bluuebunny/crossref_metadata_2025_split huggingface dataset:
66 The Effect of Transfer on Outcomes in Burns
Authors: Bruenderman Elizabeth , The Selena , Bodily Nathan , Bozeman Matthew 
Published: March 2020

Abstract

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 &lt; 0.01). Directly admitted patients were more likely to have inhalation burn (18 vs. 4, p &lt; 0.01), require intubation after admission (10 vs. 2, p = 0.03), require an emergent procedure (18 vs. 5, p &lt; 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

Abstract

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

Abstract

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

Abstract

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

Abstract

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 &gt;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

Abstract

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 &lt; 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

Abstract

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

Abstract

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

Abstract

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 &lt; 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 &lt; 0.05). Interestingly, hypertension had a protective effect (OR = 0.24, p &lt; 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 &gt;20%. LOS ratios prove to be useful benchmarks for burn units with TBSA &gt;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.