Mobile teleconsultations in acute burn care : acceptance and user-experience among emergency care providers in resource-poor settings

Background: Burn injuries are a global health problem with severe consequences for those affected and nearly 95% of all burns occur in low- and middle-income countries (LMICs). While minor burns can be treated locally such as at the emergency department, severe burns need transfer to a specialist burns centre. However, non-specialists often lack the training and experience to accurately diagnose and manage burns. While smartphones have been shown to be feasible for remote consultations between frontline providers and burns specialists, barriers may impede successful uptake.

Aims: The aims of the thesis were to deepen the knowledge about referral patterns of patients with burns in resource poor settings, and to study perceptions and experiences among emergency staff’s use of smartphones as a diagnostic support to improve the assessment, initial care and referrals of patients with burns.

Methods: Study I was a retrospective case study of 871 paediatric patients with burns at a trauma unit in Cape Town. Demographic, injury characteristics, and disposition was used to determine whether patients were referred according to local criteria. Study II was a mixedmethods study of the usability of a smartphone app (the Vula app) for burn injury consultations. Twenty-four emergency doctors and four burns specialists were enrolled in the study. A think-aloud study was conducted with all participants and their interaction with the app was video-recorded and later analysed using content analysis. The twenty-four emergency doctors also completed a usability questionnaire. Study III was a qualitative study where semi-structured interviews were conducted with 15 doctors regarding their experiences using the Vula app for burn consultations and referrals. The interview-guide and thematic analysis were informed by the Normalisation Process Theory. In Study IV, fifty-nine frontline health workers completed a questionnaire to assess their intention to use the Vula app. The questionnaire and the analysis were informed by the technology acceptance model (TAM).

Results: Study I. Most referred patients fulfilled the referral criteria. However, of those treated and discharged from the trauma unit, 8 out of 10 children also fulfilled the criteria for referral. In Study II, the usability test and questionnaire showed that the doctors perceived the Vula app to be easy to use and useful. However, some problems were identified mainly related to navigation, and understanding of meaning of icon’s terminologies. Some users also said that predefined options in the app limited their ability to express their clinical findings. Study III revealed several barriers and promotors for successful integration of the Vula app. Promotors included the already prevalent practice of using smartphones, that it was easy to use and the learning opportunity that the app offered. Barriers to successful integration included; inconsistent use of the app across specialities and lack of information, policies and infrastructure to support the users. In Study IV, almost all health professionals used smartphones in their work and were positive towards using Vula. Access to wireless internet and access to smartphones was mentioned to be a barrier.

Conclusions: Identifying patients with burns who are in need of referral is challenging. Mobile teleconsultations is therefore a way of assisting with diagnosis and initial management. The Vula app was easy to use and perceived to be useful, but several barriers need to be addressed for the app to become an integrated part of the practice in emergency care. In settings with considerably fewer resources, these barriers will likely be even more important to address prior to implementation.

List of scientific papers

I. Klingberg A, Wallis L, Rode H, Stenberg T, Laflamme L, Hasselberg. Assessing guidelines for burn referrals in a resource-constrained setting: Demographic and clinical factors associated with inter-facility transfer. Burns. 2017; 43: 1070–1077.
https://doi.org/10.1016/j.burns.2017.01.035

II. Klingberg A, Wallis LA, Hasselberg M, Yen P-Y, Fritzell SC. Teleconsultation Using Mobile Phones for Diagnosis and Acute Care of Burn Injuries Among Emergency Physicians: Mixed-Methods Study. JMIR mHealth and uHealth. 2018 Oct 19;6(10):e11076.
https://doi.org/10.2196/11076

III. Klingberg A, Wallis LA, Fritzell S, Hasselberg M. Just Vula it: Experiences among South African emergency doctors using a smartphone app for burn injury consultations. [Manuscript]

IV. Klingberg A, Sawe HR, Hammar U, Wallis LA, Hasselberg M. mHealth for Burn Injury Consultations in a Low-Resource Setting: An Acceptability Study Among Health Care Providers. Telemedicine and e-Health. 2019 Jun 4.
https://doi.org/10.1089/tmj.2019.0048