Cool Running Water as a First Aid Treatment for Burn Injuries - 23/09/25

Doi : 10.1016/j.annemergmed.2025.08.003

Maleea D. Holbert, PhD ^a,^b,^⁎ , Yvonne Singer, PhD, MPH, BSc, RN ^a, Tina Palmieri, MD ^c,^e, John Rose, MD ^d, Kevin Mackey, MD ^f, Sonia Singh, MD, MPH, MBA, MSc ^d, Nathan Kuppermann, MD, MPH ^d, Fiona Wood, AM ^g,^h, Victor Joe, MD ⁱ, Tanesha A. Dimanopoulos, GradDip(Public Health), BPsych ^a,^b, Cody Frear, MD, PhD ^b, Steven M. McPhail, PhD, BPhysio ^k, Roy Kimble, DMed(Res), MBChB ^b, Leila Cuttle, PhD ^l, Robert Katzer, MD, MBA, BA ^j, Bronwyn Griffin, PhD, RN ^a,^b
^a School of Nursing and Midwifery, Griffith University, Nathan Campus, QLD, Australia
^b Children’s Health Queensland Hospital and Health Service, South Brisbane, QLD, Australia
^c Burn Division, Department of Surgery, UC Davis Health and UC Davis School of Medicine, Sacramento, CA
^d Department of Emergency Medicine, UC Davis Health and UC Davis School of Medicine, Sacramento, CA
^e Shriners Children’s Northern California, Sacramento, CA
^f Sacramento Fire Department, City of Sacramento, CA
^g Perth Children’s Hospital, Nedlands, WA, Australia
^h Burn Injury Research Unit, University of Western Australia, Crawley, WA, Australia
ⁱ Department of Surgery, Division of Trauma, Burns, Critical Care & Acute Care Surgery, UC Irvine Health, Orange, CA
^j Department of Emergency Medicine, UC Irvine Health, Orange, CA
^k Australian Centre for Health Services Innovation, and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Australia
^l School of Biomedical Sciences, Faculty of Health, Queensland University of Technology, Kelvin Grove, Australia

^∗Corresponding Author.

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Abstract

Study objective

The application of 20 minutes of cool running water within 3 hours of a burn injury significantly improves patient burn-related outcomes. To facilitate the integration of 20 minutes of cool running water into clinical practice in the United States, this investigation aimed to determine barriers and facilitators to implementing 20 minutes of cool running water in out-of-hospital emergency medical services (EMS) and in-hospital emergency departments (EDs) and to codesign tailored strategies for its routine use in acute burn first aid.

Methods

Using a sequential mixed-methods design, we identified barriers and facilitators to 20 minutes of cool running water implementation and codesigned strategies to enhance its implementation. EMS and ED clinicians completed an online questionnaire assessing perceived barriers and facilitators, with responses coded using the Consolidated Framework for Implementation Research. Semistructured interviews with a convenience sample of participants further examined determinants and codesigned implementation strategies.

Results

A total of 371 (210 EMS, 161 ED) clinicians participated in the questionnaire, and 22 (14 EMS, 8 ED) participated in interviews. Twelve key determinants were identified across 4 Consolidated Framework for Implementation Research domains. Implementation barriers included a lack of resources, challenges adapting 20 minutes of cool running water to local clinical settings, and the absence of external policies incorporating burn first aid cooling, whereas facilitators included high clinician motivation, strong professional networks, and a supportive clinical culture. Codesigned strategies to enhance 20 minutes of cool running water uptake included portable irrigation equipment, nursing-driven protocols, and policy updates.

Conclusion

Although clinicians appear motivated to implement 20 minutes of cool running water, infrastructure, workflow, and policy challenges hinder widespread adoption. Addressing these barriers through targeted codesigned 20 minutes of cool running water implementation strategies will facilitate integration into EMS and ED settings, improving burn care outcomes.

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Keywords : Burn injuries, First aid, 20 minutes cool running water, Implementation science, Implementation barriers

Plan

	Please see page XX for the Editor’s Capsule Summary of this article.
	Supervising editor : Kathy J. Rinnert, MD, MPH. Specific detailed information about possible conflict of interest for individual editors is available at editors .
	Author contributions: YS, TP, JR, SS, NK, FW, VJ, CF, SMM, RK, LC, RK, and BG conceptualized the research and designed the trial. BG is the chief principal investigator and obtained research funding. MDH, YS, and BG undertook participant recruitment, data collection, data management, and interpretation of results. JR and SS aided in the interpretation of data form the emergency department. KM aided in interpretation of EMS data. MDH and TAD conducted data analyses. MDH wrote the draft manuscript, and all authors provided critical review and editing of the article, and approved the final manuscript. MDH takes responsibility for the paper as a whole.
	Data sharing statement: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
	All authors attest to meeting the four ICMJE.org authorship criteria:(1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Fundingandsupport: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/ ). This research received funding from the U.S. Department of Defense Clinical Translational Research Award (ID: W81XWH-2110965). The authors declare that they have no competing interests.
	Ethics approval and consent to participate: Institutional Review Board (IRB) approval has been awarded for this research (IRB ID: 18834-5) from UC Davis Office of Research.