bluuebunny/crossref_metadata_2025 huggingface dataset:
579 Outcomes of an Independent Burn Advanced Practice Provider Peer Review Process
Authors: Steiner Stephanie , Lewis Lauren , Baker Kevin , Crow John , Khandelwal Anjay
Published: March 2022

Introduction

Burn peer review (PR) is an important process for quality assurance and process improvement. Our division consists of five burn surgeons, seven advanced practice providers (APPs) and four night house officer (NHO) APPs. As the APPs are intimately integrated within the burn service - both on the inpatient (IP) and outpatient (OP) settings, a subsequent need to create an independent peer review process for the APPs was identified. We describe our process and evaluate the results after two years of a monthly APP PR meeting.

Methods

All data is entered into a quality management software. Triggers for APP PR include complex discharge, inappropriate OP referral, delay in treatment, OP treatment greater than three weeks without surgical intervention, pressure wound, patient discharge with greater than 30 morphine equivalent dose (MED) of narcotic, readmission or unexpected admission from OP clinic, substance abuse, and self referral. Cases with individual improvement opportunities result in real time direct feedback from the director, lead APP, and peers. These may be escalated to the provider’s ongoing professional performance evaluation (OPPE) or trigger a focused professional performance evaluation (FPPE). Systemic issues identified are referred for multidisciplinary discussion in our Performance Improvement/Quality Assurance (PI/QA) process. Complicated issues involving multiple disciplines may trigger a root cause analysis. If an individual or system issue is not identified, a group discussion about process improvement and standardization of practice ensues.

Results

From initiation of the Burn APP PR process in May of 2019, to September 2021, there were 37 cases reviewed. Twelve were for indicated triggers and 25 for self-referrals. Breakdown of these cases is as follows: outpatient treatment greater than three weeks without surgical intervention (3), readmission or unexpected admission from outpatient clinic (4), delay in treatment impacting clinic course (5). Self referred cases included graft loss (8), cellulitis (3), venous thromboembolic event (2), and wound dressing discussion (2). There were three cases where clinical issues were identified of which one was referred for root cause analysis, and the other two led to real-time education and feedback from the director.

Conclusions

PR is important to ensure that high quality patient care standards are met. Autonomous APP practice is important for the function of a team, quality of care delivered, professional satisfaction of the APP, and enables financial optimization for burn centers. Creating an independent burn APP peer review process allows for time-sensitive feedback to patient care related events, improves collaboration and practice standardization, and provides an important educational opportunity for the team.
580 Setting the Burn Team Up for Success
Authors: O'Rourke Cassandra , Gernt Megan
Published: March 2022

Introduction

Hybrid burn centers are challenged to meet the criteria of the ABA verification process. When burn care occurs in different units across a hospital, it is difficult to ensure all areas are aware of the verification criteria and ensure timelines and expectations of optimal burn care are understood. Our center had difficulty ensuring rehabilitation referrals were placed on admission to allow the maximum amount of time for these services to establish a plan of care. Staffing issues were identified as contributing to the inability to consistently establish a rehabilitation program within 24 hours of admission.

Methods

We had a QI goal of 100% compliance for establishing a comprehensive rehabilitation plan within 24 hours of admission. Several methods of education were provided to all providers and other burn team members to encourage immediate consultation to physical therapy and occupational therapy. Consultations to these services were frequently delayed. In 2017, 63% of the patients admitted had a rehabilitation plan of care established within 24 hours of admission. To address this, a burn order set was developed. This burn order set had the orders for PT and OT pre-populated to have the order placed on admission. The order set went live in November of 2017. In 2018, the percentage of patients receiving a comprehensive rehabilitation plan within 24 hours of admission had increased to 80%. Further education for use of the order set was provided, including additional presentations during our resident "boot camp" in 2018, our burn program manager reviewing all burn admissions and providing feedback to providers to use the burn order set, and established the role of a dedicated burn NP along with an everyday burn clinic in 2020. Staffing patterns were assessed in collaboration with the lead PT and OT. Rehabilitation established more coverage on the weekends and holidays to ensure staff was available 7 days per week to respond to the rehabilitation referrals for our patients.

Results

The compliance with the ABA verification criteria for establishment of a comprehensive rehabilitation program within 24 hours of admission had increased with consistent use of the burn order set and increased rehabilitation staffing. In the last 4 quarters of 2020-2021, our compliance has increased to 92%. In 2 of the last 4 quarters our compliance was 100%.

Conclusions

The use of a comprehensive burn order set can help a hybrid burn center ensure they are set up to meet ABA verification criteria. These order sets when used consistently can not only ensure consults are ordered, but also help remind providers of the unique needs of the burn patients and improve efficiency.
583 Photos of Burn Wounds Can Help Reduce Over-Triage and Prevent Unnecessary Ambulance Transfer
Authors: McCourt Jacita A , Strait Eli , Lee Jeanne
Published: March 2022

Introduction

Burn wounds can be difficult to assess for providers outside the burn center and can result in over triage. The combination of photos of burn wounds with a clinical history can help burn practitioners make appropriate triage decisions, including immediate ambulance transfer vs scheduling an outpatient follow up appointment. Appropriate photo triage can help reduce healthcare costs by eliminating both unnecessary transfers to the burn center and overburdening burn resources. This performance improvement project involved the development of a secure photo sharing web portal and photo triage clinical pathway to help burn practitioners appropriately triage burn patients being evaluated at health care facilities within the catchment area of an American Burn Association verified adult and pediatric burn center.

Methods

Existing technology was used to develop a burn photo sharing web portal that can be easily accessed by providers outside the burn center. A new clinical pathway for burn photo triage was developed. Education was formulated for nurses and providers within the burn center and for referring facilities. Retrospective data was collected for the 4 years of ambulance transfers captured in the outpatient burn registry prior to the implementation of the photo triage clinical pathway. Comparison data was also abstracted for the first year after implementation. Patients were categorized as over triaged or appropriately triage based on the first set of photos captured in the EMR.

Results

In the pre-triage years there were a total of 242 ambulance transfers to the outpatient burn clinic. 150 (62%) of those patients were appropriately triaged, while 92 (38%) were over triaged. In the year following implementation there were 27 ambulance transfers to the outpatient burn clinic. 25 (92.6%) of these patients were appropriately triaged while 2 (7.4%) were over triaged. Overall ambulance transfers to the outpatient burn clinic dropped by more than 50% (average of 60.5 transfer per year down to 27 after implementation).

Conclusions

Patients with burn injuries at referring facilities were more appropriately triaged when using photos of wounds which ultimately reduced the number of unnecessary ambulance transfers.
588 Utilizing a Quality Improvement Approach to Increase Compliance with Patient Positioning in the Burn Unit
Authors: Gallagher Catherine E , Slater Julia C , Dale Elizabeth L
Published: March 2022

Introduction

Patient positioning, notably positioning patients in “anti-deformity positioning”, is a standard practice in burn rehabilitation as it assists with edema management, scar contracture prevention, and wound healing. Successfully and consistently providing proper positioning of burn patients requires the combined effort of the multi-disciplinary burn team. The primary goal at our center was to increase the frequency that patients were correctly positioned to over 90% at the time of random audits.

Methods

At a medium-sized, academic burn unit, once to twice weekly audits were conducted by burn lead therapists on the compliance of proper patient positioning over a 6-month period. Using this data as a trigger, a quality improvement project was designed using the PDSA (Plan-Do-Study-Act) cycle to help identify reasons behind lack of compliance. Surveys were distributed to the therapy and nursing staff to identify any barriers to care. Effects on positioning compliance post-intervention were monitored.

Results

In the 6 months prior to intervention, our patients were positioned correctly an average of 76% of the time. Therapy and nursing surveys identified the following barriers to care: Nursing needed more education on positioning, and the approach was too heavily reliant on nursing efforts alone. To address these barriers, therapists provided education to both day and night shift nurses, communicated daily about positioning expectations, shifted the project from a nursing approach to a multidisciplinary approach, and made changes in therapy workflow. Immediately following the intervention, the compliance rates were 91% for the first month and 85% for the second month.

Conclusions

Coordinating efforts of the entire burn team improves consistency for positioning in burn patients. Utilizing the PDSA cycle allowed us to identify areas for improvement and to develop appropriate interventions aimed at both increased education for nursing staff and workflow improvements for our therapists. Following the completion of our interventions we were able to obtain an immediate improvement in our compliance with proper positioning of burn patients.
592 Strategy for Improving Wound Care Compliance in the Outpatient Setting by using Take-home Visual Aids
Authors: G'sell David , Smith Sydney , Flores Carl A , Peterson Abbey , Virgadamo Lacy , Phelan Herb A , Kopari Nicole M , Carter Jeffrey E
Published: March 2022

Introduction

Wound care compliance is a critical component in the success of treating burns in the outpatient setting. Patients and caregivers are educated with demonstration and written materials which have demonstrated a 24-hour retention rate of 30% and 10% respectively. This can leave the patient at higher risk for infection, increased pain from suboptimal dressings, and feelings of frustration. Research has shown that visual learners make up 65% of the population, with auditory learners at 30%, and tactile learners at 5%. We assessed that a combination of demonstration and visual aids could better assist different learning styles and improve wound care compliance. Our study goal was to assess the efficacy of the visual aids component through new patient encounters in the emergency department and outpatient setting using a six-question survey at subsequent encounters.

Methods

The study design is a prospective analysis with comparison to historical controls. Visual aids were designed by the burn physician assistants with assistance at an ABA-verified burn center. We created four double-sided cards made out of a water-resistant synthetic paper, with one for each of our most used dressings. The content of the cards included one of the following: bacitracin/fine mesh gauze with bismuth tribromophenate, bacitracin with low-adherent acetate gauze, silver nylon dressings, and silver foam dressings. Each card contains moulage wounds, step-by-step, and corresponding written instructions at a 4th grade education reading level. These visual aids were given to patients being discharged from the emergency department, or to new patients in the burn clinic. A six-question survey was administered at one week follow-up encounters with a scale of 1-10 (one being least helpful, and ten being the most helpful) assessing patients understanding of burn wound care and compliance. Compliance rates were abstracted from historical controls with similar burn wound severity.

Results

Limited data is available at the time of submission as the study is currently in-progress and anticipated to be completed by March 2021. We will be using descriptive statistics and comparative analysis to evaluate the results.

Conclusions

Patients initial feedback has been overall positive with a corresponding compliance rate that is successful. Our patients verbalized their approval, with multiple patients stating that they plan to keep the wound care card for any burn injuries that might occur in the future. Additional research is needed to examine the impact of combined demonstration, tactile, and auditory learning aids. In addition, we plan to further expand our engagement effort to include similar wound care cards for pediatric patients as well as language alternative cards to meet our surrounding community's needs.
600 Reconstruction of Finger Contracture with an Expanded Dorsal Metacarpal Artery Perforator Flap
Authors: Ozkan Burak , Uysal Cagri A , Abali Ayse Ebru , Haberal Mehmet
Published: March 2022

Introduction

The first dorsal metacarpal artery perforator (DMCAP) flap is frequently used to cover exposed bone, tendon and neurovascular structures in the hand after trauma and burns. The size and width of DMCAP flap is limited and rotation arc generally lets to cover defects up to middle phalanx. Expansion of the DMCAP flap has not been reported in the literature and this technique might be solution to increase flap viability and size in order to cover defects up to distal phalanx. In this study, we will describe utilization of tissue expander to first DMCAP and present a case of electric burns in with flexor contracture.

Methods

A nine-year-old male patient applied to our clinic with the complaint of inability to extend the second finger of the left hand after an electrical burn. Physical examination revealed flexor contracture in the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints. Reconstruction was planned for the patient with a two-session expanded first DMCAP flap.

In the first session, a 16 cc 5x3 cm tissue expander placed through a 3 cm vertical incision at the fifth metacarpal level. From the second postoperative week, the tissue expander was inflated with 1 ml of isotonic three days a week. Six weeks later, the DMCAP area was enlarged by giving 45 cc saline.

Results

In the second session, contractures at the level of the left hand 2nd finger DIP and PIP were excised.. Left hand 2nd finger was fixated in extension with K-wire. 9x3 cm DMCAP flap was elevated by dissection over the paratenon and the pedicle was preserved. The flap was adapted to the defect area on the volar face with 180-degree rotation angle. The flap donor site was closed primarily.

There were no complications in the post-operative period. K-wire was removed at 6 weeks postoperatively. The patient was referred to the physical therapy.

Conclusions

In cases where the tissue defect cannot be closed with loco regional flaps, extra tissue can be provided by free flaps or using tissue expanders. Primary closure of the donor area, appropriate flap thickness for the finger, and aesthetically pleasing results are among the advantages of the expanded DMCA flap.. However, in tissue expander applications in the upper extremity, the patient should be followed closely, and pain and finger circulation should be constantly questioned.
622 Oral Ketamine Administration During Bromelain Based Enzymatic Debridement of Burn Injury
Authors: Halicki Elizabeth , Kahn Steven A , Condeni Melanie S , Hirsch Jason , Turner Jonathan
Published: March 2022

Introduction

Existing literature supports bromelain enzymatic debridement as an early tool for selective escharectomy, resulting in fewer skin grafts after burn injury. Enzyme application is painful, so many centers use continuous infusions of narcotics, ketamine, and sedatives in the intensive care unit. The authors utilize oral ketamine in burn practice- as it is safe, can decrease the need for higher level of care, and be used without fasting. The purpose of this study is to evaluate whether oral ketamine can safely be utilized as an alternative to continuous infusions of medications for bromelain treatment.

Methods

This was a retrospective study of patients who received oral ketamine (for analgesia) and oral lorazepam (for anxiolysis and prevention of dysphoria) for bromelain-based selective enzymatic debridement application over a 6-month period. Data collected included patient demographics, burn characteristics, sedatives and analgesics administered, pain scores, adjunct medications, and vital signs. Presence of respiratory insufficiency (desaturations < 93%, need for bag-valve mask, or intubation), hypertensive urgency (SBP >180, DBP >110 w/out end organ dysfunction), dysphoric reactions, and uncontrolled pain were recorded. Oral ketamine (2-4 mg/kg) was given 30 minutes prior to the procedure. Patients were monitored per sedation guidelines and had capnography plus supplemental oxygen. Small PRN IV boluses of narcotics were given during the procedure, along with their baseline oral multimodals and narcotics. Pain was measured with the 1-10 verbal rating scale with minimal pain defined as < 4 or the patient clinically observed as sleeping. Patients were not made NPO for the procedure.

Results

Ten patients were included. Four patients (40%) had minimal pain during enzyme application, 3 (30%) patients slept through their procedure, and 3 (30%) patients reported 10/10 pain during treatment (2 had 10/10 pain before treatment). Five patients were treated on the floor, 7 were treated in the ICU. The median ketamine dose was 225 mg (IQR:177,250), or 3mg/kg (IQR:2.75,3). Additional oral and IV opioids received during the 8–14-hour interval was 21 morphine milligram equivalents (MEs). The median benzodiazepine dosing before and during enzymatic debridement was 1.4 lorazepam MEs. Three patients (30%) had hypertensive urgency, 2 (20%) of whom reported 10/10 pain, and all 3 received 10mg IV labetalol. No one had dysphoric reactions or respiratory insufficiency.

Conclusions

This preliminary study reveals oral ketamine administration is safe and effective for pain control during bromelain-based enzymatic debridement. Most patients required small to moderate amounts of PRN IV opioids, had acceptable pain control, and there were no significant adverse effects. Future large, prospective studies should evaluate dosing and timing for optimal patient outcomes.
707 Invasive Non-Candida Fungal Infections in Acute Burns: A 13-Year Review of a Single Institution
Authors: Akhavan Arya A , Shamoun Feras , Lagziel Tomer , Rostami Sohayla , Cox Carrie A , Cooney Carisa M , Hultman Charles S , Caffrey Julie
Published: March 2022

Introduction

Burn patients have higher infection rates due to loss of the protective skin barrier. The past decade shows increased rates of burn infection with atypical invasive fungal organisms. After a recent trend of life-threatening atypical fungal burn infections at our hospital, we conducted this study to further characterize this.

Methods

We identified patients admitted to our burn center from January 2008 to June 2021, who developed fungal non-Candida burn infections while admitted. We gathered demographic data, burn injury details, surgical treatment course, and fungal and bacterial infection data. Descriptive statistics were used to characterize the data and identify trends.

Results

We identified 37 acute burn patients with atypical invasive fungal infections. Of these, 28 were infected with 1 species, and 9 were infected with multiple fungi.

Non-Candida fungi included Aspergillus (20), Fusarium (8), Mucor (6), and 11 other species. Three fungi were resistant to antifungals including amphotericin B. Other organisms included Candida (18), Enterococcus (13), Pseudomonas (9), and 19 other species. On average, patients were infected with 5 bacteria, had 13 antibacterial resistances, and required 6.5 antibacterials. There was one case of total-drug-resistant Pseudomonas aeruginosa. Every patient required Infectious Disease consultation. Eight patients became bacteremic and 1 became fungemic.

The average burn surface area was 35%. All patients required excisional treatment, with an average of 7 excisions, 7 coverage procedures, and 3.5 other procedures; 44% of patients required amputations for infection control. The most common complications were graft loss (39%), ventilator-associated pneumonia (28%), and death (28%). The median length of stay was 40 days (IQR = 89) for survivors and 28 days (IQR = 14) for nonsurvivors. All fatalities were from overwhelming polymicrobial infection. The average modified Baux score was 73 (± 28) for survivors and 102 (± 38) for nonsurvivors. All nonsurvivors had clean wounds without penetrating trauma.

Conclusions

Burn patients with atypical invasive fungal infections have severe polymicrobial infections and extreme antibiotic resistance. Patients may require, or fail, treatment with last-line antibiotic therapy and amputation. Early Infectious Disease consultation and aggressive treatment is critical. Further research may elucidate risk factors and ideal treatment patterns.
711 Regional Burn Review: Brooke or Parkland, neither reaches the 85% accuracy mark for burn resuscitation
Authors: Azimzadeh Nava , Dahl Rachel A , Galet Colette , Wibbenmeyer Lucy
Published: March 2022

Introduction

Much has been written about burn resuscitation and, despite preponderant studies, the topic remains controversial. Over-resuscitation can result in burn wound conversion and other complications. Our team switched from using modified Parkland (PF) to Brooke formula (BF) in January 2020. Secondary to difficult resuscitations, we sought to review our data to identify factors associated with over-resuscitation using either formula. We hypothesized that the Brooke formula under-predicted resuscitation volumes compared to Parkland, particularly in older patients or in more severe burn injuries.

Methods

Medical records from patients who were admitted to the burn unit between 1/1/2019 and 8/29/2021 for a burn injury with %TBSA ≥15% were retrospectively reviewed. Exclusion criteria included age < 18 years, weight < 30 kg, patient not requiring resuscitation, or death within 24 h of admission. Demographics, injury information, resuscitation formula used, predicted 24-h resuscitation goal, the volume of resuscitation fluids, and time to reach maintenance were collected. Univariate analysis was performed to compare patients resuscitated using the BF vs. the PF. Multivariate analysis was performed to identify factors associated with over-resuscitation. Over resuscitation was defined as >2.5 mL/kg/%TBSA for BF and >5 mL/Kg/%TBSA for PF. P < 0.05 was considered significant.

Results

Sixty-four patients were included; 27 were resuscitated using BF and 37 using PF. Neither age, sex, weight, BMI, or severity of burn injury were significantly different between the groups. Patients required a median of 3.59 mL/Kg/%TBSA for BF and 3.99 mL/kg/%TBSA for PF, p = 0.32. Over-resuscitation was more likely to occur when using BF compared to PF (59.3% vs. 32.4%, p = 0.043). Stepwise multivariate logistic regression showed that over-resuscitation was associated with longer time to reach maintenance (OR = 1.179 [1.042-1.333], p = 0.009) and arrival through ground transportation (OR = 10.523 [1.171-94.597], p = 0.036). Patients who arrived through ground transportation took longer to reach the burn center (3.98 h [2.65-5.15] vs. 2.57 h [1.93-3.2], p = 0.004) and presented with lower %TBSA (20.8 [18-27.9] vs. 31.3[21-55], p = 0.004).

Conclusions

Time to reach definitive care was the only independent variable associated with over-resuscitation. While not significant, compared to PF, using BF tended to be associated with over-resuscitation. More studies are warranted to determine if BF continues to underperform and, if so, the populations in which it underperforms will be identified.
713 Mortality Benefit After Addition of Mid-level Support in Burn Intensive Care Unit
Authors: Hollowell Jamie L , Williams Felicia , Blandon-Hendrix Daniel , King Booker , Chrisco Lori , Maxwell Eli , Nizamani Rabia
Published: March 2022

Introduction

Burn Intensive Care Units (BICU)s are resource-heavy and labor-intensive units with very sick patients. The removal of burns as a requirement from the surgical curriculum has decreased the number of rotating surgical trainees, but did not impact patient care needs. Our unit adopted an Advanced Practice Provider (APP) service model in fiscal year 2018 to provide consistent standardized clinical care, with surgical trainees rotating monthly, to mitigate the loss of residents over time. We aimed to critically evaluate the impact of an APP run BICU on mortality and quality improvement initiatives.

Methods

Patients were identified using Institutional Burn Center registry, and linked to the clinical and administrative data. All patients admitted to the BICU between July 1, 2016 and June 30, 2020 were eligible for inclusion. All central line associated blood stream infections (CLABSI), catheter associated urinary tract infections (CAUTI), ventilator associated pneumonias (VAP) and mortality rates were compared. Demographics, length of stay (LOS), co-morbid conditions and mortality were evaluated. Statistical analysis was performed with Students’ t-test, and chi-squared tests. Significance was accepted as p< 0.05.

Results

There were no significant differences in admission rates over the study period. The number of CLABSIs significantly decreased each year (15 (2017), 6 (2018), 5 (2019), 3 (2020)). The number of CAUTIs significantly decreased ((13 (2017), 6 (2018), 1 (2019), 3 (2020)). The number of VAPs significantly decreased ((15(2017), 12 (2018), 7 (2019), 3 (2020)). Mortality was unchanged from 2017-2019 but significantly decreased in 2020 ((2.2% (2017), 2.4% (2018), 2.5% (2019), 0.9% (2020)).

Conclusions

There were no significant differences in admission rates over the study period. The number of CLABSIs significantly decreased each year (15 (2017), 6 (2018), 5 (2019), 3 (2020)). The number of CAUTIs significantly decreased ((13 (2017), 6 (2018), 1 (2019), 3 (2020)). The number of VAPs significantly decreased ((15(2017), 12 (2018), 7 (2019), 3 (2020)). Mortality was unchanged from 2017-2019 but significantly decreased in 2020 ((2.2% (2017), 2.4% (2018), 2.5% (2019), 0.9% (2020)).
723 Carbon Dioxide Laser Treatment Practices for Hypertrophic Burn Scars Amongst American Burn Association Burn Centers
Authors: Bruce Jon C , Dowdle Travis S , Schrader Kaylee B , Griswold John A
Published: March 2022

Introduction

Scarring is a major outcome of severe burn wound healing. Severe scars often persist and diminish quality of life by disfigurement, pain, and pruritis. In the last decade, utilization of ablative fractional carbon dioxide (CO2) laser therapy has become a popular treatment modality for severe burn scars. Although the efficacy of CO2 lasers for the treatment of hypertrophic burn scars has been established via systematic reviews, there have been no attempts to query the 63 American Burn Association (ABA) centers across the United States regarding specific treatment parameters involving serious, sometimes high, total body surface area (TBSA) burns.

Methods

Throughout October and November of 2020, a Qualtrics survey consisting of 14 questions was administered to burn surgeons practicing at all 63 ABA burn centers across the United States. Topics assessed were specific laser parameters utilized (5), treatment preferences (2), peri-operative follow-up (5), scar assessment practices (1), and TBSA treatment tolerance (1).

Results

Exploratory, descriptive data was analyzed. Surgeons practicing at 27 of the 63 total ABA burn centers responded to the survey (43% response rate). Data elucidates the level of variance regarding current initial management of hypertrophic burn scars via CO2 laser treatment. Surgeons demonstrated variation in the level of TBSA treatment tolerance and pulse energy settings, respectively.

Conclusions

Our findings show a substantial amount of variation in several aspects of CO2 laser hypertrophic scar revision between ABA centers across the country, including preoperative evaluation, laser settings, treatment regimen, and postoperative recommendations . Standardization of care when utilizing ablative fractional CO2 lasers should be further explored.
728 Chemical Burns and Eyebrow Tinting: An Unusual Case
Authors: Brondeel Kimberley C , Duggan Robert P , Kirk Katie , Palackic Alen , Branski Ludwik K
Published: March 2022

Introduction

Here we present the case of chemical burns following professional eyebrow tinting, a phenomenon rarely described in the literature.

Methods

A 50-year-old previously healthy female presented to our emergency department for evaluation and treatment of chemical burns to her eyebrows. Fifteen days prior, she underwent professional eyebrow tinting by a local esthetician. Blistering developed the following day, and progressive swelling prompted her to present to an outside hospital. There she was prescribed acyclovir, ketoconazole cream, and silver sulfadiazine, but despite these measures, her symptoms progressed, leading to her presentation to our facility. Both brows were remarkable for significant swelling with exudative crushing on the surface concerning for superficial infection of partial-thickness chemical burns. She was prescribed bacitracin, prednisone, and clindamycin and discharged with instructions to follow up in burn clinic. Six days later, both brows had developed 2x3 cm scabs, but no signs of infection were appreciated. She was instructed to apply bacitracin/polymyxin B ointment to the scabbing areas and open wounds. Forty-nine days after her tinting, both brows were noted to be completely healed with no alopecia.

Results

Burns following cosmetic procedures most commonly occur during hair lightening treatments where products frequently contain caustic chemicals such a hydrogen peroxide or persulphates leading to oxidation reactions lightening the hair. Thermal burns in hair salons have also been reported to heated hair-dressing instruments or external heat to hasten the highlighting process.

The periorbital area is becoming an increasingly popular target for nonsurgical cosmetic procedures, including permanent eyelid tattooing, eyelash dying, and extensions, more recently, eyebrow tinting. Eyebrow tinting involves the application of semipermanent dyes to give the appearance of a fuller brow. There are no FDA-approved brow tinting formulations, and many contain para-phenylenediamine (PPD), a dying agent frequently associated with allergic dermatitis and less commonly chemical burns. This patient underwent brow tinting in a professional setting and still experienced a chemical burn. As the popularity of brow tinting increases, some patients will undoubtfully seek out readily available, unregulated products for self-application. The potential for dermatitis and chemical burns following eyebrow tinting will only increase.

Conclusions

Eyebrow tinting is not a benign cosmetic procedure, and even professional application of dyes may lead to chemical burns. We believe an increased awareness of brow tinting and its potential complications is warranted given its increasing popularity, the preponderance of unregulated products, and the potential for poor cosmetic outcomes.
733 Massive Burn Injuries: Characteristics, Treatment Strategies and Outcomes from a Single Institution
Authors: Heard Jason , Wallace David L , Skipton Romanowski Kathleen S , Palmieri Tina L , Greenhalgh David G , Sen Soman
Published: March 2022

Introduction

Advances in burn care have led to improved survival, with survival after a 50% total body surface area (TBSA) or larger burn being more common. Traditionally, age, TBSA burned, inhalation injury, delayed resuscitation and evidence of early organ dysfunction have been predictive of survival. The goal of this study was to describe a large series of massive burn injuries, treatment strategies and identify factors related to survival.

Methods

Following IRB approval, a retrospective review of adult patients who sustained 50% TBSA or larger burn from 8/2009 to 7/2019 at an ABA verified burn center was conducted. Demographic, burn size/depth, mechanisms of injury, treatments, and outcome data were collected. Univariate and multivariate analyses were performed using R statistical software (R-project.org).

Results

155 patients were included which was 4.7% (155/3312) of all burn admissions during that time internal. Patients had an average age of 44±18 years, a male predominance (79%), and average TBSA burned of 70±15%. Overall mortality was 54% (83/155). One third of patients were transitioned to comfort care. The 103 treated patients were younger (37±12 vs 59±19 years; p=< 0.0001), more likely to be male (85 vs 65%; p=0.006), had smaller average TBSA (66±13 vs 78±16%; p< 0.0001) and more likely to have a psychiatric condition (31 vs 13%; p=0.02). Approximately 70% of treated patients survived to discharge. Survivors were more likely to have smaller TBSA (63±13 vs 73±13; p=0.001) and less third-degree burns (49±24 vs 61±24; p=0.01). One third of treated patients developed renal failure. One quarter of patients had a mental health condition, and these patients spent more time in the hospital (61 vs 31 days; p=0.009), more time on ventilator (29 vs 12 days; p=0.046), required more surgery (3 vs 2; p=0.048), and were less likely to die (36% vs 59%; p=0.02). On multivariate regression analysis of treated patients, psychiatric illness (OR 0.19; p=0.03) and burns related marijuana/hash oil production (OR 0.13; p=0.015) were protective against mortality.

Conclusions

Surviving burns >50% TBSA is becoming more common as burn care continues to improve. Mortality in this study is lower than what would be predicted by an established revised Baux score regression model (predicted 61% overall mortality and 48% for treated). Care for these massive burn injuries is complex and requires an experienced multidisciplinary team. There is an established link between burn injuries and mental health conditions. Despite similar burn size/depth, patients with a mental health history spent significantly more time in the hospital, more time on the ventilator and required more surgery.
739 A 14 Year Experience of Pediatric Complex Skin Disorders in a Burn Unit
Authors: Altamirano Heidi M , Johnston Mark J , Miotke Sam A
Published: March 2022

Introduction

Complex skin disorders including Stevens-Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN), Ritter's Disease (Staph Scalded Skin Syndrome), and Erythema Multiforme are uncommon, but result in significant injury to pediatric patients. Skin necrosis and desquamation occurs, which in some cases affects mucosa. Gynecologic, ophthalmologic, and dermatological complications also occur. The purpose of this work is to describe epidemiology and management trends in these cases.

Methods

Records were reviewed for all pediatric patients with skin disorders from 2006 - 2019 to evaluate trends in occurrence, age, length of stay, survivability, types of consultants, causative agent, and wound care strategies.

Results

One-hundred percent of pediatric patients were transferred from other hospitals for definitive management by the burn service. The incidence in pediatric patients was 21% compared to 79% in adults. Males were most often affected at 67% compared to 33% in females. The age range was 2-17 years, with an average of 9.2 years. The type most frequently seen was SJS/TEN at 60% of the cases. The total body surface affected ranged from 10-95%. Management of wounds commonly required operative management for dressing changes in children with large body surface area involvement, in addition to ophthalmologic and gynecologic procedures in patients with mucosal involvement. In the subset of patients with SJS / TEN, 100% had ophthalmology consults and 50% were seen by gynecology. The average hospital length of stay was 11.3 days. All children survived.

Conclusions

Complex skin disorders in pediatric patients require a multidisciplinary team approach to care and wound management and benefit from burn service care. Early transfer is beneficial in order to definitively diagnose the specific disorder and prioritize strategies in care such as nutrition, wound care, and psychosocial support.
744 Integrative Nursing framework in Burn ICU
Authors: Thomas Mini , Friedman Dina , Ha Aemilio W , Nunez Molly E
Published: March 2022

Introduction

Patient and staff experiences are enhanced through a holistic and relationship-based approach of care. An integrative nursing (IN) framework was created utilizing various therapeutic modalities to augment healing for patients. Additionally, staff RNs were encouraged to utilize some IN modalities to aid in their own well-being. In 2019, the Burn ICU (BICU) was selected as one of five pilot units in the hospital to implement the IN framework. Post-implementation, staff were surveyed on their attitudes regarding the IN framework.

Methods

The IN framework was created utilizing the IN principles and hospital policies. Two selected RN champions promoted this framework for staff and patients. In the BICU, over 95% of the RNs completed all five IN training modules: IN in Action, Acupressure, Clinical Massage, Aromatherapy, and Mind-Body skills. BICU was stocked with supplies, not limited to aromatherapy products, breathing ball, and massager chair. Additional resources were added including virtual reality (VR) and spiritual care. RNs documented interventions for pain/stress, anxiety/sleep, and nausea in the patient record. Post implementation, a self-report survey by RNs was utilized evaluated the IN framework.

Results

A total of 27 surveys were collected from 29 available RNs. Aromatherapy, VR, therapeutic touch were the most utilized patient modalities, while staff mostly utilized the massage chair, aromatherapy, and deep tissue massager. Lack of time and personal discomfort were the highest reported barriers to utilization of the IN modalities.

Conclusions

Creating and implementing an IN framework is achievable and can assist with improving patient and staff experiences in the hospital. Most staff and patients who utilized IN tools believed it provided benefits. Addition of IN modalities is the next step in providing patients with holistic care that treats not only the physical wounds but the whole patient.
763 Characteristics and clinical outcomes in patients with combined burn and trauma in Japan
Authors: Kumakawa Yasuaki , Kondo Yutaka , Suwa Kenshi , Takizawa Satoshi , Hirano Yohei , Sueyoshi Koichiro , Okamoto Ken , Tanaka Hiroshi
Published: March 2022

Introduction

Patients with combined burn and trauma are common in the United States and combined trauma in the burn increase the mortality. On contrast, their characteristics and outcomes remain unknown in Japan. The aim of present study was to elucidate the characteristics of trauma combined burn in Japan.

Methods

A multicenter retrospective study was performed between 2004 and 2017 using data from the Japan Trauma Data Bank (JTDB). We evaluated characteristics in burn patients (n=5,783) by segregating them into two groups cohorts: burn only (n=5,537) and combined burn and trauma(n=246). Clinical characteristics such as patient background, severity of burn and trauma, mechanism of injuries, total body surface area (TBSA), injury lesion, treatment and outcome were examined.

Results

The results showed significant differences in age between the burn only group and combined burn and trauma group (median [IQR]: 61 [43–76] for burn only group vs 51 [39–66] for combined burn and trauma group, p < 0.001). Most patients were injured due to flame (burn only group, 65.7%; combined burn and trauma group, 54.9%). Furthermore, 40-89% TBSA was higher in burn only group (19.3%) than in the combined burn and trauma group (9.3%). In-hospital mortality in burn only group (18.2%) was higher than that in the combined burn and trauma group (6.9%).

Conclusions

We demonstrated that the characteristics of burn only and combined burn and trauma patients in Japan. Flame was main cause of burn and in-hospital mortality was higher in burn only group because of higher burn area.
764 Ain’t no sunshine when she’s burnt - An empowering approach to improving sunburn prevention
Authors: Bednarz Bartlomiej , Thakkar Mehul , Schrire Timothy , Sen Sankhya
Published: March 2022

Introduction

Outdoor activities and the associated sun exposure is a mainstay of summer activities for many children. This UV exposure presents a significant risk to children of Anglo-Saxon or Celtic origin. Whilst UV exposure is important for mood and vitamin D synthesis, too much results in premature ageing and increased risk of skin malignancy. We propose a classification system of these burns according to pattern of injury, related directly to patient age.

Methods

We collated data concerning paediatric sun burns over a five year period (2015-2019). This was collected from our Regional Burns Unit, covering a population of roughly 5 million. We present an analysis of age, sex, total body surface area and location of the burn, correlated with the local UV index on the day of injury.

Results

We identified 138 patients presenting with sunburn. They were predominantly (71%) in males, with an age range of 1m to 16y (average 7y9m median 6y10m). All burns were superficial partial thickness in nature and averaged 2.2% TBSA (range 0.1%- 15%). No patients required surgery, however, 19 required admission for analgesia (4 of whom stayed >1 day). All burns occurred between the months of April and September, with 24 (17%) associated with foreign travel. The average UV index, where applicable, was 6.5 (ranging from 3.6 to 8). The majority of patients had no or little sun protection applied.

We propose three patterns of sunburn from analysing the data:

Neonatal and toddler sunburns usually happen in the presence of a caregiver, but with inadequate protection, such as muslin cloth or a poorly shaded area. These injuries, whilst typically small, have significant impact, as radiation injuries are cumulative and may affect future skin cancer risk for young patients.

Young (4-9 yo) children get sun burn whilst out with their friends or in the garden with parents. Inadequate sun protection or prolonged exposure is a key preventable factor.

Teenagers (12-16) are usually sun burnt whilst on a foreign trip to warmer countries or whilst with their friends during outdoor activities such as waterparks or surfing. Again minimal or no sunscreen application is a preventable cause.

Conclusions

In conclusion, this classification system, we seek to inform presenting units with a guide to management and common patterns, therefore improving the sun protection for children. Applicability of Research to Practice:

We identify three preventable patterns of sunburns in paediatric population. This allows parents and health professionals to be educated in a targeted way on prevention of injuries which may have a lifelong effect on skin cancer malignancies risk.
767 Medical Decision Making in the Burn Unit: A Qualitative Study
Authors: Gerrek Monica L , Lambrix Marcie A , Goff Anna D , Yowler Charles J
Published: March 2022

Introduction

In 1973, Dax Cowart was severely burned as a result of a car explosion. He spent the next 46 years advocating for patients’ rights to decline treatment as he felt his repeated wishes to do so and be allowed to die were ignored by his burn providers. Due in large part to his advocacy, many strongly believe that burn providers are problematically paternalistic and force unwanted treatment upon capacitated, autonomous patients (e.g., Hurst et al 2014). Unfortunately, there are only a few attempts to provide the perspectives of other severely burned patients (e.g., Brewster et al 2006 and Gerrek 2018). The purpose of this qualitative study was in part to gain further understanding of the views of severely burned patients regarding medical decision making during the acute phase of their injury.

Methods

Building on Brewster et al. and Gerrek, our team created a semi-structured interview questionnaire. We followed standard IRB research study protocols and then identified adult individuals with 2nd and 3rd degree thermal injury minimum 30% TBSA burns for recruitment. Though 20 patients met the criteria, we completed 5 (26%) interviews (3 females, 2 males).

Results

All interviewees discussed ways in which they struggled to make informed autonomous decisions for weeks or even months post-injury and felt dependent on the burn team to lead them through treatment decisions.

“[I]t's all new to me … obviously I've never been burnt like this before. I will assume it's similar for most of the people … when you wake up and find out how badly you were burned, and maybe you try to move and you figure out how bad you're hurting, you don't really make the decisions for yourself. I kinda put myself in their hands … I figured that's my best shot, to listen to them and let them do what they need to do. Really, I didn't want to make any decisions. I just listened to them and put my trust in them that they were doing the best they could for me”. (P2)

None of the interviewees, not even those who underwent amputation, felt the team acted in an inappropriately paternalistic manner. In fact, as a whole, they believed the team only did procedures that were absolutely necessary for their survival and wellbeing.

“I believe that they made all the right decisions surgery wise and everything.” (P5)

Conclusions

This study supports the limited but important work of the perspectives of severely burned patients’ regarding, among other things, how medical decisions were made during the acute phases of their injury. It shows that patients trusted their providers to make and encourage life-saving, wellbeing enhancing decisions during the early stages of treatment when patients are not sure they are capacitated and autonomous. Furthermore, the positive feelings patients had about those decisions did not change over time.