bluuebunny/crossref_metadata_2025_split huggingface dataset:
100 Use of the PHQ-2 as a Depression Screening Tool to Meet BQUIP Guidelines
Authors: Keatley Eva , Blayney Carolyn B , Wiechman Shelley A 
Published: April 2021

Abstract

Introduction
In 2015, the Burn Quality Improvement Program (BQUIP) guidelines were established with recommendations for 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. After a year of collecting data, we have been able to evaluate the program and make recommendations for other burn centers.

Methods
All patients admitted to the inpatient burn service who were over 12 years of age 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 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 inability to regain consciousness, and 116 (24%) were not screened for unknown reasons. The remaining patients, 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. Of the 28 that screened positive, 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. A 77% screening rate is high for a trauma setting. 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 (4%) but a similar rate to what is reported in the literature of burn survivors who are 5- and 10-years post burn injury. 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. We will be discussing utilization of resources for providing inpatient services to patients with a positive screen.
102 Early Palliative Care Consultation in the Burn Unit: Increasing Utilization and Areas for Improvement
Authors: Carmichael Heather , Mather Sarah E , Smith Tyler M , Duffy Patrick S , Wiktor Arek J , Lambert Wagner Anne L 
Published: April 2021

Abstract

Introduction
Despite significant morbidity and mortality for major burns, palliative care consultation (PCC) is underutilized in this population. While use of PCC is increasing, a prior study showed that less than 2% of patients with major burns had PCC during admission. The purpose of this study is to examine the impact of a protocol using recommended “triggers” for PCC at a single academic burn center.

Methods
This is a retrospective review of patient deaths over a four-year period (9/2016–8/2020). Use of life-sustaining treatments, comfort care (de-escalation of one or more life-sustaining treatments) and do not resuscitate (DNR) orders were determined. Use of PCC was compared during periods before and after a protocol establishing recommended “triggers” for early (&lt; 48 hrs of admission) PCC was instituted in 2019. Triggers included Baux score &gt; 100 and/or complex decisions about treatment including need for cardiopulmonary resuscitation (CPR)/renal replacement therapy (RRT)/vasopressors, or at least two of the following: age &gt; 70, major comorbidities, disagreement amongst family/patient/providers about best course of treatment, or no longer meeting expected milestones.

Results
A total of 33 patient deaths were reviewed. Most patients were male (n=28, 85%) and median age was 62 years [IQR 42–72]. Median Baux score was 112 [IQR 81–133]. Eleven patients (33%) had major comorbidities. Many patients had life-sustaining interventions such as intubation, RRT, or CPR, often prior to admission. Amongst patients who survived &gt;24 hrs, 67% (n=14/21) had PCC. Frequency of PCC increased after protocol development, with 100% vs. 36% of patients having PCC before death (p=0.004). However, even during the later period, only half of patients had early PCC despite meeting criteria at admission.

Conclusions
Frequently, initiation of life-sustaining measures in severely injured burn patients occurs prior to or early during hospitalization. Thus, early goals of care discussions are valuable to prevent interventions that do not align with patient values and assist with de-escalation of life-sustaining treatment. In this small sample, we found that while there was increasing use of PCC overall after developing a protocol of recommended “triggers” for consultation, many patients who met criteria at admission did not receive early PCC.
103 A Retrospective Review of the Utilization of Burn Admission Criteria
Authors: Foster Kevin N , Krueger Larisa M , Richey Karen J 
Published: April 2021

Abstract

Introduction
Evidence-based criteria for burn patient admission are poorly defined. Attempts have been made by commercial entities to align payors and providers with evidence-based admission criteria to optimize resource use. However, these admission criteria have not be examined critically to see if they are appropriate and effective. We developed an admission criteria algorithm based on these existing standards and have utilized it for nearly 18 months. The purpose of this study is to retrospectively review this algorithm with respect to inpatient needs and outcome to assess its effectiveness.

Methods
A retrospective chart review of patients admitted the burn center over a 1-year period was performed. Incomplete datasets were excluded. Patients were grouped by TBSA, &lt; 10%, 10–20% and &gt; 20%. Appropriateness of admission was measured used length of stay (LOS) as surrogate marker, hospitalizations of &lt; 3 days, unless deceased, were deemed inappropriate (IAP) and 3 days or more as appropriate (AP).

Results
There were complete datasets for 530 patients, &lt; 10% (n=423), 10–20% (n= 72), &gt;20% (n=35). There were no significant differences in age, gender, or payor sources between the groups. Patients with larger TBSA burns were more likely to have suffered a flame/flash injury. All patients in the two larger TBSA groups met admission criteria per algorithm. All IAP were in the &lt; 10% group. When compared to AP, IAP were younger, 31.6 vs. 44.0 years (p&lt; .0001), had smaller TBSA injuries 2.8% vs. 3.5% (p=.0045), had fewer clinical findings 1.4 vs 1.8 (p&lt; .0001), fewer interventions 1.8 vs 2.6 (p&lt; .0001) but were more likely to have suffered burns to the head 30% vs 13% (&lt; .00001) and neck 9% vs 3% (=.0164). AP patients were more likely to have suffered contact burns 27% vs. 17% (p=.0323), full-thickness injuries 39% vs 14% (p&lt; .0001), involvement of a major joint 42% vs 29% (p=.0085), combined burn and trauma 3% vs. 0% (p=.0444) and burns to the buttocks 7% vs 2% (p=.0357). AP patients were also more likely to require IV analgesia 82% vs 71% (p=.0107) and evaluated as likely needing surgery 82% vs 15% (p&lt; .00001).

Conclusions
The admission criteria algorithm performed perfectly in patients with a ≥ 10% TBSA injury. For patients with burn &lt; 10% TBSA the algorithm was not followed as closely leading to some inappropriate admissions. Patients with smaller burns admitted appropriately were more likely to have full thickness burns, contact burns, burns over joints and to require surgery. The algorithm was highly accurate in patients with large burns, however additional refinement is needed for those patients with smaller burn injuries.
104 A Quality Improvement Project to Reduce Orthoses Complications
Authors: Martinez Andria , Warthman Renee , Murray Derek , Hazak Kristin , Foster Kevin N 
Published: April 2021

Abstract

Introduction
Anatomical structures of the hand are complex and delicate making hand burns particularly challenging to manage. Orthoses are a cornerstone treatment modality and unsuccessful therapeutic interventions can result in hand contracture and deformities, which can result in up to 95% impairment in upper extremity function. Therapists at our burn center have varying degrees of education and credentials, and we had noticed increased incidence of orthotic induced complications in the hand. The purpose of this QI project was to implement a formal protocol that provided guidelines around fabricating and fitting hand orthoses.

Methods
The protocol mandated that custom fabricated resting hand orthoses should be fabricated by a single CHT or co-fabricated by two (non-CHT) therapists. Orthoses were fabricated as indicated. Orthosis modifications and orthosis complications, defined as erythema and/or an orthotic induced partial-thickness injury to the volar second metacarpal head (index finger) were documented. For the purposes of our study, breakdown was limited to the index finger. These modifications and complication totals were compared to pre-implementation data. Any patient with missing data points was excluded.

Results
Seventy-seven patient hands were examined from 2016–2019. Prior to implementation of the protocol, erythema occurred with 23.4% (n=18) of orthoses and orthosis induced partial thickness injury was found in 11.7% (n=9) of cases. Post protocol implementation involved examination of 51 hands. Erythema occurred in just 2.0% of cases (n=1) and partial thickness injury in 3.9% of cases (n=2) This represents a decrease of 94.4% and 77.7%, respectively. Number of modifications was reduced by 40.9%, from 22 to 13.

Conclusions
Orthosis fabrication is a specialized therapy skill, requiring hands-on training and advanced anatomical knowledge. While orthotic fabrication is part of general therapy education, the depth and breadth of this education is limited by the clinical opportunities presented to each therapist. CHT’s have undergone rigorous study and testing to make them experts in orthosis management and can bolster skills in a burn therapy department. For therapists without this specialty certification, co-fabrication can also lead to improved outcomes, through real time peer review. Data from this QI project showed a statistically significant decrease in erythema and decrease in breakdown and number of modifications needed from utilization of either a CHT or two therapists when managing hand orthoses.
107A Quality Improvement Process for Donning Custom Garments for the Burn Patients
Authors: Coffey Rebecca , Shepler Amanda , Cordova Alfredo 
Published: April 2021

Abstract

Introduction
Long term sequela of burn injuries include the development of scars leading to psychological, emotional, functional, and physical disabilities. There are multiple modalities for scar management including compression garments, topical silicone, orthotics, laser therapy, surgical releases, and medical treatment for symptom management. Multiple studies have found custom garments are a viable option to aid in improvement of range of motion, scar pliability, vascularity, color, height of scar, and improvement in appearance. Timing of garments is critical to the success of the treatment. The purpose of this quality improvement project is to develop an effective and efficient process to improve time to burn garment application.

Methods
At one verified ABA Burn Center, a retrospective chart review included adult burn patients, to compare the time for donning custom garments in the outpatient setting pre- and post-process improvement project. Pre-process improvement data was collected between October 1, 2018 and June 30, 2019. Post-process data collection carried from November 1, 2019 to August 31, 2020. A group including burn therapists, program manager, providers, and clinic staff met to identify the current practice and develop an improved workflow. An excel spreadsheet was developed to track key data points for continued improvement.

Results
A total of 33 patients were included in the initial pre-process improvement group (27 initial orders, 6 reorders) and 39 in the post-process group (24 initial orders, 15 reorders). The mean number of days for patients to receive their initial garment order was 98 days (range 19- 280) pre-process and 45.6 days (range 15 – 106) post-process (p = 0.0001). For reorders, mean days for receiving the garment was 37.3 days (range 19–70) preprocess and post process was 19.5 days (range 9–15) p = 0.039. Pre-process delays were related to packets not sent to vendor in a timely manner, necessary paperwork missing when sent to the vendor, lack of follow up for the status of the garment, insurance coverage, and staff being unaware of garment arrival. The major reason for delays with receiving garments in the post-process period was issues with insurance payments.

Conclusions
A defined, stepwise process may improve time to garment donning by patients. Support from insurance billing may further help improve this process.
109 Outpatient Nursing Care Charges: A Process Improvement Project
Authors: Caffey Carmen , Jeffries Anthony , Zelikoff Allison J , Chambers Mona , Stewart Barclay T , Pham Tam N 
Published: April 2021

Abstract

Introduction
High wound care complexity in a burn clinic mandates adequate nurse staffing and expertise to manage increasingly large wounds as outpatient. To achieve these service needs, appropriate charge capture is important for revenue generation. Our burn clinic performed a process improvement (PI) project using a Plan, Do, Study, Act (PDSA) cycle to improve the accuracy of charge capture for wound care episodes over the past 2 fiscal years (FY).

Methods
In the first phase (PLAN), we reviewed charges by 1-month sampling in FY20. We engaged stakeholders (medical and nursing providers, managers, revenue integrity and compliance teams) through iterative meetings. We performed a stakeholder analysis to identify their level of engagement, influence, and attitudes toward this PI. We next devised strategies for stakeholders to champion the project. The team developed and trialed the process by focusing on burn wound care Common Procedural Terminology (CPT) codes. In FY21, nurses began to enter CPT codes in accordance with burn wound care performed (DO). We then repeated a 1-month sampling of charges in FY21 (STUDY). We are now consolidating the new strategy, refreshing stakeholder engagement, and expanding it within our hospital (ACT).

Results
We identified multiple billing errors and opportunities to improve CPT code documentation for nursing wound care procedures in FY20. Stakeholder interviews revealed a gap between accurate billing and current practice. We proposed to alter the wound care billing workflow. Stakeholder engagement was high and well-represented among professional disciplines. In FY21 implementation, clinic nurses received the clinic coding in-service and were oriented to resource tools. We verified billing practice adherence via the institutional compliance department. FY21 sampling indicated a marked increase in accurate charges for burn wound care in the clinic (net+ $36,691). We have implemented real-time audits, identified and documented problems as they arise, and obtained feedback from nurses. The clinic is investigating non-burn wound care charge capture and has disseminated our findings through institutional shared governance.

Conclusions
The financial performance of outpatient burn nursing needs to be closely evaluated in today’s shifting healthcare environment. Using a PDSA process led by nurses, the accuracy of charge capture for complex wound care has substantially improved and led to increased revenue. This model is potentially translatable to other specialty clinics.
118 The Clinical and Demographic Predictors Associated with Physical Function in Pediatric Burn Survivors: A Burn Model System National Database Study
Authors: Ukoha Chiamaka J , Suman Oscar E , Schneider Jeffrey C , Ryan Colleen M , Kowalske Karen J , Roaten Kimberly , Diribe Chizorbam N , Gibran Nicole S , Stewart Barclay T 
Published: April 2021

Abstract

Introduction
Burns are a common pediatric injury, and severe burns can interfere with a child’s physical function. Rehabilitation for these patients continues to evolve; however, little is known about how clinical and demographic factors affect long-term physical function outcomes. This study will evaluate the association between Patient Reported Outcome Measurement Information System-29 (PROMIS) physical function-mobility subscale scores (PF) and various clinical and demographic factors among pediatric burn survivors.

Methods
Data were collected from the Burn Model System National Database (1994–2020) and was compiled from five ABA verified burn centers. The data requested included pediatric self-report PROMIS PF scores assessed at 6 months post-burn. A linear regression model was performed with PF total score at 6 months as the dependent variable and total body surface area (TBSA) burned, age, sex, etiology of the burn, length hospital of stay (LOS), and race/ethnicity as independent variables.

Results
A total of 82 patients between the ages of 8–17 were included in the regression analysis. The mean physical function scores for the participants was 46.2 (SD=11.9), 20.0–57.1 with 50 (SD=10) being the average for the general population. The mean % TBSA burned was 37 (SD=19), 2–90. The regression model revealed an association (n=82; F=7.85; p&lt; 0.001; R2=0.2648) of PF to the predictors LOS (p &lt; 0.001; regression coefficient= -0.18) and White ethnicity compared to Hispanic (p&lt; 0.001; regression coefficient=8.89).

Conclusions
In this study, pediatric burn patients’ self-reported physical function was associated with ethnicity and hospital stay, with longer hospital stay and Hispanic ethnicity resulting in lower PF.
127 Plasma from Patients with Burn Injury Increases Endothelial Permeability In-Vitro
Authors: Keyloun John W , Carney Bonnie C , Nisar Saira , Moffatt Lauren T , Shupp Jeffrey W 
Published: April 2021

Abstract

Introduction
The contribution of endothelial injury to the pathogenesis of burn shock is not well characterized. Human umbilical endothelial cells (HUVECs) have been used to study endotheliopathy in myriad shock states. This work investigates the impact of burn patient plasma on the vascular endothelium and its barrier function.

Methods
HUVECs were seeded into the apical chambers of transwell plates and cultured over 5–7 days to a confluent monolayer which was confirmed by a transendothelial electrical resistance (TEER) of ≥30Ω. After IRB approval, plasma was collected from burn-injured patients 4 hours after admission. Demographic and injury characteristics were collected from the medical record. Plasma Syndecan-1 (SDC-1) was quantified by ELISA. HUVEC monolayers were exposed to 10% multi-donor pooled healthy human plasma (HHP) or burn patient plasma. Monolayers were subsequently incubated with FIT-C Dextran (40,000 kD). FIT-C diffusion through monolayers was measured in basal chamber supernatants. Monolayer permeability was measured with indices calculated by normalizing values to blank (transwell inserts) and HHP-treated monolayer FIT-C diffusion. HUVECs were also cultured on glass slides and exposed to HHP or burn patient plasma. Cells were fixed with 4% Paraformaldehyde and F-Actin was stained with Texas Red-Phalloidin. Intercellular gap area was calculated using imaging software. Differences between treatment conditions were analyzed with Welch’s t-test and one-way ANOVA, simple linear regression was used to characterize the relationship between plasma SDC-1 and permeability indices, significance was set at p &lt; 0.05.

Results
Eight burn patient plasma samples were tested. Patients were mostly male (75%) with a mean age of 50±20 years and mean %TBSA burn of 37±34%. Five burn plasma samples significantly increased monolayer permeability. There were no significant differences between patient samples that increased permeability in age, TBSA, gender, or in-hospital mortality. Monolayer permeability indices increased between 7–15% (p&lt; 0.05) among burn plasma treatment conditions (n=6) that increased permeability. There was a strong relationship between monolayer permeability index (%) and plasma SDC-1 (µg/mL) (p=0.03, R2=0.93). Morphological F-actin rearrangement was apparent on microscopy and intercellular gap area was increased in burn plasma treatment conditions (12% vs. 49%, p≤0.0007, n=6).

Conclusions
Plasma from burn patients induces endothelial damage that increases endothelial cell monolayer permeability. The endothelial biomarker SDC-1 is a reliable indicator of endothelial damage. F-actin rearrangement and an increase in intercellular gap area likely contributes to burn endotheliopathy.
130 Burn Injury Reduces Bone Marrow Mesenchymal Stem Cells and Sensitizes Their Adrenergic Receptor Subgroups in a Murine Model
Authors: Muthumalaiappan Kuzhali , Johnson Maria Camargo , Walczak Julia , Subramaniam Vimal , Baldea Anthony J , Liu Yuk Ming 
Published: April 2021

Abstract

Introduction
Previous burn and traumatic injury studies have established that adrenergic signaling is increased after burn injury and may lead to an impairment of hematopoietic cell development in the bone marrow (BM). Nonetheless, mesenchymal stem cells (MSCs), which have gained momentum in regenerative medicine also play a predominant role in the BM niche. Understanding the propensity of the adrenergic receptor (AR) response by MSCs can be utilized for devising targeted therapies. However, the traditional plastic adherence procedure using ex vivo culture of BM cells for several weeks may skew the actual characteristics of MSCs. Our current study focused on isolating MSCs from freshly obtained BM in a murine scald burn model with a goal to characterize the expression pattern of native AR subgroups present on BM MSCs as compared to sham mice.

Methods
Eight, two-month-old adult female mice were subjected to a 15% total body 3rd degree burn or sham burn. The mice were sacrificed 7 days later. Femurs were removed and total bone marrow cells were flushed out. Multi parametric flow cytometry was used to gate for cells negative for hematopoietic cell markers (CD45, CD11B) and positive for MSC markers (CD105, CD106, SSEA, Ly6A) and AR subgroups (α1, α2, β1, β2, β3). We measured the number of BM MSCs, quantified the subtypes of ARs present on MSCs, and compared the ratio of AR antibody binding per total MSC population.

Results
Overall the frequency of MSCs per million total BM cells decreased by 48% post-burn injury with165,300 ± 194 in sham versus 110,000 ± 30 in burn displayed as bar graph in Panel A. Over 90% of MSCs consistently express β2 AR and only 10% express α2 AR subgroup in both scald and sham burn. Presence of other subgroups ranged from 50% to 80% of MSCs as seen in histograms to the right of dotted line in Panel B. Our AR propensity score based on AR mean fluorescence intensity adjusted to total number of MSCs present was increased by 2.8-fold for α1, 2.5-fold for β1, 1.6-fold for β3, and 1.3-fold for β2 AR subgroups (Panel C). These findings indicate burn injury not only decreases the frequency of BM MSCs but also increases the affinity of certain AR subgroups present on MSCs. Since BM MSCs are the major source of cytokines, chemokines and growth factors; detailed studies on AR mediated signaling in BM MSCs is warranted.

Conclusions
Polarization of AR signaling in BM MSCs by burn-induced catecholamines may have broader implications for comorbidities such as bone resorption and muscle wasting observed in human patients post burn trauma.