bluuebunny/crossref_metadata_2025 huggingface dataset:
46 Inhibition of Lipolysis with Acipimox Targets Post-burn White Adipose Browning by Altering Macrophage Polarity
Authors: Barayan Dalia , Vinaik Roohi , Jeschke Marc G
Published: March 2020

Introduction

Severe burns are accompanied by a detrimental hypermetabolic stress response that can persist for years post-injury. Our previous work revealed that, under prolonged stress, white adipose tissue (WAT) adopts brown adipose-like traits in a process termed ‘browning’. This switch, characterized by the presence of uncoupling protein 1 (UCP1), is driven by the polarization of macrophages towards an M2 phenotype. Recently, we demonstrated that inhibiting lipolysis with the clinically approved drug, Acipimox, represses the burn-induced thermogenic activation of WAT. These findings raise the possibility that elevated rates of lipolysis may play a role in regulating the macrophage polarization state after major burn. However, the interconnection between post-burn lipolysis and inflammation remains unclear. In the present study, we investigated the mechanism underlying Acipimox’s inhibitory effects on burn-induced browning. Using a mouse model of thermal injury, we determine the metabolic effects of reducing WAT lipolysis on burn-induced macrophage recruitment and M2-polarization.

Methods

Adult C57BL/6 mice received a 30% total body surface area scald burn. Mice were then given daily intraperitoneal injections of APX (50 mg/Kg). On day 7 post-burn, the inguinal adipose tissue depot (iWAT) was harvested for histological analyses. Flow cytometry and F4/80 staining were used to assess adipose macrophage distribution and profile, and gene expression was analyzed via qPCR.

Results

APX administration significantly increased mitochondrial coupling, reflected by the decrease in UCP-1 (p< 0.05) and PGC-1a (p< 0.01) levels relative to the iWAT of untreated burn mice. F4/80 immunostaining of iWAT demonstrated decreased macrophage recruitment in Acipimox treated mice (p< 0.05). Flow cytometric analysis indicated decreased macrophage infiltration at 7 days in Acipimox treated mice (p< 0.05). Furthermore, iWAT from Acipimox treated mice demonstrated a pro-inflammatory profile, indicated by a greater distribution of TLR4 positive macrophages (p< 0.05).

Conclusions

Previously, we showed that the administration of Acipimox effectively suppressed PKA-mediated lipolysis and improved mitochondrial coupling in adipose tissue post-burn. Here, we elucidate the mechanism underlying these metabolic changes. Importantly, we show Acipimox exerts its inhibitory effects on burn-induced WAT browning by directly modulating macrophage recruitment and the M2-polarization state.

Applicability of Research to Practice

Our study highlights the critical role of lipolysis in mediating the key post-burn metabolic phenomena browning and inflammation. The data presented herein validate the pharmacological inhibition of lipolysis as a potentially powerful therapeutic strategy to counteract the detrimental metabolic effects induced by burn.
124 Virtual Reality for Reducing Pain and Perioperative Anxiety in Pediatric Burn Patients
Authors: Schwartz Heather J , Fagan Shawn , Craft-Coffman Beretta , Truelove Christopher A , Mullins Robert F
Published: March 2020

Introduction

One of the most traumatizing and frightening experiences a child can experience is to sustain a burn injury. As a result, the child may experience excruciating pain and anxiety. The objective of this quality improvement project is use virtual reality as a nonpharmacologic intervention for pain and anxiety control and compare to traditional distractions methods.

Methods

There were 46 subjects ages 4 to 20 enrolled in a sample of convenience. Participants were given either virtual reality or distraction for dressing changes or minor surgical procedures. Before and after the surgical procedure or dressing change, the participants, their parent and nursing staff completed a Modified Yale Perioperative Anxiety Scale (mYPAS, Faces, Legs, Activity, Cry, and Consolability (FLACC) scale or Numeric Rating System (NRS).

Results

There was no significant difference in FLACC, NRS, and mYPAS scale scores pre-treatment. The post treatment NRS scores were significantly different between distraction and virtual reality (p= 0.031). FLACC scores for the distraction group increased 3.5-fold, while the virtual reality group scores decreased (p.0.0008). Mean mYPAS scores decreased again showing a significant difference between distraction and virtual reality with p= 0.004. The score increased with distraction and decreased with virtual reality with a difference of 12. In all cases virtual reality was better than distraction, when measuring pain and anxiety.

Conclusions

This QI project demonstrates that VR was more effective in reducing both pain and anxiety in burned pediatric patients as opposed to traditional distraction post treatment. Traditional distraction unfortunately was shown to increase both pain and anxiety post treatment. These conclusions suggest that VR may be utilized as a non-pharmacologic treatment option in conjunction with standard treatment to help decrease pain and anxiety in acutely burned children.

Applicability of Research to Practice

This study increases the knowledge base and advances the evidence-based practice of advanced practice registered nurses in the specialty of burn care. It suggests that a non-pharmacologic intervention such as virtual reality can be used to effectively reduce pain and anxiety in children who are undergoing treatment for their burn injury.
126 Multimodal Analgesia and Discharge Opioid Requirements in Burn Patients
Authors: Lee Jin A , Wright Michael
Published: March 2020

Introduction

Analgesia in burn patients is significantly challenging given the complexity of burn pain. Opioids are a mainstay of therapy, but studies demonstrate varying outcomes with respect to the efficacy of adjunctive non-opioid agents in the treatment of burn pain. The need for analgesia extends beyond hospital admission—given the known risks of opioids, the impact of multimodal analgesia on opioid requirements post-discharge needs to be further elucidated in this population.

Methods

In this retrospective, single-center cohort study, adult burn patients who were consecutively admitted to the burn ICU service and subsequently followed in the burn clinic between 2/2015 and 9/2018 were evaluated up to 6 months post-discharge. The subjects were divided into two cohorts based on discharge pain regimens: multimodal vs non-multimodal. Individuals taking long-acting opioids prior to admission were excluded. The primary outcome was the change in oral morphine equivalents (OME) between discharge and follow up occurring between 2 - 6 weeks post-discharge. Secondary outcomes included the number of multimodal agents utilized and a comparison of OME between the last 24 hours of admission and discharge.

Results

A total of 152 patients were included for analysis (n= 76 per cohort). The multimodal cohort demonstrated increased total body surface area burned (23.9% ± 15.4 vs 16.6% ± 7.1; p < 0.001) and prolonged number of days spent in the ICU (22.7 ± 23.1 vs 10.7 ± 8.9; p < 0.001). The change in OME from discharge to first follow up was -106.6 mg in the multimodal vs -75.4 mg in the non-multimodal cohort (p = 0.039; figure 1). In each cohort, discharge OME did not statistically differ from last 24 hour OME (multimodal: p = 0.067; non-multimodal: p = 0.537). The most common non-opioid agents utilized were acetaminophen and gabapentin.

Conclusions

Despite extended ICU length of stay and larger TBSA, burn patients discharged with multimodal pain regimens demonstrated a statistically significant reduction in oral morphine equivalents from discharge to first follow up compared to those discharged on opioid-only regimens.

Applicability of Research to Practice

This study demonstrates promising results with respect to lowering discharge opioid requirements by utilizing a multimodal analgesic approach in the management of burn pain.
505 Burn Sepsis: Does the Initial Vitamin C Level Matter?
Authors: Williams Jeffrey W , Craig Christopher K , Saraswat Anju , Holmes James H
Published: March 2020

Introduction

After the first 24 hours, the principle cause of death in burn patients is multiple organ dysfunction/failure syndrome. It is preceded by infection in 83% of burn patients, with reported septic mortality up to 65%. In a recent journal article involving septic medical ICU patients, Marik et al. reports that all initial Vitamin C levels were below the normal range (0.4–2.0 mg/dL) prior to any intervention. Independent of each other, both early recognition and treatment of infection and vitamin C have been shown to be beneficial in sepsis. We monitored Vitamin C levels as part of our “Burn Code Sepsis” algorithm to obtain a baseline understanding of Vitamin C levels in infected adult burn patients.

Methods

Adult (≥18 yo) admissions between 7/1/2018 – 6/30/2019 were identified from our Burn Registry and all sepsis screens were evaluated in the EMR. Patients were screened clinically at least BID and were considered a “positive” screen if MAP < 65 mmHg (SBP< 90 mmHg) or if 2 of the 3 occurred: Temp >102.2F; HR >120; RR >28 (or RR >10% of ventilator set rate if set rate is >24 bpm). A positive screen prompted lab work to include CBC, BMP, procalcitonin (PCT), lactic acid (LA) and Vitamin C (VC), per protocol. If PCT >3.0 ng/ml or LA >2.0 mmol/L, or both thrombocytopenia and hyperglycemia were present, a “Burn Code Sepsis” was initiated and included cultures, a CXR, and empiric antibiotics. If the cultures were positive or the CXR demonstrated an infectious process, a patient was considered “septic”. All burn injured patients with greater than or equal to 20% TBSA burns receive Vitamin C supplementation as part of our standard of care.

Results

There were 286 admissions during the 12-month period, with 38 positive initial sepsis screens (mean TBSA = 35%) that have an associated VC level. Of these positive screens, 26 (65%) were infected and 12 (35%) were not infected. ROC Curve analysis of VC levels and its ability to diagnose septic patients yields an AUC = 0.60 (p = 0.37). The mean VC level of infected patients at the time of initial screening was 1.9 +/- 1.4 mg/dL, and the mean VC level of non-infected patients at initial screening was 1.5 +/- 1.0 mg/dL.

Conclusions

Our results contrast with the previously published article on Vitamin C levels in a septic, non-burn injured population. Only 1 of 26 infected patients possessed a Vitamin C level below the normal range (0.4–2.0 mg/dL). Infected patients possessed higher Vitamin C levels than the non-infected patients, though not statistically significant (p = 0.35). AUC analysis indicates Vitamin C level is a poor prognostic test for sepsis.

Applicability of Research to Practice

Further research on Vitamin C levels and Its role in sepsis in the burn injured population is warranted.
570 Who Benefits the Most from Burn Camps?
Authors: Radics-Johnson Jennifer B , Chacon Daniel W , Zhang Li
Published: March 2020

Introduction

Burn camps provide a unique environment and activities for children that have experienced a burn-injury. Positive outcomes from attending burn camp include increased self-esteem, decreased feelings of isolation and a greater sense of self-confidence. In a 3-year retrospective review of camper evaluations from one of the largest and longest running week-long burn camps in the nation for ages 5–17, we aimed to assess if a child’s gender, age, TBSA or ethnicity affected the impact that burn camp had on a child.

Methods

A 3-year retrospective review of a Burn Camp’s camper evaluation forms was conducted for campers that attended burn camp between 2017–2019. Camp rosters were reviewed to determine the camper gender, age, TBSA and ethnicity. Camper self-evaluation forms completed at the end of each camp session were reviewed to record camper responses to questions regarding their opinions on the impact camp had on them as well as how camp will impact their lives once they return home. Categorical variables were summarized as frequency and percentage, and continuous variables were describes as median and range. To check the relationship between two categorical variables, Chi-square test was used. To compare the continuous variable among groups, Kruskal-Wallis ANOVA was used. Statistical significance was declared based on a p value< 0.5.

Results

Within 2017–2019, there were 413 camper records. Participants’ demographic characteristics are summarized in Table 1. There were 208 males (50.3%) and 205 females (49.6%). The median age of campers were 11.86, 12.44 and 12.45 for 2017–2019, with the range from 5.16 years to 17.96 years. The median TBSA were 20, 20 and 18 for 2017–2019, with the range from 0.08 to 90. Collectively there were 47.7% Hispanic (n= 197); 24.2% Whites (n=100); 13.1% Black (n= 54); 4.6% Asian (n=19) and 7.7% Other (n=32).

There were 395 camper self-evaluation forms submitted. Results of three questions there we were interested in are summarized collectively in Table 2. 57% of campers responded, “Yes, Definitely” to the question “After going to this event, will you feel more comfortable being around your classmates or friends?” 54% responded, “ Yes, Definitely” to the question “Do you feel more confident in sharing your burn story with others when returning home?” and 51% responded “Yes, Definitely” to “Did you learn anything that will help you when you return home?”

Conclusions

In analyzing the camper responses, there was no statistically significant difference in responses comparing gender, age, TBSA or ethnicity.

Applicability of Research to Practice

Research shows that burn camps have a positive effect on burn survivors including improving self-esteem, self-confidence and social skills. This study shows that burn camp is beneficial to burn survivors of varying gender, age, TBSA or ethnicity.
581 Basecamp: Burn Efficiency Care Pathway
Authors: Blayney Carolyn B , Gibran Nicole S
Published: March 2020

Introduction

Standardizing care has shown in the literature to be a means to improving the culture of safety in any field. Aligning burn surgeons, staff and ancillary services in the Burn ICU, Burn Acute Care floor, Burn Clinic who all have varying ideas, and plans of care creates toxic variation and communication challenges for bedside staff. While attending a medical center leadership development session, Burn Center Leadership collaborated on a project regarding burn center standardization.

Methods

A multidisciplinary Burn Center retreat in September 2017, launched the effort with a special emphasis on patient and family participation.We elicited feedback on what we did well and areas we could improve on. Using crowdsourcing methodology, the group selected 5 core QI/PI areas: resuscitation, wound care, pain/anxiety/delirium, physical mobility and psychosocial needs.Each multidisciplinary group, led by a non-physician chair and a Physician liaison established assigned tasks, rules of engagement and time frames. Work groups met weekly and reported progress to the Burn center QI committee.The project concluded with dissemination of the work products to staff. Patients and families were updated on the progress made to ensure we were still in alignment with our original goals.

Results

Burn Center orientation materials, standard operating practice documents and a Burn Center Standard of Care packet was developed. Documents were uploaded to a commonly accessible Burn Center Sharepoint website so there was one central source of information. The final BasECamP output was a daily checklist packet started on all BICU admits, that addressed key QI indicators and directives for care goals; 24 hr resuscitation guidelines, time to TF vs PO within 4 hrs of admit, daily weights, IV vs PO medication for wound care, time to first active mobility and a review of ICU and Hospital LOS per %TBSA.

71 adult burn patients >18 years admitted to the BICU between November 2018 and May 2019 were started on the pathway. Of the 71, 58 were admitted with a burn injury, 4 with TEN, 6 were burn post-ops and there were 3 deaths. The 58 new burn admits are reviewed below.

Conclusions

The BaSeCamP packet is turned in and reviewed with the team. Data shows significant improvement in knowledge of standard operating procedures, expectations and resource availability. With improved communication across the burn team, staff more clearly understand patient-specific expectations in burn care and are more easily able to educate patients and families about the plan.

Applicability of Research to Practice

This Process improvement project responds to patient and family feedback that burn teams must coordinate communication and eliminate variability in delivery of care.
596 ICU Sedation Practices for Mechanically Ventilated Burn Patients Following Guideline Implementation
Authors: Anderson Jeffrey H , Mandell Samuel P
Published: March 2020

Introduction

Our American Burn Association verified regional burn center has approximately 700 admissions for burn injury per year, 200 of which are admitted to the burn intensive care unit (BICU). Sedation practices during acute burn resuscitations remain variable. In order to standardize our sedation practices, we developed a Background Pain and Anxiety Decision Tree for Mechanically Intubated Adults in March 2017. Concern over hypotension led to the removal of propofol as the sedative of choice. The new protocol made midazolam the primary choice and recommended the use of adjunct analgesics, including acetaminophen, for background pain. It uses the Richmond Agitation Sedation Scale (RASS) to determine whether patients were oversedated (RASS< 0) or anxious (RASS >1+).

Methods

We conducted a single center retrospective chart review on intubated patients admitted to the BICU from November 2017 through November 2018. Data collection focused primarily on sedation practices during this time to determine whether our protocol had the desired effects. Highest and lowest RASS were collected, and the difference between the two (delta RASS) was used to determine changes in patient agitation and sedation.

Results

Thirty three adult patients requiring mechanical ventilation were admitted to the BICU between November 2017 and November 2018. Of these patients, 21 (66%) received propofol on hospital day one, and 12 (38%) received propofol on hospital day two. Eleven patients received both propofol and midazolam on hospital day one. Of these patients, the average propofol dose was 511 micrograms per day and the average midazolam dose was 13.3mg per day (p=0.02). Eighteen (56%) and twenty five (78%) patients received acetaminophen on hospital days one and two, respectively. Twenty four patients had a RASS recorded during their first hospital day. The average highest RASS recorded was 1.3 and the average lowest recorded RASS was -3.2. Patients who received both propofol and midazolam had a higher peak RASS (2.4) and a lower minimum RASS (3.4), creating a larger delta RASS for this group.

Conclusions

Despite eliminating propofol from our sedation guidelines, its use remains the predominant mode of sedation for burn patients throughout the first forty eight hours of hospitalization. There is also room for improvement for administration of non-opioid analgesics, including acetaminophen. Finally, our ventilated patients tend to be more oversedated than undersedated, and a combination of midazolam and propofol creates the largest swings in patients’ sedation and agitation status.

Applicability of Research to Practice

Changing sedation and pain management practices in the ICU is a multifactorial process that requires more than ICU guideline implementation. The use of two sedatives during the first hospital day can result in larger swings in RASS as opposed to use of a single agent.
614 Staff Nurse Retention in a Growing Advanced Burn and Wound Clinic Through Implementing a Hiring Best Practice: Peer Interview as a Successful Change Process Managerial Approach
Authors: Prestifilippo Kathleen M , Webb Emily , Mullins Robert F , Fagan Shawn , Hassan Zaheed , Homsombath Bounthavy , Craft-Coffman Beretta , Currington Cynthia , Whalen Meganjoy
Published: March 2020

Introduction

In recent decades, healthcare administrators and nurse managers have been challenged with identifying qualified candidates for patient care positions, and then to retain these personnel. The entire process of onboarding the right candidate requires time, money and resources on various levels. When the approach is from a top-down managerial style, it is not always accepted and therefore, is not always successful. Peer interviewing has been identified as a hiring best practice and can contribute to lowering the cost of recruitment, decreasing loss of time to screen and interview and contributes to higher employee morale. To distribute resources and thus save money and time, we adopted this approach to hiring during a critical time of growth and development of a large advanced burn and wound center.

Methods

Results

Conclusions

Applicability of Research to Practice

Sharing best practices and outcomes with other clinicians helps foster standardization and validation of care among peers.
617 Changing Onboarding to Increase Retention
Authors: Ladwig Melanie R
Published: March 2020

Introduction

Faced with some failed orientations and an increase in turnover, the Burn unit decided to change our orientation plan. There were 4 RNs who left or failed orientation in a period of a few months. The help of our practice council and feedback from preceptors was enlisted. In addition, the ABA Nursing Competencies were incorporated to revamp the orientation program. Most RNs onboarding to burn are not critical care RNs upon hire and therefore required an improved pathway to orient them to the burn care as well as critical care management.

Methods

Typical orientation started in the ICU. However, feedback following our traditional path led to specific changes based on the need to emphasize a sense of community as well as integrate specific time management skills particular to burn care. Orienting burn nurses now spend 12 shifts in the burn unit, 24–30 in the ICU, and then another 12–18 in the Burn unit. In addition, the staff taught Burn Care Principles course was restructured by practice council members and educators to focus on a case study-based learning style to emphasize important aspects of burn care. An in-situ simulation component to the Burn Care principles course was added to further solidify their learning. The competency tools used in orientation were changed to incorporate the American Burn Association Nurse competencies.

Results

Turnover was decreased from 33% (2017–2018) to 7.7% (2019). Preceptors and new RNs state they felt much more competent to begin their journey as a burn RNs the potential cost savings related to decreasing turnover would be well over $75,000.

Conclusions

The interventions made were staff driven by the orientees and preceptors, the practice council, and staff on the unit. the change in orientation allowed for less extensions and more successes. Burn RNs were more confident and less overwhelmed during their orientation. The team morale improved with their involvement with the process which was an added win.

Applicability of Research to Practice

This process needs to be followed so be able to ascertain if there will be lasting effects to retention.
648 Direct Comparison of Fractional Carbon Dioxide Lasers Systems: Ablative Well Properties and Healing
Authors: Powell Heather M , Baumann Molly E , McFarland Kevin L , Zuccaro Jennifer , Blackstone Britani N , Bailey John Kevin , Supp Dorothy M , Fish Joel
Published: March 2020

Introduction

Ablative lasers are a common tool for burn scar remodeling with numerous commercially available systems, each with varying capabilities. Among fractional CO2 (FXCO2) laser systems, the same nomenclature is utilized to describe properties of the laser including beam fluence and fractional coverage. Despite identical laser settings for these properties, the outcomes in two patient cohorts utilizing two different FXCO2 laser systems were notably different. As a result, a direct comparison of ablative wells, fractional coverage and healing between the two systems was conducted using ex-vivo and porcine models.

Methods

An ex-vivo study comparing fractional coverage settings (1%, 3%, and 5%) between the two different FXCO2 laser systems was first carried out (all measurements were obtained by a blinded rater using a high-powered microscope to quantify ablative area). Porcine skin was then treated with the two systems at 10–70 mJ. To compare ablative well properties, biopsies were collected and serial sectioned with the deepest/widest point of each well calculated from the histological section using ImageJ. Fractional coverage for each laser system was quantified for three different settings: 70 mJ 1%, 70 mJ 5%, and 30 mJ 5%. Finally, re-epithelialization rate (as measured by transepidermal water loss), erythema and expression of genes encoding inflammatory cytokines were quantified in a porcine burn model prior to and at multiple time points following treatment with both laser systems (70 mJ, 5% fractional coverage).

Results

The two laser systems produced significantly different ablative wells. In the ex-vivo study, the fractional coverage measurements obtained differed from those provided by the manufacturer by 1.6 - 8.9%. In the porcine study, at 70 mJ, the ablative wells created from system 1 were deep and narrow, on average 1251 + 183 µm deep and 142 + 32 µm wide whereas wells from system 2 were shallow and wide, 374 + 44 µm deep and 267 + 35 µm wide. Following treatment, scars treated with system 2 re-established barrier function within 7 days whereas scars treated with system 1 re-established within 4 days. A significant increase in gene expression for IL-6 was observed in both systems at 1-hour post laser. Expression levels returned to baseline in system 2 by 24 hours whereas a return to baseline was not observed until the 96-hour time point for system 2.

Conclusions

While different FXCO2 laser systems utilize the same nomenclature for user selected properties, the same settings are not equivalent between systems resulting in significantly different ablative wells and downstream healing.

Applicability of Research to Practice

Laser systems should not be considered interchangeable despite being programmed for the same settings.
657 Preliminary Study on the Effect of Various Antimicrobial Formulations Containing Silver Oxynitrate on Reducing Pseudomonas Aeruginosa Using an in-vivo Porcine Burn Wound Model
Authors: Davis Stephen C , Gil Joel , Solis Michael , Higa Alex
Published: March 2020

Introduction

Silver has long been known for its antimicrobial effects and has been commonly applied topically to burn wounds for years. More recently, wound dressings compounded with silver ions, have been developed to prevent and treat wound infection in both burn and chronic wounds.

Methods

This preliminary study evaluates the effect of a proprietary silver oxynitrate creams on Pseudomonas aeruginosa (PA) biofilms using a well-established burn wound porcine model model. Swine were used due to their skins similarities to humans and response to wound treatments. Briefly, second degree burn wounds were created and inoculated with PA. Wounds were then covered for 24 hours with a polyurethane dressing to allow for biofilm formation. The polyurethane dressing was removed and wounds were randomly assigned to one of the following treatment groups: 1) silver oxynitrate cream 0%, 2) silver oxynitrate cream 4%, 3) silver oxynitrate cream 7%, 4) silver oxynitrate cream * 10%, 5) silver oxynitrate powder, 6) silver sulfadiazine cream (SSD)~, or 7) untreated control. All treatments groups were covered with a polyurethane dressing to prevent any cross contamination. On days 3 and 7 after wounding wounds were cultured using an established scrub technique.

Results

Silver oxynitrate powder was the most effective treatment group at reducing PA counts. Silver oxynitrate 10% formulation had a high percentage of bacterial reduction. On day 7, compared to untreated control the silver oxynitrate 4, 7 and 10% treatments showed a 3.45, 4.05, and 4.30 log CFU/ml reduction, respectively.

Conclusions

These studies suggest that the silver oxynitrate formulations can reduce the bacterial bioburden in vivo against wounds that have PA biofilms. Additional animals are needed to substantiate these findings.

Applicability of Research to Practice

Gram-negative bacteria such as PA pose a challenge for wound care practitioners and new effective therapies are needed.
727 Use of a Biodegradable Dermal Matrix in Conjunction with Meshed and Sprayed Autologous Cell Suspension with a Vacuum Assisted Dressing Achieved Limb Salvage in a 73 Year Old with Deep Full Thickness Burns Despite Exposed Tendon and Bone
Authors: Olivi Joe , Rodgers Megan
Published: March 2020

Introduction

Deep Full thickness burns require tangential excision of the burned tissues down to viable tissue. This often leaves exposed muscle, tendon and bone. Coverage of these areas is vital to limb salvage. Multiple modalities are necessary with these type of patients, such as, dermal matrix graft, split thickness skin graft, sprayed autologous cell suspension (ACS) and wound vacuum therapy(VAC). A dermal matrix provides a scaffold for tissue and vascular en growth that is suitable for accepting a skin graft and also provides a layer between the muscle, tendon, bone and the skin graft which improves movement and produces a more pliable graft.

Biodegradable temporizing matrix(BTM), produced by PolyNovo Ltd, was used to cover the muscle, bone and tendon. This product has a silicone backing which can be delaminated once it has matured with tissue and vascular en growth for auto grafting.

A combination of a wide meshed skin graft at 3:1 ratio and a sprayed ACS allows for faster healing and less donor site usage which decreases the overall wound burden.

Methods

A 73 y/o male with total body surface area burn of 24 % suffered deep full thickness burns to the bilateral lower legs. He underwent multiple debridements with management of the right leg with irrigating wound vacuum therapy. The deeper right leg had a wound base with that consisted of muscle from the thigh down onto the foot with exposed tendons and anterior tibial bone. The open wounds to the right leg were grafted with BTM for dermal substitute coverage. Once the BTM was mature it was delaminated, and the wound surface was covered with a 3:1 ratio split thickness skin graft (STSG) and sprayed on autologous cell suspension. This resulted in using less donor skin than a 1.5 or 2:1 meshed graft STSG which decreased his wound burden. Donor sites were also sprayed with ACS.

Results

We had nearly 100% take of the STSG and sprayed autologous suspension epidermal graft. There was a small area over the patella tendon where the BTM did not incorporate. This is though to be because of lack of immobilization of his knee and a pseudomonal infection.

Donor sites healed faster and there were minimal open areas to the graft POD 11 excluding the patella area.

Conclusions

BTM can be used to provide a suitable dermal substitute in complex wounds when muscle, tendon and/or bone are exposed.

Immobilization of the joints is necessary to allow the tissue en growth into the dermal matrix. Wide meshed graft with sprayed ACS can be used with good results with wound vacuum therapy.

Decreased wound burden and time to heal open wounds of the graft and donor sites.

Applicability of Research to Practice

Use of a dermal matrix, wide mesh split thickness graft and sprayed epidermal ACS with wound vacuum therapy is a good option for limb salvage when vital structures are exposed.
745 Pediatric Burn Transfers: A 10 Year Analysis of Adherence to ABA Transfer Criteria
Authors: Roller Janine , Courtemanche Rebecca , Bucevska Marija , Hynes Sally
Published: March 2020

Introduction

Severe burn injuries require complex care at certified burn centres to minimize morbidity and mortality. The ABA Burn Centre Referral Criteria was developed to aid clinicians in determining which patients warrant transfer as physician comfort with the management of pediatric burns, accurate estimation of TBSA, and burn depth varies. We hypothesize that pediatric patients are often transferred despite not meeting referral criteria. The aim of this study was to review pediatric patients with burn injuries that were transferred to the provincial burn centre over the past 10 years to better understand the reasons for the transfer.

Methods

A 10-year retrospective review from January 2008 to December 2018 was performed using the provincial Burn Registry. Pediatric burn patients under 18 years old who were transferred for burn care were identified and their demographics, burn characteristics, and the basis for transfer was analyzed against the ABA Burn Referral Criteria.

Results

A total of 130 pediatric burn patients were transferred from 42 different hospitals of varying trauma levels. Patients on average were 5 years old, predominantly male (59%), and scalds were the most common etiology (53%). Most patients were transferred by a fixed-wing ambulance (54%) and the average transport time was 1.5 days after the initial injury. All children met 1 or more ABA Referral Criteria for transfer. The most common reasons for transfer were for a TBSA greater than 10% (42.2%), burn to the hand (27.7%) or perineum (11.5%), 3° burn depth (12.3%), or significant pre-existing medical disorders (9.2%).

Conclusions

Over the past 10 years, all pediatric burn patients met ABA Burn Centre Referral Criteria based on TBSA, burn depth and burn location alone. This study is limited in that we were not able to capture all pediatric burn patients to identify those that warranted a referral but were not transferred.

Applicability of Research to Practice

The results indicate that burn-related transfers to the provincial burn centre were appropriate. The dissemination of this information to the referring centres may serve to reinforce these positive referral patterns. Furthermore, this audit provides insight into the geographic origins of pediatric burn referrals in the province to help direct burn prevention and physician education efforts, as well as resources for initial burn care and post-discharge rehabilitation services.
771 Psychiatric Illness Among Burn Patients: Experience at a Single ABA Verified Burn Center
Authors: Komak Spogmai , Cross James
Published: March 2020

Introduction

Burn injury is uniquely characterized by the initial traumatic event in addition to the psychiatric component associated with physical change and recovery. Recent work has highlighted the importance of pre-existing psychiatric illness on both recovery and final outcomes in burn patients (Tarrier et al 2005, Hudson et al 2017, Wisely et al 2009). We examined the prevalence and association of psychiatric illness in our ABA verified burn unit. Knowledge of this information is critical in allocation of limited resources aimed toward addressing both the physical and mental aspect of burn injury.

Methods

The burn registry at a single verified burn center was examined from July 2017-July 2018. All consecutive burn patients with psychiatric illness who were admitted were included. Psychiatric illness was broken down into: depression, anxiety, bipolar disorder, schizophrenia and delirium. Need for psychiatric consultation, %TBSA, length of hospital stay, and operative intervention was also examined.

Results

416 patients were admitted during the study period—44 pts (10.5%) had a psychiatric diagnosis on admission. Seventy-five percent of pts were male. The average TBSA burned was 15.3%. Seventy-five percent of patients required psychiatric consultation, and 57% required operative intervention (Table 1). The most common psychiatric condition was anxiety (50%), followed by depression (36%), bipolar disorder (27%), schizophrenia (23%), and delirium (18%). Forty-eight percent of patients had multiple (>1) psychiatric conditions. Female patients had a significant less TBSA burn (5.8%) vs. male (18.2%), P=.001, as well as a shorter LOS (12.1 dys vs. 31.5 dys) p=.004.

Conclusions

The association between burn injury and pre-existing psychiatric illness is well known (Hudson et al 2017, Wisely et al 2009). We found that over 10% of pts admitted to our burn unit had a psychiatric diagnosis, and a large number of these required further inpatient psychiatry consultation. More than half of patients required operative intervention indicating that severity of burn injury was high, with optimization of pre-existing conditions especially important. Additionally, psychiatric illness did not occur in isolation--48% of pts had >1 psychiatric diagnosis —a finding which has implications for resource allocation for mental health/ dedicated psychiatrist for burn patients.

Applicability of Research to Practice

Implications for resource allocations for dedicated burn psychiatrist/ resources for mental health.
781 Evaluation of the online-presence of ABA-verified burn centers
Authors: Branski Ludwik , Tapking Christian , Hundeshagen Gabriel , Popp Daniel , Houschyar Khosrow , Haug Valentin , Kneser Ulrich , Hirche Christoph R
Published: March 2020

Introduction

Currently, patients seek health-care information online. An up-to-date online presence is vital for success among the competition amid hospitals. Hospital websites have become an important medium to communicate with patients, provide information about certain diseases/conditions and advertise healthcare services. This study aims to evaluate burn centers websites verified by the American Burn Association (ABA).

Methods

The online presence of the 73 ABA-verified burn centers was evaluated according to criteria previously published by Benedikt et al. This included general information on burns, first aid, treatment at the burn unit, research, and education. ABA verified burn centers were then compared to 48 German-speaking burn centers evaluated by Benedikt et al.

Results

Online information about patient care including treatment options and techniques was more often present in ABA-verified burn centers. However, this information was still provided in only half of the websites. Furthermore, ABA-verified burn centers more often used multimedia-based elements and social media platforms. On the other hand, German-speaking burn centers more often provided translations, general information (e.g. staff, ward) about the burn center as well as research and education.

Conclusions

This study demonstrates that although many burn centers have well-designed websites, relevant burn-related information on patient care, research and education is often missing or sparse. Today, most patients look for health-care information online. Also, applicants for residency or fellowship programs tend to get a first picture of their potential employer on websites or social media.

Applicability of Research to Practice

Keeping websites and social media up-to-date and informative can improve recruitment of patients and employees.
799 Free Transportation for Socioeconomically Disadvantaged Burn Patients: Quality Improvement Project
Authors: Perez Laura , Castro Rebecca , Wolf Steven E , Lee Jong
Published: March 2020

Introduction

Our Burn Center provides care to persons living in southeast area of our State. Patients residing in this area sometimes have low socioeconomic status (SES), and are often unable to return to burn clinic for continued care due to transportation barriers. Typically driving distance is over 80 miles involving ferry access, taking two or more hours each way. The aim of this quality improvement project was to examine the feasibility of a free transportation program for low SES patients who have barriers to transportation.

Methods

Our first step was to assess transportation needs. We started with a patient survey in clinic to determine if patients would be interested in free transportation and if the service would increase access to care. Survey with six questions was used to assess needs.

Results

We surveyed ten patients during burn clinic to determine if transportation would increase access to care. Nine patients responded positively and found transportation would be beneficial. One responded that he would not use it as he would use clinic appointment as opportunity to vacation in the area.

Funding was secured from our School of Medicine. Community transportation providers were contacted and pricing was obtained. Transportation van was contracted with existing vender. Transportation is now available to patients with burn clinic appointments. We hope to expand to other clinics in the hospital in the future. The Transportation program will assist patients with access to care, compliance, decrease non-emergent Emergency Department visits and 30-day readmissions.

Conclusions

Transportation assistance for socioeconomically disadvantaged burn patients to follow up in clinic is needed. Nine out of ten patients surveyed were willing to use free transportation. We obtained funding to start a free transportation program once a month. This project began in October 2019.

We have begun a once-a-month transportation assistance service to determine ridership and continued need. Twice monthly assistance may be needed and will be assessed over time. Our goal is ultimately to expand the program to include other clinics.

Applicability of Research to Practice

Free transportation program can assist patients with access to care, compliance, and decrease non-emergent Emergency Department visits and 30-day readmissions.
803 Utilizing the Revised Baux Score as a Trigger for Advanced Care Planning with the Palliative Care Team
Authors: Littlepage Carrie , Strait Eli , Cabrera Jeremy , Lee Jeanne
Published: March 2020

Introduction

The objectives of this performance improvement project is to facilitate earlier goals of care discussions led by the Palliative Care team for burn patients with a high risk of mortality, and to improve overall communication with families of patients. The Advanced Care Planning Trigger Tool utilizes the Revised Baux Score, a burn mortality scoring system, which is calculated by adding the patient’s age, total body surface area (TBSA) of the patient’s burn as a whole number, and adding an additional 17 points if the patient has an inhalation injury. From January 1st, 2017 to June 1st, 2018 16 patients were admitted to the Burn Center with a Revised Baux Score of over 100. Of those 16 patients, 11 passed away due to their injuries during admission, equaling a 69% mortality. Palliative Care consults were triggered for 4 out of the 16 patients (25%), and all 4 of these patients passed away during their hospital stay.

Methods

Revised Baux Score is calculated on each new burn admission. A consult to the Palliative Care Team for Advanced Care Planning is triggered within 48 hours of admission, if a patient’s Revised Baux Score is above 110 and they are greater than 60 years old; or any adult patient (over 18 years old) with a score of 130 or greater.

Results

The project was implemented in June of 2018. This tool led to an increase in Palliative Care team involvement early on for patients with a high risk of mortality from their burn injury, more effective care planning discussions with families and improved collaboration between the Burn team and Palliative Care team.

Conclusions

All patients with a Revised Baux Score that triggered the Advanced Care Planning Tool for a consult were ordered palliative care consults within 48 hours of admission.

Applicability of Research to Practice

Advanced Care Planning with the Palliative Care team leads to increased communication and more effective care planning for patients with a high risk of mortality.
810 Routine Psychosocial Screening and Follow-up of Adult Burn Patients in an Outpatient Clinic
Authors: Tiani Alaina , Williford Desiree N , Jackson Carrie B , Durkin Kristine , Langholz Ariana , Hajduk Gina , Aballay Ariel , Duncan Christina
Published: March 2020

Introduction

Sustaining a burn injury is associated with increased risk of mental health issues, and common among these are depression, anxiety, post-traumatic stress disorder (PTSD), and substance use. Unfortunately, less than half of these adult burn survivors receive services related to their mental health concerns. Moreover, few studies have examined the routine implementation of a psychosocial screener in an outpatient burn clinic setting, and there is a paucity of research which examines how to proceed when patients endorse symptomology. The aim of the current study is to report on outcomes of a routine psychosocial screener in a sample of adult burn survivors and patient response to brief psychological consultation at initial screen and 1-month follow-up.

Methods

A psychosocial screener was developed and implemented (October 2016-August 2019) in an outpatient burn clinic to identify patients who endorse clinically significant psychosocial distress. Comprised of very brief, validated scales (and their clinical cut-off scores), the screener assessed for safety at home, suicidal risk, depression, anxiety, and substance use. Adult burn survivors completed the questionnaire at their first outpatient appointment. Patients who endorsed safety concerns at home and/or suicidal ideation/risk were immediately evaluated by a physician or psychology staff. Those who endorsed significant distress, but no suicidal or safety risk, were contacted by psychology staff within one week of the screener date. Those who did not indicate significant clinically significant distress did not require further action.

Results

Of the 393 patients who completed the screener, 102 individuals (26%) indicated clinically significant mental/behavioral distress. Psychology staff were able to reach 80 patients (78%) for initial brief consultation (i.e., within one week). Of those contacted, 14 (18%) indicated that they were already receiving psychological services, 25 (31%) reported they were not interested in a psychological referral, 20 (25%) accepted a new referral for psychological services, and 19 (24%) endorsed minimal or decreased symptoms. In February 2019, we began to conduct 1-month follow-up. A total of 19 individuals were eligible (had positive screens) and 8 (42%) were reached. Of those reached, 2 (25%) accepted a new psychological referral, 2 (25%) indicated no interest in a referral, and 3 (37%) reported minimal/no psychological symptoms.

Conclusions

Implementing a psychosocial screener is a feasible way to screen for distress in outpatients.

Applicability of Research to Practice

A 1-month follow-up contact helps staff to understand whether referrals are utilized or how symptoms may change over time and yields another opportunity to provide referrals to those previously uninterested.