Abstract Title | The next step in burns training?


  1. Lindsay KJ
  2. Bedford JD
  3. Dickinson M
  4. Srinivasan JR
  5. McKirdy SW


Simulators and Simulation




Royal Preston Hospital, Lancashire Teaching Hospitals Trust



Training in emergency burn management is commonly delivered in a moulage format largely thanks to the success of the Emergency Management of Severe Burns (EMSB) course; this course has become the standard for training within the UK.

Simulation training has seen huge advances in the last few years. Not least because of the ever increasing pressures on trainee time as well as an increasing focus on learning new and potentially life saving skills away from the bedside.

Burns care is ideal for simulation based training as a result of its acute nature, fairly predictable initial pathophysiology and its relative infrequency; the National Burns Care Review 2001 estimated that 1,000 patients are admitted to UK hospitals with severe burns per annum1.


Simulation training provides a platform for trainees to hone skills that may be called into use infrequently; major burns are an ideal topic because of their rarity, significant morbidity and mortality, and the requirement for A&E, anaesthetics and plastic surgery trainees to be proficient in the stabilisation and initial resuscitation of these patients. 


Further work is already being done to incorporate a multidisciplinary team element. Currently scenarios have been developed to include Emergency Department (ED), Anaesthetics, and Plastic Surgery and Burns trainees as well as nursing staff.


An assessment tool has been proposed and is in the initial stages of development. This is an important aspect of any educational tool given the modern pressures on training and revalidation.

Take-home Messages

Severe burns education is ideally suited to Human Patient Simulator training.


The scope of the project has been extended by involving the wider multi-disciplinary team and by creating an assessment tool.


High-fidelity simulation may hold the key to standardising burns care and education.

Summary of Work

Fig 1. Trainees assessing a manikin mocked up with burn make-up in the simulation suite with three assessors in the background.


An educational programme for plastic surgery and burns trainees was devised and delivered using a state of the art high-fidelity simulation training facility at the Lancashire Simulation Centre.

The aim of the project was to incorporate the application of clinical knowledge and technical skill but also the human factors elements, or non-technical skill that can impact upon clinical effectiveness.

Several scenarios were devised with the key skills identified including, decision-making, teamwork, communication, clinical leadership, and ultimately the application of clinical skills. An initial pilot session was delivered in November 2011 and a subsequent session in May 2012 for several “early trainees” and “registrars” in the plastic surgery department. 


Two consultant plastic surgeons assessed trainees in real time within the facility. Each scenario was followed by a trainee lead video de-brief focusing on human factors elements and clinical acumen.


Participant feedback on the session was given anonymously at the end of each session and the data collated.


Special thanks to Mark Pimblett and Lorna Lees at Lancashire Simulation Centre as well Mrs Jackie Hanson and all the participants who have thus far contributed to our work.

Summary of Results

Trainees found simulation training to be an excellent adjunct to current methods of learning in burns and human factors. Collated participant feedback revealed that 100% of trainees felt that they would recommend the course to others and that they would like more simulation training incorporated into their own education.


Feedback Summary:


Participant response


Simulation themed feedback



1.    Is this your first experience of human patient simulation?



2.    The use of human patient simulation enhanced my learning experience:




Educational themed feedback



3.    Was the content suited to your educational requirements?



4.    This session has enhanced my ability to manage acute severe burns:



Course themed feedback



5.    Would you recommend this course to others?



6.    Should simulation training be incorporated into plastics and burns curriculum and formal training?



Fig 3. Tabulated results of participant feedback following simulation training


1.      National Burn Care Review Committee. Standards and strategy for burn care. ; 2001j

2.      The Australian and New Zealand Burn Association. Emergency Managament of Severe Burns Course Manual. 2006

3.      Stone CA, Pape SA. Evolution of the emergency management of severe burns (EMSB) course in the UK. Burns 1999, May;25(3):262-4

4.      Black SA, Nestel DF, Kneebone RL, Wolfe JHN. Assessment of surgical competence at carotid endarterectomy under local anaesthesia in a simulated operating theatre. The British Journal of Surgery 2010, Apr;97(4):511-6

5.      HOSLER RM. Six years' experience with the cleveland cardiac resuscitation course. AMA Arch Surg 1956, Nov;73(5):813-9

6.      Donoghue AJ, Durbin DR, Nadel FM, Stryjewski GR, Kost SI, Nadkarni VM. Effect of high-fidelity simulation on pediatric advanced life support training in pediatric house staff: A randomized trial. Pediatr Emerg Care 2009, Mar;25(3):139-44

7.      Brydges R, Carnahan H, Rose D, Rose L, Dubrowski A. Coordinating progressive levels of simulation fidelity to maximize educational benefit. Academic Medicine : Journal of the Association of American Medical Colleges 2010, May;85(5):806-12

8.      Abrahamson S, Denson JS, Wolf RM. Effectiveness of a simulator in training anesthesiology residents. Academic Medicine 1969;44(6):515

9.      Donoghue A, Nishisaki A, Sutton R, Hales R, Boulet J. Reliability and validity of a scoring instrument for clinical performance during pediatric advanced life support simulation scenarios. Resuscitation 2010, Mar;81(3):331-6

10.    Donoghue A, Ventre K, Boulet J, Brett-Fleegler M, Nishisaki A, Overly F, et al. Design, implementation, and psychometric analysis of a scoring instrument for simulated pediatric resuscitation: A report from the EXPRESS pediatric investigators. Simul Healthc 2011, Apr;6(2):71-7

11.    Savoldelli GL, Naik VN, Hamstra SJ, Morgan PJ. Barriers to use of simulation-based education. Can J Anaesth 2005, Nov;52(9):944-50

12.    Reznick RK, MacRae H. Teaching surgical skills--changes in the wind. The New England Journal of Medicine 2006, Dec;355(25):2664-9

13.    Kalson NS, Jenks T, Woodford M, Lecky FE, Dunn KW. Burns represent a significant proportion of the total serious trauma workload in england and wales. Burns 2012;38(3):330 – 339

14.    Bond WF, Lammers RL, Spillane LL, Smith-Coggins R, Fernandez R, Reznek MA, et al. The use of simulation in emergency medicine: A research agenda. Acad Emerg Med 2007, Apr;14(4):353-63.

15.    Rudolph JW, Simon R, Raemer DB, Eppich WJ. Debriefing as formative assessment: Closing performance gaps in medical education. Acad Emerg Med 2008, Nov;15(11):1010-6.

16.    Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high- fidelity medical simulations that lead to effective learning: A BEME systematic review. Med Teach 2005, Jan;27(1):10-28.




The Emergency Management of Severe Burns (EMSB) course was developed by the Australian and New Zealand Burn Association with the intention of improving the quality of care that burn patients receive

The course is delivered via a manual, a series of lectures, skill stations, interactive discussion groups and simulated moulage cases. To complete the course, participants must pass written and clinical moulage assessments.

It is aimed at medical and nursing personnel who may come in to contact with burn care in any setting and emphasises the benefits of universally applied, protocol driven care2.

The course was adopted by the British Burn Association in 1997 and is now a requirement for all UK plastic surgery trainees; the course is also commonly attended by doctors, nurses and other professionals from pre-hospital and emergency care3.

Further information on EMSB can be found online:


Simulation has been a focus for research into critical event management training since the 1950s, with early work in particular focussing on the management of cardiac arrest. Early forms of simulation included anaesthetised animals; technology has since progressed, particularly in the last decade, to provide us with realistic equipment such as the manikins used at the Lancashire Simulation Centre (LSC)4,5.

Developments like high fidelity Human Patient Simulator (HPS) systems have increased the educational impact of simulation6,7. Key elements of the increasing level of fidelity that can be achieved with simulation include dynamic physiological changes in response to scenario progression8, auscultation of heart and lung sounds, and airways which are suitable for intubation6,9,10.

Simulation training that focuses on the management of rare events is both intuitively important and desirable11 thus it can be best applied to situations where a diverse team of personnel are required to effectively manage complex or infrequent occurrences, as is the case with severe burns.

Modern pressures such as shortened training, as well as an emphasis on patient safety and accountability have meant that new assessment methods for surgical and procedural skills have had to be developed12. Simulation training and evaluation of performance is one way we can enhance modern training and assessment within the confines of restricted training time.


The LSC development was lead by consultant emergency physician Mrs Jackie Hanson. The suite has two full time, and two part-time staff. They facilitate simulation training for postgraduate and undergraduate trainees as well as allied healthcare professionals within the area and to a wider audience through courses.

The manikins in use at LSC are METIman pre-hospital and METI PediaSIM (CAE Healthcare, Saratoga, FL). The adult manikin is completely wireless and therefore portable, the paediatric manikin is tethered by a large umbilicus that provides data output.  The manikins are made up by the centre staff to provide visual context to a range of scenarios; centre staff are trained by METI in simulation makeup techniques.

More information can be found online:


A recent estimate calculated that major burns leading to death, or a hospital stay exceeding 72 hours, occurred at a rate of 4.7 per 100,000 per year in the UK13. 

The National Burn Care Review 2001 was commissioned by the British Burns Association as a result of evidence that UK burns services were “disorganized, fragmented, inadequate, and inequitable from a patients’ perspective”. 

Following their review, a number of key recommendations were put forth:

1. National clinical management and referral guidelines were developed to include a new way of classifying those with burn injuries as well as suggesting the development of national education programmes, such as EMSB.

2. All inpatients with burns were to be treated by specialists

3. The UK Burns service was restructured to have National Burn Injury Referral Guidelines and stratification of patients to Burn Facilities (BF), Burn Units (BU), and Burn Centres (BC).

4. Burn Centres must have dedicated critical care departments for the provision of burns care

5. Continuing care of patients with a burn injury was mandated as part of burns services to ensure that every patient had access to specialist functional, aesthetic and psychological rehabilitation.

6. All of the units BFs, BUs, and BCs were connected to one another in local networks to ensure seamless care for patients

7. Research and analysis into burn injuries and their management was commissioned

8. Improved data gathering and information analysis of burn injuries was suggested


A pilot session was carried out in July 2012 incorporating an initial assessment by ED staff, airway management by anaesthetists with handover and continuing care undertaken by the plastic surgery and burns trainees. Nursing staff from the ED were also involved to increase the fidelity and multi-disciplinary approach to training.


An assessment tool has been developed allowing for real-time video tagging of acceptable and unacceptable practice by consultant specialists. This is then incorporated into the video debrief. Work will continue to validate this method of assessment with the aim of providing a new tool for formative and eventually, summative assessment.

Take-home Messages
Summary of Work


The LSC is one of the most advanced facilities of its kind within the UK. The study was devised in consultation with the LSC staff, and scenario scripts were developed according to a standard template. The scenarios were devised with a panel of experts and referenced the most recent published works on burn care management.


Several areas of burns management including assessment and initial management of major (>10% total body surface area) burns, escharotomy, inhalational injury, toxic shock syndrome, and paediatric burn injuries were incorporated into the pilot sessions.

Fig 2. METI PediaSIM manikin with burn make-up detail to left forearm.




The simulation suite staff are experienced at facilitating video aided, trainee-led debrief at the end of each scenario.


Good quality feedback, as mandated by Ericsson, is seen as an essential component of skill acquisition and improvement14; a learner who reflects on feedback can integrate insights from experience into later action15. Feedback is seen as a key feature of simulation-based learning, being associated with a reduction in skill-decay over time16.


Summary of Results

Participant feedback was taken immediately after the session. The following questions were asked:

1.    Was the content suited to your educational requirements?

2.    Were the topics covered in sufficient detail?

3.    Is this your first experience of human patient simulation?

4.    The use of human patient simulation enhanced my learning experience

5.    This session has enhanced my ability to manage acute severe burns?

6.    My daily practice has been enhanced by this session

7.    The lectures/presentations enhanced my learning experience

8.    Instructors ability to provide real world experience?

9.    Instructors ability to respond appropriately to questions?

10. Instructors knowledge of subject matter?

11. Instructors presentation abilities?

12. Overall rating of Instructors/Facilitators

13. Professionalism of staff at the Simulation Centre?

14. Were the classrooms comfortable and conducive to learning?

15. Was the standard of the equipment appropriate to this course?

16. Were you satisfied with the refreshment facilities?

17. Overall rating of the course?

18. Would you recommend this course to others?

19. Should simulation training be incorporated into plastics and burns curriculum and formal training?


NB// Yes was coded for by Yes, Strongly Agree and Agree depending upon whether the responses used a Likert scale or were simply yes and no results. Simlarly No was used to represent No, Disagree and Strongly Disagree.


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