bluuebunny/crossref_metadata_2025 huggingface dataset:
511 Mobilization with Femoral Catheters in the Burn Intensive Care Unit: A Case Series
Authors: O'Neil Audrey , Rush Cassandra , Roggy David , Hartman Brett
Published: May 2023

Introduction

Femoral catheters are a known barrier for ICU therapy sessions and mobility progression due to the anatomical location and potential risk of complications. Safety and feasibility of mobilization has been studied in ICU populations but has not been explored specifically within the burn population. Burn survivors in the ICU have challenges in terms of line access and are at high risk of complications concerning thrombosis A previous retrospective study found that 21% of mobility sessions within the burn ICU on vented patients were limited due to line limitations. This case review was completed following implementation of new mobility guidelines allowing the mobilization of patients with femoral catheters within the burn ICU.

Methods

This retrospective case series was completed in the first year following implementation of new femoral catheter mobility guidelines within a 15-bed adult burn unit. Burn therapy notes were reviewed for burn admissions with at least one femoral catheter in place, including arterial and central lines. Mobility was recorded based on achieved activity levels achieved during each session. Passive interventions (stretching, ROM, and positioning) were excluded.

Results

13 patients were admitted with a total of 55 femoral catheters (8 arterial, 46 central venous) treated. Patients were seen by PT and OT for a combined 417 sessions with lines in place. A total of 65 active therapy sessions occurred with 112 mobility activities including bed exercises/cycle ergometry (11), chair mode (13), cardiac chair transfer (28), tilt table (1), sitting on the side of the bed (32), standing (15), active chair transfers (8), and ambulation (4). No catheter related complications including catheter malfunctions, removal, bleeding, or thrombosis occurred during any therapy sessions.

Conclusions

Active therapy sessions including out of bed activities are safe and feasible in burn ICU patients with femoral catheters. Early mobilization within ICU settings is necessary in preventing complications, combating muscle wasting, and improving long term outcomes for survivors. This study supports that the presence of femoral catheters alone should not limit the progression of mobility interventions.

Applicability of Research to Practice

Using clinical judgement and specialty training, burn therapists can safely mobilize burn ICU patients with femoral catheters in place.
515 Retrospective Review of Silver Sulfadiazine use in Sulfa Allergic Patients at a Regional Burn Center
Authors: Gemayel Kristina , McLaughlin Mariel , Laun Jake , Smith David
Published: May 2023

Introduction

Plastic Surgeons are commonly called upon to evaluate wounds. Most wounds in otherwise healthy individuals will heal with minimal intervention, however in patients with comorbid conditions and systemic disease the incidence of nonhealing wounds is much more prevalent. Silver sulfadiazine is the most common topical antimicrobial used in burn management. Current literature recommends avoiding the use of silver sulfadiazine in burn patients with sulfa allergies. The intent of this retrospective review is to examine the safety of silver sulfadiazine use in documented sulfa allergic burn patients at a level one trauma hospital and regional burn center.

Methods

After obtaining IRB approval for electronic chart review of patients who were treated with silver sulfadiazine, charts were reviewed and exclusion criteria applied. Patients included in the study had documented burns treated by burn team providers, application of topical silver sulfadiazine for primary burn management, and a documented sulfa allergy. Chart review identified 70 patients who met the stated criteria out of 2,644 patients treated over a five year period.

Results

None of the 70 patients with documented sulfa allergies suffered adverse reactions to silver sulfadiazine use for primary burn care. There were no documented systemic or anaphylactic reactions, hives, or additional adverse reactions after administration. No cessation of the medication was documented due to intolerance.

Conclusions

Silver sulfadiazine is a common topical antimicrobial treatment in acute burn care. It has previously been avoided in patients with documented sulfa allergy due to concern for cross reactivity. However, in this population of patients, there were no documented adverse reactions to topical silver sulfadiazine. This study suggests that withholding topical sulfonamides from patients with prior reactions to antibacterial sulfonamides may not be clinically justified.

Applicability of Research to Practice

We present evidence in our retrospective review that administration of topical silver sulfadiazine for primary burn care can be done in a safe manner, without adverse allergic reactions.
522 Safe Use of Thrombolytic Therapy for Severe Frostbite in Pediatric Patients
Authors: McCormick Melanie , Miotke Sam , Lacey Alexandra
Published: May 2023

Introduction

Frostbite in children is very rare with few citations in the literature. Thrombolytic therapy is commonly used to salvage threatened tissue in frostbitten adults, but there is little to no data on the use of such therapy in children. The aim of this case series is to advance our understanding of pediatric frostbite by describing risk factors and outcomes, as well as commenting on the safety of thrombolytic therapy in this population. To our knowledge, thrombolytic therapy has not been studied in children, and this is the largest case series of pediatric frostbite to date.

Methods

This is a retrospective, single-center study reviewing cases of pediatric (< 14 years) frostbite from 2006-2022. Thirteen patients (6 males and 7 females) were found to fit inclusion criteria, and data was collected from the electronic medical record.

Results

A total of thirteen cases were reviewed. Nine patients were managed conservatively with diligent local wound cares, while four were prescribed thrombolytic therapy in an attempt at tissue salvage. Two patients underwent intravenous thrombolytic therapy, and two underwent intra-arterial thrombolytic therapy; there were no complications in either group. We also reviewed patient demographics. Thirty-eight percent of patients were documented as Black or African American, 23% Asian, 23% Caucasian, and 8% Hispanic or Latino. The remainder were unlisted. Notably, 31% of the children had trouble with communication (whether foreign speaking or non-verbal). None of the patients had a positive EtOH or urine drug screen. All of the children were poorly supervised when the frostbite occurred. Outcomes were as follows: 69% were completely healed upon follow up, 23% had very severe frostbite injury upon arrival with significant tissue loss likely requiring amputation (but did not return for follow up), and 8% never followed up.

Conclusions

The use of thrombolytics for the treatment of frostbite injury appears to be safe in children. We have found that risk factors for frostbite in this population include an inability to communicate and poor supervision at the time of injury.

Applicability of Research to Practice

We have been able to safely treat children presenting with severe frostbite injury with thrombolytic therapy. This work is highly applicable to practice. Specifically, the ability to administer intravenous thrombolytic therapy is nearly ubiquitous. This can be done at referring hospitals if there are issues with inclement weather or transportation that would delay transfer to a verified burn center.
523 Retrospective Application of Guidelines for Referral to Palliative Care for Persons Who Have Been Burned
Authors: Grossoehme Daniel , Bish Brianna , Lou Richard , Khandelwal Anjay , Brown Miraides , Brown Carrie , Teo Esther , Friebert Sarah
Published: May 2023

Introduction

Palliative Care (PC) is a limited resource, requiring allocation to those most likely to benefit. One currently underserved population is persons sustaining burns, as these injuries may severely limit quality of life, psychosocial and physical health. Additionally, treatment decisions must frequently be made on an emergent basis on behalf of someone unable to participate in decision making. PC services could benefit patients and caregivers substantially, yet only 2% of persons who have been burned are referred to PC. We developed empirically-derived referral criteria; the purpose of this study was to quantify the sensitivity, specificity, and predictive value of the criteria when retrospectively applied.

Methods

Retrospective review of regional burn center admissions (1/1/2019-1/31/2022) to determine adherence to criteria indicating referral to PC should be made or considered. Descriptive statistics characterizing the sample and criteria performance were calculated.

Results

N=388 admissions occurred study period (29.9% female; mean(SD) age=39.9 (24.1) years. N=28 persons were referred to PC; n=27 met consult criteria, and n=1 met consider criteria. Criteria for PC consultation indicated referral for n=62, and had 0.96 sensitivity, 0.90 specificity, 0.44 positive predictive value, 1.00 negative predictive value, 0.91 total accuracy. Criteria for considering PC consultation were indicated for n=181 and had 1.00 sensitivity, 0.45 specificity, 0.01 positive predictive value, 1.00 negative predictive value, 0.45 total accuracy.

Conclusions

Criteria for PC consultation were sensitive and specific, though the positive predictive value was low. Criteria for consideration show low values; however, documentation did not reveal whether referral was considered or not. Presence of comorbidities was the most commonly-met criterion for referral consideration. Despite the robust sample size, data from a single site may have limited generalizability. Criteria have promising characteristics, may be used as basis for quality improvement efforts, and merit ongoing study and revision to improve predictive ability.

Applicability of Research to Practice

These criteria advance clinical practice by providing guidance on identifying persons most likely to benefit from specialist PC.
536 Firework Injuries in Pediatric Patients: A 15 Year Review
Authors: Johnston Mark , Altamirano Heidi , Miotke Sam
Published: May 2023

Introduction

The United States Consumer Product Safety Commission (CPSC) estimated that 15,600 firework-related injuries were treated in US hospital emergency departments during calendar year 2020 and that there has been a trend of increased injuries from 2005-2020. The goal of this project was to look at the experience of one center with a large referral network, to identify trends and opportunities.

Methods

A retrospective chart review was performed to analyze data points including mechanism, age, sex, TBSA, injury locations, procedures performed, outcomes and complications length of stay, and services involved. The burn registry was utilized to identify cases throughout a 15-year period.

Results

During this period, 24 pediatric patients required admission for firework injuries. Eighty-four percent were males compared to 16% in females. Most injuries (67%) occurred while the patient was holding the firework and lighting it as opposed to being struck by a firework. Most of the injuries had small TBSA percentages (84% < TBSA of 15). In addition, most were referred from outside facilities. Most common sites of injury included the hands and face, followed by the eyes. Sixty percent of patients required operative intervention for their injuries, some requiring multiple surgeries. The average length of stay was 2 days, while 8 patients stayed longer than 5 days. Ninety-two percent were admitted to the burn service with additional specialty consultants. Most children required multiple follow up visits.

Conclusions

Firework related injuries in children result in significant injury often requiring surgical procedures along with a long outpatient treatment course. This work highlights a need for continued advocacy, education, an intervention. This program uses a curriculum and process for children who are injured due to setting fires. The program is evaluating a similar model of intervention and 1:1 counseling for children injured due to fireworks.

Applicability of Research to Practice

This project is applicable to practice as it highlights the continued opportunity for intervention and prevention for firework related injuries. The trends are not decreasing, and the injuries are significant. Evaluation of a model for youth who have fireworks related injuries, similar to the youth fire-setting program, would be a beneficial next step.
548 Volatile Sedation in the Burn Intensive Care Unit: A Quality Improvement Initiative
Authors: Nardi Julie , Wong Lauren , Rogers Alan
Published: May 2023

Introduction

Achieving optimal sedation and analgesia in patients with major burn injuries can be challenging. Reliance on benzodiazepines results in longer durations of mechanical ventilation, delirium and withdrawal. Recent evidence and local experience in our critical care unit has supported the application of volatile agents such as isoflurane for sedation. A local audit determined that 70% of mechanically ventilated patients in our burn center are managed on 3 or more continuous sedative infusions. The aim of this initiative was to reduce the number of continuous sedative infusions to maintain target sedation range (SAS 2-4) by 25% in the 48 hour period following initiation of isoflurane.

Methods

A multifaceted education approach was applied to engage all bedside staff, including burn surgeons, respiratory therapists and nurses. Training occurred though self-directed modules, in-person learning and just-in-time training upon new patient initiation. Data from the 18 month period since implementation were collected retrospectively via manual chart review.

Results

Since implementation in March 2021, 18 patients were sedated using isoflurane in our burn intensive care unit (ICU). Within 48 hours of isoflurane initiation, 50% (9/18) of patients had a decrease in the number of sedative infusions and 56% (10/18) obtained an optimal level of sedation using isoflurane and hydromorphone alone.

Conclusions

Volatile agents provide a safe and reliable method of sedation in mechanically ventilated patients with major burn injuries. Despite limitations related to specialized equipment and training, the introduction of this strategy has been well received, with positive feedback relating to both ease of implementation and titration.

Applicability of Research to Practice

Patients with major burn injuries require multiple painful surgeries and dressing changes. Volatile sedation has been shown to reduce the number of sedative infusions, specifically, our reliance on benzodiazepines.
550 Retrospective Review of Fluid Resuscitation and Associated Complications for Adults in a Large Burn Center
Authors: Richerbach Stacey , Nikjou Devin , Osborn Suzanne , Dobbe Van , Kesler Natalie , Islas Claudia , Richey Karen , Foster Kevin
Published: May 2023

Introduction

The foundation for burn fluid resuscitation is well established, however an opportunity exists to improve outcomes for patients requiring such intervention. Resuscitation is influenced by a variety of factors, including associated complications. The purpose of this study was to establish a baseline at our center using historical performance and outcomes to drive quality improvement initiatives.

Methods

This was a retrospective chart review of patients admitted over a five-year period requiring resuscitation. Due to factors, such as early enactment of comfort care, patients who expired < 48 hours of injury were excluded.

Results

Charts were reviewed for 346 patients with a total body surface area (TBSA) >20%, 297 were adults. Of these, 32 died < 48-hours post-injury and 127 did not undergo fluid resuscitation or complete records were not available. Thus 138 were evaluable. Averages at admission were age 44.9, weight 86.4 kg and TBSA 39%. Most patients were male (71%). Mechanism was predominantly flame (86%), followed by 7% scald, 3% contact, 2% electrical, and 1% chemical. Concomitant inhalation injury was diagnosed for 34%. Average hourly fluid resuscitation volume was 6.5mL/kg/TBSA with a duration of 31.8 hours. Total volume exceeded Parkland formula calculations for 80%. Continuous albumin was administered for 97%, initiated on average at 8 hours post-injury. Boluses of lactated ringer’s and albumin were administered for 43% and 36% of patients, respectively. Urine output averaged 91 mL/hr and we identified a mean low optimal urine output of 43.2 mL/hr and mean high optimal output of 69.1 mL/hr.

Associated complications during fluid resuscitation included temperature < 36◦C (58%), vasopressor administration (12%), intra-abdominal pressure >12 (59%) and/or >19 (14%), and peripheral vascular pulses < +1 (70%). Escharotomy was performed for 42%; 32% preventative, 2% required subsequent fasciotomy. Laparotomy/open abdomen was performed for 7.9%. Diagnosed complications were low for compartment syndrome (9.5%), abdominal compartment syndrome (6.5%), and acute respiratory distress syndrome (1.4%). Continuous renal replacement therapy was initiated for 11.5% of patients < 48 hours post-burn and for 22.4% >48 hours; 25% requiring CRRT had a dialysis or renal history. The overall survival rate for this population was 76.1%. Patients were discharged most often to rehab (37%), home (19%), or skilled nursing facility (12%).

Conclusions

A baseline for resuscitation in our center revealed a rate double historically accepted rates. Despite nonconformity with tradition, complications remain low. Outcomes have been favorable, yet opportunity for improvement endures.

Applicability of Research to Practice

Further research is needed to evaluate the predictive value of assessment measures to forecast associated complications.
566 Posterior Spinal Cord Syndrome after High Voltage Electrical Injury
Authors: Rodgers Ariel , Thompson Callie , Murphy Daniel , Fleming Irma , Lewis Giavonni , LaChapelle Christopher , Hobson Greg
Published: May 2023

Introduction

High voltage electrical injuries have been called “the grand masquerader”, and significant neurological sequalae have been described. Here, we report the case of a 73-year-old man who sustained a 14.5% total body surface area (TBSA) full thickness electrical burns, most significantly to his scalp (Figure 1). On initial evaluation, there was concern for loss of proprioception resulting in gait instability. A magnetic resonance image (MRI) of the cervical spine performed on post injury day 9 showed no evidence of cervical spinal cord injury.

Methods

A novel descriptive case report of a high-voltage electrical injury with incomplete spinal cord injury

Results

The patient underwent several operative interventions for wound coverage and preservation of function with the known challenges experienced with high voltage burn wounds. Despite lack of imaging confirmation, suspicion for an occult neurological injury remained high. Neurological consultation confirmed limited proprioception and loss of 2-point discrimination. Due to these specific findings that resulted in an inability to make significant rehabilitation gains, a subsequent MRI of his cervical spine performed on post-injury day 30 demonstrated T2 hyperintensity in the dorsal column in the cervical spine at the C2-3 and C5-6 levels, suggestive of myelopathy (Figure 2).

Conclusions

To our knowledge, this is the first reported case of an incomplete spinal cord injury (posterior spinal cord syndrome in this case) due to an electrical injury without bony abnormality the association of paralysis. With the knowledge of this injury, our burn therapists have been able to develop a rehabilitation plan with reasonable expectation and goals. While discussing prognosis with the patient and his family, we noted the absence of data regarding outcomes after injuries of this nature and sought to contribute to the literature with this case.

Applicability of Research to Practice

A novel case of delayed imaging confirmation of posterior cord syndrome contributes to the body of evidence for neurological sequelae due to electrical injuries.
571 Effectiveness of Compression Garments with Silicone versus Compression Garments Alone on Hypertrophic Scar
Authors: Robertson Karen , Wang David , Tran Khoa , Yun Ejun , Stevens Katelyn , Hartman Brett
Published: May 2023

Introduction

Only a few studies have looked at the effects of custom compression garments with silicone sheeting sewn into the garments versus garments alone on scar management. This retrospective study hypothesizes that garments with silicone will improve the Modified Vancouver Scar Scale (mVSS) total scores and sub-scores of pliability, vascularity and height of hypertrophic scars(HTS) when compared to garments alone.

Methods

This is a retrospective study of patients that were autografted or required >21 days to heal and placed in compression garments with or without silicone between 2013 and 2020. Charts were reviewed and mVSS scores from 91 patients with 191 scar locations (134 silicone/57 non-silicone) were collected at 1,3,6,9,12 months. Descriptive statistics were used to describe the sample characteristics. The mean mVSS score and mean sub-scores for pliability, height and vascularity were computed at 1,3,6,9,12 months and reported for the silicone and non-silicone groups.

Results

When comparing the two groups at 9-months (with 45% of initial scars scored), the silicone group had a greater decrease in numerical value and overall % change from 1 to 9-months as compared to the non-silicone group in all areas. The results at 12-months (with 30% of initial scars scored) demonstrated the non-silicone group had a greater decrease in numerical value and % change in height and overall score. Pliability had a 25% improvement in silicone group compared to 16% change in non-silicone group. Vascularity % change was similar with a 47% change in non-silicone group and 46% change in silicone group. The scars in silicone group that were analyzed at 12-months were consistently scored higher across prior months. 

Conclusions

Silicone group demonstrated improved %change in all categories at 9-months and in pliability %change at 12-months despite the decreased sample size. Pliability is improved with the use of silicone garments. Although the 12-month %change in mean for height, vascularity and total score did not show improvement over non-silicone, this reflects the return patients having significant scarring throughout treatment and needing continued interventions. These returning patients had scars in the non-silicone group as well that were also rated resulting in the disparity in the groups. The patients in the silicone group with improved scars did not continue follow-up at 12-months. Further research with focus on 9-18 month follow-up mVSS scores is warranted.

Applicability of Research to Practice

Effectiveness of adding silicone to garments in scar treatment.
710 Assessing the Impact of Prone Positioning Among Adult Burn Patients with Acute Respiratory Distress Syndrome
Authors: Nemec Hannah , Cheng Abigail , Chestovich Paul , Saquib Syed , Fraser Douglas , Flores Carmen , Ho Joshua , Batra Kavita
Published: May 2023

Introduction

Critically-ill burn patients are at high risk for extensive adverse systemic complications due to the severe inflammatory reaction following deep thermal injury. A common but dangerous pulmonary complication associated with deep burns is acute respiratory distress syndrome (ARDS), with incidence and mortality ranging up to 24% and 31%, respectively. Prone positioning (PP) as a means of improving mortality in patients with ARDS has become more widely utilized. However, PP is not well described in the burn population and remains controversial due to the risk of wound complications. We hypothesize that PP in burn patients with ARDS would improve mortality compared to non-prone (NP) patients without adverse outcomes.

Methods

Retrospective data were collected for all burn patients with ARDS from 2018-21. A total of 7 patients who underwent prone positioning (PP) were matched via TBSA, age, and gender 1:2 with 14 patients not proned (NP). Categorical variables were presented as count (percentage) and continuous variables presented as mean (SD). P values were two-sided and P< 0.05 significant.

Results

A total of 58 adult burn patients with ARDS were identified from the burn registry between the years of 2018-2021 and 7 of these were identified as having been treated with PP. Matching was completed to identify 14 NP burn patients with ARDS. Characteristics of these groups are shown in Table 1. The PP patients had significantly higher APACHE II scores, airway pressure release ventilation (APRV) usage, and tracheostomy placement. For the PP patients, mean days to ARDS diagnosis from injury was 4.7±2.6, mean days to PP from ARDS diagnosis was 4.1±6.0, and total days prone was 4.3±3.5. P/F ratios for both the PP and NP groups are shown in Figure 1. P/F ratios for the PP group were declining prior to PP and increased after PP. P/F ratios for the NP group gradually improved without PP. There was no difference in mortality between the two groups (PP=42.8%,NP=57.1%,p=0.6) despite the significantly increased APACHE II scores. No wound complications were noted in the PP group.

Conclusions

ARDS remains a significant cause of mortality in burn patients. The PP patients had similar mortality compared to the NP group despite a two-fold increased expected mortality estimated by the Apache II scores. None of the PP patients had wound complications due to PP. PP appears to be a safe and useful adjunct therapy for burn patients with severe ARDS.

Applicability of Research to Practice

ARDS is a significant cause of mortality in severe burn patients, this study evaluates PP as a treatment.
713 Acute Change in qSOFA Score as a Prognostic Tool for Diagnosing Sepsis in Burn Patients
Authors: Avery Emma , Zhu Jane , Rehou Sarah , Sharohki Shahriar
Published: May 2023

Introduction

Sepsis is a diagnostic challenge in all critically ill patients, but particularly so in the burn patient population. The objective of this study was to evaluate if the modified sepsis-3 criteria defined as an acute change in SOFA score ≥2 was predictive of clinical infection.

Methods

The hospital database was reviewed between 2016 and 2019 to identify patients who received broad spectrum antibiotics within 2 days of sustaining their injury. Culture specimens taken at the time of antibiotic administration determined presence of a clinical infection.

Results

Between 2016 and 2019, a total of 98 patients were admitted to the burn unit within 2 days of their injury and received prophylactic meropenum and/or piperacillin/tazobactam for suspicion of clinical infection. When stratified based on an acute change in SOFA score within 48 hours prior to receiving antibiotics, 67 (72%) patients received antibiotics with an acute change in SOFA score ≤1, and 26 (27%) patients received antibiotics with an acute change in SOFA score ≥2. Of those patients with the acute change in SOFA score ≥2, 22 patients (85%) had positive cultures associated with the timing of prophylactic antibiotics, as compared to 60 patients (90%) with a change in SOFA score ≤1 (p value 0.05).

Conclusions

Our data suggests that the modified sepsis-3 criteria is not a reliable tool for diagnosing burn sepsis.

Applicability of Research to Practice

Improving our ability to accurately predict sepsis in burn patients can improve patient outcomes and decrease unnecessary administration of broad spectrum antibiotics.
714 Actinomyces Necrotizing Soft Tissue Infections: A Case Series from a Single Institution
Authors: Lewis Aislinn , Prazak Ann Marie , Thompson Callie
Published: May 2023

Introduction

Necrotizing soft tissue infections (NSTI) are rare, severe infections that can lead to septic shock. NSTI have a mortality rate of 20-50% in patients who require intensive care. Management includes surgical debridement and broad-spectrum antibiotics until definitive culture results. Actinomyces is a slow-growing bacterium found in the mouth, skin, genitourinary, and gastrointestinal tracts, with several case reports of actinomyces related NSTI. At this single institution, NSTI are managed by burn surgeons. The goal of this study is to quantify patients with actinomyces-related infections, identify modifiable risk factors, and demonstrate the pharmacology of effective antibiotic treatment.

Methods

All patients with actinomyces-related infections admitted to a single institution’s burn center from January 2020 to September 2022 were included. Patients were identified via the institution’s data warehouse. Patient demographics, infection location, associated injuries or illnesses, antibiotic exposure, and treatments required were obtained. Results were recorded and compared using descriptive statistical analysis.

Results

A total of 22 patients with actinomyces infections were identified, 18 with NSTI and 4 with non-NSTI infections (1 hidradenitis suppurativa, 1 Job’s syndrome, and 2 burn-related). Average age was 50.3 years old, and 68% of patients were male. Seventy-four percent of patients were obese, and average BMI for obese patients was 40.3 kg/m2. Fourteen NSTI patients had diabetes or pre-diabetes (mean A1c 9.4%), and two were taking a sodium-glucose co-transporter 2 inhibitor. All NSTI patients underwent surgical debridement and broad-spectrum antibiotic treatment. The groin was the most common site of infection. Time from collection of sample to culture resulting with Actinomyces was 44 to 185 hours (mean 111 hours). Species isolated were A. europaeus, A. radingae, A. turicensis, A. odontolyticus, and A. funkei. Three of the NSTI patients died. Among NSTI survivors, average length of stay was 34 days, duration of antibiotics was 10.7 days (6 to 16 days), and 50% of patients were de-escalated to either ampicillin/sulbactam, or ertapenem.

Conclusions

To our knowledge this is the largest single institutional series to date for patients affected by Actinomyces related NSTI. The high percentage of patients with diabetes, 73% of NSTI patients, suggests an increased susceptibility to infection for these patients. A variety of Actinomyces isolates are present in NSTI. The mortality rate (17%) of these ICU admitted NSTI patients agrees with prior studies.

Applicability of Research to Practice

Novel findings of actinomyces infection in NSTI patients
720 Transcultural Collaboration in Burn Mass Casualty Response Under Austere Conditions
Authors: Arbour Richard
Published: May 2023

Introduction

Burn mass-casualty incidents (BMCI) overwhelm local resources challenging communication, triage, basic care provision and education of non-burn specialist personnel. This is more acute in austere conditions such as the recent international BMCI in November, 2021, in an extremely resource-limited developing country. Greater than 250 severely burned survivors overwhelmed local resources requiring an international response. Effective burn care dictated adapting to austere conditions, educating local providers and cultural competence, vital to teaching and obtaining feedback in ways meaningful to host providers and building burn care capacity.

Methods

Needs assessment showed local healthcare providers needed burn care education focused on wound care, fluid management, pain management and assessment. Cultural competence/cultural humility were integral in avoiding ethnocentrism and collaboration barriers. Understanding local language and communication styles (including nonverbal cues) was prioritized. Pre-test/post-test measured baseline burn care knowledge vs. education efficacy. Lecture/discussion, case study, clinical application and class participation were used to disseminate content. Attention was paid to pace of content discussion and nonverbal indications of understanding as English was not the learners first language. Pacing/terminology was adjusted to optimize understanding. Meaningful recognition was accomplished by public congratulations and formal completion certificates.

Results

Pre-test: Number of students-57; high score-80%; low score-27.5%; average score-53.9%. Content was presented as described in methods section and supplemented with bedside instruction. Post-test: Number of students-38; high score-95%; low score-55%; average score-79.3%. Almost immediately, many participants framed and posted their completion certificates and quickly utilized education content when delivering care.

Conclusions

Optimal interdisciplinary/international collaboration for burn care and education in austere conditions mandates cultural humility and a spirit of inquiry on the part of international guest providers to best understand cultural norms in host countries. A spirit of inquiry on local communication and cultural nuances is integral to optimal collaboration, education and building effective local burn care capacity.

Applicability of Research to Practice

When providing care internationally in austere settings, proactive cultural humility, understanding local cultural and communications nuances and developing education/content delivery that can be readily utilized in addressing critical needs is essential. Meaningful recognition for healthcare team members in host countries develops good will and helps build capacity to continue providing health care upon conclusion of the immediate crisis.
732 Economic and Environmental Benefits of Telemedicine Expansion
Authors: Miotke Sam , Oxton Emily
Published: May 2023

Introduction

The COVID-19 pandemic mandated a robust expansion of our program’s telemedicine bandwidth. Despite the lifting of pandemic restrictions, the number of telemedicine visits has stayed consistent, which is a credit to both the quality of care provided and to the convenience of receiving care via computer or smartphone. We sought to quantify some aspects of this convenience to more thoroughly understand the benefits of our program's expansion.

Methods

We examined home addresses for all patients seen via telemedicine from June, 2021 through May, 2022. We estimated the distance that telemedicine saved each patient by searching a navigation website for the most time efficient route from their hometown to our burn center. Patients who lived in the same city as our center were assigned a distance of 1 mile. Hours saved were estimated by assuming a driving speed of 70 miles per hour. Fuel money saved was estimated by assuming an average fuel economy of 24.2 miles per gallon and an average gas price of $3.61. The overall carbon footprint was estimated by assuming an average CO2 emission of 411 grams/mile.

Results

1,794 patient visits were conducted via telemedicine over this 12 month span. The total estimated amount of roundtrip travel saved was 621,718 miles which equated to 8,882 hours and $92,744 dollars saved. The carbon footprint saved was 255.5 metric tonnes. On average, our telemedicine program saved an estimated 4.95 hours and $51.70 in gasoline per patient-visit.

Conclusions

Even when ignoring the potential hurdles of transportation access, family care, missed time at work, and parking fees there are clear quantifiable reasons behind the program’s popularity. The environmental benefit is an important byproduct of its convenience.

Applicability of Research to Practice

Our telemedicine program requires dedicated staffing and significant patience with technology but has remained popular due to the outlined advantages and has facilitated the expansion of our program into a broader catchment area.
741 Implementation and Effectiveness Outcomes of Geriatric Burn Bundle at a Regional Burn Center
Authors: Pham Tam , Blayney Carolyn , O'Connell Kathleen , Oehlers Julia , Stewart Barclay , Arbabi Saman , Tucker D Andrew
Published: May 2023

Introduction

Strong evidence supports geriatric consultation and targeted management in the care of older injured patients. We developed and implemented a geriatric care bundle that includes clinical frailty screening, mini-nutritional assessment and feeding protocol, and reduction in initial prescribed opiate doses for patients ≥65 years. Clinical frailty scores and co-morbidities trigger consultation to geriatric and palliative care services rather than chronological age. We sought to evaluate process adherence, length of stay (LOS) and mortality as measures of bundle implementation and effectiveness.

Methods

We performed a retrospective medical record review of older burn-injured patients aged ≥65 years hospitalized at a regional burn center over the first two years of implementation (July 2019 to June 2021). We reviewed patient and injury characteristics. Primary outcome was adherence to specific bundle components: clinical frailty scale (CFS-9) and mini-nutritional screening rates, and geriatric and palliative consultation rates, stratified by implementation year. Secondary outcomes included LOS and mortality.

Results

All 127 older adult patients admitted to the acute burn service were analyzed. Median age was 71 years (IQR67-78), median burn size was 6% TBSA (IQR2-13), median frailty score was 3 (IQR3-4), and median mini nutrition score was 11 (IQR9-14). CFS-9 scoring and mini nutrition completion rates, as well as geriatric service consultations increased over 2 years (Table). In contrast, palliative care consults decreased over 2 years (from 34% to 16%). LOS and mortality decreased each year from 9 to 7 days and 14 to 10%, respectively.

Conclusions

Implementation of a geriatric burn bundle demonstrated a sustained increase in utilization of geriatric focused interventions, tailored to patients most likely to benefit based on frailty and comorbidities. Electronic medical records system integration during the initial implementation phase of the geriatric burn bundle was effective in obtaining high compliance and completion rates. However, there is still progress to be made toward full compliance with screening.

Applicability of Research to Practice

Implementation of a targeted bundle should be considered for optimal geriatric burn care.
742 Evaluation of Anti-Xa Levels and Venous Thromboembolism Prophylaxis with Enoxaparin in Burn Patients
Authors: Boyd Allison , Walroth Todd , Hartman Brett , Bjornstad Matthew , Garelli Alyssa , Spera Leigh , Grooms Cortni
Published: May 2023

Introduction

Previous studies have found that standard dose enoxaparin is inadequate in achieving goal prophylactic anti-Xa levels in burn patients. A new venous thromboembolism (VTE) prophylaxis protocol was implemented at our institution (Table 1). The objective of this study was to assess the efficacy and safety of the updated VTE prophylaxis protocol to determine if goal anti-Xa levels can be achieved earlier compared to the previous enoxaparin dosing protocol.

Methods

This was a retrospective cohort study evaluating a historic protocol group from 3/1/21 to 5/31/21 and a new protocol group from 10/1/21 to 12/31/21. Revisions were made to the new protocol group and evaluated from 7/1/22 to 8/31/22. Adult patients admitted with cutaneous and/or inhalation burn who received enoxaparin for VTE prophylaxis and had anti-Xa monitoring were included. The primary endpoint was protocol efficacy defined as percentage of initial anti-Xa levels within goal range and time to goal anti-Xa level. Secondary endpoints included protocol adherence, rate of VTE occurrence, number of missed or held doses if VTE occurred, correlation to published enoxaparin dosing equations in burn patients, and bleeding events.

Results

Results can be found in Table 2. The median (IQR) initial anti-Xa level in the historical (n=29) vs. new protocol group (n=22) was 0.09 (0.04-0.14) units/mL vs. 0.15 (0.10-0.19) units/mL (p=0.036). After adjusting the BMI cutoff in the new protocol from 40 kg/m2 to 35 kg/m2, the median initial anti-Xa was 0.16 (0.12-0.22) units/mL vs. 0.24 (0.19-0.28) units/mL (p=0.018). The mean ± SD time for patients to achieve goal anti-Xa level was 5 ± 3 days in the historical protocol and 5 ± 2 days in the new protocol group (p = 0.456). After protocol modification, the median time to goal anti-Xa level was 4 (3-6) days vs. 2 (1-3) days (p=0.002). No differences were noted in secondary outcomes.

Conclusions

The new protocol resulted in a higher initial anti-Xa level with more patients within goal anti-Xa range which was reached in less time after modification of the BMI cutoff for weight-based dosing. The maximum anti-Xa level in the modified group was still within the prophylactic range with the new protocol, indicating no increase in supratherapeutic levels compared to previously utilized dosing strategies and there were no differences in major or minor bleeding events which supports its safety.

Applicability of Research to Practice

This protocol can be replicated and utilized by other burn centers with the potential for a multicenter analysis and provides a framework for developing standardized VTE prophylaxis dosing recommendations with enoxaparin in burn patients.
750 Development of a Guideline for the Integration of Speech-Language Pathology into the Burn Multidisciplinary Team
Authors: Cappel Heather , Mohr Tiffany
Published: May 2023

Introduction

Speech Language Pathology roles include assessment and treatment of communication, orofacial contractures and oral motor weaknesses, head and neck mobility, ventilator weaning, progression towards tracheostomy decannulation, and swallowing. Specific services may include augmentative and alternative communication, speaking valve implementation on and off the ventilator, advance instrumental assessment of swallowing, and innovative therapeutic interventions. The speech-language pathologists at a single verified burn center recognized a gap in knowledge regarding the scope services they provide resulting in underutilization by the multidisciplinary burn team. The purpose of this study was to develop and disseminate a proposed clinical guideline leading to the inclusion of the speech-language pathologist in the multidisciplinary burn team.

Methods

Two hospital-based Speech-Language Pathologists undertook an exploratory research approach with an extensive review of available literature describing and defining their professional role both within the hospital system, and, more specifically, as a member of the burn multidisciplinary team. Burn team members were queried regarding their knowledge of speech services and appropriate patient referrals. Interviews and discussions with fellow professionals at other verified burn centers provided practice examples for comparison and consideration.

Results

Results from the review of literature and interprofessional discussions within our institution and with other verified burn centers were synthesized into the development of a structured practice guideline. Speech-Language pathology was officially included in the burn multidisciplinary team at our institution. The guideline was shared with outside Speech-Language Pathologists who were not yet a part of their burn multidisciplinary teams to describe and validate the role.

Conclusions

This foundational study led to increased awareness of Speech-Language pathology and the potential benefits to the hospitalized adult burn population. Active participation in the burn multidisciplinary conference has expanded patient care planning and led to generation of appropriate new consultations. Dissemination of the guideline supports the inclusion of Speech-Language in the burn multidisciplinary team.

Applicability of Research to Practice

This guideline details the many specialty services provided by speech-language pathology and provides the foundation for future research to detail the impact on burn patient outcomes.
764 Comparison of Topical Silver Sulfadiazine and Triple Antibiotic Ointment in a Porcine PT Burn Model
Authors: Sober Samara , Wong Stacey , Sandoval Steven , Singer Adam
Published: May 2023

Introduction

The standard of care for partial thickness burns is topical antibiotics or occlusive dressing. Silver Sulfadiazine (SSD) emerged at a time of burn wound infection and sepsis prevalence and is now the most used topical worldwide. Despite its antimicrobial benefits, SSD has been shown to inhibit keratinocytes and there is concern that it might delay wound healing. This study compared time to complete wound closure and reepithelialization in partial thickness porcine burns treated with SSD, triple antibiotics ointment or petrolatum ointment

Methods

We created 21 deep partial thickness (DPT) burns per animal on the backs and flanks of 3 anesthetized domesticated pigs (30-35 kg) using an established vertical progression model (aluminum bar preheated to 80° C for 20s). In each pig, burns were randomly assigned SSD, triple antibiotic ointment, or petrolatum ointment (in a 1:1:1 ratio) applied daily for two weeks followed by twice weekly for another 2 weeks. Healing progression was measured by wound digital photography and punch biopsies to assess gross wound closure, reepithelization and scar depth respectively.  

Results

The median (IQR) days to complete wound closure were 17 (17-21), 17 (14-21), and 21 (17-21) for wounds treated with SSD, petrolatum and triple antibiotic ointment respectively (p=0.06). The mean percentage of wound reepithelization at days 10, 14, 17, 21, and 28 for wounds treated with, SSD, petrolatum, and triple antibiotic ointment were 10%±20 vs. 8%±14 vs. 3%±12 (p=0.34), 45%±49 vs. 37%±44 vs. 48%±42 (p=0.74), 82%±38 vs. 86%±20 vs. 90%±27 (p=0.7), 74%±38 vs. 65%±50 vs. 93%±16 (p=0.049), and 92%±17 vs. 91%±28 vs. 98%±5 (p=0.4). The mean scar depth was 3.9 (1.1), 4.2 (0.9), and 3.4 (0.9) mm for wounds treated with SSD, petrolatum, and triple antibiotic ointment respectively (p=0.07). RMANOVA analysis showed significant change over time (p< 0.001) and a near significant difference between groups (p=0.054). On macroscopic analysis, appreciable pseudoeschar formation and erythematous allergic reactions were identified on wounds treated with SSD and triple antibiotic ointment respectively.

Conclusions

No significant differences in wound healing were found between groups in this porcine DPT burn model. SSD did not delay closure. Hypersensitivity to topical triple antibiotics was common.

Applicability of Research to Practice

This study provides insight into the topical ointment standard of care for burns and helps establish the standard comparator topical treatment for future preclinical and clinical studies.