals. Rather they are meant to pro- quite broad, such as the Geriatric Trauma PMG, to
vide a fail-safe road map to provide the best possible quite narrow, such as the Screening for Blunt Cardiac
patient care. The development and implementation Injury PMG. Regardless of the scope, each PMG is
of CGs must balance standardizing care with inde- devoted to a particular clinical situation.
pendent practitioner decision making. Examination of the details of the individual PMGs,
The keys to success in this balance are transparency, such as Diagnostic Evaluation of Blunt Abdomi-
open debate, and stakeholder consensus. Implicit in nal Trauma ([Link]

Table 7. GRADE approach to rating quality of evidence1,5

Initial Quality of
Study Design Evidence Lower If Higher If Quality Overall

Randomized trial High Risk of bias−1 Serious−2 Very Large effect+1 Large+2 Very High (four pluses: ++++)
serious large
Moderate Inconsistency−1 Serious−2 Dose response+1 Evidence Moderate (three pluses:
Very serious of gradientAll plausible +++)
confounding
Observational study Low Indirectness−1 Serious−2 +1 Would reduce a Low (two pluses: ++)
Very seriousImprecision−1 demonstrated effect or+1
Serious−2 Very serious Would suggest a spurious
Very low Publication bias−1 Serious−2 effect when results show Very low (one plus: +)
Very serious no effect

GRADE, Grades of Recommendation, Assessment, Development, and Evaluation.

 Journal of Burn Care & Research
278   Foster et al July/August 2014

Table 8. GRADE definition of strong and weak definitions1

Strong Recommendation Weak Recommendation

For patients Most patients would want the recommended Most patients would want the course of action, but many
course of action would not
For clinicians Most patients should receive the recommended Different choices will exist for different patients, and
course of action clinicians should help patients decide
For policy makers Recommended course of action should be Considerable debate and stakeholder involvement needed
adopted as policy to make policy

GRADE, Grades of Recommendation, Assessment, Development, and Evaluation.

treatment-guidelines/blunt-abdominal-trauma,- the databases(s) used, the search terms used, and

evaluation-of) PMG,9 shows that the PMG is divided search limitations such as language, date of publica-
into several sections. The first section lists the Authors tion, and so on. This section also includes the num-
of the PMG. These authors comprise the working ber of publications included in the analysis for the
group for PMG development. PMG. The second part of this section describes the
The second section is a Statement of the Problem. method used to qualify the literature obtained in the
This section is comparable to an introduction in a first part. In most cases, the ranking system will be
scientific manuscript. This section briefly reviews the very similar to that shown in Table 1. EAST now
clinical situation to be examined, comments on cur- uses GRADE methodology to evaluate the literature
rent practices and controversies, and states the pur- and make recommendations. GRADE methodology
pose of the PMG. is described in a subsequent section.
The third section, Process, describes the search for The fourth section is Recommendations and is the
evidence-based literature on which the PMG is to be formal PMG. For this particular PMG in this particular
based. This section consists of two parts. The first is organization, the CG takes the form of specific recom-
a description of the literature search. This includes mendations for distinct clinical situations. In this PMG,

Table 9. EAST clinical guidelines for trauma

Clinical Guideline and Reference (If Any) Publication Date

Blunt Abdominal Trauma Diagnostic Evaluation of  J Trauma 2002 53(3):602–15 2001
Blunt Aortic Injury, Diagnosis and Management of  J Trauma 2000 48(6)1128–443 2000
Blunt Cardiac Blunt Injury, Screening for  J Trauma 1998 44(6):941–56 1998
Blunt Cerebrovascular Injury, Diagnosis and Management of  J Trauma 2010 68(2):471–7 2007
Blunt Liver and Spleen Injuries, Non-Operative Management 2003
Cervical Spine Injuries Following Trauma, Identification of  J Trauma 2009 67(3):651–9 2009
Genitourinary Trauma, Diagnostic Evaluation of 2003
Genitourinary Trauma, Management of 2004
Geriatric Trauma (Update) 2010
Geriatric Trauma, Parameters for Resuscitation  J Trauma 2003 54(2):391–16 2001
Geriatric Trauma, Triage of  J Trauma 2001 54(2):391–16 2001
Hemothorax and Occult Pneumothorax, Management of  J Trauma 2011 70(2):510–8 2011
Mild Traumatic Brain Injury, Management of  J Trauma 2001 51(5):1016–26 2001
Pancreatic Trauma, Diagnosis and Management of 2009
Pelvic Fracture Hemorrhage—Update and Systematic Review  J Trauma 2011 71(6):1850–68 2011
Penetrating Abdomnial Trauma, Prophylactic Antibiotics in  J Trauma 2000 48(3):508–18 1998
Penetrating Arterial Extremity Trauma, Management of 2002
Penetrating Colon Injuries, Management of  J Trauma 1998 44(6):941–56 1998
Penetrating Combined Arterial and Skeletal Extremity Trauma, Management of 2002
Penetrating Neck Injuries, Management of  J Trauma 2008 64(5):1392–405 2008
Penetrating Trauma, Selective Non-Operative Management of  J Trauma. 2010 68(3):721–33 2009
Penetrating Venous Extremity Trauma, Management of 2002
Thoracolumbar Spine Injuries Following Trauma, Identification of  J Trauma 2007 53(3):709–18 2006
Trauma in Pregnancy  J Trauma 2010 69(1):211–4 2005
Triage of the Trauma Patient 2010
Journal of Burn Care & Research
Volume 35, Number 4 Foster et al   279

these recommendations are divided into sections based development and implementation of all of the mela-
on the level of evidence. For level 1 evidence, definitive noma CGs.14 The level of evidence used is shown at
recommendations can be made. For level 2 evidence, the very beginning of this discussion.
the PMG does offer some specific recommendations,
but mostly lists options. Finally, for level 3 evidence, the Clinical Guidelines From the American
PMG primarily discusses options. The CG does include College of Physicians
flow charts and algorithms for care. The American College of Physicians is an internal
The fifth section, Scientific Foundation, discusses medicine group and their CGs are focused primarily
the Recommendations in much greater detail. This on conditions typically seen in a primary care office
is similar to a Discussion section of a scientific manu- setting ([Link]
script. In this particular PMG, the discussion focuses mation/guidelines/).15 Guidelines exist for condi-
on the individual diagnostic modalities and cites the tions such as breast cancer screening, diabetes, low
literature from the Process section and how it was back pain, and stable ischemic heart disease among
used to develop the PMG described in the Recom- other things. The unique aspect of this particular
mendations section. CG website is that there are two additional catego-
The sixth section, Summary, is a brief restatement of ries of clinical recommendations in addition to tra-
the purpose, scope, and recommendations in the PMG. ditional CGs. Traditional CGs are found under the
The final sections are the References, a bibliogra- Current Guidelines tab. The second category, Guid-
phy of evidence-based literature used in the PMG, ance Statements, provides recommendations based
and a section for tables and figures. on a review of existing CGs, as opposed to a review
An additional section frequently included in this of existing evidence. These Guidance Statements
organization’s PMG is Areas for Future Investiga- are particularly useful when two or more CGs have
tion. This section describes the gaps in knowledge in conflicting statements or recommendations. The
the PMG and suggests what research studies could third category, Best Practice Advise, makes recom-
fill in these gaps and improve patient care. mendations regarding specific diagnostic tests and
therapeutic interventions. Colorectal screening and
Clinical Guidelines From the National imaging in low back pain are examples.
Comprehensive Cancer Network
The NCCN website houses many CGs for the man- Clinical Guidelines From the Agency for
agement of various types of malignancies. One signs Healthcare Research and Quality
into the website and selects NCCN CGs for physi- The Agency for Healthcare Research and Quality
cians. Then one selects NCCN Guidelines for Treat- is a division of the U.S. Department of Health and
ment of Cancer by Site and then selects the anatomic Human Services. Their website is a clearing house
site of interest, for instance, melanoma ([Link] for existing CGs ([Link]
[Link]/professionals/physician_gls/f_guidelines. From a CG development perspective, this is a great
asp#site).10 place to start by looking for existing guidelines. For
Clicking Continue on the opening page for mela- instance, the site has 2344 CGs for Diseases, nar-
noma takes one to the Working Group.11 rowed to 241 CGs for Wounds and Injuries, nar-
Clicking Continue again takes one to a menu of rowed to 9 CG for Burns specifically. None of these
CGs.612 These CGs are based largely on the stage of CGs are from burn centers.
the disease and particular clinical situations but also
include principles of specific management, such as Algorithms From the Western Trauma
wide excision of the primary lesion and lymph node Association
dissection. The WTA offers a unique presentation of CG in the
Clicking on stage III (ME-4) takes one to the spe- form of algorithms ([Link]
cific CG for stage II melanoma.13 In contrast to the algorithms/[Link]).17 A WTA committee
EAST CGs, which are mostly narrative, the NCNN reviews the literature including established CGs and
CGs are usually comprised of flow diagrams and drafts an algorithm. This is revised by the WTA mem-
algorithms. These are usually limited to one or two bership and then submitted for peer-review publica-
pages for each clinical situation. Additional informa- tion and publication on the WTA website. The key
tion is contained in foot notes. benefit of using an algorithm format for CGs is that
If one clicks on Discussion in the upper-right-hand it focuses the use on decisions points and assists in
corner, the web page shows the detailed discussion of the decision-making process.
 Journal of Burn Care & Research
280   Foster et al July/August 2014

BURN-SPECIFIC CLINICAL these guidelines represent individual or group efforts

GUIDELINES and are not part of past Organization for Burn Care
and Delivery (ODBC) efforts. The list is fairly com-
Table 10 lists the current CGs for burn patient man- prehensive covering resuscitation, wound care, inha-
agement published under the auspices of the Ameri- lation injury, nutrition, pain, infection, skin diseases,
can Burn Association (ABA). It should be noted that and a few other miscellaneous topics. The majority

Table 10. Current burn care clinical guidelines

Publication Publication
Clinical Guideline Date Type Category Citation

Disaster management and the ABA plan 2005 Summary article Disaster ABA Board of Trustees JBCR
26(2):102–106
Burn Specialty Teams 2005 Summary article Disaster Sheridan et al JBCR 26(2):170–173
Burn disaster response planning: an 2008 Article Disaster Delaney et al JBCR 29(1):158–65
urban region’s approach
Infection control practices in U.S. 2006 Article Infection Hodle et al JBCR 27(2):142–51
burn units
ABA consensus conference to define 2007 Article Infection Greenhalgh et al JBCR 28(6):776–90
sepsis and infection in burns
Initial management of carbon 2001 Guideline Inhalation 2001 Practice Guidelines for Burn Care
monoxide and cyanide exposure 14S–18
Inhalation injury: diagnosis 2001 Guideline Inhalation 2001 Practice Guidelines for Burn Care
19S–22
Inhalation injury: initial management 2001 Guideline Inhalation 2001 Practice Guidelines for Burn Care
23S–26
ABA practice guidelines for prevention, 2009 Guideline Inhalation Mosier et al JBCR 30(6):910–28
diagnosis, and treatment of VAP in
burn patients
Inhalation injury consensus conference 2009 Summary articles Inhalation Various authors JBCR 30(1):141–10
Initial nutritional support of burn 2001 Guideline Nutrition 2001 Practice Guidelines for Burn Care
patients 59S–66
Glutamine supplementation in critical 2006 Article Nutrition Windle JBCR 27(6):764–72
illness: evidence, recommendations
and implications for clinical practice
in burn care
Practical guidelines for nutritional 2007 Article Nutrition Prelack et al Burns 34(1):141–43
management of burn injury and
recovery
Nutrition support—is there 2008 Article Nutrition Masters and Wood. JBCR 29(4):561–71
consistency in practice?
Actual burn nutrition care practices: 2009 Article Nutrition Graves et al JBCR 30(1):77–82
an update
Deep venous thrombosis prophylaxis 2001 Guideline Other 2001 Practice Guidelines for Burn Care
in burns 67S–69
Guidelines for burn fellowships 2004 Guideline Other Warden and Heimbach JBCR
25(6):469–71
Practice guidelines for burn care, 2006 2006 Guideline Other Gibran JBCR 27(4):437–38
Guidelines for the operation of burn 2007 Guideline Other JBCR 28(1):134–41
centers
Practice guidelines for deep venous 2007 Guideline Other Faucer and Conlon JBCR 28(5):661–63
thrombosis in burns
The evolution of burn care facilities in 2008 Article Other Brigham and Dimick. JBCR 29(1):
the United States 248–56
Practice guidelines for the management 2006 Guideline Pain Faucher and Furukawa JBCR
of pain 27(5):659–68
(Continued)
Journal of Burn Care & Research
Volume 35, Number 4 Foster et al   281

Table 10. (Continued)

Publication Publication
Clinical Guideline Date Type Category Citation

Response to a nursing-driven protocol 2009 Article Pain Fry et al JBCR 30(1):112–18

for sedation and analgesia in a
burn-trauma ICU
SOPs for the clinical management of 2007 Article Research Silver et al JBCR 28(2):222–30
patients enrolled in a prospective
study of inflammation and the host
response to thermal injury
Clinical research in burns: state of the 2007 Summary articles Research Various authors JBCR 28(4):544–26
science 2006
Burn rehabilitation and research: 2009 Article Research Richard et al JBCR 30(4):543–73
proceedings of a consensus summit
Initial assessment of the burn patient 2001 Guideline Resuscitation 2001 Practice Guidelines for Burn Care
5S–9S
Burn shock resuscitation: initial 2001 Guideline Resuscitation 2001 Practice Guidelines for Burn Care
management and overview 27S–37
Hypertonic fluid resuscitation 2001 Guideline Resuscitation 2001 Practice Guidelines for Burn Care
38S–42
Fluid resuscitation: colloid 2001 Guideline Resuscitation 2001 Practice Guidelines for Burn Care
resuscitation 43S–47
Fluid resuscitation: monitoring 2001 Guideline Resuscitation 2001 Practice Guidelines for Burn Care
48S–52
ABA practice guidelines burn shock 2008 Guideline Resuscitation Pham et al JBCR 29(1):257–66
resuscitation
Treatment strategies in TENS: where 2008 Article Skin disease Abbod et al JBCR 29(1):269–76
are we at?
Toxic epidermal necrolysis: guidelines 2008 Guideline Skin disease Endorf et al JBCR 29(5):706–12
Necrotizing soft-tissue infections: 2009 Guideline Skin disease Endorf et al JBCR 30(5):769–75
clinical guidelines
Outpatient management of burn 2001 Guideline Wound 2001 Practice Guidelines for Burn Care
patients 10S–13
Escharotomy 2001 Guideline Wound 2001 Practice Guidelines for Burn Care
53S–58
Review of evidence-based practice for 2004 Article Wound Gordon et al JBCR 25(5):388–10
the prevention of pressure sores in
burn patients
Primer on the management of 2005 Article Wound Klein et al JBCR 26(1):2–6
face burns at the University of
Washington
Practice guidelines for the management 2006 Guideline Wound Arnoldo et al JBCR 27(4):439–47
of electrical injuries
Evidence-based review for the 2009 Article Wound Bell and Gabriel JBCR 30(10):55–61
treatment of postburn pruritis
Pruritis in burns: review article 2009 Article Wound Goutos et al JBCR 30(2):221–28
Critical review of burn depth assessment 2009 Article Wound Jaskille et al JBCR 30(6):937–47
techniques: part I. historical review
Critical review of burn depth 2009 Article Wound Jaskille et al JBCR 31(1):151–57
assessment techniques: part II.
Review of laser Doppler technology
Escharotomy and decompressive 2009 Guideline Wound Orgill and Piccolo JBCR 30(5):759–68
therapies in burns
Practice guidelines for early ambulation 2012 Guideline Wound Nedelec et al JBCR 33(3):319–29
of burn survivors after lower
extremity grafts

ABA, American Burn Association; ICU, intensive care unit; SOP, standard operating procedure;TENS, transcutaneous electric nerve stimulation; VAP, ventila-
tor-associated pneumonia.
 Journal of Burn Care & Research
282   Foster et al July/August 2014

of the guidelines have been developed and published metrics assessment, evidence-based clinical studies,
as guidelines. However, quite a few of the guidelines and education at every health care provider level.
have simply been published as journal articles, and
several have been published simply as summary arti-
cles. All guidelines, regardless of format, have been
RECOMMENDATIONS
published in the Journal of Burn Care and Research.
•• The ABA should adopt a system for CG devel-
The format for ABA CGs, published as such, is
opment, implementation, and review for the
similar in most ways to the two examples we have
examined previously. Most of the guidelines begin delivery of burn care
with recommendations that fall into one of three cat- •• This process should be the proximate responsi-
egories. Standards, the highest level recommenda- bility of the ODBC Committee
tion, are the equivalent of level 1 recommendations. •• The ODBC Committee should generate a list
Guidelines, the second highest recommendation, of desired CGs
are the equivalent of level 2 recommendations. And •• Each member of the ODBC Committee would
Options, the lowest recommendation, are the equiv- be responsible for one or more of these CGs.
alent of level 3 recommendations. The guidelines Initially, this would involve generation of new
then follow a format similar to the EAST CGs with CGs, but ultimately it would involve periodic
the following sections: review of existing CGs also.
•• ODBC members would develop Working
•• Recommendations Groups from outside the ODBC Committee.
•• Overview •• The recommendations from the Working
•• Process Groups would be presented, discussed, modi-
•• Scientific foundation fied, and approved by the ODBC Committee.
•• Summary •• The recommendations from the ODBC would
•• Areas for future investigation be presented to the ABA members for com-
•• Evidentiary tables
ment and review
•• References
•• After an additional modification, a final recom-
The ABA CGs, thus, are well developed and mendation from the ODBC Committee would
researched. And they are easily accessible. However, then be presented to the Board of Trustees for
there are some problems. First, although many areas final review
of burn care are addressed by the CGs (eg, resusci- •• The CGs would then be implemented as
tation and inhalation injury), there are several areas specified
that are not adequately addressed. For instance, •• CGs, once implemented, must be analyzed for
there is little concerning operative management of effectiveness and outcomes and then modified
the burn wound and care of donor sites. There is based on these results. This process should be
also very little information regarding physical ther- facilitated by the ODBC Committee on a con-
apy and occupational therapy. Second, most of the tinuous basis.
CGs are at least 3 to 5 years old, and some are over
a decade old. Only two CGs, deep venous prophy-
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