bluuebunny/crossref_metadata_2025_split huggingface dataset:
591 Cost Savings in Operative Burn Care
Authors: Williams Tracy L , Voycik Meaghan , Ziembicki Jenny A 
Published: March 2020

Abstract

Introduction
“Over the past 30 years, techniques of early excision and grafting along with enhancement of critical care have significantly improved survival following severe burn. Despite these advancements, large volume blood loss associated with surgical intervention continues to be a challenging aspect of burn surgery.” (Sterling, 2011)
“Estimates of blood loss in adults during burn surgery range from 196 to 269 ml for each percent of the body surface area excised and grafted.” (Cartotto, 2000)
A gold standard to achieve hemostasis does not exist. Therefore, institutions rely on their habit, practices, and FDA guidelines to formulate a standard of care. (Groenewold et al, 2011) In multiple comparison studies, “telfa pads soaked in epinephrine solution are a mainstay of hemostasis.” (Sterling, 2010)
In 2018, an epinephrine shortage led to an increase cost to the operating room (OR) during the surgical treatment of burn wounds.
This prompted the pharmacy and OR to collaborate on a more cost-effective measure without compromising patient care.

Methods
In November 2018, the epinephrine dosages were modified. Dosages were changed from Epinephrine 1;1000, 1mg/ml, 60mg/L for adults and 30mg/L for pediatrics to Epinephrine 1:1000, 1mg/ml, 30mg/L for adults and 15mg/L for pediatric patient’s.
Parameters were set as to the amount of product that would be preordered from the pharmacy for each patient based on the total body surface area to be excised and or grafted:
Should additional quantities be needed, an arrangement was made that the pharmacy would prepare and deliver the solution to the OR within 15 minutes of order to avoid delays in treatment. The time periods examined were: June 1, 2018 though November 7, 2018 and November 8, 2018 through June 20, 2019. Total burn patients requiring surgical intervention admitted during this time frame were 180 and 184 patients. June 2018-November 2018 represents previous practice. November 2018-June 2019 represents the implementation of changes in epinephrine dosage and establishing parameters for ordering.

Results
The overall Cost Savings In Operative Burn Care in relation to decreasing the dosage of Epinephrine from November 2018 to June 2019 was $100,952.25.
Setting parameters provided better estimation of need and resulted in a 26% decrease in ordered product.
Better estimation of product led to a 9.3% decrease in waste.
Decreasing waste led to a savings of $28,463.61.
Monthly cost to the OR for Epinephrine solution decreased to $9708.30 per month indicating a savings of $26,291.70 per month.

Conclusions
Operative costs decreased therefore leading to departmental savings.

Applicability of Research to Practice
Burn wound hemostasis was accomplished using reduced doses of Epinephrine solution.
Nurses have a clearer picture on the amount of Epinephrine solution to order for each patient.
The amount of product waste was reduced.
615 Bacterial Nanocellulose as Cooling Agent
Authors: Luze Hanna , Holzer Judith , Tiffner Katrin , Kainz Sonja , Reisenegger Peter , Nischwitz Sebastian P , Funk Martin , Birngruber Thomas , Mautner Selma , Kamolz Lars-Peter 
Published: March 2020

Abstract

Introduction
Cooling of burn injuries is most important, not only to reduce pain but also to reduce the intradermal damage as well as the burn wound conversion. Studies have shown that cooling for about 20 to 30 minutes using only plain tap water at moderate temperature is most efficient resulting in least intradermal damage. However, many burn injuries reach the hospital without any pre-clinical cooling, possibly due to the lack of a cooling agent. After a pilot study, we investigated if a bacterial nanocellulose (BNC)-based wound dressing containing about 95% water can cool a burn injury and if so the effect suffices to reduce the damage in the skin.

Methods
Skin explants from human donors were burned with inflicted a contact burn injury, of which half were treated with a BNC-based wound dressing and a paraffin gauze dressing. Intradermal temperature sensors measured the temperature changes in the dermis over the course of 24 hours. Biopsies were taken for histological evaluation at different time points.

Results
The intradermal measurements show high temperature spikes at the moment of the burn injuries. After the application of a BNC-based wound dressing the intradermal skin temperature was significantly reduced. The area under the curve in the treated group was significantly less than the untreated. The histological assessment showed according results with less damage in the treated group in comparison to the untreated.

Conclusions
Bacterial nanocellulose-based wound dressings with high water content significantly lower the intradermal temperature after a contact burn and reduce the thermal damage inflicted to the skin. A secondary dressing that permits the water to evaporate slower additionally prolongs the cooling effect. The use of such a wound dressing could find use in a preclinical setting where other cooling options are not available.

Applicability of Research to Practice
The findings of this experiment should be tested in an in-vivo setting prior to clinical use to investigate the possibility of inducing hypothermia with this treatment.
621 Successfully Advocating to Make Microwave Ovens “child-resistant” to Protect Young Children from Severe Scalds
Authors: Robinson Marla R , Quinlan Kyran , Lowell Gina , Gottlieb Lawrence , O’Connor Annemarie , Cowles Nancy A 
Published: March 2020

Abstract

Introduction
Scald burn injuries are the leading cause of burn-related emergency room visits and hospitalizations for young children. An increasing portion of these injuries occur when children are removing items from microwave ovens. Many of these occur on the face/chest and can have lifelong physical, functional, aesthetic and psychological consequences. Over the past 15 years we have published a series of studies supporting our advocacy for a change in microwave oven design to protect children from severe scalds. Requiring microwave oven doors to be more difficult for a child to open would help to protect young children from these types of burn injuries. Our analysis of the National Electronic Injury Surveillance System found an estimated 7000 young children were treated in US emergency departments over the last decade for burns suffered when the child opened a microwave oven door and spilled the heated contents. This report describes our continued research and advocacy to finally get a regulatory agency to pass a “child-safety” mechanism for opening microwave doors.

Methods
In the United States, microwave ovens must meet the published microwave standard administered by Underwriters Laboratories (UL 923). In 2013, we formally proposed a change in the standard which underwent a voting process by the Standards Technical Panel. Microwave makers are well represented on the panel. This attempt did not pass. We continued to publish focused research, presented at national meetings, enlisted engineering students to design “child-resistant” microwave doors to demonstrate feasibility, and created a video to put a face to the statistics. In 2017, we became active members of a National Task Group convened by UL, and two authors became voting members on the 17 member microwave Standards Technical Panel. A new proposal was introduced by the Association of Home Appliances Manufacturers requiring “two distinct actions” to make it more difficult for a young child to open a microwave oven door. Multiple concerns were addressed including those related to the impact on seniors. We lobbied members who appeared undecided.

Results
On September 17, 2018, the UL 923 STP voted by a narrow margin to pass the measure. In the future, new microwave ovens sold in the United States will be required to be made with “child-resistant doors”.

Conclusions
Research and advocacy work together to protect children. Child scald risk will be reduced as microwaves with child-resistant doors replace current models.

Applicability of Research to Practice
Our research demonstrated that very young children are able to open microwave ovens putting them at risk for burn injuries. We worked diligently through various advocacy channels to actively improve the safety of microwave ovens. With the approved changes for future microwave design requirements, research and advocacy have now resulted in practice changes.
639 Face Masks - The Negative Impression Makes a Positive Impact
Authors: O’Rourke Cassandra 
Published: March 2020

Abstract

Introduction
Providing timely and appropriate pressure to prevent/address hypertrophic scarring for burn survivors is an ongoing challenge. From time of measurement to obtaining a custom compression garment can be several weeks requiring creative solutions to providing interim pressure, particularly in the pediatric population and even more challenging for a facial burn scar. Historically, fabric custom garments were ordered, then with the advancement of silicone lined materials, clear facial masks could be fabricated. This process started with taking a plaster cast of the survivors’ face, frequently using sedation to allow for optimal fitting, but sedation can change the tone of the facial muscles adding to the challenge. With the advancements in technology, less invasive, more accurate, and more timely fabrication of face masks is possible.

Methods
A 3D picture was taken of a 14-month-old pediatric burn survivor with hypertrophic scarring on the face. This image was uploaded to a 3D printer and a positive print (facial surface down) was completed. The positive print was used to make an alginate mask and plaster was poured to create a casting of the positive printed face. A check mask was pulled from this positive plaster cast (+ mask). This check mask was too large for the patient’s face. To have a better fitting mask, another approach to the mask fabrication was completed. From the same 3D picture, a negative print (facial surface up) was completed. Plaster was poured directly into this negative print to create a casting of the negative printed face. A check mask was pulled from this negative plaster cast (- mask). Both check masks were fit to the patient to assess for accuracy of fit and estimation of required adjustments for optimal fit.

Results
There was a significant difference in the fit of the two masks created from the same 3D picture. The mask pulled on the positive casting was too large. The required adjustments to have the mask fit properly to provide appropriate compression to the hypertrophic scarring on the face would have been extremely difficult and time consuming to complete. The mask pulled on the negative casting fit well and only required small adjustments to ensure adequate pressure would be provided to the focused areas of hypertrophic scars on the face.

Conclusions
With advances in technology, 3D photography partnered with 3D printing allow for significant improvement in the accuracy of fitting facial masks, improve timeliness of compression, and improve the patient experience in the process of obtaining a facial mask.

Applicability of Research to Practice
The availability of technology can allow burn survivors to receive compression for facial scars in a faster, more accurate, and patient friendly manner to allow for early intervention to prevent and/or improve facial hypertrophic scarring. From the 3D picture to mask fitting can be as little as 48–72° as compared to several weeks with historical methods.
711 A Retrospective Review of Enoxaparin Dosing Practices in Burn Patients
Authors: Quan Asia N , Aden Aisha , Islas Claudia , Richey Karen J , Foster Kevin N 
Published: March 2020

Abstract

Introduction
Enoxaparin, a low molecular weight heparin, has been proven to safely and effectively prevent venous thromboembolism (VTE) in acutely ill patients. Burn patients may be particularly vulnerable to the occurrence of a VTE due to prolonged immobility, frequent operating room procedures, and low flow states. Treatment of acute VTE is associated with a direct medical cost of $12000-$15000 and subsequent complications increase costs to $18000 to $23000 per case. Current institutional protocol for initiation of enoxaparin an all burn adult patients is 40 mg administered subcutaneously every 12 hours. Anti-Xa levels are used to monitor anticoagulation prophylaxis, with 0.3–0.5 U/mL recognized as the prophylactic range. Doses are subsequently modified in 10 mg increments to achieve goal prophylaxis anti-Xa levles. The purpose of this study was to evaluate current practice (CP) and assess if the implementation of a published enoxaparin dosing algorithm could minimize delay in achieving anticoagulation prophylaxis.

Methods
A retrospective chart review was performed of 94 adult burn patients. The doses and time required to reach goal prophylaxis anti-Xa levels using current practice (CP) were compared to the predicted algorithm dose (AD). The number of dose adjustments and the number of days needed for adjustments for CP were documented. Charges related for laboratory determinations and medication administration were calculated.

Results
Of the 94 patients reviewed, the average age was 47 years, the majority were male (74%), mean actual weight 92 kilograms and mean TBSA 15.7%. The most common mechanism of injury was flash/flame (63%) with 18% suffering an inhalation injury. On average, using CP, it took 9.3 days to get to goal prophylaxis anti-Xa levels, with a mean of 2.86 anti-Xa lab tests needed and an average prophylactic dose of 55.5 mg. A total of 360 labs draws were performed and 74% were timed correctly. The CP average starting dose was lower than the AD 40 mg versus 45 mg (p &lt; .0001). If the algorithm had been used the number of dosing adjustments would have been 25% less. The algorithm overestimated the starting dose in only 2.1% of the population. The average charges until goal was met for enoxaparin were $2,933 and $787 for anti-Xa levels.

Conclusions
This study demonstrates increased clinical efficacy and cost-effectiveness for an algorithm driven enoxaparin dosing regimen for burn patients. Prospective study with larger patient numbers is warranted.

Applicability of Research to Practice
Increased efficacy combined with decreased cost for an new enoxaparin dosing regimen.
721 Treatment of Hypertrophic Burn and Wound Scars Using a Novel Cold Laser System
Authors: Tsai Jenn , Bendjemil Samy , Dowling Colin , Poulakidas Stathis 
Published: March 2020

Abstract

Introduction
Hypertrophic scars are seen in 70% of individuals after a burn. Survival from acute burns have psychosocial and functional challenges. Hypertrophic scars contain disorganized whorls of collagen, an increase in occluded blood vessels resulting in raised discoloration, inflamed dermis/epidermis and painful sequelae. Management of such scars have been limited to invasive and non-invasive management. One innovative technology is a non-invasive high-intensity laser operating at 1275 nm and 74 Watts, optimizing increased depth of penetration into the tissue utilizing photomechanical effects to biostimulate tissue to heal and regenerate. We present a series of 10 patients.

Methods
10 patients were enrolled with hypertrophic scarring secondary to deep partial or full thickness burns. Hypertrophic areas were identified and numerical pain scale, Vancouver Scar Scale and the World Health Organization Quality of Life score were recorded. The non-contact, high-intensity laser was passed over the hypertrophic scars, continuously moving the laser over the entirety of the scar. Each area of hypertrophic scar tissue was lasered for progressively longer sessions, reaching a therapeutic time of 10 min in each section.

Results
Patients were utilizing previously known non-invasive therapies for scar reduction, such as, compression garments, scar treatment ointments, as well as steroid injection and non-medical therapies such as acupuncture. In our series, 90% of the patients reported decrease in scar pain, inflammation, pigmentation and improved pliability by the second treatment. Decreased scar height was identified by the eighth session, where conventional protocols could require months to years before any changes were observed. Changes in the scars were even identified after the normal time period identified for maximal improvement using conventional burn therapies. In a survey presented to patient, even pain was improved, identified with reduction in narcotic/NSAID use in patients undergoing the therapies.

Conclusions
Non-invasive high-intensity laser therapies are useful adjuncts for reduction of hypertrophic burn scars. Our case series presents a treatment option in patients that have functional, physical and cosmetic challenges. We anticipate broader applications for hypertrophic burn scar reduction utilizing adjunctive non-invasive laser therapy, reducing the need for invasive scar revision and limiting psychosocial strain.

Applicability of Research to Practice
In this case series, non-invasive high-intensity laser therapy provided timely decrease in hypertrophic scar characteristics in an outpatient setting. Thus, leading to decrease in invasive operative therapy and overall improvement in quality of life. Further studies are needed to elucidate other benefits and utility of the laser and possible evaluation of keloid scars.
864 Perioperative Multimodal Analgesia Reduces Opioid Use Following Skin Grafting in Burn Patients
Authors: Gibson Angela , Lennertz Richard C , Zimmerman Haley , McCormick Timothy , Faucher Lee 
Published: March 2020

Abstract

Introduction
Burn injuries cause severe pain and patients often require high doses of opioid medications. Pain management is particularly challenging during dressing changes and following skin grafting procedures. Non-opioid analgesic medications and multimodal analgesic strategies have been promoted to improve pain management and decrease opioid use.

Methods
We performed a retrospective chart review to identify burn patients who underwent autologous skin grafting procedures between January 2011 and June 2018. We included patients who underwent were 18–80 years old and were inpatients for at least 24 hours before and after their procedure. We excluded patients who remained intubated in PACU, had surgery the day prior or had active opioid prescriptions prior to their hospitalization. We evaluated the effect of different non-opioid analgesic medications on opioid use following a skin grafting procedure. The primary outcome measure of this study compared opioid use 24 hours before skin grafting to 24 hours after skin grafting.

Results
We found that most patients (69%) reported severe pain (NRS ≥7) immediately after autologous skin grafting. On average, patients required an additional 54 mg of oral morphine equivalents (ME) in the 24 hours after the procedure compared to the 24 hours before. The use of perioperative non-opioid analgesia varied between patients (Acetaminophen 29%, gabapentin 29%, ketamine 33% and all three 8%). Patients who received either gabapentin or a combination of acetaminophen, gabapentin and ketamine had a smaller increase in their opioid use than patients who did not receive the medications (-24 ME, CI -46, -3 and -40 ME, CI -75, -5 respectively).

Conclusions
Burn patients who received perioperative acetaminophen, gabapentin and ketamine required relatively less opioid following their skin grafting procedure.

Applicability of Research to Practice
These results support the use of multimodal analgesia for perioperative analgesia in burn patients.
867 The Effect of Financial Reward on Opioid Use After Thermal Injury to the Upper Extremity
Authors: Coffey Rebecca , Schubauer Kathryn , Xiang Henry , Bailey John Kevin 
Published: March 2020

Abstract

Introduction
The widespread use of opioids for the treatment of pain has come under progressive scrutiny in an attempt to address multiple unintended consequences. Despite multiple psychological, social, biological, and legal factors that contribute to pain management strategies, narcotics remain a mainstay for the treatment of burn-pain. As efforts are underway to test novel methods for mitigating pain, it is essential to clearly define models for testing these tools and strategies. This study examines the impact of financial incentives alone on the use of opioids at a single center.

Methods
Patients with thermal injury to the upper extremity, managed as outpatients, no more than three days from the date of injury and were prescribed the state-encouraged narcotic dosage of no more than 4 tablets (oxycodone, 5mg) per day for no more than 7 days were included. Enrolled patients (n=33) then answered a series of descriptive questions, completed the QuickDASH and had grip strength measurements of each hand. Patients were randomized to one of two groups. Both groups were offered a financial incentive to return a completed pill diary. One group (Incentivized- IC) was offered the possibility of additional financial incentive for each unused oxycodone tablet returned at one week follow up. Only patients who presented a completed pill diary were included in analysis (n=23).

Results
The Unincentivized (UIC)(n=13) and IC (n=10) were similar age, gender race, ethnicity, mean burn size (1.72% TBSA) and completed level of education. Mechanism of injury was predominantly scald burns (17 scalds, 5 flame injuries, 1 contact injury). Mean difference in grip strength between hands was similar between study groups at enrollment for both UIC and IC patients (-16.60 ±15.92lbs p=0.32,-16.45 ± 12.681lbs p=0.21). The initial QuickDASH scores (15.6lbs, SD 24.6 vs. 7.3lbs SD±10.4 p=0.01) were significant between groups. At one week follow up the difference between grip strength in each hand had improved similarly in each group (-13.16 ±19.71lbs p = 0.51vs. 3.07 ±19.44 lbs, p=0.87 and the increase in QuickDASH score was similar (34.83 SD 23.90 vs.46.09 SD 30.67 p=0.33). The UIC group used a mean of 2.5 tablets/day (±1.5 tab/day) versus the IC group used 2.1 tablets/day (±1.5 tab/day), p=0.46.

Conclusions
Modest financial incentives do not appear to alter opioid use for acute pain from thermal injury involving the upper extremity. These results support the use of financial rewards, which may encourage participation in future studies without independently affecting opioid use. Finally, it also appears that our state’s encouragement of more stringent prescription practices is appropriate for this mechanism of injury.

Applicability of Research to Practice
Ongoing research is needed to identify the best tools to decrease use of opioids in acute injury.