bluuebunny/crossref_metadata_2025 huggingface dataset:
601 A Simple Dressing for Prevention of Central Line Infections in Pediatric Burn Patients
Authors: Vanamala Milly , Hartman Brett , Zieger Madeline
Published: March 2020

Introduction

Between 2017 and 2018, the burn unit saw 16 patients with major burns. A major burn is considered a total body surface area of 20% or greater. The burns ranged from 20% to 85% total body surface area averaging 44.14 %. Of those 16 patients, 8 patients required central lines that could not utilize a traditional occlusive central line dressing. Central line access is often placed near a burn or grafted site, and an occlusive dressing cannot be maintained. On average, a central line was changed in the operating room every seven days for infection prevention or sooner if an infection is suspected. The lines were changed preferably to a new site or over a wire if limited sites. In 2017, our Burn unit’s central line associated bloodstream infection rate of 4.1 infections per 1000 catheter days. This was higher than the national benchmark centerline from the Children’s Hospital Solutions for Patient Safety national collaborative for pediatric intensive care units of 1.365 infections/1000 catheter days. The unit implemented the use of a 4x4 betadine dressing for microbial coverage as an innovative strategy to prevent central line associated blood infections. The method not only proved to be effective but also cost efficient.

Methods

While the standard of changing the central line every 7 days remained the same, our unit began using a 4x4 gauze soaked in betadine and placed over the central line insertion site. The gauze is moistened with the betadine solution, then rung out so that the gauze is not oversaturated. That gauze is placed directly over the insertion site using sterile technique. A dry gauze is then placed over the wet one to protect from pathogens in the environment. Both gauze pads are then changed every 4 hours to keep the betadine moist and working as an antimicrobial agent.

Results

In 2018, 4 patients with various central lines utilized the betadine technique with our overall central line associated blood infection rate for 2018 decreased to 0 infections/1000 catheter days. The cost of each occlusive central line dressing in our facility is $2.10, whereas the betadine method costs $0.97. These supplies can be used for more than one dressing change on each patient compared to the occlusive dressing that is used once.

Conclusions

Using the betadine dressing technique to protect against central line associated bloodstream infections has proven to be an effective, low cost technique to prevent line infections and improve patient outcomes for major burn patients with compromised skin integrity. By utilizing this technique, our overall central line infection rate has dropped significantly below the national average, while decreasing cost by over 50%.

Applicability of Research to Practice

Maintaining a low cost, effective dressing to help prevent line infections in major pediatric burn patients.
610 Small Pediatric Burns Can Be Safely Managed on an Outpatient Basis
Authors: Grote Andrea C , Lacey Alexandra M , Garner Warren L , Gillenwater Justin , Maniago Ellen , Yenikomshian Haig A
Published: March 2020

Introduction

American Burn Association guidelines recommend that all pediatric burns be transferred to a burn center if their presenting hospital lacks the necessary personnel or equipment for their care. Our institution often treats small (< 10% TBSA) burns in pediatric patients as outpatients with a non-daily dressing. The aim of this study was to determine if small pediatric burns could be managed in an outpatient manner and risk factors for failure.

Methods

A retrospective chart review was conducted from July 2016 to July 2019 at a single ABA-verified burn center. All patients under the age of 18 who presented for evaluation were included. Post burn day, age, sex, TBSA, burn etiology, body area burned, burn dressing type, outpatient versus inpatient management, reason(s) for admission, and any operative intervention were collected.

Results

In total, 742 patients were included in our cohort (Table 1). The most common burn etiologies were scald (68%), contact (20%), and flame (5%). From initial presentation, 101 patients (14%), mean TBSA 9%, were admitted to the burn unit and 641 patients (86%), mean TBSA 3%, were treated outpatient. Of those, 613 (96%) were treated entirely outpatient and 28 (4%) were admitted at a later date. There were no significant differences in age (p=0.6) nor gender distribution between those who were successfully treated outpatient and those who failed. There was a significant difference (p < 0.001) in TBSA between the patients who were treated successfully as outpatients (3±2%) versus those who failed outpatient care (4±3%). The primary reason for admission of these patients was nutrition optimization (61%).

Conclusions

The vast majority of small pediatric burns can be treated as an outpatient with a non-daily dressing with good results. Over 80% of pediatric patients seen in our clinic were successfully managed in this manner. As suspected, when the burns are larger in size (>4% TBSA) there is a potential increased risk for admission especially with regards to poor PO intake, so this requires close monitoring and family education.

Applicability of Research to Practice

Pediatric patients with small burns can be safely managed in an outpatient setting with a non-daily dressing. Those who fail will most likely fail from poor PO intake at home.
637 Disparities in Discharge Disposition: A Burn Model Systems National Database Study
Authors: Mason Stephanie A , Carrougher Gretchen J , Kowalske Karen J , Schneider Jeffrey C , Amtmann Dagmar , Gibran Nicole S
Published: March 2020

Introduction

Previous data suggest that disparities exist in access to inpatient rehabilitation following burn injury. We aimed to characterize the association between patient race/ethnicity and discharge disposition across multiple centers.

Methods

Data were derived from the prospectively maintained Burn Model Systems national database. All participants admitted to one of five participating centers between 1994 and 2019, who survived to discharge with a known disposition, were included. The relationship between patient characteristics, injury factors and discharge to home, a skilled nursing facility (SNF), or inpatient rehabilitation was modeled using multinomial generalized estimating equations. Pre-specified stratified analyses were conducted to examine effect modification.

Results

We identified 4395 participants who met inclusion criteria. Participants were 74% White non-Hispanic (n=3269), 18% Black non-Hispanic (n=812), 3% Hispanic (n=122), 0.5% Asian (n=24), and 4% Other (n=168). Most were aged 18–64 years (68%, n=2998). Overall, 79% (n=3585) of participants were discharged home, 12% to inpatient rehabilitation (n=534), and 6% to SNF (n=276). After adjustment for patient characteristics and injury factors, there were no differences in discharge destination by race/ethnicity. However, subgroup analyses demonstrated effect modification by both center and burn size. At 2 centers, Black participants were significantly more likely to be discharged to SNF or inpatient rehabilitation (Center 1 OR 1.98, 95% CI 1.02–3.85; Center 2 OR 2.36, 95% CI 1.07–5.19). Similarly, among all participants with >20% TBSA, Black participants were more likely to be discharged to SNF or inpatient rehabilitation (OR 1.38, 95% CI 1.06–1.81). Across all groups, having insurance was associated with discharge to SNF or inpatient rehabilitation (OR 1.68, 95% CI 1.21–2.33).

Conclusions

Although no overall difference in discharge destination by race was identified, stratified analyses indicate disparities in discharge disposition at the patient and system level. At specific centers, and among those with >20% TBSA injury, Black participants are more likely to be discharged to SNF and inpatient rehabilitation than other ethnic groups.

Applicability of Research to Practice

Both patient and system level factors are associated with discharge to higher levels of post-discharge care, suggesting that further characterization of these factors is warranted. Such data can inform interventions and policy changes aimed at ensuring equitable access to appropriate post-discharge care.
638 Auricular Splinting Following Severe Facial Burn Injury and Reconstruction
Authors: LePage Lisa
Published: March 2020

Introduction

With a severe facial burn, injury often involves the ear(s) resulting in damage or loss which may require reconstruction. In consideration of the functional and psychological effect that loss of a defined ear lobe may entail, reconstruction is an important consideration for the burn survivor. Two cases described in detail with illustration will highlight an auricular contracture release; one with V-Y Advancement and the other with a transposition flap. Preservation of the auricular reconstruction is accomplished by implementing necessary splinting. The auricular splint fabricated was made from a combination of silicone and low-temperature thermoplastic material. A step-by-step process will illustrate the needed materials and techniques to fabricate a worthy splint in order to preserve what was surgically achieved. The splint maintains the space between the ear and head to properly position and prevent contracture through the healing and scar maturation process. It secured with a one-inch head band that is sublime enough to foster compliance with wear. The auricular splint material also serves as scar management with the many proven benefits of silicone.

Methods

Two case studies are reviewed with auricular contractures that required release and reconstruction. The auricular splints were fabricated to stabilize and preserve the reconstructed ear lobe. The wear schedule was intermittent during the day and overnight in combination with scar massage. The patients reported good compliance with wear and stability of splint position with overnight wear. Skin integrity was not compromised with overnight or intermittent wear. The splint fabrication process is reviewed and illustrated with a simplistic innovative end result that is user friendly.

Results

Surgical reconstruction was required following development of auricular contractures and partial loss. With post-operative bandage removal and wound closure, positioning was a necessary consideration to preserve post-surgical reconstruction.

Conclusions

In conclusion, the peri-auricular splint is fabricated with low temperature splinting material lined in silicone proved worthy for effective positioning and reported comfort with wear. Effective splinting is necessary for the preservation of surgical reconstruction and to prevent contracture from sabotaging surgical efforts.

Applicability of Research to Practice

Consideration of fabrication of silicone auricular splints to preserve the accomplishments of auricular surgical reconstruction.
642 The Use of Laser Speckle Contrast Imaging in Assessing Depth and Progression of Burn Wounds
Authors: Cooper Laura , Chan Rodney K , Bohan Phillip Kemp , Carlsson Anders H , Everett Tyler
Published: March 2020

Introduction

The ability of laser speckle contrast imaging (LSCI) to provide real-time images of blood flow makes this modality appealing in the assessment of burn wounds, particularly for clinicians making treatment decisions based on burn wound depth and presumed progression. Here we present 2 preclinical studies that used LSCI to assess wound progress, both immediately and months after injury.

Methods

LSCI images were taken 10-40cm away from the wound and captured with a 1388x1038-pixel CCD camera. In the first study, LSCI images were captured prior to and immediately following creation of superficial partial-thickness (SPTB, 10s), deep partial-thickness (DPTB, 15s), and full-thickness burns (FTB, 20s), and on post-burn day (PBD) 1, 2, and 3. In the second study, LSCI images were obtained before and after DPTB creation and on PBD 7, 14, 21, 28, 60, 90, and 120.

Results

92 wounds from 9 swine were included. Speckle data was normalized to control sites and converted to percentages ([speckle wound/speckle control] x 100), producing speckle percentage of control (SPOC) which quantifies the relative decrease or increase in speckle output (vascularity). SPOC was significantly decreased for all burn times on PBD 0, 1, and 2. By PBD 3, only DPTB and FTB remained diminished (p=0.028 and p=0.005, respectively), and FTB SPOC was significantly less than the SPTB (p=0.015). In the second study, SPOC showed an increase post-debridement on PBD 7, noted as post-debridement day (PDD) 0. SPOC continued to increase significantly to a peak at PDD 7 (p< 0.0001) and remained elevated until PDD 28. By PDD 60, SPOC was no longer significantly increased.

Conclusions

LSCI is a reliable method for analyzing burn depth and wound progression in the preclinical setting. LSCI data shows an immediate decrease in vascularity at all burn depths immediately following burn creation, followed by a peak in vascularity on PDD 7, with a trend back to normal by PDD 60.

Applicability of Research to Practice

The correlation of wound bed vascularity based on LSCI to known data on burn depth and progression suggests that LSCI could be a useful measurement tool in the clinical setting for the provider determining wound viability.
645 Topical Application of a Novel Powdered Scaffold for Rapid Treatment of Skin Injuries
Authors: Jalili Reza , Verly Myriam Maude , Russ Breshell , Kilani Ruhangiz T , Ghahary Aziz
Published: March 2020

Introduction

In large skin injuries, lack of matrix deposition impedes timely healing process. The longer a wound remains open, the greater is the risk of infection, non-healing, and other complications. It is therefore crucial to find effective means to promote rapid closure of skin defects. Our group has previously developed a liquid in situ-forming nutritional scaffold, known as MeshFill (MF). MF has been previously proven to be very effective in accelerating the wound repair process, notably that of complex wounds. However, MF is limited in its application to deep and tunnelling wounds, and requires reconstitution with a solvent as well as maintenance at cold temperature until application. To address these limitations, our group has developed a powdered form of MF for rapid topical application on superficial skin injuries such as dehisced surgical wounds and burn injuries.

Methods

Our goal was to investigate whether a powdered form of MF could be directly applied onto the wounds to accelerate healing. Ideally, powdered MF would absorb the moisture within the wound environment and reconstitute into the gel form in situ. We examined the efficacy of powder MF (PMF) compared to reconstituted gel MF (GMF) and to a standard dressing protocol. To do so, splinted full thickness wounds were generated on the back of mice and treated with either PMF or GMF or were bandaged with no treatment (NT). The healing process was monitored until wounds were fully closed. Clinical wound measurements and histological assessments were performed to compare different treatment regimens.

Results

Application of both PMF and GMF accelerated wound epithelialization at days 7 and 14, compared to NT, and had faster wound closure times. On average, the PMF treatments healed 17% faster than the NT control, and the GMF treatments healed 21% faster than the NT control. No significant difference between PMF and GMF was found for any outcomes. Additionally, our results suggest that epidermis formation was more effective in P and MF conditions compared to NT.

Conclusions

These findings suggest that topical application of a powdered form of MeshFill is as effective as standard reconstituted MeshFill gel in accelerating the healing process of skin injuries.

Applicability of Research to Practice

Topical application of a powdered scaffold may be a very convenient and practical method for rapid treatment of large superficial wounds such as dehisced surgical wounds, burn injuries, and filling gaps in meshed skin grafts.
646 Impact of Inflammation on Wound Healing
Authors: Luze Hanna , Holzer Judith , Kainz Sonja , Reisenegger Peter , Holecek Christian , Kotzbeck Petra , Hofmann Elisabeth , Birngruber Thomas , Mautner Selma , Kamolz Lars-Peter
Published: March 2020

Introduction

Inflammation is part of the physiological phases of wound healing. It serves the purpose to attract different immune cells in order to clean the wound from pathogens and debris and create an ideal environment for fibroblasts and keratinocytes to differentiate, migrate and divide in order to close the wound. Pathological inflammation caused by many different factors is often the underlying cause of prolonged wound healing and unfavourable outcome in burn patients. We wanted to investigate what influence an induced hyper-inflammation on wound healing has in a controlled environment.

Methods

In a porcine wound model, pigs received full-thickness wounds on their backs where hyper-inflammation was induced by application of a chemotherapeutic for 6 days. Control wounds were left without induction. Wound were scored on a daily basis for 16 days in total and biopsies were taken for RNA analysis as well as histological assessment.

Results

The results showed a rise in inflammation of the wounds and the surrounding tissue due to the induction. The wounds healed slower, needing up to seven more days to completely heal. The results of the RNA analysis showed high values of pro-inflammatory cytokines after the induction in comparison to the baseline and control wounds. Histological assessment showed thick layers of necrosis, adipocyte as well as leucocyte infiltration in the hyper-inflamed wounds compared to completely healed control wounds with all layers of epidermis visible.

Conclusions

Hyper-inflammation, even just for a short period of time, can significantly prolong the time of wound healing. These findings underline the importance of preventing and treating wound infections of burn patients in order to support physiological wound healing as well as to avert complications such as infections with multi-resistant microbes that are associated with prolonged hospital stays.

Applicability of Research to Practice

The findings of these experiments cannot be directly applied to practice however, the influence of inflammation should kept in mind when treating burn patients.
666 The Effect of Burn Wound Size on Caloric Requirements: A Correlation of Nutritional Changes to the Clinical State
Authors: Matthews Marc , Calder Sara , Kowal-Vern Areta , Spadafore Philomene , McCollum Hunter , Richey Karen J , Foster Kevin N
Published: March 2020

Introduction

Caloric intake has been a vital component for burn wound healing and recovery. The hypothesis was that caloric requirements are based on injury severity & post-burn week as predicated by indirect calorimetry (IC)/predictive equations.

Methods

This was a retrospective chart review of 115 burn patients (2012–2017). Caloric requirements were determined by the Curreri equation [which includes % total body surface area (TBSA)] and IC for a 5-week period provided mainly by enteral nutrition. Patients received supplements and total parenteral nutrition as needed.

Results

The mean±sd age was 43±18 years, 41±18 % TBSA, Body Mass Index of 28±7 kg/m2, and mortality of 26 (23%). The major mechanisms of injury were flame/flash/explosions. There were 59 (51%) of patients with < 40 % TBSA burns, [median Injury Severity Score (ISS) 9; Apache score 14], and 56 (49%) with ≥40 % TBSA (median ISS 25; Apache score 21), p < .0001. The Respiratory Quotient (RQ) had a median of 0.94 (range 0.79 to 1.02). The median number of surgeries for the < 40 % TBSA group was 5 versus 12 for the ≥40 % TBSA, p < .0001. The Injury Factor did not differ from weeks 1–5 (1.8 for < 40 % TBSA and 2.0 for the ≥ 40 % TBSA). The Curreri equation calculation for this study was a median 3640 (range 2161–5950) calories. The Curreri equation resulted in significantly increased caloric recommendations for the ≥ 40 %TBSA compared to the < 40 %TBSA patients, p < .0001. The < 40 %TBSA group had caloric requirements ranging between 1500- 2700 calories compared to the ≥ 40 %TBSA group, whose calories ranged between 2000–3700. The total daily caloric recommendations were also significantly increased in the ≥40 %TBSA compared to the < 40 %TBSA patients. The maximum levels of resting energy expenditure (REE) from IC, total daily calories recommended by the dietitian and average calories ranged between 3000–4500 in the < 40 %TBSA group and 3600–6700 in the ≥ 40 %TBSA group. The caloric recommendations increased for all patients from week 1 to week 3 and leveled off during weeks 4–5.

Conclusions

Patient caloric requirements were dependent not only on the severity of the burn injury but also the post-burn hospitalization during which surgeries, debridement/grafting, and infectious complications occurred. They increased until the third week post-burn and leveled off in the recovery period. The study caloric recommendations and requirements were consistent with the REE and Curreri equation assessments.

Applicability of Research to Practice

There is no constant number of calories for all patients. Caloric requirements are modified by the severity of Burn %TBSA and phases of resuscitation through recovery.
709 24 Hour Patterns of Vital Signs as Predictors of Blood Infection in Pediatric Burn Patients
Authors: Munoz Elena Maria S , Weber Joan , Lydon Martha , Uygun Korkut , Sheridan Robert
Published: March 2020

Introduction

Blood infection diagnosis requires a positive blood culture, which may take 3 days, thus hindering early treatment and negatively impacting clinical outcomes.

Methods

In a retrospective review, 100 patients were screened, 34 remained after exclusions for incomplete data, leaving 89 blood cultures. Subjects were separated by infection (positive blood culture), or control (negative blood culture) groups.

Results

A combination of vital signs to aid in early and accurate prediction of blood infection.

Within 24 hours of blood draws and antipyretic administration, the vital sign combination of 1 or more MAP Dips (MAP below 60 mmHg) and 2 or more Fever Spikes (temperature above 39°C) or 2 or more Heartrate Spikes (heartrate above 2 SD age-specific norms), show: True Positive Rate (Sensitivity), 95%, True Negative Rate (Specificity), 94%, Positive Predictive Value (Precision), 92%, Negative Predictive Value, 96%, False Positive Rate, 6%, False Negative Rate, 5%, False Discovery Rate, 8%, Accuracy, 94%, F1 Score, 94%, Informedness, 0.89, Markedness, 0.88, Matthews Correlation Coefficient, 0.89. We evaluated different combinations of vital signs associated with blood infection including temperature below 36.5°C and various numbers of MAP dips, fever spikes, and heartrate spikes, with weaker predictive metric values.

Conclusions

Blood infection can be predicted with patterns in vital signs within 24 hours.

Applicability of Research to Practice

Vital signs and readily available data may be beneficial for use in clinical care of pediatric burn patients in relation to blood infection. We are currently analyzing dynamic trends in vital signs and infectious organism to not only predict infection, but anticipate appropriate treatments.
717 Using the VDR to Safely Transport Critically Ill Burn Patients to the OR
Authors: Mehta Anupama , Marano Michael , Englert William , Zanni Elyse
Published: March 2020

Introduction

Critically ill burn patients’ inability to tolerate conventional mechanical ventilation often results in delays, postponements and cancellations of surgical interventions. Early intervention with surgical excision and debridement can help prevent infection, multi-system organ failure and mortality. Severe burn victims often sustain lung injury due to inhalation of toxic smoke and heated gases. Severe respiratory distress due to smoke inhalation has been associated with a mortality of up to 80%. The application of conventional mechanical ventilation can rupture healthy alveoli and may intensify lung injury due to the constant opening and closing of lung units. Volumetric diffusive respiration allows for the diffusion of oxygen via intrapulmonary percussion with convective removal of carbon dioxide. This mode of ventilation in burn patients aids in the clearance of small airway debris. Diffusive oxygenation provides alveolar protection by eliminating repetitive opening and closing while convective forces provide CO2 and debris clearance. At our facility, with the assistance of the Volumetric Diffusive Respirator (VDR), we have been able to successfully stabilize the respiratory status of compromised patients by improving their oxygenation and ventilation. This technology has allowed us to safely transport patients to the operating room sooner to undergo surgical procedures.

Methods

A retrospective review was conducted of all VDR transports for surgery from January 2017 to May 2019. A total of eight patients were transported on the VDR to and from the OR on twenty-eight separate occasions. Patients presented with 19% to 73% TBSA burns with or without smoke inhalation. The population consisted of four males and four females, ranging in age from 21 – 61 years. Patients with severe burns and hypoxemia that failed conventional ventilation were placed on VDR. The VDR was initiated a minimum of 24 hours prior to surgery. Settings were optimized to achieve a PaO₂ of 60 mmHg or greater and a pH within 7.35–7.45 range. Patients were transported to the OR on VDR with a BICU Nurse, VDR technology trained Respiratory Therapist and a Burn Surgeon. Patients remained on the VDR throughout the entire operative case and were transported directly back to the BICU on the VDR.

Results

No difference was noted in EtCO2 or SpO2 with use of the VDR. A difference is PaO2 was noted with use of the VDR.

Conclusions

This study demonstrates that patients requiring VDR support can be safely transported to the OR. Critically ill burn patients who have refractory hypoxemia can undergo early surgical excisions and debridement. These timely surgical interventions can reduce the delay to surgery which could potentially lead to a negative impact on the patient’s outcome.

Applicability of Research to Practice

The use of VDR can lead to more timely surgical intervention and thus, the rate of infections and pulmonary injury can be studied.
723 Should Allograft / Homograft Still Be Used for Small and Medium Size Burns?
Authors: Gasteratos Konstantinos , Goverman Jeremy
Published: March 2020

Introduction

There is no doubt that human cadaveric allograft has been invaluable for the temporary coverage of large and extensive burns. In such cases, allograft has important systemic effects with respect to fluid and heat loss, inflammation, and metabolism. The incidence of large burns, however, has decreased over time. Small and medium-sized burns remain constant and are often treated with allograft as a means to test and/or prepare a wound bed after excision. This allows for a conservative, staged approach to burn wound closure but it remains unclear if the use of allograft in this way is advantageous. Knowing the deleterious immunomodulatory effects of allogeneic transplantation and given current applications of negative pressure wound therapy (NPWT), is allografting still a valid option for temporary coverage of small and medium-size burns.

Methods

A patient with a 20% TBSA full-thickness flame burn underwent tangential excision of the left thigh down to the level of the subcutaneous tissue. A 3x3 cm square of freshly thawed, commercially available, human cadaveric allograft was applied to a portion of the wound and the entire would be placed into an NPWT dressing for 3 days. The dressing was removed in the OR and photos of the underlying wound bed were obtained.

Results

Macroscopically, the wound bed beneath the allograft appeared markedly less vascular (figure 1-2-3-A and B) than that of the control. Additionally, the wound bed beneath the allograft appeared to have more necrotic, or unhealthy appearing, adipose tissue. The wound bed beneath the allograft appeared desiccated while the control appeared healthy and vascular.

Conclusions

Allograft may not prevent desiccation, may not prepare a wound bed as well as NPWT, and may not be the best option for the staged treatment of small and medium-sized burns. Controlled trials are needed, as is an open and honest discussion regarding the potentially negative implications this may have on reimbursement.

Applicability of Research to Practice

Challenging the status quo in the surgical management of severe deep burns and the current reconstruction methods can be useful in order to make a change and improve patient safety and outcomes.
732 Evaluating the Cost-effectiveness, Efficacy, Safety, and Tolerance of Silver Sulfadiazine Dressings Once Daily versus Twice Daily in the Treatment of Burn Wounds
Authors: Lagziel Tomer , Born Louis , Quiroga Luis H , Duraes Eliana F , Slavin Benjamin R , Shetty Pragna N , Javia Vidhi , Cox Carrie A , Caffrey Julie , Hultman C Scott , Asif Mohammed
Published: March 2020

Introduction

Topical antibacterial agents are an essential component of burn wound management. The aim is to prevent wound infection effectively and promote healing. A poorly treated wound can result in scarring or even sepsis and multi-organ dysfunction in severe cases. Topical Silver Sulfadiazine cream (SSD 1%) has been the gold standard for burn care since 1960s. Due to the immediate burst release of the drug into the exposed areas, application is relatively frequent, usually twice daily. However, it remains unknown whether twice-daily SSD dressings are superior to once-daily.

Methods

Our institution maintained a twice-daily dressing change standard of care until 01/01/2019. Patients admitted after that date had their dressing changed once daily. Our goal is to review outcomes for 75 patients before the change-of-practice and 75 patients after the change. Our main outcomes recorded are wound infection, average pain scores, average daily narcotic requirements and length-of-stay.

Results

Preliminary results of 20 pre-change-of-practice and 20 post-change-of-practice patients showed no difference in the outcomes between the two groups. The infection rates were the same for both groups (15%), average pain scores (Graph 1) for the post-change group were slightly higher (pre=5.5, post=5.8; p=0.7), average length-of-stay (Graph 2) was longer in the pre-change group (pre=9.2, post=5.7; p=0.04), and no other surgical complications were reported for patients in either group.

Conclusions

Preliminary results show that a once-daily dressing change of SSD, has no negative impact on burn wound outcomes. In addition, it is associated with a decreased length-of-stay. A decreased length-of-stay means reduced medical expenses for the patient and the hospital. Changing the standard-of-care to once-daily could prove beneficial. Further patient review will shed more light on the significance of these results, however so far there is no inferiority in wound healing.

Applicability of Research to Practice

The frequency of dressing changes directly affects staff workload who are required to spend a lot of time carefully changing dressings. In addition, patient discomfort associated with frequent dressing changes including interference with sleep hygiene and increased pain medications could also be avoided. Finally, fewer dressing changes are associated with less medical supplies and hospital utilization without putting the patient at any further risk of infection.
740 Mechanisms, Outcomes and Management of Pavement Burns
Authors: Eisenberg Matthew T , Chestovich Paul J , Saquib Syed F
Published: March 2020

Introduction

Burns from contact with hot pavement are commonly seen at burn centers located in desert climates. Previous work has shown increased risk of pavement burns as ambient temperatures rise above 95 degrees. In direct sunlight pavement absorbs radiant energy causing it to rise to temperatures high enough to cause second degree burns in under 35 seconds. This study aims to review the experience of treating pavement burns in a desert climate.

Methods

A retrospective chart review was performed on pavement burns at an ABA-verified Burn Center for 5 years from 2014–2018. The data collected included %TBSA, surface area per body region, cause, operative management, comorbidities, complications, incident location and cause of death. Patients were separated by cause into groups which included found down, walked on pavement, heat/dehydration, mechanical fall, syncope, seizure, trauma, substance/psych and unknown.

Results

A total of 185 patients admitted for pavement burns were identified in the study period. The average length of stay for survivors was 16.7 days. Of the survivors, 23% spent time in the ICU with an average stay of 11.4 days. The average TBSA was 5.5% (IQR 2–7.5%) with a maximum of 25%. TBSA breakdown by body region is shown in figure 1. It was found that 50.5% of admitted pavement burn patients required burn excision and 35.9% required split thickness skin grafting. The leading causes of pavement burn admissions were being found down by EMS and walking on pavement at 21.6% each, followed by mechanical falls at 15.1% (See figure 2). Of the 185 patients admitted 17.8% were under the influence of alcohol or drugs. Comorbidities were common; 32.4% had hypertension, 21.6% had diabetes, 13.5% had neuropathy, 2.2% had coronary artery disease, 5.4% had chronic kidney disease. Of the patients that walked on pavement to receive their burns, 50% also had peripheral neuropathy. Rhabdomyolysis developed in 5.4%, and hospital 30-day mortality was 4.9%.

Conclusions

Pavement burns are a common burn mechanism in hot and sunny climates, but may be seen in other locations during periods of high heat. Patients at risk are those with medical comorbidities and who come in contact with hot pavement for long time periods.

Applicability of Research to Practice

Data provided from this study can be used for a public health initiative to help patients who may be at risk of acquiring pavement burns. The data may also be helpful for clinicians gaining information about the management, cause and outcomes of pavement burn patients.
777 Use of the PHQ-2 as a Depression Screening Tool
Authors: Wiechman Shelley A , Keatley Eva , Blayney Carolyn B
Published: March 2020

Introduction

In 2015, the Burn Quality Improvement Program (BQUIP) guidelines recommended systematic screening of Major Depressive Disorder at all verified burn centers. Our level one trauma center rolled out a program to screen all patients entering the burn service starting in June 2018. This project evaluates the program after the first year of implementation.

Methods

All patients over age 12 admitted to the burn service were screened by bedside nurses using the 2-item Patient Health Questionnaire (PHQ-2). Exclusion for screening included those who were intubated and sedated and/or not alert or oriented. A reminder for the PHQ-2 screener automatically popped up in the nursing task list in the electronic medical record until it was given or patient was coded as not appropriate for screening.

Results

A total of 509 patients were admitted to the Burn Service between June 2018 and May 2019. Of those, 40 were identified as not being appropriate for screening due to prolonged mental impairment (e.g. not able to regain consciousness), and 116 (24%) were not screened for unknown reasons. The remaining patients (n=353, 77%) were screened with the PHQ-2 and 94% of these patients were screened on the same day of admit. Of the patients screened, 28 (8%) scored above the clinical cut-off for probable depression (PHQ-2 ³ 3) and 265 (75.1%) did not endorse any symptoms on the PHQ-2 (PHQ-2 = 0). Of the 28 that screened positive on the PHQ-2, 16 (57.1%) received psychological services. Of those that did not receive psychology services, the majority were admitted for less than 3 days (n=10, 76.9%).

Conclusions

In the first year of the program the vast majority of eligible patients were able to be screened by nursing staff with a 2-item measure within one day of admit to the burn service. This success is likely due to the automation of the task in the electronic medical record, the ease of use of the PHQ-2 and the dedication of the nursing staff. The 8% rate of a positive screen is higher than the general population. Given that most patients were screened within 24 hours of admission, we are capturing depressive symptoms that predate the injury. We know that depression can impair burn recovery (e.g. affect participation in therapy, impede wound healing) and lead to poorer long term outcomes. Systematic screening of depressive symptoms upon admission will allow us to intervene earlier and potentially reduce barriers to optimal recovery. Despite high screening rates, about 40% of patients did not receive psychological intervention. We will be discussing utilization of resources for providing inpatient services to patients with a positive screen.

Applicability of Research to Practice

The PHQ-2 is an effective screening tool for depressive symptoms for patients on an inpatient burn unit. These findings are important for hospital systems looking to screen for and treat the mental health needs of burn patients. Depression screening will be required for BQUIP starting in 2020.
783 Scar Revisions: Are We Asking the Right Questions?
Authors: Ziolkowski Natalia , Zuccaro Jennifer , Fish Joel
Published: March 2020

Introduction

Scars have wide-ranging effects on the individual and as such, many seek to have their scars. Currently, there is no gold standard for conducting scar revision consults. Scar-specific patient-reported outcome measures (PROM) are questionnaires created by individuals with scars and encompass all concepts of interest (COI) important to them. PROMs can be used for quality improvement (QI) initiatives to determine if all COI are being asked of patients. SCAR-Q, a new, internationally validated, scar-PROM measuring COI related to scar appearance, symptoms and function, and psychosocial impact was used. The purpose of this QI study was to determine if COI important to patients with scars are routinely asked during scar revision consults.

Methods

All scar revisions consults from July 1, 2017 to June 30, 2019 were reviewed at a single pediatric hospital using an electronic database. This study represents Phase 1 of the QI study approved by the institution and follows Model for Improvement methodology. Inclusion criteria were: patient aged ≥8 years, had a cutaneous scar, and speak English. Demographic information included: gender, age; and items related to the patient’s scar including etiology, time since injury, location, interventions; COI encompassed by SCAR-Q.

Results

162 electronic patient charts were reviewed with 88 meeting inclusion criteria. 45 were females (51.1%) with an average age of 12.6(SD 3.1, 8–20 years) with time since injury scar of 4.0 years (SD4.6,1 month-17 years). Burns, specifically scalds (18,45.0%) were the most common etiology (40,45%). Scars were located predominantly on the face/scalp (34,39.5%), chest (16,18.6%), and arm (15,17.4%). Most patients had no previous scar intervention at the time of the consultation (43, 51.2%). No scar revision consults encompassed all COI as defined by the SCAR-Q with appearance and Symptom/Function questions being more common than Psychosocial (Table 1). Specifically, scar color, hardness/thickness, disliking the scar were the most frequently asked questions (Table 2).

Conclusions

There is currently no established gold standard for conducting scar revision consults. SCAR-Q, a newly validated scar-specific PROM was used to determine if all questions that are important to individuals with scars were asked during routine scar revision consults. The most common questions asked of individuals with scars were related to appearance followed closely by symptoms/functional implications. Questions related to psychosocial impact are not routinely asked and represent a large area of improvement. Next steps include implementing a scar-specific PROM to ensure that all COI are implemented in routine clinical care.

Applicability of Research to Practice

This research is applicable to practice as it shows that PROM can be utilized for QI studies including identifying areas that are lacking in scar revision consults.
789 Split-thickness Skin Graft Meshing: The True Mesh Ratio
Authors: Egro Francesco M , Roy Eva , Konanur Anisha , Murphy Carolyn , Corcos Alain C , Ziembicki Jenny A
Published: March 2020

Introduction

Skin graft meshing is frequently used to allow coverage of extensive wound areas, reduction of donor site size, and prevention of fluid accumulation underneath the skin graft. Meshers allow for various ratios to be used but no studies have confirmed the accuracy of the mesh ratio provided by the manufacturers. The objective of this study was to measure the true mesh ratio achieved using some of the most commonly used skin meshers.

Methods

A prospective cohort study was performed in 2019. The true expansion ratio was calculated for standardized human split-thickness skin grafts (4x4cm harvested 0.0012in depth using an air dermatome) of the most commonly used meshing ratios (1:1, 1:5:1, 2:1, 3:1, 4:1, and 6:1).

Results

We had a total of 18 patients resulting in 86 measurements. The study population consisted of 12 males and 6 females; 89% white, 11% non-white; average age of 43 years (SD 21.2). The true mesh ratios of 1:1, 1.5:1, 2:1, 3:1, 4:1, and 6:1 meshers were found to be 1.20 (SD 0.14), 1.55 (SD 0.32), 1.68 (SD 0.32), 2.62 (SD 0.51), 2.87 (SD 0.92), 4.94 (SD 1.35), respectively. The percent errors were 20.2%, 3.3%, -15.8%, -12.5%, -28.3%, -17.7% respectively.

Conclusions

Mesh ratios of 2:1 meshers and above established by manufacturers are inaccurate. Therefore, overestimation of 2:1 meshers and above is recommended. We recommend an overestimation of 10% or more for meshers 2:1 and above.

Applicability of Research to Practice

This has significant applicability to practice as it can affect surgical decisions related to estimating the extent of donor area needed to cover skin and soft tissue defects.
790 Venous Thromboembolism Prophylaxis in Burn Patients: Analyzing the Effectiveness of a Standardized Protocol
Authors: Folliard Sarah A , Gabbert Jared L , Thompson Callie M
Published: March 2020

Introduction

Burn patients have a high risk of developing venous thromboembolism (VTE) due to extensive immobilization, surgical interventions, endothelial injury, and the presence of polytrauma. Studies have shown VTE rates ranging from 0.25% to 23.3% in this patient population. Although burn patients have a greater risk for VTE compared to other hospitalized patients, there are no standardized guidelines on how to approach VTE prophylaxis in the burn population. In March 2018, the Burn Intensive Care Unit (BICU) implemented a new VTE prophylaxis protocol that stratified patients based on risk factors for VTE. Patients were started on enoxaparin 30mg every 12 hours or 40mg every 12 hours depending on body mass index (BMI). The purpose of this study was to examine compliance with the new protocol and overall rates of VTE in the burn population.

In March 2018, the Burn Intensive Care Unit (BICU) implemented a new VTE prophylaxis protocol that stratified patients based on risk factors for VTE. Patients were started on enoxaparin 30mg every 12 hours or 40mg every 12 hours depending on body mass index (BMI). Patients with impaired renal function or a contraindication to enoxaparin were given LDUH 5,000 units every 8 hours. The purpose of this study was to examine compliance with the new protocol and overall rates of VTE.

Methods

A single-center, retrospective analysis was conducted from March 1, 2018 to July 31, 2018. Patients included were admitted to the BICU with a documented burn injury for at least 48 hours and were ≥ 18 years of age. The primary outcome was compliance with the VTE prophylaxis protocol. Secondary outcomes included reasons for non-compliance and incidence of VTE events.

Results

Out of 105 patients that met inclusion criteria (median age, 53 years [36 to 63]; BMI 27.1 kg/m2 [25.7 to 33.2]; total body surface area 6% [3% to 18%]), the protocol was correctly utilized in 81 patients (77%). The most common reason for non-compliance to the protocol was incorrect dosing (60.9% [14/105]). Of 105 patients, 1 (0.9%) developed a VTE.

Conclusions

Overall, the compliance to the Burn Intensive Care Unit VTE pharmacologic prophylaxis protocol has room for improvement. Despite following the protocol, one VTE event occurred during the five-month study period. To improve compliance, additional education and training regarding the dosing of and monitoring anti-coagulants was provided to nursing and medical staff.

Applicability of Research to Practice

Although protocols can improve consistency of health care, reduce costs and improve health outcomes, they must be properly utilized in order to see the benefits. Successful implementation of protocols requires a multistep approach that includes a strong quality improvement process, multidisciplinary buy-in, ongoing education efforts, and assessment to review adherence to and efficacy of the protocols themselves.
820 Transgender Patients with Assault by Burn
Authors: Sanchez Uriel J , Sheckter Clifford C , Karanas Yvonne L
Published: March 2020

Introduction

The transgender population is estimated at 25 million worldwide and 1 million in the United States. Transgender individuals or those experiencing gender dysphoria are at a higher risk of intimate partner violence and assault (60%) as well as suicide (40%), with reports of 18 transgender individuals killed this year alone in the United States. Trauma and burn care providers need to be aware of this population’s unique medical and surgical needs. To our knowledge, we describe the first reports of burn injuries in transgender patients.

Methods

We performed a retrospective review of all transgender or gender dysphoric patients admitted to a regional burn center from 2010 to 2019 with a major burn diagnosis (>20% total body surface area). Patients were identified by International Classification of Disease codes in addition to self-identification at time of admission. We describe the mechanism of injury, circumstances surrounding the incident, hospital course, disposition at discharge, and outcomes in clinic follow up.

Results

The cohort consisted of two patients who were transgender females (i.e. born biologic male and identified as female), aged 31 and 36. Both patients were homeless and had histories of substance abuse and mental health issues. The burn sizes were 20% and 80% and both were flame injuries. One was injured by her domestic partner. The other was injured in a tent fire from a camping stove. The 20% TBSA patient underwent 3 surgeries and was discharged to medical respite on PBD #55. The 80% TBSA patient underwent 9 surgeries and was discharged to inpatient rehabilitation on PBD #75. Regarding their transgender medical care, neither patient was actively being treated by a medical professional although they both reported taking estrogens. Neither patient had undergone transgender surgery. Hormone therapy was not continued during their hospital stay due to lack of information surrounding prior use and limited knowledge regarding the safety of hormonal therapy during burn treatment. Both patients were initially lost to follow up but subsequently reentered our health care system. Both patients have since been referred to our county transgender clinic and are now actively followed by a transgender provider.

Conclusions

Transgender patients are at high risk for violence and assault, which includes burn. These patients are more difficult to identify and may have inadequate transgender medical care. Burn providers of all levels should be aware of the unique needs of this population and involve transgender medical providers in the acute and rehabilitative care when feasible.

Applicability of Research to Practice

Raise public awareness regarding assault by burn in the transgender population.