bluuebunny/crossref_metadata_2025_split huggingface dataset:
744 The Unhoused Burn Population: An Alarming Increase of Leaving Against Medical Advice and Unplanned Readmissions
Authors: Speiser Noah , Donohue Sean J , Pickering Trevor A , Pham Christopher H , Johnson Maxwell B , Gillenwater Justin , Yenikomshian Haig A 
Published: April 2024

Abstract

Introduction
Unhoused burn patients (UBP) have historically been more likely to leave against medical advice (AMA) and suffer worse health outcomes compared to the general population. The COVID-19 (CV) pandemic has created major strain on the healthcare system that has resulted in worse overall health outcomes in burn patients. Currently, there is sparse data on how UBP have fared since the start of CV. We sought to investigate how CV impacted treatment for UBP, specifically the rate of leaving AMA and unplanned readmissions.

Methods
We conducted a retrospective chart analysis of UBP admitted to a regional burn center from 2014 through 2022. March 2020 was used as the cutoff to separate the cohorts into pre-CV and CV patients. Outcomes studied included leaving AMA and readmission rates within 30 days. Data analysis included distributions of continuous variables using the Wilcoxon rank sum test and dichotomous variables using Pearson’s Chi-squared test.

Results
385 patients met inclusion criteria, of which 130 were placed in the pre-CV and 255 were placed in the CV group. UBP were significantly more likely to leave AMA during CV (19.2% vs. 6.2%, p&lt; 0.001). These patients also experienced a significantly higher 30-day readmission rate during CV (11.8% vs. 4.6%, p&lt; 0.05).

Conclusions
CV has changed the paradigm of many health systems and the approach to treating UBP is no exception. Our findings identify two alarming increases: the rate of leaving AMA and the readmission rate in this population. While the root of this is unclear, these factors represent the inadequate care being provided to this vulnerable patient population. Future research should identify the root causes of these factors and identify early interventions to mitigate them.

Applicability of Research to Practice
Leaving AMA is associated with worse health outcomes and understanding the driving force behind this increase can improve care for this population.
750 Discharge to Door Metrics: Collaboration Matters!
Authors: Granger Jenny , Bujanda-Sotelo Nora , Hockenberry Tiffany , Richey Karen J , Foster Kevin N 
Published: April 2024

Abstract

Introduction
Timely hospital discharges are an essential part of patient satisfaction and emergency department throughput. The discharge process for burn patients is complex and delays can be both frustrating and anxiety producing. In addition, delayed discharges affect the financial bottom line, patients that are discharged late in the day still require care but if not on unit when midnight strikes, hospitals are unable to charge for that inpatient day. Our institutional benchmark is ≤ 90 minutes from time of written discharge order to patient leaving the center. The purpose of this quality improvement (QI) project was to evaluate our center’s current status, identify process barriers, develop interventions, and decrease delayed discharges (DC).

Methods
This was a retrospective chart review examining the relationship between placement of the DC order and the following elements, terminal dressing change, rehabilitation clearance, pending care management/transportation needs, and discharge destination.

Results
A total of 96 charts were reviewed and 47% (n=45) of center DC exceeded 90 minutes, with an average time to DC of 3 hours 33 minutes. Of the 45 patients with delayed DC, only 17 (38%) had all elements of the DC process completed prior to the order being placed. Those who did not have all elements completed were split evenly between having 1-2 tasks pending. The most frequently uncompleted tasks were pending care management/transportation needs (47%), completion of terminal dressing change (33%) and rehabilitation clearance (13%). Patients with timely DC were more likely to have been DC home (78%) compared to untimely DC (62%). A multidisciplinary task force was formed, and the following interventions were initiated; formalization of daily Clinical Resource Leaders report to include estimated discharge date, discharge destination, status of family/support discharge teaching and targeted education for the ordering clinicians, nurses, rehabilitation and the care management team. Within 4 months of instituting these interventions, delayed DC dropped to 25% and at 6 months were down to 15%. These results have been sustained and over the past 10 months less than 10% of burn DC have exceeded the 90-minute benchmark.

Conclusions
Overwhelmingly, this QI project demonstrated the importance of a fully integrated, collaborative approach to timely discharges. Discharge planning begins on admission and is an ongoing process. Establishing an estimated date of discharge, ensuring teaching is done prior to the day of discharge, ensuring wound care is complete as well as all rehabilitation and care management needs are met, are essential to making sure the patient is ready for a safe and timely discharge.

Applicability of Research to Practice
Discharge collaboration increases patient satisfaction, decreases discharge times, improves hospital throughput, and improves the financial health of the organization.
751 Assessing Functional Outcomes in Pediatric Burn Acute Rehabilitation
Authors: Coakley Katie , Berry AnnMarie , Davis Allison 
Published: April 2024

Abstract

Introduction
Pediatric burn survivors experience difficulty returning to daily activities. Functional outcome measures are needed for therapists to use in acute care. At one burn center the Center for Appearance Research (CARe) Burn Scales Parent Quality of Life Form and Boston Activity Measure for Post Acute Care (AM-PAC) were used with the pediatric burn population.

Methods
Therapists used the AM-PAC with children 4-17. Therapists scored the child’s functional abilities at evaluation and discharge. The child’s ability to perform self-care was scored using the Daily Activity form and functional mobility was scored using the Basic Mobility form. Scores range from 6-24. Higher scores indicate greater independence. The AM-PAC was recently validated for use with the pediatric population, ages 4 and up. The project’s inclusion criteria were children 4 years and older with a burn injury, hospitalized for &gt;4 days.
For children under 4, therapists used the CARe. This form has several subscales and uses a Likert scale for rating. This project focused on subscales 2, 3, and 5, which assess parent confidence with burn care, social concerns about their child’s injury or scars, and parental stress, respectively. Sessions targeted building parent confidence and parents were appropriately referred if they indicated stress and social concerns. The CARe was administered to parents/caregivers of children 0-3 years old with a burn injury who were hospitalized &gt;4 days.

Results
For the AM-PAC, data was collected on 17 patients who met inclusion criteria from September 2022-September 2023. 8 patients were female and 9 were male. The average affected total body surface area was 8.5%. The average scores for the AM-PAC Basic Mobility at evaluation was 18 and at discharge was 19.3. The average scores for the AM-PAC Daily Activity at evaluation was 16.6 and at discharge was 17.8. 9 children demonstrated improvement.
For the CARe, data was collected on 12 patients who met inclusion criteria from September 2022-September 2023. The average age was 1.67 years old. The average score on the Confidence subscale was 26/35 at eval and the average score at discharge was 33.3/35. 10 patients demonstrated improvement from evaluation to discharge. Parents who reported social concerns and stress were referred to the unit Social Worker.

Conclusions
The AM-PAC and CARe are feasible and helpful tools to employ in acute burn rehabilitation for pediatric patients. They allow therapists working with these patients to evaluate and treat the functional needs of the child and caregivers.

Applicability of Research to Practice
This QI project adds to the body of knowledge about pediatric burn rehabilitation. More research is needed to evaluate the clinical utility of the AM-PAC and CARe. The presenters will continue to collect data and update the results prior to presentation if accepted.
753 Implementation of a QR-code-linked Instructional Video for Resting Hand Splint Application by Non-therapists
Authors: Terken Tonya S , Parker Kristine A , Carrougher Gretchen J , MacKenzie Paige L , Jason Dylan S , Pham Tam N 
Published: April 2024

Abstract

Introduction
Custom-made rigid orthotics such as a resting hand splints are a cornerstone of burn rehabilitation. Non-therapists are often asked to apply or reapply these specialized splints. Improper application not only reduces their efficacy but may also risk harm, such as pressure ulceration. This quality improvement project aims to improve resting hand splint application via a short instructional video accessible by QR code placed directly on the splint.

Methods
Phase I consisted of directly observing non-therapists in resting hand splint application, which informed the development of a &lt; 2-minute video demonstrating correct application. Suboptimal techniques were compiled and rated on a 4-point error severity scale by 3 therapists. Phase II queried providers who reviewed the initial draft video and informed the team on finalizing the instructional video. Phase III determined video effectiveness: 1) by comparing application techniques before and after watching the video, and 2) by tracking of QR code usage.

Results
Phase I assessed 9 clinicians for splint application. All trials contained application errors, (mean 4 errors/trial, range 2-8, with 87% agreement between 2 trained observers). In Phase II, 8 clinicians evaluated the draft video: 100% reported that the content was clear; with ideal video length reported as &lt; 2 to 5 minutes; and video speed and length were deemed “just right”. In Phase III, viewing the video resulted in fewer applications errors and shifted toward milder error types (Figure 1). Additional Phase III assessments are ongoing.

Conclusions
A short instructional video improves application accuracy by providers less familiar with resting hand splint application. A QR-code that links to a short instruction video is a useful strategy for delivery of just-in-time education for non-therapists.

Applicability of Research to Practice
Just-in-time instructional videos facilitate burn rehabilitation tasks for non-therapists. This strategy can potentially expand to patients and caregivers as well.
776 Use of Paraffin Wax During Occupational Therapy Treatment of Burn Survivors
Authors: Rainey Kristin 
Published: April 2024

Abstract

Introduction
Burn survivors face long and often painful rehabilitation after injury. Unfortunately, the severe pain from burn injuries can lead to chronic pain and stress-related disorders. Occupational therapists work with burn survivors to improve movement and reduce negative impacts of scars to increase independence with self-care tasks, return to work and hobbies, and facilitate social participation. Paraffin wax is used as a modality by occupational therapists to decrease pain and assist with soft issue mobilization. It is imperative to determine if paraffin is beneficial specifically for burn injuries to facilitate physiological and psychological recovery.

Methods
Low melting point paraffin wax at a temperature between 120-130 degrees without scent was chosen to prevent any burns or allergic reactions. Inclusion criteria was for subjects over the age of 18 years and all wounds on extremity being assessed must have been closed. Active range of motion (AROM) and passive range of motion (PROM) were assessed as well as pain score. The patient then washed the extremity with soap and water, dried, placed into the paraffin bath, dipped four times, then placed into a plastic liner and wrapped in a towel for 10 minutes. After the treatment was complete, ROM and pain were assessed and the patient was offered an opportunity to provide any feedback or comments.

Results
A total of 7 burn survivors were identified and chosen for participation in the study. All patients showed improvement of AROM and PROM measurements of the tested extremity. Pain was reduced with every patient by an average of 30%. Every patient reported less pain and better movement, subjectively. Most patients reported less fear or anxiety. 42% of patients felt like their scar was softer after the paraffin treatment. Unfortunately, the study has a limited trial size due to requirement of completely closed wounds with continued follow up by the patient in clinic. Many patients with closed wounds do not follow up in the clinic on a regular basis. Interestingly, women reported more psychological benefits and also more likely to report a plan to continue using paraffin at home, compared to the men. AROM and PROM improved consistently within each session after paraffin was used, however week to week improvement was more variable between patients. This could be due to varying compliance of each individual’s home exercise program.

Conclusions
Paraffin wax can be beneficial during occupational therapy for soft tissue mobilization of burn scars to increase range of motion and reduce pain and anxiety. Utilizing paraffin wax as a modality helps to reduce physiological and psychological barriers of traditional occupational therapy interventions and should be considered as an adjunct treatment.

Applicability of Research to Practice
While the use of paraffin has been studied for treating conditions such as arthritis, scleroderma, and stroke, there is limited research on the use of paraffin for treating burn scars.
788 Lower BMIs Are Correlated with Increased Risk of Graft Loss
Authors: Tran Vivie , Sauers Delaney A , Ugwa Destiny , Nanni Amber , Gabrilska Rebecca , Pang Alan , Griswold John A 
Published: April 2024

Abstract

Introduction
The relationship between obesity and burn injuries in the United States remains poorly understood. Skin grafts, frequently used for burn treatments, are considered successful when they effectively merge with the damaged tissue, relying heavily on restored blood flow in the affected area. Inadequate graft incorporation, known as "graft loss," is linked to unfavorable health outcomes. Obesity, characterized by a high body mass index (BMI), is a known condition that reduces peripheral blood flow. Our hypothesis posits that burn patients with higher BMIs are likely to experience lower rates of successful grafting.

Methods
We conducted a retrospective analysis based on a hypothesis, using a cohort of 193 burn patients from October 1, 2012, to October 1, 2022. Inclusion criteria encompassed patients who underwent grafting surgery for burns involving a total body surface area (TBSA) greater than 20%, while females who were pregnant or breastfeeding were excluded. All patients were carefully matched for age, comorbidities, and TBSA percentage. Our primary objective was to utilize the information collected to determine whether patients with higher BMIs exhibited significantly increased rates of graft loss. We employed logistic regression analysis to examine the relationship between BMI and various variables, including the number of surgeries, the presence of infections, graft success, and mortality rates.

Results
We accounted for age, comorbidities, and total body surface area (TBSA) percentage in our analysis. The range of BMIs varied from 17.56 (indicating underweight) to 47.26 (indicating morbid obesity), with an average BMI of 29.81 (classifying as overweight). Our findings revealed a notable link between lower BMIs and increased mortality among burn patients (p=0.0107). Furthermore, lower BMIs were significantly connected to patients requiring more than three grafting surgeries (p=0.0094).

Conclusions
Our study indicates that patients with lower BMIs face elevated mortality risks and are prone to needing multiple grafting surgeries for successful outcomes. This could stem from the fact that lower BMIs might leave the body malnourished and depleted, impacting overall healing. However, it's crucial to note that our study has limitations, including a relatively small sample size and limited geographical diversity.

Applicability of Research to Practice
Medical practitioners can assess surgical risks using BMI, especially for grafting surgeries. Patients with lower BMIs may be considered high-risk and require close post-surgical monitoring. Preoperative nutritional assessments and interventions, such as dietary changes and supplements, can optimize their nutritional status. After surgery, specialized postoperative care, like enhanced nutritional support, can aid healing. Prompt identification and management of signs of malnutrition can enhance recovery.
803 Evaluation of Burn Depth and Reactive Inflammation Using Perioperative Fluorescence Imaging
Authors: Junak Mary , Zajac Jocelyn C , Liu Aiping , Jupitz Sydney , Seets Trevor , Kawahara, Tisha , Uselmann Adam , Lin Christie , Nosanov Lauren B , Faucher Lee D , Gibson Angela 
Published: April 2024

Abstract

Introduction
Early determination of burn depth is essential for guiding proper treatment of burn injuries. The primary technique used to evaluate burn depth is visual assessment, relying heavily on subjective interpretation while risking over-excision. Second window indocyanine green (SWIG) is a novel method of delayed fluorescence imaging with possible utility in burn surgery, as indocyanine green (ICG) persists in burn wounds 24 hours after intravenous injection. The objective of this study is to correlate intraoperative SWIG florescence with burn depth as evaluated by lactate dehydrogenase (LDH) staining. Additionally, given inflammation is thought to impact the progression of a burn, we investigated the relationship between SWIG florescence signal and reactive inflammation.

Methods
Consented patients with indeterminate depth burns received a 5 mg/kg ICG infusion during their third daily burn care after admission or 24-hours prior to surgery. SWIG was performed 24 hours after ICG injection on a region of interest (ROI) during wound care or during burn excision. A full thickness skin biopsy was taken from the center of the ROI and processed for ICG microscopy and staining. Burn depths were scored using LDH-stained sections. To investigate the relationship between SWIG and inflammation, nude mice underwent a full thickness contact burn or received endotoxin to induce inflammation. Mice were injected with ICG at 5mg/kg and SWIG signal was captured at the non-burned control, burned, and inflamed ROIs 24 hours after injection. Signal-background ratio (SBR) was calculated using the ratio between the averaged ICG intensity in the burned or inflamed ROI and the control ROI. GraphPad Prism 8.0 was used for statistical analyses.

Results
There was no correlation between the raw SWIG fluorescence value of the ROI in vivo and burn depth as determined by LDH staining. Furthermore, when the fluorescence value of the ROI was normalized to the SWIG intensity of the overall image and the SWIG intensity of non-burn control skin, there was no correlation to burn depth. In mice, SWIG SBR was significantly higher in the burned region (3.2±0.5) compared to the endotoxin induced inflamed regions (1.6±0.1).

Conclusions
There is heterogeneity in the intraoperative fluorescence signal when compared to burn depth. This variability in fluorescence signal could be attributed to the effects of local inflammation on the burn wound microenvironment as animal studies have shown that ICG signal is present in non-burn inflamed tissue. Further studies are warranted to discern the role of inflammation on burn wound progression and fluorescence signal in humans.

Applicability of Research to Practice
This data supports the potential utility of perioperative ICG fluorescence imaging for guidance of surgical excision in patients with indeterminate depth burns.
807 The Effects of Fish Skin on Wound Healing in a Standardized Pre-clinical Model
Authors: Pignet Anna-Lisa , Hofmann Elisabeth , Hahn David , Fink Julia , Hecker Andrzej , Prevedel Manuel , Einsiedler Johanna , Carnieletto Martina , Kamolz Lars-Peter , Kotzbeck Petra 
Published: April 2024

Abstract

Introduction
Acellular fish skin grafts (FSG) have proven to be effective in acute and chronic wound healing, as well as in burns. However, the underlying mechanisms promoting healing are still unknown. The aim of this preclincal study was to investigate the effects of fish skin grafts on wound healing properties under standardized conditions in a full-thickness skin defect pig model.

Methods
FSGs were tested in a full-thickness skin defect (3 cm x 3 cm) pig model (n=9, male landrace pigs) and compared intra-individually to untreated control wounds. The experiment lasted for 21 days. Reapplication of the dressings was carried out after 9 days post wounding. Wound scoring, photo-documentation and non-invasive imaging were carried out 5, 9, 14 and 21 days post wounding. Tissue biopsies were sampled at the same time points and subjected to histologic (HE and Masson’s trichrome stains) and gene expression analysis of various cytokines.

Results
As soon as on day 5, wounds treated with FSG showed a thicker formation of new tissue compared to control wounds. Planiometry revealed lower residual wound areas of the wounds treated with FSG, especially on day 9 and 14 post wounding. Gene expression analysis revealed a higher upregulation of the pro (eg. IL-8) and anti-inflammatory markers (eg. IL-10) in the first days after wounding compared to the controls. In the later phases, there were no differences between the two groups. On day 21, control wounds showed severe signs of contraction, which were not observed in the wounds treated with FSG.

Conclusions
FSGs modulate the local immune response by upregulation of both, pro- and anti-inflammatory markers. Moreover, FSGs support wound healing due to the accelerated formation of new tissue and the prevention of wound contraction in a pre-clinical full thickness wound model.

Applicability of Research to Practice
The study gives insights into the mode of action of FSG and therefore aids at redefining the ideal clinical indications for the use of the product.