bluuebunny/crossref_metadata_2025 huggingface dataset:
507 Earlier Graft Takedown Using Autologous Keratinocyte Suspension in Conjunction with Split Thickness Skin Grafting for the Treatment of Deep 2nd and 3rd Degree Burns
Authors: Credo Roald , Brown Elizabeth , Dhaiti Cris , Pang Alan , Raghuram Akshay , Bharadia Deepak , Griswold John
Published: May 2023

Introduction

Autologous split-thickness skin grafts (STSG) have been the gold standard concerning treatment of both full and partial thickness burns. However, new treatments are emerging such as spray-on autologous keratinocyte suspensions (AKS). AKS is composed of a patient’s own keratinocytes, fibroblasts, and melanocytes. STSG in conjunction with AKS has showed promising results for the treatment of deep partial and full thickness burns. The standard graft takedown with STSG has historically been on postoperative day (POD) 6. Once graft take down occurs, occupational therapy can begin along with cessation of continuous splinting leading to more convenience and comfortability for the patient. With AKS, we propose that faster wound healing allows graft take down to occur earlier on POD 4.

Methods

A retrospective chart review was conducted at TTUHSC’s UMC Burn Center looking at patients that underwent STSG with AKS for the treatment of their burn. Patients were divided based on graft takedown on POD 4 or 6. Factors such as time to complete wound closure and postoperative complications were analyzed.

Results

The average age and total burn surface area in both groups was 43 years old and 28%. In the POD 4 group (n=10) the average time to healing was 2 months while the POD 6 group (n=21) had an average healing time of 3.1 months. Graft take and percentage of patients with changes in postoperative mobility and hypertrophic scarring were the same across both groups (98%, 30%, and 50%, respectively).

Conclusions

While time to healing was slightly different, there was not a statistically significant difference between the two groups. From this study we can conclude that graft take down can occur earlier in patients treated with STSG in conjunction with AKS. This allows for earlier therapeutic intervention and more convenience for the patient.

Applicability of Research to Practice

• Graft takedown can occur earlier on postoperative day 4 instead of 6 in patients treated with split-thickness skin grafting in conjunction with autologous keratinocyte suspension.

• Earlier graft takedown allows for earlier occupational therapy and reduces the need for extensive splinting which can be uncomfortable for the patient.

• Graft takedown can occur earlier in those treated with split-thickness skin grafting in conjunction with autologous keratinocyte suspension due to the rapid healing the suspension offers.
514 Incidence, Manifestation, Treatment and Outcomes related to Adrenal Insufficiency in Adult Burn Patients
Authors: Segura Ana , Curry Dominick , Rainey Andrew , Smith Susan
Published: May 2023

Introduction

In the setting of hypotension, serum cortisol levels are obtained to eliminate adrenal insufficiency as a contributing cause. Morbidity, prolonged length of intensive care unit and mechanical ventilator dependent days with higher mortality rates have been associated with adrenal insufficiency. The primary objective was to identify patient characteristics and treatment indications, approaches, and outcomes in adult burn – injured patients diagnosed with adrenal insufficiency.

Methods

This is a single center, five-year retrospective medical record review of adult patients aged 18 years and older admitted to the burn service were included. The data was analyzed using simple and correlational statistics to describe categorical data. Logistic regression, One-way ANOVA, and univariate analyses were conducted in Statistical Analysis System (SAS)® v 9.4.

Results

Sixty nine patients were included, 64% male, 51years old, with 27 % total body surface area, nearly half with smoke inhalation, and 32% mortality.

Duration of hydrocortisone therapy in days, total dose in milligrams, duration of wean in days, and number of times therapy reinitiated were found to be (unadjusted) significantly related to intensive care length of stay, p = < 0.001. Hydrocortisone total dose in milligrams was found to be significantly related with increased vasopressor hours, p = 0.00927, p = 0.0163.

Conclusions

Hypotension, leading to shock, directly correlates with overall burn survivability. Functional adrenal insufficiency may result for shock and sepsis. Hypotension was the instigating factor for hydrocortisone therapy. Random cortisol levels were obtained in all patients included in the study, with an average of 14 mcg/dl which did not exclude adrenal insufficiency as a contributing cause.

Applicability of Research to Practice

This exploratory research will assist with formalizing a list of triggers for initiation of adrenal replacement therapy. These results are foundational in development of outcomes resulting from treatment with varying doses of hydrocortisone and lengths of therapy.
519 Weekend Admission for Patients with Hidradenitis Suppurativa Have Better Outcomes than Weekday Admission
Authors: Atayeva Rena , Tiongco Rafael Felix , Cooney Carisa , Caffrey Julie , Lee Jonathan
Published: May 2023

Introduction

Hidradenitis suppurativa (HS) is a condition that involves recurring inflammation and fibrosis of intertriginous areas. With increasing inpatient hospitalization rates in patients with HS, our study sought to examine differences in outcomes between weekend and weekday admission. The authors hypothesized that patients admitted on a weekend will have worse in-hospital mortality rates when compared to those admitted on a weekday.

Methods

We used a national database to perform a cross-sectional study focusing on 12,365 patients with a primary diagnosis of HS from 2017-2019. The variables measured were weekend or weekday admission, age, gender, race, and zip income quartiles, with the latter four identified as confounding factors controlled for in the logistic regression analysis. Descriptive analyses were performed to determine frequencies, means, and significance. Statistical significance was set at p< 0.05.The multivariate binomial logistic regression was used to calculate the odds ratio (OR) for the identified outcomes. The primary outcome was in-hospital mortality. The secondary outcomes were morbidity factors (infection and wound dehiscence rates, postoperative complications), time from admission to first procedure, and resource utilization (total hospitalization charges and costs, and length of hospitalization).

Results

Weekend admission is not associated with worse inpatient mortality in patients with HS (p=0.345). From 2017-2019, 5 patients died, all of whom were admitted on a weekday. Compared to weekday, weekend admission had significantly lower incidences of wound dehiscence (0.38% vs 0%; p=0.007) and postoperative complications (0.24% vs 0%; p=0.035). No significant difference was observed for incidence of infection in weekday (0.43%) vs weekend admission (0.27%) (p=0.311). Weekend admission was also not found to have significant difference in the odds of contracting an infection (OR=0.74 (0.29-1.90); p=0.536). Weekend admission had significantly lower length of stay (mean days=6.40 vs 4.94; p=0.001), total charge ($64598.94 vs $44616.44; p< 0.001), and total cost ($14441.22 vs $10082.79; p< 0.001).

Conclusions

In contrast to previous studies focused on other pathologies that have shown increased morbidity, treatment metrics, and resource utilization on weekend admission, our study demonstrates that specifically for patients with HS, weekend admission is associated with lower rates of morbidity, length of stay, and charge.

Applicability of Research to Practice

Given that patients with HS who have a weekday admission have worse outcomes than a weekend admission, it is imperative for the medical team providing care to this group of patients on a weekday to be aware of this and begin to identify any potential factors.
524 Traveling Pediatric Burn Care on Wheels
Authors: Pruitt Mary , Queale Lydia
Published: May 2023

Introduction

Many burn patients initially seek treatment at a community hospital after suffering a burn injury and are then transferred to various hospitals before being evaluated by a burn specialist. Due to the increased volume of patients in the emergency department, pediatric burn patients in the past have waited on average 90 minutes to be assessed by a burn provider. A new process was implemented to decrease wait times and increase overall patient and family satisfaction. A breakdown in the process, noted by burn care staff, was the availability of burn care supplies located in the emergency department.

Methods

• A process developed for burn unit nurses to respond to the emergency department to evaluate all pediatric burn patients was implemented.

• A survey was sent to burn nurses looking for the most used supplies while caring for a pediatric burn patient.

• Collaborative efforts with the pharmacy department to obtain space in the medication pyxis for the most used ointments in burn care.

• Collaborative efforts with the Child Life Specialist to stock the cart with stickers, small toys, and distraction items for pediatric patients.

• Collaborative efforts with the attending burn surgeon to develop and implement a protocol for burn team response.

• Collaborative efforts with infection control department to ensure proper regulation standards of the cart.

Cart Contents:

• Gauze

• Securement wraps

• Wound cleansers

• Silver impregnated foam dressing

• Non-stick petroleum gauze

• Staplers

• IV start supplies

• Paper tracking tool

• Discharge & dressing change instructions

• Stickers, small toys, & distraction items

Results

The Hydro on Wheels cart was implemented in January 2022. A retrospective study of data including pediatric burn patients seen in 2021 was completed. The average wait time to be seen by a burn provider in the emergency department decreased from 90 minutes in 2021 to 34 minutes in the first 6 months of 2022.

A follow up survey was sent to hydrotherapy burn nurses to assess the satisfaction of the new process and equipment available.

Conclusions

Overall decreased wait time for pediatric burn patients to be evaluated by a burn care provider.

Burn care nurses felt prepared when responding to a pediatric burn patient in the emergency department.

Applicability of Research to Practice

The burn unit plans to continue this approach to improve patient and family satisfaction & patient outcomes

Future considerations to further improve the process would be to include a patient and family follow up satisfaction survey.
526 Results of Implementation of a Nurse Driven Fluid Resuscitation Protocol in a Regional Burn Center
Authors: Werthman Emily , Caffrey Julie , Cox Carrie
Published: May 2023

Introduction

Our prior research has demonstrated the effect of nurse driven fluid resuscitation on provider and nurse team dynamics. Our primary purpose with this new research on our nurse driven fluid resuscitation protocol is to determine the effect of the nurse-driven fluid resuscitation protocol on resuscitation associated complications (i.e., acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), and abdominal compartment syndrome). The study hypothesis is that the rate of resuscitation associated complications will remain stable or not increase post-protocol implementation.

Methods

Retrospective review for all patients within a one-year period pre-protocol implementation and post-protocol implementation was completed. 44 patients were included in the total sample, 22 in the pre-implementation group and 22 in post-implementation group. Exclusion criteria for patients included in nurse driven fluid resuscitation included delayed presentation, morbid obesity, electrical injury, cardiac history, DKA, polytrauma, and renal failure.

Results

Pre and post nurse driven fluid resuscitation implementation samples of 22 patients with total body surface area (TBSA) greater than 20% were analyzed. The incidence of serious complications including ARDS, compartment syndrome, and wound conversion was not statistically significantly different between samples. Rates of acute kidney injuries were similar across groups. In addition, the mean and median TBSA were not statistically significantly different pre and post implementation. The length of stay for the pre-implementation sample was on average longer than for the post-implementation sample. Our results are limited by the significant comorbidities of the pre-implementation group.

Please note tables and graphs were not yet available by time of submission. Attached tables are from prior analysis at approximate half-way of study. Updated graphs and tables will be complete by conference time.

Conclusions

As hypothesized, there were no differences in outcomes between patients receiving nurse driven fluid resuscitation. Our results indicate that nurse driven fluid resuscitation is a safe and clinically effective practice in the burn center. Coupled with our previous results that indicate a significant increase in nurse satisfaction with interdisciplinary communication associated with nurse driven, these results signal the importance of implementing nurse led resuscitations.

Applicability of Research to Practice

Nurse driven fluid resuscitation is a safe and effective. Further research into barriers to implementation is warranted.
527 Opportunity Amongst the Opportunistic: Improving Administration of Time-Critical Medications within a Burn Center
Authors: Richerbach Stacey , Hockenberry Tiffany , Richey Karen , Foster Kevin
Published: May 2023

Introduction

The absence of skin places patients with burns at an increased risk for a compromised immune system, thus susceptible to opportunistic infection. The use of time-critical medications (TCM) is often required for treatment. By definition, untimely administration may result in suboptimal therapy and put the patient at risk for harm. Our institutional goal for administration is 90%. In 2021 we observed a drop in compliance to 86.8% and instituted a multidisciplinary, quality improvement (QI) approach to improve TCM administration. The purpose of this study was to evaluate the efficacy of our interventions and identify trends in medication administration by staff type.

Methods

QI interventions included a collaboration between Nursing, Pharmacy, and Informatics to overcome barriers to timely administration related to unavailability of medication, education, and options for documentation in the electronic health record (EHR). Medication dispensing systems were floor stocked with eligible TCMs and pharmacists were instructed to refrain from scheduling TCMs within 30 minutes of shift change. Education was disseminated via weekly newsletter, staff huddle, and individual feedback was provided for low performers. TCM metrics were added to the quality board and top performers were acknowledged in a ‘Benchmark Brief.’ Lastly, the EHR was updated to enhance documentation. Medication administration was grouped by year. Staff was identified as burn staff or non-burn staff; comprised of internal resource, contract, and float staff.

Results

Following initiation of the QI project, timely administration increased by 8.6% to a 95.4% rate of timely administration.

Conclusions

Despite increases in annual inpatient admissions, our multidisciplinary quality improvement project was successful, increasing administration of TCM by 8.6%. Further, improvement by burn staff exceeded that of non-burn staff in the burn center. This supports a need to enhance quality initiatives for non-burn staff in the center.

Applicability of Research to Practice

Further research is needed to evaluate efficacy of education, specifically related to temporal dissemination amongst non-burn staff.
529 Job Sharing: An Innovative Approach to Increasing Research Resources and Improving Staff Satisfaction
Authors: Richey Karen , Hockenberry Tiffany , Dobbe Van , Kesler Natalie , Osborn Suzanne , Islas Claudia , Foster Kevin
Published: May 2023

Introduction

Pre-pandemic job openings for clinical research staff increased by nearly 10% a month nationwide yet was outpaced by an increase of greater than 12% in clinical trial activity. With the onset of the pandemic, the gulf between supply and demand widened in research. Simultaneously hospitals were stretched to capacity, staff suffered extreme burn-out and there was a dire need for additional bedside nurses. The pandemic shown a bright light on an age-old problem in nursing, whereas for a nurse to grow professionally, it often required leaving the bedside and giving up vital clinical skills, skills that were suddenly in great demand. The purpose of this project was to create a novel new job role, utilizing existing burn nursing staff to job share a research position, while maintaining their clinical expertise.

Methods

Nurse leaders from both areas worked in concert with the burn center’s director of research, senior hospital administration, human resources and existing staff to develop a new job role. The job description incorporated the scope and standards for nursing practice in both areas into one document. Additionally, a second-level position was created which allowed bedside nurses to trial the new role without a formal commitment to the permanent position. Staff were scheduled to rotate every 2 weeks between the two areas. Two months following implementation, core research staff and job-sharing staff were polled for feedback on benefits and challenges.

Results

Staff members (n=4) provided feedback independently from each other. A total of 41 comments were received, 27 benefit responses vs 14 challenges responses. Responses were grouped into themes and both benefits and challenges had 6 themes each. Benefit themes included: increased interdepartmental collaboration / trust (26%), professional growth (26%), supported learning (22%), enhanced screening for research patients (11%), unit-based resources (7%) and prevention of burnout (7%). Challenge themes included: scheduling (29%), variability in training opportunities (21%), role transitioning (21%), communication (14%), success personnel driven (7%), compensation (7%). Anecdotally, study investigators have expressed great satisfaction with the new position and there has been an increased interest expressed by other bedside staff in research involvement.

Conclusions

The response to the new position has been overwhelmingly positive. Staff entered the trial period realizing that it may be “messy” at first but quickly adapted and have worked through many of the challenges. Based on this early success, we are exploring the viability of cross training additional staff.

Applicability of Research to Practice

Cross training has been demonstrated to increase efficiencies, improve collaboration, trust and job satisfaction.
533 Medical Photo Application–Delivering Expert Burn Care in the Intermountain West
Authors: Mark Elizabeth , Rizzi Zach , Lewis Giavonni
Published: May 2023

Introduction

As the only verified Burn Center in the Intermountain West, we are faced with the challenge of providing care and support to a referral area spanning five states. In an effort to make consulting with our Burn Center more efficient and direct, we provide TeleHealth services. We typically provide real-time facility-to-facility consultation, facility-to-patient consultation, phone consultation, and photo consultation. Prior to development of our medical photo application (MedPic app), photo consults were completed via encrypted email. The consult process was inefficient resulting in multiple phone calls for one consult. As a result, we received requests to improve the process, making it more user friendly and HIPPA compliant.

Initially, our Burn Center created a photo consultation website that enabled referring providers to go to a webpage and upload photos. The consult began with a phone call from the referring provider. The Burn Center staff would inform the referring provider of the photo website and the referring provider would upload the photos. This improved the photo consult process, however it was still inefficient.

Based on these requests from our referring providers, staff, and patients, we developed the MedPic app. With the new MedPic app, we provide an easy to access and efficient process to consult with our Burn center; thus improving efficiency, reducing unnecessary hospital admissions, and associated medical transport costs.

Methods

The photo app was created and made available in March of 2020. The app streamlined the consult process by creating a direct link from referring providers to Burn providers. Burn providers receive images as soon as they are uploaded through the app.

The MedPic app is a photo consultation tool and requires three steps: 1. Take photos of the wounds; 2. Enter patient information; and 3. Enter a return call back number. A plan of care is communicated back to the referring provider within 30 minutes. Photos taken within the app are not saved to any device. The images are encrypted to protect patient information making the app HIPPA compliant.

We collected encounter data generated by photo consultation to our burn center prior to and after the MedPic app development (January 2016- September 2022).

Results

Since the MedPic app was released in March of 2020 we have noted 2,071 app downloads and have seen a steady increase in photo consultations. Figure 1 shows the total number of photo consultations to our Burn Center from January 2016 through September 2022.

Conclusions

Our Burn Center created the MedPic app resulting in over 2,000 downloads. The app is integrated into our Burn Center Telehealth consultation workflow. By providing a direct approach to acute burn injury consultations, we are able to efficiently assess patient wounds and ensure the patient receives the level of care they need in a timely manner.

Applicability of Research to Practice

This directly impacts triage and management of outpatient acute burn injuries.
534 If You Build It, They Will Come: Everyday Burn Clinic Enhanced Access to Care
Authors: O'Rourke Casey , Gernt Megan , Burton-Williams Kristen
Published: May 2023

Introduction

Prior to 2020, our small burn center had 1x/wk adult burn clinic and 1x/wk pediatric burn clinic. This schedule did not allow for optimal access to care for the geographic area our burn center serves. Also, our inpatient daily census was steadily increasing, and we identified many barriers to discharge for our acute burn survivors that would help to justify to hospital administration the need for increasing the frequency of our burn clinic to daily. These barriers to discharge included decreased availability of visiting nurse agencies for dressing changes, poor quality of rehabilitation services through visiting nurse agencies, and comfort and/or competence with family and/or caregivers being able to provide quality needed burn care.

Methods

Our burn leadership team developed a business plan for an everyday burn clinic to provide to hospital administration. This daily burn clinic would allow for both adult and pediatric burn survivors to be seen Monday-Friday, provide rehabilitative services a space within our burn clinic, and availability of daily dressing changes in burn clinic. The business plan was reviewed by hospital administration, meetings were held with hospital administration, rehabilitation department leadership and ancillary services leadership to help validate the need for the daily burn clinic.

Results

Hospital administration approved our daily burn clinic in July of 2020 allowing for improved outpatient dressing and wound management, easy access to quality burn rehabilitation, translating to decreased length of stay. Communication was sent to all area emergency rooms, urgent cares, pediatrician offices and primary care offices to inform them of the increased availability of the burn clinic. This communication included the American Burn Association transfer criteria, a referral form to facilitate access to our burn clinic, and a simple algorithm for assistance with triaging burn care. Prior to the everyday burn clinic in 2019, we were seeing 1,155 outpatient visits annually and in 2021 we saw 1,728 visits in our burn clinic. This is a 150% increase in outpatient burn clinic visits in two years.

Conclusions

Increasing accessibility to outpatient care for the burn survivor can benefit many aspects in their journey to recovery as well as support the surrounding community in quick access to quality burn care. Burn survivors benefit from shorter hospital stays with the availability of a daily burn clinic for ongoing dressing management while maintaining quality rehabilitation services to maximize their functional outcomes.

Applicability of Research to Practice

Data could be collected to evaluate the true impact the creation of the daily burn clinic had on burn survivors’ length of stay. Also, data can be collected regarding the number of burn survivors treated at other local emergency rooms and/or urgent care facilities prior to the creation of the daily burn clinic to evaluate the efficacy of the communication provided to the community.
560 Utilization of Alternate Hinge for Static Progressive Shoulder Orthosis: A Case Study
Authors: Martinez Andria , Warthman Renee , Foster Kevin , Murray Derek , Richey Karen
Published: May 2023

Introduction

Management of shoulder burn injuries creates unique challenges as the shoulder girdle is comprised of four joints and has the largest degree of motion in the body. The complexity of arthrokinematics and cutaneokinematics requires creative positioning devices to achieve the desired effect. Shoulder positioning devices for pediatric patients are limited, and devices that allow positioning at end range can be bulky, heavy, and costly. Available hinges for upper extremity devices offer limited utility and do not withstand the tensile forces of burn scar contracture in conjuncture with and prolonged use. This is a report of a single patient for which a locking knee hinge was used to fabricate a custom static progressive shoulder flexion device.

Methods

This case study analyzes the impact of bilateral custom static shoulder flexion orthoses and static progressive orthoses on range of motion in a pediatric patient. Static shoulder flexion orthotics were implemented, and then transitioned to static progressive orthotics. Goniometric measurements were obtained through out hospitalization. Average variance in of range of motion at the glenohumeral joint (GH), and standard deviation of goniometric measurements comparing static and static progressive orthoses were collected.

Results

There was a total of 33 bilateral sets of goniometric measurements. Sixteen sets were collected utilizing static shoulder flexion orthoses. Mean flexion was 149.6⁰ and 154.6⁰ abduction of the left shoulder. Right shoulder flexion and abduction means were 149.3⁰ and 152.8⁰ degrees. There was a standard deviation (STD) of 22⁰ for the left shoulder mean goniometric measurements and STD of 23.2⁰ for the right shoulder. Seventeen sets were collected utilizing static progressive shoulder flexion orthoses. Results revealed a mean of 166.1⁰ and 166.7⁰ for flexion and abduction of the left shoulder. Right shoulder flexion and abduction averages were 169.3⁰ and 170.6⁰ respectively. There was an STD of 8.9⁰ for mean goniometric measurements of the left shoulder and STD of 4⁰ of the right shoulder. Introduction of a locking hinged shoulder flexion orthosis resulted in an increase of 80⁰ left and 90⁰ right shoulder flexion in 24 hours. The patient was able to achieve and maintain an average of 165⁰ of shoulder flexion throughout hospitalization (47 days).

Conclusions

Use of a locking hinged shoulder orthosis allowed for progressive increase in shoulder flexion without neurological symptoms and decreased pain and anxiety related to therapy and orthotic application. Compliance with wearing schedule was increased due to ease of application.

Applicability of Research to Practice

Utilization of locking hinges to create custom static progressive shoulder flexion orthoses may allow therapists to increase and maintain shoulder range of motion in pediatric patients following burn injury.
562 Therapy Resources for Management of Large TBSA Burns: A Case Study
Authors: O'Neil Audrey , Rush Cassandra , Roggy David , Hartman Brett
Published: May 2023

Introduction

Therapy studies involving large percent TBSA burns ( >50% TBSA) are not well described. Studies show the highest predictor of preventing burn scar contracture is the amount of burn rehabilitation time received per cutaneous functional units involved, but what does “more therapy time” mean for larger burns in terms of therapy resources for burn centers?

Methods

A case study was completed on a 20-year-old male admitted after sustaining 85% TBSA full thickness flame burns to his face, neck, arms, legs, and trunk, along with an inhalation injury. He was admitted to the inpatient burn ICU for 113 days, undergoing 16 surgeries to achieve skin coverage prior to discharge to acute rehab. Therapy was initiated < 24 hours after admission to the Burn ICU. Direct therapy contact minutes were tracked during all session and divided into therapy treatment domains. (resource). If co-treating occurred, a single unit of time was used for the time of the session to avoid doubling the units provided.

Results

Therapy occurred on 106/113 days of admission, receiving 238 therapy sessions (113 PT, 125 OT). He received 21,027 minutes of direct therapy, averaging 196.5 min/rehab days. The highest number of therapy minutes were spent on ROM (9,032 min). Other domains of care included Mobilization (3,171 min), Positioning (2,298 min), Orthotic management (1,326 min), etc. (Table 1). Despite focus on ROM and positioning, he discharged with 7 moderate (left wrist extension, bilateral hip abduction, bilateral ankle dorsiflexion, left neck rotation, and left forearm supination) and 4 severe contractures (right wrist extension, bilateral hip extension, neck extension). He was able to transfer with moderate assistance and walk 150 ft with a platform walker at discharge.

Conclusions

Therapy interventions in the literature are often described in isolated “domains” of practice, however guidelines on a global approach to management of those with catastrophic injuries does not exist. Prioritization between domains with limited therapy resources when facing patients with extensive deficits is challenging. A dedicated burn therapy staff with availability to secure additional resources was required to ensure optimal outcomes in the management of this patient

Applicability of Research to Practice

This case study demonstrates the comprehensive burden of care and need for additional therapy resources in the management large TBSA burns.
565 Rehabilitation Time to Evaluation Report: A Quality Improvement Study
Authors: Vocke Scott , Werthman Emily , Caffrey Julie , Dean Brooke , Rodriguez Joshua , Andre Gregory
Published: May 2023

Introduction

Successful rehabilitation of patients with burn injuries requires an in-depth occupational therapy (OT) and physical therapy (PT) evaluation early in the acute phase of a patient’s injury to develop a detailed therapy plan of care. In addition, it is a standard of the American Burn Association for verified burn centers to have a comprehensive rehabilitation program designed for burn patients within 24 hours of admission. However, there is no standardized report for tracking timeliness of issuing PT/OT orders or completion of therapy evaluations by PT/OT after a patient is admitted to a burn unit. This quality improvement study details the creation of a “Time to PT/OT Order Placement and Evaluation Completion Report” and results of a quality improvement process used to improve these metrics.

Methods

A multi-disciplinary workgroup was created and included a burn surgeon, PT and program nurse coordinator and an electronic report was created in collaboration with the hospital’s business intelligence team. The report included the following metrics: average time from admission to PT/OT order placement, average time from PT/OT order placement to therapist acknowledgement, and average time from PT/OT order placement to therapist completion of initial evaluation. A baseline report was run (3-months) and results were analyzed. A quality improvement process was then put into place including education of burn attending physicians, fellows, and rotating residents on timeliness of therapy order placement, therapy staff education on findings and a new process for morning coordination of burn therapist caseloads to prioritize new evaluations, and initiation of monthly reporting at the burn joint practice committee meetings. The report was then run for an additional 3-months and results were analyzed.

Results

Baseline and post-quality improvement process results (3-month averages) were as follows: Average time from admission to PT/OT order placement increased from 3.4 to 8.3 hrs, average time from PT/OT order placement to therapist acknowledgement decreased from 43.2 to 31.5 hrs, and average time from PT/OT order placement to therapist completion of evaluation decreased from 43.6 to 35.1 hrs.

Conclusions

After development of this report findings showed that the quality improvement process used to improve timeliness of inpatient PT/OT initial evaluation completion was effective. In addition, this report has been useful for metric reporting during burn joint practice committee meetings, the ABA verification process and burn therapy staffing/daily caseload management.

Applicability of Research to Practice

This report could be used by other burn centers to help track and improve timeliness of initial PT/OT evaluations for acute burns. In addition, metrics created from this report could be used for the ABA verification process and help justify burn unit therapy staffing needs.
568 Mobilization, Splinting & Positioning: Increasing Nursing Participation in the Rehabilitation Plan of Care
Authors: Knight Deborah , Dowling Lynn , Berry Lisa
Published: May 2023

Introduction

The foundation for long-term functional outcomes of the burn patient is laid in the Burn ICU. Nursing plays a vital role in the Rehabilitation Plan of Care for patients with burn injuries. As the member of the critical care team who is most present with the patient around the clock, the burn nurse is essential for carrying over and following through with interventions initiated by Occupational Therapy, Physiotherapy and Speech & Language Pathology. Without cohesion and partnership on the interdisciplinary burn team, the Rehabilitation Plan Care cannot succeed. In the midst of the COVID-19 pandemic, burn nursing turnover rates are higher than pre-pandemic rates. Burn Centers are relying on travel nursing contracts or novice nurses fresh out of school to provide specialized burn care. Our center developed a didactic and “hands on” learning initiative to improve collaboration between the Burn Nursing and Burn Physical Medicine departments in order to equip the critical care burn nurses to actively participate in the Rehabilitation Plan of Care.

Methods

• Collaboration between Burn Nursing leadership and Burn Physical Medicine leadership to examine ABA nursing competencies pertaining to the Rehabilitation Plan of Care

• Team of PTs/OTs identified to develop curriculum based off these competencies

• Learning objectives set

• Hands on training program developed

• 8 small group training sessions completed

• Competency assessments completed

• 7 question pre- & post-testing completed to assess learning

• Opportunity for input from participants for quality improvement

Results

104 Burn ICU nurses participated in the classes. 99% passed competency assessment.

Improvements between Pre- and Post- Test scores demonstrate learning of desired knowledge and skills.

Feedback assessment from RNs regarding value of course participation & ongoing need for collaborative training (most common was related to positioning & compression)

Conclusions

104 burn ICU nurses participated in hands-on, didactic training related to nursing competencies related to the Rehabilitation Plan of Care. Data is now being collected regarding follow through of knowledge and skills implementation.

Applicability of Research to Practice

This project showed the improvement that can be made in regards to the cooperation of burn ICU nurses with the rehabilitation plan of care.
570 Effectiveness of Hand Edema Management Strategies in the Acute Burn Patient
Authors: Warthman Renee , Mehta Ari , Martinez Andria , Islas Claudia , Murray Derek , Foster Kevin , Williams Sierra , Richey Karen
Published: May 2023

Introduction

Hand edema is a common sequalae of burn injuries involving the upper extremity (UE) and larger total body surface area (TBSA) burns requiring fluid resuscitation. Hand edema can be challenging to manage depending on the severity of the injury and, if not adequately addressed, can have long-term functional implications. Multiple edema management techniques are available for therapists treating burn injuries, but little is known about their efficacy. A quality improvement project examined the efficacy of 4 strategies used at our burn center.

Methods

Edema management strategies evaluated included: elevation using a pre-cut foam wedge and pillow, elevation and self-adhesive wrap, elevation and cotton-elastic wrap, and elevation with a chip-bag. Figure-of-8 measurements were taken pre and post intervention. Outcomes included length of time intervention was in place, reason intervention selection, time required to apply intervention, and if intervention was intact prior to removal. Training was completed with staff to ensure consistent application of intervention. Only adult patients were included.

Results

A total of 23 interventions were measured. At follow up, 61% of the interventions were not intact. In each instance this was due to displacement of either the wedge or pillow. Self-adhesive wrap (3.25 cm) followed by cotton-elastic wrap (2.57 cm) in conjunction with elevation achieved the greatest reduction in edema. Elevation of the UE with a wedge and pillow are less effective in managing hand edema alone, with a mean difference of .26 centimeters (cm) decrease in edema. On average, it took therapists less time to apply cotton-elastic wrap (6.4 minutes) vs self-adhesive wrap (14.25 minutes).

Conclusions

In this limited sample, elevation with a pre-cut foam wedge or a pillow was least effective in reducing edema in the hand. Including a secondary edema management technique in conjunction with elevation is more effective in managing hand edema. A larger sample size may benefit increased understanding of edema management techniques within a burn center.

Applicability of Research to Practice

Interdisciplinary training on maintaining edema management strategies is important to promote maintenance of positioning. Further research is warranted to examine the efficacy of hand edema intervention strategies in the acute burn patient.
577 Impact of the Bismuth Tribromophenate Stick-down Method on Pediatric Burns
Authors: Joshi Nikita , Grauberger Jennifer , Joo Alex , Lalikos Janice
Published: May 2023

Introduction

Burn injuries are a leading cause of morbidity and mortality in the pediatric population. Patients require frequent dressing changes to minimize infection risk and promote wound healing via re-epithelialization. Bismuth Tribromophenate, an affordable petrolatum-based dressing, has been shown to have rapid re-epithelization of skin grafts and low infection rates in clean wound environments. A stick-down (SD) protocol has been developed to minimize the frequency of dressing changes. This SD protocol involves daily assessment and changing of the dressing until it begins to adhere to the underlying wound bed, where the dressing is then left in place as a protective layer as re-epithelialization occurs. The objective of this study is to characterize baseline features and compare outcomes associated with the SD dressing compared to non-stick-down (NSD) Bismuth Tribromophenate dressing.

Methods

Patients under 18 years treated at our institution for partial thickness burn injuries were retrospectively identified using our medical records. Demographic data, injury characteristics, dressing type, length of hospitalization, and outpatient outcomes were collected from these records. Statistical analysis between dressing types was achieved using Fisher’s exact test and Mann-Whitney U test, with statistical significance defined as p < 0.05.

Results

A total of 106 individuals receiving Bismuth Tribromophenate were identified. 36 patients received the Bismuth Tribromophenate SD dressing and 70 patients received NSD dressing. SD patients had a higher hospital admission rate compared to NSD patients (52.8% versus 33.3%, p = 0.088), though not statistically significant. 47.3% of admitted SD patients were admitted for burn severity compared to 25% in NSD patients. SD patients also had higher PICU admission rates compared to NSD patients (36.8% versus 4.8%, p = 0.017). SD patients also required initial debridement sedation more often (63.6% versus 36.7%, p = 0.017). SD and NSD patients had re-epithelialization rates of 66.7% and 65.6% (p = 1), respectively. Median time to re-epithelialization was 13 (10.8-17.2) days in SD patients compared to 12 (10-20) days in NSD patients (p = 1).

Conclusions

SD-receiving patients were more likely to be admitted to the hospital and admitted for burn severity. In contrast, patients receiving NSD were less likely to be admitted, but more commonly admitted for pain. SD-receiving patients were also more likely to be admitted to the PICU and require sedation for debridement. Despite this difference in baseline characteristics, re-epithelialization rates and time to re-epithelialization between SD and NSD patients were not statistically distinct, with comparable rates and days to healing.

Applicability of Research to Practice

Identifying cost-effective, efficacious, and convenient dressing protocols for the treatment of pediatric burns.
578 Impact of Acellular Fish Skin on Wound Healing in a Standardized Pre-Clinical Model
Authors: Pignet Anna-Lisa , Hofmann Elisabeth , Fink Julia , Schwarz Anna , Hahn David , Prevedel Manuel , Kamolz Lars-Peter , Kotzbeck Petra
Published: May 2023

Introduction

Acellular fish skin has proven to be effective in acute and chronic wound healing. Multiple human studies have to date demonstrated that products from acellular skin grafts accelerate wound healing and are efficacious, safe and cost-effective. Here we wanted to investigate the effects of acellular fish skin on wound healing in a pig model.

Methods

The primary aim of this study was to investigate the effects of acellular fish skin on wound healing progression in a full thickness skin defect pig model. The superiority of fish skin was tested in a standardized pig model and compared to normal wound healing (without acellular fish skin grafts) (n=6).

The experiments were carried out in male landrace pigs with a mean weight of 28.8 +/- 2.8 kg at the start of the study. The experiment lasted for 21 days. Wound documentation, thermography, photo-documentation and wound perfusion were carried out 5, 9, 14 and 21 days post wounding.

Results

Clinical evaluation of the wounds showed that there were no major differences between the different dressings on day 5 post wounding. On the next evaluation days ( day 9, 14 and 21 post wounding) the acellular fish skin showed rapid epithelialization with minimal wound contraction, when compared to untreated control wounds, which showed significant signs of contraction (i.e. star-like wound appearance).

Wound area measurements clearly showed that wound size upon treatment with the acellular fish skin and the untreated control rapidly and significantly decreased through contraction of untreated controls. However, wound perfusion seemed to be affected by the treatment with acellular fish skin. Thermography at day 9 and 14 showed higher surface temperature in treated wounds (d9 and d14; p = 0.0005), followed by a trend towards increased oxygenation and perfusion, analyzed by laser speckle and hyperspectral imaging.

Conclusions

Acellular fish skin seems to provide fast wound healing and counteract wound contraction. Untreated wounds showed a slight trend of faster healing, but showed significant signs of wound contraction which points towards wound healing by contraction but not by epithelialization. This contraction was not observed in wounds treated with acellular fish skin.

Applicability of Research to Practice

Standardized preclinical models give valuable insights to the mechanisms of wound healing. Porcine in vivo models are of special interest as the porcine skin is highly similar to human skin with regard to anatomical and physiological structures. Therefore, data generated in such models, as described here, show a high rate of translatability to the human situation.
702 Hydroxycobalamin is An Independent Risk Factor for Acute Kidney Injury.
Authors: Gondek Stephen , Streams Jill , Beyene Robel , Ayers Claci , Dennis Brad , Hayhurst Christina , Dale Slater Elizabeth , Summitt Blair , Wagner Anne
Published: May 2023

Introduction

Previous studies have reported a correlation between the use of hydroxocobalamin and acute kidney injury (AKI), but this is often attributed to the severity of their burn injury. In this study, we use a matched control group to correct for severity of injury and assess the relationship between hydroxycobalamin and AKI.

Methods

All patients receiving hydroxycobalamin over a three year period were identified. The patients were matched 1:1 based on TBSA and age to create a control group. Creatinine and change in creatinine every 24 hours for the first 72 hours were recorded and compared, with an increase in creatinine >1.5 being considered an AKI. A retrospective matched cohort study was performed using the student’s T-test for continuous data and a chi squared test for categorical data.

Results

A total of 50 patients receiving hydroxycobalamin were identified and matched with 50 patients who did not receive hydroxycobalamin. The groups were no signficant differences between groups in terms of age, TBSA or baseline creatinine. Patient receiving hydroxycobalamin had a mean increase of creatinine of 0.13, 0.13 and 0.07 at 24, 48, 72 hours respectively versus 0.0, 0.04 and 0.0 in the control group (p = .09, .06, .49). Qualitatively, 15/50 patients receiving hydroxycobalamin developed AKI vs 2/50 in the control group (p < .001 ), with 6/33 minor burns developing AKI with hydroxycobalamin vs 1/33 in the control group (p=.058). Five patients receiving hydroxycobalamin developed AKI lasting greater than 72 hours, two of which had only minor burns.

Conclusions

Hydroxycobalamin is an independent risk factor for the development of acute kidney injury, even in the setting of minor burns and should only be used in patients with high risk for cyanide poisoning. Empiric and protocolized use may result in harm to patients and should be discouraged.

Applicability of Research to Practice

This study demonstrates the risk of AKI with the use of hydroxycobalamin in both major and minor burns, which burn centers should consider when creating protocols regarding potential cyanide poisoning.