bluuebunny/crossref_metadata_2025_split huggingface dataset:
579 Outcomes of an Independent Burn Advanced Practice Provider Peer Review Process
Authors: Steiner Stephanie , Lewis Lauren , Baker Kevin , Crow John , Khandelwal Anjay 
Published: March 2022

Abstract

Introduction
Burn peer review (PR) is an important process for quality assurance and process improvement. Our division consists of five burn surgeons, seven advanced practice providers (APPs) and four night house officer (NHO) APPs. As the APPs are intimately integrated within the burn service - both on the inpatient (IP) and outpatient (OP) settings, a subsequent need to create an independent peer review process for the APPs was identified. We describe our process and evaluate the results after two years of a monthly APP PR meeting.

Methods
All data is entered into a quality management software. Triggers for APP PR include complex discharge, inappropriate OP referral, delay in treatment, OP treatment greater than three weeks without surgical intervention, pressure wound, patient discharge with greater than 30 morphine equivalent dose (MED) of narcotic, readmission or unexpected admission from OP clinic, substance abuse, and self referral. Cases with individual improvement opportunities result in real time direct feedback from the director, lead APP, and peers. These may be escalated to the provider’s ongoing professional performance evaluation (OPPE) or trigger a focused professional performance evaluation (FPPE). Systemic issues identified are referred for multidisciplinary discussion in our Performance Improvement/Quality Assurance (PI/QA) process. Complicated issues involving multiple disciplines may trigger a root cause analysis. If an individual or system issue is not identified, a group discussion about process improvement and standardization of practice ensues.

Results
From initiation of the Burn APP PR process in May of 2019, to September 2021, there were 37 cases reviewed. Twelve were for indicated triggers and 25 for self-referrals. Breakdown of these cases is as follows: outpatient treatment greater than three weeks without surgical intervention (3), readmission or unexpected admission from outpatient clinic (4), delay in treatment impacting clinic course (5). Self referred cases included graft loss (8), cellulitis (3), venous thromboembolic event (2), and wound dressing discussion (2). There were three cases where clinical issues were identified of which one was referred for root cause analysis, and the other two led to real-time education and feedback from the director.

Conclusions
PR is important to ensure that high quality patient care standards are met. Autonomous APP practice is important for the function of a team, quality of care delivered, professional satisfaction of the APP, and enables financial optimization for burn centers. Creating an independent burn APP peer review process allows for time-sensitive feedback to patient care related events, improves collaboration and practice standardization, and provides an important educational opportunity for the team.
580 Setting the Burn Team Up for Success
Authors: O'Rourke Cassandra , Gernt Megan 
Published: March 2022

Abstract

Introduction
Hybrid burn centers are challenged to meet the criteria of the ABA verification process. When burn care occurs in different units across a hospital, it is difficult to ensure all areas are aware of the verification criteria and ensure timelines and expectations of optimal burn care are understood. Our center had difficulty ensuring rehabilitation referrals were placed on admission to allow the maximum amount of time for these services to establish a plan of care. Staffing issues were identified as contributing to the inability to consistently establish a rehabilitation program within 24 hours of admission.

Methods
We had a QI goal of 100% compliance for establishing a comprehensive rehabilitation plan within 24 hours of admission. Several methods of education were provided to all providers and other burn team members to encourage immediate consultation to physical therapy and occupational therapy. Consultations to these services were frequently delayed. In 2017, 63% of the patients admitted had a rehabilitation plan of care established within 24 hours of admission. To address this, a burn order set was developed. This burn order set had the orders for PT and OT pre-populated to have the order placed on admission. The order set went live in November of 2017. In 2018, the percentage of patients receiving a comprehensive rehabilitation plan within 24 hours of admission had increased to 80%. Further education for use of the order set was provided, including additional presentations during our resident "boot camp" in 2018, our burn program manager reviewing all burn admissions and providing feedback to providers to use the burn order set, and established the role of a dedicated burn NP along with an everyday burn clinic in 2020. Staffing patterns were assessed in collaboration with the lead PT and OT. Rehabilitation established more coverage on the weekends and holidays to ensure staff was available 7 days per week to respond to the rehabilitation referrals for our patients.

Results
The compliance with the ABA verification criteria for establishment of a comprehensive rehabilitation program within 24 hours of admission had increased with consistent use of the burn order set and increased rehabilitation staffing. In the last 4 quarters of 2020-2021, our compliance has increased to 92%. In 2 of the last 4 quarters our compliance was 100%.

Conclusions
The use of a comprehensive burn order set can help a hybrid burn center ensure they are set up to meet ABA verification criteria. These order sets when used consistently can not only ensure consults are ordered, but also help remind providers of the unique needs of the burn patients and improve efficiency.
583 Photos of Burn Wounds Can Help Reduce Over-Triage and Prevent Unnecessary Ambulance Transfer
Authors: McCourt Jacita A , Strait Eli , Lee Jeanne 
Published: March 2022

Abstract

Introduction
Burn wounds can be difficult to assess for providers outside the burn center and can result in over triage. The combination of photos of burn wounds with a clinical history can help burn practitioners make appropriate triage decisions, including immediate ambulance transfer vs scheduling an outpatient follow up appointment. Appropriate photo triage can help reduce healthcare costs by eliminating both unnecessary transfers to the burn center and overburdening burn resources. This performance improvement project involved the development of a secure photo sharing web portal and photo triage clinical pathway to help burn practitioners appropriately triage burn patients being evaluated at health care facilities within the catchment area of an American Burn Association verified adult and pediatric burn center.

Methods
Existing technology was used to develop a burn photo sharing web portal that can be easily accessed by providers outside the burn center. A new clinical pathway for burn photo triage was developed. Education was formulated for nurses and providers within the burn center and for referring facilities. Retrospective data was collected for the 4 years of ambulance transfers captured in the outpatient burn registry prior to the implementation of the photo triage clinical pathway. Comparison data was also abstracted for the first year after implementation. Patients were categorized as over triaged or appropriately triage based on the first set of photos captured in the EMR.

Results
In the pre-triage years there were a total of 242 ambulance transfers to the outpatient burn clinic. 150 (62%) of those patients were appropriately triaged, while 92 (38%) were over triaged. In the year following implementation there were 27 ambulance transfers to the outpatient burn clinic. 25 (92.6%) of these patients were appropriately triaged while 2 (7.4%) were over triaged. Overall ambulance transfers to the outpatient burn clinic dropped by more than 50% (average of 60.5 transfer per year down to 27 after implementation).

Conclusions
Patients with burn injuries at referring facilities were more appropriately triaged when using photos of wounds which ultimately reduced the number of unnecessary ambulance transfers.
588 Utilizing a Quality Improvement Approach to Increase Compliance with Patient Positioning in the Burn Unit
Authors: Gallagher Catherine E , Slater Julia C , Dale Elizabeth L 
Published: March 2022

Abstract

Introduction
Patient positioning, notably positioning patients in “anti-deformity positioning”, is a standard practice in burn rehabilitation as it assists with edema management, scar contracture prevention, and wound healing. Successfully and consistently providing proper positioning of burn patients requires the combined effort of the multi-disciplinary burn team. The primary goal at our center was to increase the frequency that patients were correctly positioned to over 90% at the time of random audits.

Methods
At a medium-sized, academic burn unit, once to twice weekly audits were conducted by burn lead therapists on the compliance of proper patient positioning over a 6-month period. Using this data as a trigger, a quality improvement project was designed using the PDSA (Plan-Do-Study-Act) cycle to help identify reasons behind lack of compliance. Surveys were distributed to the therapy and nursing staff to identify any barriers to care. Effects on positioning compliance post-intervention were monitored.

Results
In the 6 months prior to intervention, our patients were positioned correctly an average of 76% of the time. Therapy and nursing surveys identified the following barriers to care: Nursing needed more education on positioning, and the approach was too heavily reliant on nursing efforts alone. To address these barriers, therapists provided education to both day and night shift nurses, communicated daily about positioning expectations, shifted the project from a nursing approach to a multidisciplinary approach, and made changes in therapy workflow. Immediately following the intervention, the compliance rates were 91% for the first month and 85% for the second month.

Conclusions
Coordinating efforts of the entire burn team improves consistency for positioning in burn patients. Utilizing the PDSA cycle allowed us to identify areas for improvement and to develop appropriate interventions aimed at both increased education for nursing staff and workflow improvements for our therapists. Following the completion of our interventions we were able to obtain an immediate improvement in our compliance with proper positioning of burn patients.
592 Strategy for Improving Wound Care Compliance in the Outpatient Setting by using Take-home Visual Aids
Authors: G'sell David , Smith Sydney , Flores Carl A , Peterson Abbey , Virgadamo Lacy , Phelan Herb A , Kopari Nicole M , Carter Jeffrey E 
Published: March 2022

Abstract

Introduction
Wound care compliance is a critical component in the success of treating burns in the outpatient setting. Patients and caregivers are educated with demonstration and written materials which have demonstrated a 24-hour retention rate of 30% and 10% respectively. This can leave the patient at higher risk for infection, increased pain from suboptimal dressings, and feelings of frustration. Research has shown that visual learners make up 65% of the population, with auditory learners at 30%, and tactile learners at 5%. We assessed that a combination of demonstration and visual aids could better assist different learning styles and improve wound care compliance. Our study goal was to assess the efficacy of the visual aids component through new patient encounters in the emergency department and outpatient setting using a six-question survey at subsequent encounters.

Methods
The study design is a prospective analysis with comparison to historical controls. Visual aids were designed by the burn physician assistants with assistance at an ABA-verified burn center. We created four double-sided cards made out of a water-resistant synthetic paper, with one for each of our most used dressings. The content of the cards included one of the following: bacitracin/fine mesh gauze with bismuth tribromophenate, bacitracin with low-adherent acetate gauze, silver nylon dressings, and silver foam dressings. Each card contains moulage wounds, step-by-step, and corresponding written instructions at a 4th grade education reading level. These visual aids were given to patients being discharged from the emergency department, or to new patients in the burn clinic. A six-question survey was administered at one week follow-up encounters with a scale of 1-10 (one being least helpful, and ten being the most helpful) assessing patients understanding of burn wound care and compliance. Compliance rates were abstracted from historical controls with similar burn wound severity.

Results
Limited data is available at the time of submission as the study is currently in-progress and anticipated to be completed by March 2021. We will be using descriptive statistics and comparative analysis to evaluate the results.

Conclusions
Patients initial feedback has been overall positive with a corresponding compliance rate that is successful. Our patients verbalized their approval, with multiple patients stating that they plan to keep the wound care card for any burn injuries that might occur in the future. Additional research is needed to examine the impact of combined demonstration, tactile, and auditory learning aids. In addition, we plan to further expand our engagement effort to include similar wound care cards for pediatric patients as well as language alternative cards to meet our surrounding community's needs.
600 Reconstruction of Finger Contracture with an Expanded Dorsal Metacarpal Artery Perforator Flap
Authors: Ozkan Burak , Uysal Cagri A , Abali Ayse Ebru , Haberal Mehmet 
Published: March 2022

Abstract

Introduction
The first dorsal metacarpal artery perforator (DMCAP) flap is frequently used to cover exposed bone, tendon and neurovascular structures in the hand after trauma and burns. The size and width of DMCAP flap is limited and rotation arc generally lets to cover defects up to middle phalanx. Expansion of the DMCAP flap has not been reported in the literature and this technique might be solution to increase flap viability and size in order to cover defects up to distal phalanx. In this study, we will describe utilization of tissue expander to first DMCAP and present a case of electric burns in with flexor contracture.

Methods
A nine-year-old male patient applied to our clinic with the complaint of inability to extend the second finger of the left hand after an electrical burn. Physical examination revealed flexor contracture in the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints. Reconstruction was planned for the patient with a two-session expanded first DMCAP flap.
In the first session, a 16 cc 5x3 cm tissue expander placed through a 3 cm vertical incision at the fifth metacarpal level. From the second postoperative week, the tissue expander was inflated with 1 ml of isotonic three days a week. Six weeks later, the DMCAP area was enlarged by giving 45 cc saline.

Results
In the second session, contractures at the level of the left hand 2nd finger DIP and PIP were excised.. Left hand 2nd finger was fixated in extension with K-wire. 9x3 cm DMCAP flap was elevated by dissection over the paratenon and the pedicle was preserved. The flap was adapted to the defect area on the volar face with 180-degree rotation angle. The flap donor site was closed primarily.
There were no complications in the post-operative period. K-wire was removed at 6 weeks postoperatively. The patient was referred to the physical therapy.

Conclusions
In cases where the tissue defect cannot be closed with loco regional flaps, extra tissue can be provided by free flaps or using tissue expanders. Primary closure of the donor area, appropriate flap thickness for the finger, and aesthetically pleasing results are among the advantages of the expanded DMCA flap.. However, in tissue expander applications in the upper extremity, the patient should be followed closely, and pain and finger circulation should be constantly questioned.
622 Oral Ketamine Administration During Bromelain Based Enzymatic Debridement of Burn Injury
Authors: Halicki Elizabeth , Kahn Steven A , Condeni Melanie S , Hirsch Jason , Turner Jonathan 
Published: March 2022

Abstract

Introduction
Existing literature supports bromelain enzymatic debridement as an early tool for selective escharectomy, resulting in fewer skin grafts after burn injury. Enzyme application is painful, so many centers use continuous infusions of narcotics, ketamine, and sedatives in the intensive care unit. The authors utilize oral ketamine in burn practice- as it is safe, can decrease the need for higher level of care, and be used without fasting. The purpose of this study is to evaluate whether oral ketamine can safely be utilized as an alternative to continuous infusions of medications for bromelain treatment.

Methods
This was a retrospective study of patients who received oral ketamine (for analgesia) and oral lorazepam (for anxiolysis and prevention of dysphoria) for bromelain-based selective enzymatic debridement application over a 6-month period. Data collected included patient demographics, burn characteristics, sedatives and analgesics administered, pain scores, adjunct medications, and vital signs. Presence of respiratory insufficiency (desaturations &lt; 93%, need for bag-valve mask, or intubation), hypertensive urgency (SBP &gt;180, DBP &gt;110 w/out end organ dysfunction), dysphoric reactions, and uncontrolled pain were recorded. Oral ketamine (2-4 mg/kg) was given 30 minutes prior to the procedure. Patients were monitored per sedation guidelines and had capnography plus supplemental oxygen. Small PRN IV boluses of narcotics were given during the procedure, along with their baseline oral multimodals and narcotics. Pain was measured with the 1-10 verbal rating scale with minimal pain defined as &lt; 4 or the patient clinically observed as sleeping. Patients were not made NPO for the procedure.

Results
Ten patients were included. Four patients (40%) had minimal pain during enzyme application, 3 (30%) patients slept through their procedure, and 3 (30%) patients reported 10/10 pain during treatment (2 had 10/10 pain before treatment). Five patients were treated on the floor, 7 were treated in the ICU. The median ketamine dose was 225 mg (IQR:177,250), or 3mg/kg (IQR:2.75,3). Additional oral and IV opioids received during the 8–14-hour interval was 21 morphine milligram equivalents (MEs). The median benzodiazepine dosing before and during enzymatic debridement was 1.4 lorazepam MEs. Three patients (30%) had hypertensive urgency, 2 (20%) of whom reported 10/10 pain, and all 3 received 10mg IV labetalol. No one had dysphoric reactions or respiratory insufficiency.

Conclusions
This preliminary study reveals oral ketamine administration is safe and effective for pain control during bromelain-based enzymatic debridement. Most patients required small to moderate amounts of PRN IV opioids, had acceptable pain control, and there were no significant adverse effects. Future large, prospective studies should evaluate dosing and timing for optimal patient outcomes.
707 Invasive Non-Candida Fungal Infections in Acute Burns: A 13-Year Review of a Single Institution
Authors: Akhavan Arya A , Shamoun Feras , Lagziel Tomer , Rostami Sohayla , Cox Carrie A , Cooney Carisa M , Hultman Charles S , Caffrey Julie 
Published: March 2022

Abstract

Introduction
Burn patients have higher infection rates due to loss of the protective skin barrier. The past decade shows increased rates of burn infection with atypical invasive fungal organisms. After a recent trend of life-threatening atypical fungal burn infections at our hospital, we conducted this study to further characterize this.

Methods
We identified patients admitted to our burn center from January 2008 to June 2021, who developed fungal non-Candida burn infections while admitted. We gathered demographic data, burn injury details, surgical treatment course, and fungal and bacterial infection data. Descriptive statistics were used to characterize the data and identify trends.

Results
We identified 37 acute burn patients with atypical invasive fungal infections. Of these, 28 were infected with 1 species, and 9 were infected with multiple fungi.
Non-Candida fungi included Aspergillus (20), Fusarium (8), Mucor (6), and 11 other species. Three fungi were resistant to antifungals including amphotericin B. Other organisms included Candida (18), Enterococcus (13), Pseudomonas (9), and 19 other species. On average, patients were infected with 5 bacteria, had 13 antibacterial resistances, and required 6.5 antibacterials. There was one case of total-drug-resistant Pseudomonas aeruginosa. Every patient required Infectious Disease consultation. Eight patients became bacteremic and 1 became fungemic.
The average burn surface area was 35%. All patients required excisional treatment, with an average of 7 excisions, 7 coverage procedures, and 3.5 other procedures; 44% of patients required amputations for infection control. The most common complications were graft loss (39%), ventilator-associated pneumonia (28%), and death (28%). The median length of stay was 40 days (IQR = 89) for survivors and 28 days (IQR = 14) for nonsurvivors. All fatalities were from overwhelming polymicrobial infection. The average modified Baux score was 73 (± 28) for survivors and 102 (± 38) for nonsurvivors. All nonsurvivors had clean wounds without penetrating trauma.

Conclusions
Burn patients with atypical invasive fungal infections have severe polymicrobial infections and extreme antibiotic resistance. Patients may require, or fail, treatment with last-line antibiotic therapy and amputation. Early Infectious Disease consultation and aggressive treatment is critical. Further research may elucidate risk factors and ideal treatment patterns.