A planned study in Sacramento will examine whether 20 minutes of cool running water can be built into routine burn first aid when it is given within three hours of a burn. The research team will look at whether the practice is used in emergency and prehospital care, whether patient outcomes differ after implementation, and how clinicians, adult burn survivors and paediatric caregivers receive it.
The article is a protocol, which means it describes a study still to be carried out. It contains no observed outcome estimates. It cannot show yet whether adherence will rise, whether skin-grafting requirements will fall, or whether other measures such as hospital stays, wound healing or readmissions will improve.
A study built around routine care
Researchers describe the project as an effectiveness and implementation hybrid type III study. In ordinary terms, it is designed to track both whether the practice is taken up in routine care and what happens to patients. The comparison will use a 28-month retrospective period before implementation and a 28-month prospective period after it, with adherence and clinical outcomes assessed in the UC Davis emergency department.
The intervention is more than an instruction to put a burn under a tap. It combines 20CRW with co-designed implementation strategies and tailored resources. Cool running water is to be provided for a minimum of 20 minutes within three hours of the burn, and any shorter duration is recorded as a deviation. Educational materials are included in four online supplemental files.
The records will cover patients with acute thermal burns who present to or are transported to the UC Davis emergency department and are then admitted to the regional burn center or discharged with a referral to UC Davis Burn Outpatient care. These are the records that will form the planned patient review.
The planned record review includes 774 patient-record reviews: 387 from the preimplementation period and 387 from the postimplementation period. The researchers will look for record evidence that 20CRW was provided and, separately, evidence of cool running water for less than 20 minutes. Both adherence measures are recorded as yes or no.
What would count as progress
The primary implementation outcome is whether 20CRW guidance is followed and provided 28 months after implementation in the UC Davis emergency department. The protocol's stated percentage threshold is incomplete, so its precise target cannot be reported.
The primary effectiveness outcome is the difference in skin-grafting requirements 28 months after implementation. A 10% reduction is offered as an example target, but it is not a result from the study.
Secondary measures will broaden the picture. They include other surgical interventions; hospital and intensive care admissions and length of stay; outpatient appointments and dressing changes; scar management; readmission; wound complications; and mortality. The protocol will also record the time to 95% wound re-epithelialisation, meaning the point at which the wound has regained surface skin across 95% of the measured area.
Patient outcomes are only one side of the plan. At 28 months after implementation, electronic questionnaires and semistructured interviews will ask emergency department, burn and emergency medical services clinicians, burn survivors and caregivers of children with burns how acceptable the approach is. At least 10 face-to-face interviews are planned.
The answers are still ahead
The protocol's co-design element is meant to help the intervention fit the local services and support longer-term use. But a strategy built with one region in mind may not transfer directly to other emergency departments or ambulance systems.
The comparison is nonrandomized, with records examined before and after implementation; no randomized intervention control is reported. If the postimplementation period shows different grafting or other outcomes, the design alone will not establish that 20CRW caused the difference. The authors say the hybrid approach is not intended to provide robust causal estimates of patient-outcome effects.
The study is also confined to one Sacramento metropolitan region, involving the UC Davis emergency department, its regional burn center and the Sacramento Fire Department. The planned patient records cover a defined acute thermal-burn group, so results would not automatically apply to excluded cases or to dissimilar health systems.
For now, the key question is practical rather than conclusive: can a 20-minute burn first-aid practice be made routine in the participating emergency and prehospital settings, and will the completed study show any accompanying differences in care or outcomes? Those answers depend on the record review and the acceptability data, which this protocol has yet to collect.
Paper data and sources
Original title: Implementing best-practice burn first-aid in emergency care: a type III hybrid effectiveness-implementation study protocol in emergency department and prehospital settings.
Authors: Maleea Holbert, Tina Palmieri, John Rose et al.
Journal/Repository: BMJ open
Status: Peer-reviewed
First online: 2026-08-20
DOI: 10.1136/bmjopen-2026-120249
Original paper