MTG2 MoorLDI2-BI laser doppler blood flow imager for burn wound assessment - No.1 Implementing the guidance
Mrs Sarah Pape, Consultant Plastic Surgeon at Newcastle Upon Tyne Hospitals NHS Foundation Trust discusses new NICE guidance on the MoorLDI2-BI laser doppler blood flow imager for burn wound assessment.
This podcast was added on 25 Mar 2011
Interviewer: Hello and welcome to this NICE podcast about the NICE medical technology guidance on the moorLDI2-BI laser doppler blood flow imager for burn wound assessment. In particular this podcast will be focusing on implementing the recommendations in the guidance.
For the purpose of this podcast we will shorten the name of the device to the moorLDI.
I am Katie Worrall, implementation lead for this guidance and with me is Mrs Sarah Pape, Consultant Plastic Surgeon at Newcastle Upon Tyne Hospitals NHS Foundation Trust. Mrs Pape has published research using this technology and provided expert advice to the medical technologies advisory committee who developed the recommendations on the moorLDI.
Q1 Interviewer: Mrs Pape, what is the moorLDI device?
SP: It is a technique that is used for measuring blood flow in the surface of a burn. The normal blood flow in skin is actually very low, most of the time we are conserving heat in our body and we are stopping the blood from flowing to the surface where it would lose heat. But under conditions where there is inflammation in the skin then the blood flow is increased in that location and the moorLDI is able to measure the increase in blood flow. This is simply an infer red laser which is moved, scanned over the surface of the burn and the way that it works is that the machine contains sensors that are able to detect the speed of the blood flow. What we have worked on over the years is using those measurements to predict how likely it is that that burn will heal. We can use that information to predict the likely outcome of the burn and make decisions about how we are going to treat the patient.
Q2 Interviewer: Thank you very much for that information, why is it important to accurately assess a burn?
SP: If we don't know the depth and we don't know the healing potential of the burns and then we have got uncertainty about what we should be doing. Most poor scars will also produce quite rigid inelastic skins, if that is close to a joint it may impeded the movement, may give somebody a very stiff joint, a stiff hand. If it is close to a relatively mobile area of the body such of the corner of the mouth then that can lead to distortion of the corner of the mouth and that can cause functional problems as well as problems with appearance. The very best outcome for any burn would be for it to heal spontaneously through the normal skin regeneration. It might have a slight difference in quality particularly in colour temporarily but over the longer term maybe 6 - 12 months it will return entirely to normality no scarring, no functional problems, no disfigurement. If the burn is deeper then we have to be sure that we can justify surgery because any skin graft will leave a scar. So it is really important in my opinion that you can absolutely justify that decision you make. If you know that the burn is not going to heal within 21 days therefore going to leave scarring then our duty is to produce the very best quality of scar and quite frequently that will be through surgery.
Q3 Interviewer: In which situations does the NICE guidance recommend the moorLDI for use in?
SP: The main area is in burns that are intermediate in depth most experienced burns clinicians would be able to look at a very superficial burn where the skin was bright pink possibly combined with blisters and maybe some broken blisters that are weeping and say this is clearly a superficial burn this does not required surgery and this will be healed within 21 days. The moorLDI will confirm that but it does not really add any extra information. The other group where the moorLDI does not really have any particular benefit is in the clearly very deep burns where the skin is charred or leathery and there will be no doubt that that skin is non viable and needs to be removed and replaced with a skin graft. But in between those two extremes there is a significant number of patients who's burns in their entirety or some areas within the burn will be of an intermediate depth and we often refer to that as indeterminate in other words clinical assessment alone finds it very difficult to determine what the depth is. The experience of the clinician does make a difference.
Q4 Interviewer: Thank you very much. Can the scan result alone be used to guide treatment?
JP: In my opinion it should not be that the scan can be taken at a time that the doctor who is going evaluate them is not available to interpret them but really the best evaluation of the scan will be made by somebody who knows the patient and who has seen the wound or at the very least has access to a high quality colour photograph of the wound. The analogy that I would make there is that if somebody asked me to interpret a chest xray, I would not want to do that if I had not actually already examined the patient and listened to their chest and knew about their symptoms. With the clinical information I would learn so much more from the xray information than I would the xray alone.
Q5 Interviewer: Currently how are patients with intermediate burns wounds assessed and why is the moorLDI device advantageous to these patients and the NHS in comparison to the standard assessment?
SP: The standard assessment is what we would call a clinical assessment in other words a clinician with appropriate experience would examine the patient with all of the dressing removed and would make an assessment of the appearance of the burn. The problem is that you are trying to inspect the burn through a layer of dead skin and so you are trying to interpret what is happening underneath the skin by what you can see on the outside, and the deeper the burn the more dead skin is on the surface and therefore the more difficult it is to see through that to what is happening a little bit further down. In my opinion that is the main reason that clinical inspection alone may fail to give an accurate picture. But unfortunately, what we have realised with the research done using the moorLDI is that possibly as many as 30% of patients who the clinician truly and sincerely believed would need to have a skin graft actually could have been managed with dressings. The experience of the clinician does make a difference but even experienced clinicians like myself may only be accurate in their assessment of an intermediate depth burn about 80% of the time. That means in 20% of patient's clinical assessment alone is not enough. So the advantage of the moorLDI is that it seems to see things that we can't see with our naked eyes and it quantifies them to the expected healing time. So we can colour code them to areas which we expect to be healed within 14 days, these will heal without any scars what so ever and therefore clearly did not need to have any surgery. We can also predict which areas are likely to heal longer than 14 days but still within 21 days and again unlikely to have scaring except in particular areas of the body, in younger children and in people with darker skin. The third category that we can identify is burns that are predicated to take longer than 21 days to heal and in all situations unless they are very very small or the patient is extremely unfit those are areas that you would expect to have a better outcome with surgery. So the advantages to the patient are that they have confidence that the advice they are given in the management of their burn is going to give them the best outcome, the best outcome in terms of the appearance of the scars and absence of scars and in terms of the function. From the point of view of the NHS and our productivity clearly we need to make best use of our facilities, we should not be carrying out unnecessary procedures on patients, we should not be exposing them to unnecessary anaesthetics and we can confidently predict which patients require surgery. We can plan the timing of that surgery to give the best result for the patient and we then can be sure that the patients that do not need to have surgery can be dealt with swiftly and frequently in the community with support from the hospital but not needing to take up time in the hospital and they can be managed in their own environment where frequently they are much more comfortable to be and we reserve the beds in the burns wards for those patients who truly do need them.
Q6 Interviewer: Thank you very much there are clearly benefits for patients and the NHS. I wanted to ask some practical questions about using the device. When should the device be use post injury and how long does it take to do a scan?
SP: In the guidance we suggest that the best time for imaging is between 48 and 72 hours after the burn injury but infact it can be used up until 5 days after injury. Now that is not because of any particular feature of the technology that simply relates to what is happening in the burn wound. In any burn there will be areas of skin that are killed immediately by the heat or chemical or whatever has caused the burn and those areas will be dead from the time of the injury and will never change until it has healed or it has been operated on. But there are areas that are particularly common in intermediate depth burns where there has been a significant insult to the skin where the circulation may have become rather sluggish there may be tiny thrombi in the blood vessels so the delivery of oxygen and nutrients to the damaged skin is less than good and that may evolve and deteriorate over a period of time. So it would be untrue to say the technology is not stable until 48-72 hours after the burn it is the burn that is not stable until 48-72 hours after the injury. There is always a balance to be made if a clinician feels that in that particular clinical situation that person must have their burn excised on the day then no technology is going to be able to assist in that decision but if there is no clear benefit to the patient to have the burn excised sooner than 48 hours then the scan can be delayed until 48 hours and the surgery can follow. From the point of view of how long the scan takes it depends on how we set it up but most of the scans can be done within about 30 seconds to 2 minutes and then there is a pause before the next area is scanned. If the patient wishes to move their position then they are able to do so in between the scan. It is however, important that they keep still during the scan because movement of the body parts will be picked up by the scanner.
Q7 Interviewer: Where would the device be routinely used and by who?
SP: In my opinion all of the burns services from facility right through to centre will be able to offer a better service to their patients, make better use of their time and their costs and be more productive if they use the moorLDI to scan all of those patients who have intermediate depth burns or areas of intermediate depth burn in areas of superficial burns.
Q8 Interviewer: Do you need to be an experienced burn clinician to interpret the scan or can anybody do it?
SP: There is no doubt that the more experienced the burn clinician is the better the interpretation of the scan. We found that after about between 4 and 8 hours of practical training and instruction most plastic surgery trainees would be able to make a reasonable assessment and they would certainly be able to identify areas of low flow within a burn that would require surgery.
Q9 Interviewer: Brilliant thank you. What advice do you have for clinicians who are looking to use this technology in practice?
SP: Clearly the most important thing is to receive some training so that they become familiar both with setting up the device, how to use it, how to reduce the possibility of any artifactual elements being introduced into the scan. Really attending training given by somebody who is experienced in using the scan, setting it up and interpreting it. We are probably really only talking about a few hours of training for those who are already experienced in looking after patients with burns
Q10 Interviewer: Brilliant thank you. Do you have any advice for managers on how best to support this change in practice?
SP: Yes I think that managers should ensure that their staff are fully trained and comfortable in the practical use of the scan. It is important to make sure that there is time every day for scans to be performed because there are always days that will be appropriate for that patient. If that patient comes in late at night it may be that the scan needs to be during the later part of the day, 2 days after the injury and we need to be sure that whatever the time of day there are staff around who can do the scan. I am not saying in the middle of the night that would clearly be unnecessary but if the scan needs to be done late on a Friday afternoon we need to make sure that we have enough staff around who can perform the scan. It is also important to make sure that the service is backed up with experienced clinicians who are available to look at the scans. It is also important that the device itself is kept up to date. From time to time there are software upgrades and it is important that managers insure that the staff are able to upload these, it is important that the data is able to be stored safely so we need to have facilities for that to be carried out. It is also important that the devices are serviced from time to time and the easiest way to make sure that this happens is to set up a service contract and then routine service takes place, the devices are checked over, the sensors are checked, the alignments everything can be checked over on a regular basis and then one doesn't have the worry that some technical issues with the machine or the quality of the scan is going to interfere with the process of determining the burn depth and determining the best treatment for the patient.
Interviewer: Thank you very much Mrs Pape. We hope that you will find the information in this podcast useful in helping you implement this NICE guidance in practice. For more information about the NICE medical technology guidance on the moorLDI2-BI blood flow imager for burn wound assessment, and access to the NICE implementation tools which can all be adapted for local use, please visit our website, www.nice.org.uk/MT
This resource should be used alongside the published guidance. The information does not supersede or replace the guidance itself.
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This page was last updated: 19 September 2012