bluuebunny/crossref_metadata_2025 huggingface dataset:
546 Winning the Race Against Pathogens: A Regional Burn Center Experience with a Cleansing Protocol
Authors: Dries David , Miotke Sam , Popma Emily , Johnston Mark , Rogers Bradley , Obst Mary Anne
Published: May 2023

Introduction

The skin is the first immune defense mechanism, and it functions as a barrier against various microorganisms. Burn injury will compromise this important barrier. Infections are the primary factor contributing to burn mortality, resulting in >50% of deaths in burn patients. In 2020, our Adult and Pediatric Burn Center instituted a pure Hypochlorous Acid (pHA) antimicrobial protocol to enhance skin barrier function.

Methods

We conducted a retrospective analysis on the effect of the introduction of the pHA protocol on the number of reportable infections in our Burn Center. The period of observation in this report is 2017-2021. Beginning in 2020, adults and children received topical wound care and bathing with our pHA protocol. No dilution of the product was used. The product was placed into a sterile basin and the patient was cleaned head to toe, including the genitalia and the wounds. Since invasive procedures such as placement of central venous catheters or urinary collection catheters may be a conduit of infection, the present report includes data regarding the number of patients experiencing clostridium difficile, central line-associated blood stream infection and catheter-associated urinary tract infections.

Results

From 2017-2021, our Burn Center admitted 2,223 patients. We computed a percent change in infections from before (2017-2019) to after (2021) the pHA protocol was implemented. We used 2021 because this was the first full year after the pHA protocol was introduced. We subtracted the total number of infections in 2021 from the average number of infections per year in 2017-2019 and divided by the average number of infections per year in 2017-2019. We found a 55% decrease in infections after the pHA protocol was introduced. There was no evidence of toxicity in adult or pediatric patients associated with care during introduction of the pHA protocol, including skin graft sites.

Conclusions

This analysis indicates a notable decrease in infections. The pHA procedure shows no evidence of viral, fungal or bacterial pathogens causing significant issues with the studied patient group. This analysis does not determine whether the decrease in infections is clinically or statistically significant.

Applicability of Research to Practice

Reducing infections in burn patients which can be life saving.
547 Volume-based Feeds: A Quality Improvement Project for Better Nutrition
Authors: Levine Emma , Dale Slater Elizabeth , Slutsky Hanna , Ladele Olatundun , Gondek Stephen , Wagner Anne
Published: May 2023

Introduction

Nutrition is a critical component to recovery in burn patients. Their heightened metabolic demand is well established. In our burn population, patients often received significantly less volume of feeds than they were prescribed, primarily due to stoppages for sedations and procedures. We, therefore, developed a quality improvement (QI) project to help improve the quantity of feeds received.

Methods

Under the direction of nursing QI leadership and our burn nutritionist, we established an outcome measure of increasing average feeds received from baseline 68% of those prescribed to greater than 75% of those prescribed. Using a process of iterative changes, we initially developed a calculator for volume-based feeds to make up the volume lost during times tube feeds were paused. Nursing staff gave feedback, and we ultimately used a chart for adjusted volumes based on the total 24 hour goal and number of hours remaining in which to make up the goal. On a bi-weekly basis, we examined the amount of tube feeds as a percent of total prescribed prior to and after the interventions.

Results

Early results have demonstrated improvements in the percent of tube feeds a burn patient is receiving. Prior to the interventions patients were receiving about 68% of the prescribed tube feeds and within 6 weeks of project initiation, patients were receiving 82% of the prescribed tube feeds (Figure 1). In addition, variability in feeds received decreased markedly, as have number of days above the target.

Conclusions

In conclusion, this has been an effective QI intervention as we surpassed our initial target within 6 weeks of initiation. Next steps are to consider increasing the target to 90% of prescribed feeds, as well as investigating adequacy of feeds using nitrogen balance in select patients. Future directions for this project include assessing outcome measures such as graft take and hospital length of stay.

Applicability of Research to Practice

Purpose is to share our methods in quality improvement to aid others efforts facing similar challenges in the care of the critically ill burn patient.
551 Reduction of Fungus-Related Complications in a Burn Center
Authors: Shingleton Sarah , Chafin Kristine , Britton Garrett , Aden James , Basel Anthony , Cancio Leopoldo
Published: May 2023

Introduction

Fungal wound infections (FWI) cause morbidity and increase mortality in burn patients. Our burn center experienced 44 patients with fungal wound colonization (FWC) and/or FWI between JAN 2015 and JAN 2019. In response, we undertook a performance improvement project to prevent and treat FWC and FWI.

Methods

Members of the multidisciplinary team met to develop a clinical practice guideline (CPG) for the prevention and management of FWC and FWI based on current evidence. We focused on patients with elevated risk, that is, with burns ≥20% total body surface area (TBSA) and in the Burn ICU (BICU). Interventions included: utilizing alternating silver sulfadiazine and mafenide acetate creams upon admission; reducing the use of mafenide acetate solution; utilizing silver nitrate solution post-operatively; and applying topical nystatin cream or powder for suspected FWC or FWI. We educated all staff members and updated order sets and training materials. We collected data on all burn patients who had a wound biopsy out of concern for possible infection. Biopsy results were categorized as FWC or FWI. Retrospective data were collected for MAR 2020 - MAR 2021 (PRE). Post-implementation, prospective data collection began MAR 2022 (POST) and will continue for one year. Adherence to the CPG was assessed by chart review. Mann-Whitney and Fischer Exact tests were performed.

Results

The PRE (n=15) and POST (n=9) groups were similar in age (43±13 vs. 48±18 years) but differed in TBSA (49±19 vs 28±25%, p< .05). PRE group biopsies showed FWC in 0 patients and FWI in 11 of 15 patients (73%); 8 of these (53%), all with FWI, died. In the POST group, FWC was found in 1 patient (11%) and FWI was found in 2 of 9 patients (22%); one death occurred in the patient with FWC. Adherence to the CPG for admission topical wound care was 7% in the PRE group vs 89% in the POST group (p=0.0001); adherence to the CPG for day-of-biopsy topical wound care was 27% in the PRE group vs 89% in the POST group (p< 0.01).

Conclusions

Adherence to a CPG for the prevention and treatment of FWC and FWI was associated with a lower (but not statistically significant) prevalence of these complications. Limitations include a difference in the TBSA between the 2 groups and potential concurrent changes in practice. Ongoing data collection includes the evaluation of other potential contributing factors.

Applicability of Research to Practice

Fungi are common in the environment, and when combined with immunosuppression and extensive open wounds, may cause wound infection in burn patients. More research is needed to further evaluate effective treatments for the prevention and treatment of FWC and FWI in these patients.
555 Pain Management During Bromelain-Based Enzymatic Debridement in a U.S. Adult Burn Center
Authors: Buta Martin , Annand Domenic , Findeisen Sarah , Hickey Sean , Sheridan Robert , Friedstat Jonathan , Schulz John , Bojovic Branko , Goverman Jeremy
Published: May 2023

Introduction

Outside the United States, bromelain-based enzymatic debridement (BBED) has become an effective tool for removal of burn eschar. BBED can be performed at bedside and allows for complete eschar removal with maximal dermal preservation and markedly reduced blood loss. It may also decrease the need for autografting or the amount of autograft required. A primary concern with BBED is that it is a painful procedure requiring appropriate analgesia. Experience with BBED in the U.S. has been gained through a multicenter phase 3 clinical trial (DETECT) and an expanded access treatment protocol (NEXT). In this retrospective study, we describe our experience using BBED, with particular focus on pain management.

Methods

A retrospective review was conducted on 29 adult burn patients enrolled in the DETECT or NEXT trials who underwent BBED of acute deep partial- and full-thickness thermal burn wounds at a major burn center between November 2016 and July 2022. Patient demographics and procedural characteristics, including pain management strategies and Numerical Pain Rating Scale (NPRS) scores before, during, and after debridement, were analyzed and described.

Results

Twenty-nine patients with an average age of 41.2 years (SD=17.8, range 18-72) and an average TBSA of 6.3% (SD=5.6, range 1-24.5) underwent a total of 29 BBED. For pain control during debridement, 6 patients required conscious sedation (CS), 7 a regional block (RB), 5 a local block (LB), and 9 only IV and oral (IVPO) medications. Two patients were intubated and sedated prior to the procedure. No patient required additional BBED treatment and all patients achieved >95% eschar removal. The average NPRS pain score 24 hours before treatment, during treatment, and 24 hours after treatment was 4.0, 4.6, & 4.4, respectively (P=0.65). Sixteen patients (55%) healed without the need for autografting. The average number of days from debridement to wound closure for all patients was 34.9 days (SD=11.9) and for patients who underwent autografting was 40.1 days (SD=12.3).

Conclusions

With appropriate analgesia, it is possible to perform BBED of acute deep partial- and full-thickness thermal burns without significant changes in patient-reported pain scores. Prior to debridement, it is critical to establish procedure logistics and reasonable patient expectations.

Applicability of Research to Practice

The authors review their experience controlling pain associated with BBED.
559 Verticalization Therapy for ICU-Level Burn Patient: A Case Study
Authors: Tepe Melinda , Gerlich Nicole , O’Donnell Allison , Drake Mack , Feldman Michael
Published: May 2023

Introduction

The entire interdisciplinary team can be faced with many challenges when treating a bariatric, critically ill patient with significant burn injuries. Some studies suggest that the care of these patients increases staff workload and leads to the need for increased assistance for proper turning, positioning, and completion of wound care. When caring for these types of patients, patient and staff safety should be considered, as well as what will ensure the best patient outcomes. Our rehab team initiated the use of verticalization therapy with a patient on the burn unit with 28% TBSA full-thickness burns to back, chest, BUEs and a BMI of 45.8 in order to promote improved healing, cognitive status, and pulmonary function. While verticalization therapy is described for use in patients with pulmonary issues or invasive cardiac support devices, this was the first time this therapy was used in our busy ABA-verified burn center.

Methods

Once deemed appropriate for participation with PT/OT, a collaborative protocol with nursing, therapy, and burn provider team was developed. The patient was transitioned into a specialized bed allowing for verticalization up to 90 degrees. The patient was incrementally verticalized by 10 degrees at a time while monitoring vitals, assessing patient safety and pain response. Ultimately, the patient reached 40 degrees vertical and maintained this position for up to 2 hours. This intervention was utilized by both rehab specialists and nursing staff and was taught to nursing staff to be performed daily until patient was able to actively participate and tolerate edge of bed or out of bed activity.

Results

Use of the verticalization positioning was used to promote weight bearing activity, improve pulmonary function, improve cognitive status through upright positioning, and for pressure relief of graft areas specifically for offloading pressure to back wounds and grafts. The bed was used for 1 month. During this time, the patient successfully liberated from mechanical ventilation and shock state and mobilized with therapy assistance. The patient demonstrated improved strength, active participation with therapies, and decreased agitation as the month progressed. Autograft split-thickness skin grafts with autologous cell suspension epithelial autografts to the patient’s posterior torso healed well and were fully closed by the time of discharge to inpatient rehabilitation.

Conclusions

Use of verticalization beds can be implemented in the care of patients with burn injuries safely and successfully. Further research regarding skin healing related to use of the bed and verticalization therapy in burn injured patients should be conducted.

Applicability of Research to Practice

This intervention can be used for patients of all sizes and can be implemented as soon as hospital day one, if the patient is medically appropriate
567 Outcomes of an Education Program on the Rehabilitation of Face and Neck Burns
Authors: Knight Deborah , Serghiou Michael , Niszczak Jonathan
Published: May 2023

Introduction

Face and neck burns bring unique complications and often require specific training and experience for the burn physical rehabilitation professional. The COVID-19 Pandemic created a need for virtual learning during a time when in-person learning was not possible. While this format can meet some needs, it does not allow for practice and interaction with instructors. There are limited education and training opportunities for burn therapists which include such extensive practical opportunities. This unique didactic training program provided mentorship and tangible skills of a complex and specialized area of burn rehabilitation.

Methods

• Learning Objectives were determined using the Burn Therapist Competency Tool-Version 2

• Developed curriculum for each facial/neck regions as well as various scar management techniques throughout the continuum of care

• Individual modules were developed by Occupational Therapists, Physical Therapist and Speech and Language Pathologist with experience in the field

• The in-person course consisted of 4 hours of lecture and 8 hours of hands-on splinting and scar management training

• Instructors provided interactive and collaborative feedback for every participant Pre & Post testing completed to assess learning

• Feedback from participants was assessed for quality improvement

• Follow up questionnaire was provided to assess implementation into clinical practice and self-perceived level of experience related to rehabilitation of face/neck burns

Results

24 Occupational, Physical and Speech Therapists participated in the 2-day course. Results of the post-test indicate increased knowledge pertaining to the learning objectives. 21 participants remained for the second day of the hands-on splinting and scar management portions and demonstrated learned knowledge of these intervention techniques. Post-course assessments attest to increased comfort with new skills. Participant follow up gaged overall effectiveness of clinical practice improvements.

Conclusions

Participant feedback provided valuable insight into the ongoing need for training and mentoring of burn therapists. This is vital in developing additional training resources, including step-by-step explanation and video content for repetition and learning. Ultimately, implementation of these new skills into each participant’s clinical practice was the desired outcome of this course.

Applicability of Research to Practice

This project highlighted the gap in knowledge for burn therapists when it came to face and neck burns.
705 Evaluation of Invasive Fungal Infections in the Burn ICU
Authors: Pournezhad Sam , Etter Elaina , Mittal Rohit
Published: May 2023

Introduction

Fungal infections are increasingly associated with critical illness, especially in major burn injury. The risk factors of invasive fungal infections include central venous catheter (CVC) placement, mechanical ventilation, broad-spectrum antibiotics, renal replacement therapy (RRT), and total parental nutrition. Critically ill burn patients have additional risk factors including extensive wounds, impaired immune system, and repeated surgical intervention. Despite significant morbidity and mortality caused by invasive fungal infections, efforts to prevent them with antifungal prophylaxis have not improved outcomes. In patients who develop invasive fungal infection, appropriate empiric antifungal therapy is imperative to reduce morbidity and mortality especially in the setting of delayed culture and sensitivity data. The purpose of this study was to characterize risk factors associated with the development of invasive fungal infection, invasive fungal infection organisms and surgical and pharmacological management.

Methods

A retrospective chart review was completed of adult patients admitted to the burn ICU found to have an invasive fungal infection (defined as at least one positive blood or tissue fungal infection and receipt of systemic antifungal therapy). The primary outcome was to identify common fungal organisms. Secondary outcomes included susceptibility pattern of the organism, location of infection, surgical management including debridement and amputation, pharmacological management, median ICU and hospital length of stay, and in hospital mortality.

Results

A total of 10 patients of a goal of 100 patients with a median 54% TBSA burns were evaluated at this time. The most common yeast species included candida albicans; mold species included a variety of organisms such as fusarium, zygomycete and paecilomyces. Common risk factors among these patients included CVC access (57%), mechanical ventilation (43%), and RRT (43%). Yeast infections were primarily treated with anidulafungin and fluconazole, while mold infections were managed with systemic amphotericin as backbone in addition to voriconazole or isavuconazole. Patients underwent aggressive surgical debridement for source control. Median ICU stay was 53 days with a median hospital stay of 63 days, and 42% mortality.

Conclusions

Fungal infections among critically ill burn patients are associated with the high morbidity and mortality rates. Therefore, mitigation of modifiable risk factors is of utmost importance. This retrospective review of common fungal growth in our unit will inform future empiric antifungal management for patients with concern of invasive fungal infections.

Applicability of Research to Practice

Fungal infections present a clinical challenge for burn practitioners, especially in geographically moist areas. Prevention and informed surgical and pharmacological management are key to overcoming this infectious disease threat.
706 Epidemiology, Therapeutic Complexity and Prognostic Challenges of Burns to the Perineum, Buttocks and Genitals
Authors: Hundeshagen Gabriel , Bonaventura Bastian , Runkel Alexander , Tapking Christian , Haug Valentin , Hummedah Kamal , Kneser Ulrich
Published: May 2023

Introduction

Burns that involve the perineum, buttocks and genitals (PBG) have been associated independently with more challenging therapeutic needs and worse clinical outcomes in case series and smaller patient collectives, while large scale epidemiology of this injury is lacking. We studied a cohort of 1024 patients admitted to our burn center to assess clinical outcomes based on the presence of PBG burns.

Methods

Medical records were screened for patients who did or did not sustain PBG burns and patients stratified accordingly (PBG vs. control (CTR)). Demographic baseline data, burn etiology, presence of inhalation injury (IHT), presence of full thickness burns (FT), number of operations (NOR), mortality, length of ICU treatment (LOS ICU) and hospitalization (LOS) were assessed to compare clinical characteristics and outcomes between the groups. Multivariate regression analyses adjusting for TBSA, sex and age were conducted for key clinical outcomes.

Results

Between 2014 and 2022, 1024 patients were included in the analysis (PBG: n=227; CTR: n=797). PBG burns were older (median (IQR) 54 (38) vs. 44, (31) years, p< 0.0001), more frequently female (35% vs. 23%, p=0.002) presented with larger TBSA burns overall (27 (37) vs. 10 (13) %, p< 0.0001) and sustained FT burns more frequently (69% vs. 26% p< 0.0001). Scald burns were more frequently the cause of PBG burns (45% vs. 15%, p< 0.0001), PBG patients needed twice as many surgical procedures (2 (4) vs. 1 (1), p< 0.0001) as CTR. PBG patients remained longer in the ICU per per cent TBSA (0.9 (1.1) vs. 0.5 (0.8) days/%TBSA, p< 0.001). Mortality was higher in patients with PBG burns (33.1% vs. 7.8%, p< 0.0001). Multivariate logistic regression yielded significant effects of PBG burns on LOS ICU, LOS and NOR.

Conclusions

Burns to the perineum, buttocks and genitals are associated with more challenging baseline characteristics upon admission and substantially worse clinical outcomes than burns not involving PBG.

Applicability of Research to Practice

Expectable therapeutic challenges regarding prolonged intensive care, more frequent surgeries and increased risk for mortality should be taken into account and planned for when admitting patients with PBG burns.
711 Analysis of the Risk Factors for Mortality in Elderly Burn Patients
Authors: Yao Wen-Teng , Tung Kwang-Yi , Liu Ying-Jun
Published: May 2023

Introduction

The elderly experience higher mortality rates compared to younger burn patients with similar burn injuries. The aim of this retrospective study was to analyze the clinical factors affecting mortality in elderly burn patients admitted to single burn center.

Methods

Data were collected on all elderly burn patients admitted to Mackay memorial hospital burn center between 2010 to 2020, focused on the population over 60 years old. The demographic data, burn profiles, hospital length of stay, use of mechanical ventilation and inotropic agents, delayed burn-related complication and hospital mortality were studied retrospectively. Both univariate and multivariate analysis were used to identify the risk factors for mortality.

Results

61 elderly burn patients were evaluated and flame was the most common cause of burns(57.4%). All of the burns involved more than 20% of total body surface area. Sixteen patients(26.2%) expired during hospitalization. Univariate analysis showed that the mortality among elderly burn patients was associated with age(P< 0.001), burn surface area(P< 0.001), burn grade(P=0.016), use of inotropic agents(P< 0.001), initial endotracheal tube insertion(P< 0.001) and delayed burn-related acute kidney injury(P< 0.001), sepsis(P< 0.001) as well as pulmonary edema(P< 0.001). We stratified the above risk factors into two subgroups: Initial presenting patient profile(Age, TBSA, Burn grade) and delayed burn-related complication(Acute kidney injury, Sepsis, Pulmonary edema). Multivariate logistic regression was used to analyze the two subgroups. We found that in the initial presenting patient profile subgroup, age(P=0.014) and TBSA(P=0.004) were positively correlated to patient mortality. Conversely, among the burn-related complications subgroup, only sepsis(P=0.002) was the only significant independent factor related to patient mortality.

Conclusions

This study identified key factors that affect mortality among elderly burn patients. Attention should be paid to those elderly burn patients with older age, increased TBSA, or delayed burn-related sepsis due to significantly increased mortality risk.

Applicability of Research to Practice

Classic determinants of burn mortality are age, burn size, and the presence of inhalation injury (Revised Baux score). Several studies revealed that in-hospital complications was one of the strongest mortality predictors after burns. Understanding that sepsis is a major factor for mortality in elderly burn patient, we may improve our quality of care to decrease the mortality rate.
719 Decreased Morbidity in Patients with Hidradenitis Suppurativa Insured by Medicaid or Medicare
Authors: Atayeva Rena , Tiongco Rafael Felix , Caffrey Julie , Cooney Carisa , Lee Jonathan
Published: May 2023

Introduction

Hidradenitis suppurativa (HS) is a chronic condition that is defined by recurring inflammation and fibrosis of intertriginous areas. Patients with HS have had increasing inpatient hospitalization rates over the years. Our study investigates inpatient mortality and morbidity factors in patients with HS by primary payer status. We hypothesized that patients who are uninsured or insured by Medicaid or Medicare will have worse in-hospital mortality rates when compared to those insured by private insurance.

Methods

Using a national database, we performed a cross-sectional study of patients hospitalized from 2017-2019 with a primary diagnosis of HS. The sample size included 12,365 patients with HS. The independent variable was primary payer status, and the dependent variables were age, gender, race, and zip code income quartiles. 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). Statistical analyses were performed to determine frequencies, odds ratios, and significance. Statistical significance was set at p< 0.05. We controlled for the above-defined dependent variables in the logistic regression analysis.

Results

Primary payer status was not associated with inpatient mortality in patients with HS (p=0.092). From 2017-2019, there were a total of five (0.04%) of in-patient mortalities in patients with HS, with all five being insured by Medicaid and occurring in 2017. Compared with private insurance, Medicare was associated with significantly lower incidences of wound dehiscence (aOR=0.21 (0.06-0.70); p=0.011) and longer time from admission to first procedure (mean days=1.85 vs 1.23; p=0.01). Medicaid was associated with significantly lower incidences of infection (aOR=0.21 (0.08-0.58); p=0.002) and longer time from admission to first procedure (mean days=1.73 vs 1.23; p=0.024). The only difference observed in the uninsured, when compared to privately insured, was significantly lower total costs ($10601.78 vs $13658.37; p=0.030).

Conclusions

Our study demonstrates that in patients with HS, inpatient morbidity factors are overall better in those who are publicly insured over those privately insured. However, publicly insured patients face a longer wait to first procedure from admission over those privately insured.

Applicability of Research to Practice

By raising awareness in treatment outcomes and resource utilization for patients with HS in inpatient settings, the medical team caring for these patients can begin to identify reasons for the disparities shown by insurance status.
723 Provincial Burn Mass Casualty Incident Planning: Preliminary Results
Authors: Fuchko Danielle , King-Shier Kathryn , Gabriel Vincent
Published: May 2023

Introduction

Burn mass casualty incident (BMCI) response planning includes involving relevant stakeholders, assessing regional burn care capacity, and addressing the specialized needs of burn patients. An essential component of these processes is an evaluation of existing resources and plans. In this study, a province with three important elements—a singular health authority to plan for, two burn centres, and updated health technology—was selected for evaluation.

Aim

What are the current policies, protocols, and practices that address a provincial response to a BMCI?

Methods

In this ethics approved case study, qualitative description methodology was used for data analysis. Data were gathered from documents outlining the health system response to a mass casualty incident from the health system internal emergency response plans. Health care professionals directly involved in the response were recruited for interviews. Participants were recruited from prehospital emergency management services, hospital emergency departments, inpatient burn units, and a provincial patient transport department. Interviews were conducted online, recorded, and transcribed. Qualitative description was used to code common themes across documents and transcripts.

Results

Thirteen documents and nine participant interviews were included. Only two documents included burn-specific considerations. Current policies and protocols were limited to all-hazards mass casualty incident planning and did not address specialized needs of burn care. Current plans were based on assumptions that all burn patients would be triaged and transported to burn centres and that surge capacity would be adequate to accommodate for increased demands. Prehospital participants (n=3) felt that existing plans would adequately manage a BMCI. Six participants stated the current plans were not sufficient to manage a BMCI. A comprehensive description of the complex health system response to a potential BMCI was obtained. Some major deficiencies identified included a lack of strategies to bolster burn care staffing capacity such as just-in-time training resources for non-burn trained staff or utilization of outpatient burn clinic staff. Considerations for increased operating room and wound care resources were absent.

Conclusions

Current provincial all hazards response plans are not sufficient to support adequate response to a BMCI and need to be amended to address the specialized needs of burn patients. Strategies for expanding capacity such as care of burn patients at non burn facilities and utilization of outpatient clinics must be integrated into future plans.

Applicability of Research to Practice

The provincial health authority needs to support BMCI response planning efforts to better address this unique hazard prior to an incident occurring for best patient outcomes.
740 Implementation and Retrospective Assessment of a Modified Graft Loss Grading System
Authors: Conner Adam , Beaucock Beverly , Khandelwal Anjay , Wilson Mallory , Lewis Lauren , Lou Richard , Elkady Djoni
Published: May 2023

Introduction

Success of split-thickness skin grafting (STSG) is a cornerstone of modern burn care and sets the stage for success in acute, rehabilitative and reconstructive care. Shupp et al, proposed a graft loss grading system, which the authors then modified to reflect true clinical practice and changes in management. Purpose of the quality improvement (QI) project was to design, implement and assess this grading system.

Methods

A modified graft loss grading system was developed and implemented. Burn patients requiring STSG were tracked over a five month period, and initial (first takedown) and subsequent (either outpatient or 7 days after initial assessment) graft loss grades and contributing factors were noted. Assessments were performed an APP and burn surgeon with agreement of an assigned grade. Patient demographic data was recorded.

Results

63 patients underwent 66 STSG procedures during the review period (44 males, 19 females). Average age was 33.3 years (range: 1-86). Average % TBSA burn was 10.2% (range 0.2-67%). Obesity was present in 33.3% of patients, cardiac disease (hypertension, coronary artery disease or congestive heart failure) in 21.2%, DM in 21.2% and 24.2% of patients were active smokers. Flame burns represented the etiology in the majority (51.5%) of patients. Overall, 10 patients (16%) on initial assessment and 18 patients (29%) on subsequent assessment had evidence of graft loss. Etiology of graft loss included wound bed viability - the default etiology (10 patients/55%), infection (3 patients/17%) and hematoma/seroma (4 patients/22%). Of the 18 patients, 5 (28%) required re-grafting. Of patients with graft loss, 89% had a comorbidity including DM (28%) and smoking history (28%). Malnutrition was felt to contribute in 3 (17%) of patients.

Conclusions

A graft loss grading system is a beneficial quality improvement project to characterize the surgical results of burn patients undergoing STSG. This modified grading system better characterizes graft loss outcomes and subsequent changes in management if applicable. Wound bed viability remains a major factor in graft loss, although the majority of these patients had a contributing comorbidity.

Applicability of Research to Practice

Implementation of a graft loss grading system can be a valuable quality improvement tool that can be employed by burn centers to assessment surgical results.
747 Burn Mortality Prediction Model and Communication Tool for Healthcare Providers
Authors: Pangli Harpreet , Raman Karanvir , Papp Anthony
Published: May 2023

Introduction

Communication is a key competency – the effective exchange of information is essential to a physician’s role. Currently, our centre does not have a communication tool to help guide point of care discussions between healthcare providers and during family meetings. Prognostic relationship of the BAUX score and ABSI index should be determined. An objective communication tool that shows predicted mortality, length of stay (LOS), and number of operations, specifically in our hospital using BAUX index and ABSI score will allow patients and healthcare providers to better understand prognosis, course in hospital, and develop appropriate expectations for outcomes in our centre.

Methods

In this cross-sectional study, all burn patients admitted to our Centre from 2012 to June 2022 were retrospectively recruited. Our burn registry was used to extract complete data of patient information including age, gender, %TBSA, burn depth, presence of inhalational injury, need for ventilator support, intensive care unit (ICU) admission days, hospital LOS, BAUX score, rBAUX score, and ABSI index. Patients were divided into three cohorts: all patients without an inhalation injury, a subgroup of smokers with and without an inhalation injury, and all patients with an inhalation injury. For each cohort, a mean LOS in hospital and/or ICU, number of burn operations, and mortality rate per incremental BAUX score and ABSI index was computed.

Results

A total of 839 patients were included, 725 without and 114 (13.6%) with an inhalation injury. A subgroup of patients (n=286) smokers with and without inhalational injury were separately analyzed. With severity of burn and presence of inhalational injury, both BAUX score and ABSI index show an incremental increase in LOS in hospital, number of operations, and increased mortality. Smokers with rBAUX ≥110 had the longest LOS in hospital, 78.4 hospital days and 35 ICU days. Interestingly, all patients with ABSI 6-7 had the longest LOS/%TBSA and those patients who additionally had an inhalational injury had the highest LOS/%TBSA (5.1 days/%TBSA). Increase in BAUX and ABSI did not correlate with increase in LOS/%TBSA. For BAUX ≥ 90 and ABSI ≥ 8, number of operations and mortality exponentially increased.

Conclusions

Patients with BAUX ≥ 90 and ABSI ≥ 8 should be counselled on a complex course in hospital. Higher BAUX and ABSI correlate with increased mean LOS and number of operations but not LOS/%TBSA. Using our Centre’s burn registry, we can predict course in hospital and provide this to patients, family, and healthcare providers before tertiary centre transfer and admission.

Applicability of Research to Practice

An objective communication model showing the burn centre’s mean LOS, LOS/%TBSA, number of operations, and risk of mortality, can help guide physician-patient and physician-healthcare provider communication. This tool will provide realistic burn recovery expectations at admission, family meetings, and when discussing consent.
748 Accidental Thermal Injury From Ignition of Home Oxygen: Is Burn Center Admission Advantageous?
Authors: Bailey John , Werenski Hope , Saraswat Anju , Holmes James , McEathron Rachel , Craig Christopher , Williams Jeff
Published: May 2023

Introduction

Home oxygen therapy is available for the supportive treatment of patients with chronic lung disease. Nevertheless, complications associated with home oxygen use have been well described. The typical injury pattern associated with the accidental ignition of home oxygen does not mandate emergent intubation. However, due to the thermal component of the injury, patients are initially directed towards admission to burn units. The recent stress applied to the healthcare system by COVID-19 has highlighted the potential benefit of flexibility in the disposition of injured patients. In particular, we wanted to determine if there is a demonstrable benefit from admission to an American Burn Association (ABA) verified burn center for patients presenting with home oxygen ignition injuries.

Methods

After obtaining approval from our local Institutional Review Board, we conducted a retrospective review of our institution's ABA-verified burn center database from January 2016 through May 2022. Individual charts were inspected for discrete data points related to the general descriptor of the patient's injuries, comorbidities, and hospital course. Using independent samples t-tests, we compared patients admitted to the burn service with those primarily cared for by non-burn service teams.

Results

We identified 49 adult patients admitted with burn injuries associated with home oxygen use during the study period. These patients were divided into those intubated at or near the time of admission and those managed without intubation. Of the 29 patients intubated on admission, the burn service managed 19 of these patients, and non-burn services managed 10. There were no identified differences in the outcomes of ventilator days, days in the ICU, total length of stay, or mortality between the two groups. Similarly, we examined the 20 patients admitted without intubation. The burn service managed 7 of these patients, and non-burn services managed 13. Again, the two groups had no identified differences in the outcomes of days in the ICU, total length of stay, or mortality.

Conclusions

This single-center review revealed no difference in outcomes between patients cared for in an ABA-verified burn center versus non-burn services for home oxygen ignition injury. From a care perspective and resource utilization, the outcomes appear similar. Further, we note that patients required only brief periods of mechanical ventilation – supportive of the opportunity to avoid intubation in these patients. Prevention efforts, like those in the burn center, need to continue, and further studies must be done to confirm these preliminary findings.

Applicability of Research to Practice

These findings are supportive of potential opportunities to wisely use Burn Center capacity.
756 Effects of Bioengineered Allogeneic Cellular Constructs on Macrophage Phenotype in the Context of Burns
Authors: Hernaez-Estrada Beatriz , Steele Lindsay , Spiller Kara
Published: May 2023

Introduction

The persistent inflammatory and stress responses generate in burn patients have a strong effect on the immune system. Macrophages that are activated in response to burn injuries polarize towards an immunosuppressive phenotype commonly known as M2b. Furthermore, due to sepsis, the chronic exposure to the pro-inflammatory environment also leads to an exhausted macrophage phenotype. Together these effects compromise macrophage behavior that influences the healing outcome. In clinical trials, bioengineered allogeneic cellular constructs (BACCs) have shown potential in promoting healing in patients with deep partial thickness burns. However, the mechanism(s) behind these successful effects are not totally understood yet. For this reason, the aim of this study is to investigate how the crosstalk with the BACC influence different burn-related macrophage phenotype.

Methods

Primary human macrophages (N=4 healthy donors) were co-cultured with the BACC or collagen controls. Macrophages were isolated over 6 days of co-culture and their RNA was extracted for gene expression analysis, and conditioned media was collected to analyze the secretion of proteins. To assess phenotype changes, we performed gene set analysis using single sample gene set enrichment. To investigate changes in the phenotype of macrophages relevant to burn wounds macrophages were polarized to the immune suppressive M2b phenotype or LPS-exhausted phenotypes before co-culturing them with the BACC. Undifferentiated macrophages (M0) were used as controls.

Results

Gene expression analysis revealed a shift in undifferentiated macrophage phenotype towards an M2 phenotype by day 3 and 6 in co-culture as demonstrated by an increase in the expression of multiple M2 genes, including MRC1 and CCL18. Secretory analysis revealed a decrease in the secretory of inflammatory proteins, like interleukin 6.

Conclusions

Collectively these results demonstrate that BACCs promote the transition of macrophage phenotype towards a pro-reparative M2 phenotype which may contribute to the construct’s pro-healing capabilities.

Applicability of Research to Practice

This study provides insight into the mechanism by which BACCs promote healing in the burn wound environment.
760 Building Cold Injury Prevention and Control Strategies with People Who are Experiencing Homelessness
Authors: Orton Caitlin , Gannon Mark , Stewart Barclay , Pham Tam , Mesic Aldina , Carrougher Gretchen
Published: May 2023

Introduction

The incidence of hypothermia and frostbite is increasing given larger numbers of people experiencing homelessness (PEH) across the country. Cold injuries create functional deficits that compound comorbidities of people who already experience disproportionate disability burdens. We collaborated with PEH to identify modifiable cold injury hazards, understand prevention knowledge and first aid techniques, and develop prevention strategies.

Methods

We conducted 12 interviews with PEH with and without lived experience of cold injury. Interviews covered domains of risk factors/hazards, utility of existing educational materials, novel strategies, and acceptable stakeholders for dissemination. Interviews were transcribed and coded by two analysts using both deductive and inductive approaches.

Results

Participants varied in the type (e.g., street, encampment, shelter) and chronicity of homelessness. Six themes emerged: i) PEH are engaged in prevention, ii) there is a need for improved awareness around synergistic risks (e.g., rain, nicotine or amphetamine use, diabetes), iii) existing materials are not sufficiently contextually specific, iv) a narrowly focused prevention and dissemination strategy will not suffice, v) prevention strategies need to be framed within the realities of living homeless, and vi) respect and kindness are integral to successful uptake (Table 1).

Conclusions

Insightful perspectives shared by PEH provided key strategies for cold injury prevention. Prevention strategies must fit into the reality of homelessness, be respectfully delivered, and need to be a collective community effort where voices of PEH are valued.

Applicability of Research to Practice

Themes and specific perspectives uncovered by this study can help clinicians, community service providers, and public health practitioners develop cold injury prevention strategies alongside people with lived experience of homelessness.
761 Albumin to Alkaline Phosphatase Ratio in Burn-Induced Liver Damage
Authors: Ketels Taryn , Hosokawa Patrick , Wiktor Arek , Kovacs Elizabeth , Idrovo Juan
Published: May 2023

Introduction

Liver damage following burn injury is associated with a poor prognosis. Thus, prevention, and early identification, of burn-induced liver damage will improve the outcomes of burn patients. Aspartate-aminotransferase (AST) and alanine-aminotransferase (ALT) help detect liver injury in extensive burns >50% of Total body surface area (TBSA). However, their efficacy may be questionable in burns < 50% TBSA. Clinical reports describe albumin to alkaline phosphatase ratio (AAPR) to predict liver injury and dysfunction more accurately than AST and ALT in pathologies like non-alcoholic fatty liver disease and primary liver tumors. However, this ratio has never been tested in burn victims. Herein, we hypothesize that the AAPR may be more useful in detecting burn-induced liver damage. Given that liver biopsies are invasive methods with several complications, we correlated liver histological findings from a burn injury murine model

Methods

Livers and serum were collected from C57BL/6 8-12 weeks female mice, 1, 2, and 4 days after a 15% TBSA scald burn, n=5/group. Histological findings were scored by a pathologist blindly. Serum liver function tests were measured with a colorimetric method. We also conducted a pilot, prospective observational study on 58 burn patients admitted to the Burn Intensive Care Unit (ICU) to follow AST, ALT, and AAPR values. Furthermore, in an initial survival model, we correlated hospital days of stay with the AAPR values

Results

In our murine model of burn injury, liver damage worsens with time. Compared to postburn day 1 the histological damage score significantly increased by 75% at 4 days postburn. AST and ALT were elevated within the first day; however, their values normalized by day 3 postburn, failing to match the progression of liver injury showed by histology. Comparing postburn day 1 the AAPR significantly decreased by 40% on postburn day 4. The enrolled patients were mostly male (74%), with a median age of 50 and an average TBSA of 9.13%. While AST-ALT did not show significant changes in the first 2 weeks after burn, the AAPR on an initial run of a linear model of day predicting ratio decreased over time by -0.08/day (p=0.006). Moreover, our statistical model detected that the likelihood of discharge from ICU increases with the AAPR ratio (Hazard-Ratio 1.18/0.01 increase ratio p =0.003)

Conclusions

AAPR showed a better correlation of burn-induced liver injury in mice than AST and ALT. AAPR decreases in burn patients and may represent postburn liver alterations. AAPR increase raises the likelihood of ICU discharge

Applicability of Research to Practice

Identification and monitoring of liver injury and dysfunction with new modalities may improve the outcome of burn patients