bluuebunny/crossref_metadata_2025 huggingface dataset:
109 Vascular Composite Allotransplantation in Burn Reconstruction: Systematic Review and Meta-analysis
Authors: Peterson Joshua , Padilla Pablo , Gray Kelsey , Zapata-Sirvent Ramón , Norbury William , Branski Ludwik , Dziewulski Peter
Published: March 2020

Introduction

The first vascular composite allotransplantation (VCA) was performed in 1998, with the first post-burn VCA in 2003. Since then, 21 burn patients have been recipients of VCAs. Controversy exists regarding safety of VCA in burn patients due to high levels of immunologic sensitization attributed to use of cadaver allograft. We seek to understand unique considerations of VCA in burn reconstruction and its relative safety compared to VCA in non-burn reconstruction.

Methods

A systematic review of VCA in burn reconstruction was conducted using the PubMed, Media and EBSCO database to retrieve all articles and news stories studying VCA from Jan. 2000 to May 2019. Only articles containing composite tissue allotransplantation, VCA, and reconstructive surgery were included. Articles that did not report outcomes or patient information were excluded. Reported cases were grouped according to injury and tissue (face vs. upper extremity) with mortality as a dependent variable. Statistical analysis was performed with the Fisher exact test.

Results

Of 63 articles obtained, 21 met criteria. After secondary review by the senior author, 6 more articles were included. To date, 147 VCAs are reported in 112 patients, including 40 face VCAs and 107 upper extremity VCAs. Of these, 30 (20%) were performed for post-burn deformities, and 117 (80%) for non-burn deformities. A total of 21 post-burn patients received VCAs with 4 subsequent deaths (19%). Post-burn recipients of upper extremity VCAs had significantly higher mortality than non-burn recipients of the same (p = 0.01), but there was no significant difference in face VCA mortality (p = 1.0) or overall mortality (p = 0.06) between groups.

Conclusions

VCA is a forefront procedure employed worldwide for reconstruction of devastating injuries. Presently, burn patients are at greater risk of mortality after upper extremity VCA, but not face VCA. Burn patients will benefit from focused investigation of unique post-burn risk factors of VCA mortality.

Applicability of Research to Practice

Disparities between post-burn and non-burn VCA outcomes suggest the presence of unique risk factors in burn patients. Investigation of unique risk factors will improve safety of VCA for burn patients.
510 Incidence of Extubation Failure in a Burn Intensive Care Unit: Examination of Contributing` Factors
Authors: Rizzo Julie A , McMahon Ryan , Aden James K , Brillhart Daniel B , Cancio Leopoldo C
Published: March 2020

Introduction

Extubation failure is associated with negative outcomes making the identification of risk factors for failure paramount to patient selection. Burn patients experience a high incidence of respiratory failure requiring mechanical ventilation. There is no consensus on the acceptable rate of extubation failure and many conventional indices used in critical care do not accurately predict extubation outcome in burn patients. The purpose of this study was to examine the rate of extubation failure in the burned population and to examine the impact of inhalation injury, as well as other factors, on extubation outcome.

Methods

Burn patients from a single center over the period 2009–2017 were examined and included if they were intubated prior to arrival or within 48 hours of admission and underwent a planned extubation. Patients were excluded if they proceeded directly to tracheostomy, died prior to extubation, or experienced an unintentional extubation. From this cohort, a matched case-control analysis based on age, TBSA and gender was performed of patients who succeeded after extubation, defined as not requiring reintubation within 72 hours of extubation, to those who failed. Characteristics and clinical parameters were compared between these two groups to determine if any factor(s) could predict extubation failure.

Results

A 12.3% incidence of extubation failure was found in our cohort of 106 burn patients. In the matched case-control analysis of 48 extubation successes and 58 extubation failures, the presence of inhalation injury was surprisingly associated with extubation success as was a higher PaO2:FiO2 ratio immediately prior to extubation. Higher heart rate and lower serum pH was associated with extubation failure. ANCOVA analysis demonstrated that a sodium trending higher before extubation was associated with more successes, possibly indicative of a lower volume status.

Conclusions

Classic extubation criteria do not accurately predict extubation outcome in burn patients; analysis of other characteristics and clinical parameters may be able to provide better predictions. A constellation of these parameters needs to be studied prospectively.

Applicability of Research to Practice

Defining a constellation of parameters that can aid in identifying those at high risk of extubation failure could change practice.
516 Mortality from Inhalation Injury in Oxygen Dependent Patients Exceeds Prediction from Prognostic Models
Authors: Singer Kathleen , Harvey Jalen , Dale Elizabeth
Published: March 2020

Introduction

The Boston Criteria and the Abbreviated Burn Severity Index (ABSI) are two widely accepted models for predicting mortality in burn patients. We aimed to elucidate whether these models are able to accurately predict risk of mortality in patients who sustain burns while smoking on home oxygen given their overall clinical fragility.

Methods

We conducted a retrospective chart review of 48 patients admitted to our burn center from November 2013 to September 2017 who sustained a burn while smoking on home oxygen. Yearlong mortality was the primary outcome of the investigation; secondary outcomes included discharge to facility, length of stay, and need for tracheostomy. We then calculated the expected mortality rate for each patient based on Boston Criteria and ABSI, respectively, and compared the mortality rate observed in our cohort.

Results

Patients in our cohort suffered a 54% mortality rate within a year of injury, compared to a 23.5% mortality predicted by Boston Criteria, which was found to be statistically significant by chi-square analysis (p < 0.05). ABSI predicted mortality was 19.7%. While the absolute value of difference in mortality was greater, this was not found to be significant on chi-square analysis due to the small sample size. Our secondary outcomes revealed 42% discharge to facility, average length of stay of 6.2 days, and 6.25% required tracheostomy. Patients in our cohort suffered a 54% mortality rate within a year of injury, compared to a 23.5% mortality predicted by Boston Criteria, which was found to be statistically significant by chi-square analysis (p < 0.05). ABSI predicted mortality was 19.7%. While the absolute value of difference in mortality was greater, this was not found to be significant on chi-square analysis due to the small sample size. Our secondary outcomes revealed 42% discharge to facility, average length of stay of 6.2 days, and 6.25% required tracheostomy.

Conclusions

Patients whose burns are attributable to smoking on home oxygen may have an increased risk of mortality than prognostication models, such as the Boston Criteria and ABSI, may suggest. This bears significant clinical impact, particularly regarding family and provider decision-making in pursuing aggressive management.

Applicability of Research to Practice

This data indicates that these injuries are direr than expected, which may have significant impact on family and provider decision-making.
535 Intermediate Skin Substitutes Are Unnecessary in Small (< 10% TBSA) Burns
Authors: Lacey Alexandra M , Gillenwater Justin , Maniago Ellen , Yenikomshian Haig A , Garner Warren L
Published: March 2020

Introduction

The use of intermediate skin substitutes between debridement and final autografting is routine for many practitioners. Materials such as xenografts and allografts have been promoted to help with wound coverage before autografting. However there is limited data for their use in relatively small burn wounds (< 10% total body surface area, TBSA). In this study, we analyzed the outcomes of one hundred consecutive patients who underwent autografting for burns < 10% TBSA at our ABA verified burn unit in the absence of intermediate skin substitute use.

Methods

We retrospectively analyzed one hundred patients who underwent split thickness skin graft autografting for burns < 10% TBSA between November 2017 and June 2019. No patients were treated with intermediate skin substitutes. Analysis included basic demographics, comorbidities, TBSA burned, mechanism of burn, time to grafting, if grafting was performed in a single procedure or staged, graft loss (>50% graft failure), and time to complete healing (no further wound care required).

Results

Twelve patients (12%) had unpredictable graft beds and their procedure was staged. These patients underwent surgical debridement and were dressed in antimicrobial dressing for an average of 5 days before autografting. No patients had intermediate skin substitutes between procedures. Eighty-eight patients (88%) were debrided and grafted in a single stage. In the staged group, there was a 0% rate of graft failure compared to 9.1% rate of graft failure in the primarily grafted group (p=0.004). There was a similar length of stay and time to complete healing in the staged group and primarily grafted group (p=0.496 and p=0.571). There was a significantly shorter time from injury to first procedure between the staged group and the primarily grafted group (8.7 days and 13.5 days, p=0.014). Many of the patients with these small burns were first managed outpatient and then brought in for autografting leading to a longer time from injury to surgery; while the staged group often presented with wounds that appeared infected and required urgent debridement. In the eight instances of graft failure, infection or inadequate debridement was the cause. Seven of these eight cases required further surgical intervention.

Conclusions

Intermediate skin substitutes are an unnecessary step in grafting small burns. These add only complexity and cost to patient care. Many patients can be debrided and grafted in a single stage. Debridement alone with delayed grafting is a highly effective surgical method when the wound bed is not suitable for immediate grafting.

Applicability of Research to Practice

The use of intermediate skin substitutes in small burns requires further investigation as this study finds low benefit for this product.
538 Successful Wound Closure in Patients with Large Total Body Surface Area (TBSA) Calciphylaxis with Aggressive Medical and Surgical Therapy
Authors: Curfman Eric , Khandelwal Anjay
Published: March 2020

Introduction

Calcific Uremic Arteriolopathy (CUA), commonly known as Calciphylaxis, is a rare disorder characterized by ischemic necrosis of the skin and histologically by arteriolar calcification. CUA is most commonly seen in patients with end-stage renal disease (ESRD), but can be seen in other patients as well. CUA is an extremely morbid condition and carries a high mortality rate, up to 80% in some studies, even in patients with limited disease. In light of this, many surgeons have adopted a “do-not-touch” approach. Over the past five years, our institution has seen an increase in the referrals of patients with large total-body-surface-area (TBSA) CUA.

Methods

Retrospective review of all patients with biopsy-proven (by dermatopathology) large, >5% TBSA CUA admitted to a Verified Adult and Pediatric Burn Center from 2015 to present. Demographics, laboratory data, treatment modalities, infectious complications and outcomes, including mortality and wound closure were recorded. Secondary observations included exposure to anticoagulants and recent significant weight loss.

Results

A total of eight patients with large TBSA CUA were admitted after being transferred from outside hospitals. Average TBSA affected was 13.76% (range 5–27%). Six of these patients (75%) were noted to have non-uremic calciphylaxis. One patient (12.5%) had elevated parathyroid hormone (PTH) levels and hyperphosphatemia while one patient each had isolated hypercalcemia and hyperphosphatemia. All patients had positive wound cultures on admission, and one patient (12.5%) developed a bacteremia in hospital. There were no central line associated bloodstream infections, catheter associated urinary tract infections or ventilator associated infections. All patients underwent surgical debridement (average 4.125, range 2–5), and 5 patients (62.5%) underwent grafting, (average 1.6, range 2–5) and subsequently proceeded to wound closure. In-hospital mortality was 25% and another patient was referred to a hospice facility after being readmitted with medical complications related to her calciphylaxis. Secondary findings included 50% of the patients recently experienced significant weight loss (>100 lbs) and 25% of the patients were taking warfarin within 6 months of presentation. Percent TBSA involvement did not correlate with mortality.

Conclusions

Utilizing a multi-modal management strategy that includes surgical debridement and skin grafting, patients with large total body surface area calciphylaxis can progress to wound closure.

Applicability of Research to Practice

Findings may influence surgeons to be aggressive surgically with patients with calciphylaxis leading to improved morbidity and mortality. Improved medical multi-modal therapy has been shown to influence outcomes as well.
542 Lessons Learned from Implementation and Management of Skin Allograft Banking Programs in Low- and Middle-income Countries: A Systematic Review
Authors: Roberson Jeffrey L , Pham Julie , Shen Jolie , Stewart Kelly , Adu Emmanuel , Mehta Kajal , Pedraza Morales , Allorto Nikki L , Pham Tam N , Stewart Barclay T
Published: March 2020

Introduction

Wound excision and temporary coverage with a biologic dressing can improve survival for patients with large burns. Allograft skin possesses many of the ideal properties of biologic dressings and can play a major role in the management of large burns when autologous tissue is not available or the patient’s condition does not allow safe autografting. Healthcare systems in low- and middle-income countries (LMICs) rarely have access to allografts, which may contribute to limited survival in large burns. Therefore, we aimed to describe the lessons learned from the implementation and maintenance of tissue banks in LMICs to guide system planning.

Methods

PubMed, MEDLINE, CINAHL, and World Health Organization (WHO) Catalog were systematically searched with database-specific headings and language to represent a priori terms (e.g., skin, allograft, tissue bank) and all LMICs as defined by The World Bank. Data regarding tissue banking programs (e.g., date of creation, location, lead agency, functions, products), governance, capital investments, safety, maintenance and operations, costs per donation, ethics and sociocultural issues were extracted and described in a narrative synthesis.

Results

The search returned 3,346 records. After eliminating duplicates and non-relevant records, 33 reports were analyzed. The synthesis represented tissue banks from 17 countries. Commonly reported barriers to ideal or planned implementation included high capital costs and operational costs per graft, opt-in donation schemes, and sociocultural stigma around donation and grafting. Reports repeatedly recommended: i) developing a legal framework for oversight, accreditation and ethical practice; ii) engaging diverse stakeholders (e.g., government and non-governmental agencies, community and religious stakeholders, health officials) to improve donation and transplantation rates, iii) creating regional training hubs, and iv) facilitating international cooperation across tissue banking programs to improve transplantation efficiency.

Conclusions

Many lessons were learned from the development and management of tissue banks around the world. The availability of skin allografts can be improved through strategic investments in international governance and regulatory structures, regional cooperation and training initiatives, standardized protocols, and inclusive public awareness campaigns. Capacity-building efforts that involve key stakeholders may increase rates of transplantations.

Applicability of Research to Practice

Ubiquitous challenges in implementing and maintaining tissue banks represent important lessons in program planning to improve allograft availability for patients in countries of all national income levels.
546 Impact of the Affordable Care Act on Burn Outcomes
Authors: Oh Jamie , Fernando Amali , Sibbett Stephen , Carrougher Gretchen J , Stewart Barclay T , Pham Tam N , Mandell Samuel P , Gibran Nicole S
Published: March 2020

Introduction

With changes in insurance coverage after the implementation of the Affordable Care Act (ACA) in 2014, we aim to analyze the impact of Medicaid expansion on clinical outcomes and patient disposition after burn injury. We hypothesize that with increased insurance coverage, more patients are discharged to a skilled nursing facility (SNF) or rehabilitation center.

Methods

Under IRB approval, we reviewed trauma registry data for patients with burn injuries admitted to a regional burn center from 2011 to 2018. Patients were grouped into two categories: before (2011–2014) and after (2015–2018) ACA; we excluded data from 2014 to serve as a washout period. Outcomes of interest were length of hospital stay controlled for burn size (LOS/TBSA), number of complications, patient disposition (Home, SNF, or Rehab), and mortality. Chi square analysis and student t-tests were performed to determine differences between the two groups. Multivariate logistic regression including age, sex, race, distance from medical center, burn size, and etiology of the burn as covariates were used to determine the impact of ACA implementation on patient disposition.

Results

Inpatient mortality rates did not change following ACA implementation. Average LOS/TBSA and number of complications increased, which may be due to increased average age, burn size, and distance from the burn center after ACA. Fewer patients were discharged home and more patients were sent to rehabilitation centers and SNF, which may relate to more patients being insured. Even after adjusting for covariates, discharge to inpatient rehabilitation was significantly increased and discharge to a SNF approached significance.

Conclusions

Since ACA implementation, there has been no change in mortality after a burn injury, but an increase in average LOS and complication rates, consistent with increased injury severity. Rates of discharge to rehab centers and SNF improved with the increase in overall insurance coverage in the burn population.

Applicability of Research to Practice

This work highlights changes in patient outcomes with ACA implementation and can help to guide understanding of health disparity and resource utilization in this population.
547 Long-term Outcomes of Chemical Burn Injuries: A Burn Model System National Database Study
Authors: Grant Gabrielle G , Stockly Olivia , Wolfe Audrey E , Wolf Steven E , Schneider Jeffrey C , Ryan Colleen M
Published: March 2020

Introduction

Information on long-term outcomes following chemical burn injury is sparse. This study aims to examine whether or not there are differences in long-term outcomes for individuals with chemical burn injuries compared to those with fire/flame injuries.

Methods

Data from the Burn Model System (BMS) National Database (1997–2019) were used for analysis. Demographic and clinical characteristics of adult burn survivors with chemical injuries and fire/flame injuries were compared. Regression analyses for the Mental Health Composite Scale (MCS) and the Physical Health Composite Scale (PCS) of the Short Form Health Survey-12, employment status, and Satisfaction with Life Scale (SWLS) were conducted at 12 and 24 months post-burn, adjusting for age, gender, race, and burn size.

Results

A total of 2,522 database participants (96 with chemical burns; 2,426 with fire/flame injuries) were included in the analyses. Those with chemical injuries had smaller burn sizes, shorter hospital stays, and fewer ventilator days (p< 0.0001, p=0.0034, and p=0.0005, respectively). Chemical burn survivors were more likely to be employed at the time of the burn (p< 0.0001), to have sustained an employment-related injury (p< 0.0001), and to have been discharged to their own home following their acute stay (p< 0.0001). No significant differences in the MCS, PCS, employment status or SWLS were found at either 12 or 24 months post-burn between groups in the regression analyses.

Conclusions

Chemical burn injuries were not found to have a significant difference on mental health, physical health, employment status, and satisfaction with life outcomes compared to fire/flame injuries. However, the effects of chemical burn injury on long-term outcomes may be difficult to detect due to the relatively small sample size of this population.

Applicability of Research to Practice

Further investigation is needed to better understand long-term outcomes following chemical injuries. Individuals with chemical burn injuries may require more specific assessment tools to improve how these types of injuries are studied.
557 Use of Online Clinical Guidelines for Burn Care in the Deployed Environment: A Model for Care in Rural or Remote Locations
Authors: Gurney Jennifer M , Cancio Leopoldo C , Remley Michael , Shackelford Stacy , Rhodes Rachel
Published: March 2020

Introduction

During the last decade, our national Joint Trauma System (JTS) has served as the reference body for trauma care throughout our military. The JTS has published 63 Clinical Practice Guidelines (CPGs) on its website to set standards and to provide guidance for deployed providers in the management of challenging clinical scenarios. Given that there is limited burn expertise in the military, the JTS CPGs are a major source of information for most providers. It has been possible to track CPG download activity for over a year. We hypothesized that assessment of download activity would reflect the relative value of JTS CPGs. In particular, we aimed to document the value of burn-related CPGs.

Methods

Download activity was determined from data pulled for jts.amedd.army.mil, utilizing Google’s Digital Analytics Program (DAP), for 27 Feb 2018 to 3 Sep 2019. After refining results from all of the military down to jts.amedd.army.mil, a search was then launched to determine the top activities on the JTS webpage. An additional refinement was conducted to establish search-date parameters. Data were exported into an Excel spreadsheet for further analysis. The data were analyzed for specific titles and numbers of downloads; those downloads consistently appearing at the top of the download activity were split out and detailed.

Results

Downloading was consistently the top “event” or tangible action on the site. In 17 months, total CPG downloads from the JTS website were 75,901. Burn-related CPGs and supporting documents (e.g. Lund-Browder chart; resuscitation flowsheet) were downloaded 6,177 times. The next most frequently downloaded CPG was the traumatic brain injury (TBI) CPG, which was downloaded 6,041 times. If each guideline had equal distribution of downloads, they would each be downloaded 1,205 times; burn-related CPGs were download 5 times more frequently than the mean.

Conclusions

This study emphasizes the importance of burn-related CPGs to providers throughout the global continuum of care. These providers frequently work in expeditionary, remote and austere environments without rapid access to specialty surgical expertise. The use of detailed CPGs can help bridge this gap.

Applicability of Research to Practice

This model can be used for remote rural areas nationally and internationally. Computer-based tracking of CPG and educational material downloads can, furthermore, be used to identify ongoing educational needs.
575 Determining Risk Factors Associated with Development of Depression Following Burn Injury
Authors: Stockly Olivia , Wolfe Audrey E , Wiechman Shelley A , Roaten Kimberly , Ryan Colleen M , Schneider Jeffrey C
Published: March 2020

Introduction

Depression symptoms following burn injury are common, however a tool to risk stratify the likelihood of development of these symptoms does not exist. This study aims to examine the demographic and clinical factors associated with depression symptoms at 12 months post-injury. This data will be used to develop a depression risk scoring system.

Methods

Data from the Burn Model System National Database (2015–2019) were analyzed. Depression subscale scores of the PROMIS-29 were examined at 12 months and those with scores greater than 60 were considered to have depression symptoms. Demographic and clinical characteristics of the study population were compared between those with and without depression symptoms. Predictors of depression symptoms at 12 months post-injury were determined using multivariate logistic regression.

Results

The analysis included 298 individuals (52 with and 246 without depression symptoms). Those with depression symptoms at 12 months post-injury were more likely to be female, have had psychological treatment in the year prior to injury, and have sustained a suspected self-inflicted burn injury. Those with depression symptoms were less likely to be married or working at the time of injury compared to those without depression symptoms. No differences in age, burn size, race/ethnicity, etiology of injury, or education level were observed between groups (Table 1). Psychological therapy or counseling in the year prior to injury was the only significant predictor of depression symptoms at 12 months post-injury (p= 0.016). Age and female gender approached significance (p=0.092 and p= 0.086, respectively).

Conclusions

A history of recent pre-injury psychological treatment was the only significant predictor of depressive symptoms found one-year post-injury.

Applicability of Research to Practice

This data will be used to create a depression risk scoring system to be used at time of acute care admission to identify burn survivors who are at high risk of developing depression. Identifying those at high risk of depression will facilitate appropriate utilization of resources and potential treatment prophylaxis.
576 Firefighter Post-injury Return to Work: A Balance of Dedication and Obligation
Authors: Nosanov Lauren B , Romanowski Kathleen S
Published: March 2020

Introduction

Over the duration of firefighters’ careers there exists a high probability of sustaining burn injuries necessitating medical evaluation and treatment. While many are minor and do not significantly affect the ability to work in full capacity, there exists risk for both short and long-term incapacitation. It is not uncommon for firefighters to push for earlier return to work than is medically advisable. However, there are additional external factors which drive premature return to duty.

Methods

An online cross-sectional survey was sent to firefighters who were members of a statewide Professional Firefighters’ Union. A multiple-choice format was used to assess demographics, injury details, medical care received and return to work. Free text format allowed for elaboration regarding factors influencing decisions to return to work.

Results

The survey was sent to 30,000 firefighters, with 413 (1.4%) responses received. Excluding those with incomplete data, 354 remained for analysis. Of these, 132 (37.3%) reported a burn injury which required medical evaluation. The majority were sustained during active duty, with 90.7% using protective gear at the time. Most burns were small and affected the head (50.8%) and upper extremities (48.3%). The majority were not treated at a Burn Center. While 12 (16.2%) reported returning to work prematurely themselves, nearly half indicated that they knew a colleague whom they felt had returned to work too soon. Factors cited include firefighter culture, finances, limitations of workman’s compensation, pressure from peers and employers, dislike of light duty and a driving desire to get back to work.

Conclusions

While many cite love of the job and a culture of pride and camaraderie that is “in our DNA”, firefighters’ decisions to return to work after burn injury are equally driven external pressures and obligations. Additional education is needed at both the individual and organizational level, which may best be facilitated by evaluation and treatment at a Burn Center.

Applicability of Research to Practice

Improved understanding of factors driving firefighters’ views on returning to duty after injury may help establish support systems and improve education regarding risks of premature return to work, particularly with regard to reinjury.
580 Factors Affecting Research Productivity of Burn Surgeons: Results from a Survey of American Burn Association Members
Authors: Elkbuli Adel , Narvel Raed , Zajd Sarah , Hai Shaikh A , McKenney Mark , Bonvea Dessy
Published: March 2020

Introduction

While previous studies have examined factors that impact research productivity for surgeons in general, few studies address research productivity specifically of Burn specialists. This study aimed to identify factors that promote and impede research participation and productivity of Burn surgeons, and help elucidate what changes can be made by Departments/Divisions to improve the research productivity.

Methods

A 44-question anonymous research survey tool was administered to Burn surgeons that are members of the American Burn Association (ABA). The questions analyzed factors such as demographics, career accomplishments, current institution type, educational background, research background, barriers to conducting research, and current research productivity. Chi-square tests were used to analyze significance at p< 0.05.

Results

Most respondents reported not having any protected research time (71.4%) or resources provided by their institution (84.5%). A majority believed increasing regulatory policies/IRB restrictions have negatively impacted productivity (65.1%). Factors associated with positive impact on research productivity included having a mentor, conducting research prior to completing residency, and provision of research resources from institution such as statistical support, start-up funds, grant writing support, and laboratory space. Age and gender had no statistically impact on research productivity.

Conclusions

Burn surgeons are more likely to publish research and to receive grants when they have mentors, a history of research prior to completion of residency, and research resources from their institution. Barriers to research productivity include lack of institutional support, lack of protected research time, and increased regulatory policy.

Applicability of Research to Practice

This study provides a starting point for analyzing factors that contribute to research success amongst burn surgeons. Individually, burn surgeons must take better advantage of the resources available to them through organizations such as the American Burn Association and seek mentorship where available. Surgical departments should aim to increase research resources for burn surgeons, honor protected research time, and strive to create a culture of research activity if research productivity is the goal.
583 Impacting the Length of Stay of Burn Patients in the Emergency Department
Authors: Kopari Nicole M
Published: March 2020

Introduction

Burn patients represent a challenging patient population and require early interventions. Advance Burn Life Support classes have been developed to guide first responders with assessing and treating burn patients in the pre-hospital setting. In the emergency department (ED) patients may experience hypothermia, delayed resuscitation, inadequate pain control, and delayed wound cares.

Methods

ED length of stay (LOS) was retrospectively reviewed for burn patient who met trauma activation criteria from 2013–2018. Patients were categorized based on ED disposition to burn stepdown, burn unit intensive care (BICU), or directly to the burn operating room (OR). Patients who died in the ED or were discharged home were excluded. In 2019, guidelines for burn activations, responses, and consults were developed to mirror the activation criteria for a Level 1 trauma institution. ED nurses and physicians were educated on burn assessment, wound care, and the new triage guidelines with emphasis on the importance of early transfer out of the ED.

Results

Prior to the change in burn activation guidelines, rapid transfer of burn patients out of the ED had not been emphasized. Of the 144 patients examined, ED LOS was 5.4 hours for those going to burn stepdown, 4.3 hours for BICU, and 3.7 hours for those who went directly to the burn OR. Several barriers to early transfer out of the ED were identified including lack of bed availability, lack of cleaning staff on nights and weekends, difficult lateral transfers of non-burn patients out of the Burn Unit, and a lack of education on the importance of early interventions by nursing staff. Since the implementation of the guidelines, there has been an improvement in LOS for BICU patients, but the goal of less than one hour in the ED has not yet been achieved.

Conclusions

Unacceptable ED LOS for burn patients were identified, triage guidelines were developed, and education was provided to staff. Guidelines and education, in conjunction with emphasizing the importance of having available beds in the Burn Unit, have led to a decrease in ED length of stay. Ongoing education and process improvement are key for rapid transfer of burn patients out of the ED.

Applicability of Research to Practice

Burn Centers can improve patient accounts by identifying areas that put burn patients at risk. Implementation of protocols can lead to process improvement and lead to better patient outcomes.
592 Prevention of CAUTIs in a Burn ICU
Authors: Vargas Vina , Rivera Emiko , Sidhu Teresa , Zaballero Lea Lyn , Karanas Yvonne L
Published: March 2020

Introduction

Catheter-associated urinary tract infections (CAUTIs) are the most common hospital-associated infection (HAI). Urinary catheter use is associated with urinary tract infections (UTIs) that can lead to complications such as cystitis, pyelonephritis, bacteremia, septic shock, and death. CAUTIs are associated with an excess length of stay of 2–4 days, increase costs of $0.4–0.5 billion per year nationally, and lead to unnecessary antimicrobial use. Through numerous implementations, a Burn ICU was able to drastically decrease their incidence of CAUTIs.

Methods

A Burn ICU implemented several interventions to reduce CAUTI rates. These interventions included:

Results

When this project was initiated in September of 2017, there were 9 CAUTIs identified in a Burn ICU, per the hospital’s Infection Prevention Department. By the end of 2017, there were 11, which equated to a rate of 14.67 per 1000 urinary catheter days. In 2018, the Burn ICU had 1 CAUTI, with a rate of 1.92 per 1000 urinary catheter days. In 2019 (through quarter 2), the Burn ICU has not had a CAUTI per the Infection Prevention Department. We believe the interventions made have drastically decreased the incidence of CAUTIs.

Conclusions

A Burn ICU implemented many new practices in 2017 when the CAUTI rate and SIR were above the hospital’s overall SIR. The Burn ICU staff now practice proper care and maintenance of urinary catheters and continue to provide excellent care. Although we have decreased our incidence of CAUTIs for 2018 and 2019, it is equally important we sustain this improvement. Therefore, we will continue to provide an open forum for discussion with staff so we can all do our part in keeping patients safe.

Applicability of Research to Practice

A Burn ICU decreased the incidence of CAUTIs by educating staff on proper care and maintenance of urinary catheters, removing catheters as soon as possible, and testing for UTIs upon admission to determine the patient’s baseline. By doing so, CAUTI rates went from 14.67 to 0 per 1000 urinary catheter days.
606 Establishing a Deep Sedation Program: Challenges and Successes from a Nursing Management Perspective
Authors: Lane Christine , Doherty Kathleen , Poteet Mark
Published: March 2020

Introduction

A burn center with a high volume of burn admissions was looking for ways to decrease the pain and anxiety experienced by patients during wound care. Patients requiring surgical dressing removal or demonstrating difficulty in coping during wound care were of particular concern. Discussions between anesthesia providers and the burn team led to the concept of anesthesia safely providing deep sedation in the inpatient wound care center for select dressing changes. Nursing management began to work through the challenges of implementing the Burn Center Deep Sedation Program.

Methods

Processes for identifying, scheduling, and recovering patients were established. All Burn Acute Care Unit (BACU) patients requiring a surgical dressing removal or demonstrating poor coping during wound care would qualify for deep sedation. Nursing management worked to create an online scheduling system, and designated a room which was set up with anesthesia equipment and supplies. Candidates were reviewed for deep sedation and a schedule created for the following day. All patients required a Burn Intensive Care Unit (BICU) nurse during the recovery period. A BICU room adjacent to the wound care center became the deep sedation recovery room, and was staffed by the BICU charge nurse. BICU nurses received additional training in post anesthesia care prior to the program implementation. Once all educational needs and logistical changes were addressed, the deep sedation program began operating seven days per week.

Results

Starting in January 2016 deep sedation has been provided to approximately 400 cases per year. No additional staff was required, only shifting responsibilities of existing nursing personnel. Designating a specific room for deep sedation has ensured that anesthesia providers have access to the appropriate equipment and has minimized disruptions to the flow of other dressing changes occurring throughout the day. The impact of the program on pain and anxiety is currently under evaluation. Informal feedback from patients and staff members has been very positive.

Conclusions

The challenge in developing this program was the amount of education and planning required prior to implementation. Once the program was active, the challenges that occurred involved the scheduling system. An additional benefit of the program was the teamwork required between BICU and BACU nurses to safely handoff patients. The deep sedation program has also strengthened the burn team’s relationship with the anesthesia providers, whose commitment to the project was appreciated by all involved. A team approach and a collective mission to improve care for burn patients have driven this project to its current success.

Applicability of Research to Practice

The collaboration between the burn team and anesthesia has resulted in an improved wound care experience for the patient.
607 Reducing Burnout Related to Night Shift Calls to Physicians – a Process Improvement Project
Authors: Hemingway Kristy D , Cabrera Victor
Published: March 2020

Introduction

Call volume is directly linked to resident and physician burnout according to the literature. Nurse education and experience effect their ability to prioritize events that require a call to a physician, which can lead to increased calls for non-emergent issues. This is particularly challenging at night when resources are limited and physician workload is increased. Our burn team was experiencing high call volumes at night and the attending and resident physicians collaborated with nursing to initiate a process improvement that would address this issue so that burnout could be prevented from both nursing and physician teams. The overall goal was to reduce the call volume at night while still maintaining safe, quality care for our patients.

Methods

A call log was developed to track calls made to MD’s at night for a one-week period in September 2018 and then again in February 2019. The log included the time, the reason, the physician team, method of contact, response and the number of attempts to call. Based on the results of the September 2018 tracking log, 3 interventions were created and implemented before tracking again in February 2019. The 3 interventions implemented included:

Results

Reduction in calls was achieved. Calls to the burn team were reduced by 71% from period in September 2018 to the time period in February 2019. Concerns were reduced from 17 to 5 indicating improved knowledge on ability to prioritize routine versus urgent calls.

Conclusions

Collaboration amongst nursing and physicians to reduce calls at night can be achieved when a true understanding of the nature of the calls are identified. Having data logs of the calls allowed the team to break down urgent, emergent and important needs so that education could be provided to the nursing team, which then helped them analyze appropriate reasons to call physicians at night. Proactive calls or rounding also developed from this project have contributed to improved relationships between nurses and physicians as well as decreased calls.

Applicability of Research to Practice

The generational change in the work force requires considerable forethought in regards to education and orientation of new nurses working in the acute care setting. This process improvement project provides a template for others working in burn centers to implement methods to educate nurses and physicians on the importance of collaborating to define urgent, emergent and routine needs of our patients so that both benefit from being able to provide excellent patient care by minimizing unnecessary calls at night.
609 Development and Implementation of the Burn Nurse Mentor Role
Authors: Hemingway Kristy D , Fernandez Megan
Published: March 2020

Introduction

Training and preparation of nurses in the burn unit is a long and costly process. Attrition of seasoned staff and a shortage of qualified preceptors places added pressure on experienced preceptors. Additionally, attrition of established preceptors leaves the crucial job of preparing new nurses to novice preceptors who are less experienced or inadequately prepared. High rates of burnout and turnover have been shown to negatively affect patient care outcomes and can lead to further increased staff turnover. Quality of environment and adequate job preparation are evidence-based strategies to increase new nurse retention. Our Burn Center’s Step Down unit was averaging a staff turnover rate of 14%, and 60% of the nursing team had less than one year of experience. We determined the need to create a mentorship role in order to increase staff retention and satisfaction, with the potential to improve patient outcomes.

Methods

The goals of the Burn Nurse Mentor role are to encourage and develop the competency of the nursing staff on the Burn Step Down unit. In planning for the role, an additional full time position was drafted and justified prior to creation. The job requirements included having a BSN, a minimum of 2 years ICU experience with the burn population, classified as a clinical nurse III or higher on the clinical ladder, and functioning as a preceptor. The role was designed to be at the elbow support for new nurses who are either being precepted or newly off of orientation. This support for the nursing staff would help offload preceptor burden and encourage development of critical thinking skills. Additionally, the Burn Nurse Mentor would assess and intervene when educational, practice, or process gaps arise on the unit. The goals of the position are to encourage and develop the competency of the nursing staff on the Burn Step Down unit.

Results

The anecdotal response to the Burn Nurse Mentor role from nursing staff has been generally positive. As this was an entirely new role for the Burn Center, periodic clarification of scope and responsibilities was needed to ensure staff comfort and familiarity with the role. Initial qualitative and quantitative data regarding quality outcomes and staff retention have trended upward as well.

Conclusions

The Burn Nurse Mentor is a newly designed and implemented role for our Burn Center. As such, there is a limited amount of data and research available. Future analysis of the impact of this role will include formal staff feedback at the one year mark and nursing-sensitive and patient quality indicators.

Applicability of Research to Practice

Using the information presented in this project, other Burn Centers can analyze the need for a mentor on their unit and use it to develop a mentor on their own unit.
611 Screening Adults for Depression and Suicidality in an Outpatient Burn Center
Authors: Rose Amanda , Gilbertson Alan D , Belacic Heather , Crow John
Published: March 2020

Introduction

In response to NIH recommendations and ABA verification standards, a protocol was initiated to screen adult burn patients in an outpatient verified burn center for depression and suicidality. It utilized the Patient Health Questionnaire (PHQ-9), a widely recognized depression screening tool. The protocol dictated patients scoring 10 or greater, or endorsing the suicide risk question would require further assessment. This project was part of a quality improvement initiative to assess initiating the protocol, identifying at-risk patients, and making appropriate referrals.

Methods

The initial visit of adults (ages 19 and over) seen over a one year period were retrospectively reviewed. For adults screening positive in the EMR, a Data Collection Form was completed gathering information on PHQ-9 scores, mental health treatment and diagnosis, and burn injuries.

Results

There were 748 adults seen for an initial visit at the burn center, ages 19–85, 61% men and 39% women. Of those patients, 572 had a PHQ-9 score documented in the EMR, demonstrating a 76% compliance rate with administration. Of those screened, 52 met criteria for inclusion by scoring 10 or greater or endorsing the suicide risk question on the PHQ-9. Scoring ranges on the PHQ-9 were as follows (N=52): 15.4% mild; 50% moderate; 19.2% moderate-severe; and 15.4% severe. Sixty percent of patients endorsed some suicidal ideation. Fifty two percent of patients were documented clearly as being on psychotropic medication or in specialized mental health services. Results were reviewed or discussed with patients in 81% of the initial visit notes. Nineteen of the 52 patients were offered a referral for mental health services.

Conclusions

Initiating this protocol creates an opportunity to begin conversations about mental health and offer additional support to patients. Approximately 9% of the outpatients screened at the burn center endorsed significant symptoms of depression and or suicidal ideation. Nearly half of these patients were not actively receiving treatment for these symptoms and could potentially benefit from mental health services. This project highlighted that compliance with administering and documenting the PHQ-9 and referral for follow-up services could be improved at this institution.

Applicability of Research to Practice

This protocol supports the need for continued evaluation and screening for depression and suicide risk in adult burn patients. Consideration should be given for monitoring other mental health conditions that could create barriers to care or compliance with treatment, such as anxiety, PTSD, psychosis, etc.