Enzymatic debridement for burn wound care: Interrater-reliability and impact of experience in post-intervention therapy decision.

INTRODUCTION Enzymatic debridement (ED) has become a reliable tool for eschar removal. Although ED application is simple, wound bed evaluation and therapy decision post-intervention are prone to subjectivity and failure. Experience in ED might be the key, but this has not been proven yet. Aim of this study was to assess interrater reliability (IR) in post-intervention wound bed evaluation and therapy decision as well as the impact of experience. In addition, the authors introduce video assessment as a valuable tool for post-ED decision making and education. MATERIAL AND METHODS A video-based survey was conducted among physicians with various experience in ED. The survey involved multiple choice and 5-point Likert scale questions about professional status, experience in ED, confidence in post-ED wound bed evaluation and therapy decision. Subsequently, videos of 15 mixed pattern to full thickness burns immediately after removal of the enzyme complex were demonstrated. Participants were asked for evaluation of each burn wound, including bleeding pattern and consequent therapy decision. IR ≥80% was considered as a consensus. Responses were stratified according to participants' experience in applying ED (<10; 10-19; 20-49; ≥50 applications). IR was assessed by Chi^2-test (raw agreement (RA); ≥80% was considered as a consensus) and by Krippendorff's Alpha-test. In addition, expert consensus for therapy decision was compared to the actual clinical course of each shown patient. Last, participants were asked for their opinion on video as an assessment tool for post-ED wound bed evaluation, decision making and training. RESULTS 31 physicians from 11 burn centers participated in the survey. Overall consensus (RA≥80%) in post-ED wound bed evaluation and therapy decision was achieved in 20 and 40%, respectively. Krippendorff's Alpha are given by 0.32 (95% CI: 0.15,0.49) and 0.31 (95% CI: 0.16,0.47), respectively. Subgroup analysis revealed that physicians with high experience in ED achieved significantly more consensus in post-intervention wound bed evaluation and therapy decision compared to physicians with moderate experience (60% vs. 13.3%; p=0.02 and 86.7 vs. 33.3%; p=0.04, respectively). Video analysis was considered a feasible (90.3%) and beneficial (93.5%) tool for post-intervention wound bed evaluation and therapy decision as well as useful for training purposes (100%). CONCLUSION Reliability of wound bed evaluation and therapy decision after ED depends on the experience of the rating physician. Video analysis is deemed to be a valuable tool for ED evaluation, decision making and user training.