bluuebunny/crossref_metadata_2025 huggingface dataset:
66 The Effect of Transfer on Outcomes in Burns
Authors: Bruenderman Elizabeth , The Selena , Bodily Nathan , Bozeman Matthew
Published: March 2020

Introduction

Burn care in the United States takes place primarily in tertiary care centers with specialty-focused burn capabilities. Patients are often initially transported to centers without burn capabilities, requiring subsequent transfer to a higher level of care. This study aims to evaluate the effect of this treatment delay on outcomes.

Methods

Under IRB approval, adult burn patients meeting American Burn Association (ABA) criteria for transfer at a single burn center were retrospectively identified. Cohorts were divided into patients who were initially taken to a non-burn center and subsequently transferred versus patients taken immediately to a burn center. Outcomes between the groups were compared.

Results

A total of 122 patients were identified, 61 in each cohort. There was no difference between the transfer and direct admit cohorts with respect to median age (52 vs. 46, p = 0.45), percent total body surface area burn (10% vs. 10%, p = 0.08), concomitant injury (0 vs. 4, p = 0.12), or intubation prior to admission (5 vs. 7, p = 0.76). Transfer patients experienced a longer median time from injury to burn center admission than directly admitted patients (1 vs. 8 hours, p < 0.01). Directly admitted patients were more likely to have inhalation burn (18 vs. 4, p < 0.01), require intubation after admission (10 vs. 2, p = 0.03), require an emergent procedure (18 vs. 5, p < 0.01), and develop infectious complications (14 vs. 5, p = 0.04). However, there was no difference between transfers and direct admits in ventilator days (9 vs. 3 days, p = 0.37), number of operations (0 vs. 0, p = 0.16), length of stay (3 vs. 3 days, p = 0.44), or mortality (6 vs. 3, p = 0.50).

Conclusions

This study suggests that significantly injured, hemodynamically unstable patients were more likely to be immediately identified and taken directly to a burn center. Patients who otherwise met ABA criteria for transfer were not affected by short delays in transfer to definitive burn care.

Applicability of Research to Practice

Initial triage and evaluation of hemodynamically stable patients at non-burn centers does not negatively impact outcomes in patients who meet ABA criteria for transfer to a burn center.
67 Tissue Plasminogen Activator Protocol for Frostbite in Rural and Remote Areas
Authors: Jarrell James , Stadler Christopher , Capo Jason , Brownson Elisha G
Published: March 2020

Introduction

Use of tissue plasminogen activator (tPA) for treatment of severe frostbite has facilitated limb salvage when previously amputation was inevitable. To address rural and remote areas with limited access to care, our institution adopted a protocol in 2017 for administration of systemic tPA in patients with grade 3 or 4 frostbite extremity injuries. This allows for early tPA administration prior to specialty center to help mitigate long distances to care. This study evaluated the efficacy of this protocol and identified barriers to its success.

Methods

All patients treated for frostbite at this institution from October 2012 – May 2019 were included. This established a pre-treatment cohort from October 2012 – September 2017 and a tPA eligible cohort from October 2017 – May 2019. Retrospective chart review determined key variables including injury grade, timing and location (of injury, first evaluation, and tPA administration), distance from treating facility, amputation level, and tPA candidacy. Descriptive statistics were gathered, and chi-squared tests were used to compare the cohorts.

Results

Clinical characteristics were similar in both groups. Retrospectively, we determined that 29.8% of the pre-cohort patients would have been tPA candidates based on our protocol. Post-protocol, 20% of the patients received tPA. Average time from rewarming to tPA administration was 5.1 hours [3.9 (3.4–7.3)]. There were no adverse events of tPA treatment. Of the two amputations after tPA, one was complicated by infection, and one received amputation after a second re-freezing injury. Many patients were not considered for tPA based on time from rewarming to evaluation.

Conclusions

Systemic tPA administration is shown to be effective in decreasing amputation rates among patients with grade 3 and 4 frostbite injuries while providing means of timely and accessible treatment in rural and remote settings.

Applicability of Research to Practice

Education of frostbite as a time-critical injury may increase patient identification for treatment and improve outcomes.
71 Early Donor Site Harvesting in Burn Patients
Authors: Roggy David , Sood Rajiv
Published: March 2020

Introduction

Donor sites harvested for split-thickness skin grafts (STSG) are typically applied immediately to the intended recipient site. The size of a harvested donor site may delay discharge from the Burn Unit related donor site pain and healing. In September 2018, our burn center began to harvest donor sites early and banking the STSG for later use. In this paper, we evaluated the benefit and effectiveness of early donor site harvesting.

Methods

A retrospective review was performed to identify patients who underwent one homograft procedure followed by one autograft procedure that had donor sites harvested at the time of their homograft procedure and banked for later use (Group A). These patients were matched by TBSA and age to a patient that underwent a one homograft procedure followed by one autograft procedure that had a donor site harvested in their autograft procedure (Group B). TBSA, Total Length of Stay, and Length of Stay in terms of number of days per TBSA were reviewed for comparison.

Results

Since September 1, 2018, we have harvested STSG from 43 patients with their initial burn debridement and banked the STSG for their next surgery. The mean donor site size harvested early was 1520cm2. The average number of days the STSG was stored = 6.2 days. As seen in table 1, Group A has a larger mean TBSA and a shorter overall length of stay and lower number of days per TBSA. Both groups experienced graft loss in 2 patients that required regrafting. The graft loss in both groups was attributed to either poorly controlled diabetes or wound infection. The difference in length of stay is not statistically significant but is considered clinically and financially significant as the shorter length of stay is an average savings of $23662.80 in room and board charges.

Conclusions

Early harvesting of donor sites is successful and clinically effective. It is clinically safe to harvest and store STSG for delayed application. By harvesting donor sites early, patient discharge is not delayed due to an unhealed donor site which may be a financial savings for the patient and / or the institution.

Applicability of Research to Practice

Decreased of length of stay provides financial savings to the patient and the institution, as well as, decreasing possible complications.
72 Frailty Assessment in the Burn Population: A Single Center Retrospective Review
Authors: Horrell Erin Wolf , Mubang Ronnie , Folliard Sarah A , Beyene Robel , Gondek Stephen , Thompson Callie M
Published: March 2020

Introduction

Burn morbidity and mortality increases with advancing age. Frailty is characterized by reduced homeostatic reserves and is associated with an increased biological age compared to chronological age. Our primary aim was to determine whether frailty as assessed on admission would be predictive of outcomes in the burn population.

Methods

We conducted a single institution 7-month retrospective chart review of all admitted acute burn patients ages 45 and older. Patient and injury characteristics were collected and compared using standard statistical analysis. Frailty scores were assessed upon admission using the FRAIL Scale.

Results

Eighty-five patients met inclusion criteria and were able to complete the FRAIL assessment. Patient and injury characteristics are listed in Table 1. . Mean burn size was 6.7%TBSA (95%CI 4.9–8.4%). 34 patients (40%) were classified as robust (FRAIL score 0), 26(30.6%) as pre-frail (FRAIL score 1–2) and 25(29.4) as frail (FRAIL score 3–5). When comparing the robust, pre-frail, and frail cohorts, there was no difference between potentially confounding variables including %TBSA, presence of inhalation injury, presence of full thickness burns, intubation status on admission, presence of infection on admission, mechanism of injury, or delayed presentation status. There was no difference between the robust cohort compared to the pre-frail/frail cohort in overall mortality (p=.971), Patients in the pre-frail/frail cohort received more palliative care consultations (p=.096) and had a longer length of stay (3.3d vs 7.55d p = .002), while prefrail patients had a similar LOS to frail patients (7.46 vs 7.64d p =.938). Patients in the pre-frail/frail cohort were also more likely to be discharged to a higher level of care than they were admitted from(p=.032) with prefrail patients experience an escalation in level of care more frequently than frail patients. The distribution by age by half-decade ranges is in Figure 1. By age 55–59, the majority of patients were prefrail or frail.

Conclusions

We demonstrated that frailty as assessed by the FRAIL score was predictive of increased length of stay and an escalation in post discharge care. In addition, patients characterized as pre-frail experience outcomes similar to frail patients and should be managed as such. Given the prevalence of frailty and prefrailty in the younger group of patients, we advocate for routine frailty screening beginning at age 55.

Applicability of Research to Practice

Frailty scores upon admission may allow for a more complete assessment of a patient’s functional status and can help guide discussions of expected outcomes.
82 Retrospective Review of Burn Resuscitation Outcomes Between 4 mL and 2 mL as a Starting Guide for Parkland Formula
Authors: Rampetsreiter Kyle R , Bhavsar Dhaval , Nazir Niaman
Published: March 2020

Introduction

The ABA changed their fluid resuscitation guideline in 2011 for adult thermal burn injury patients from 4 mL to 2 mL per kilogram body mass per percent total body surface area (%TBSA) affected as a starting point for the Parkland formula. The primary aim of this change was to reduce the incidence of over resuscitation. We implemented this guideline at our institution in 2013. This retrospective analysis compares burn resuscitation outcomes prior to and post guideline change.

Methods

After approval from IRB, we collected data for all adult thermal burn injury patients with >20% TBSA from 2010 to 2012 for pre group and 2014–2016 for post group. Demographics, injury mechanisms, 24 and 48 hr resuscitation volume, 24 and 48 hr urine output, 24 hr peak serum creatinine, and mortality data was collected. Pre and post implementation groups were compared for 24 and 48 hr resuscitation volume, 24 and 48 hr urine output, 24 and 48 hr peak serum creatinine with t-test using SAS software. Mortality rates were compared too.

Results

The data is presented in table below. There was a significant reduction in total volume of resuscitation at 24 and 48 hr after implementation of the new guideline. There was also a significant reduction in the average 24 and 48 hr fluids used in the Parkland formula for the post group. This was achieved without significant reduction in urine output or increase in serum creatinine. Mean TBSA for pre and post groups were 36.2% and 33.1% respectively. There was no significant difference between extent of burn injury between these two groups.There was no significant change in mortality rate between the groups.

Conclusions

We observed lower volume of resuscitation for major thermal burn injury patients after implementation of the new guideline without adverse effect on renal function or outcomes.

Applicability of Research to Practice

The current guideline serves as a useful starting point for healthcare providers, allowing them to further resuscitate patients with additional fluids if needed. This change accomplishes optimal urine output and serum creatinine levels, while also providing better control of fluids to avoid over resuscitation.
84 Development of a Risk Prediction Model and Comparison with Clinical Severity Scores in Burn Patients
Authors: Kym Dohern
Published: March 2020

Introduction

The purpose of this study was to develop a new prediction model to reflect the risk of mortality and severity of disease and to evaluate the ability of the developed model to predict mortality among adult burn patients.

Methods

This study included 2009 patients aged more than 18 years who were admitted to the intensive care unit (ICU) within 24 hours after a burn. We divided the patients into two groups; those admitted from January 2007 to December 2013 were included in the derivation group and those admitted from January 2014 to September 2017 were included in the validation group. Shrinkage methods with 10-folds cross-validation were performed to identify variables and limit overfitting of the model. The discrimination was analyzed using the area under the curve (AUC) of the receiver operating characteristic curve. The Brier score, integrated discrimination improvement (IDI), and net reclassification improvement (NRI) were also calculated. The calibration was analyzed using the Hosmer-Lemeshow goodness-of-fit test (HL test). The clinical usefulness was evaluated using a decision-curve analysis.

Results

The new prediction model showed good calibration with the HL test (χ2=8.785, p=0.361); the highest AUC and the lowest Brier score were 0.943 and 0.068, respectively. The NRI and IDI were 0.124 (p-value = 0.003) and 0.079 (p-value < 0.001) when compared with FLAMES, respectively.

Conclusions

This model reflects the current risk factors of mortality among adult burn patients. Furthermore, it was a highly discriminatory and well-calibrated model for the prediction of mortality in this cohort.

Applicability of Research to Practice

There are many severity scoring systems widely used in the ICU to predict outcomes and characterize the severity of the disease. All of these scoring systems have been developed for the mixed population in the ICU. Their accuracy among subgroups, such as burn patients, is questionable and therefore, burn-specific scoring systems are required for accurate prediction.
95 Early Clinical Experience with an Autologous Homologous Skin Construct to Treat Deep Partial-thickness and Full-thickness Burns
Authors: Feldman Michael J , Han Jinfeng , Marcu Andreea C , Burkey Sarah E , McLawhorn Melissa M , Travis Taryn E , Johnson Laura S
Published: March 2020

Introduction

Split-thickness skin grafting (STSG) is the standard of care for treating deep burns. They often contract, have limited cosmesis, lack dermal appendages, and result in painful, conspicuous donor sites. An Autologous Homologous Skin Construct (AHSC) has been shown to result in full-thickness skin formation.1,2 This study examined the safety profile, graft take, and quality of healing of a pilot group of AHSC-treated burn wounds.

Methods

Following IRB approval and informed consent, patients with deep-partial/full-thickness burns requiring grafting underwent side-by-side treatment with AHSC and STSG. A 2cm2 full-thickness harvest was processed into AHSC at an FDA-registered facility, returned within 48 hours, and applied to a 4cm2 area alongside a STSG. AHSC donor site was closed primarily. Wounds were evaluated for healing with digital photography and investigator assessments for 90 days. All adverse events (AEs) were recorded.

Results

Eight patients with 12% TBSA [range 2–40%] burn wounds were treated; 5 Caucasian and 3 African American with an average BMI of 26.8. Injury was due to predominantly flame burn, with additional injury from grease, scald, contact, friction, and flash. Mean time between injury and AHSC treatment was 11 days [range 5–35 days]. All patients had graft take and complete epithelialization by the end of the study. Patients required one application of AHSC and no other additional surgical procedures at the application sites. The most common AEs for STSG-treated wounds included hypertrophic scarring, pruritus, and insomnia. One non-infected AHSC harvest site experienced a mechanical dehiscence. There were no other AEs related to AHSC treatment.

Conclusions

No related adverse events at the treatment sites were noted in this study. However, the size of the treatment area limited the ability to comment on the presence of complex dermal elements including hair follicles. Additional investigation with application to larger areas is warranted to evaluate the utility of AHSC for the treatment of acute burn wounds.

Applicability of Research to Practice

Novel therapy may provide an alternative treatment for burns requiring skin grafting however larger studies are needed.
100 Actionable, Revised (Version 3), and Amplified American Burn Association Triage Tables for Mass Casualties: A Civilian Defense Guideline
Authors: Kearns Randy D , Bettencourt Amanda P , Hickerson William L , Palmieri Tina L , Biddinger Paul , Ryan Colleen M , Jeng James C
Published: March 2020

Introduction

Burn mass casualty incidents (BMCI) produce a sudden surge of burn-injured patients that will stress healthcare resources, including supplies, space, and experienced workforce. Existing guidelines for standard of care and catastrophic circumstances fail to account for contingency and crisis situations. This work attempts to align existing data with recommendations of the Committee on Crisis Standards of Care for the Institute of Medicine, National Academies of Sciences.

Methods

The Triage Tables- Seriously Resource-Strained Situations (Version 2), derived based on data from the National Burn Repository, and literature from various BMCIs regarding triage methods were reviewed. Relying on a multidisciplinary team of burn experts, four new triage tables were developed to assist secondary burn center triage during disasters. These prototype tables were tested in a BMCI functional exercise.

Results

We created four tables designed to sort patients into three triage categories:

The first three tables align with the National Academies guidelines; (Conventional, Contingency, and Crisis Care). However, comparing conventional capacity of the national burn care system (approximately 2000 beds) to the current national disaster planning scenarios, we recommend dividing crisis care (adding a fourth echelon when burn injuries are considered) to reflect the profound gap between current capacity and potential demand in certain scenarios.

Nationally, the burn care community could manage approximately 2000 patients if time permits (up to 120 hours) and transportation resources exist to treat and redistribute the patients to centers across the nation. While crisis care may be the standard at the onset of an incident with 2000 patients, as patients are treated and distributed, surge equilibrium is reached, the standard will revert to contingency or conventional care.

For the rare scenario with potentially hundreds of thousands with burn injuries such as hostile military action leading to the detonation of a thermonuclear weapon, the catastrophe would create an austere environment for an extended period. Thus, we identified this higher-order event as catastrophic care.

Conclusions

It is essential that the triage process is led by a clinician who can accurately assess burn injuries. During their trial use with the recent BMCI exercise, the use of the triage tables added clarity to the triage process and should add clarity to real-world events as well.

Applicability of Research to Practice

The use of Crisis Standard of Care Burn Triage Tables could improve resource utilization during disasters.
101 Predicting and Estimating Burn Outcomes: A Single Institution Analysis of over 4000 Cases
Authors: Zhang Jacques X , Pangli Harpreet , Papp Anthony
Published: March 2020

Introduction

Advances in burn care have improved patient outcomes, and independently validated indices, scores, and predictors of burn outcomes warrant re-evaluation. The purpose of this study is to consolidate predictors of burn outcomes and determine the factors that significantly contribute to length-of-stay (LOS) and mortality.

Methods

A retrospective review of all burn patients (n = 5778) admitted to a quaternary provincial burn unit from 1973 to 2017, was conducted. Removal of blank and pediatric entries yielded 4622 independent cases. Goodness-of-fit models and multivariate logistic regression was performed. Burn predictors included %TBSA, Baux (classic, revised) index, Abbreviated Burn Severity Index, and Ryan score. Primary outcomes were mortality and LOS. Variables considered in the multivariate logistic regression included: diabetes, hypertension, smoking, obesity, alcohol use, drug abuse, full-thickness burn, ventilator support, and ICU referral.

Results

Multivariate logistic regression for mortality showed the classic Baux index to be a significant predictor for mortality (OR = 1.118, p < 0.001). Other predictors included male sex, ICU referral, diabetes, smoking, and alcoholism (OR = 1.96, 4.97, 2.38, 1.63, 1.98, all p < 0.05). Interestingly, hypertension had a protective effect (OR = 0.24, p < 0.013). Linear regression for LOS found %TBSA, ICU referral, alcoholism, age, male sex, significant. The area under the ROC curve for Baux index was 0.945.

Conclusions

The regressions show that burn mortality and LOS are best predicted with the Baux index. Hypertension may have a protective effect on burn outcomes and may be attributed to increased perfusion to the periphery. Goodness-of-fit models, although variable, tended to show tighter grouping in patients with TBSA >20%. LOS ratios prove to be useful benchmarks for burn units with TBSA >20%. Similar findings are preliminary found in the NBR, national burn repository, database.

Applicability of Research to Practice

LOS ratios and burn index scores prove to be valuable markers to predict burn outcomes. The results of this study will directly help the clinician make decisions and communicate clinical severity to patient and family members.
514 Post-burn Malnutrition and Associated Cardiomyopathy
Authors: McQuitty Alexis L , Brown Frances , Talon Mark , Martinez Robert
Published: March 2020

Introduction

It is known that systolic dysfunction (dilated cardiomyopathy) may occur in a high percentage of patients with large TBSA burns. The reversible myocardial depression may be due to many factors: thermal injury, sepsis, severe malnutrition. Malnutrition and delayed wound healing may occur with a combination of primary and secondary protein-energy undernutrition.

Methods

Serial transthoracic and transesophageal echocardiographic parameters were measured during perioperative care (ejection fraction, fractional shortening, pericardial fluid) in 8 patients with evidence of malnutrition (low BMI, low albumin and prealbumin, muscle wasting) and a delayed presentation to the hospital. Initial echocardiography was performed post-injury day 30 -142; follow-up exams were performed in some patients at 2 years post-injury. Acutely-injured patients or those with sepsis were excluded.

Results

From 2015–2017, echocardiographic measurements were obtained in 8 patients, ages 7–21. The presenting TBSA ranged from 30–82% and included flame injury, electrical burns, and 1 case of pemphigus vulgaris. The initial ejection fraction ranged from 12–45% in patients with a BMI range of 10–25. The mean initial albumin was 2g/dL; the mean prealbumin was 9.5mg/dL. Two patients had mild to moderate pericardial effusions, which resolved after 1 month of proper nutrition. Selenium deficiency was noted in 1 patient. Four patients required perioperative short-term dobutamine.

Conclusions

Patients presenting with malnutrition and impaired wound healing all had evidence of cardiomyopathy; however, the degrees of systolic dysfunction varied significantly. BMI, albumin, and prealbumin all had a strong correlation with the degree of myocardial depression. Despite the lower ejection fractions, many patients maintained an adequate cardiac index and did not require inotropic medications. With time and adequate nutrition, cardiac function improved, although many remained with mild dysfunction in the first year.

Applicability of Research to Practice

This case series demonstrates the continued need for early recognition of malnutrition and cardiomyopathy in this patient population and the need for early intervention. Echocardiographic diagnosis may improve acute perioperative care. In addition, future studies are needed to determine the chronic cardiac effects of reversible dilated cardiomyopathy. Nutrition, refeeding, and perioperative management require a multidisciplinary team.
522 Skin Graft Donor-site Morbidity: A Systematic Literature Review
Authors: Asuku Malachy , Yan Qi , Yu Tzy-Chyi , Boing Elaine A , Hahn Helen , Hovland Sara , Donelan Matthias B
Published: March 2020

Introduction

Although split-thickness skin grafts (STSGs) are part of standard treatment for burn, traumatic, and chronic wounds, the harvesting of STSGs creates iatrogenic injuries at the donor sites. This review summarizes the scientific literature on morbidity associated with STSG donor sites.

Methods

A systematic literature search from 2014 to 2019 was performed in MEDLINE, Embase, and Chemical Abstracts to identify English-language articles reporting on the clinical-study findings, complications, management, financial burden, and patient-reported outcomes pertaining to STSG donor sites.

Results

Of 1426 articles identified, 44 met eligibility criteria and were included in the analysis. Most studies (n=31; randomized controlled trials [RCTs], n=26; observational studies, n=5) compared the outcomes of donor-site wounds that were treated with different dressings. Several studies (n=9; RCTs, n=5; observational studies, n=4) evaluated new agents or methods to improve donor-site outcomes. Only 3 studies focused on patient- or physician-reported outcomes. No studies reported on the length of hospital stay or the financial burden associated with donor-site wounds. Among the studies that indicated donor site location (n=34), the thigh was the most common. The most frequently reported donor-site outcome was the mean time to wound healing (n=21), which was 4.7±0.2 to 28.2±5.6 days. In some studies (n=13), the pain score assessed by visual analog scale (0–10 scoring, 0 being no pain and 10 being extreme pain) was 1.46 to 10.0 on postoperative day (POD) 1 and was 0.2 to 8.0 between POD 10 and 12. In a few studies (n=5), donor-site scar assessment using the Vancouver Scar Scale (0–13 scoring, 0 being normal skin and 13 being the worst scar) showed scores ranged from 0 to 10.9 at postoperative year 1. One study reported a 48.3% incidence of donor-site scar hypertrophy at 8 years. Infection rates were generally low but ranged from 0%-50%. Less frequently reported outcomes included pruritus, stiffness, and patient esthetic dissatisfaction.

Conclusions

This systemic literature search revealed a wide range of healing variation noted in STSG donor-site outcomes. Despite optimal wound care, donor sites required days to heal and were frequently associated with morbidities, including pain and scarring. Less frequently, donor sites were linked with severe morbidities, such as wound infection. Since majority of articles were RCTs with short follow-up, more research is warranted to assess the long-term outcome of hypertrophic scarring, another serious complication. These negative outcomes impose a substantial burden on patients and may impact their quality of life.

Applicability of Research to Practice

The elimination or reduction of STSG donor sites and their associated morbidity have long been identified by patients and providers as an unmet need deserving urgent attention.
548 The Economics of Burn Injuries Among Children Aged 0–4 Years
Authors: Beaulieu Emilie , Zheng Alex , Rajabali Fahra , MacDougall Frances J , Pike Ian
Published: March 2020

Introduction

Children under the age of five years are particularly vulnerable to scalds and contact burns and have the highest rate of hospitalization and mortality from burns. Studies of costs associated with pediatric burns have included a limited number of patients and focused on inpatient and complication costs, limiting our understanding of the full economic burden of pediatric burns, including costs incurred through outpatient care and caregivers’ productivity loss. This study aimed to develop a societal costing model for burn injuries among children aged 0 to 4 years.

Methods

Children aged 0 to 4 years identified through the local Burn Registry with a burn injury between January 1, 2014 and March 15, 2018 were included in this study. Patients with inhalation injury, electrical, chemical and friction burns were excluded. An incidence-based cost-of-illness analysis with a human capital approach was used to quantify the cost of partial and full-thickness burns according to the percentage of total body surface area (%TBSA) involved. The cost of a burn injury was assessed from a societal perspective through the following cost categories: emergency department visits, inpatient, outpatient dressing changes, outpatient burnbaths, day surgeries, clinic visits and caregiver productivity losses. A list of resource items for each category were extracted from patient chart review, the local Burn Registry, and the local Hospital Finance Database, and assigned unit prices. Costs were discounted to a present value in 2017 dollars at 1.5% per annum.

Results

Burn injuries were observed for 342 children, of which 249 (73%) had their burn severity classified (%TBSA and partial/full thickness) and were included in this study. Burn severity categories (1–5%, 6–10%, 11–20%, and >20%) were developed based on the differential distribution of the costs allocated to each burn incident. The majority of children (60.8%) suffered from a 1–5% burn. A 1–5%, 6–10%, 11–20%, and >20% burn respectively cost an average of $2,229, $8,653, $13,663, and $98,634 to society. Costs incurred by the 1–5% burns were related mostly to emergency department visits and dressing changes, while costs incurred by the >20% were related mostly to inpatient and clinic visits (garments) costs.

Conclusions

This costing approach raises awareness about the important, yet preventable economic burden that pediatric burn injuries place on society.

Applicability of Research to Practice

This evidence may persuade policymakers and clinicians to invest in pediatric burns prevention programs in order to decrease pediatric burns costs allowing for the allocation of funds towards other clinical initiatives. This costing model may also facilitate cost-effectiveness analyses of burn prevention programs in the coming years.
550 Real World Treatment Trends for Patients TBSA ≤ 20%: Evaluating Important Shifts in Care and Budget Impact of ASCS Adoption
Authors: Holmes James H , Kowal Stacey , Ferrufino Cheryl P
Published: March 2020

Introduction

Treatment pathways in burn care are typically determined based on burn center (BC) and patient characteristics, although decisions may be influenced by anecdotal experience, personal preference, and hospital policies/purchasing decisions. Health economic (HE) evaluations can support improved decision-making, identifying the most cost-effective interventions for tailored care. A novel burn care model (BEACON) was developed with burn surgeons over several years and validated through numerous publications, including an assessment of the HE impacts of autologous skin cell suspension (ASCS) use for definitive burn closure. To ensure that BEACON accurately represents the current state of care, it is vital to update data that underpins model projections. This study collected real world data on practice patterns and patient outcomes for the most commonly seen burns (TBSA ≤ 20%) to update the current understanding of standard of care (SOC) costs and outcomes and to refine estimates on the impact of ASCS use in TBSA ≤ 20% patients.

Methods

Data was collected from a 10% sample of BCs, including: BC and patient characteristics, resource use, inpatient costs, and length of stay (LOS). NBR based inputs in BEACON were updated to reflect survey data for patients with TBSA ≤ 20%, with the ability to view data as a national aggregate sample and across BC characteristics. BEACON estimates patient and BC costs and outcomes across a spectrum of patient profiles (age, gender, inhalation injury, comorbidity status, burn depth, TBSA) and combines information on each patient profile to understand annual budget impact. Key outcomes were compared across the survey sample and published NBR trends. Using the updated BEACON, the BC budget impact of ASCS in burns TBSA ≤ 20% was assessed.

Results

The survey was collected from 16+ BCs, focusing on inpatient encounters in 2018. LOS was lower than NBR estimates, with some centers reporting LOS per %TBSA far below 1 d/%TBSA. Using the detailed bottom-up estimation of cost from BEACON with survey data, trends suggest total hospital costs for SOC are lower than published NBR charges given shorter LOS and updated cost and resource use assumption.

Conclusions

Compared to NBR 8.0, contemporary data suggests that fewer small TBSA burns are being treated in the inpatient setting; those treated have a LOS below NBR estimates. When using real world data, the impact of ASCS use in burns TBSA ≤ 20% was still calculated to be cost saving to a BC overall, given reductions in LOS and number of definitive closure procedures. Incorporating ASCS into appropriate TBSA ≤ 20% procedures can still result in a positive financial impact for BCs.

Applicability of Research to Practice
566 Representation and Consequences of Guilt in Parents of Young Children with Unintentional Burns
Authors: Lin Yuting , Lewis Frances M , Kantrowitz-Gordon Ira , Carrougher Gretchen J , Qiao Liang , Whitney JoAnne (Joie)
Published: March 2020

Introduction

The incidence of unintentional burn injuries provides a natural condition that induces guilt and other emotions, such as blame, in the parents of the inflicted child. Empirical evidence generated has suggested that the consequences of guilt include both prosocial behaviors and antisocial behaviors. Therefore, the effects of guilt on parental behavioral and emotional outcomes have long-term implication. The purposes of this study were to examine guilt and its representation in parental responses to a child’s burn, and to look for the immediate consequences that guilt for parents.

Methods

Semi-structured interviews were conducted with 20 parents or caregivers in the hospital during their child’s clinical visit in a regional burn center in eastern China. We used a combination of deductive and inductive content analysis to analyze the interview data.

Results

Parents expressed feelings of guilt using both the word “guilt” or sentences that conveyed the manifest meaning, which reflected the definition of guilt. Analysis of the data produced three conceptual domains of the consequence of guilt. Reappraisal of guilt toward the self included eight categories: regret, blaming myself, thinking about why, not wanting to talk, wanting to be punished, blaming others, having trouble sleeping and feeling irresponsible. Motivational reactions toward the child were sorted into four categories: paying more attention to prevent injuries, feeling sorry for the child, providing the best care, and placating the child. Other reported accompanying emotions included upset, anger and heartache.

Conclusions

Guilt and its consequences are correlated but have distinct semantic representation.

However, guilt and its related emotions were often expressed within one parent’s account of his or her emotional experience. Blaming has been a significant reaction among parents and family caregivers, including self-blaming and blaming others. The results of this study suggest that guilt appears to promote both prosocial and antisocial emotions and behaviors in parents.

Applicability of Research to Practice

This paper’s findings help to extend our theoretical understanding of the guilt and its effects on the development and persistence of emotional distress in parents facing their child’s unintentional burn injury. What’s more, these results have practical implications for professionals caring for parents or family caregivers who are in greater need of professional mental health support and interventions, given the long-term recovery period in children with moderate to severe burn injury and the meaning and visibility associated with the burn scars. Further research is needed to elucidate the role of guilt in the development and persistence of emotional distress in parents facing their child’s unintentional burn injury.
568 Appearance Related Concerns Among Pediatric Burn Patients
Authors: Cloonan Taya Z , O’Donnell Ellen , Lydon Martha , Prelack Kathrina
Published: March 2020

Introduction

A primary outcome goal for pediatric burn patients is to regain social functioning and achieve developmental social milestones. Research regarding appearance related concerns and their relevance to social development is still lacking. The purpose of this study is to evaluate how appearance-related concerns affect social and academic functioning for children with visible scars. The overall aim of this project is to develop a screening process to identify patients at risk so that appropriate supportive interventions can be implemented.

Methods

A secondary analysis of data collected using Burn Outcomes Questionnaire (BOQ) and the Pediatric Symptom Checklist (PSC) which measures psychosocial well-being, was conducted in a pediatric burn center. These questionnaires were administered to patients aged 11–18 years who were admitted to our hospital between 2000 and 2017. Using these validated tools, the relationship between scores on the BOQ and PSC specifically associated with appearance related concerns and their implication on social and academic functioning were compared. Subscales for externalizing psychiatric symptoms (hyperactivity, aggression) or internalizing psychiatric symptoms (anxiety, depression) were compared to appearance related scores using Pearson’s correlation.

Results

Data on 36 patients was obtained and analyzed. Results are shown in Table 1.

There was a moderate correlation between appearance-related concerns and internalizing symptoms (R = 0.55; p < .001). There was no relationship between externalizing symptoms and appearance related concerns.

Conclusions

Appearance related concerns are significantly associated with internalizing psychiatric symptoms that include anxiety and depression. Additional research is needed to identify demographic factors such as gender as well as cultural moderators that can be used to identify patients at risk.

Applicability of Research to Practice

Results of this study have determined that there is a need for greater screening of internalizing psychiatric symptoms among our patient population. Once identified, patients can be offered appropriate interventions.
571 Perspectives on Research Participation Feedback: Results from Burn Survivor Focus Groups
Authors: Amtmann Dagmar , McMullen Kara , Bamer Alyssa M , Gibran Nicole S , Holavanahalli Radha K , Schneider Jeffrey C , Wolfe Audrey E , Sanchez Adriana
Published: March 2020

Introduction

Research participants often receive little to no feedback after participating in a research study. We sought to better understand what information burn survivors might want to receive based on their participation in research, and what formats might be most useful. Participant preferences will be used to develop summary reports based on their responses to survey questions and can inform patient information dissemination in burn clinics.

Methods

Adult burn survivors and caregivers/partners participated in focus groups. Multiple formats of reports on health domains, such as pain, depression and itch were discussed. All participants were asked whether they would be interested in receiving a summary of the responses they provided, even if their answers suggested problems (e.g., high depressive symptoms). Understandability of the information, preferred format (graph, table, list), and opinions about the formats were discussed. Audio recordings were transcribed, anonymized and summarized.

Results: A total of 11 burn survivors and 4 caregivers/partners participated in three focus groups at different locations in the U.S. Average age of the survivors at the time of the focus groups was 49 years, 62% were male and 71% were white. Mean burn size was 50% and 75% of participants had a fire/flame etiology of injury. Burn survivors and their partners unanimously wanted to receive reports about their health after study participation, regardless of whether the feedback was positive or negative. Longitudinal graphs were too complex and tables were more understandable. The preferred format listed the health domains in which the burn survivor was doing well and the areas of concern, with optional links to more details. Burn survivors found the links to online resources helpful and suggested that information about drugs, alcohol, and PTSD be provided to all regardless of a problem in these domains. Most survivors were not concerned about the potential negative impact of reports indicating continued health problems but suggested that any negative feedback should be provided no sooner than 1-year post injury.

Conclusions: Burn survivors are very interested in receiving summary reports of their responses to research surveys. Most would share the results with their caregivers and only a few would share it with care providers. Simple displays and messaging are essential for the reports to be useful. More research is needed to evaluate whether the reports can aid burn survivors in their recovery and to develop strategies for reaching out to survivors in distress.

Applicability of Research to Practice

Results help clinicians and researchers provide understandable health information to patients and encourage patient/family member engagement in clinical care or research.
574 Assessment of the Relationship Between Mental Illness and Inpatient Length of Stay
Authors: Collins Carolyn , Dao Sylvia , Lorico Jeremiah
Published: March 2020

Introduction

Mental illness and burn injury requiring hospitalization are uniquely intertwined. While literature has shown that burn patients are more likely to experience acute stress disorder, post-traumatic stress disorder, and depression, the impact of pre-existing mental illness on the duration of inpatient hospitalization for burn patients is unclear. We aim to assess the impact of acute mental illness requiring treatment by a psychiatrist during admission to a burn unit on patient length of stay (LOS).

Methods

A retrospective analysis was conducted using burn registry data to evaluate patients age 18 to 65 admitted between January 1, 2017 and December 31, 2018. Patients admitted with burns, inhalation injury, frostbite and Steven Johnsons Syndrome were included. Patient age, total body surface area (TBSA), LOS, and psychiatry consult (PC) incidences were collected. Patients were separated into psychiatric (P) and non-psychiatric (NP) groups to compare the impact of PC on LOS. Multiple linear regression analysis was conducted in both groups to evaluate the impact of TBSA and age on LOS. Two-sample t-test assuming unequal variances was conducted to compare age, TBSA, and LOS in both groups.

Results

Multiple regression in the P (n=71) group indicated both age and TBSA explained 48.4% of the variance of LOS (R²= 0.48, F(2,68)= 31.96, p< 0.005). TBSA significantly predicted LOS (β= 275.9, p< 0.005), but age was insignificant (β= 0.177, p=0.4). Multiple Regression in the NP (n=617) group found that both age and TBSA explained 11% of the variance of LOS (R²= 0.11, F(2,613)=39.9, p< .005). TBSA and age significantly predicted LOS (β = 59.9, p< .005), (β = 0.09, p= 0.05), respectively. T-test assuming unequal variance found there was no significant difference in age for NP group (m= 41.73, SD= 14.02) and P group (m= 43.77, SD= 13.53; t(87)= 1.98, p = 0.11). TBSA held no significant difference between both P (m=0.05, SD= 0.08) and NP (m=0.05, SD= 0.09; t(93)= 1.98, p= 0.94). However, LOS was significantly different for P (m=26.20, SD= ±32.92) than NP (m=9.58, SD= ±17.57; t(75)= 1.99, p < 0.005)

Conclusions

It is an expected finding that TBSA had a significant impact on LOS, and age did not. Since the TBSA and age between N and NP are not significantly different, the impact of this correlation cannot account for the difference between LOS in the two groups. The correlation between PC and increased LOS may be used to more effectively estimate duration of inpatient admission for burn patients with psychiatric illness.

Applicability of Research to Practice

Directly applicable to practice.
589 Enhancing Care Providers’ CAUTI (Catheter-associated Urinary Tract Infection) Knowledge, Skills and Attitudes in the Burn Intensive Care Unit (BICU) and Burn Special Care (BSC) Environments
Authors: Beckwith Emily , Zynkian Megan
Published: March 2020

Introduction

CAUTIs, or Catheter-associated Urinary Tract Infection, are one of the leading causes of healthcare associated infections. Since 2008, Centers for Medicare and Medicaid Services (CMS) stopped reimbursing hospital for the cost of CAUTIs, forcing hospitals to modify and improve care provided to patients with indwelling urinary catheters (IUC). They are reportable events to CMS, which can signify the quality of care provided at any medical institution. These infections also cause extra pain and suffering and can complicate any hospital stay. Treatment requires antibiotic use, which helps create and spread antibiotic-resistant organisms with excessive use.

Methods

BICU and BSC staff were evaluated for knowledge of IUC care, maintenance and policies using a quiz dispersed to RNs. This quiz identified knowledge gaps to help focus on specific topics for training. During Skills Day, all Burn RNs were given a mandatory training, including a PowerPoint presentation, hands-on training performing catheter care, and a handout with quick tips for maintenance. All technical partners (TP) were also trained, though they were not given the quiz. To assess effectiveness of training, RNs were encouraged to take a post-training quiz. Rates of CAUTI will also be closely monitored.

Results

For the pre-training quiz, average scores were 13.1 correct answers (out of 23 questions) or 56.5%. Post-training quiz scores were 18.5 correct answers (out of 23 questions) or 81%. Since the training in September 2018, no new CAUTIs have been recorded.

Conclusions

The training provided helped enhance burn staff skills to maintain and care for indwelling urinary catheters, as well as changed attitudes on the unit.

Applicability of Research to Practice

CAUTIs are a reflection of the quality of care an institution and unit provides its patients. It is also closely monitored and used to compare similar units across the nation. The training provided to the burn staff has shown to decrease the number of CAUTIs in the Burn ICU and Burn Special Care environments, thus decreasing costs, pain and suffering and antibiotic use.