Comparative accuracy and inter-rater reliability of digital tools for burn surface area estimation: A systematic...

Total Burned Surface Area (%TBSA) estimation is essential in guiding effective burns resuscitation. Traditional methods of %TBSA estimation remain limited by poor inter-rater reliability and operator-dependent accuracy. Several digital applications have been developed to assist with %TBSA estimation; however, there is a paucity of evidence directly comparing their accuracy, inter-rater reliability, and clinical utility. We aimed to synthesise the performance metrics of digital tools for %TBSA estimation as compared with traditional methods and established reference standards, to assess their suitability for clinical integration. A PRISMA-guided search of Embase and MEDLINE (January 1, 1990-August 20, 2023) was conducted to identify studies reporting accuracy or inter-rater reliability for computer- or smartphone-based digital %TBSA estimation tools. 20 studies (2006-2023) evaluating 16 unique digital tools met the inclusion criteria. Against an established standard, digital tools demonstrated superior accuracy over traditional methods (mean error: digital -5.47% to +4%; traditional -0.47% to +19.7%), with EasyTBSA achieving the closest agreement to the established reference (-0.01 ± 3.59%) compared with Lund and Browder (4.42 ± 5.52%), Rule of Palms (3.92 ± 10.71%), and Rule of Nines (5.05 ± 6.87%). Digital tools demonstrated higher inter-rater reliability (ICC: digital 0.986-0.998; traditional 0.886-0.910). Time-to-estimation varied across digital platforms without a consistent advantage over traditional methods. While direct cross-application comparisons were precluded due to study heterogeneity, these findings suggest that digital tools for %TBSA estimation offer measurable improvements in accuracy and reliability over conventional methods, warranting consideration for broader clinical integration as digital health technologies continue to advance.