"Gearing to a time table"; the evolution of earlier surgical eschar excision in massive burns by British burns surgeons at the battles of Cassino, 1944: an example of real-time audit.

The effectiveness of burns care delivery is difficult to measure within a realistic workload and resource framework. In addition, workers must develop new tools for this purpose. We describe a historical example from World War II describing the evolution of burns excision in the context of thorough outcome assessment, during the allied advance from North Africa up the Italian peninsular, including the battles of Cassino 1942-1945. Patrick Clarkson and Rex Lawrie working as plastic surgeons in a small forward Maxillofacial Unit were able to fully assess the management and outcome of 800 burnt servicemen. 192 burns were full thickness and required grafting. Prospective data revealed that those burns which were surgically excised and grafted between 12 and 18 days recovered more quickly than those managed by conservative dressings until the eschar had sloughed off followed by grafting. Burns managed by excision and grafting in less than 5 weeks following burning (n=86) healed 8.6 days faster than those grafted later (n=106). This difference was increased for massive burns of over 1000 cm(2), with those grafted in less than 5 weeks (n=17) healing 13 days faster than the delayed group (n=27). Their transparent and simple method of prospective audit is described.