A protocol in Sacramento will examine whether emergency-department and prehospital teams can make a specific burn first-aid practice routine: 20 minutes of cool running water within three hours of an acute thermal burn. Its main focus is implementation, meaning whether the practice is adopted in care, while clinical-effectiveness data are collected at the same time. The paper describes the planned evaluation, not a completed result.
The planned intervention pairs the water treatment with co-designed implementation strategies and tailored resources. If the water is stopped before the 20-minute minimum, the reason is to be documented.
The approach follows a completed first phase that identified barriers and facilitators across ED and EMS settings and produced co-designed, tailored strategies with clinicians and stakeholders. The protocol says phase-one results have been published.
The test will track both uptake and outcomes
The evaluation spans the UC Davis emergency department, a regional burn center and the Sacramento Fire Department. It uses a 28-month retrospective period and a 28-month prospective period. UC Davis ED electronic medical records and Sacramento Fire Department prehospital records will be used to assess adherence, while burn-center electronic records will provide clinical-outcome and resource-use data.
The primary implementation measure is adherence to the 20-minute guideline 28 months after implementation in the UC Davis ED. The source also states a provision threshold of at least 20%, but does not specify the unit behind that percentage. That leaves an important detail of the planned threshold unclear.
The primary clinical measure is the difference in skin-grafting requirements 28 months after implementation. The protocol gives a 10% reduction as an example target for planning, not as a result already seen. Secondary measures include surgery; hospital and intensive-care admissions and lengths of stay; outpatient visits and dressing changes; time until 95% of the original burn wound has closed over; scar management; readmission; wound complications; and mortality.
Eligibility is limited to acute thermal burns. The protocol excludes burns sustained more than three hours earlier, non-thermal burns, burns affecting 30% or more of the body's surface, facial or suspected inhalation injuries, intubated patients, hypothermia below 36°C, non-responsive or critically unwell patients, and patients needing urgent escharotomies.
A before-and-after comparison
The planned quantitative sample is 774 medical-record reviews: 387 from the preimplementation period and 387 from the postimplementation period. A separate qualitative component will add a minimum of 10 interviews 28 months after implementation.
The sample-size plan calls for 387 observations per period to estimate adherence within plus or minus 5 percentage points at a 0.05 significance level, assuming a 50% prevalence. The full set of 774 records is planned to detect a 10% reduction in skin-grafting requirements with 80% power.
Researchers will compare the two periods with descriptive statistics and regression models. The plan allows for differences in demographics, injury severity and other health conditions. A mixed-effects logistic model will examine receipt of 20CRW, with site treated as a random effect to allow for differences between sites; other models will be chosen according to the type and spread of each outcome.
The interviews will include ED, burn and EMS clinicians, adult burn survivors and caregivers of paediatric burn survivors. They may be held by videoconference or face to face and audio-recorded with consent. Transcript analysis will combine inductive and deductive coding, using the Theoretical Framework of Acceptability and the Consolidated Framework for Implementation Research. The qualitative work is intended to examine acceptability and barriers that could affect uptake and sustainment.
Medical-record access is covered by a waiver of consent. Questionnaires use consent-to-continue or implied consent, while interview participants must give verbal consent, including permission for audio and video recording.
What the design cannot settle
The authors caution that the type III design is not intended to provide robust causal estimates. Because the evaluation compares retrospective and prospective periods, a difference in grafting or another outcome would not by itself establish that the rollout produced the change.
The setting is narrow: one emergency department and its associated EMS agencies in Sacramento. The authors warn that locally co-designed strategies may not transfer to dissimilar emergency-care systems.
IRB approval was awarded under ID 18834-5. The protocol plans dissemination through participating hospitals and EMS organisations, conferences and open-access peer-reviewed journals.
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 · Full text