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STANDING COMMITTEE ON HEALTH AND AGEING
House of Reps
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STANDING COMMITTEE ON HEALTH AND AGEING
CHAIR (Mr Georganas)
Ms T Scroggie
Ms J Scroggie
Mr van Gerwen
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STANDING COMMITTEE ON HEALTH AND AGEING
(House of Representatives-Monday, 1 February 2010)
van GERWEN, Mr Stephen Joseph
PETRYS, Mrs Debra Ruth
CAMERON, Professor Peter
CHAIR (Mr Georganas)
SCROGGIE, Ms Terri
Mr van Gerwen
KIMBLE, Professor Roy
SINGER, Dr Andrew Harris
KAVANAGH, Mrs Sheila Mary
GRIFFITH, Mr Wayne
McCARTNEY, Mrs Nerissa
Ms J Scroggie
TOWERS, Mr Kurt
BUZA, Mrs Yvonne
Ms T Scroggie
O’NEILL, Mrs Susie
BURTON, Mr Julian, OAM
MAITZ, Professor Peter, AM
SCROGGIE, Ms Jessica
DUNN, Mrs Kellie
- Mrs Kavanagh
Content WindowSTANDING COMMITTEE ON HEALTH AND AGEING - 01/02/2010 - Burns prevention
CHAIR (Mr Georganas) —I declare open this public forum on burns prevention. According to the Julian Burton Burns Trust, burn injury in Australia is the third highest cause of accidental death in children under the age of five, affects 200,000 Australians each year, is 65 per cent more likely to occur in the home environment, is 23 per cent more likely to occur in a remote area than in a metropolitan location and costs the community over $150 million per year. These are pretty astonishing figures. Therefore the committee has decided to convene this roundtable into burns prevention to discuss both the costs of burn injury to Australia and ways to minimise or prevent burn injuries from occurring in the first place.
I would like to take this opportunity to thank everyone here for making time to speak with all of us here at the committee. Your evidence will be used in the preparation of a report which will make recommendations to the Minister for Health and Ageing. I remind participants that today’s proceedings are covered by parliamentary privilege. Essentially this means that there is no legal action that can be taken against participants in relation to the evidence being given during this roundtable session. This immunity does not apply if, after the hearing, any participant repeats statements made in evidence.
Although the committee does not require you to speak under oath, you should understand that these hearings are formal proceedings of the Commonwealth parliament. Giving false or misleading evidence is a very serious matter and may be regarded as a contempt of parliament. I will ask if we can quickly introduce ourselves around the table, starting from this end and working our way around.
Dr Singer —I am the Principal Medical Adviser in Acute Care for the Department of Health and Ageing and I am also an active clinician in emergency medicine.
Mrs O’Neill —I am the founder of the KIDS Foundation and the Burn Survivor Network. I am a qualified primary and preschool teacher and I am currently pursuing a PhD at Monash University. My focus is on developing safety risk management skills in children.
Mrs Dunn —I am the Head of Injury Recovery at the KIDS Foundation.
Mrs McCartney —I am the Burn Survivor Network coordinator at the KIDS Foundation.
Mrs Petrys —I am the General Manager of National Programs for COTA, which represents the interests of people over the age of 50.
Prof. Maitz —I am a burns surgeon and a plastic surgeon from Sydney and I am here in my capacity as a board member of the Julian Burton Burns Trust.
Mr Burton —I am the founder of the Julian Burton Burns Trust.
Ms T Scroggie —I am the parent of two girls who have been through burns.
Ms J Scroggie —I am a burn survivor.
Mr Griffith —I am also a burn survivor from South Australia and I am also a volunteer for the Julian Burton Burns Trust.
Mrs Kavanagh —I am the President of the Australian and New Zealand Burn Association and I am also the nurse in charge of the Burns Unit at Royal Adelaide.
Prof. Cameron —I am Academic Director of the Emergency and Trauma Centre, the Alfred Hospital, and I am here as Chair of the ANZBA Registry Steering Group, which is the national registry for burns.
Mrs Buza —I am Chairperson of the Aboriginal Health Council of South Australia.
Mr Towers —I am coordinator of the Burns SA Aboriginal Burns Program. Yvonne is here representing the program as a major stakeholder.
Prof. Kimble —I am a paediatric surgeon and Director of the Stuart Pegg Paediatric Burns Centre at Royal Children’s Hospital in Brisbane and I am also Director of Paediatric Trauma in the Queensland state-wide network.
Mr van Gerwen —I am the National Training Manager for St John Ambulance Australia.
CHAIR —Thank you very much. I will now begin the interactive roundtable session. However, before we commence, I would like to remind the participants of the format these sessions will follow. At the start of each session, I will announce the theme and then we will provide each organisation with the option to speak on that particular theme for up to three minutes. The secretary will ring a bell when you have 30 seconds remaining and that will enable you to complete your statement within the allocated three minutes.
Participants should note that they are not obliged to make a statement on a particular theme. If, for example, we are discussing a particular theme and you do not wish to make a statement because you feel it is outside of your area or knowledge, or has already been addressed by another organisation’s statement, you do not have to speak on it. To ensure that everyone has an equal opportunity to speak and to maximise time for questions and discussions, the three-minute time limit will be strictly adhered to—at least I would like to think that we will try to strictly adhere to it.
Following the introductory statements, members of the committee will have the opportunity to ask questions, so we will then open it up to the panel here to ask particular questions. Following questions, I will then invite members and participants to engage in a general discussion relevant to the theme. The general discussion will be the focal point of each session. It will allow clarification of issues and will provide the setting for participants to exchange ideas.
The first topic is the impact of burns injury on the individual, the family and the health system. The objective of this discussion is to better understand the financial and social costs of burn injuries on survivors, on their families and on society as a whole. I will now invite different organisations to make their three-minute statement before we then proceed to questions and answers.
Dr Singer —In terms of the impact on the health system, I can report that the Australian Institute of Health and Welfare’s national hospital morbidity database, which covers the 10-year period from 1998-99 to 2007-08 financial years, shows that there were almost 74,000 hospital separations over that 10-year period where the principal diagnosis was a burn or burn injury. Compared to the total injury burden across the nation, that is approximately 1.6 per cent of the total number of separations related to either an injury or a poisoning. By far the majority of those burdens are due to a partial thickness burn in one or more parts of the body.
The age distribution is pretty much as expected. There is a peak amongst young children. There is then a second peak amongst young adults. If you look at the data in relation to the proportion of each age group to the population, there is also a peak amongst elderly people as well, though it is not reflected when you look at the population as a whole. The length of stay of these patients has been gradually reducing over the last 10 years. On average, it is reducing by about a day per separation. That does not sound like very much, but remember that this is averaged over quite a large group.
In terms of the costs, I was able to obtain data from the department’s database that gives information based on diagnostic related groups and that essentially says that for the 2007-08 financial year there were 7,912 separations that they were able to include in that collection and the estimated cost based on the diagnostic related groups was around $65 million for a year. That is all I need to say about this.
CHAIR —Thank you. I believe one of the committee members has a question.
Ms KING —How does that compare with the other injuries in terms of the actual costs?
Dr Singer —Unfortunately I do not have comparative data about the costs.
Ms KING —Are you able get that for us? I know that when I worked in the health department one of the really powerful statistics that we had was falls amongst older people and the amount that was costing the community. That resulted in the government actually investing some money. It would actually be really helpful to know, if there are other statistics in relation to other areas of injury, just how much burn injuries are costing.
Dr Singer —I can certainly do that. There are different major diagnosis groups that we can get the collections from.
Ms KING —That would be very helpful. Thank you.
Mrs O’Neill —In the KIDS Foundation we are dealing with families post trauma. The most common incidents of burns have been car accident survivors, playing with matches, house related fires, scalds and self harm. The work in the recovery has been reconnecting the families, and Kellie will talk a bit more on that.
Mrs Dunn —In 2006 we conducted a burns survivors support survey, which I would like to put up as an exhibit. We will be referring to that as the data that we have collected. We surveyed burns survivors who are part of our network. In total we surveyed 30 families, which can represent up to about 100 burns survivors, with multiple people being burnt in the one incident. We discovered that there were short-term needs, medium-term needs and obviously longer term needs that our burns survivors needed help and support with. That included support whilst they were in hospital. Obviously financial support was a big issue in terms of transport—getting families to the hospitals and home again—as well as finding somewhere for them to stay, food and things like that. Often income had decreased dramatically with the burns survivor not being able to continue with their employment and then with the family members being the carers and not being able to continue with their employment either. That was one of the major issues that our burns survivors reflected.
Some of the longer term supports they spoke about needing after hospital were pain relief for scar tissues and medications and vitamins for skin care. So there was the ongoing cost of the medical treatments. Psychological and psychosocial rehabilitation sometimes also incurred an out-of-pocket expense. There was also the emotional support from family and friends. That became quite significant and sometimes quite a load on family and friends, so having other people to offer support, like a burns support network, was very important. Returning to the work environment, if the person was working, or the study environment was one of the longer term needs that we are looking to focus on. Reintegrating the burns survivor, who now has different self-esteem and a different self-concept to what they had prior to the accident, requires quite a large adjustment. So we have been working with schools and looking at reintegration, especially for younger ones. We found that that is a great need out there.
There are also little things like home improvements that need to happen in the house for the burns survivor, who may have a loss of limbs and sometimes has quite a large disability. Then there are the processes of going through that, and they found that they needed long-term support with that. Some of the issues that they found when they left hospital were about heading back into the environment that they knew themselves in once before and how much that has changed. There is the perception of the community around them and the public. Some of the things that we experience when we have our family camps and when we have our young burns survivor camps are the loss of self-esteem or the diminution of what was high self-esteem beforehand. Looking at helping our burns survivors with their psychosocial rehabilitation has been really important.
CHAIR —Before we go to the next speaker, is it the wish of the committee that the submissions tabled earlier by the Department of Health and Ageing be accepted as evidence to the roundtable forum on burns prevention and authorised for publication?
Mr IRONS —So moved.
Ms HALL —I second it.
CHAIR —It is so ordered. Also, is it the wish of the committee that the documents tabled by the Burn Survivor Network be accepted as an exhibit and received as evidence to the roundtable forum on burns prevention?
Mr IRONS —So moved.
CHAIR —There being no objection, it is so ordered.
Mrs Dunn —May I just say one more thing? I forgot to mention at the very start that it was a collaborative survey that was done on advice from ANZBA after an ANZBA conference. So there were other organisations who are listed on that document who also helped us with that survey.
Ms KING —How are the KIDS Foundation and the Burn Survivor Network funded?
Mrs Dunn —Susie might help me out in this one, as I am a newer staff member, but my understanding is that we have different private philanthropic funding that we apply for, and donations.
Mrs O’Neill —The majority is our own fundraising, but we also received grants fairly recently through private foundations that have been engaging in the work that we do.
Ms KING —And you have just recently had a small amount of federal funding.
Mrs O’Neill —We just got our first government funding recently. It was not related to this area, but yes. That was pretty exciting, pre-Christmas.
Mrs McCartney —Kellie has addressed topic 1 quite well. I would like to address the question: ‘Are there sufficient specialists to treat and manage burn injury in Australia?’ My answer is yes, of course. However, I do strongly believe that there is still a need for post-hospital support. There is a big need for that out there. I also think collaboration is really important across Australia for burns support networks. We would really like to work hard on that this year. Thank you.
Mrs Petrys —I represent the Council on the Ageing, COTA. We believe that the data on burns related to older people under-represents the situation. Looking at the collected data, we feel that the statistics are poor nationally. Many older people are attending their GPs for burns treatment, and we do not believe that this area has been captured as sufficiently as we would have hoped.
Generally, scalds are the most common burn for older people and they tend to take a significantly longer time to recover from burns. There are also risk factors that compound the issue, and those are particularly around the areas of dementia, cardiac and respiratory diseases, smoking and alcoholism. Social factors relating to burns also contribute to this issue. There is a lack of supervision of older people who live alone, particularly those with dementia, and there is a lack of domestic support, particularly after the event.
There is a significant cost for older people with burns. This is particularly so for people who are on a pension or limited income. There tends to be a greater number of medical, surgical and wound healing implications as a result this, which is more expensive on the health system. As I said previously, the recovery of older people with burns tends to be slower and they require more rehabilitation, because a number of older people usually have other compounding factors such as chronic illness. As I said, there are few studies, particularly looking at the long-term psychological factors of burns on older people. So we would like to see more work done in this area. Thank you.
Prof. Maitz —I think I am in a unique situation, because I can already comment on other speakers before me. According to the statement that the annual cost of burns treatment is $65 million in Australia, I can refer to a publication from a British burns association that states that the true cost of a burn injury is hidden in one-third of the acute hospital cost and two-thirds in rehabilitation and loss of income. If we were to accept the cost of $65 million per year then that would be one-third of the true cost.
Currently, my group is undertaking a project to try and find out what is the actual dollar value if an adult burns patient is admitted and treated and they survive to go back to their family. I treat only adults so I cannot speak for the paediatric population. We estimate that an adult burn injury in the vicinity of 50 per cent of the body surface area will cost more than $700,000. This is for one patient undergoing acute care only. I believe that will be the result.
It may also make sense to educate the members of the parliament about a universally accepted formula, a very basic formula, to chart the severity of a burn. That formula goes back to a French surgeon called Baux. The formula states that, if you add the percentage of the full thickness or the deep dermal burns of a person to their age in years and that number is over 100, that person has a more than 50 per cent chance of not surviving that injury.
This is a very old rule of thumb calculation, and science and modern treatment are pushing the boundaries. But this is just in support of what Mrs Petrys said; I think the elderly population is a major problem because it is much more difficult to treat and to rehabilitate these patients. There is a huge issue, I believe, in this country that we have admissions almost every week. I run the busiest adult burns centre in the country. Almost every week I get a patient in the age group between 60 and 80 that has a sometimes lethal scald from a shower. I did not grow up in this country. When I came to this country I thought, ‘Why is this? I have not seen this in Europe, where I was trained.’ This is because the water is so hot. This does not happen in the United States or in central Europe, because we do not have water that is hotter than 40 degrees in the bathroom. It is one of these examples. I believe my colleague, Roy Kimble, will talk about the problems in children where, by far, the most common one is a scald as well.
The statement by Ms McCartney that we believe there are sufficient specialists who treat burns in this country I think is very questionable. I believe that I, as a person, am a good example, because I would not be here as a foreigner if Australia would produce enough specialists. And I am not the only leading burns specialist in this country who has not been educated and trained in this country. We are currently working very diligently with the Royal Australasian College of Surgeons to try and ensure that the next generation in Australia will provide burns specialists.
There are not only the surgeons; there is a nationwide shortage for specialised nursing treatments. If you talk to any nursing unit manager in burns in Australia they will tell you that it is very difficult to get enough staff. There are certainly not enough specialised allied health people. The surgeon and the nursing staff are only one part of the treatment. To get these people back to normal activities they need a lot of physiotherapy and occupational therapy. I would state, whilst I cannot prove this with published evidence, that a severe burn injury is probably the most debilitating and difficult health issue that a patient can sustain. Whilst the total numbers in a country like Australia would seem small, all these patients have life-changing experiences. I think that is what we are facing. This is why individuals like Julian Burton came out and established a fund, because there is not enough knowledge about this out there.
Finally, when I came to Australia 10 years ago I ran a burns unit with six beds. I now have 10, and I have an occupancy of more than 110 per cent. It does not seem to abate, and this is why I believe we should be talking about this.
Mr Burton —As the founder of the Julian Burton Burns Trust, I suppose I am also a burns survivor, suffering life-threatening burns in the Bali bombings. I would just like to talk about the impact of burns on an individual.
From my point of view, I fully support what Peter Maitz is saying with regard to the physical and emotional impact of burns on an individual. In one way I was very fortunate; I was 29 when I suffered my burns, so I think I was mature enough to understand a little bit about it—having a sporting background. But the impact of the burns is that physically they are disabling and disfiguring and emotionally they are shattering. I can sit here and cover my burns—it is easy. Unfortunately, we have a young girl to my right who cannot. I think Jess and I are two of many that deal with a burn every day and, unfortunately, it is a disability, it is disfiguring and it has a huge impact on you emotionally.
Ms T Scroggie —As a mum of two kids who have been through burns—both my girls were disfigured, and amputees as well—I think people do not realise that it affects the whole family. It does not affect just the two, or whoever is involved or who has the direct burns. The whole family unit breaks down, and the support is not there.
One of my children has something like Tourette syndrome now. A bit of the background is: the girls got burnt and my husband and I just left to be at the hospital. I had a one-year-old at that stage as well, and he did not see us for about three months. I would walk out the door and he would scream. I could not afford to come home all the time to see the kids, and I could not bring the kids to the hospital, because they were in the ICU and that is not something you want to put your children through.
I just want you guys to know that it is not just the ones who survive the burns but a whole unit of people who are affected. My parents have also been affected. They had to leave their jobs and their home to come and look after the other children. There was no income or support for them.
Mr Griffith —I was involved with a bushfire in which I lost my wife and my two grandchildren at the same time. I found that when I was in hospital I felt so secure that, when it came time to leave, I had to push the doctor to let me leave because we had three funerals to attend to. The moment he said ‘yes’ to me, I looked out the window onto North Terrace in Adelaide and thought, ‘I don’t want to go out there.’ I became very hermit-like and could not go out. I was living at home by myself and trying to treat myself. If I had to do some shopping I would do it very early in the morning or very late at night so I did not have to meet people. I did not like people looking at me, because I had this second skin on. At the time I had 75 to 80 per cent burns to my upper body with 17 per cent full-thickness burns. I could not handle it. I tried to drive my car to go into hospital, but because the burns were to my upper body I was trying to lean forward and change gears, and I found that very difficult and I was scared of having an accident. It was a very tough time. I feel that there has got to be somewhere to go where there is a supporting group, maybe of burns survivors like me, who can talk to some of these other survivors and give them an opportunity to know what is before them and how to overcome these problems. I would like to see something along those lines set up if it were possible.
Ms KING —Could I ask Nerissa: does the Burn Survivor Network cover the whole of Australia, or is it patchy—
Mrs McCartney —It covers the whole of Australia. I think that maybe one of the reasons for Wayne not finding out about us is lack of awareness and the funding to be able to have that awareness. I am quite passionate about it becoming prevalent within Australia, because my husband is a burn survivor and I understand completely what you are speaking about as survivors and family members. I would like to get together with you, Wayne, and have a chat, and we could probably work together with Julian and the Scroggie family and achieve what you would like to see achieved.
Mr Griffith —I have become a volunteer with the Julian Burton Burns Trust, and that is one thing I try to do. I have been involved in going out to classes about fire prevention and talking to children about my experience and the effect it has had on me and also my family. I have talked to them about the repercussions if they light a fire and their family or friends are involved further down the fire front. I have found that it is having a profound effect on what they think. We have had reports back that three months later the children are still saying, ‘There’s no way I’ll light a fire.’ To me that has been a good thing, but I have found that I have had to give it up just recently, around last August, because I have been telling my story all that time since 2005 and I have not been recovering myself. So I have had to give it up for the time being.
Mrs Kavanagh —We talk about the cost of burn injury, and I think there are a couple of facets to that. The financial cost is one, and when we look at the decreased length of stay, that is directly linked to rising costs in terms of the use of skin substitutes and specialised dressings. So we are seeing a trade-off in terms of costs around length of stay and financial implications.
The other thing is the emotional cost, which Wayne and Terri have spoken about, to burns survivors. Also, we have to consider the impact on the health workforce in terms of the emotional toll. I agree with Peter, I think the clinical workforce at the moment is probably just adequate, but one of our problems is succession planning. Burns surgery especially is physically hard work. The guys work in operating rooms that are kept at temperatures of between 30 and 32 degrees and it is long, arduous surgery. The caring for the patients takes a high emotional toll on the nursing staff, the therapists and all the other clinicians who look after them. I agreed that the allied health workforce in particular is not well funded to provide the sorts of numbers that are required to adequately look after these patients. Patients currently are getting well looked after—I am not saying they are not. But you will find that burns clinicians have a very high sense of personal responsibility to make sure that we get the best outcomes that we can for people, so that means people doing a lot of things in their own time. Another thing is trying to attract people into the workforce, which we know is challenging.
The other thing that we do not know is the true extent of injury across society. We see the high end, the high cost, but what we do not see are the numbers of people who get smaller burns who are treated locally and the impact that has in terms of loss of time. Everybody in this room will have been burnt at some time, whether it be just putting a hand in the oven or something small. If you work in hospitality or in the health industry, having a bandaid on your hand is not a good look. We know that the casual component of the workforce is rising, and we do not capture how many people who have casual jobs lose their wages because of small burn injuries. So it is about making sure that we have a system to capture a broad spectrum of information.
CHAIR —Thank you.
Prof. Cameron —My main point is that at the moment we do not have systematic data collection on this across Australia. We have some estimates—guesstimates—along the lines that Andrew mentioned around hospital admissions. The problem with all this is that burns management is changing. Most burns management is as an outpatient, and that will continue, and there are new treatments. So we do not really know whether the burden is increasing or not and we do not have systematic ways of looking at outcomes, such as the psychosocial outcomes we are talking about here. We do not have a systematic way of measuring that, so we do not even know whether the Burn Survivor Network is making a difference. I suspect it is, but we cannot in any way measure the impact of these interventions.
Even in the burns community, the surgeons themselves are doing fantastic work but they do not know whether they are doing the right work. If you go to each state they are doing it slightly differently, using different forms of treatment. This is a terrible injury, with terrible outcomes, and we do not have any systematic way of knowing whether we are offering the best treatment around Australia. That is why we have started the ANZBA burns registry, which is a national collaboration of all our major burns units, including in New Zealand. The aim of that is to benchmark outcomes between the units to make sure they are all doing as well as they can—they are all trying to do as well as they can, but they do not actually know—and also to measure the burden of injury so that we can see whether it is increasing or decreasing over time. At the moment this registry is not funded by the government. It has actually been funded by the Australian and New Zealand Burn Association itself and by the Julian Burton Burns Trust. To me, it is so important to get systematic measurement of both the burden of injury and the outcomes so that we know that what we are doing is actually making a difference. Otherwise, you put a whole lot of money into things and you just do not know what is happening.
The Australian Commission on Safety and Quality in Health Care gave us a small amount of money to help get this up and running. Again, they have seen the need for systematic measurement of clinical domains, but there is no certainty of ongoing funding. So there is an issue. For a very important topic, we have got uncertainty about what we are measuring, how we are measuring it and whether it is making a difference. It just seems so obvious that we actually need to have some sort of systematic measurement across Australia.
Mrs Buza —For those of you who do not know, AHCSA is the peak body representing, at both state and national levels, Aboriginal community controlled health services, substance abuse services and Aboriginal health advisory committees across South Australia, representing some 29,000 Aboriginal people. In 2008, Burns SA approached AHCSA to address the high incidence of life-threatening burns in Aboriginal communities. A partnership was formed to develop units of competency to train our Aboriginal health workers in rural and remote communities. These units of competency will form the basis of a skill set within the certificate IV in Aboriginal and Torres Strait Islander Primary Health Care (Practice).
The main cause of burn injury within our Aboriginal children is from scalds. Many are preventable. A typical example is a traditional grandmother boiling bathwater on the campfire because the hot water system failed. Feedback suggested the system was inappropriate for the hard water conditions in a remote location and it was not designed for the number of people who were using it. The boiling water was accidentally spilled on the child during transfer to the bath, resulting in severe burns and nearly four months in hospital. The main cause of burn injury in Aboriginal men and women is campfires, and many of these are influenced by our drug and alcohol issues. Burns injury does not just have a negative impact on the patient but on the whole family and community. These may include: pain, fear, depression, post-traumatic stress, grief, loss, guilt, isolation from family, communities and schools, and further loss of family role, identity and culture. Thank you.
Mr Towers —Just adding to what Yvonne said, Aboriginal people are over-represented in the Royal Adelaide Hospital Burns Unit and the Women’s and Children’s Hospital Burns Service. On average, Aboriginal people do sustain 25 times the rates of severe burn injury of non-Aboriginal people. Between 2003 and 2008, Aboriginal children represented 73 per cent of the burn admissions of people with over a 40 per cent total burn surface area. Burns are often more severe due to the poor first aid response in the community or delayed referral to a burns centre.
Aboriginal people, on average, have 2½ times longer hospital stays. This length of hospital stay is not always due to the severity of burn injury but may be because of the delayed discharge back to the community due to the lack of capacity in the community health service. The average cost to evacuate a person from a remote community, we have found, can cost the health system upwards of $50,000 just for the evacuation. This is not including the initial treatment or ongoing treatment.
Prof. Kimble —In Queensland we have just completed a data set for the year 2007 and this includes all paediatric trauma admissions to hospitals for greater than 24 hours. I am going to use some of that data to explain paediatric burns. In Queensland in 2007, 174 children under the age of 16 were admitted for 24 hours or more to a Queensland hospital. There were an extra five children who died as a result of house fires. They all died at the scene and never reached a hospital. No child died in hospital as a result of their burns. The male to female ratio was two to one, which is what you see in all paediatric trauma. The median age was three. That is a very important age because at three you are very small and you have a lot of growing to do. When you have a deep burn, the scar which develops over it will not grow with that child. Unlike adults, who do not have to grow any more, kids will require plastic reconstructive surgery throughout their childhood. I am a burns surgeon but 50 per cent of my work is reconstruction rather than primary grafting.
Twenty per cent of our admissions in Queensland were from the Indigenous population. The Indigenous population only makes up six per cent of the population. So the admission rate is about three and a half times more than the rest of the population. Fifty per cent of the admissions were from scalds; 25 per cent from contacts and 25 per cent from flames. If you look at the outpatients, you will find that scalds and contacts are in equal proportion because a lot of our contact burns can be treated as outpatients—such as burns from oven doors and hot irons et cetera. Thirty-one hospitals in Queensland give definitive care to these children—and remember there is only one paediatric burns centre. Forty-four per cent went to the Royal Children’s Hospital and five per cent went to the adult burns centre—this data was for those up to 16 years of age.
Thirteen per cent of kids went to what we call a burns unit, where there is a paediatric burns surgeon but not enough staff to call it a centre. That means that 38 per cent of children were treated in the centre with no burns surgeons present and no burns facilities available. There was no significant difference in the month of the year for the incidents, but 38 per cent of burns occurred at the weekend, whereas weekends only contribute 29 per cent of the week. The median length of stay was four days, but it ranged from one to 53 days. That is the inpatients but, as has been said before, most burns patients are treated as outpatients.
In 2007, the Royal Children’s Hospital treated 650 new burns patients and only 74 were admitted for greater than 24 hours. Only 11 per cent of burns patients were actually admitted. If you assume this percentage holds for all 31 hospitals that treated kids, almost 1,500 children would have presented in Queensland to a hospital with new burns. This is probably an underestimate, as many more hospitals would be involved with kids with burns. The Royal Children’s Hospital would have been referred a disproportionate number of the larger burns, which would have been treated as inpatients. That number is almost certainly a lot larger.
Regarding submitting to databases, it is difficult because most hospitals are not funded to collect data to send to national databases. Most centres tell people it is also part of their job. Of course the funding is not there and if you really want a good database, it has to be properly funded—and that goes right back to the hospitals that supply data.
Mr van Gerwen —St John Ambulance can be divided into two arms: one is the commercial training side and the second is the volunteer first-aid services side, which involves volunteers going out to do events in the community. From that perspective, the burns we see tend to be fairly minor—sunburn and workplace burns. At a number of the events that we go to, hot beverages and hot foods are prepared and provided. In that environment, people receive minor burns and we treat them.
Another aspect we see is the increasing incidence of burns from glow sticks. When they rupture, youngsters quite often get the chemical in their eyes and a minor chemical burn is caused around the eye. A significant amount of flushing is required to get the liquid out of their eyes. Unfortunately, that seems to be a growing incidence. It is only minor, but the kids think it is a fairly big thing when they have the chemical in their eyes.
The other aspect that St John is becoming increasingly involved in is responding to major emergencies—for example, the Victorian bushfires. Our volunteers spent hundreds and hundreds of hours providing medical support to the rural firefighters. Many of our volunteers unfortunately were exposed to many of the victims of those fires and they saw their dead bodies. As Terri was saying, there is a ripple effect. It is not just the victim who is impacted on; the pre-hospital care practitioners are as well. Normal members of the community out there doing volunteer jobs become exposed and many of them can be significantly psychologically traumatised. Some never go back to providing volunteer services again. There is not a lot of support to help these people cope with that. We do as much as we possibly can within our own organisation, but there is not a large network. As St John becomes increasingly involved in emergency response, I think we will see more of this.
CHAIR —Thank you. That brings us to the end of the statements. Thank you all for the informative nature of your statements. We will open up for questions from the panel and a discussion. Being the chair, I have the privilege of asking the first question. My question is to Professor Peter Maitz. I was very interested to hear about the temperature of water in Australia. It is not something I have heard before nor have I noticed it when I have been overseas. Would you like to tell us a little bit more about that? I am sure my committee would be unaware of it as well.
Prof. Maitz —I was raised in Austria and I trained in Austria and the United States. I came into this country some 10 years ago because there was no burns surgeon available in Sydney. As an example, in the year 2000 Sydney hosted the Olympic Games and it was interesting to note that just before that event Sydney airport services managed, on every single tap at the airport, to get a sign saying that this water may scald you. Why is that? Because the visitors from the United States and Europe were not used to this. If you turn on the tap in Europe it will be 40 degrees tops. In this country, it can be 70 and that will scald you. This is a huge problem because, for instance, my grandmother, who is 70 years old, might run a hot bath, have a syncopic episode, lose consciousness and topple into that bath. If that bath is 40 degrees, nothing happens. If that bath is 60 degrees, she may die because of that because she may sustain a scald of both lower extremities including buttocks—which is about 35 per cent—plus her age of 70 gives her a bulk score of 105, which makes it more likely that she dies from this injury than that she will survive. This is a completely preventable injury by the simple passing of legislation.
To my knowledge this legislation, to some extent, exists in New South Wales in aged care centres, in schools and in nursing homes. But it is certainly not in the private dwelling and it is surprising for me because in my house I turn on the water and I can boil an egg with it—which is totally unnecessary because you cannot shower. We did some preliminary research with so-called volunteers—people who work for me who were coerced into taking a shower in the morning on a hot winter day—and do you know that the hottest shower that one of my colleagues was able to take was 46 degrees. Why do we have 70 degrees hot water in our showers? We do not need it.
I am sure that the more we talk about these issues the more examples will come. You may not be aware that any chemical burn is treated as a burn injury as well. So any chemical injury will end up at a burn service. There is a much higher incidence of electrical burns in this country than there is in other developed countries because some of the electrical switchboard installations in this country can apparently, according to the Electrical Trades Union, not be turned off when the electricians work on them. This is a huge issue because they are all work injuries. They are all with very, very longstanding and very severe sequelae. An electrical conduction injury may render that person unable to work for ever. It is a completely preventable injury if the legislation gets changed.
I think this opens up a huge amount of work, I believe. The reason why I was always so interested to speak to the federal government about this is because in New South Wales we were very, very lucky to an extent to have the fallout of the Bali bombings and then we had a very, very prominent parliamentarian from a family die. Then we had a young child being injured very severely and very publicly in a car accident. So the politicians in New South Wales were very, very open to our suggestions and we were able to get funding for burns.
We have a directorate, we have a prevention officer and we have an education officer, but I believe that this is something that the nation, Australia, needs, not just a small proportion of the nation. Having had this established for six years we are now able to slowly show that there are impacts to be had. Despite that fact, I maintain the view, and I believe my colleagues in other states will support it, that the number of patient admissions is still rising. I have more than 300 in-patients per year and more than 3,000 outpatients per year. I treat only adults and we are one of two adult burns units in Sydney.
Compared with, say, heart attacks, it is a small number, but that small number costs an unbelievable amount of money to the health system because the patients are so difficult to treat. Whilst the health department somewhat forces us to reduce length of stay, which is fine—that is how the health system regulates itself and that is how we are judged—as Sheila said before, I can do this by buying more expensive products that I can apply to these patients and treating them as outpatients, but that does not mean that the injury is now cheaper. It may end up being more expensive simply because the industry supporting us more and more comes up with more and more technical support for us, such as providing bioengineered products. We recently had a patient where the products only that were applied to this patient cost more than $500,000. That was for one patient and it was for products only. It is like saying that I am giving half a million dollars worth of antibiotics to treat somebody with pneumonia. That is what we are talking about.
CHAIR —Thank you.
Ms KING —A lot of you have said that scalds is one of the largest groups of injuries. Is that predominantly caused from hot water? Do we have a figure on that?
Prof. Kimble —I would like to speak about hot water. I believe legislation was introduced in 1999 in all states—certainly in Queensland and New South Wales—that all hot water taps in bathrooms are to be set at 50 degrees maximum temperature. Unfortunately, the rest of the house was not regulated in the same way. These laws were only for new houses built after that time. This means that, if you have an older house, there is absolutely no regulation for your hot water system in the bathroom. Quite a few studies have been done since then to look at the impact. One was done in New South Wales fairly recently, published by John Harvey, a paediatric surgeon in Sydney, which shows that, possibly, there has been a slight decrease over the years from 1999 to the present. That is really all you would expect because of the lack of a law to cover all houses and all taps within houses. So, really, there needs to be a movement by the state to say that all bathroom taps should have a maximum temperature of 50 degrees. Personally, I would like to see all taps in all houses with a maximum temperature of 50 degrees.
Ms HALL —Following on from your comments just now, and looking at a way to resolve it practically, could it be linked to the installation of new hot water systems as opposed to being linked to the building of new houses? So, if a new hot water system is installed, it would be set so that it could operate only at a certain temperature. Would that be a practical way to deal with it?
Prof. Kimble —I think that is happening just now, but the number of new hot water systems going into existing houses is very low. If you are relying on that, it will take an awfully long time to convert houses.
Prof. Maitz —The way it is done in Central Europe is not by tackling the hot water system. There is an issue with that because most hot water systems, certainly in this country, have hot water stored in a tank or some sort of device. In theory this is not a good idea because if you have standing hot water, at whatever degree it may be, it will encourage the breeding of some sort of bacteria. This was meant to be the main reason why the hot water systems in this country are between 65 and 70 degrees, because then legionella and all those types of bacteria may die, or they may not. We do not actually have evidence that they do. The way the European Union went about it was to force people to install a mixing thermostat before the water reaches the tap. You can only change that thermostat by pressing two buttons. So, whilst the hot water system still heats up to 70 degrees, it will never reach the tap unless you forcefully change the thermostat in your bathroom. I was told—I am not a plumber—that this is a relatively inexpensive way to do it. It still costs money, of course. It may be somewhere between $500 and $1,000 per household, which may be forbiddingly expensive if it is not supported by a grant.
Ms HALL —Thanks very much.
CHAIR —We spoke earlier and you mentioned 40 degrees Celsius in Europe, but we are talking about 50 degrees. Would that 10-degree difference have an impact on burns?
Prof. Maitz —It is difficult to say because the evidence is not very strong. We know that a burn is the denaturation of protein in the cellular wall. That is the biological background for any burn—it does not matter what sort of burn it is. In theory, protein can be denatured in temperatures above 45 degrees. It is probably not because the surface of our skin does not contain live cells, which means that the protein that is natured is of dead cells anyway, so it may not burn. I think there is some argument to be had about where the temperature should really be. I was just mentioning that the volunteer study that we did showed that you do not need 50-degree hot water, because you cannot shower with it anyway—it is too hot.
Prof. Kimble —Fifty degrees will definitely burn you. We have just conducted studies in Brisbane with our animal models and 42 degrees hot water running for one hour makes no difference—it does not cause a burn. So there is a difference between 40 degrees and 50 degrees, but from a burn surgeon’s point of view we would settle for 50 degrees, because households go all the way up through to 80 degrees. We have even seen it up in the 90s in houses where there are faulty systems. We would settle for 50 degrees. Forty degrees would be ideal, though.
Ms HALL —The question I would like to ask next is in relation to post-hospital support. I know that a number of you identified the need for greater post-hospital support as an issue. Could you share with us what is available and what you think an ideal system would be in relation to post-hospital support for victims of burns.
Prof. Maitz —Could I say something very quickly before we go to the support group. Post-hospital care starts when the people go home. If your house burned down, there is no home. That is one issue. Post-hospital care starts after a child has been scalded due to negligence or malicious intent by the parents, but that child cannot go back there. We just fix the burn, which is the symptom of the problem. There are two aspects. One is that, once the acute care is over, where does the patient go? This is where the help group comes in: how do we reintegrate that patient in the long term? From my point of view as a clinician, it can be a very frustrating exercise if I work at four o’clock in the morning on a Sunday to save somebody’s life and put them back together, which is a very mechanical thing. It is actually not a very smart thing; it is a very basic thing. Then those people have no support structure for them to have a meaningful life. I fix the organism, but I cannot help the person to have a normal life. There is a huge disparity in what we are currently doing. Australia can be very proud in having reached one of the best acute burns services in the world. In fact, WHO is using some of our numbers because we are so good in the really bad cases. But what happens after that is a completely different story.
CHAIR —Perhaps Wayne or Jessica would like to add to that.
Ms J Scroggie —I would like to say that, when you are in hospital, you are safe; you are looked after and you know that you are going to get what you need. You are then shoved out not knowing anything or anyone and you are pretty much on your own. It was only through pure luck that I met Susie and Julian. We were not told about that in hospital; we were not told about anything. We were sent home with a big bag of medications and bandages and were left to it. Basically, that is the support that we had; there was nothing else.
Mr Griffith —As I said, I was very secure in the hospital and when I went home I had nothing to go home to. My wife had passed away. I have a lot of guilt about what happened, because they were in one car and I was in the car right alongside them. They died; I survived somehow. By the time I got to hospital I had 20 minutes to live, apparently; I was breaking down. When I got into hospital and I started to recover, I felt quite good. A social worker came to see me on two occasions while I was there and a psychiatrist came in on one occasion and sent his assistant in on another. At that stage, my mind was all over the place. He would come in and say to me, ‘How’re you going, Wayne?’ and I would say, ‘I’m going fine.’ He said, ‘How’re you sleeping,’ and I said, ‘I had this dream last night but I reckon that’s because I was thinking about the fire—I had a lot of thoughts. I actually say my wife laying on the seat of a car as if she were asleep and, in the next instant, the flesh just dropped off her body.’ After the fire passed, I got out of the car and looked in the back behind her seat, and the two children were in the same state. I think I was trying to cover this up by saying, ‘I can fight this’, because a social worker told me that I could go two or three ways with my life. I could take on drinking alcohol, I could take on drugs or I could fight it. I said straight away, ‘There’s no way I’ll do the first two but I will fight this,’ so I set about doing self-analysis of myself daily. I went along like this for three years and, in the end, I got all of my wife’s family offside from the point of view that I was doing and saying things that I did not know were affecting them so much. It was only at my son’s wedding that I had an argument with my wife’s sister. I did not know what was going on; I had this big argument. My daughter was there—the one who had lost her two children in the fire—and she said, ‘Dad, you need help.’ I thought that maybe I did; that was the first time that someone had pointed something out to me. Next time I went to the hospital the psychologist said, ‘I recommend you go and chat with Alexander “Sandy” McFarlane’—he is from South Australia and is a very prominent trauma psychiatrist—so I started seeing him.
I think it all comes back to the security I had in the hospital. I think that it would be good if a psychiatrist came into the hospital—I do not know whether they work for the hospital or whether they work for a support group—because I found I was very comfortable with the nursing and management staff of the unit; that is why I was so secure. If the psychiatrist had been part of the secure feeling I was having, even if he came in each day and just said to me, ‘How’re you going, Wayne,’ and could see, from experience, how I was—but I do not think there was anybody in that particular position who could do that—I could probably have saved three years of hell in my life. I really think that for any burns victim and for the likes of Terri, the mother, there is some requirement for something like that initially. I was an old man at the time; I was 62 when this happened to me, but it takes the likes of Jess or any young woman—any woman, for that matter—who has pride in herself, as women do. I think it is a big trauma for them compared, probably, with me. I thought, ‘Well, I’m an old man; I got scarred; so what?’ Initially I was not thinking like that. I have taken that on only since I have started getting help. I think we need something in the early days to help.
But that is not overcoming the problem. My case was an accident. There was a wind change, and fireballs came two kilometres and hit us. In the case of household burns, it comes back to: how do we prevent them? And that comes back to education. So I think there are two areas. One is to treat the person outgoing. The other thing is that somehow we have to get through to the public that they can prevent a lot of burns within their household. So, personally, I think we have to look at two different aspects.
Ms RISHWORTH —I just want to follow up on the comment that you made, Terri—and this comes back to what you were saying, Professor Cameron. Terri, you said you were sent home with bandages and medication and that was it. Obviously there is some concern about the outcome measures. Do we know how well families are able to stick to those treatment regimes when they are there as outpatients?
Prof. Maitz —Obviously this is a very, very difficult question. If you come to me with an ear infection and I give you antibiotics, how do I know that you will take them? I do not know. Even if you tell me you take them I still do not know, because you can throw them away or give them to somebody else. We do not know. I think the way to tackle that is to have people reviewed at regular intervals, and these intervals have to be quite short, for as long as the person has an open wound. This is also a financial problem, because every single time that person goes to a doctor, a hospital service or an outpatient service there are costs incurred, not only to the acute service but also to the patient—the transport, not being able to go to work and all of that sort of thing. But I believe there is no other solution. The more complicated and advanced our treatments are—with bioengineered skins and things like that—the more we have to supervise these patients and help their families, because they are dealing with things that we are still fighting somewhat to make work. It is a very difficult area.
CHAIR —Before we go on to the next question I remind everyone that there are cameras here. It is being broadcast on the website for parliamentary services. It was in the email that there would be a camera here, but if anyone was unaware of it and is uncomfortable about it just let us know.
Prof. Cameron —Thank you. I think the question you raise about treatment regimes, Ms Rishworth, is really important. We have different ways of tackling this problem, different ways of managing the same patients in each state and even within states, both as inpatients and outpatients, in terms of support services and so forth. We do not actually know the best way of doing this. We know there are people who suffer really badly. We know there are also people who have really good outcomes. But we do not know what the best approach is. So, unless we measure this systematically, unless we actually get some handle on this, we do not really know whether Peter’s unit does better than Roy’s or if the way they approach it is better or not. We do not even know if there are deficits, whether some units have no support services or not. We really have to get some sort of systematic approach to this.
Mr Burton —I think there is another thing missing here. We are talking a lot about emotional challenges. But I still have physiotherapy and massage every fortnight. I totally support what we are saying here, but I am a grown man who is committed and who has a sporting background; it is different for a young child or an older person.
When you are burnt you are scarred, but when you get skin grafts it does not stretch or breathe, so you have to train your whole body again. I stood in a fixed position next to a wall to stretch my skin for two hours a day to get my skin’s flexibility back again. The thing here is that we are talking about another health cost—physiotherapy—and that is a lifelong commitment, because if I do not then when I get older my body will start to shut down. I do not really know the medical terms. I am sure Roy and Peter would help. We are talking about emotions, but there is a lifelong physical challenge, and I see myself as pretty lucky.
Ms T Scroggie —Can I interrupt? I cannot afford that for my daughters. I do not have the money to be able to give the girls the massages that they need. One of mine was three. She needs releases all the time. Releases are where they add extra skin to your scars. Right now she cannot open her mouth enough to fit in a banana, but I cannot afford the proper things to help her out—such as for her to be massaged—because it is not covered. I cannot give them what they need.
Mrs O’Neill —I am speaking on behalf of the KIDS Foundation and the Burn Survivors Network. Part of our charter is to prevent the psychological after-effects of a burns injury. The services that we provide originally started from family camps. The reason we had the camps was to reconnect the families, but what came from that is that we now have counselling programs; case management; personal development programs to help the young children, adolescents or teenagers to achieve their goals; mentoring; relationship networks; and hospital and rehab communications. In some hospitals we have an excellent communication process, but in others we do not. The Royal Children’s Hospital recommended Terri and Jessica. We visited them in the home a week after they went home. But some hospitals do not refer those people on, so we get them two and three years later, when they are either suicidal or have a huge number of psychological after-effects that their families are dealing with. Sometimes it is simply meeting people who are in the same situation and being able to share an experience.
One thing I wonder about that jumps out and has not been discussed here today is whether there is statistical data on car accident survivors who have serious burn injuries. We have a number of families where there has been a death or a number of injuries and they have huge post-trauma issues. We have bulimia, obesity, a mum who has been in psychological care recently, and another child who cannot sleep, because he saw his brother with flames coming from his mouth. There are four families with exactly the same experience. For them just to share the same experience and know that they are not on their own they need all those other support networks behind them, but they also need to feel that they have something other than the security of the hospital and that there is a reason for them to contact each other and share that experience.
The other thing that we have is a website. We are developing a new monitoring online network because our families are all over Australia and it is not always convenient for them to be close to one another to communicate. We are establishing that process and we have newsletters. We are now on Twitter, Facebook and all those sorts of things, which I am not really familiar with. It is the communication and the sharing of that experience to help them deal with it. We have had young people talk about medical procedures that they have had. One young girl, who is sixteen, is in her eighty-fifth operation or whatever it may be. Just to talk about those issues is so important.
But, again, the service can only go so far, because you only have so much funding, but there are some fantastic support networks once the families leave hospital. We are all doing different things, so if we can collaborate, promote one another and share then I think we can develop a really good network for people who have suffered burns outside the hospital support care system.
Mrs Dunn —I will continue on from what Susie has just spoken about. One of the things that I have found quite hard is that hospitals, through privacy and everything else that hospitals have to have, cannot actually refer on to us or give the burns survivors and their family members information about us, because they do not actually really know who we are unless they delve further and find out about us. What I am wondering, and I have emailed ANZBA about this, is whether we can actually put in place an accreditation program for burns survivor networks or burns survivor support groups so that we can be accredited so that we can be known as the people to go to in our field or that sort of thing. I feel that we are missing a lot of people in the community for whatever reason that we are not being suggested or referred on to at the hospital level.
Mr Towers —Let me talk about the use of long-term peer support and physiotherapy and things like that. Correct me if I am wrong but they are usually metropolitan or regionally based. Many of the patients we are discharging back, Aboriginal people, are from rural and remote communities. We have not even scratched the surface as to support yet. We are still trying to manage the burns.
Prof. Kimble —The vast majority of paediatric patients do get adequate post-hospital care and the parents tend to be very compliant. However, we do have a sizable group of what we call dysfunctional families with quite a high proportion from the Indigenous population and a lot of single-parent families. One partner might be in prison. These parents tend to be non-compliers. They tend to fail to come to appointments and often get lost in the system. We are limited in our ways of getting these patients back but we do use social services and sometimes the police to get them back. This is the lost group that tends to do very badly and will often present years later with contractures. They are the ones that have significant problems.
Ms HALL —I will go back to the need for post-hospital support. What I have heard is that you have got the initial issues about returning to the home, you have the need for ongoing physical support and then there are the psychosocial and peer support issues. But what about when you return as far as the practical changes are concerned, with maybe some home modifications and also modifications that need to be made in the workplace? What sort of support is there out there for people returning to work and for people getting past those initial stages, past the physical and past the psychosocial ones and going through, I suppose, the steps that are needed to get back some sort of normality in their life?
Mr Burton —No-one knows. Your family do not know. They do not know what you are going through and you do not expect them to know what you are going through. That is the challenge. This is just from my own personal experience. When I went home the shower pressure was too hard so we had to change the shower cap because the pressure would split your skin. You are constipated for three months. This is when we are talking only about burns. You cannot even drive a car. You cannot even put your seatbelt on. You cannot walk properly. You cannot sleep. You cannot do anything because of the disability. I suppose that is where Fiona Wood comes in. This is where it becomes chronic and this is where it becomes lifelong. It really comes down to your personal endeavour, because you have got to work really hard to get back to reality. But you never get back to reality. I was a schoolteacher. For me to go out and teach in 33-degree heat was impossible, so really my teaching came to an end. I was a PE teacher. I could no longer go and show the kids how to do a high jump—and I was not very good at it anyway—or something like that. Depending on what profession you are in you might have to change your profession. That is my personal experience. You really do not know and you cannot really expect your family to know. Your family do not really know what to do either. Nutrition changes. Your world is turned upside down unfortunately.
Ms T Scroggie —And there is no such word as ‘normality’ anymore. That is never going to happen again for us.
Ms HALL —How is the support to deal with those things?
Prof. Maitz —It is not all bad and bleak. I really need to say that. My burns unit has a full-time psychiatrist, a full-time psychologist and a full-time social worker. Every patient that comes to us gets seen by all three of them automatically. If I have a patient who due to large burns cannot regulate their body temperature, which is one of the long-term effects, my physiotherapist and occupational therapist go out to the patient before they get discharged and assess their home for suitability. Things are changed like different stairs, different beds or different air-conditioners. It is not an easy thing to do and there are a lot of things that we have to fight for, mainly to get it approved and get it funded. There are a lot of private negotiations, there are funds—not only the burns trust but other funds—that have been set up to help these patients. It is not all bad, but it is very poorly integrated.
Australia is a very modern, very developed country, but if I were judging by the returning and reintegration of these patients, frankly I would say that it is not developed and sophisticated there. While there are things available, if you do not go after it yourself and put your effort in there, if you do not have private funds, if you do not have somebody helping you, it is very difficult to get to these things. I think it is important to realise that things are there, but they are not for everybody and not for every case. It is not as easy as it should be, I believe.
Mr Burton —I do agree with Peter, because Sheila and her team at the Royal Adelaide Hospital burns unit were outstanding for me, but I was one of 300 for the year. So as much as you are in your own world, they have many other patients to look after who are in a worse position than I was. So that is where I do endorse that extra support within the hospital, because I agree with Wayne: that is your home. That is where you start to rebuild your life—in the home. That is why you always go back to the hospital and that is where the key people need to be.
Mr Griffith —What I have experienced physically since coming out of hospital is the fact—I do not know if my age has something to do with this too—that, because my upper body was all burnt, I have lost a lot of the capacity to perspire and I find now that I have a very high body odour content under the arms because that is where I am expelling all my heat. I find that I cannot drink a hot coffee or a hot cup of tea; I am now drinking iced coffee whenever I want a coffee. I have had to put the darkest legal tinting on my car because with this arm I find that as I drive along the heat coming through the glass starts to sting me—it tingles, then starts stinging and I feel uncomfortable—and I have to change hands on the wheel because of heat coming through the windscreen.
Being retired, I do not have to be in the workforce, and that has been a saviour for me, because I find that once the temperature gets above 22 or 23 degrees, my body starts stinging once again. So I find that if I want to go outside and do some gardening or anything like that, I have to do it early in the morning or late at night during the cooler times of the day; the rest of the time I have to stay in air-conditioning. The air-conditioning in my car is always running at 20 degrees because that suits me, but, if I have got people in the car, I do turn it up to 23 degrees just so they do not feel so cold.
These are all little things that you do not realise happen until you have been in a situation such that some of us have. I love red wine and I can have one glass and I am not too bad, but if I have the second glass I start heating up inside. If I go into a restaurant and have a hot meal, I have to walk outside and cool down. It is just these types of things that nobody ever really thinks about. It is a life changing thing when you have burns.
Mrs McCartney —In terms of post hospitalisation and going home, my husband was fortunate enough to have me at home with him. I was a primary school teacher and I left my job. I left my position to care for him—sorry if I get a bit emotional; the memories are not nice. That care was quite traumatic for me because I had to pull his garments on and try not to scratch his burns. I would cover my head with my hair and cry while I was trying to pull those garments on. I had to help him get up and down the stairs. Just that level of everyday care at home is as traumatic for the family as well, not just the survivor.
Help could be as simple as a care nurse that meets the patient in the hospital. My husband was stubborn and did not want to go to a rehab centre, because most rehab centres are not very attractive and they are not nice places to be. He was fortunate enough to have me to drive him every day back to the Alfred Hospital for rehab. I participated in that rehab and then learnt what I had to do at home with him. He suffers the same as Julian and still needs to have massages to help his skin. One of his arms always tightens up. He is having massages all the time as well. So it could be something simple just like a care nurse.
Some survivors do not want to join a support group immediately. Sometimes they are a bit stubborn. Sometimes they think they can do it on their own. So from my point of view as a carer at home for quite a long time, something simple like someone that has some qualification in just visiting them at home and making sure that they are getting support and helping them do the things they need to do. What Peter said before, I think, was a fabulous idea, where your staff go out and check the home. We did not have that in Victoria. It is just little things like that.
So it had a big impact. My husband fully recovered and was able to go back out into society and try to get back to the job he wanted to achieve. I was a full-time carer and then suddenly he had part of his independence back, and I suffered emotionally because I thought, ‘What do I do now?’
Mrs Petrys —I am probably going to talk about something that is not from a COTA point of view but something previous to that. I was one of the national coordinators looking after the Bali victims and I had a case management load of over 66 victims. I can tell you that no one victim was the same as another. Every one of them had different issues, and our biggest issues in helping these people were those services when they came home. That was not only from a nursing or care perspective; it was from a home audit perspective as far as what was suitable for them at home. Many of them had to have their homes changed to be able to suit the injuries that they had. But one of the biggest issues that we found was the lack of clinical psychological support particularly around post-traumatic stress disorder, and to this day that still has not been rectified. We learned a lot of lessons after Bali, but there are still a lot of areas that we are deficient in.
When I put my COTA hat back on, when we look at people who have burns, it depends on the significant of those burns. If a person is quite significantly burned they are more likely to receive help. But those people, who have what is classed by the health system as burns that people can manage, are not looked after as far as what happens when they do get home. This is particularly in the case of the elderly and particularly with people who have mental health issues as well or chronic disease health issues. Therefore they are going back into situations exactly of the type that created the issue in the first place and nothing changes for them.
CHAIR —Thank you.
Mr IRONS —I was initially going to talk about employment, but Jill touched on that. I guess it is pretty hard to look at employment or the prospect of employment if you are standing with your hand up against the wall for two hours a day. Not many employers would look at that as a talent that they would want to take on board. But I guess we could just touch on that again and the prospect of employment.
The other area I want to get some feedback on is insurance. With some disabilities you can get insurance cover for upgrading houses. Depending on what type of accident you have had or depending on what you have been in, there is insurance industry support above and beyond support for people who have got burns or who are the victims of burns. So I just open that up to the floor.
Mr Burton —I am unsure of insurance and whatever but—funny story—well, it wasn’t funny, but four weeks before I went to Bali I signed an income protection policy. I was 29 and I had three investment properties and a full-time job. If it were not for that income protection I would have lost everything. Red Cross were fantastic to me in that time—especially Deb, because I was one of her 66, and I thought, or hoped, that I was one of her favourites! So I was pretty lucky with the income protection and Red Cross. I am unsure about insurance and so on but I suppose that with burns—and I can only speak from personal experience—depending on what you do, whether you are labourer or you work your hands, and on where you get your burns, it could certainly be very difficult to go back into your work. For me, it was different, because, a bit like Nerissa’s husband, Jason, I come from a sporting background, so I already had the mentality of how to overcome an injury. And we had some good support from a sporting club. If you were to take someone who did not have that background, who did not have any family support and lived by themselves or did not have that income support, it would be a very difficult journey. Employment is just another part of it, a big piece of the pie.
Ms T Scroggie —I would add that you also have to be in the right frame of mind to want to go out and get a job and be in the public eye. Jessica will not go out in public without a support person. She has not got the mind frame to go out and get a job, to be looked at and whispered about all the time—because that is what happens. So you have to be able to have that correct mind frame to be able to go out into the workforce. So it is not just whether the work is there; it is, ‘Is that person able to go out into the workforce?’
Prof. Maitz —On the question of insurance companies: insurance companies will never pay anything if they do not have to; it does not matter what sort of insurance it is. Some data that may be useful—and I am sure that this is very different in Roy’s population group, which is kids only; I only treat adults, so you have to be 15 or over to come to me—is that just under 30 per cent of the patients who come to us are what we call compensable patients, so they are covered by either workers compensation, car insurance, private health insurance or something like that. That means, though, that more than two-thirds are not. The difference is: if I have a person from a place 800 kilometres away from Sydney, who still comes to me because they are from New South Wales, and who needs physiotherapy three times a week for the next three years, if he was in a work injury then no problem. If it was not, then forget it—impossible. So what I am saying is that two-thirds of my patients do not get the required aftercare so that the surgery that I perform is actually ultimately successful, because while he might have cover of his hand he will never be able to make a fist if he does not have the physiotherapy. So it is a very frustrating exercise. And I am sure it is worse for kids because the percentage of compensable patients would be much lower.
CHAIR —Kurt had his hand up earlier.
Mr Towers —Many of the consumers we work with, the Aboriginal population, are insured by the government. Basically we are reliant on the financial services from government in terms of coming to hospital. And one of the things that I wanted to mention was the Patient Assistance Transport Scheme. As I mentioned before, the Aboriginal population has a longer length of stay than the non-Aboriginal population in South Australia, and therefore they are often more isolated from their communities, schools and families for a longer period of time. Currently, under the Patient Assistance Transport Scheme, if you are a patient you are only allowed one escort to come to hospital. So it is a long time to be isolated from the community not only for the patients but also for the family member. I think one simple thing we could probably change is to allow an extra family member or an escort swap, just to take that burden off the family when that patient is having a long stay in hospital by allowing that one extra family member to come to hospital and support the patient.
Ms RISHWORTH —In terms of the nurses and the specialisation is there extra training that nurses do to become specialised in the burns area?
Mrs Kavanagh —We have a graduate program for registered nurses that is run through the University of Adelaide, but it is accessed nationwide. It was a huge initiative that was a collaboration of all the units. We really have small numbers of nurses. Royal Adelaide had 450 admissions last year, 1,800 outpatients and something like 18 FTE nurses on the roster, so you are not talking about a big workforce. To sustain postgraduate education on site is very difficult, so we have distance based education. We have pioneered the use of the virtual classroom and we now use that for our rural and remote education.
In terms of workforce sustainability ANZBA runs an emergency management severe burns course. Motivation of our nurses and retention is excellent. Certainly, the smaller numbered professions, the allied health professions, struggle. At this point in time there is no base requirement for the workforce levels of a burns unit. Currently, ANZBA is working on some accreditation guidelines. Royal Adelaide have just been verified through the American Burn Association. But even their guidelines, especially for allied health workforce, are very loose. Peter will have a full-time psychologist at his unit. We appoint five psychologists. There are many units who do not have any psychologists on the staff. Our occupational therapists visit the home to do home assessments. It is about how they justify that because, in terms of the hospital, it is about in-patient care and sometimes it is allocated to outpatients of those currently in the system. But how do you allow time for those who have actually moved out of the phase? You would expect them to have to interact with your in-patient clinicians. It is a huge challenge and I think we need to go towards setting a standard for what is a minimum requirement for our burns service.
Because we are so geographically spread about, you could say if you looked at the pure numbers of burns patients in a year it would only sustain a couple of units but, in reality, at a minimum we need an adult and paediatric unit in every state and territory. You need to move past what is financially viable to what is required in terms of providing a service. If you say you are going to provide a service then you have to provide a full service and that includes a full service for life. One thing we need to mention is that the severity of a burn injury does not necessarily reflect the patient’s response to that. Often people with what we would see as minor burns are severely debilitated at an emotional level for the rest of their lives.
Prof. Cameron —I just want to go back to the compensation issue, because it is quite a difficult area. I also do quite a lot of work with major trauma other than burns. The evidence would suggest that, in general, giving people compensation results in worst outcomes. It is not because of the services you provide; it is because of the psychology involved, because you get involved with lawyers, you get involved in trying to prove that you are ill and so it sets up a whole dynamic. When you are looking at this you need to look at it carefully. The issue is around availability of services and ensuring that they are available for everyone, whether they are in regional or city areas or wherever. The issue of compensation and income support and so forth is very vexed, because you can actually get a perverse result and there is a lot of evidence out there to suggest that.
CHAIR —We have two more questions to go and then we will finish off this session of the roundtable, have our break and then come back for the second session.
Ms HALL —Listening to you all talk this morning, it is obvious that you are very dedicated and you are totally absorbed in the issue of burns. I hear different issues being raised, one of which is the standardisation of service across units and across the nation. Another issue that you have raised today, and which I do not think we have properly picked up on so much, is the issue of research and the need for us to collect more data to ensure there are better services in the future. Also, there are the recording of data and a standard system for recording data so that it can be compared across all jurisdictions and across all units. Would you comment on that? Also, what type of education is available at a community level and what type of education we should be supporting?
CHAIR —We will be covering that topic in the second session.
Ms HALL —That is right, we are. Forget education. Take education out of what I was asking and concentrate on the others and tell us about education later.
Mrs Kavanagh —Can I comment in relation to survivor support that you were asking about before? Historically, in Australia, the clinicians and burns units have been responsible for every facet of burn prevention, survivor support and clinical care delivery. This has started to change and we have seen support groups come to the fore. There is no doubt that there has been some resistance in some clinical groups, based on a lack of knowledge and a protectiveness of the clients to ensure that we do not refer them on to people we do not know and that we know what we are referring them on to. Support needs to come in many forms. Whether it be online, one-to-one or group, everybody wants something different to support them. We have seen a huge development in that area. You have identified that we need some information sharing so that clinicians feel safe about referring their burns survivor and family into somebody else’s care; clinicians feel very responsible for that. That is one of the barriers that is present and that we have to work on. The idea of a burn care nurse is excellent, especially if you look at the way the breast care nurses have been so successful. That is a good model, but I think it is a privately funded model.
Ms HALL —Is there an optimal composition for a unit? Should all units have a minimum number of people across professions? Should each state have a population level at which there should be a burns unit attached to it? What areas should be targeted by research?
Mrs Kavanagh —I think there is a minimal level of staff that you need to have available. I do not think you can link it to population.
Ms HALL —Demographics; taking in all the—
Mrs Kavanagh —You need a geographical level of service. Although you would have one end of the spectrum where there would be more people in the burns unit than you could poke a stick at, I think we would all agree on a level of surgical input, nursing, physiotherapy, occupational therapy, psychology services, social work, play therapists and dietitians, and that we should be able to expand that into the home service, whether that be metropolitan or regional. For example, there is the use of technologies: Kurt has put video phones into health clinics to facilitate communication and we use the virtual classroom for distance education consultations. Queensland uses a lot of telemedicine. So, yes, it is not that hard to come up with what should be the baseline requirements. Part of the challenge is about having the population to sustain that number but we have to accept that given our geographical locations some units will be less busy than others but will need the same base level resources.
Prof. Maitz —I think this is obviously a very important area. Most people who work in this area would be directly affected by this. The British Burn Association conducted in 2003 a review of their services. Maybe I should state why we are actually sitting here. We are sitting here because 20 years ago the majority of our patients would just simply be dead, and I think we need to accept that. We have learned and we have developed and now they are not dead; they are here, so we need to deal with them. So we made our own problem by saving our patients’ lives. This is where the support groups all come from. I think as a society we need to take responsibility for that.
The British Burn Association was actually tasked by the British government to make a review of their services: what happens to a patient in England when they get burnt, where they go, why they go there and what happens to them. This was on a parliamentary level for the whole country. Some of the findings were very surprising. It is very difficult to extrapolate them to Australia and I think that is why Sheila was very careful in wording this. Yes, there are base requirements for a burns unit. The question is: what is a burns unit? Do we need physical space with quarantined beds? So if you are not burnt you cannot go in there because something might happen and then we would need them all. Do we need all these beds staffed fully at any time when you might not have a single patient for three months? What are the staff going to do in those three months? Will we be able to retain these staff and their level of expertise, especially their surgical level of expertise, if they do one operation, not 20, per month?
All these have been addressed in this report by the British government and the findings have been so surprising. Even the British government is starting to doubt if it can implement it. As for the findings, yes, we do need X amount of beds available at any time according to population density and geographical location. Yes, they need to be staffed completely and fully, which means you are paying people who do not look after patients. The time that they do not look after patients should be dedicated to do research and to professional development. This is extremely expensive. The problem with that is that if I do not treat a patient I cannot write the bill, so nobody is paying for me so the government will have to pay for me. It becomes very complicated. The Americans go about this very differently, and I do not believe that we want to adopt a system that makes the people who have money healthier than the people who do not have money. I absolutely think this is something that Australia is not about. In this country, for instance, it is very difficult to get a plastic surgeon to become a burns surgeon. Why? Because a facelift pays a hundred times more and takes 10 times less time than a burns surgical procedure. Why would they do it? This is one of the main problems that we are facing. It is about making what we are doing attractive and making it affordable for the country, because if the government takes all our recommendations we will send the government broke because it is all too expensive, which is why ANZBA has started to do a workforce survey. Currently we are trying to find out who is actually working with burns patients, why they are working where they are, how many patients are they treating and whether that makes sense. Whilst I think it was a good exercise for South Australia to get an accreditation for the American system, I want to warn everybody that that may be a devastating way for this country to go.
Ms KING —We have certainly heard from Wayne, Julian and also Nerissa—and thank you for that—about the impact on adults but I really want to hear a little bit more about the impact of burns on children and in particular young adults because the nature of it is just so catastrophic for the rest of their lives, and I do understand that for adults it is as well. I just want to see if there is slightly different support that kids need.
Prof. Kimble —We actually do have an awful lot of services available for kids, if the parents bring them along, and everything is free. With kids’ burns, our private patient population is actually very low—it is less than one in 10. So they are all, generally speaking, public patients. For those who are compliant with treatment, the services are good. Most paediatric units have got psychologists and psychiatrists attached. We have occupational therapists, who will go out for home visits and request modifications, which are paid by the state—air conditioning, rails for steps and that sort of thing. So, in a way, things are very good for children.
We tend not to discharge any of our children from our clinics. They stay with us all the way through—with us it is till 15—then we have transitional clinics where we transit them to the adult world, and then the situation totally changes for them. We have got problems with youth suicide, usually after they leave our service, though. They do not tend to have these sorts of thoughts until they are 17 or 18 years of age, then it becomes a big problem. But, yes, I would like to say that paediatric services in Australia are very good, and it is all paid by the state.
Ms KING —I do not come from a medical background, so can you give me a sense of what sort of surgery you are talking about. I guess each burn is different, but what length of treatment could someone expect, certainly in terms of continued surgery?
Prof. Kimble —As I said, from our 2007 data the median age for our inpatients is three years. At that age it tends to be scald injuries. Because the scars that result do not grow with them, they will develop contractures, despite the best treatment with pressure garments, splints, physiotherapy. The major burns will have contractures, which means surgery over the years as they grow—and that will go on until they are 15 or 16 years of age and fully grown. It varies greatly, but I just finished reconstructing a child last year and I performed 74 operations on that child, each of them distressing and painful and with a long rehabilitation after each one. So some children unfortunately do go through an awful lot of surgical and psychological trauma. It is a huge burden.
Ms KING —Thank you.
CHAIR —There being no further questions, we will close this session. Thank you all for your statements and your information.
Proceedings suspended from 11.02 am to 11.34 am
CHAIR —Welcome back, everyone, and welcome to the second session, the focus of this discussion being to examine ways to prevent and/or minimise burn injuries and therefore decrease the financial costs to the health system. We will go through the same procedure as we did earlier. This time we will start with Stephen, on the other end, with a three-minute statement about this particular topic. We will work our way around the room to Andrew and then we will open it up for a general discussion with questions and answers. We will try to stay on time and finish at 1 pm. I know many of you have to catch flights this afternoon, and many of the committee are heading off to caucus meetings and a whole range of other things, so we really have to try to keep to a finishing time of 1 pm. I ask Mr Stephen van Gerwen to start off with his three-minute statement.
Mr van Gerwen —I am from St John Ambulance, and I guess this is an area where St John can have a significant input. St John trains in excess of 400,000 Australians in first aid annually, and that is the figure for 2008 so we are probably much higher than that now as Australia’s leading first-aid training organisation. Certainly, burns management and treatment is integral to most of our courses. We have a specific module that is dedicated to that, and our teaching is based on the recommendations from the Australian Resuscitation Council. So it is significant that we train a significant number of people around Australia in first aid.
Having said that, one of our aims would be to have at least one person in every household trained in first aid. Given that the vast majority of burns seem to happen in the household, it would be reasonable for people to be trained in first aid. If that is the case, then they are trained to manage a burn in the first instance. That is where we really need to start minimising the damage, in those first minutes after the burn occurs—cooling the burn as quickly as we possibly can using cool running water. The longer that takes, the more impact the burn has and the worse it becomes.
From our perspective, by being able to promote first aid training more within the community we can have an impact in being able to minimise burns when they first occur, especially in children—grabbing them and putting them in a cool shower or wherever people can get water from. My previous background was as an intensive care paramedic. The Ambulance Service here in the ACT utilise burns dressings. Where they do not have running water, in the back of an ambulance, they use a dressing which helps to extract the heat from the burn to try to minimise the damage.
It is really important, from an education perspective, to try and get as much first aid training as possible out there for people. By so doing, hopefully we can enable people to react more quickly to treat a burn and minimise further damage down the track.
Prof. Kimble —A good statistic is that, for every $1 you put into prevention, you get $5 of saving within the health service. That is not surprising when you think that some of our burns patients are multimillion-dollar patients. You can imagine that the kids who have more than 50 operations are costing that much. If you can prevent just one of them, just think how much money you can spend on prevention.
The other thing about burn injuries in kids is that they are all preventable—every single one. From the aspect of first aid for burns, this is the world centre for first aid research. Between the Children’s Hospital at Westmead and the Royal Children’s Hospital in Brisbane, the research groups for the last few years have been doing all the vital studies to determine exactly what first aid you should give to either adults or kids after they have had a burn. We have come down to immediate application of cold running water. The temperature at which it comes out from the tap is ideal and you should apply it for 20 minutes.
Despite this being the world centre for first aid research and all the recent data coming from this country, recent data from Brisbane, which is now published, shows that only 86 per cent of burns victims had first aid and only 12.1 per cent actually had what we would call the ideal first aid. That means that 88 per cent had suboptimal or no first aid. The only way we are going to get good first aid for burns is by education and public awareness campaigns. There is no doubt about it: good first aid for burns decreases of the depth of a burn, which means that the re-epithelialisation time is shorter, you have less scarring and much better outcomes.
Mr Towers —In collaboration with the Aboriginal Health Council of South Australia and community stakeholders, the Aboriginal Burns Program has developed a successful model to address the high incidence of life-threatening Aboriginal burns admitted into the South Australian Burns service. The program has a three-pronged approach in metropolitan, rural and remote communities. One is to prevent the burns from happening in the first place, through appropriate education strategies to schools and community forums. The second is to reduce the severity of burn injury to Aboriginal people through appropriate education, including first aid and emergency management to Aboriginal health workers, doctors and nurses in community settings. The third is to improve the hospital journey by working with Aboriginal patients, whilst they are in-patients, and their healthcare providers to put in strategies to improve their long-term outcomes after discharge.
The initiatives of the program include: the development of the three burns units of competency for the Aboriginal health worker curriculum; rural and remote study days for Aboriginal health workers, doctors and nurses; and virtual training being implemented to address the high turnover of doctors and nurses in rural and remote settings. The Aboriginal schools program with the Julian Burton Burns Trust is just another example of an initiative targeting Aboriginal population. We are also changing protocols and strategies within the hospital setting to improve care.
Mrs Buza —It is extremely important that any program developed for Aboriginal communities is done appropriately, with true partnerships and meaningful engagement. The Burns SA Aboriginal Burns Program and its stakeholders, including the AHCSA, have developed a successful program that Kurt has talked about. This is due to consistent and collaborative approaches with non-government agencies, targeted community stakeholders, health workers and consumers. Some of the challenges around that have been that burn treatment and prevention have not been seen as a priority in some of our communities as there are higher priorities, as you would know, around the management of chronic disease—such is the emphasis in COAG at the moment—including diabetes, cardiovascular and kidney disease; addressing low literacy in schools and unemployment; and improving housing and eye health.
The Aboriginal Health Council of South Australia recommends on behalf of our communities that from the very beginning we should identify the stakeholders and be real on who the stakeholders are in burns prevention and collaboration. We should make an effort to define, I guess, a more consistent and collaborative approach to start with—a national database to get a more accurate baseline of burn injury. This will help measure the effectiveness of education and prevention programs, particularly in our communities in remote locations.
Prof. Cameron —I think no-one would disagree that prevention campaigns are good value for money in general. But one of the problems we have found in all areas of injury is that quite a lot of the time you spend money and you get community effort but it makes no difference. I think a targeted prevention campaign that you know works is really good. To get to that stage you have to actually have, again, standardised data collected across Australia in a way that allows you to know whether your campaign is working or not, whether you have targeted the right people, and whether you have spent the right amount of dollars for specific groups, whether it be Indigenous, rural, urban or whatever, because without that data you cannot mount an effective campaign.
Mrs Kavanagh —I think that to prevent or minimise burn injury requires a multipronged approach and we certainly need different tactics for different demographics, genders and age groups. As Peter said, that needs to be underpinned by good data. We are talking about behaviour changes, and that is about decreasing risk-taking behaviour, about increasing the knowledge of first aid across the community and also about structural changes such as the hot water issue and then identifying at-risk groups like the elderly and people with things like epilepsy, for example, who are also at great risk of scalds. I think injury minimisation is about ensuring optimal care from the very time of injury regardless of your geographical location. That is about every state and territory having in place robust education programs that go out across all of the areas of their regions.
It is interesting that in the Victorian fires I think there were 400 people burnt, and only 20 presented at or needed transferring to a burns unit. That is over 300 people who were managed with smaller burns in the regional areas. How do you provide the support for those when your burns unit—remembering that the teams are small—are under pressure themselves with their own work? That is not the time to be sending people out from the burns unit. The only way to address those sorts of surged responses is to ensure that you have a system in place where you have already taught people the correct way to treat burns and they are just ramping up their activity. That is important.
There are some good models around the country for the use of telemedicine. As clinicians we share our information but perhaps we could improve on the way that we share information with other major stakeholders—perhaps based on a model similar to the Australian Resuscitation Council which brings major stakeholders together to standardise information.
In terms of our delivery of care we have just recently collaborated nationally to launch the Joanna Briggs Institute burns node and that will enable us to have some standard of care delivery and also to audit it regardless of your physical location. We have raised the issue about burns care nurses. In fact, in South Australia we have rolled out a series of burns link nurses to facilitate early discharge of patients back into the regional areas but we have not taken it to the next step of providing ongoing support. Certainly, the other states, including Queensland and New South Wales, have done large programs on the targeted prevention of treadmill burns and campfires, and there has been a lot of good material put together.
Mr Griffith —On education, I am probably going to take some of Julian’s work here. I have been involved with an education program, as I said before, with school children at the primary school level. I think the way preventative education is done through the Julian Burton Burns Trust is excellent. I can give you an example. Deb Bates, who runs this for the Julian Burton Burns Trust, received a phone call from a mother one day. She just rang to say that she had burned herself the night before and her daughter had treated her because she had learnt what to do through the preventative education of the Julian Burton Burns Trust. She just rang up to let people know that this was a great case.
In my eyes, starting with the children at school is a good idea. At least we are getting it at the base stage and they are aware of what happens to them and to their siblings. This is because the preventative instruction they get is not to put coffee cups near the edge of the table but to move them back; turning saucepan handles around and all that. They are learning all these types of things and it is only going to have some benefit. But on a national level I think we probably need a more advertised type of education program for adults. I do not know how this would be done. It would probably have to be some form of media.
I can give you examples. I would like to wring the necks of some of the adults out there. Sorry, but that is the way I feel about this. When you go to these schools you ask the children how many of them have been burnt. In most cases you will find two-thirds of the class put their hands up. Then you ask some of them, ‘How did you get burnt?’ and one example is, ‘I put my hand in a fire’. You ask, ‘Why did you do that?’ and they say, ‘My dad said he would give me $5 if I put my hand in the fire’. This is fact. Another one, a girl, put her hand up and said, ‘I got burnt because I was putting petrol down an ant hole and lighting it’. We asked, ‘Why did you do that?’ and she said, ‘Mum and dad were there with me and they said it was alright’.
Not only do we have to train the young ones so they know what to do but also we need to train some of the adults in some way to realise what happens. I think maybe the likes of me or some type of burn victim who has been involved should be in these care areas to try and get their story across about what actually happens to you and to the family around you when you get burnt. I do not know how you do this but I think it needs some type of media acknowledgement.
Ms KING —Terri, I know you do not want to give evidence, but there is one thing. I know, Jess, that you were burnt by a gas bottle. I have got a little boy and it is only because I have a little boy that I have recently started to think a little bit about injury prevention. I was trying to find out what I need to do about the gas bottle for our barbeque because I have not checked it for years and I did not know anything. It was really hard to find any information about how to check it, how old it was allowed to be and what I could safely do with it. We ended up exchanging it for a new one, which was probably the smartest thing we could have done. Can you talk about what happened with you and how you would have known about any of that sort of stuff?
Ms T Scroggie —We didn’t; it was a Swap’n’Go gas bottle. Apparently, they are all sent overseas, mass checked and sent back. This is all I have heard.
Ms KING —Really. Now I am not going to use one of those either.
Ms T Scroggie —It had a faulty seal. It was not checked.
CHAIR —It was a faulty seal?
Ms T Scroggie —Apparently. It is still under investigation, but that is what we have been told.
Ms KING —There are standards in place, we have rules about how they should operate but there are still problems.
Ms T Scroggie —Yes.
Ms KING —I am sorry to ask you about that. I just wanted to highlight that as an engineering issue.
Mr Burton —We run a BurnSafe schools program. Roy said all burns in children are preventable. I would probably say two-thirds, but if Roy says all I will take that. Thank you, Roy. Given the statistics, for me prevention is the key. First aid is very important, but if we were preventing burn injuries we would not need first aid. That is the motto at the Julian Burton Burns Trust. The aim of the BurnSafe program is to reduce the incidence of burns through encouraging behavioural and social change. That is why we are focusing on young primary school students. We believe that if we can educate young children, they will go home and educate their parents. They receive a take-home bag, which has all sorts of educational material, including a magnet.
Our BurnSafe program is a targeted program. We work very closely with the burn unit directors, especially in South Australia. We go to the Women’s and Children’s Hospital or the Royal Adelaide Hospital and ask for the statistics on the incidence of burns. That is what we do in South Australia and if we have the opportunity to roll it out nationally that is the way we would do it. That is where I think we have been very blessed to have a great relationship with ANZBA. We know where we need to target—which communities and what the demographics are. We also work very closely with Burns SA. Under Kurt’s leadership, we work collaboratively to drive the Aboriginal education program. Again, that is another collaboration. As we have heard from Kurt, the incidence of burn injuries in Aboriginal areas is quite high. Our programs also look at community awareness, as Debra talked about, targeting the elderly and the young. There is a lot of data to show when there are spikes in the number of radiator burns or fat fires. We work with the burn unit directors to target a specific campaign to improve community awareness about these things. Another example is that, under Kate Ellis we are starting to work with bounty bags, which is about raising awareness for new mothers and their newborns about scalds. Scalding is a topic about which we are trying to drive awareness.
The BurnSafe program is focused in four categories: the young children, the Aboriginal community, the elderly and general community awareness. It is a mix of trying to create social change. Social change will be delivered through behavioural change. Another part of all this is the legislation. If you could legislate for the installation of thermostats, that would be a big driver for behavioural change straightaway.
We have been very successful in educating through our community service announcements, which reach about 2.5 million nationally. This involves our corporate partners. We started the BurnSafe program with a federal government grant of $200,000 in 2008. In the first year we educated around 8,000 to 10,000 students plus their families. It is very worthwhile. It has measured a 91 per cent retention rate and about 86 per cent in Aboriginal communities, I think, Kurt. Due to collaboration and partnerships, it is working really well. It is not just our idea; it is very much about a lot of ideas around this table and it has worked really well. Thank you.
Prof. Maitz —This is a unique opportunity, and I have already thanked Steve for inviting us to come here and talk to you. It is unique in that you are seeing a couple of clinicians here who are trying to talk to you so you will put us out of work. That is why we are here: if we can prevent all burn injuries, then I can go home.
There are three points we should be thinking about. First, there is the aspect of telling people what to do when it happens, so basic first aid needs to become better in this country. I am the educational chairman for the Australian and New Zealand Burn Association, so I oversee the training of all the health professionals—allied health, nursing and surgeons—for the whole country. That is going so well that Australia is now exporting this to England, Holland, South Africa, Bangladesh and Malaysia, so all those people are licensing that education from us. So it is a good thing and it works well. But I can only educate the small number of people who are actually interested in it and want to know, and they are people who think, ‘Maybe one day I will see a burn patient in my practice.’ Currently we cannot reach the general population. It would be of benefit to all of us if every person in Australia knew what to do immediately when something like that happens. A lot of people know something, but it could be much better. So that is one of the points: education, imparting knowledge. I think it is the responsibility of the knowledgeable to impart knowledge to somebody who may be able to use it for the greater good. We have a responsibility to do that.
Another point, which Julian has been talking about, is trying to achieve behavioural change. I am not trying to tell the people in Australia to stop barbecuing only because in Austria we do not do any barbecues—and because I would fail! But we have just talked about gas bottles, and I think we need to raise awareness that this is dangerous. It is even more dangerous when we drink 10 beers and handle a gas bottle. So it is about awareness. I was invited to go to Holland on one of the educational visits, and I saw that the Dutch Burns Foundation has created with all sorts of mechanisms an awareness about the possibility of getting burnt that is absolutely startling. I can tell you that a tourist or any person who goes to Holland will not make it out of that country without hearing about burns somewhere. This is startling. As an ordinary adult in Australia I would not hear anything about burns so there is no general awareness that this is a problem. In Holland I was really startled, from the airport on, to see there are community groups, news announcements, print media, TV—everything. It is not in your face; it is just there. And they have one of the world’s lowest incidences of burns. I cannot prove that this is because of what they are doing, but it is certainly an interesting fact.
The third point, which Julian mentioned too, is that there is a responsibility for legislation. As we said before, Australia created the self-extinguishable cigarette but we have not legislated that this cigarette has to be sold in Australia. It is sold in the United States. That is an oxymoron—that we found it and we have not legislated for it. It is the same thing with the water, and this needs to be changed. It is a cheap and easy way, I believe, to prevent something that is not only devastating but also very expensive, just by saying, ‘You can’t have that hot water in your bathroom.’ It is the same with electrical injuries, and there need to be workplace surveys and things like that.
So I believe there are three points that we should really be thinking about: first-aid education, behavioural change through awareness, and legislation. Thank you.
CHAIR —Thank you.
Mrs Petrys —There are three areas for us around prevention. The first is around regulation, particularly on home water temperature. This has been an issue for us for some time. We have been relatively successful in aged-care institutions, but within the home this has not been done. We think this is quite achievable. There are a number of different home safety audits that are conducted, particularly for older people, and we can see that water temperature regulation could be incorporated into this. We are very aware about smoke detectors, and we cannot see why this cannot become a predominant area as well.
We are also very keen to work with burns education. COTA are extremely successful with a program that deals with all sorts of different topics under our peer education model. This is national and is predominantly delivered by volunteers over the age of 50 to all sorts of groups right through all sorts of communities, and burns prevention would be an ideal program to deliver. It acts under key messages, gives people strategies on what they should do and provides information on where they should go to seek help, so not only would it be educating people about burns awareness but also those people who have suffered burns and who have no idea of where they can seek help.
Our third area is around first aid training. We believe this is particularly significant for older people, particularly carers of older people. A number of older people have misconceived ideas about how to treat burns. This goes back to previous days—for instance, a number of older people still think you should put butter on a burn. So the reality of telling people to turn on the tap and place the burn under cold water is quite significant for us.
We believe there should be mass media campaigns. This can be done quite easily—a bit like Peter was saying. If you talk about this often enough in all different types of ways, those messages will get through to people. We also believe this is a multifaceted issue. It needs to be across all age groups. We are responsible for people over 50 years of age and education targeting them has a ripple effect. Maybe these people are grandparents and have families. Obviously the information they take home goes to their families and to other age groups. If we have education from primary schools and education from older people, we should be able to make a difference.
Mrs O’Neill —The philosophy in the KIDS Foundation is that accidents are predictable and preventable. Sadly enough, parents are not always the best educators, especially in relation to safety. So when the KIDS Foundation—which is an injury prevention and recovery organisation—was first established, we got together with safety organisations, emergency services and the government department and we actually had the education minister sit in on our meetings. We went out into schools and said, ‘There are some fantastic programs around but why are they not working?’ The reason was that they were sitting on the shelves. The teacher did not have time to deliver them. At the end of it, we decided that we needed to look at a child-centred approach.
The KIDS Foundation went away and developed a program called the Safety Club. The Safety Club is a program where students initiate it in the school—they run the safety club, they meet with the principal, they meet with the teachers and they have parents support. We found a significant decrease in injuries. An independent survey was done through an organisation which showed that there was a decrease in injuries, an increase in safety awareness and also a substantial decrease in bullying. We wanted to find out at how young this needed to start. We were also funded at the time by WorkSafe and they wanted to see when this process could start. So the KIDS Foundation, along with Monash University, was given an Australian Research Council grant to have a look at this particular subject. Because we developed the program, we wanted to stay independent.
So in 2008 a pilot study was conducted by the Geelong city council to test whether safety intervention programs designed for children between the ages of four and six were effective in providing a foundation for children to gain greater safety awareness, knowledge and problem-solving skills in managing decisions about their own safety. Resources and a preschool intervention program named the Seymour Safety Program were developed by the KIDS Foundation to educate children on safety and were used in the study. 251 children and 160 parents were invited to participate and they all chose to be involved. The results from the data collected, both from the children and the parents, demonstrated substantial significance and an increase in the school pre and post the intervention program. The findings of the pilot study portrayed varying degrees of increased safety awareness, knowledge and problem-solving skills by the children participating in the research and the ability of children to recognise safe and unsafe situations was improved. There was evidence suggesting participating parents changed their perceptions and safe practices at home, resulting in a positive behaviour change. The pilot study provided results also to confirm that the intervention materials and the reliability of the testing instruments were validated. We talked about a pronged approach. We were saying that schools and preschools are an ideal learning environment, that it was okay to educate them at school but how was it going to get home.
I just want to show two things that we have developed which have been extremely successful. One is when a child goes to kindergarten. The program is with a group. All the children’s photographs are placed in the picture and they go through the journey. They become the characters in the book and they experience all the situations that are unsafe, or whatever the particular message is. Most importantly, a duplicate book is sent home with every preschool child. They put their photograph in that and they share it with their families. At the moment we have our primary school program in 400 schools and we are reaching 450,000 children in Victoria alone. We have just completed our main research. There are over 400 children in that study, plus independent studies of another 400 children. So 1,000 children have been involved in the research project.
There is a journal article coming out fairly shortly and there is also a PhD report coming out later in the year which will show the effect of that. Most importantly, as an organisation we are also involved in Safe Communities. The year before last we were the first organisation in the world to be accredited as a Safe School affiliated agency. That was to prepare schools to become safe schools and there was also the education process in the meantime. There are 10 books in the series and there is one being done independently on fire safety and water safety.
We are getting most of our funding through corporate partners. One of our organisations, Alcoa, has seven sites. They choose to fund 10 schools at the seven sites and five preschools. We take the program there and that has been extremely successful. We got our first government small grant of $20,000 to further that process and now we have the Catholic education department. They started with 10 schools, there were 30 schools in the second year and they are looking at a national program. The Fire Safe program will be going into all those schools. As I said, that is a national program.
CHAIR —Thank you very much, Mrs O’Neill. Would you like to submit that material as an exhibit?
Mrs O’Neill —I would. I would like to do that over the next few weeks because the paper is going to a journal article. Because I am under instructions from supervisors, I have to get permission for that to be tabled.
CHAIR —That is fine. Our next speaker is Dr Andrew Singer.
Dr Singer —I have nothing specific to say on this area.
Ms KING —Dr Singer, you are with the Acute section of the health department—am I correct?
Dr Singer —That is correct.
Ms KING —And we do not have anyone here from the population, health or prevention areas today?
Dr Singer —No. They do not have specific funding in relation to burns prevention. That comes out through their division.
Ms KING —The injury prevention area is an area that has some interest in this, I would assume.
Dr Singer —Yes, of course.
CHAIR —We will now open it up for questions and general discussion. I ask the committee to keep questions specific and to a particular person, through the chair. We will have a discussion, as we did in the first session. Ms Rishworth will start because she has to leave.
Ms RISHWORTH —I have to give my apologies. It is a busy day in parliament. My question is probably to St John Ambulance Australia and to anyone involved in early intervention, the first aid moment of a burn. Obviously there is general training around that. What is the optimal time for refreshing? Obviously burns do not happen all the time. I think about my first aid training and whether I would know what to do in a situation where I am confronted with that. Is there an optimal time in terms of refreshing for the first aid component when faced with a burn? There would be an optimal early intervention outcome.
Mr van Gerwen —Senior first aid certificates are applied first aid certificates. The industry recommendation is three years. People are able to do it at any time that they wish, but the industry standard is three years. I am not aware of any research. Research has been done around CPR retention but not necessarily about other first aid interventions.
CHAIR —There was some talk earlier about a national database. Have there been any studies on a national database by the different organisations or are there any plans in that direction?
Prof. Maitz —Professor Cameron can talk about this because he is actually working on it. ANZBA, the Australia and New Zealand Burn Association, has been trying to establish something like this for 15 years, I think. I was successful in New South Wales in achieving a statewide burns-dedicated database. It has been running for five years and currently collects data on every inpatient burn victim admission in the state. In 2010 we will start to collect outpatient data as well. It is obviously a large amount of data. I am saying this because I think after only five years we can already show that this makes sense. We have a prevention officer in New South Wales and she gave me a short brief that she wanted me to pass on to you. This database enables them to hot-spot geographic areas. For instance, there are more kids burned in Dubbo than in, say, Newcastle—so let’s go to Dubbo and not to Newcastle; it makes a lot of sense. The only way we can do that is to collect data, and I think we need to do this not just in one state but everywhere in this country. They have rolled out primary school programs similar to Susie O’Neill’s and also high school programs. Most recently, they gave statistics to the ACCC about hot-water bottle safety and were able to only because it could be supported with data. Why are there so many hot-water bottle burns in Australia? Because there is no proper standard for the entry onto the market and production of hot-water bottles. From my point of view, five years is only a small snippet of time, but it has already produced ammunition to achieve something, on a legislative level as well as on an educational level.
Prof. Cameron —The good thing is that all the burns units in Australia and New Zealand have gotten together through ANZBA and Julian Burton’s trust and decided to do this properly at a national level, with their own funds, to get it off the ground. We are only just starting out, but we are systematically collecting burns admission data from those units right across Australia and New Zealand. We hope to build on that to look at both the prevention side and circumstances of burns and the other side of it, as we were discussing before: the long-term effects of burns. That data is integrated with the other data we have around admissions and outpatients and you actually get a very comprehensive picture of what is going on right across Australia and New Zealand. As I say, in my mind it is a no-brainer. You cannot conduct any of these programs effectively without having systematically collected data to ensure that what you are doing is working and that you are not missing out on certain areas or groups. It is just common sense.
CHAIR —How far off are we from establishing that national database and collating all the information from the different groups?
Prof. Cameron —It is established but it is very tenuous. We have been given money by charities and bits and pieces of money from here and there, but, as to its being a long-term project, we are taking it year by year—and we are okay for the next short while. What I would like to see in the future is the federal department saying to each state, ‘You must give us this date on a routine basis,’ and then it would be up to them to work out how to do that, whether with a data nurse or whatever, in much the same way we get admissions data and other data.
Mr Burton —Just building on what both Peter Cameron and Peter Maitz said, we went and spoke to all the burns unit directors around the country within ANZBA, and there was a big push for education on prevention. Everyone was on the same page. ANZBA approached us to play a founding role in the burn registry. It is quite clear that we wanted to get involved in a two-prong attack. It is great to get out and prevent but we need to have the data to tell us where to go. We can sit here and start to work collaboratively with governments—whether state or federal—but you have to be accountable for the funding. So the whole idea for us of a two-prong attack is to have the statistic information that we get from Peter, which gives us some guidance and direction as to our future campaigns—whether it is schools, community awareness campaigns et cetera. This gives us some credibility and some accountability with regard to where we are going to go from a financial point of view and also the social impact that we are making as well. I think it is imperative both from a prevention point of view and a treatment point of view.
Mrs Kavanagh —Most of the states are going along the lines of developing e-health records. As a group, clinically, we are fairly small, and I think it is important that we somehow get a voice in that development and the state strategies that link into the national strategy. The perfect way for us to feed data into the national database is to have it come through the electronic health record, which means that we would hopefully capture things, even from those patients who did not come to the regional burns unit but who were treated at the local hospital and, then I would imagine, into the longer term, even general practice and that would feed into that system. My understanding of an e-health record is that it is a lifetime record. We would be keen to get a voice in the state and federal strategies about electronic health records, so that the datasets are captured appropriately.
Ms KING —Whilst I know that you have been entirely self-funded, have you talked with the AIHW about the development of that dataset or have they been unwilling to do so?
Prof. Cameron —I am involved in a number of different registries and also with the Australian Commission for Safety and Quality in Health Care. One of the issues is that at present the routinely collected data—although it is useful for some broad population base thing—is actually very difficult to interpret. I do not like to cast doubt on the numbers that AIHW presents, but of the problems is that if, for example, one of the burns units changed their practise and they start treating all their patients as out patients or they put them all in intensive care because that is the new way of doing things, they just give you a whole lot of numbers and you have no idea what it means.
The first thing we have had to do with this collaboration is work out a standardised approach—for example, describing the severity of the burns, how they are assessed and all that sort of thing. To interpret anything to do with this area you have to know what you are talking about. One of the problems with the AIHW is that it just says there are 50,000 burns admissions a year. Who knows what that means? Although we obviously work with the AIHW, the way the AIHW is set up it cannot do this sort of work. It has to actually come from the clinical units and be agreed by the clinicians as to how to interpret this data and use this data.
Ms KING —Acknowledging that COTA raised the issue around burns presentations at GPs, are there any MBS or PBS items that would only be used by people who are needing to treat burns that are worth having a look at?
Dr Singer —There are MBS items in relation to burns treatment, though most of it is more at the burns surgical end rather than the kinds of treatments that GPS were doing. I did ask for that data but, unfortunately, it has not become available in time.
Ms KING —So you will make available to the committee what you have?
Dr Singer —If I receive it I will make it available to the committee, yes.
Ms HALL —I have a couple of really brief questions. Has there been some evaluation done of the various education programs that are available in the area of burns? If so, what programs come across as state-of-the-art programs? What should a really good burns prevent program or education program in relation to the treatment of burns include?
Prof. Kimble —Can I speak to that?
Ms HALL —Yes.
Prof. Kimble —I think Professor Cameron mentioned it before. The important thing about any prevention campaign or educational campaign is targeting the right population. If you do not target the right population, you have really wasted your money. A very good example of that is a project we had in Queensland. Back in the early 2000s, we identified a lot of kids getting burned by camp fires. We investigated and found that it was not actually the flames from the campfires which were causing the problems; it was that kids were getting up early the next morning and going in and playing in the ashes of camp fires. Sometimes they did not even realise there was a camp fire there because people had covered it over with sand or dirt.
We worked with the fireys on this and we worked out that the only safe way to get rid of a camp fire after you have used it is to put it out with water. If you let it burn out itself, especially in Queensland, with the heat—if you just let go out itself—12 or 18 hours later it is still hot enough to burn a child with a less than one second contact time. Putting sand or dirt over it makes it even worse; it creates a furnace-like effect and keeps it warmer for longer.
So, with a very small budget, less than $2,000, we worked with companies to produce a million flyers and 2,000 posters and we targeted people going camping. When you went to a camping store and bought anything, you would get a flyer. If you went to a national park to stay overnight, you saw the poster and got a flyer and the information. We put this campaign out and we actually stopped all camp fire burns for about eight months after that campaign. It was incredibly successful.
Ms HALL —Could I just ask about ‘for about eight months afterwards’. What happened after eight months?
Prof. Kimble —They started to creep back again and—
Ms HALL —Why?
Prof. Kimble —Because it was different parents. Either people forgot or, for the parents who had the small kids, the kids were older and they were not in that risk group anymore—because, remember, it is the two- and three-year-olds.
CHAIR —Were people still getting the material?
Ms HALL —Yes, was the material still being supplied to the new parents that were coming on line?
Prof. Kimble —No, the materials were running out also. About three or four years later, we thought, ‘Okay, we’re back to where we were at the beginning again.’ This time we managed to get a grant of about $40,000, so we thought: ‘Okay, we’ll go on a big scale here. We will put it out. We will make an advert for TV and just put it out to the general population.’ We did that, and it was playing through the cricket and that sort of thing, but it was not targeted and, despite spending $40,000 and several weeks, it did not do anything to the incidence. It is just a good example that, if you do not target the population that you want to get the message to, you may as well throw your money down the drain.
Ms HALL —Should that targeting be long term, though, rather than short term?
Prof. Kimble —Yes, it has to be sustained. And this is a problem, because most of these campaigns have been organised by the burns unit themselves, where no-one is really employed to do this job, so it is the burns surgeons and burns nurses using their spare time to run these campaigns, and therefore sustainability is just not there.
CHAIR —I suppose it is quite evident that the eight-month period where this campaign was being targeted to specific people who were going camping or whatever actually did work, so when the material ran out or when the—is it because the campaign finished after eight months that it started to increase?
Prof. Kimble —That is right. You can only maintain your enthusiasm for a campaign for so long.
CHAIR —When you say ‘enthusiasm’—
Prof. Kimble —People were performing this task in their own spare time. We do not get paid for that; we get paid to be burns surgeons, but we are enthusiastic and very passionate about what we do. But this is a case—and I am sure every unit has a story like that, where you do something that is really good—where we found it is not just about spending money; it is about targeting.
Ms KING —With population health programs it is invariable—and road safety is a classic example—that you hit a saturation point with people and people stop hearing messages, so there is always a decline in those as well.
Mr Burton —What the Julian Burton Burns Trust has found in its experience is exactly what Roy is saying. As a community organisation, that is our role. We follow the direction, the clinical expertise and the statistics from the Peter Camerons, the Roy Kimbles and the Peter Maitzes to strategically drive targeted education campaigns. I think that when you say ‘best practice’ there is community awareness, but there has to be a mix of targets as well. And it is long-term targets. Sustainability is important; there are going to be new children born every day. It is never going to stop. A big thing is that we are never going to find a cure for burns, so we are going to have to be driving different campaigns. There has to be a strategic campaign over a long time. Yes, there are times when the market will be saturated, but there are also times when there have to be specifically targeted campaigns.
CHAIR —I do not know whether there was a study done over that eight-month period. What do you think cost savings will be for burns victims? Have there been any studies in that area?
Prof Kimble —Campfire burns are very diverse, going from fairly minor burns to quite severe ones, because it tends to be hands and feet. With kids, the contractures they develop are very important. Although the surface area is not large, they carry considerable morbidity throughout their lives. Although we did not do a cost analysis on it, I can quite easily say that for the $2,000 we spent on it we probably saved hundreds of thousands of dollars.
CHAIR —Thank you.
Mr Burton —To support Roy there—John Greenwood is not here today, so I will speak—we did a fat fire CSA in South Australia and the Northern Territory. John came to us and said, ‘I’ve had a spike in fat fires over February and March.’ Then we played the fat fires CSA the following year at the same time on his recommendation. The previous year he had five and the year after he had zero. He firmly believes that CSA was right. I do not know whether he would want to see his face on it again, but the bottom line is that he would say that the cost saving to him was a million dollars. That cost us $5,000 to do. You look at the savings from that. It supports what Roy was saying.
Mrs Petrys —I cannot talk about burns prevention education, but I can give you a couple of examples of what we have used our peer education model in. One is falls prevention, where we have had quite significant peer education programs running across the country. We know through evaluation that we have done over a number of years on older people that we have changed their focus to being more mindful and preventative, using strategies to prevent falls by over 80 per cent from when we started. This program is national, but unfortunately in South Australia we had to discontinue the program two years ago and we are now seeing an incidence of increased falls. We do not know whether that is related or not.
I can give you another example: we have a significant program around depression, working with beyondblue across the country. When we first started this program, only 23 per cent of this age group were aware that depression was an illness in older people and that they could be treated. We now know through the national depression database that over 72 per cent of people are aware that depression is an illness and that they are seeking treatment. So preventative education does work.
When you talk about saturating the market, yes, you can, but what you continually do is change the messages. You can be creative in doing that. It is how you deliver the message so you are not continually doing it in the same way and so you are working with other organisations and people to continually change how you deliver your messages.
Ms KING —Susie, with the evidence that you gave you were challenging a little bit some of the things that have been said, saying that you actually need a different type of prevention or education program with kids rather than the education programs that we probably traditionally think about in relation to this. Do you want to talk a little more about that?
Mrs O’Neill —We have found that children are effective educators. If your child tells you to put your seatbelt on, you are more likely to do it than if another adult in the car tells you to put your seatbelt on. You are more likely to do it if the child says so. There is a bit of reverse psychology involved here. Part of our research was to look at a child’s ability to retain information about risk management. We found that children between the ages of four and 12 acquire the ability to recognise an unsafe situation, to analyse it, to respond to it and then to evaluate it. We thought, ‘Okay. That is the critical time when we should be educating children about the thought processes of managing risk.’ One grandparent wrote back about the program saying, ‘When I took my twin grandchildren, who I have custody of, to school, I used to take them on a leash because I could not control their behaviour. At the end of the program, they are no longer leashed.’ One of the teachers wrote in the report that a parent rode to school on a bike with his son and that neither of them wore helmets but that, by the end of the program, they were both wearing helmets. So the children were reinforcing the safety message and changing the behaviour of their parents.
We understand that there is a place for everything—education for parents and legislation. However, at the end of the day, you can put an airbag in the car and that is forced behaviour because it happens; it is not controlled by you. And you can put a seatbelt in a car but, unless you put it on, it is not going to fulfil the purpose that it was put there for, unless the child is educated—and there is a time and a place for that.
Prof. Maitz —A year ago, at one of our medical conferences, there was an invited British surgeon who presented a paper that I thought was really startling. Subsequently, we tried to invite her to publish it. In the paper she challenged a local council in the British Isles to look at the incidence of road accidents versus burns accidents in that council area, calculate the costs that the council spends on road safety messages compared to burns safety messages, which was zero, and then calculate the costs of treating the burns injuries versus the road injuries. They have now changed the legislation. If you are interested in this paper and there is a chance to do that, we should try and retrieve this data. It was really startling. I have never heard of anything like it before. It makes a lot of sense, because Australia has a lot of road safety messages but no burns safety messages.
The other thing that I again want to support is the idea that, without data and targeting people, we will not achieve anything. Sydney is a very diverse community. However, all of a sudden, in a very affluent part of the city, we had a lot of palm burns in small children, all of which came from postcodes where usually burn injuries are non-existent. Because of socioeconomic reasons, a selective group was sustaining burns. We asked ourselves: What is happening? Why? With the database, we were able to find out that every single one of these children had friction burns off treadmills, because their parents were affluent enough to have treadmills at home. We now have, via the ACCC, changed the labelling of all treadmills that are sold in this country. They now have to come with a warning leaflet. This is a perfect example of clinicians seeing something and asking: ‘Why is this happening? We have never seen this before?’ We went to the data collection unit and said: ‘They’re all living there. Why would they all live there? They all have treadmills.’ The legislative body listened to us. It took less than six months to get the legislation through, and now every treadmill you buy in Australia has a little leaflet that says: ‘This is dangerous if the kids crawl up and put their hands on it.’
Mrs Buza —NACCHO, the National Aboriginal Community Controlled Health Organisation, which you would all be aware of, is currently seeking a national partnership agreement with the government. We are promoting the comprehensive way that we deliver primary healthcare service. That comes with a whole lot of health promotion in our communities. I would like to see a lot more collaboration and a real review of what we have and how we can do it better around burns prevention. I have already mentioned the need to identify key stakeholders.
I also wanted to say that there is a whole raft of differences and disadvantages in our communities—for instance, cold running water is not very often an option in our isolated communities, bar a couple of weeks of the year. The other thing is that around campfires traditionally our young people, through initiation—although I cannot mention the details around that—are exercising activity that could be influencing burns and scalds. I think it is about engagement. I think it is about really talking about the differences, and I think we all need to put our cards on the table and effectively engage people who perhaps are not being engaged at the moment.
Ms HALL —I have one more question, but before I ask it, on what Professor Maitz just said about burns coming from postcodes where you would not expect them to—and I do not think this has been mentioned this morning—are burns skewed according to people’s socioeconomic status?
Prof. Maitz —That is a very difficult question to ask and to answer. The answer is yes. Unfortunately I use this when I talk to people: you and I and all others sitting in this room are very unlikely to sustain a very severe burn, because we are educated and affluent enough to prevent it. That is a very, very strong message.
Prof. Cameron —All injury is much higher as well. Even in a place like Sydney or Melbourne, it is as much as six to 10 times in frequency.
Ms HALL —I thought that was really important to put on the record as it had not been said earlier. Thanks for that. My final question relates to legislation. There has been a lot of talk about legislation being needed to be put in place to address a number of different aspects relating to burns. Maybe this is something that some of you could come back to us with: I am wondering about the types of legislation that you feel need to be changed and types of legislation that you feel could be introduced that would be beneficial to addressing burns and the treatment of burns. That can be followed up at a later date.
Prof. Maitz —I can certainly say that, because I have a prevention officer, I will put that sentence to her. She is going to work on this and she will definitely get back to you—quite substantially, I think.
Ms HALL —Thank you.
Mr IRONS —In pilot models such as the BurnSafe program run by the Burns Trust or similar models that might be working in the states but need to be run on a national basis—I guess a bit like your program and the process of attacking that and rolling it out—is there an easy pathway? Does it need to be improved? Does it involve it dealing with governments—local and state—in trying to roll out national programs?
Mrs O’Neill —I think it is again a funding issue and taking responsibility for it or getting some of the corporate organisations. If we are looking at our future workforce and we are educating our children, big organisations are very willing to engage in such a program. So the more support we get there, the better. We really need to look at what are effective programs that have a wide reach. We have 16 staff. Eight are educationally based trained and qualified. We can nearly reach the whole of Australia with our programs, providing we have the right support, and we still have one-to-one contact with those. The opportunity is there, and maybe we can talk with Julian about the BurnSafe program and the new program we are about launch, which will be available to all schools and preschools in Australia. Equally importantly, we have also had interest from other countries, so if we can be a leader of a collaborative group in burns injury prevent, that would be great.
Prof. Cameron —We mentioned road safety before. The issue there is that each state effectively has a compensation body that has a vested interest in maintaining those prevention programs and so forth, whereas with burns it is more charitable groups and foundations and so forth that are funding it. That is based on individual enthusiasm and so forth in their spare time. There is a very different dynamic going on between burns and, say, road safety, but the sorts of programs we are talking about should be systematised as they are in road safety.
Mr Burton —In supporting Susie, I can say that a lot of the research we found shows that education programs—and being an ex-teacher I know this—suggests that you do not want programs that end up on a shelf, like Suzie was saying before. I do not know what the statistical data is on this but I am sure that with a lot of the education programs that you send out, with DVDs or whatever, teachers just take them, say, ‘That’s beautiful,’ and whack it on a pile. We have found that actually getting to the schools is a high resource but when you have go to targeted areas, when you have a targeted schools campaign, you have to do face-to-face in the schools because then you can give them the pack to take home.
The other thing that we have found, from a collaboration point of view, is that a lot of corporate and private sectors have shown interest in the BurnSafe program, because it is prevention and they want to be seen to be preventative rather than reactive. So, from a Burns Trust point of view, it is very much about collaboration and finding the best model that you can get out there—and it sounds like Susie’s model is fantastic—but it is also about getting the funding to inject into it while you partner the government to do it.
Mrs O’Neill —Our prevention program in the schools has been running for over 10 years now, and we have a part-time person who works 0.5 per week on research and evaluation. So every program is researched and adapted accordingly—and that is being done on a national level. That research is available and is both internal and external, so it might be worth getting together with that as well.
Prof. Maitz —I have spoken to Fiona Wood about this; she is very passionate about this too, being a mother of five. She is trying—and I am not sure whether she has succeeded—to make it part of the education curriculum; so there would actually be a curriculum change in the schools and the teacher would not have the option of putting it on the shelf. I do not know if this is possible, if this is a good idea; it just came to me because Julian said that he as a past teacher would probably just put it somewhere.
Mr Burton —I was a very good teacher; do not worry about that.
Mrs O’Neill —We have a really high uptake of our preschool program because in preschools they have less resources than in primary schools and the ability for something to go home to the parents incorporates the whole preschool community, so you are engaging them and you have a greater reach. So the preschools cannot get enough of it. As soon as they finish, they ask, ‘Can you make sure we get the program next year.’ At primary schools, there might be a change in teachers and a teacher who does not have that safety culture. It is all about developing a safety culture within the school. When we went into the preschools we found that there was no safety culture. A lot of preschools did not even have the word ‘safety’ in their documentation or their school core values. So, when the program went into the preschools, they had to look at a whole change of culture within the preschool. The children did not understand the terms ‘unsafe’ and ‘safe’; they perceived it as ‘naughty’—to be ‘unsafe’ was a ‘naughty’ thing. We had to try to explain to them that there are actually consequences and that they could really be injured. That is going extremely well. So I think we have a huge opportunity with the preschools, because they are lacking in resources. They are the families that cannot afford it, so these resources are going home to the families as well and it incorporates that community.
Mrs Kavanagh —Talking about programs targeting health workers and health professionals, I do not know whether from a government level there is any way of monitoring where money is handed out related to burns. When people want information on burns it always comes back to the burns units. Last year there was a group that had received money to go into Aboriginal communities in the context of a wider wound based education, but there was going to be a burns component in there. I looked at that and thought this is really a duplication in part. I do not know whether there is any way, in terms of grants at state and federal level, to avoid that sort of duplication or get some comment, because it would seem that sometimes the words ‘Aboriginal health’ are plopped in front of something and then that is seen as something that will get funding more easily. Even if it is not necessarily the main thrust of the program, it is put in there as an add-on. If it is a duplication of effort or if it is not appropriate, then I think that is a risk and I think there needs to be some sense of what is going on from national and state perspectives—if that makes sense.
Mrs Buza —That is another reason why a review of sorts, or an effort to have a look at where we are at and how we can better do things, is important. I am not quite sure which way you are going with that. I might disagree with some of its content, because I think we struggle as an organisation both at the affiliate level jurisdictionally and nationally to get enough money to provide the services we need to our communities. For example, you mentioned the resources you are developing, Susan. Another problem that we have of course is getting out there or having funding to get people out there to translate, if you like, what those things mean, because most of our children in communities do not read.
The other issue is getting them engaged in the first place. So it is a matter of accessing them as a community and accessing traditional families and then getting them interested to learn how to be safe around burns prevention. So what might be, I guess, considered duplication might be another way of expanding knowledge within communities to be interested in that. So I would just like to have that on the record.
CHAIR —In the Aboriginal communities are programs getting up there, for example, the ones we have spoken about here today, or is there a lack of programs? Even though programs exist, is it about implementing them out in communities—
Mrs Buza —I maintain what I said. It is about consolidating what we truly have. There are amazing programs out there—the Burns Trust, the burns kits—there is so much stuff happening. But the left hand does not really know what the right hand is doing in terms of Aboriginal communities. This is why I mentioned effective engagement processes through our sector, whether that is through the jurisdictions, like the Aboriginal Health Council of South Australia or the national body, which is NACHO. It may be that we just need to talk it up a little bit more and make sure that we engage appropriately. I think that what those people on the ground can do, and particularly the community organisations, is advise on how best to make those programs work better out there, and to find duplication, if there is any.
Ms KING —I just want to ask a couple of questions around first aid and then go to another issue as well. Stephen, am I right in assuming that your organisation is the largest provider of first aid training in the country? I know that there are a number of private providers—
Mr van Gerwen —We train the most people and issue the greatest number of certificates of any such organisation in Australia.
Ms KING —And they are people choosing to go to you to get them because they have got an interest or they want to get first aid training—
Mr van Gerwen —A lot of the people who come to us for formalised training are required to for work purposes. We do have a number of non-accredited courses—Caring for Kids, for example. New parents come to us to learn about injury prevention, and if their child is injured, they come along for that training also.
Ms KING —I now have a young son so I have been interested in doing first aid training. How much outreach work in terms of first aid is actually done in childcare centres, in maternal and child health groups that are put together? I know that St John is only capable of doing so much, but—
Mr van Gerwen —The workers in the childcare centres are required by legislation to hold a senior first aid certificate. So, whether it be through us or another organisation, they are required to do that. We get a number of parent groups from childcare centres or just day-care centres or playgroups that come together and want to do the Caring for Kids course and we are quite happy to facilitate that. Recently Target promoted new parents to do that course, and that was quite successful. They had a number of parents around the country who came and did that. There are certainly a lot of parents out there who do choose to come and do some sort of first aid training. They do not all want the bit of paper to hang on the wall but the non-accredited training, which does include burns; they do choose to come and do that as well. It is becoming very popular.
Ms KING —It would be a great corporate initiative if someone, as you say, like Target, decided to assist parents, in particular low socioeconomic groups, to get their first aid certificates.
Mr van Gerwen —Absolutely, and we do promote ourselves also, I believe, through the Bounty Bags, to try and encourage new parents to come along.
Ms KING —Do any of the education programs work with volunteer fire brigades? I am a CFA volunteer and we do Brigades in Schools all the time. I have not done it myself but I know that the boys who go out love it. But I have no idea about what burns prevention stuff they do and whether there has been any collaboration with volunteer fire brigades around that sort of stuff.
Mrs O’Neill —We run safety field days. That engages all organisations, and the fire brigade are part of that and they run a program.
Mrs Dunn —Also, as part of our recovery arm, we are looking at developing a state based model for our burns survivors networks, and we have had great expressions of interest from the CFA in the different states to be able to become quite active in that role, which has been really good.
Mrs O’Neill —And actually in two states we are purely funded by the CFA.
Mr Burton —In South Australia we work closely with the MFS and the CFS, and we work very closely with Kurt as well. So there is a cross collaboration which is certainly on target to really work. In Victoria, we have spent the last year being a part of the Victorian Burns Prevention Partnership which includes the MFB, the CFA, the Royal Children’s Hospital and the Alfred Hospital. We have found out that the CFA do not do anything about burns, so we are working on a collaboration project with them so that, when they go out to do their education, they will hopefully take a five-minute DVD and play that as part of their burns prevention. So there is certainly a collaboration. I think we have all found that the MFB are very open to collaboration. So I think everyone is on the right page on that, which is good.
Mr Towers —Just reinforcing: to avoid duplication, we are working closely with the Metropolitan Fire Service.
Mrs Dunn —Some of the firefighters come on our camps as volunteers because they feel so passionately about working with burns survivors because they have often been there and seen what can happen to people’s lives and with people afterwards. So I think that that is a great motivator for volunteers for us.
Mr Towers —To add to that, the Australian Professional Firefighters Foundation fund 100 per cent an organisation called Camp Smokey, which is a support camp for paediatric burns survivors. The firefighters are really passionate about burns prevention and burns care, especially in South Australia.
CHAIR —Is there anything anyone else would like to add?
Mrs Kavanagh —I want to clarify a comment from before: I was actually specifically speaking about non-Aboriginal health organisations that were working outside of collaboration with Aboriginal health that were trying to access money. It was not—
Mrs Buza —We hear so often about money thrown at Aboriginal organisations.
Mrs Kavanagh —No, it was not at all that there was money; it was a reference to groups that worked outside of this sort of collaboration that concerned me.
Mr Towers —And the other point is that it can be quite damaging when so many stakeholders—for example, in burn prevention—target the same community from different angles. It can be quite overwhelming and quite damaging. So that is just reinforcing the need for collaboration between the stakeholders in implementing any program to Aboriginal communities.
Mrs Buza —To make one last point about that: as part of our cultural tradition, we have protocol and process in engagement and going out into communities. That is why it is extremely important that everybody knows what everybody is doing, because we can damage relationships that we have worked so hard to improve.
Prof. Kimble —I would just like to go on the record as saying that, when it comes to research into burns, Australia really does lead the world. For its size, Australia puts out more burns literature than any other country in the world, on treatments and, especially, prevention. And, as I said before, Australia is definitely performing the majority of the work in first aid in the world. So we have all the evidence that we need. What we really need is money to get these messages out to and to educate the public, and I think that is where the discrepancy is. There is no shortage of enthusiasm from the research groups.
Mrs Dunn —I also just want to share with everybody here that we run a program called TANGO, Together Achieving New Goals and Opportunities. This program is specifically for 12- to 25-year-olds across the nation who have sustained a life-changing injury. With that program we have a young burns survivors’ camp. One of the things I want to talk about in education is that part of some of our young people’s therapy involves being able to talk to their peers about how they have sustained their injuries. Through our guidance, support and mentoring some of our young burns survivors have gone into schools, workplaces and different places to share what has happened to them so that other people can learn from their injury. From a counsellor’s point of view, watching these young people grow and then become mentors for the younger burns survivors has been the most rewarding part of the job that I do.
Mr Burton —I just want to say thank you. On behalf of everyone around the table you gave Fiona Wood and the Julian Burton Burns Trust an opportunity to present. We are all around the table representing organisations and I want to say thank you for the opportunity to put burn injury on the agenda.
CHAIR —On behalf of the committee I thank everyone for participating today. Certainly, this is not the end of it. If there is anything else that you would like to add, please feel free to send it through to the secretariat. We will be coming up with a report in the near future. We will be visiting the burns unit in Perth in a few weeks, and today I have had another offer for us to see some work that is being done in Sydney. We look forward to seeing whether we can perhaps do something with that as well. If there is anything else that you feel we need to know, please feel free to feed it through. It will form part of your submissions and part of our report. Thank you to all of you for your submissions and your statements today, especially the burns survivors who are here. I thank them for their input.
Resolved (on motion by Ms Hall)
That this committee authorises publication, including publication on the parliamentary database, of the transcript of the evidence given before it at public hearing this day.
Committee adjourned at 12.57 pm