IHTSDO-810 (artf6238) Burns
SNOMED CT Content Improvement Project Combined Inception and Elaboration phases | |
Project ID:
Topic: | JIRA: IHTSDO-810 CollabNet: artf6238 Burns |
Date: | 15 March 2016 |
Version: | 0.01 |
IHTSDO-810 - Getting issue details... STATUS
Amendment History
Version | Date | Editor | Comments |
0.01 | 20160315 | Sarita Keni | First draft for comments |
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- Matt Cordell Requesting review of Version 0.01 of this document. Review template: JIRA IHTSDO-810(artf6238) Burns Documentation Review
Review Timetable
Review date | Responsible owner | Comments |
20160607 | Matt Cordell | Accepted This final version of the document incorporates all reviewer feedback and author responses in Appendix E. See also Confluence Document Review page |
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Note: This document was reviewed by the Head of Terminology in March 2017: Provision approval with the noting that there is a need for a minor update in relation to modelling of 3rd and 4th degree burns. These concepts need to be modelled with FINDING SITE = Skin and subcutaneous tissue of <body structure>. Please see the document review page when constructing the tracker. See Cathy Richardson for access.
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Table of Contents
1 Glossary
1.1 Domain Terms
Skin | The thin layer of tissue forming the natural outer covering of the body of a person or animal. (Oxford University Press, 2016) Skin consists of two layers, the epidermis and dermis. The epidermis has no vasculature and depends entirely on the dermis for nutrition. The dermis consists of two layers: 1) the papillary layer consisting of capillaries, elastic fibers, and collagen; and 2) the reticular layer, consisting of thicker connective tissue, larger blood vessels, hair follicles, sebaceous glands, and sweat glands among other structures. The skin rests on a layer of subcutaneous tissue, which then covers deeper structures such as muscle, bones, and joints. (Amirlak & Shahabi, 2015) |
Burn | An injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals. Skin injuries due to ultraviolet radiation, radioactivity, electricity or chemicals, as well as respiratory damage resulting from smoke inhalation, are also considered to be burns. (World Health Organization, 2016) |
First degree burn | Burn injury limited to the epidermis layer of the skin Synonyms: Epidermal burn, Superficial burn, Burn erythema |
Second degree burn | Burn injury involving both the epidermis and dermis layers of the skin, subdivided into two types: - Superficial: Burn injury is limited to the papillary layer of the dermis - Deep: Burn injury extends into the reticular layer of the dermis Synonyms: Partial thickness burn, Superficial partial thickness, Deep partial thickness |
Third degree burn | Burn injury involving both the epidermis and dermis layers of the skin, and extending into the subcutaneous tissue Synonym: Full thickness burn |
Fourth degree burn | Burn injury involving the skin, subcutaneous tissue, and extending into underlying structures such as muscles, bones, and joints Synonym: Deep full thickness burn |
2 Introduction
2.1 Purpose
The purpose of this project is to consider the representation of content within the Burn (disorder) hierarchy, specifically naming conventions and modeling guidelines.
2.2 Audience and stakeholder domain
The audience for this document includes all standards terminology leaders, implementers, and users but is especially targeted at the community of clinicians or implementers who utilize SNOMED CT to represent burn <disorder> content within clinical information systems or for research purposes as well as SNOMED CT authors who may be requested to implement the recommended specification.
2.2.1 Input from stakeholders
SIRS: As of March 2016, there are only 5 requests related to burn <disorder> content in the IHTSDO SNOMED CT International Request Submission (SIRS) system. These requests are listed in Appendix D. The low number of outstanding requests is likely because existing content in the Burn (disorder) hierarchy is already comprehensive. However, Section 3.4 will detail the primary issue related to this content: inconsistent naming conventions and modeling. One SIRS request refers to this issue:
Request ID 531381 (submitted 22 April 2015)
Request summary: Consistency required to ensure users are able to search easily and reduce ambiguousness of concept
Request description: Burn concepts are represented in SCT by several classification systems. Currently, older concepts contain references to older classification systems (e.g. first/second/third degree) as well as the newer classification system (e.g. superficial, partial thickness, full thickness). Many concepts that have been recently created only contain the newer classification term, and do not contain the older first/second/third term. We are concerned for the lack of consistency and while these older terms may not be the preferred term, they are still commonly in use and having some concepts with these synonyms and some without could confuse users into thinking there were gaps (even though the concepts exist).
IHTSDO: An IHTSDO SNOMED CT author also commented on the JIRA tracker for this project that current Burn (disorder) hierarchy content is inconsistently modeled, specifically, second and third degree burn content. These comments are provided in Section 3.1 and addressed in Section 6.1.1.5.
2.2.2 Degree of consensus on the statement of problem
Based on the artifact description as well as the stakeholder input provided above, it is clear that there is a strong consensus on the need for comprehensive and consistent representation of content in the Burn (disorder) hierarchy.
3 Statement of the problem or need
3.1 Summary of problem or need, as reported
The IHTSDO content project title and description originally submitted on 24 January 2010:
Burns
JIRA: IHTSDO-810 | CollabNet: artf6238 https://jira.ihtsdotools.org/browse/IHTSDO-810
“Naming and modeling of “Burn” disorder concepts. Currently, burn concepts are represented in SNOMED CT by several classification systems. Some concepts contain terms from classification systems that have either been superseded or are terms that are not international in usage. Naming conventions and modeling guidelines are needed in this hierarchy. There are bout 800 *burn* (disorder) concepts.”
In addition, an IHTSDO SNOMED CT author provided the following comments on the JIRA tracker for this project (25 November 2015):
“There are about 160 concepts for Second degree burn. There are inconsistencies in concept modeling for finding sites. Some of them are modeled by skin structure but some are not. Therefore, not all of them are classified under 284196006|Burn of skin (disorder).
There are about 250 concepts for Third degree burn. Two issues need to be addressed. The first issue is that finding site should be 'skin structure' or more specifically 'structure of skin and subcutaneous tissue' instead of structure of a body region. The second issue is whether third degree burn should be subconcept of Burn of skin. The definition of third degree burn indicates the burn of skin (both epidermis and dermis layers).”
3.2 Summary of requested solution
The requested solution is to provide naming conventions and modeling guidelines to harmonize content within the Burn (disorder) hierarchy.
3.3 Statement of problem as understood
The artifact description suggests that content in the Burn (disorder) hierarchy is based on several classification systems, some of which are outdated. According to the artifact description as well as the stakeholder input, the representation of this content is inconsistent. Naming convention and modeling guidelines are needed to harmonize existing content as well as new content that may be added in the future.
3.4 Detailed analysis of reported problem, including background
3.4.1 Scope of this project
Based on the artifact description, this document will focus on naming conventions and modeling guidelines for the subtype concepts of the 125666000 | Burn (disorder) hierarchy. Additionally, some changes to the 48333001 | Burn injury (morphologic abnormality) hierarchy will also be suggested to support recommendations for modeling content in the Burn (disorder) hierarchy.
3.4.2 Overview of this project
All content in this document is current as of the January 2016 SNOMED CT International Release. There are 839 Burn (disorder) concepts. In general, existing Burn (disorder) content in SNOMED CT is well-organized into three primary patterns:
- Burn of <body structure> (disorder) (214 concepts):
- 37645002 | Burn of head AND/OR neck (disorder)
- 52405000 | Burn of trunk (disorder)
- 6055000 | Burn of upper limb (disorder)
- 84677008 | Burn of lower limb (disorder)
- <Type of> burn (disorder) (50 concepts):
- 426284001 | Chemical burn (disorder)
- 405571006 | Electrical burn (disorder)
- 425656005 | Radiation burn (disorder)
- 314534006 | Thermal burn (disorder)
- <Depth of> burn (disorder) (575 concepts):
- 403190006 | First degree burn (disorder)
- 403191005 | Second degree burn (disorder)
- 403192003 | Third degree burn (disorder)
Burn of <body structure>: This content has consistent naming conventions and modeling patterns, and Section 6.1.1.1 will recommend continuing these guidelines.
<Type of> burn: There are currently 50 concepts following this pattern. Because they comprise a small subset of total Burn (disorder) content and have their own content issues, this set of concepts will be reviewed and recommendations provided in Appendix A.
<Depth of> burn: This set of content pertains to burn depth of skin and underlying tissues (e.g., first, second, third, and fourth degree burns) and is the most inconsistent in terms of naming conventions and modeling patterns. Therefore, this content will be the predominant focus of this document. The remainder of Section 3.4 will describe pertinent background information including:
- Review of the anatomy, naming conventions, and classification of skin burns
- Review of existing content issues related to <Depth of> burn concepts
- Review of naming conventions and modeling patterns for existing <Depth of> burn content
3.4.3 Anatomy, naming conventions, and classification of skin burns
3.4.3.1 Anatomy of skin
As shown in the image below, the skin consists of two layers, the epidermis and dermis. The epidermis has no vasculature and depends entirely on the dermis for nutrition. The dermis is comprised of two layers: 1) the papillary layer, consisting of capillaries, elastic fibers, and collagen; and 2) the reticular layer, consisting of thicker connective tissue, larger blood vessels, hair follicles, sebaceous glands, and sweat glands. The skin rests on a layer of subcutaneous tissue, which then covers deeper structures such as muscles, bones, and joints. (Amirlak & Shahabi, 2015)
Image source: Shiland, 2015
3.4.3.2 Naming conventions and classification of skin burns
The naming and classification of skin burn injuries is generally based on the depth of the injury. Burn depth is a significant determinant of mortality and the primary determinant of the patient’s long-term appearance and functional outcome. It is also a primary determinant of whether a burn will heal spontaneously or will require medical or surgical intervention. (American Burn Association, 2009)
Most authoritative references agree that there are at least three levels of burn depth corresponding to the layers of skin and subcutaneous tissues. The traditional classification of burns as first, second, or third degree injuries is still in common use. However, among authoritative organizations, the naming conventions appear to be evolving into more descriptive terminology: superficial, partial thickness (subdivided into superficial and deep subtypes), or full thickness burns. Kearns et al. performed a literature review of over 1000 academic publications to evaluate the use of burn depth terminology. They found that both numeric and descriptive terminologies were used, but that the use of descriptive terms was considerably greater than the use of numeric terms. (Kearns, Holmes, & Cairns, 2013)
Both types of naming conventions are listed and defined in the table below. Note that these definitions are somewhat generalized, since clinically it is often difficult to estimate the depth of a burn injury and because most burn injuries consist of multiple areas with different depths of tissue involvement.
Skin burn depth definitions
Numeric term | Descriptive term | Definition |
First degree | Epidermal (Superficial) | Depth of burn is limited to the epidermis |
Second degree | Partial thickness
| Depth of burn involves the epidermis and dermis
|
Third degree | Full thickness | Depth of burn involves the epidermis and dermis, and extends into the subcutaneous tissue |
Fourth degree | Deep full thickness | Depth of burn extends into structures underlying subcutaneous tissue, such as muscles, joints, and bones |
The table below lists the naming conventions and classification of skin burns described by some authoritative references. The organization’s primary naming convention is provided first, and if the organization has a secondary or tertiary accepted convention, it is provided in brackets. Note that there are some discrepancies.
- Some major burn authorities support the designation of fourth degree burns while others do not. As of March 2016, WHO ICD-11 Beta lists several codes for “Deep full thickness or complex burn of <body structure>,” suggesting that this category of burn depth will be recognized in the forthcoming edition of ICD-11.
- Most organizations concur that there are two types of second degree burns, though the Australia and New Zealand Burn Association has categorized this level into three subtypes.
- WHO ICD-9 and ICD-10 also classify “corrosions” (chemical burns) into first, second, or third degree burns. This content is inconsistently represented and is addressed in Appendix A.
Skin burn injury naming conventions and classifications
Source | First degree | Second degree | Third degree | Fourth degree |
WHO ICD-9 | Erythema [First degree] | Blisters, epidermal loss [Second degree] | 1) Full-thickness skin loss [Third degree] 2) Deep necrosis of underlying tissues [Deep third degree] |
|
WHO ICD-10 | First degree [Erythema] | Second degree [Blister] [Epidermal loss] | Third degree [Deep necrosis of underlying tissue] [Full-thickness skin loss] |
|
WHO ICD-11 Beta (March 2016) | Epidermal | 1) Superficial partial thickness 2) Deep partial thickness | Full thickness | Deep full thickness or complex |
British Burn Association
| Epidermal | Partial thickness 1) Superficial partial thickness 2) Deep partial thickness | Full thickness | Full thickness + |
Australia and New Zealand Burn Association | Epidermal | 1) Superficial dermal 2) Mid dermal 3) Deep dermal | Full thickness |
|
American Burn Association | Epidermal [First degree] [Superficial] | Partial thickness [Second degree] 1) Superficial 2) Deep | Full thickness [Third degree] | Deep full thickness [Fourth degree]
|
Based on the information provided above, Section 6 will recommend that SNOMED CT burn content use the descriptive terminology (superficial, partial thickness, full thickness, and deep full thickness) as the primary convention and the numeric terminology (first, second, third, and fourth degree) as a secondary convention.
3.4.4 <Depth of> burn concepts: existing content issues
The primary content issues which pertain to <Depth of> burn content include:
- Inconsistent and ambiguous naming conventions (reviewed in Section 3.4.5)
- Inconsistent modeling patterns, causing insufficient or incorrect classification (reviewed in Section 3.4.5)
- The application of skin burn injury terminology to non-skin body structures (reviewed below)
As previously stated, first, second, third, and fourth degree burn terminology applies to burns of skin and underlying tissues. However, for approximately 45 existing concepts, this terminology has been applied to burns of non-skin body structures. For example:
- 110192005 | Second degree burn of buccal mucosa (disorder)
- 110235001 | Second degree burn of tongue (disorder)
- 284199004 | Partial thickness burn of eye (disorder)
- 110217005 | Third degree burn of floor of mouth (disorder)
- 110221003 | Third degree burn of hard palate (disorder)
These concepts present challenges for a few reasons:
- The meaning of these concepts is ambiguous. The unique histology of these body structures does not necessarily correlate with that of skin and deeper tissue structures, therefore, it is unclear what first, second, or third degree burns of these body structures actually mean.
- There are separate authoritative burn classification systems for some non-skin body structures that utilize distinct terminology and definitions (e.g., classification systems for burns of the eye, gastrointestinal tract, and respiratory tract). The use of skin burn terminology for these structures may result in a different meaning. For example, a Roper-Hall Grade II ocular surface burn has a specific definition which may not be conveyed by the existing concept 284199004 | Partial thickness burn of eye (disorder).
- Naming and modeling burns of non-skin body structures by skin burn terminology results in compromises to concept definitions for concepts that do represent skin structures. For example, first and second degree burns are both burns of skin, but currently, First degree burn (disorder) is a subtype of Burn of skin (disorder) while Second degree burn (disorder) is not. As will be described in the next section, this difference is due to differences in modeling which impact the grouper concept Second degree burn (disorder) and many of its subtypes.
The list of relevant concepts as well as references for authoritative burn classifications for some non-skin body structures is provided in Appendix B and addressed further in Section 6.1.1.2.1.
3.4.5 <Depth of> burn concepts: existing naming conventions and modeling patterns
This section will focus on <Depth of> burn content naming conventions and modeling patterns. The concept numbers provided are current as of the January 2016 SNOMED CT International Release.
3.4.5.1 Overview
The table below provides an overview of existing Burn (disorder) content:
Burn (disorder) hierarchy concepts | Number of concepts |
Burn of <body structure> (disorder) | 214 |
<Type of> burn (disorder) Chemical burn (disorder) Thermal burn (disorder) Electrical burn (disorder) Radiation burn (disorder) | 50 24 23 3 1 |
<Depth of> burn (disorder) First degree burn content Second degree burn content Third degree burn content (Includes Fourth degree burn content) | 575 110 163 302 |
Total | 839 |
3.4.5.2 First degree burn content
Naming conventions
There are currently 110 concepts referencing first degree burn disorders. As noted in the sections above, SNOMED CT has burn injury content originating from multiple sources, resulting in a mix of terminology for this content. Also, the terms “burn erythema” and “corrosion” (chemical burn) are only found in WHO ICD-9 and ICD-10. The preferred terminology for this content is 1) Epidermal burn and 2) First degree burn. The table below lists all of the various terms currently used to represent first degree burns in Fully Specified Names (FSN) of existing concepts.
Term in FSN | Number of concepts |
Epidermal burn | 8 |
First degree burn | 5 |
Superficial burn | 17 |
Burn erythema | 60 |
Corrosion of first degree | 7 |
Superficial corrosion | 13 |
Total | 110 |
Modeling patterns
Because first degree burns involve the epidermis layer of the skin, First degree burn (disorder) is appropriately a subtype of Burn of skin (disorder). There are 75 First degree burn (disorder) concepts which are modeled and classify appropriately. However, there are 35 concepts which have naming conventions consistent with first degree burns, but do not classify as subtypes of First degree burn (disorder). Of these 35 concepts, 13 concepts reference first degree burns of non-skin body structures. These “missed inferences” are actually correct: since these concepts do not represent burns of skin, they should not be subtypes of Burn of skin (disorder). The lists of concepts with skin burn terminology applied to non-skin body structures is provided and addressed in Appendix B. Additional concepts with modeling issues indicated in the table below are provided in Appendix C.
Query | Concepts |
Total number of First degree burn (disorder) concepts | 75 |
Total number of concepts with naming conventions consistent with first degree burns, but do not classify as subtypes of First degree burn (disorder): Concepts not modeled with a FINDING SITE value of <skin structure> (19) Concept with appropriate attribute-value pairs, but not role grouped (1) Concepts referencing first degree burns of non-skin body structures (13) Concepts not modeled with ASSOCIATED MORPHOLOGY: First degree burn injury (morphologic abnormality) (2) | 35 |
Total | 110 |
3.4.5.3 Second degree burn content
Naming conventions
There are currently 163 concepts referencing second degree burn disorders. Similar to first degree burn content, there is a mix of terminology used to represent second degree burn content. The term “burn blister” is only found in WHO ICD-9 and ICD-10. The preferred terminology for this content is 1) Partial thickness burn (divided into Superficial and Deep) and 2) Second degree burn. The table below lists all of the various terms currently used to represent second degree burns in existing concepts.
Term in FSN | Number of concepts |
Partial thickness burn | 20 |
Superficial partial thickness burn | 35 |
Deep partial thickness burn | 35 |
Second degree burn | 64 |
Burn blister | 2 |
Corrosion of second degree | 7 |
Total | 163 |
Modeling patterns
Second degree burns refer to burns of the dermis layer of the skin. However, Second degree burn (disorder) is not a subtype of Burn of skin (disorder), because it is not modeled with a FINDING SITE value of <skin structure>. There are two important consequences of this modeling pattern:
- Even though Second degree burn (disorder) is not a subtype of Burn of skin (disorder), approximately 130 of its descendants are subtypes of Burn of skin (disorder) because they are modeled with a FINDING SITE attribute value of <skin structure>. There are a total of 17 concepts referring to second degree burns which do not have a FINDING SITE value of <skin structure>. These concepts are provided in Appendix C.
- All concepts modeled with an ASSOCIATED MORPHOLOGY value of Second degree burn injury (morphologic abnormality) classify as subtypes of Second degree burn (disorder), including 16 concepts that reference second degree burns of non-skin body structures. These concepts are listed and addressed in Appendix B.
Query | Concepts |
Total number of Second degree burn (disorder) concepts | 161 |
Total number of concepts with naming conventions consistent with second degree burns, but do not classify as subtypes of Second degree burn (disorder) | 2 |
Total | 163 |
3.4.5.4 Third and fourth degree burn content
Third and fourth degree burn content are addressed together because this content is currently intermixed in SNOMED CT. Fourth degree burn content (Deep full thickness burn (disorder)) is a subtype of third degree burn content (Third degree burn (disorder)). In addition, there are concepts referencing “deep third degree burns” (a term found only in ICD-9) which are both subtypes of and descriptions for concepts referring to fourth degree burns.
Naming conventions
There are currently 302 concepts referencing third or fourth degree burn disorders. As shown below in the table below, there is a mix of terminology used to represent this content, and terms such as “deep third degree burn” and “deep necrosis” are only found in ICD-9 and/or ICD-10. The preferred terminology for third degree burn content is 1) Full thickness burn and 2) Third degree burn. The preferred terminology for fourth degree burn content is 1) Deep full thickness burn and 2) Fourth degree burn. The table below lists all of the various terms currently used to represent third and fourth degree burns in existing concepts.
Term in FSN | Number of concepts |
Third degree burn content |
|
Full thickness burn | 77 |
Third degree burn | 61 |
Deep third degree burn | 66 |
Deep necrosis (burn) | 2 |
Corrosion of third degree | 7 |
Total | 213 |
Fourth degree burn content |
|
Deep full thickness burn | 89 |
Fourth degree burn | 0 |
Total | 89 |
Total | 302 |
Modeling patterns
There are multiple modeling issues relevant to this content including:
- Third degree burns involve the skin and subcutaneous tissues, while fourth degree burns involve skin, subcutaneous tissues, and underlying structures. Currently, neither of these sets of content classify as subtypes of Burn of skin (disorder).
- Almost all Deep full thickness burn (disorder) [Fourth degree burn] concepts are modeled with an ASSOCIATED MORPHOLOGY value of Third degree burn injury (morphologic abnormality) or its descendant. As a result, Deep full thickness burn (disorder) is a subtype of Third degree burn (disorder), but should be its sibling.
- There are 14 third degree burn concepts and 2 fourth degree burn concepts which reference burns of non-skin body structures, and the meaning of these concepts is ambiguous. These concepts are listed and addressed in Appendix B.
- There are also 50 concepts which should classify as a Third degree burn (disorder) or Deep full thickness burn (disorder) but currently do not. These concepts are provided in Appendix C.
Query | Concepts |
Total number of Third degree burn (disorder) concepts (includes Deep full thickness burn (disorder) and descendants) | 252 |
Total number of concepts with naming conventions consistent with third or fourth degree burns, but do not classify as subtypes of Third degree burn (disorder) or Deep full thickness burn (disorder): Concepts referencing third degree burns (46) Concepts referencing fourth degree burns (4) | 50 |
Total | 302 |
3.5 Subsidiary and interrelated problems
This artifact is associated with the JIRA artifact IHTSDO-268 | artf6307-Concepts with the expressions "with loss of body part" or "without loss of body part." These phrases are found for some third and fourth degree burn concepts, and may have originated from ICD-9-CM, the United States Clinical Modification version of the WHO ICD-9.
4 Risks / Benefits
4.1 Risks of not addressing the problem
Risks of not addressing the problem include:
- Potential for inadequate search or query results due to outdated or insufficient descriptions
- Potential for missed or incorrect classification of skin burn <disorder> content in SNOMED CT due to inconsistent modelling
- Potential for ambiguous and redundant content
- Each of the above issues has the potential to cause challenges for implementers
4.2 Risks of addressing the problem
Risks of addressing the problem include:
- Addressing the recommendations provided in this project will require additional authoring and quality assurance review of content, and therefore, additional resources may be needed
- To harmonize and update Burn (disorder) content within SNOMED CT, it may be determined that some existing content should be edited or retired; these changes would need to be accounted for by implementers
- Further review of existing content may result in the discovery of additional problems that have not yet been discovered
4.3 Benefits of addressing the problem
Benefits of addressing the problem include:
- Comprehensive and up to date representation of burn injury content in SNOMED CT
- Enhanced Burn (disorder) content, consistent with terminology and classification supported by authoritative references as well as WHO ICD-11 Beta
- Elimination of redundant and ambiguous content
- Significant enhancements for implementation by providing users with current, comprehensive, and non-duplicative concept selection for recording patient data
5 Requirements: criteria for success and completion
5.1 Criteria for success/completion
The criteria for success will be:
- Implementation of up to date naming convention and modeling guidelines
- Harmonization of existing content as well as any future content
- Comprehensive representation of burn injury content, consistent with terminology and classification supported by major burn organizations and WHO ICD-11 Beta
- Removal of instances of ambiguity and redundancy
5.2 Strategic and/or specific operational use cases
Based on the document, IHTSDO Strategic Directions to 2015, this project meets the following IHTSDO strategic goals:
- IHTSDO Strategic Priority 1: Make it easier to use SNOMED CT for priority use cases
- Providing comprehensive Burn (disorder) content in SNOMED CT will enhance implementation by providing users with current, accurate, and comprehensive concept selection for recording patient data, which will also assist interoperability.
- IHTSDO Strategic Priority 2: Produce robust terminology standards that are “fit for purpose” for priority use cases
- Recording patient problem list information in electronic health records is a high priority use case for SNOMED CT. This document provides guidance for naming conventions and modeling guidelines for problem list content related to the Burn (disorder) hierarchy. It also identifies areas of insufficient, ambiguous, and duplicative content. Addressing these issues will strongly contribute to creating high quality content for user implementation.
- IHTSDO Strategic Priority 3: Facilitate use of SNOMED CT with other international standards
- The guidelines provided in this document are based on international burn authority recommendations as well as WHO ICD-11 Beta classification (as of March 2016). These guidelines aim to make SNOMED CT Burn (disorder) content congruent and up to date with these authoritative standards.
5.2.1 Use case 1
Requests relating to Burn (disorder) content for use within a problem list:
1A Patient summary / Discharge summary
1B Problem list
2B Continuity of care / Discharge plans
5.2.1.1 Fit with IHTSDO strategy
These proposed solutions support IHTSDO Strategic Priorities as outlined above in Section 5.2. Implementing the proposed recommendations will enhance existing SNOMED CT content. The proposed naming conventions and modeling guidelines will make SNOMED CT query results more consistent and robust (Priority 2), and therefore easier for implementers to use (Priority 1). The guidelines will also allow harmonization of SNOMED CT content with authoritative references in burn injury disorders (Priority 3).
6 Solution Development
6.1 Initial Design
6.1.1 Outline of initial design
This section will address the following topics:
- Recommendations for naming conventions and modeling guidelines for content following the pattern Burn of <body structure>
- Recommendations for naming conventions and modeling guidelines for content following the pattern <Depth of> burn
- Recommendations for changes to the Burn injury (morphologic abnormality) hierarchy to support modeling Burn (disorder) content
- Identification of potentially duplicative content in the Burn (disorder) hierarchy
- Address comments posted on the JIRA tracker for this artifact
6.1.1.1 Burn of <body structure> content recommendations
Naming conventions and modeling patterns for content following the pattern Burn of <body structure> have been consistently applied in the Burn (disorder) hierarchy. It is suggested that these conventions be continued as outlined in the tables below.
Recommended naming convention
Description component | Recommended pattern |
Fully Specified Name | Burn of <body structure> (disorder) |
Preferred Term | Burn of <body structure> |
Recommended modeling pattern
Modeling component | Recommended pattern |
Definition status | Concept should be sufficiently defined as appropriate |
Role group | FINDING SITE: <Body structure> (body structure) ASSOCIATED MORPHOLOGY: Burn injury (morphologic abnormality) |
*Post-review addendum: Please see reviewer’s comment and author’s response in Appendix E.
6.1.1.2 <Depth of> burn content recommendations
There are a few issues to address with respect to new and existing skin burn content:
- The application of skin burn injury terminology to non-skin body structures in some concepts
- Inconsistent and/or ambiguous naming conventions
- Inconsistent modeling patterns, causing insufficient or incorrect classification
Specific recommendations for naming conventions and modeling patterns for each category of <Depth of> burn content are provided in the sub-sections below. In addition, the following general recommendations are proposed:
- Naming conventions: To harmonize existing content, it is suggested that each new and existing concept within a given category be given all appropriate descriptions. Because SNOMED CT editorial policy has traditionally discouraged changes to existing concept FSNs, the recommendations below attempt to create consistency through the use of descriptions. However, if feasible, it would be ideal to make FSNs consistent within each category. In this case, additional descriptions should still be added to provide comprehensive search results for implementers.
- Modeling patterns: Likewise, it is suggested that each new and existing concept within a given category be modeled according to the recommended specifications. This will require changes to some existing concepts as will be described further below.
6.1.1.2.1 Concepts with skin burn terminology applied to non-skin body structures
Section 3.4.4 described the limited number of concepts in the Burn (disorder) hierarchy where skin burn terminology has been applied to non-skin body structures as well as the challenges this content presents. The list of 45 relevant concepts as well as references for authoritative burn classifications for some non-skin body structures are provided in Appendix B. It is recommended that a separate content project be undertaken to determine if these concepts should remain in SNOMED CT and, if so, what classification systems are appropriate to apply to burns of these body structures.
6.1.1.2.2 First degree burn content
Recommended naming conventions
Naming conventions for first degree burn concepts could be harmonized if the following guidelines are implemented:
Description component | Recommended naming convention |
Fully Specified Name | Epidermal burn of <body structure> (disorder) |
Preferred Term | Epidermal burn of <body structure> |
Synonym 1 | First degree burn of <body structure> |
Synonym 2 | Superficial burn of <body structure> |
Synonym 3 | Burn erythema of <body structure> |
Recommended modeling pattern
First degree burns involve the epidermis layer of the skin; therefore, it is appropriate that this content is currently a subtype of Burn of skin (disorder). The current modeling pattern which has been fairly consistently applied should continue to be implemented as outlined below. Section 3.4.5.2 noted existing concepts which are currently not modeled according to the recommended specification. These concepts and specific modeling suggestions are listed in Appendix C.
Modeling component | Recommended modeling pattern |
Definition status | Concept should be sufficiently defined as appropriate |
Role group | FINDING SITE: Skin of <body structure> (body structure) ASSOCIATED MORPHOLOGY: First degree burn injury (morphologic abnormality) |
6.1.1.2.3 Second degree burn content
Recommended naming conventions
Naming conventions for second degree burn concepts could be harmonized if the following guidelines are implemented:
Description component | Recommended naming convention |
Fully Specified Name | Partial thickness burn of <body structure> (disorder) |
Preferred Term | Partial thickness burn of <body structure> |
Synonym 1 | Second degree burn of <body structure> |
| |
Fully Specified Name | Superficial partial thickness burn of <body structure> (disorder) |
Preferred Term | Superficial partial thickness burn of <body structure> |
Synonym 1 | Superficial second degree burn of <body structure> |
| |
Fully Specified Name | Deep partial thickness burn of <body structure> (disorder) |
Preferred Term | Deep partial thickness burn of <body structure> |
Synonym 1 | Deep second degree burn of <body structure> |
Recommended modeling pattern
Second degree burns involve the dermis layer of the skin. Currently Second degree burn (disorder) is not a subtype of Burn of skin (disorder), though the majority of its subtypes are. The modeling pattern suggested below will allow appropriate second degree burn content to classify as subtypes of Burn of (skin). This pattern will also make Second degree burn (disorder) content consistent with First degree burn (disorder) content. Section 3.4.5.3 noted existing concepts which are currently not modeled according to the recommended specification. These concepts and specific modeling suggestions are listed in Appendix C.
Note that implementation of the recommended guidelines will result in 16 concepts referring to second degree burns of non-skin body structures no longer classifying under Second degree burn (disorder) and Burn of skin (disorder). This outcome is expected and appropriate. Concepts with skin burn terminology applied to non-skin body structures are addressed in Section 6.1.1.2.1 and Appendix B.
Modeling component | Recommended modeling pattern |
Definition status | Concept should be sufficiently defined as appropriate |
Role group | FINDING SITE: Skin of <body structure> (body structure) ASSOCIATED MORPHOLOGY: As appropriate: Second degree burn injury (morphologic abnormality) Superficial partial thickness burn (morphologic abnormality) Deep partial thickness burn (morphologic abnormality) |
6.1.1.2.3 Third and fourth degree burn content
As stated in Section 3.4.5.4, third and fourth degree burn content are addressed together because this content is currently intermixed in the Burn (disorder) hierarchy.
Recommended naming conventions
Naming conventions for third and fourth degree burn concepts could be harmonized if the following guidelines are implemented. Please also note:
- There are 66 concepts referencing “deep third degree burns,” and while this content is somewhat unclear, it is not suggested to be retired as it can be linked to ICD-9 terminology and may be relevant to some users. However, it is not recommended that new “deep third degree burn” content be added.
- There are 7 existing concepts which have incorrect descriptions: 6 fourth degree burn concepts have “deep third degree burn” descriptions and 1 “deep third degree burn” concept has a “deep full thickness burn” description. These concepts and their incorrect descriptions, which should be retired, are listed in Appendix C.
Third degree burn content
Description component | Recommended naming convention |
Fully Specified Name (FSN) | Full thickness burn of <body structure> (disorder) |
Preferred Term (PT) | Full thickness burn of <body structure> |
Synonym 1 | Third degree burn of <body structure> |
Fourth degree burn content
Description component | Recommended naming convention |
Fully Specified Name (FSN) | Deep full thickness burn of <body structure> (disorder) |
Preferred Term (PT) | Deep full thickness burn of <body structure> |
Synonym 1 | Fourth degree burn of <body structure> |
Recommended modeling patterns
Third degree burns involve the skin and subcutaneous tissues, while fourth degree burns involve skin, subcutaneous tissues, and underlying structures. Currently, fourth degree burn concepts are subtypes of third degree burns concepts, and neither of these types of content classify as subtypes of Burn of skin (disorder) because they are not modeled with a FINDING SITE value of <skin structure>.
Modeling options
There are various options to incorporate the individual anatomical components of third and fourth degree burns (i.e., skin, subcutaneous tissue, and underlying structure(s)) into the modeling of this content including:
- Use of multiple FINDING SITE attribute value pairs within a single role group to represent each anatomical component
- Use of multiple role groups, each with a FINDING SITE attribute value pair, to represent each anatomical component
- Use of a single FINDING SITE attribute with values of complex precoordinated <body structure> concepts such as 127856007 | Skin AND subcutaneous tissue structure (body structure) or its descendants
However, these options present challenges including:
- The potential for unwieldy and inconsistent modeling with multiple role groups or multiple attribute-value pairs within a single role group, which could be difficult to maintain, especially if there are changes to the <body structure> hierarchy.
- It is unclear if a concept with multiple FINDING SITE attribute-value pairs within a single role group can have a definition status of sufficiently defined. If these concepts were made primitive, determining and maintaining appropriate relationships could be challenging. This approach would also be affected by changes to the <body structure> hierarchy.
- The potential need to create numerous complex precoordinated <body structure> concepts to support FINDING SITE modeling of a relatively small subset of SNOMED CT concepts. (Note that the Skin AND subcutaneous tissue structure (body structure) hierarchy has its own challenges, including not having all of the necessary subtypes and having incomplete classification. In addition, Skin AND subcutaneous tissue structure (body structure) is actually a parent of Skin structure (body structure), so even if this hierarchy was used, third and fourth degree burns would still not classify under Burn of skin (disorder).)
- The potential inability to maintain consistency in modeling between third and fourth degree burn content. Modeling the individual anatomical sub-components of fourth degree burns would be difficult, because the value for the “underlying structure” (e.g.., muscle, bone, or joint of a specific body structure) is not always stated.
Recommended pattern
For the reasons noted above, it is suggested to maintain the current general modeling pattern of using a single role group with a FINDING SITE value of <body structure> and an ASSOCIATED MORPHOLOGY value of Third degree burn injury (morphologic abnormality) or Deep full thickness burn (morphologic abnormality (a new concept discussed in the next section). Though it will not classify as subtypes of Burn of skin (disorder), it will still continue to classify under specific Burns of <body structure> grouper concepts. This approach will allow this content to be modeled consistently and continue to be sufficiently defined.
This recommendation maintains the pattern that currently exists, and therefore, other than making fourth degree burn content a sibling to third degree burn content, there will not be a significant change. It is also consistent with some concepts in SNOMED CT, where the decision to sufficiently define a concept can take precedence over modeling the most detailed value for a given component (e.g., modeling 397825006 | Gastric ulcer (disorder) as described in Section 4.2.1.3.3.1 Sufficient definition of the SNOMED CT Technical Implementation Guide). Given the modeling challenges described above and that current content is already modeled in this manner, this approach seemed the most appropriate.
Additional content issues
There are additional modeling issues pertaining to existing content, including:
- Deep third degree burn content: This content should remain subtypes of Third degree burn (disorder) and be modeled with an ASSOCIATED MORPHOLOGY value of Deep third degree burn injury (morphologic abnormality).
- Missing content: Appendix C lists the concepts which require modeling changes to classify as subtypes of Third degree burn (disorder) and Deep full thickness burn (disorder).
Third degree burn content
Modeling component | Recommended modeling pattern |
Definition status | Concept should be sufficiently defined as appropriate |
Role group
| Third degree burn of <body structure> concepts: FINDING SITE: <Body structure> (body structure) ASSOCIATED MORPHOLOGY: Third degree burn injury (morphologic abnormality)
Deep third degree burn of <body structure> concepts: FINDING SITE: <Body structure> (body structure) ASSOCIATED MORPHOLOGY: Deep third degree burn injury (morphologic abnormality) |
Fourth degree burn content
Modeling component | Recommended modeling pattern |
Definition status | Concept should be sufficiently defined as appropriate |
Role group | FINDING SITE: <Body structure> (body structure) ASSOCIATED MORPHOLOGY: Deep full thickness burn (morphologic abnormality) *Note that this is a new concept recommendation to support modeling fourth degree burn disorder content (see Section 6.1.1.3 below) |
6.1.1.3 Burn injury (morphologic abnormality) content recommendations
There are a few changes to the Burn injury (morphologic abnormality) hierarchy that are suggested to support the above recommendations for the Burn (disorder) hierarchy:
- Add the description “Epidermal burn” to 77140003 | First degree burn injury (morphologic abnormality)
- Add the description “Partial thickness burn” to 46541008 | Second degree burn injury (morphologic abnormality)
- Add the description “Superficial second degree burn” to 262587005 | Superficial partial thickness burn (morphologic abnormality)
- Add the description “Deep second degree burn” to 262588000 | Deep partial thickness burn (morphologic abnormality)
- Create a new <morphologic abnormality> concept to support modeling fourth degree burn concepts using the guidelines below. The naming convention supports newer skin burn terminology; however, it would also be acceptable to use “Fourth degree burn” for the FSN to make this concept consistent with existing Burn injury (morphologic abnormality) concepts.
Description component | Recommended naming convention |
Fully Specified Name | Deep full thickness burn (morphologic abnormality) |
Preferred Term | Deep full thickness burn |
Synonym 1 | Fourth degree burn |
Modeling component | Recommended modeling pattern |
Definition status | Concept should be primitive |
Parent concept | 48333001 | Burn injury (morphologic abnormality) |
6.1.1.4 Potentially duplicative content in the Burn (disorder) hierarchy
There are several sets of potentially duplicative concepts in the Burn (disorder) hierarchy. These concepts should be reviewed and redundant content retired.
Potentially duplicate concepts |
33824005 | Burn erythema of face, head AND/OR neck (disorder) 211684007 | Superficial burn of face, head or neck (disorder) |
25515000 | Second degree burn of face, head AND/OR neck (disorder) 211691005 | Partial thickness burn of face, head or neck (disorder) |
61455009 | Third degree burn of face, head AND/OR neck (disorder) 211715009 | Full thickness burn of face, head or neck (disorder) |
284207003 | Burn of throat (disorder) 35447004 | Burn of pharynx (disorder) |
26729007 | Third degree burn of upper limb (disorder) 211849005 | Full thickness burn of arm (disorder) |
211896002 | First degree burn of multiple sites of wrist or hand (disorder) 111718007 | Burn erythema of multiple sites of wrist AND/OR hand (disorder) |
275450006 | Blister of wrist and hand, second degree burn (disorder) 43138003 | Second degree burn of wrist AND/OR hand (disorder) 269244007 | Partial thickness burn of wrist and hand (disorder) |
4310000 | Third degree burn of wrist AND/OR hand (disorder) 269245008 | Full thickness burn of wrist and hand (disorder) |
78202006 | Burn erythema of lip (disorder) 211687000 | Superficial burn of lip(s) (disorder) |
6.1.1.5 Comments posted on the JIRA tracker for this artifact
There are two comments on the JIRA tracker for this artifact posted by an IHTSDO SNOMED CT author. These comments are restated from Section 3.1 and addressed below.
Comment 1: There are about 160 concepts for Second degree burn. There are inconsistencies in concept modeling for finding sites. Some of them are modeled by skin structure but some are not. Therefore, not all of them are classified under 284196006|Burn of skin (disorder).
It is agreed that there are inconsistencies in the modeling of second degree burn content and that some concepts do not classify under Burn of skin (disorder). Of the 163 second degree burn concepts, there are 130 concepts which classify under Burn of skin (disorder), and 33 which do not, including the grouper concept Second degree burn (disorder). There are 16 concepts which require a FINDING SITE value of “Skin of <body structure>” to classify correctly under Burn of skin (disorder); these concepts are listed in Appendix C. However, there are 17 concepts which reference second degree burns of non-skin body structures. The meaning of these concepts is ambiguous, since skin burn terminology has been applied to body structures not consisting of skin (e.g., Partial thickness burn of eye (disorder)). These concepts are listed and addressed in Appendix B and addressed in Section 6.1.1.2.1.
*Post-review addendum: Please see reviewer’s comment and author’s response in Appendix E.
Comment 2: There are about 250 concepts for Third degree burn. Two issues need to be addressed. The first issue is that finding site should be 'skin structure' or more specifically 'structure of skin and subcutaneous tissue' instead of structure of a body region. The second issue is whether third degree burn should be subconcept of Burn of skin. The definition of third degree burn indicates the burn of skin (both epidermis and dermis layers).
These comments describe difficult questions which were given extensive consideration. It is agreed that third degree burns represent burns of skin and subcutaneous tissues, and that fourth degree burns represent burns of skin, subcutaneous tissue, and underlying structures. Modeling each of the individual anatomical components for third and fourth degree burns presents significant challenges as described in Section 6.1.1.2.3.
Because of these challenges, it is recommended that this content maintain the current general modeling pattern of using a single role group with a FINDING SITE value of <body structure> and an ASSOCIATED MORPHOLOGY value of Third degree burn injury (morphologic abnormality) or Deep full thickness burn (morphologic abnormality) (a new concept recommendation). This approach will mean that third and fourth degree burn content will remain direct subtypes of Burn (disorder) and will not classify as subtypes of Burn of skin (disorder). However, this approach will allow this content to be modeled consistently and continue to be sufficiently defined. Given the modeling challenges this content presents, maintaining the current general pattern seemed to be the most appropriate approach.
*Post-review addendum: Please see reviewer’s comment and author’s response in Appendix E.
6.1.2 Significant design or implementation decisions / compromises
The significant decision pertains to the modeling recommendation for third and fourth degree burn content. As described in Section 6.1.1.2.3, modeling each of the individual anatomical components of third and fourth degree burns (i.e., skin, subcutaneous tissue, and underlying structures) would present considerable challenges. Therefore, it is recommended to model this content in a manner that will allow consistent modeling and sufficient definition, even though the content will not classify under Burn of skin (disorder). Given the modeling challenges described in Section 6.1.1.2.3 and that this recommendation maintains the current pattern, this approach seemed the most appropriate.
6.1.3 Evaluation of Design
6.1.3.1 Exceptions and Problems
The main exception pertains to modeling recommendations for third and fourth degree burn content as described in Sections 6.1.1.2.3 and 6.1.2.
6.1.3.2 Design Strengths
The design strengths include:
- There are no changes to editorial policy required and there are no dependencies on other projects. The recommendations work within the framework of the existing Concept Model; therefore, they can be implemented immediately.
- Recommendations for the three primary patterns of Burn (disorder) content are provided, therefore, the suggestions can be applied to all concepts in this hierarchy.
- The solutions address naming convention inconsistencies, such that when implemented, users will have access to burn <disorder> terminology which is consistently represented, up to date, and harmonized with terminology supported by authoritative burn organizations as well as ICD-11 Beta.
- The solutions address modeling inconsistencies, such that when implemented, existing content should aggregate in appropriate hierarchical relationships and be consistent with the classification systems supported by authoritative burn organizations as well as ICD-11 Beta.
- The suggested modelling guidelines are consistent with URU (Understandable, Reproducible, and Useful) criteria and provide straightforward guidelines for terminology authors.
- The solutions address ambiguous and duplicative content, such that when implemented, the quality of burn <disorder> content will be significantly enhanced.
- The solutions address concepts outside the Burn (disorder) hierarchy (e.g., <morphologic abnormality> concepts) which will improve the quality of burn content across SNOMED CT.
6.1.3.3 Design Weakness
Third and fourth degree burn content will not classify as subtypes of Burn of skin (disorder). However, given the challenges described in Section 6.1.1.2.3, this approach seemed the most appropriate.
*Post-review addendum: Please see reviewer’s comment and author’s response in Appendix E.
6.1.3.4 Design Risks
Description of risk | Importance | Mitigation plan |
Third and fourth degree burn content will not classify as subtypes of Burn of skin (disorder) | Third and fourth degree burn content currently do not classify as subtypes of Burn of skin (disorder), so this issue is not new. | However, to mitigate this risk, it might be useful to implementers to incorporate this information into the SNOMED CT Editorial Guide (or other publically accessible documentation). This would allow users to be aware of this issue and address it accordingly in their specific implementation use cases if needed. |
7 Recommendation
7.1.1 Detailed design final specification
Section 6.1.1 provided detailed design specifications including recommendations for the three primary patterns of content in the Burn (disorder) hierarchy as well as associated content issues. Specific recommendations are outlined in the sections listed in the table below.
Content pattern / issue | Recommendations |
Burn of <body structure> (disorder) | Section 6.1.1.1 |
<Depth of> burn (disorder) Naming conventions & modeling guidelines Application of skin burn terminology to non-skin body structures Changes needed for existing content | Section 6.1.1.2 Section 6.1.1.2 Section 6.1.1.2 and Appendix B Appendix C |
<Type of> burn (disorder) | Appendix A |
8 Quality program criteria
8.1 Quality metrics
8.1.1 Quality metric 1
Component | Characteristic and Description | Metric | Target | Result | |
Logic definitions of concepts in the Burn (disorder) hierarchy | Char: | Adherence to recommended modeling guidelines | - Proportion modeled according to guidelines - Numerator: count of concepts following modeling guidelines - Denominator: count of all concepts under Burn (disorder)> | 90% |
|
Descr: | Concept logic definitions should have one role group with correct attribute-value pairs, be sufficiently defined as appropriate, and classify correctly. | ||||
8.1.2 Quality metric 2
Component | Characteristic and Description | Metric | Target | Result | |
Fully specified names and descriptions in the Burn (disorder) hierarchy | Char: | Adherence to terming guidelines | - Proportion meeting guidelines, based on manual review | 100% |
|
Descr: | All descriptions should adhere to terming guidelines suggested in Section 6.1. Guidelines should be applied consistently and comprehensively across all relevant content. | ||||
8.1.3 Quality metric 3
Component | Characteristic and Description | Metric | Target | Result | |
Address existing content issues in SNOMED CT | Char: | Adherence to terming guidelines | - Proportion meeting guidelines, based on manual review | 100% |
|
Descr: | Address issues related to ambiguous and duplicative content as outlined in Section 6.1 | ||||
9 Project Resource Estimates
9.1 Scope of construction phase
Content | Number of concepts |
<Type of> burn (disorder) (Content project recommended) Existing content following this pattern Corrosion burn content (61 total, 34 included in <Depth of> burn content below) Friction burn content Thermal burn (morphologic abnormality) content Subtotal |
50 27 6 6 89 |
<Depth of> burn (disorder) First degree burn content Second degree burn content Third degree burn content Fourth degree burn content Subtotal |
110 163 213 89 575 |
Additional issues relevant to <Depth of> burn (disorder) content: Concepts with skin burn terminology applied to non-skin body structures (45) (Content project recommended) Concepts requiring review for duplication/redundancy (19) | (Included in <Depth of> burn content above) |
Total | 664 (approximate) |
9.2 Projection of remaining overall project resource requirements
9.2.1 Expected project resource requirement category
9.2.2 Expected project impact and benefit
9.2.3 Indicative resource estimates for construction, transition and maintenance:
10 References
Albright, J., Davis, C., Bird, M., Ramirez, L., Kim, H., Burnham, E., . . . Kovacs, E. (2012). The acute pulmonary inflammatory response to the graded severity of smoke inhalation injury. Critical Care Medicine, 40(4), 1113-1121. Retrieved February 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3290689/
American Burn Association. (2009). Surgical Management of the Burn Wound and Use of Skin Substitutes. American Burn Association. Retrieved February 2016, from http://www.ucdenver.edu/academics/colleges/medicalschool/departments/surgery/divisions/GITES/burn/Documents/American%20Burn%20Association%20White%20Paper.pdf
Amirlak, B., & Shahabi, L. (2015, July). Skin Anatomy. Retrieved from Medscape: http://emedicine.medscape.com/article/1294744-overview#showall
Ansell Healthcare. (2015). Burns: Assessment and Management. Iselin, New Jersey, United States: Ansell Healthcare. Retrieved February 2016, from http://ansellhealthcare.com/pdf/edPro/RN_CEU_BurnsMgmt_Final.pdf
Australian & New Zealand Burn Association. (2016). Minor Burns. Retrieved February 2016, from Australian & New Zealand Burn Association: http://anzba.org.au/care/minor-burns/
British Burn Association. (2002). European Practice Guidelines for Burn Care. Retrieved February 2016, from British Burn Association: http://www.britishburnassociation.org/european-standards
Cheng, H.-T., Cheng, C.-L., Lin, C.-H., Tang, J.-H., Chu, Y.-Y., Liu, N.-J., & Chen, P.-C. (2008). Caustic ingestion in adults: The role of endoscopic classification in predicting outcome. BioMed Central Gastroenterology, 8, 31. Retrieved February 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2533005/?report=classic
Chibishev, A., Pereska, Z., Chibisheva, V., & Simonovska, N. (2013). Ingestion of Caustic Substances in Adults: A Review Article. Iranian Journal of Toxicology, 6(19), 723-734. Retrieved February 2016, from http://ijt.arakmu.ac.ir/files/site1/user_files_3a0bf3/rahbar-A-10-29-9-1839e33.pdf
Contini, S., & Scarpignato, C. (2013). Caustic injury of the upper gastrointestinal tract: A comprehensive review. World Journal of Gastroenterology, 19(25), 3918-3930. Retrieved February 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3703178/
Dries, D., & Endorf, F. (2013). Inhalation injury: epidemiology, pathology, treatment strategies. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 21, 31. Retrieved February 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653783/
Dua, H., King, A., & Joseph, A. (2001). A new classification of ocular surface burns. British Journal of Ophthalmology, 85, 1379-1383. Retrieved February 2016, from http://bjo.bmj.com/content/85/11/1379.full
International Health Terminology Standards Development Organisation (IHTSDO). (2014, July). Section 4.2.1.3.3.1 Sufficient definition. Retrieved February 2016, from SNOMED CT Technical Implementation Guide: http://ihtsdo.org/fileadmin/user_upload/doc/en_us/tig.html
Kearns, R., Holmes, J., & Cairns, B. (2013, September). Burn injury: what’s in a name? Labels used for burn injury classification: a review of the data from 2000-2012. Annals of Burns and Fire Disasters, 26(3), 115-120. Retrieved February 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3917143/
Oxford University Press. (2016, February). Skin. Retrieved from Oxford Dictionary: http://www.oxforddictionaries.com/us/definition/american_english/skin
Shiland, B. (2015). Medical Terminology & Anatomy for ICD-10 Coding. St. Louis, Missouri, United States: Elsevier. Retrieved February 2016, from https://books.google.com/books?id=UjKPBAAAQBAJ&pg=PA154&lpg=PA154&dq=%22deep+full+thickness+burn%22&source=bl&ots=A1RIqoxlR1&sig=gVC7Ok_DFWVTvqkNHWn8bPsFIUY&hl=en&sa=X&ved=0ahUKEwjpiNjn6NnKAhVCnoMKHcoFAy8Q6AEILzAE#v=onepage&q=154&f=false
Singh, P., Tyagi, M., Kumar, Y., Gupta, K. K., & Sharma, P. D. (2013, May-August). Ocular chemical injuries and their management. Oman Journal of Ophthalmology, 6(2), 83-86. Retrieved February 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3779420/
Walker, P., Buehner, M., Wood, L., Boyer, N., Driscoll, I., Lundy, J., . . . Chung, K. (2015). Diagnosis and management of inhalation injury: an updated review. Critical Care, 19, 351. Retrieved February 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4624587/
World Health Organization. (2008). World Report On Child Injury Prevention. Geneva, Switzerland: World Health Organization (WHO). Retrieved February 2016, from http://apps.who.int/iris/bitstream/10665/43851/1/9789241563574_eng.pdf
World Health Organization. (2016, February). Burns. Retrieved from World Health Organization (WHO): http://www.who.int/violence_injury_prevention/other_injury/burns/en/
World Health Organization. (2016). Burns . Retrieved February 2016, from International Statistical Classification of Diseases and Related Health Problems Eleventh Revision (ICD-11) Beta Draft: http://apps.who.int/classifications/icd11/browse/l-m/en#/http://id.who.int/icd/entity/163532889
World Health Organization. (2016). Burns and corrosions (T20-T32). Retrieved February 2016, from International Statistical Classification of Diseases and Related Health Problems Tenth Revision (ICD-10) Version for 2016: http://apps.who.int/classifications/icd10/browse/2016/en#/T20
11 Appendix A – <Type of> burn content
This Appendix will consider concepts following the pattern <Type of> burn (disorder).
11.1 Overview
As stated in the WHO definition provided in the document Glossary, there are several causes of burn injuries. The most common burn injury mechanisms are described in the table below. (World Health Organization, 2008) (Ansell Healthcare, 2015) (World Health Organization, 2016)
Burn type | Description |
Thermal | Burn due to an external heat source, including:
|
Chemical | Burn caused by exposure to or ingestion of reactive chemical substances such as strong acids or alkalis. WHO ICD-9 and ICD-10 also use the term “corrosion” to refer to chemical burns. |
Electrical | Burn caused by an electrical current. The current may cause injury in areas other than the contact/entry site; therefore, electrical burns cannot be judged by the external, visible injury alone. |
Radiation | Burn caused by alpha, beta or gamma radiation. |
Friction | Burn caused by exposure to hard, abrasive surfaces such as roads or carpet. |
Cold | Burn caused by exposure to prolonged cold and/or temperatures below freezing point. |
Inhalation | Burn caused by breathing in superheated gases, steam, hot liquid, or noxious products, causing thermal and/or chemical injury to the respiratory tract. |
As noted in Section 3.4.5, there are currently 50 concepts following the pattern <Type of> burn (disorder). These concepts are outlined in the table below.
Burn (disorder) hierarchy concepts | Number of concepts |
<Type of> burn (disorder) Chemical burn (disorder) Thermal burn (disorder) Electrical burn (disorder) Radiation burn (disorder) | 50 24 23 3 1 |
11.2 <Type of> burn concepts: existing naming conventions and modeling patterns
Specific issues relevant to individual types of burn content are summarized below.
Chemical burn content
Subtypes of 426284001 | Chemical burn (disorder) have some inconsistent naming conventions in the use of terms such as “caustic burn,” “acid chemical burn,” and “alkali(ne) chemical burn.” Most of this content appears sufficiently modeled and defined appropriately at first glance. However, there are 61 <disorder> concepts referring to “corrosions” which are not subtypes of Chemical (burn) and do not have “chemical burn” descriptions. The term “corrosion” is an ICD-9 and ICD-10 derived term referring to chemical burns, though as of March 2016, this term is not found in ICD-11 Beta. Of the 61 corrosion <disorder> concepts, 34 follow the pattern “Corrosion of first / second / third degree” and are included in the summary of <Depth of> burn content in the tables in Section 3.4.5. These concepts are modeled with an ASSOCIATED MORPHOLOGY value of First / second / third degree burn injury (morphologic abnormality), therefore, they only classify by <Depth of> burn. Since there are no <morphologic abnormality> concepts that combine <Type of> burn and <Depth of> burn, these concepts present a modeling challenge.
Thermal burn content
Subtypes of 314534006 | Thermal burn (disorder) have inconsistent naming conventions. These inconsistencies include variable inclusion of the <body structure> involved and variable phrasing such as “Burn caused by X” and “X burn” (e.g., Burn caused by hot liquid (disorder) and Hot oil burn of skin (disorder)). Some concepts in this hierarchy are inconsistently modeled in that they have a role group with an ASSOCIATED MORPHOLOGY value of Burn injury (morphologic abnormality) as well as a second ASSOCIATED MORPHOLOGY attribute with a value of Thermal burn (morphologic abnormality) inherited from the parent concept. In addition, there are concepts in the Thermal burn (morphologic abnormality) hierarchy that are very similar to concepts in the Thermal burn (disorder) hierarchy, and the distinction between these concepts is unclear (see table below).
Thermal burn (morphologic abnormality) | Thermal burn (disorder) |
Fat burn (morphologic abnormality) Food burn (morphologic abnormality) Hot drink burn (morphologic abnormality) Hot oil burn (morphologic abnormality) Hot water burn (morphologic abnormality) Steam burn (morphologic abnormality) | Fat burn of skin (disorder) Food burn of skin (disorder) Hot drink burn of skin (disorder) Hot oil burn of skin (disorder) Hot water burn of skin (disorder) Steam burn of skin (disorder) |
Friction burn content
The WHO definition of burns includes friction burns, though existing concepts following the pattern Friction burn of <body structure> (disorder) are currently not subtypes of the Burn (disorder) hierarchy. This is likely because Friction burn (morphologic abnormality) is not a subtype of Burn injury (morphologic abnormality). There are only 5 friction burn <disorder> concepts which could be considered for addition to the Burn (disorder) hierarchy:
Concept ID | FSN |
262539000 | Superficial friction burn (disorder) |
447405001 | Friction burn of hand (disorder) |
447406000 | Friction burn of neck (disorder) |
445739004 | Friction burn of face (disorder) |
447150006 | Friction burn of scalp (disorder) |
11.3 <Type of> burn content recommendations
There are currently 50 existing concepts following the specific <Type of> burn patterns; however, there are over 70 additional concepts that require further review:
- Corrosion <disorder> concepts (61, including 34 “Corrosion of first / second / third degree” concepts)
- Thermal burn (morphologic abnormality) subtype concepts (6)
- Friction burn <disorder> concepts (5) and Friction burn (morphologic abnormality) (1)
It is recommended that a content project be undertaken to review all <Type of> burn content for naming convention and modeling inconsistencies as well as concepts in the <morphologic abnormality> hierarchy. The tables below provide general guidelines, though please note:
- The term “corrosion” could be added in descriptions for existing Chemical burn (disorder) content; however, it is not recommended that new corrosion content be added. Also, concepts following the pattern “Corrosion of first / second / third degree” will require review to determine the appropriate value for the ASSOCIATED MORPHOLOGY attribute.
- For Radiation burn (disorder) content, there is no specific <morphologic abnormality> concept pertaining to model radiation burn content. Unless there are a large number of requests in the future, it is suggested that this content be modeled with an ASSOCIATED MORPHOLOGY value of Burn injury (morphologic abnormality) and remain primitive.
- If known, an additional attribute can be used to model the cause of burn. CAUSATIVE AGENT is suggested for modeling a <substance> value, since there are a limited number of existing concepts that already use this attribute, and use of this attribute will maintain consistency.
Recommended naming conventions
Description component | Recommended naming convention |
Fully Specified Name | <Chemical / Electrical / Thermal / Radiation / Friction> burn of <body structure> due to <X> (disorder) |
Preferred Term | <Chemical / Electrical / Thermal / Radiation / Friction> burn of <body structure> due to <X> |
Synonym | Corrosion of <body structure> due to <substance> (existing Chemical burn (disorder) concepts) |
Recommended modeling pattern
Modeling component | Recommended modeling pattern |
Definition status | Concept should be sufficiently defined as appropriate |
Role group | FINDING SITE: <Body structure> (body structure) as appropriate ASSOCIATED MORPHOLOGY: <Morphologic abnormality> as appropriate: Chemical burn (morphologic abnormality) Electrical burn (morphologic abnormality) Thermal burn (morphologic abnormality) Friction burn (morphologic abnormality) |
Additional attribute | CAUSATIVE AGENT: If cause is <physical force> or <substance> DUE TO: If cause is an <event> |
*Post-review addendum: Please see reviewer’s comment and author’s response in Appendix E.
12 Appendix B – <Depth of> burn content: existing concepts with skin burn terminology applied to non-skin body structures
As stated in Section 3.4.4, the terms “first degree,” “second degree,” “third degree,” and “fourth degree” burns and their synonyms apply to burns of skin and underlying tissues. However, for 45 concepts, this terminology has been applied to burns of non-skin body structures, and the meaning of these concepts is unclear. This Appendix outlines the set of relevant concepts for each category of burn depth as well as literature references for authoritative burn classifications for some non-skin body structures. As stated in Section 6.1.1.2.1, it is recommended that a separate content project be undertaken to determine if these concepts should remain in SNOMED CT and/or what authoritative burn classification systems are appropriate to apply to these body structures.
12.1 Existing concepts
12.1.1 First degree burn content
From Section 3.4.5.2, the 13 concepts below refer to first degree burns of non-skin body structures:
Concept ID | FSN |
211686009 | Superficial burn of the eye (disorder) |
110191003 | Burn erythema of buccal mucosa (disorder) |
110215002 | Burn erythema of floor of mouth (disorder) |
110219008 | Burn erythema of hard palate (disorder) |
110195007 | Burn erythema of labial mucosa (disorder) |
110211006 | Burn erythema of mandibular attached gingiva (disorder) |
110203001 | Burn erythema of mandibular vestibule (disorder) |
110207000 | Burn erythema of maxillary attached gingiva (disorder) |
110199001 | Burn erythema of maxillary vestibule (disorder) |
110223000 | Burn erythema of soft palate (disorder) |
110231005 | Burn erythema of tonsillar area (disorder) |
110227004 | Burn erythema of oropharynx (disorder) |
110234002 | Burn erythema of tongue (disorder) |
12.1.2 Second degree burn content
From Section 3.4.5.3, the 16 concepts below refer to second degree burns of non-skin body structures:
Concept ID | FSN |
284199004 | Partial thickness burn of eye (disorder) |
269234005 | Superficial partial thickness burn of the eye (disorder) |
211704004 | Deep partial thickness burn of the eye (disorder) |
287137008 | Burn to cornea - blister (disorder) |
110192005 | Second degree burn of buccal mucosa (disorder) |
110216001 | Second degree burn of floor of mouth (disorder) |
110220002 | Second degree burn of hard palate (disorder) |
110196008 | Second degree burn of labial mucosa (disorder) |
110212004 | Second degree burn of mandibular attached gingiva (disorder) |
110204007 | Second degree burn of mandibular vestibule (disorder) |
110208005 | Second degree burn of maxillary attached gingiva (disorder) |
110200003 | Second degree burn of maxillary vestibule (disorder) |
110228009 | Second degree burn of oropharynx (disorder) |
110224006 | Second degree burn of soft palate (disorder) |
110235001 | Second degree burn of tongue (disorder) |
110232003 | Second degree burn of tonsillar area (disorder) |
12.1.3 Third degree burn content
From Section 3.4.5.4, the 14 concepts below refer to third degree burns of non-skin body structures:
Concept ID | FSN |
211717001 | Full thickness burn of the eye (disorder) |
287138003 | Burn to cornea - full thickness (disorder) |
110193000 | Third degree burn of buccal mucosa (disorder) |
110217005 | Third degree burn of floor of mouth (disorder) |
110221003 | Third degree burn of hard palate (disorder) |
110197004 | Third degree burn of labial mucosa (disorder) |
110213009 | Third degree burn of mandibular attached gingiva (disorder) |
110205008 | Third degree burn of mandibular vestibule (disorder) |
110209002 | Third degree burn of maxillary attached gingiva (disorder) |
110201004 | Third degree burn of maxillary vestibule (disorder) |
110229001 | Third degree burn of oropharynx (disorder) |
110225007 | Third degree burn of soft palate (disorder) |
110236000 | Third degree burn of tongue (disorder) |
110233008 | Third degree burn of tonsillar area (disorder) |
12.1.4 Fourth degree burn content
From Section 3.4.5.4, the 2 concepts below refer to fourth degree burns of non-skin body structures:
Concept ID | FSN |
211725004 | Deep full thickness burn of the eye without loss of body part (disorder) |
211738007 | Deep full thickness burn of the eye, with loss of body part (disorder) |
12.2 Classification systems for burns of some non-skin body structures
12.2.1 Burn injuries of the eye
With respect to burn injuries of the eyes, most literature references focus on ocular surface burns, presumably because deeper burn injuries result in damage to the entire eye structure and/or prevent the ability to recover vision. A notable exception is the use of laser technology to intentionally create micro-burns of the retina to treat certain disorders (e.g., photocoagulation for diabetic retinopathy).
In 1964, P. Ballen first suggested a classification system for ocular surface burns. This system was modified a year later by M. Roper-Hall and was essentially the standard from 1965 until 2001, at which time, Dua et al. published an expanded version of the Roper-Hall system. Both the Roper-Hall and the Dua systems appear to be in clinical use today and are shown in the tables below. Note that ocular burn injuries are described by “grades” rather than by the “degree” or “thickness” conventions used for skin burn injuries. Additional information related to ocular burn injuries can be obtained from the following sources provided in the References section: Dua et al., 2001 and Singh et al., 2013.
Roper-Hall classification
Grade | Prognosis | Cornea | Conjunctiva/Limbus |
I | Good | Corneal epithelial damage | No limbal ischemia |
II | Good | Corneal haze, iris details visible | <1/3 limbal ischemia |
III | Guarded | Total epithelial loss, stromal haze, iris details obscured | 1/3-1/2 limbal ischemia |
IV | Poor | Cornea opaque, iris and pupil obscured | >1/2 limbal ischemia |
Dua classification
Grade | Prognosis | Clinical findings | Conjunctiva involvement |
I | Very good | 0 clock hours of limbal involvement | 0% |
II | Good | ≤ 3 clock hours of limbal involvement | ≤ 30% |
III | Good | < 3-6 clock hours of limbal involvement | > 30-50% |
IV | Good to guarded | < 6-9 clock hours of limbal involvement | > 50-75% |
V | Guarded to poor | < 9 - <12 clock hours of limbal involvement | > 75 - <100% |
VI | Very poor | Total limbus (12 clock hours) involved | Total conjunctiva (100%) involved |
12.2.2 Burn injuries of the gastrointestinal tract
Burn injuries of the gastrointestinal (GI) tract are generally the result of ingestion of corrosive chemical substances or thermal injuries due to ingesting hot liquids and food. Thermal injuries are generally limited to the oral cavity, while corrosive injuries can affect the full length of the GI tract. Both acidic and alkaline substances can produce corrosive burn injuries. The primary classification systems for burn injuries of the GI tract, Kikendall and Zagar, focus on depth of mucosal injuries due to corrosive substances. The Zagar classification appears more commonly in literature searches.
GI tract burn injuries are described as “grades,” though it appears that some authors use the term “degrees” as well. It is important to note that terms such as “first degree burn,” “second degree burn,” etc. have a different meaning with respect to the GI tract than with respect to skin. Additional information related to GI tract burn injuries can be obtained from the following sources provided in the References section: Contini & Scarpignato, 2013, Cheng et al., 2008, and Chibishev et al., 2013.
Kikendall classification
Grade | Description |
I | Edema and erythema of the mucosa |
II A | Hemorrhage, erosions, blisters, superficial ulcers |
II B | Circumferential lesions |
III | Deep grey or brownish-black ulcers |
IV | Perforation |
Zagar classification
Grade | Description |
0 | Normal examination |
1 | Edema and hyperemia of the mucosa |
2a | Superficial ulceration, erosions, friability, blisters, exudates, hemorrhages, whitish membranes |
2b | Grade 2a plus deep discrete or circumferential ulcerations |
3a | Small scattered areas of multiple ulceration, areas of necrosis with brown-black or greyish discoloration |
3b | Extensive necrosis |
4 | Perforation |
12.3.1 Burn injuries of the respiratory tract
Respiratory burn injuries can result from heat exposure (thermal inhalation injury), chemical irritation of the respiratory tract, or systemic toxicity due to carbon monoxide (CO) and cyanide, or a combination of injuries. Thermal airway injury is generally limited to upper respiratory structures, whereas injury to the lower airway is usually chemical in nature.
Based on considerable literature review, the primary system use to classify inhalation burn injuries of the respiratory tract appears to be the Abbreviated Injury Score (AIS) criteria. This classification is outlined in the table below. Additional information related to respiratory tract burn injuries can be obtained from the following sources provided in the References section: Albright et al., 2012, Dries & Endorf, 2013, and Walker et al., 2015.
Abbreviated Injury Score (AIS)
Grade | Class | Description |
0 | Normal | Absence of carbonaceous deposits, erythema, edema, bronchorrhea or obstruction |
1 | Mild injury | Minor or patchy areas of erythema, carbonaceous deposits in proximal or distal bronchi |
2 | Moderate injury | Moderate degree of erythema, carbonaceous deposits, bronchorrhea, or bronchial obstruction |
3 | Severe injury | Severe inflammation with friability, copious carbonaceous deposits, bronchorrhea or obstruction |
4 | Massive injury | Evidence of mucosal sloughing, necrosis, endoluminal obliteration |
13 Appendix C – <Depth of> burn content recommendations: existing concepts requiring changes
Section 3.4.5 described <Depth of> burn content and the concepts which require modeling changes. This Appendix provides recommendations for each set of <Depth of> burn content.
13.1 First degree burn content
The recommendations below will allow concepts to classify under First degree burn (disorder).
Change ASSOCIATED MORPHOLOGY value to First degree burn injury (morphologic abnormality) (2)
Concept ID | FSN |
287132002 | Burn to eyelid - erythema (disorder) |
54674008 | Burn erythema of forehead AND/OR cheek (disorder) |
Role group the ASSOCIATED MORPHOLOGY and FINDING SITE attribute value pairs (1)
Concept ID | FSN |
200833005 | Sunburn of first degree (disorder) |
Change FINDING SITE value to Skin of <body structure> (body structure) (19)
Note that the concepts flagged with an asterisk are probably duplicates (see Section 6.1.1.4).
Concept ID | FSN |
111716006 | Burn erythema of trunk (disorder) |
211896002 | First degree burn of multiple sites of wrist or hand (disorder)* |
16333002 | Burn erythema of male genitalia (disorder) |
20945009 | Burn erythema of face AND/OR head (disorder) |
49523001 | Burn erythema of multiple sites of upper limb (disorder) |
78202006 | Burn erythema of lip (disorder)* |
284204005 | Superficial corrosion of lip (disorder) This concept should also be evaluated in the context of <Type> of burn content presented in Appendix A. |
33824005 | Burn erythema of face, head AND/OR neck (disorder) |
110175001 | Burn erythema of preauricular region of face (disorder) |
211687000 | Superficial burn of lip(s) (disorder)* |
473253006 | Epidermal burn of multiple sites of face without involvement of eye proper (disorder) |
110171005 | Burn erythema of periorbital region (disorder) |
473272006 | Epidermal burn of multiple sites of upper limb without involvement of wrist and without involvement of hand (disorder) |
77830003 | Burn erythema of multiple sites (disorder) |
473244004 | Burn of eye region with epidermal burn of face (disorder) |
447157009 | First degree burn of face (disorder) |
52425001 | Burn erythema of female genitalia (disorder) |
111718007 | Burn erythema of multiple sites of wrist AND/OR hand (disorder)* |
473248001 | Burn of eye region with epidermal burn of head and/or neck (disorder) |
13.2 Second degree burn content
The recommendations below will allow concepts to classify under Second degree burn (disorder).
Change ASSOCIATED MORPHOLOGY value to Second degree burn injury (morphologic abnormality) (1)
Note that there is one additional concept with a naming convention consistent with second degree burn, but not modeled with an ASSOCIATED MORPHOLOGY value of Second degree burn injury (morphologic abnormality); however, this concept, 287137008 | Burn to cornea - blister (disorder), references a non-skin body structure and has been added to Appendix B.
Concept ID | FSN |
287133007 | Burn to eyelid - blister (disorder) |
Change FINDING SITE value to Skin of <body structure> (body structure) (17)
Concept ID | FSN |
403191005 | Second degree burn (disorder) This concept should have a FINDING SITE value of Skin structure (body structure) |
5083008 | Second degree burn of back (disorder) |
446905000 | Second degree burn of face (disorder) |
54975007 | Second degree burn of face AND/OR head (disorder) |
25515000 | Second degree burn of face, head AND/OR neck (disorder) |
62738008 | Second degree burn of upper arm (disorder) |
111720005 | Second degree burn of multiple sites of lower limb (disorder) |
13212004 | Second degree burns of multiple sites (disorder) |
275450006 | Blister of wrist and hand, second degree burn (disorder) |
200834004 | Sunburn of second degree (disorder) |
284205006 | Partial thickness burn of lip (disorder) |
473254000 | Partial thickness burn of multiple sites of face without involvement of eye proper (disorder) |
473245003 | Burn of eye region with partial thickness burn of face (disorder) |
473249009 | Burn of eye region with partial thickness burn of head and/or neck (disorder) |
269235006 | Superficial partial thickness burn of lip(s) (disorder) |
211705003 | Deep partial thickness burn of lip(s) (disorder) |
287133007 | Burn to eyelid - blister (disorder) |
13.3 Third and fourth degree burn content
13.3.1 Recommended description changes
As noted in Section 6.1.1.2.3, there are inaccurate descriptions associated with this content. The table below lists descriptions which should be retired.
Concept ID | FSN | Description to be Retired |
211937005 | Deep full thickness burn of a single finger with loss of body part (disorder) | Deep third degree burn of finger with loss of a body part |
211943007 | Deep full thickness burn of wrist, with loss of body part (disorder) | Deep third degree burn of wrist with loss of a body part |
211932004 | Deep full thickness burn of the wrist without loss of body part (disorder) | Deep third degree burn of wrist, without loss of a body part |
211927000 | Deep full thickness burn of the thumb without loss of body part (disorder) | Deep third degree burn of thumb, without loss of a body part |
211938000 | Deep full thickness burn of thumb, with loss of body part (disorder) | Deep third degree burn of thumb with loss of a body part |
211926009 | Deep full thickness burn of a single finger without loss of body part (disorder) | Deep third degree burn of finger,without loss of a body part |
23252003 | Deep third degree burn of trunk with loss of body part (disorder) | Deep full thickness burn of the trunk, with loss of body part |
13.3.2 Recommended modeling changes
The recommendations below will allow concepts to classify under Third degree burn (disorder) or Deep full thickness burn (disorder) [Fourth degree burn].
Add ASSOCIATED MORPHOLOGY value of Third degree burn injury (morphologic abnormality) (46)
There are 46 concepts following the pattern “Burn involving more than X percent of body surface, with Y-Z percent of body surface with full thickness burn (disorder)“ which can be found in the 212049006 | Burns classified according to percentage of body surface involved (disorder) hierarchy. These concepts refer to full thickness burns (third degree burns), but are not modeled as such.
Add ASSOCIATED MORPHOLOGY value of Deep full thickness burn (morphologic abnormality) (89)
Note that this <morphologic abnormality> concept is a new concept recommended in Section 6.1.1.3.
None of the 89 Deep full thickness burn of <body structure> (disorder) concepts are modeled with an appropriate ASSOCIATED MORPHOLOGY value. The 4 concepts below have no ASSOCIATED MORPHOLOGY attribute, while 85 additional concepts have an ASSOCIATED MORPHOLOGY value of Third degree burn injury (morphologic abnormality) or its descendant, which is incorrect and the value should be changed to the new <morphologic abnormality> concept.
Concept ID | FSN |
211722001 | Deep full thickness burn of the face, head or neck - without loss of body part (disorder) |
211735005 | Deep full thickness burn of the face, head or neck, with loss of body part (disorder) |
269247000 | Deep full thickness burn of the wrist and hand with loss of body part (disorder) |
211932004 | Deep full thickness burn of the wrist without loss of body part (disorder) |
14 Appendix D – IHTSDO SIRS requests for burn <disorder> content
The table below lists the 5 SIRS requests for burn <disorder> concepts as of March 2016. Please note that the first 4 requests have already been addressed in the past and are essentially complete.
With respect to the final request, this document provides specific recommendations to address inconsistencies. By implementing the suggested specifications, Burn (disorder) content should not only become more consistent, but also congruent with authoritative burn injury organizations. With respect to the second concern, the term “superficial partial thickness burn” has a specific meaning and is used by multiple international burn injury organizations and, as of March 2016, is also included in ICD-11 Beta (please refer to Section 3.4.3). One means of addressing this concern would be to add text definitions to Burn injury (morphologic abnormality) and/or Burn (disorder) concepts. However, in general, unless a large number of these types of requests are received, the systematic application of text definitions to burn content does not seem necessary.
Batch ID | Request ID | Summary |
311174 | 330499 | New concept request: Third degree burn of multiple sites of upper limb, not involve wrist (disorder) |
311174 | 330500 | New concept request: Deep third degree burn of multiple sites of upper limb, not involve wrist and hand (disorder) |
311174 | 330621 | New concept request: Deep third degree burn of multiple sites of upper limb, not involve wrist (disorder) |
518297 | 518681 | Retire concept request: 20311006 | Burn erythema of multiple sites of trunk (disorder) and 211769006 | Superficial burn of multiple sites of trunk (disorder) are duplicates |
531371 | 531381 | Other request: Consistency required to ensure users are able to search easily and reduce ambiguousness of concept. Burn concepts are represented in SCT by several classification systems. Currently, older concepts contain references to older classification systems (e.g. first/second/third degree) as well as the newer classification system (e.g. superficial, partial thickness, full thickness). Many concepts that have been recently created only contain the newer classification term, and do not contain the older first/second/third term. We are concerned for the lack of consistency and while these older terms may not be the preferred term, they are still commonly in use and having some concepts with these synonyms and some without could confuse users into thinking there were gaps (even though the concepts exist). We also have had feedback from external users that the FSNs for the degree of partial thickness burns could be considered ambiguous as the term "superficial partial thickness burn" does not make lexical sense as "superficial" and "partial thickness" seem to be conflicting 211906005 |Superficial partial thickness burn of wrist|. A suggested term would be "superficial dermal partial thickness burn" |
15 Appendix E – Post-review addendum: Reviewer comments and author responses
This document was reviewed and approved on 7 June 2016. This appendix provides each of the reviewer’s comments along with the author’s responses.
15.1 Comment 1 – Section 6.1.1.1 Burn of <body structure> content recommendations
Referenced text (highlighted below):
Recommended modeling pattern
Modeling component | Recommended pattern |
Definition status | Concept should be sufficiently defined as appropriate |
Role group | FINDING SITE: <Body structure> (body structure) ASSOCIATED MORPHOLOGY: Burn injury (morphologic abnormality) |
Reviewer comment:
I’m just wondering about the relationship between leg proper and skin of leg.. This kind of feels like a redundant concept – 284196006|Burn of skin| or does it duplicate 125666000|Burn|… Are there any concepts that might be duplicates? E.g. Finding Site = some skin structure vs some Finding site = ancestor of skin structure.
Author response:
I believe the comment is asking:
1- Are “Burn of <body structure>” and “Burn of skin of <body structure>” the same?
2- Are there multiples pairs of such concepts in SNOMED CT?
For Question 1:
This is a good question and reflects a significant challenge for this project: representing the clinical definitions and connotations of burn disorder content within the context of SNOMED CT concept modeling.
At first glance, it is understandable from a clinical perspective that “Burn of <body structure>” and “Burn of skin of <body structure>” seem redundant; however, in the context of SNOMED CT modeling, these concepts have different logical definitions and serve different purposes. Burn of <body structure> concepts serve as grouper concepts for any burns of that structure – first and second degree burns (which are burns of the skin), but also third and fourth degree burns (which involve skin as well as subcutaneous tissue, muscle, bone, etc.). Therefore Burn of skin of <body structure> concepts are more specific than (and are subtypes of) Burn of <body structure> concepts in the context of SNOMED CT.
To address 125666000 | Burn (disorder) and 284196006 | Burn of skin (disorder) specifically: Burn (disorder) is a top-level grouper concept modeled with only an ASSOCIATED MORPHOLOGY (AM) value of Burn injury (morphologic abnormality). This concept aggregates burn disorder concepts (with the same AM value) – whether the concept represents a burn of the skin or not. In addition, it also subsumes burn disorder content of different categories (as described in Section 3.4.2): Burn of <body structure> (including burns of skin and non-skin structures), <Type of> burn (chemical, electrical, etc.), and <Depth of> burn (first, second, third degree, etc.).
284196006 | Burn of skin (disorder) only aggregates concepts representing burns of the skin and separates these concepts from those representing burns of non-skin structures (e.g., burns of the eye, GI tract, respiratory tract, etc.).
For Question 2:
I don’t believe there are concepts which represent duplicates as defined in the comment. However, the use of <skin structure> vs. <body structure> to model the FINDING SITE value for first, second, third, and fourth degree burn concepts can vary as described in the sub-sections of Section 6 in this document. These sub-sections emphasize that finding a balance between representing the clinical definitions of burn disorders within the context of SNOMED CT modeling is a challenging task.
15.2 Comment 2 – Section 6.1.1.5 Comments posted on the JIRA tracker for this artifact
Referenced text:
JIRA tracker artifact – comment from an IHTSDO SNOMED CT author: There are about 160 concepts for Second degree burn. There are inconsistencies in concept modeling for finding sites. Some of them are modeled by skin structure but some are not. Therefore, not all of them are classified under 284196006|Burn of skin (disorder).
Reviewer comment:
This was the kind of thing I was wondering about.
Author response:
I hope my original text was sufficient. To summarize, it is agreed that this content is modeled inconsistently. Some second degree burn concepts do not classify under Burn of skin (disorder) – 33 out of the total 163 second degree burn concepts. Of these 33 concepts, 17 concepts require modeling changes to classify correctly under Burn of skin (disorder). These concepts are addressed in Appendix C. The remaining 16 concepts reference non-skin body structures, therefore, it is actually correct that they do not classify under Burn of skin (disorder). These concepts are listed and addressed in Appendix B.
15.3 Comment 3 – Section 6.1.1.5 Comments posted on the JIRA tracker for this artifact
Referenced text (highlighted below):
This approach will mean that third and fourth degree burn content will remain direct subtypes of Burn (disorder) and will not classify as subtypes of Burn of skin (disorder). However, this approach will allow this content to be modeled consistently and continue to be sufficiently defined. Given the modeling challenges this content presents, maintaining the current general pattern seemed to be the most appropriate approach.
Reviewer comment:
But they do involve the skin? The burn just penetrates deeper/beyond?
Author response:
Yes, that is correct – third degree burns involve the skin and subcutaneous tissues, while fourth degree burns involve skin, subcutaneous tissues, and underlying structures.
15.4 Comment 4 – Section 6.1.3.3. Design Weakness
Referenced text (highlighted below):
Third and fourth degree burn content will not classify as subtypes of Burn of skin (disorder). However, given the challenges described in Section 6.1.1.2.3, this approach seemed the most appropriate.
Reviewer comment:
Could we state third and forth as subtype of skin? And perhaps have some modelling guidance for content authors to about how to model these? (ie. A deviation from proximal primitive modeling). It’s easier to communicate to the authoring alumni than it is the implementers?
Author response:
This is a challenging question which was given due consideration as a potential modeling option for this content.
It is technically possible to make third and fourth degree burn disorder concepts stated subtypes of Burn of skin (disorder); however, third and fourth degree burns are more than burns of the skin - they also involve burns of underlying structures (subcutaneous tissue, muscle, bone, etc.). These additional body structures would also need to be captured in the stated definitions. To capture all of these structures in the stated definitions for the third and fourth degree burn grouper concepts as well as all of their subtypes would be very challenging. It is also not clear if these concepts could remain sufficiently defined with multiple FINDING SITE attribute-value pairs.
As a side note, if only the third and fourth degree burn grouper concepts are made subtypes of Burn of skin (disorder), after classifying, most of the subtypes of these grouper concepts would no longer remain subtypes because they are not modeled with a FINDING SITE of <skin structure>, but rather <body structure> (because third and fourth degree burns involve more than the skin). For these reasons, modeling this content should address not only the grouper concepts, but all of their subtypes as well.
There are multiple potential options for modeling third and fourth degree burn disorder content (as outlined in Section 6.1.1.2.3). The author ultimately chose to recommend the option that seemed to optimize the logical definitions and taxonomic structure of this content in SNOMED CT – which was essentially to maintain the existing modeling patterns with slight modifications. However, the risks/benefits profile for a given modeling option may appear differently to various implementers; therefore, the author defers the preferred choice of modeling options to the IHTSDO. The author hopes that this document will be useful in guiding their decision.
15.5 Comment 5 – Appendix A Section 11.3 <Type of> burn content recommendations
Referenced text (highlighted below):
Recommended modeling pattern
Modeling component | Recommended modeling pattern |
Definition status | Concept should be sufficiently defined as appropriate |
Role group | FINDING SITE: <Body structure> (body structure) as appropriate ASSOCIATED MORPHOLOGY: <Morphologic abnormality> as appropriate: Chemical burn (morphologic abnormality) Electrical burn (morphologic abnormality) Thermal burn (morphologic abnormality) Friction burn (morphologic abnormality) |
Additional attribute | CAUSATIVE AGENT: If cause is <physical force> or <substance> DUE TO: If cause is an <event> |
Reviewer comment:
It seems to me that causative agent would be sufficient for the “type”. However, I can imagine there might be some benefit in modeling the morphologic nature of the burn…
Author response:
The primary benefit to using the ASSOCIATED MORPHOLOGY is the aggregation of content by <Type of> burn in the Burn (disorder) hierarchy. There are approximately 89 concepts representing <Type of > burns in SNOMED CT. About 50 concepts are currently nicely organized into the sub-hierarchies:
- Chemical burn (disorder)
- Electrical burn (disorder)
- Thermal burn (disorder)
Each of the above concepts is modeled with the corresponding ASSOCIATED MORPHOLOGY value that allows concepts aggregate under these grouper concepts, rather than be listed flatly under Burn (disorder). In addition, there are 61 corrosion (chemical burn) and 5 friction burn concepts which are not modeled with a corresponding ASSOCIATED MORPHOLOGY value and do not aggregate under a grouper concept in the Burn (disorder) hierarchy (some are not even in the Burn (disorder) hierarchy). Therefore, the main benefit of this modeling recommendation is to ensure that content classifies and aggregates optimally within the Burn (disorder) hierarchy.
15.6 Comments posted to the Confluence Document Review Page
Additional comments from the author were posted to the Confluence Document Review Page. They have been added here along with responses from the author.
Comments | Author’s response (optional) |
This is a really well written and researched document. I've made a number of comments through it, for the author to consider - but consider it as feedback and action as the author considers appropriate. My only questions I was left with concern: |
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| The author attempted to provide clarification to this topic in this Appendix E, Section 15.5. |
| This is a challenging question which was given extensive consideration during the course of researching and writing this document. It is reassuring that the reviewer shares the same thoughts. Options for modeling this content are provided in Section 6.1.1. In addition, the author attempted to provide additional information and clarification in this Appendix E, Sections 15.1 and 15.4. Hopefully, the challenges have been outlined sufficiently. As stated in Section 15.4, the author tried to recommend the options that seemed to optimize the logical definitions and taxonomic structure of this content in SNOMED CT. However, the risks/benefits profile for a given modeling option may appear differently to various implementers; therefore, the author defers the preferred choice of modeling options to the IHTSDO. The author hopes that this document will be useful in guiding their decision. |
I think the author has addressed both these sufficiently in the document, but I still wonder... Either way, it is an excellent document, and I really enjoyed reading it, and happy to approve this version in it's current state. Apologies for the delay in uploading feedback. | The author very much appreciates the reviewer’s comments and feedback. |
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