Assessment and Management of Pain in Patients Sustaining Burns at Emergency Department Kenyatta National Hospital, Kenya: A Descriptive Study
Round 1
Reviewer 1 Report
Thank you for the submission of this descriptive study on pain assessment and management of burn patients in your centre.
There is globally quite poor grammar and writing which is both unprofessional and difficult to understand at times.
My main issue is with the methods and valadility of such a study. The methods were poorly explained. Why did you choose to stop at a sample size of 138? Why were people that arrived >24hrs after burn excluded? These patients surely still have pain. If only 3% of participants had a pain assessment in ED how did you have VAS scores on almost all of them? Were they assessed once they got to the ward? It is really unclear how this study was performed. If you did the pain assessment once they got to the ward it does make more sense. But I would also suggest that this paper is essentially just an audit of the performance of your emergency department and not something that is groundbreaking or going to change practice for the rest of the world.
I don't understand how the aetiology of the burn is relevent to the results. There was no explanation in the introduction or methods of why things like burn aetiology, depth or TBSA would be relevant to the results. The design of the paper seemed to mostly be around understanding pain assessment or lack there-of.
How do you explain the fact that almost all participants had analgesia prescribed in the ED? I would say that although a VAS pain assessment was not done there must be some recognition by the medical personnel that these patients are in pain otherwise they would not be offered or provided with analgesia.
Regarding the discussion, what exactly do you mean by few trained personnel in the hospital? Who exactly is providing the care? You also insinuate that people working the hospital are not aware that burns can be painful i.e. they have been "slacking". But again, they are actually providing the analgesia. Could you offer an explanation as to why burns patients receive unimodal analgesia? is it because of the availability or cost of medications in your area? Perhaps you could provide some solutions to the problem you have elicited i.e. how this paper is going to effect change in your area.
In general, i think this manuscript has a long way to go to before it can be published. The material needs to make sense and be relevant on a global scale which it is not. I applaud your team for looking into this and hope that you have created some local pathways to improve pain management for burns patients in your area.
Author Response
Responses to Reviewer 1
Reviewer 1:
Comments and Suggestions for Authors
Thank you for the submission of this descriptive study on pain assessment and management of burn patients in your centre.
There is globally quite poor grammar and writing, which is both unprofessional and difficult to understand at times.
This has been improved, and the Grammarly app was used to address the English
My main issue is with the methods and validity of such a study. The methods were poorly explained.
This was a descriptive study, where we were just looking at the practice of pain assessment and management at the ED of Kenyatta National Hospital.
Why did you choose to stop at a sample size of 138?
This was from sample size calculation by Kish and Leslie formula for descriptive studies. I have included this in the methods section
Why were people that arrived >24hrs after-burn excluded? These patients surely still have pain.
Pain is most acute in the 24 hour period, and those who came late had some other treatment elsewhere which would bias our assessment of pain and its treatment. In our experience, there are those patients who come in late, after 3-7 days,s with burn wounds that are already infected. So actual cause of pain would be compounded by an infection. We were interested in looking at pain in burn victims directly atHospitalspital.
If only 3% of participants had a pain assessment in ED how did you have VAS scores on almost all of them?
This is looking like the practice of pain assessment at ED, only 3% natively had pain assessed by the ED care providers. The other victims has no pain assessment by the ED staff. It was the investigator who was assessing pain in burn victims meeting the inclusion criteria. The VAS score reported in the results was a study variable for which data was collected.
Were they assessed once they got to the ward?
This study aimed at collecting data in the ED, a follow-up study was done in the wards, but it was not the purpose of this paper. We hope to publish ward pain assessment and management sometime in the future. This study aimed at looking at pain assessment and management practices in the ED only. Pain assessment in the ward was not a part of this study. We also looked at the extent and depth of burn and compared it to the degree of pain.
It is really unclear how this study was performed. If you did the pain assessment once they got to the ward, it does make more sense.
The research assistant and the principal author would be at the ED waiting for burn victims, and upon seeing receiving them, they were quickly assessed for inclusion criteria. If they met and consented, then they would be enrolled. The aetiology, the depth, the TBSA and VAS score were recorded. The patient followed routine Hospital procedures. Once a treatment plan was written, this was recorded in the datasheet. Research assistants or principal investigators did not interfere with my physician decisions on pain or burn management at the ED.
But I would also suggest that this paper is essentially just an audit of the performance of your emergency department and not something that is groundbreaking or going to change practice for the rest of the world.
Thank you for this comment. Kenya is a big country, and Burn practices do not follow any guidelines. This paper would be a reason for hospitals and burn Societies to adopt the findings to develop models of improving care. In the East African region, similar studies have not been done, and so the authors believe that there is vital information to share with clinicians dealing with burn victims. An audit would just mean that the results remain with Hospital. KNH is the National referral Hospital for Kenya. All research arising from here would have a bigger impact on the Country at large.
I don't understand how the aetiology of the burn is relevant to the results. There was no explanation in the introduction or methods of why things like burn aetiology, depth or TBSA would be relevant to the results.
We did collect data on aetiology and also the depth of burn to compare it to the extent of pain. This was to see if the depth of burn was related to the extent of pain felt in our population and thereafter to relate It care offered in terms of pain control—Eg extent of burn and the mode of analgesia offered in table 2.
However, more literature is added pertaining to this by Castana Et al
The design of the paper seemed to mostly be around understanding pain assessment or lack thereof.
Yes, this paper did aim to look at burning pain-related practices by ED staff and also its management.
How do you explain the fact that almost all participants had analgesia prescribed in the ED? I would say that although a VAS pain assessment was not done, there must be some recognition by the medical personnel that these patients are in pain; otherwise, they would not be offered or provided with analgesia.
At the ED, the staff/ doctors are aware that burn victims are in pain; however, how much pain they had was not quantified by any tool; because of this, each clinician had his own way of prescribing analgesics. No protocol was followed. Most of the patients did receive some sort of analgesia, but the variation was vast. It is seen in table 3 mode of analgesia unimodal, multimodal. Most of the victims had unimodal, and opioids were the most common from this study. However, evidence from the literature suggests that pain management should be guided by the severity of pain, not only that it is also recommended to be multimodal, our study reports findings contrary to literature recommendations. The authors feel that this is a big gap in inpatient care, and it should be availed as a publication so that people treating burn victims realize the degree of pain should be tallied to the extent of burn and use this to guide the analgesia to use.
Regarding the discussion, what exactly do you mean by a few trained personnel iHospitalspital?
Trained personnel to assess pain and its management. Often in the ED, most of the care is offered by Medical officers, who can manage burn victims immediately, but they do not focus on the aspect of appropriate pain management. An analgesic prescription would be written, but it is through a routine. If they were trained on how to assess for the pain, they would be called "TRAINED PERSONNEL".
Who exactly is providing the care? You also insinuate that people working Hospital are not aware that burns can be painful, i.e. they have been "slacking". But again, they are actually providing the analgesia.
Care in the ED is provided by medical officers (MD, MBBS, MBChB holders). They are aware that burns cause pain, but they are not aware of their appropriate management. Burn related pain has undergone a revolution from using any analgesics, e.g. either one, without relation to the extent of burn or intensity of pain. This information is lacking from our study. We would have expected more of multimodal pain medication, i.e. more than a single analgesic prescription, we would have expected the pain to be measured, but this was not mirrored in our study hence the utility of the word slacking. We acknowledge that pain management is done, but it is not optimum hence the word slack.
Could you offer an explanation as to why burns patients receive unimodal analgesia? is it because of the availability or cost of medications in your area? Perhaps you could provide some solutions to the problem you have elicited, i.e. how this paper is going to affect change in your area.
We have no reason why the patients received Unimodal analgesia since we aimed to look at pain assessment and its management. Medications are available, but they are not prescribed together.
In conclusion, we advise more studies to be conducted to understand why pain management is mostly unimodal at the ED of KNH. We also recommend that burn surgeons and pain therapists be urgently involved in the improvement process of pain care in burn victims.
In general, I think this manuscript has a long way to go before it can be published. The material needs to make sense and be relevant on a global scale which it is not. I applaud your team for looking into this and hope that you have created some local pathways to improve pain management for burns patients in your area.
Thank you for your overall final remark. I hope the explanations provided will offer you a wider angle of looking at this manuscript.
Author Response File: 
Author Response.docx
Reviewer 2 Report
This is an interesting article and I enjoyed reading it.
This article aims to describe the assessment of pain in burns patients presenting to ED and the management thereof. It contributes valuable information to the literature regarding management of pain in burns patients, it identifies a need for improvement.
The title includes the word management and it is recommended to expand on this in the background section as it will contribute to the discussion as well. For example the authors include multimodal pain management, but how would such a regimen look like. What about intravenous vs oral pain management options? What do guidelines recommend? And are the results from the study aligned with these recommendations.
The methods section can be expanded. Was this a retrospective study? Was a sample calculation done (how was the 138 sample size calculated)? Was a data collection tool designed and what type of data was collected (allergies?) ? Who collected the data? Do you know how often pain was assessed in ED?
On page 3 the abbreviation TBSA is mentioned but this word has not been spelled out with the abbreviation in brackets. Just ensure all abbreviations are spelled out first with the abbreviation in brackets.
With regards to the results section - sometimes less is more. See how you can combine graphs/tables. A table 1 with demographics would be interesting and contribute to the data. It would be interesting to see the different types of analgesia used for the severity of burns. This could be expanded on in the discussion and compare with literature. Is there a significant difference between burn prevalence and gender. The p value on page 6 is different from the p value on page 4.
No limitations /recommendations are listed. What about possible confounders that could have influenced your results?
This is an important study and highlights an urgent need for improvement. SMART recommendations are needed to act upon these findings. Recommendations will strengthen your conclusions.
Author Response
Reviewer 2
Comments and Suggestions for Authors
This is an interesting article and I enjoyed reading it.
Thankyou for the nice comment.
This article aims to describe the assessment of pain in burns patients presenting to ED and the management thereof. It contributes valuable information to the literature regarding management of pain in burns patients, it identifies a need for improvement.
The title includes the word management and it is recommended to expand on this in the background section as it will contribute to the discussion as well. For example the authors include multimodal pain management, but how would such a regimen look like. What about intravenous vs oral pain management options? What do guidelines recommend? And are the results from the study aligned with these recommendations.
There are no clear guidelines on how to control pain in burn but different authors propose certain formulation. Eg Patterson suggest multimodal with opioid and any other medication like NSAID, anxiolytics, acetaminophen and they also propse a route of admisitation. I have added this on the introduction part and also in the discussion (kindly trace it in the document using trackchanges addressed “In response to review 2”
The methods section can be expanded. Was this a retrospective study? Was a sample calculation done (how was the 138 sample size calculated)? Was a data collection tool designed and what type of data was collected (allergies?) ? Who collected the data? Do you know how often pain was assessed in ED?
This was a prospective descriptive study, sample size was calculated using the kish and Leslie formula for descriptive studies. The data was collected by the author main author and trained research assistants. Pain was assessed once by the investigator since pain assessment was not a practice at the KNH ED. It was Assessed immediately as the victim arrived at the ED
On page 3 the abbreviation TBSA is mentioned but this word has not been spelled out with the abbreviation in brackets. Just ensure all abbreviations are spelled out first with the abbreviation in brackets.
The abbreviation TBSA has now been addressed.
With regards to the results section - sometimes less is more. See how you can combine graphs/tables. A table 1 with demographics would be interesting and contribute to the data. It would be interesting to see the different types of analgesia used for the severity of burns. This could be expanded on in the discussion and compare with literature. Is there a significant difference between burn prevalence and gender. The p value on page 6 is different from the p value on page 4.
Table 3 has been changed. Included now is the severity of pain and the preference of analgesics offered in each group of severity. A discussion has been added for the same too
The P-value has was a typo error. The correct one is on the chart under results.
No limitations /recommendations are listed. What about possible confounders that could have influenced your results?
The journal format didn’t have a place to put the limitation or recommendations and so recommendations were part in the conclusion.
I have added some limitation of this study.
This is an important study and highlights an urgent need for improvement. SMART recommendations are needed to act upon these findings. Recommendations will strengthen your conclusions.
Addressed in the conclusion again. Shall insert a recommendation bullet? As it was not in the journal format. However as posrt of the conclusion I have put recommendation under it.
Round 2
Reviewer 1 Report
there have been significant improvements in the writing. I now at least understand how this study was performed, previously it was a bit of a mystery. There are a few recommendations I made previously that have not been acted upon. The conclusion is also very basic. Given that this paper is essentially a write up of your local audit that demonstrates significant flaws in your system perhaps you could write a more detail and thought provoking conclusion. offer solutions as to why and how things might change in your local area. Otherwise I fear this whole thing was for futility (and getting a paper published) if nothing ever changes.
Author Response
Reviewer 1:
There have been significant improvements in the writing. I now at least understand how this study was performed, previously it was a bit of a mystery. There are a few recommendations I made previously that have not been acted upon.
Acted upon in the lower section of this review
The conclusion is also very basic. Given that this paper is essentially a write up of your local audit that demonstrates significant flaws in your system perhaps you could write a more detail and thought provoking conclusion. offer solutions as to why and how things might change in your local area. Otherwise I fear this whole thing was for futility (and getting a paper published) if nothing ever changes.
WE write this paper not for the reason of futility but an eye opened. KNH is the pinnacle of Surgical care in the country, it is the hub for Training Surgeons, medical doctors and nurses. Through the publication of this paper not only wound there be a spark in the change of care for burn victims. I feel it is very hard to treat something whose magnitude is not known despite the presence of tools for identifying it.
Another reason is an audit would only mean change at this hospital, but this knowledge gap can be spread to hospital in this and neighbouring country so that it would also generate interest in their own practices. Overall the main reason is to create awareness about catering for pain in burn victims it remains a problem in the developing world.
I have tried to make the conclusion better I hope it suffices your requirements.
To conclude, 65% of burn victims sustained moderate to major burns and minority of the patients had any sort of pain assessment done at emergency department, as result burn pain was inappropriately managed. There is an urgent need to improve assessment of burn pain treatment through scoring and thereby improve its management through the involvement of burn surgeons and pain therapists. These specialists ED. Further studies at KNH.
Response to questions from initial review
Regarding the discussion, what exactly do you mean by a few trained personnel in Hospital?
Trained personnel to assess pain and its management. Often in the ED, most of the care is offered by Medical officers, who can manage burn victims immediately, but they do not focus on the aspect of appropriate pain management. An analgesic prescription would be written, but it is through a routine. If they were trained on how to assess for the pain, they would be called "TRAINED PERSONNEL".
Who exactly is providing the care? You also insinuate that people working Hospital are not aware that burns can be painful, i.e. they have been "slacking". But again, they are actually providing the analgesia.
Care in the ED is provided by medical officers (MD, MBBS, MBChB holders). They are aware that burns cause pain, but they are not aware of their appropriate management. Burn related pain has undergone a revolution from using any analgesics, e.g. either one, without relation to the extent of burn or intensity of pain. This information is lacking from our study. We would have expected more of multimodal pain medication, i.e. more than a single analgesic prescription, we would have expected the pain to be measured, but this was not mirrored in our study hence the utility of the word slacking. We acknowledge that pain management is done, but it is not optimum hence the word slack.
Could you offer an explanation as to why burns patients receive unimodal analgesia? is it because of the availability or cost of medications in your area? Perhaps you could provide some solutions to the problem you have elicited, i.e. how this paper is going to affect change in your area.
We have no reason why the patients received Unimodal analgesia since we aimed to look at pain assessment and its management. Medications are available, but they are not prescribed together.
In conclusion, we advise more studies to be conducted to understand why pain management is mostly unimodal at the ED of KNH. We also recommend that burn surgeons and pain therapists be urgently involved in the improvement process of pain care in burn victims.
Thank you for your overall final remark. I hope the explanations provided will offer you a wider angle of looking at this manuscript.
Reviewer 2 Report
Thank you for reviewing and resubmitting the article.
Please ensure references are correct after changes has been made and new references added. There might be a discrepancy with reference 17 and 9 on page 2.
Author Response
Please ensure references are correct after changes has been made and new references added. There might be a discrepancy with reference 17 and 9 on page 2.
Thank you for noting this, actually, there was a discrepancy I have addressed it accodingly.
