The Burns Registry of Australia and New Zealand: progressing the evidence base for burn care

Cleland and colleagues1 have analysed the data collected from the Burns Registry of Australia and New Zealand. The main purpose for the development of health care registries is to monitor and measure the effectiveness and quality outcomes of clinical care,2 thus enabling professionals to improve standards and treatments to patients by providing optimal care and management. The authors concluded that there was significant variation in management and outcomes of patients treated for severe and complex burn injury. They recommended further analysis and development of the registry in order to put in place clinical guidelines to improve the quality of care for patients with burn injury across Australia and New Zealand.1 While I agree with the importance of understanding the variations in practice and outcomes, it is also important to understand the authors’ definition of “evidence-informed clinical guidelines”, as implementing a practice that is too proscriptive or rigid may hinder the resilience of health care.

The article concluded that “the focus of ongoing research is … to develop evidence-informed clinical guidelines for burn management in Australia and New Zealand”. There is a risk that clinical guidelines could be developed into prescriptive procedures that can be restrictive and, in some cases, may cause more harm.3 The Oxford English Dictionary describes a guideline as “a general rule, principle or piece of advice,” providing the user with a resource to follow but not restricting them to a direct path from which they are unable to deviate. Health care processes need to be flexible and adaptable to change, as they are being used in highly complex systems. It is essential that procedures and guidelines are implemented to support this system and not to trap or transfer responsibility, accountability or blame from management to employees, secondary to deviation from a flawed procedure. Wears proposed that “‘failure to follow procedure’ is often noted as a cause of accidents, while ‘poorly designed procedures’ is almost never cited”.3

Procedures or guidelines need to be written in a manner that does not stifle innovation or appropriate complex reasoning and decision making. Moreover, they need to allow for adaptation due to the unique context of the situation.4 The registry should provide the ability to record and reflect these modifications or deviations of practice to assist with the evolution and improvement of treatment plans and patient outcomes,3 learning from both successful and failed events. The production of flexible and effective procedures will support and sustain resilience in health care and improve rather than hinder patient outcomes.3