bluuebunny/crossref_metadata_2025 huggingface dataset:
23 Nutritional Intake and Weight Change in Severely Burned Patients
Authors: Fossati Sandrine O , Shields Beth A , Cole Renee E , Kieffer Adam J , Vega Saul J , Aden James K , Williams Alicia M , Cancio Leopoldo C
Published: April 2021

Introduction

Nutrition is crucial for recovery from burn injuries, as severe weight (wt.) loss can lead to impaired immunity and wound healing, infections, skin graft failure, and mortality. Previous studies recommended avoiding more than 10% wt. loss, as this level resulted in increased infection rates. However, wt. loss is often not quantifiable during the critical illness phase, with severe edema masking non-fluid related body wt. changes. Energy (kcal) deficits can be used to estimate wt. loss until the edema has resolved, but previous studies in non-burn patients indicate that actual wt. loss is less than the commonly used 3500 kcal per pound of fat (7700 kcal per kg of fat). The objective of this performance improvement project was to evaluate nutritional intake and the resulting dry wt. change in severely burned patients.

Methods

This performance improvement project was approved by our regulatory compliance division. We performed a retrospective evaluation on patients with at least 20% total body surface area (TBSA) burns admitted for initial burn care to our intensive care unit over a 7-year period. Patients who died or who had major fascial excisions or limb amputations were excluded. Patients who did not achieve a recorded dry wt. after wound healing were not included in this analysis. Retrospective data were collected, including sex, age, burn size, kcal intake, kcal goal per the Milner equation using activity factor of 1.4, admission dry wt., dry wt. after wound healing (defined as less than 10% TBSA open wound), and days to dry wt. after wound healing. Descriptive statistics and linear regression were performed using JMP. Significance was set at p< 0.05.

Results

The 30 included patients had the following characteristics: 90% male, 30 ± 11 years old, 45% ± 15% TBSA burn. They received 2720 ± 1092 kcal/day, meeting 68% ± 24% kcal goal, and took approximately 53 ± 30 days from injury to achieve dry wt. after wound healing. These patients had wt. loss of 8 ± 8 kg from the kcal deficit of 69,819 ± 51,704 during this time period. The kcal deficit was significantly associated with wt. change [p < 0.001, R2 = 0.49, wt. change in kg = (-0.000103 x kcal deficit) – 1]. This translates to one kg of body wt. loss resulting from 9709 kcal deficit.

Conclusions

This performance improvement project found that an energy deficit of approximately 9700 kcal in our patients equates to 1 kg of body mass loss (4400 kcal deficit equates to 1 pound of body mass loss). These findings are similar to wt. loss studies in other patient populations and contrary to the commonly used 3500 kcal per pound of fat (7700 kcal per kg of fat).
32 Does the Use of Silicone Gel Sheeting Impact the Overall Physiology of Hypertrophic Scar Development? A Feasibility Trial Using Laser Doppler Imaging to Assess Perfusion in Native Skin and Immature Burn Scar
Authors: Vocke Scott F , Dean Brooke , Andre Gregory , Caffrey Julie
Published: April 2021

Introduction

The use of silicone gel sheeting (SGS) has long been observed clinically as an effective modality in reducing hypertrophic scar (HTS) formation. Although the use of SGS is widely accepted, the exact mechanism is not fully understood. Prevailing theory suggests silicone suppresses collagen production in immature active scar. Collagen production is enhanced as blood flow increases in areas of scar hyperemia. Reduction of blood perfusion to the immature scar may act as a potential mechanism in limiting excessive scar proliferation.

Methods

Laser Doppler Imaging (LDI) was used to assess 2 areas in 2 subjects (85% TBSA w/ CEA and native skin control): A control site and SGS testing site were traced on the skin of each subject and 5 LDI scans were performed on both subjects: 1) initial without SGS; 2) initial with SGS applied; 3) 4-hours post-SGS application with SGS on; 4) 4-hours post-SGS application immediately after removal; 5) 15-minutes post-SGS removal. The control and testing site for both subjects were then analyzed using the LDI software and the average perfusion units (PU) over the region of interest (ROI1: testing site; ROI2: control site) areas were calculated for each scan.

Results

Perfusion within both ROI had a marked increase in perfusion for HTS scans after 4-hours when compared to the initial scan. However, after initial SGS application to ROI1, the mean PU decreased by 23.1% while the perfusion to ROI2 remained relatively constant (-5.8%). Subsequently, the ROI2 increased in mean PU by 23.4% 4-hours after the initial scan while the ROI1 showed a blunted response in perfusion in comparison increasing by only 2.3%.

Conclusions

Perfusion for both NS and HTS were notably decreased when SGS was applied compared to the matched ROI without SGS. In addition, prolonged SGS application created a greater difference in perfusion between silicone (less perfusion) and non-silicone sites (greater perfusion) for both NS and HTS when compared to initial SGS application demonstrating a greater effect on perfusion the longer SGS was worn.
33 An Evidence Based Laser Therapy Algorithm for the Treatment of Burn Scars
Authors: Sood Rajiv
Published: April 2021

Introduction

Hypertrophic scarring after burn injury can be extremely painful, cause profound itching, and affect the way patients view themselves and how the outside world perceives them. We have utilized laser therapy as a modality for scar modulation for our patients since 2013. In 2014, we initiated and completed a prospective IRB approved study to evaluate the outcome of scars treated with fractional CO2 laser therapy (FLT) utilizing objective and subjective tools. Recently, we have completed a prospective study evaluating the use of pulse dye laser (PDL) therapy and the impact on post-burn pruritis. In reviewing the outcomes from these two studies, we have developed an evidence-based laser therapy algorithm for burn scar management.

Methods

The FLT study entailed a series of three CO2 laser treatments minimally 4–6 weeks apart with scar measurements and POSAS form completion performed prior to each laser treatment and four weeks after the last FLT. Scar measurements that included color, pliability, and scar thickness; and completion of the POSAS form were obtained prior to each laser therapy session and four weeks after the third laser treatment. The measurements of color, pliability, and scar thickness were measured with the Colorimeter, Cutometer, and ultrasound. The PDL study utilized the 5-D Itch scale to evaluate post-burn pruritis. A baseline measurement was obtained prior to any laser treatments. Each patient underwent two PDL sessions and a 5-D itch scale was completed four to six weeks after the second PDL session. The baseline measurement was then compared to the final 5-D itch scale measurement.

Results

Data from the FLT study is in Table 1 and shows that there were statistically significant improvements in the Patient and Observer POSAS scores, patient rated Itch score, scar thickness, and measured skin density. Changes to patient rated scar pain, scar color, and pliability were noted but were not of statistical significance. Data from the PDL study is in Table 2 and shows a statistically significant decrease in the treated patients’ post-burn pruritis.

Conclusions

In reviewing the outcomes of these two studies, we have developed an algorithm based on our studies. All of our patients undergoing laser therapy receive two PDL sessions that are four to six weeks apart followed by 3 FLT sessions. The use of both PDL and FLT decreases post-burn pruritis, decreases scar thickness, decreases pain, and increases patient satisfaction as shown in our research.
35 Outcomes for Hand Burns Treated with Autologous Skin Cell Suspension in 20% TBSA and Smaller Injuries
Authors: Taylor George M , Carter Jeffrey E , Tuggle Charles T , Barnett Scott , Phelan Herb A
Published: April 2021

Introduction

Our group has previously reported our experience with autologous skin cell suspension (ASCS) in the treatment of all subjects with hand burns regardless of the total body surface area (TBSA) involved. In order to better address the confounder of TBSA on burn outcomes, we sought to analyze our experience in a cohort of subjects whose TBSA totaled 20% or less. We hypothesized that the use of ASCS in conjunction with a 2:1 meshed autograft would provide comparable outcomes to hand burns treated with smaller meshed autograft alone.

Methods

A retrospective review was conducted for deep 2nd and 3rd degree hand burns treated with split thickness autograft (STAG) at our urban verified burn center between April 2018 to September 2020. Exclusion criterion was a TBSA greater than 20%. The cohorts were those subjects treated with ASCS in combination with STAG (ASCS(+)) versus those treated with STAG alone (ASCS(-)). All ASCS(+) subjects were treated with 2:1 meshed STAG and ASCS overspray while all ASCS(-) subjects had 1:1 or piecrust mesh only. Outcomes included demographics, proportion returning to work (RTW), length of time for RTW, and time to wound closure. Mann-Whitney U test was used for comparisons of continuous variables, and Fishers Exact test for categorical variables. Values are reported as median and interquartile range.

Results

Fifty-one subjects fit the study criteria (ASCS(+) n=31, ASCS(-) n=20). The ASCS(+) group was significantly older than the ASCS(-) cohort (44 yrs. [32, 54] vs 32 [27.5, 37], p=0.009) with larger %TBSA burns (15% [9.5, 17] vs 2% [1, 4], p < 0.0001), and larger size hand burns (190 cm2 [120, 349.5] vs 126 cm2 [73.5, 182], p=0.015). Comparable results were seen between ASCS(+) and ASCS(-), respectively, for time to wound closure (9 days [7, 13] vs 11.5 [6.75, 14], p=0.63), proportion RTW (61% vs 70%, p=0.56), and days for RTW among those returning (35 [28.5, 57] vs 33 [20.25, 59], p=0.52). The ASCS(+) group had two graft infections with no reoperations, while ASCS(-) had one infection with one reoperation. No subjects in either group had a dermal substitute placed.

Conclusions

Despite being significantly older, having larger hand wounds, and larger overall wounds within the parameters of the study criteria, patients with 20% TBSA burns or smaller whose hand burns were treated with 2:1 mesh and ASCS overspray had comparable time to wound closure and return to work as subjects treated with 1:1 or pie-crust meshed STAG. Our group plans to follow this work with scar assessments for a more granular picture of pliability and reconstructive needs.
39 Managing Burn Wounds with Silvadene
Authors: Lagziel Tomer , Born Louis J , Quiroga Luis H , Duraes Eliana , Shetty Pragna N , Slavin Benjamin R , Cox Carrie A , Javia Vidhi , Caffrey Julie , Hultman Charles S , Asif Mohammed
Published: April 2021

Introduction

Topical delivery of antibacterial agents is typically incorporated and is an essential component of burn wound therapy. The goal is to prevent infection and promote the healing process. Poorly treated wounds can result in scarring or severely in sepsis and multi-organ dysfunction. Topical SSD cream has been the gold-standard for initial local care in partial thickness or full thickness burns. Due to immediate burst release of the drug into the exposed areas, application is relatively frequent (usually twice daily). However, it remains unknown whether twice-daily SSD dressings are superior to once-daily.

Methods

We maintained a twice-daily dressing change standard of care until 01/01/2019. Patients admitted after that date had their dressing changed once-daily. Our goal is to review outcomes for 75 patients before the change-of-practice and 75 patients after. The main outcomes recorded are wound infection rates, hospital-acquire complications (non-wound related), pain scores, daily narcotic requirements, average amount of SSD used, and length-of-stay.

Results

Preliminary results of the 75 pre-change-of-practice and 75 post-change-of-practice patients showed slightly better outcomes in the post-change group. Wound-infection rates were the same for both groups (pre=5.33%, post=5.33%), average daily pain-levels for the pre-change group were slightly higher but the difference was negligible and not statistically significant (pre=5.76, post=5.69). The pre-change group had a higher average daily narcotic dosage (pre=6.81mg, post=6.38mg), hospital-acquired complication rates were higher pre-change (pre=10.67%, post=6.67%), and length-of-stay was longer in the pre-change group (pre=10.81, post=9.25). The average amount of SSD jars used per patient was higher as well (pre=6.30, post=2.85). Statistical analysis of the distribution of burn type, age, and burn depth showed no discrepancy and a generalized decreased length-of-stay with once-daily SSD dressing change.

Conclusions

Preliminary results show that once-daily dressing changes of SSD in burn wounds have no negative impact on wound outcomes. However, it is associated with a decreased length-of-stay, decreased pain levels, and less hospital-acquired complications. A decreased length-of-stay means reduced medical expenses for the patient and the hospital. In addition, less hospital-acquired complications result in better patient recovery. Since the difference in wound outcomes is negligible and statistically insignificant, changing the standard-of-care to once-daily could prove beneficial.
40 Wildfire Burn Victims: A Unique Population
Authors: Stokes Sarah C , Romanowski Kathleen S , Sen Soman , Greenhalgh David G , Palmieri Tina L
Published: April 2021

Introduction

In the past ten years, wildfires have burned an average of 6.8 million acres annually. The frequency of wildfires is expected to increase with climate change. Wildfire burn victims have not been previously well characterized in the literature. As we prepare for more wildfires it is necessary to target populations at risk for sustaining burns with prevention efforts and to prepare hospital systems to meet these patients’ needs.

Methods

A retrospective review of patients admitted to a burn center between 2016 and 2019 was performed. Patients who were admitted after sustaining a burn attributable to wildfires were identified from the burn center database. Controls were matched to wildfire burn patients by age, gender and total body surface area of burn. The primary outcome was mortality. Secondary outcomes included number of operations, length of stay (LOS), intensive care unit (ICU) LOS, development of wound infections and pneumonia, wound culture microbiology.

Results

A total of 16 patients who had sustained burns in wildfires were identified and matched with 32 controls. There was no difference in mortality (19% wildfire vs. 9% non, p=0.386), LOS (18 days wildfire vs. 15 days non-wildfire, p=0.406), ICU LOS (17 days wildfire vs. 11 days non-wildfire, p=0.991) and number of skin grafts (1 wildfire vs. 0.5 non-wildfire, p=0.519). Patients who had sustained burns in a wildfire trended towards higher rates of pneumonia (31% wildfire vs. 13% non-wildfire, p=0.117), and higher rates of wound infection (31% wildfire vs. 19% non-wildfire, p=0.361). On evaluation of wound cultures for the 5 wildfire patients and the 7 non-wildfire patients who developed wound infections, more patients who sustained burns in wildfires had gram positive bacteria cultured from their wounds (100% wildfire vs. 29% non-wildfire, p=0.027). Patients who had sustained burns in wildfires trended towards increased likelihood of readmission (23% wildfire vs. 3% non-wildfire, p=0.080).

Conclusions

Patients who sustain burns in wildfires are likely at increased risk of readmission, of developing pneumonia and of developing gram-positive wound infections. Interventions for these patients should focus on pneumonia prevention and assistance with wound care after discharge.
47 COVID-19 Impact on Burn Care- A Summary of Weekly Bed Counts and Surge Capacity
Authors: Carter Jeffrey E , Phelan Herbert , Ryan Colleen M , Jeng James C , Mai Kathryn , Conlon Kathe M , Newman Annette F , Johnston Mark , Placek Judy , Wegryn Cindy , Joe Victor C
Published: April 2021

Introduction

The COVID-19 pandemic has raised global awareness of healthcare resource limitations. Specifically, the pandemic has demonstrated that burn disaster planning should involve non-burn disasters that threaten staff, supplies, or space. The ABA facilitated bed counts with the assistance of regional disaster coordinators from April through August of 2020. Our analysis examines the impact of the pandemic on burn surge and bed capacity in the U.S.

Methods

Bed availability was obtained by the ABA regional disaster coordinators through an initiative by the Organization and Delivery of Burn Care Committee. Bed availability was defined as immediately available burn beds and categorized as adult, pediatric, or flexible. Surge capacity was defined as the maximum number of patients that a burn center could admit in a surge situation. Data was deidentified by the central office with descriptive statistics to determine bed availability and surge capacity trends regionally and nationally.

Results

Bed counts were performed 6 times from 04/17/2020 through 08/14/2020. Response rates from the 137 North American burn centers varied from 86–96%. At least 6 burn centers (5%) were either closed or converted for COVID patients during the initial two bed counts. The total number of adult or pediatric burn beds was 2,082. Total bed availability decreased from 845 at the first survey down to 572 beds at the last survey. Surge capacity baseline was 1,668 beds and decreased from 1,132 beds in the initial survey down to 833 beds in the final survey.

Conclusions

Our study demonstrates a significant impact on burn bed availability due to the COVID-19 pandemic with a 37% reduction in available burn beds from April to August and a 26% reduction in surge capacity. This study demonstrates a substantial reduction in bed availability during the pandemic with additional analysis in process to examine regional trends.
50 A Retrospective Review of Enoxaparin Dosing Practices in Burn Patients
Authors: Quan Asia N , Aden Aisha , Islas Claudia , Richey Karen J , Foster Kevin N
Published: April 2021

Introduction

Enoxaparin, a low molecular weight heparin, has been proven to safely and effectively prevent venous thromboembolism (VTE) in acutely ill patients. Burn patients may be particularly vulnerable to the occurrence of a VTE due to prolonged immobility, frequent operating room procedures, and low flow states. Treatment of acute VTE is associated with a direct medical cost of $12000-$15000 and subsequent complications increase costs to $18000 to $23000 per case. Current institutional protocol for initiation of enoxaparin an all burn adult patients is 40 mg administered subcutaneously every 12 hours. Anti-Xa levels are used to monitor anticoagulation prophylaxis, with 0.3–0.5 U/mL recognized as the prophylactic range. Doses are subsequently modified in 10 mg increments to achieve goal prophylaxis anti-Xa levels. The purpose of this study was to evaluate current practice (CP) and assess if the implementation of a published enoxaparin dosing algorithm could minimize delay in achieving anticoagulation prophylaxis.

Methods

A retrospective chart review was performed of 94 adult burn patients. The doses and time required to reach goal prophylaxis anti-Xa levels using current practice (CP) were compared to the predicted algorithm dose (AD). The number of dose adjustments and the number of days needed for adjustments for CP were documented. Charges related for laboratory determinations and medication administration were calculated.

Results

Of the 94 patients reviewed, the average age was 47 years, the majority were male (74%), mean actual weight 92 kilograms and mean TBSA 15.7%. The most common mechanism of injury was flash/flame (63%) with 18% suffering an inhalation injury. On average, using CP, it took 9.3 days to get to goal prophylaxis anti-Xa levels, with a mean of 2.86 anti-Xa lab tests needed and an average prophylactic dose of 55.5 mg. A total of 360 labs draws were performed and 74% were timed correctly. The CP average starting dose was lower than the AD 40 mg versus 45 mg (p < .0001). If the algorithm had been used the number of dosing adjustments would have been 25% less. The algorithm overestimated the starting dose in only 2.1% of the population. The average charges until goal was met for enoxaparin were $2,933 and $787 for anti-Xa levels.

Conclusions

This study demonstrates increased clinical efficacy and cost-effectiveness for an algorithm driven enoxaparin dosing regimen for burn patients. Prospective study with larger patient numbers is warranted.
54 Modified Frailty Index is an Independent Predictor of Death in the Burn Population: A Secondary Analysis of the Transfusion Requirement in Burn Care Evaluation (TRIBE) Study
Authors: Andre John A , Romanowski Kathleen S , Mandell Justin A , Greenhalgh David G , Palmieri Tina L , Sen Soman
Published: April 2021

Introduction

Previous studies in the burn population have noted frailty as an independent predictor of inpatient and outpatient mortality. The Modified Frailty Index (MFI) uses comorbidities tracked by the American College of Surgeons National Surgical Quality Improvement Program to help to predict morbidity and mortality in patients. The purpose of this study was to determine whether or not the MFI-5 and MFI-11 would predict mortality in the burn population.

Methods

A secondary analysis of the prospective, randomized, multicenter Transfusion Requirement in Burn Care Evaluation (TRIBE) study was conducted. Statistical analysis with chi-square for categorical variables and student’s t-test for continuous variables were conducted. Frailty was determined using the MFI-5 (functionally dependent, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, hypertension) and MFI-11 (using the aforementioned 5, as well as myocardial infarction, hypertension, delirium, transient ischemic attack/cerebrovascular accident (without deficits), cerebrovascular accident (with deficits), peripheral vascular disease) from comorbidities included in the Burn Registry. Patients were considered frail if they had an MFI > 1 on either scale. Multivariate regression was used to compare mortality between those who were and those were not considered frail based on this index.

Results

A total of 347 patients with a mean age of 43±17 years, 73 women and 274 men, were analyzed. Mean total body surface area burn (TBSA) was 38±18%, and 23% had inhalation injury. As continuous variables, MFI-5 (OR 1.86; 95% CI 1.11–3.11; p-value 0.02) and MFI-11 (OR 1.83; 95% CI 1.18–2.8; p-value 0.007) were independent predictors of mortality. In addition, TBSA total, age, and female gender were all independent predictors of mortality. Having a MFI-11 > 1 was considered an independent predictor of mortality (OR 2.91; 95% CI 1.1–7.7; p-value 0.03); whereas, having a MFI-5 > 1 was not considered an independent predictor of mortality (OR 2.6; 95% CI 0.95–7; p-value 0.06).

Conclusions

A MFI-11 > 1 in the burn population was an independent predictor of mortality, as were total TBSA, age, and female gender. Given these findings, further study on the predictive value of MFI-11 in major burn injury is warranted.
55 Designing and Implementing an Obese Lund and Browder: A Pilot Study
Authors: Schoenborn Taylor , Thomas Mini , Miller-Willis Kelsey , Frerk Rita , Bernal Nicole O
Published: April 2021

Introduction

Accurate determination of the total body surface area (TBSA) burned is an essential element for the clinical management of burn care. The Lund and Browder (LB) is a tool that allows practitioners to calculate the TBSA burned, which is used to determine fluid needs, nutritional requirements, and graft site availability. Studies have shown that individuals with a body mass index (BMI) greater than 30 have an increase in surface area in the trunk and lower extremities, making the applicability of the traditional LB less accurate. The objective of this study was to develop and implement an electronic obese LB and compare it to the traditional LB.

Methods

Using the paper by Williams et al. as a guide, an obese LB was constructed for each body type: android, gynecoid and mixed (Table 1). Based on the patients BMI, the hospital’s Electronic Medical Record (EMR) would direct staff to the appropriate LB. All providers were formally trained on the obese LB, body types and changes in body surface area measurements. A retrospective chart review of adult patients admitted from January 2020 to September 2020 with a BMI≥30 was conducted. The BMI, body type, and location of burn was analyzed for each patient. The TBSA burned was recalculated for each patient using the traditional LB and compared to the obese LB completed at admission.

Results

A total of nineteen patients had a BMI≥30 and an admission obese LB completed. The TBSA burned ranged from 0.25–78.5%. The difference in TBSA burned calculated by the traditional and obese LB was 4.2±8.8 % (Figure 1). In patients with burns to the trunk or lower extremities (n=7) a difference of 12±10.5% was observed.

Conclusions

Limited research exists demonstrating the use of a standardized obese LB in clinical practice. No patient complications were identified with the use of the developed obese LB. Evaluation of the data revealed that the traditional LB often underestimated the TBSA burned in obese patients with burns to the trunk and/or lower extremities. This could lead to under-resuscitation and complications related to hypovolemia. In addition, expectations on patient survival and outcomes become inaccurate. As obesity grows in prevalence having a LB that recognizes the difference in surface area observed in the trunk and lower extremities can improve patient outcomes. Further research with a larger sample size is needed to gain a greater understanding of the clinical impact of an obese LB. We have shown that accurate determination of the burn area in obese patients can be done in a standardized fashion within the EMR.
57 Safety and Cost Effectiveness of Outpatient Surgery in Acute Burn Care
Authors: Zhang Zach Z , Golin Andrew , Papp Anthony
Published: April 2021

Introduction

Outpatient burn surgery is increasingly utilized for delivery of acute burn care. Reports of its safety and efficacy are limited. The purpose of our study was to evaluate the safety and cost reduction associated with outpatient burn surgery and to describe our centre’s experience.

Methods

This was a single centre, retrospective cohort study of consecutive patients who underwent outpatient acute burn surgery requiring split thickness skin graft or dermal regenerative template from January 2010 - December 2018. Patients with insufficient follow up to evaluate operative site healing were excluded. Patient demographics, comorbidities, burn etiologies, operative data and postoperative care were reviewed. The primary outcome is complication involving major graft loss requiring reoperation.

Results

165 patients and 173 procedures met the inclusion criteria. The average age was 44 years and 60.6% (100/165) were male. The number of annual outpatient procedures increased 48% from 23 to 34 cases over the 9-year period. The mean grafted total body surface area was 1.0 ± 0.9%. Rate of major graft loss requiring reoperation was 5.2% (9/172). Greater than 95% graft take was achieved in 80.9% of patients. Age, sex, co-morbidities, total body surface area, and procedure types were not significantly associated with postoperative complication rate. Outpatient burn surgery model was estimated to save CA$7,875 per patient from inpatient costs. This extrapolates to a total of over CA$1.36 million in savings over the 9-year study period.

Conclusions

Acute burn care at our centre is increasingly being delivered through an outpatient day surgery model. Our demonstration of its safety and considerable cost savings is compelling for further utilization. Our experience found the adoption of improved dressing care, appropriate patient selection, increased patient education, adequate pain control, and regimented outpatient multidisciplinary care to be fundamental for effective outpatient surgical burn care.
59 Impact of A Mature Burn Telemedicine Program On Inpatient, Outpatient, and Aftercare Programs During COVID19.
Authors: Bennett Bruce , Surgery Burn , Surgery Trauma , Altamirano Heidi M , Johnston Mark
Published: April 2021

Introduction

In 2014, a multidisciplinary burn telemedicine program was developed in order to increase access of burn specialists and improve care. This proved to be beneficial in the face of the pandemic through utilization of existing programs and development of new processes.

Methods

The basis of this burn telemedicine program utilizes a partnership approach. Visit types include inpatient and outpatient consultation, with visits occurring in in-patient settings, emergency departments, out-patient clinics, and in patient’s homes. During the COVID 19 pandemic, a weekly meeting was held with telemedicine program and clinic leadership, program coordinators, and our burn surgeon to triage patients to telemedicine or inpatient visit types. This often required the nursing staff to contact the patients to obtain more information about the injury and help them to securely upload photographs. The telemedicine visits were primarily video visits occurring either in clinic settings or the patient’s home. The burn psychotherapist and occupational therapists also utilized telemedicine for patient care. In addition, aftercare support groups, which originally were held twice each month onsite, transitioned to video and increased to three times. Telemedicine is also being utilized for school re-entry programming and the annual burn camps. The program is also tracking reimbursement for telemedicine activities.

Results

The pandemic resulted in a significant increase of telemedicine visits as compared to in person clinic visits often occurring directly into the patient’s homes. A greater number of burn patients were seen overall than previous to this process. Attached graphs show the comparison of in person visits compared to telemedicine visits during this time frame. Additional data will be presented showing the breakdown of visit location, provider (psychotherapist versus surgeon for example), and usage with aftercare programming.

Conclusions

This telemedicine program with established processes and partnerships, allowed transitioning alternative care due to the pandemic to be less stressful event. Benefits to patient care included the ability of the multidisciplinary burn team to see more patients safely via video especially in their own homes and allowed continuation and expansion of aftercare support. Challenges experienced included needing additional staff to ensure patients were triaged appropriately, scheduling of visits, and technology training for patients and families, and to ensure that patients were receiving medications and dressings as needed. The increased volume of patients seen could be attributed to more frequent visits and an increased volume of burn injuries.
69 Defining Numerical Cutoff Values for Mild, Moderate, and Severe Pain in Adult Burn Survivors
Authors: Carrougher Gretchen J , Bamer Alyssa M , Baker Claudia , Mason Stephanie A , Stewart Barclay T , Gibran Nicole S
Published: April 2021

Introduction

Pain is a common and often debilitating sequelae of a significant burn injury. Clinicians and researchers need clinically valid, reliable pain measures to guide treatment decisions and to provide evidence for study protocol development. Pain rating scores that represent mild, moderate, and severe pain in the burn survivor population have not been established. The aim of this study was to determine the numerical pain intensity rating scores that best represent mild, moderate, and severe pain in adult burn survivors.

Methods

Average pain intensity visual analog scale (VAS; 0–10) and customized PROMIS pain interference short form was administered to adult burn survivors (age ≥18) treated at a regional burn center at hospital discharge and at 6, 12, and 24-months postburn. To identify the optimal VAS scores for mild, moderate, and severe pain we computed F values and Bayesian Information Criterion (BIC) statistics associated with multiple ANOVA comparisons for mean pain interference scores by various VAS pain intensity cut points. Six possible cut points (CP) were compared: CP 3,6; CP 3,7; CP 4,6; CP 4,7; CP 2,5; and CP 3,5. For example, CP 3,6 refers to pain categorized as mild (0–3), moderate (4–6), and severe (7–10). Optimal cutoffs were those with the highest ANOVA F statistics. Models with similar F statistics were compared using changes in BIC.

Results

178 participants (85% white, 65% male, mean age of 46 years) with pain intensity and interference scores at one or more timepoints comprised the study sample. The optimal classification for mild, moderate, and severe pain at baseline and 12-months was CP 2,5. Although CP 3,6 had the highest F value at 6-months, there was not strong evidence to support CP 3,6 over CP 2,5 (BIC difference: 2.9); similarly, CP 3,7 had the highest value at 24-months, but the BIC difference over CP 2,5 was minimal (2.2).

Conclusions

We recommend that visual analog pain intensity scores for adult burn survivors be categorized as mild (0–2), moderate (3–5), and severe (6–10). These findings advance our understanding regarding the meaning of pain intensity ratings following a burn injury and provide an objective definition for clinical management, quality improvement, and pain research.
70 Measuring Itch Intensity in Young Children with Burns: What We Learnt from Parents. A Mixed-Methods Study
Authors: Lin Yuting
Published: April 2021

Introduction

Despite the persistence and debilitating symptoms among inflicted children and their families, little is known about children’s itching behavior as perceived and described by parents. This study examined the parental description of young children’s itching behavior corresponding to the itch intensity rating, which can inform the future development of itch measurements for young children.

Methods

This analysis was part of a larger descriptive study that examined parental behavioral and psychological responses to children’s itch following the child’s unintentional burn injury. Parents of young children with deep second or third-degree burns were recruited. Parents were asked to rate the child’s itching intensity under four situations during the 7-day time frame using a 0–10 numerical rating scale (0 indicates no itch, and 10 indicates the worst itch possible). Parents were subsequently interviewed to describe the child’s observed behavior that reflected the itch intensity rating. The four itch situations were the current itch, the worst intense itch, the least intense itch, and the itch by a mosquito bite. Qualitative data were analyzed using inductive content analysis methods.

Results

Twenty parents of children 34 (±11.5) months old participated in the study. The average length of time since the child’s burn accident was 6.4 (±3.1) months. The mean ratings of the current itch, the worst intense itch, the least intense itch, and the itch by a mosquito bite were 3.45 (±2.4), 8.35 (±2.3), 1.5 (±1.7), and 4 (±1.2), respectively. Two themes that described a child’s itching behavior were identified: the level of a child’s needs for parental comfort and the frequency and disturbance (to activity and sleep) of scratching behavior.

Conclusions

Results suggest that the parent’s description of a child’s needs for parental comfort and scratching behaviors may serve as objective indicators of itching intensity. Interpreting inching intensive based on a child’s needs for parental comfort offered a creative way to evaluate itch considering the developmental perspective in young children. Future development of itch measures for children under 5 years of age shall consider these two important aspects.
72 Parent Behavioral Responses to Children’s Itching following Unintentional Burns: Persevering Through Devastation. A Mixed-Methods Study
Authors: Lin Yuting
Published: April 2021

Introduction

Postburn itch is one of the disturbing symptoms that persist throughout the burn wound healing period. Parents often assume the responsibility to respond to their child’s symptoms; consequently, their responses to their child’s symptoms contributed to the child’s symptom experience and long-term outcomes. To date, literature examining parental behaviors in response to symptoms has been limited to children with pain. This study examined parents’ behavioral responses to itching in young children with burns.

Methods:: This analysis was part of a larger descriptive study that examined parental behavioral and psychological responses to children’s itch following the child’s unintentional burn injury. Parents of young children with deep second or third-degree burns were recruited. Semi-structured interviews were conducted with parents to learn about parental behavioral responses to the child’s itching. The Adult Responses to Children’s Symptoms (ARCS) scale was used to evaluate parental responses as part of the interview. The ARCS scale consists of 29 items that allow parents to self-report their responses to children’s itch. However, four items were excluded: three items were not appropriate to the study sample; one item related to sleep because children’s sleep pattern has been dramatically disturbed. We used the inductive content analysis that adapted from Grounded Theory to analyze the data.

Results

Twenty parents of children 34 (±11.5) months with moderate to severe burns 11.2% (±8.7%) total burn surface area (TBSA) participated in the interview. The mean length of time since burn injury was 6.4 (±3.1) months. Persevering through Devastation was the core construct that captured the lived experience of parental itching management. Parental behavioral responses to their child’s itch involved shifting their children’s attention, touching the scar, and tending to the itching scar. Data triangulation revealed that the ARCS scale captured parent behaviors in response to their child’s itch that was not reported in the interview.

Conclusions

Parents were devastated when they struggled on their own to relieve their child’s incessant itching during the prolonged wound healing stage. They cared for children with perseverance in the face of traumatic burn event; however, some parents responded to their child’s distress and call for comfort with anger or reactive behavior.
77 Insurance Status Plays a Role in Burn Patient Disposition Following Burn Injury
Authors: Comish Paul B , Abraham Sarah , Meier Jennie , Arnoldo Brett , Carlson Deborah
Published: April 2021

Introduction

According to the Emergency Medical Treatment and Labor Act (EMTALA), patient insurance status has no role in stabilization and treatment of patients brought into the emergency department. However, uninsured patients with burn injuries are more likely than insured patients to face early hospital discharge, and less likely to receive care in skilled facilities for post-hospital rehabilitation. Following trauma, insured patients are more likely to have longer hospital lengths of stay (LOS) compared to uninsured patients, resulting in a loss of clinical equipoise. The purpose of this study was to evaluate whether insurance status affects morbidity, mortality, LOS, and post-discharge care for patients with burn injuries. We hypothesized that insured patients would experience fewer complications but would more frequently be referred to skilled facilities for extended post-discharge care.

Methods

We retrospectively queried our prospectively collected burn database for all patients suffering from burn trauma and admitted to our burn facility from July 2015-December 2015. Patients under the age of 18 years and those without documented insurance status were excluded. Our primary outcome was any complication. Secondary outcomes included LOS, ICU days, mortality, and disposition. Chi-square and multivariate logistic regression analyses were performed using Stata.

Results

A total of 451 patients were included (74% male, median age 51 years, TBSA 20% ± 1.1, 27% were uninsured). Univariate analysis showed that uninsured patients were less likely to have complications following burn injury, as well as less likely to have any comorbidities (28.5% vs. 40.6%, p=0.02; 55.3% vs. 72.3%, p=0.001, respectively). After controlling for confounding variables (Baux score, comorbidities, gender, and smoking) we found there was no association between complications and insurance status (OR 1.45, 95% CI 0.91–2.33). Using the same regression model, we secondarily found that there was a significant association between disposition after hospital admission and insurance status (OR 1.94, 95% CI 1.04–3.62) as well as an association between mortality and insurance status (OR 0.35, 95% CI 0.17–0.72).

Conclusions

At our institution, insurance status for burn patients was not associated with differences in length of stay or complications. Despite this, insured patients were more likely to be discharged to skilled facilities and less likely to die from burn injury. Disparate outcomes between insured and un-insured burn patients remain a significant concern, and more studies are needed to understand underlying etiologies.
82 The Significant Burden of Burn Injuries in the Middle East: An Epidemiological Study of Nineteen Countries over 27 Years
Authors: Collier Zachary J , Samaha Yasmina , Naidu Priyanka , Choi Katherine J , Pham Christopher H , Potokar Tom , Amarin Marzouq , Gillenwater Justin
Published: April 2021

Introduction

Despite ongoing improvements in burn care around the world, the burden of burn morbidity and mortality has remined a significant challenge in the Middle East due to ongoing conflicts, economic crises, social disparities, and dangerous living conditions. Here, we examine the epidemiology of burn injuries in the Middle East (ME) relative to socio-demographic index (SDI), age, and sex in order to better define regional hotspots that may benefit most from sustainability and capacity building initiatives.

Methods

Computational modeling from the 2017 Global Burden of Disease (GBD17) database was used to extrapolate burn data about the nineteen countries that define the ME. Using the GBD17, the yearly incidence, deaths, and Disability-Adjusted Life Years (DALYs) from 1990 to 2017 were defined with respect to age and sex as rates of cases, deaths, and years per 100,000 persons, respectively. Mortality ratio represents the percentage of deaths relative to incident cases. Data from 2017 was spatially mapped using heat-mapping for the region.

Results

Over 27 years in the ME, an estimated 18,289,496 burns and 308,361 deaths occurred causing 24.5 million DALYs. Burn incidence decreased by 5% globally but only 1% in the ME. Although global incidence continued to decline, most ME countries exhibit steady increases since 2004. Compared to global averages, higher mortality rates (2.8% vs 2.0%) and DALYs (205 vs 152 years) were observed in the Middle East during this time although the respective disparities narrowed by 95% and 42% by 2017. Yemen had the worst death and DALY rates all 27 years with 2 and 2.2 times the ME average, respectively. Sudan had the highest morality ratio (3.7%) for most of the study, twice the ME average (1.8%), followed by Yemen at 3.6%. Sex-specific incidence, deaths, and DALYs in the ME were higher compared to the global cohorts. ME women had the worst rates in all categories. With respect to age, all rates were worse in the ME age groups except in those under 5 years.

Conclusions

For almost three decades, ME burn incidence, deaths, DALYs, and mortality rates were consistently worse than global average. Despite the already significant differences for burn frequency and severity, especially in women and children, underreporting from countries who lack sufficient registry capabilities likely means that the rates are even worse than predicted.
85 Did Shelter-in-place Mandate Lead to an Increase in Suspected Abuse Cases?
Authors: Williams Felicia N , Sljivic Sanja , Chrisco Lori , Maxwell Eli , Hollowell Jamie , Nizamani Rabia , King Booker
Published: April 2021

Introduction

The shelter-in-place mandate to mitigate the effects from the 2019 severe acute respiratory syndrome coronavirus 2 was associated with an increase in admissions of school-aged children to our burn center but a decrease in adult admissions. It was unclear how many admissions were from suspected abuse. Our objective was to determine the social impact of the shelter-in-place mandate on the number of burn admissions secondary to suspected abuse during the COVID pandemic compared to previous years.

Methods

Patients were identified using Institutional Burn Center registry and linked to the clinical and administrative data. All patients admitted from January 1, 2016 to July 31, 2020 with suspected abuse were eligible for inclusion. Demographics, patient and burn characteristics were evaluated. Statistical analysis was performed with Students’ t-test, and chi-squared test.

Results

There were 7177 patients included in the study. Prior to 2020, each year the percentage of cases with suspected abuse decreased compared to previous years (19% decrease in 2017, 23% decrease in 2018, 30% decrease in 2019). Compared 2019, the number of patients admitted with suspected abuse during the COVID pandemic increased 257%, p=0.00046. There were no significant differences in race, ethnicity, sex, burn mechanism, or burn size in those admitted with abuse-related injuries. The average age of patients with abuse-related injuries in 2020 was 13 years old, compared to an average age of 28 years old for the period from 2016–2019 (p< 0.003).

Conclusions

There is a significant increase in number of patients admitted for suspected abuse. Shelter-in-place mandate limited viral transmission of COVID-19 but led to unfathomable increases in abuse cases at our institution.