bluuebunny/crossref_metadata_2025_split huggingface dataset:
520 Efficacy of high volume hemofiltration (HVHF) with step-down approach in critically ill burn patients
Authors: Khandelwal Anjay , Lou Richard B , Raina Rupesh 
Published: March 2022

Abstract

Introduction
Continuous renal replacement therapy (CRRT) is the standard of care for critically ill burn patients with acute kidney injury. Historical mortality rates for burn patients requiring CRRT is over 50%. High volume hemofiltration (HVHF) is a purification method that may have superior outcomes in the critically ill but has not been well studied in burn patients. We report results of utilizing HVHF with a step-down approach in our burn center.

Methods
Retrospective review of all adult burn patients at a verified adult and pediatric burn center requiring continuous veno-venous hemodiafiltration (CVVHDF) from 2018 to 2021 when HVHF (50ml/kg/hr) for 18-24 hours with a step-down approach (25-30ml/kg/hr) was started. A normocarbia bicarbonate based dialysate was used with blood flow rates of 200ml/hr along with citrate anticoagulation. Demographics, indications and duration of CVVHDF, duration of vasopressor requirements, days on mechanical ventilation, length of stay, correction of acidosis and mortality were recorded.

Results
Thirteen patients were identified, of which four were excluded as they had an exfoliative skin disease (two patients) or were treated with conventional CVVHDF (two patients). Of the remaining nine patients (six male and three female) the average age was 58.7 years (range: 42-75) and average total body surface area burn (%TBSA) was 46% (range: 20-92). All patients were diagnosed with AKI (Acute Kidney Injury Network [AKIN] Class III) with the indication for CRRT being diuretic resistant fluid overload in three patients and sepsis in the remaining six patients. Of the three patients with fluid overload, two developed sepsis while on CRRT. Acute respiratory distress syndrome (ARDS) as defined by the Berlin criteria was noted in six patients (66%). Three patients died (33% mortality) with the remaining six being eventually converted to intermittent hemodialysis and progressing to renal recovery. Amongst survivors, the duration of CRRT ranged between 7-33 days (average 13.8 days) and duration of vasopressor support from 1-30 (average 17 days). Metabolic acidosis resolved in all survivors within 48 hours. No hemorrhagic events were noted and all patients tolerated regional citrate anticoagulation well. Reduction in serum creatinine was noted to be significant.

Conclusions
High volume hemofiltration resulted in improved mortality rates compared to what is reported in the literature. Further research and comparative studies are required to determine if HVHF with a step-down approach is superior.
529 Outcomes of Total Parenteral Nutrition Use in Burn Patients at a Single Institution
Authors: Sljivic Sanja , Chrisco Lori , Long Cindy A , McKinzie Brian P , Bui An , Nizamani Rabia , King Booker , Williams Felicia 
Published: March 2022

Abstract

Introduction
Total parenteral nutrition (TPN) has been widely used among critically ill patients. Some of the controversy surrounding parenteral nutrition stems from its early use in the 1980s, which primarily focused on hyperalimentation. In burn patients, nutritional support is a critical aspect of treatment. The metabolic rate in this patient population can be greater than twice the normal rate, and this hypermetabolic response can last more than a year after the burn injury has occurred. The objective of this study was to evaluate the outcomes of patients in our Burn Center who received TPN during their hospitalization.

Methods
This was a single-site, retrospective review using our institutional Burn Center registry. All adult patients (18 years or older) admitted to our Burn Center between July 1, 2015 and June 30, 2021 who had received TPN during their hospitalization were included in this study. Adult patients who had not received TPN were included for comparative purposes. Variables of interest included demographics, burn mechanism, length of stay (LOS), ICU and ventilator days, and mortality.

Results
There were 20 burn patients who received TPN during their hospitalization. Of those patients who received TPN, 90% were male. The mean age was 45 years, and the mean total body surface area (TBSA) involvement was 32%. The mean resting energy expenditure (REE) was 3,084. On average, the time from day of admission to initiation of TPN was 40 days, and the mean length of TPN administration was 20 days. The overall decrease in patient weight from admission to discharge was 10%. The mean LOS for the TPN group was 118 days. The mean LOS in the ICU was 92 days. The mean ventilator days were 89 days. The overall hospital mortality of patients who received TPN was 20%. When matched with patients who had similar TBSA involvement and who had not received TPN, there was no difference in mortality. However, there was a significant difference in weight loss (4% for non-TPN group), overall LOS (63 days), ICU LOS (29 days), and ventilator days (31 days).

Conclusions
Burn patients who received TPN during their hospitalization had a greater decrease in their overall weight, had a longer hospital and ICU length of stay, and were ventilated longer than those patients who did not receive TPN. These findings are to be expected given that patients who receive TPN tend to be more critically ill, and therefore, require more nutritional support.
536 Objective Quantification of Hypertrophic Scar and Donor Scar between 2 to 7 months Post-burn Injury
Authors: Edger-Lacoursière Zoë , Marois-Pagé Elisabeth , de Oliveira Ana , Réadaptation M , Calva Valérie , Nedelec Bernadette 
Published: March 2022

Abstract

Introduction
Very few objective scar evaluations have been conducted with the burn survivor population, which limits our knowledge of the clinical recovery profile of hypertrophic scars (HSc) and donor site scars (D), thus having an impact on rehabilitation intervention and treatment prioritization. The purpose of this study was to prospectively quantify the thickness, pliability, erythema and pigmentation of post-burn HSc, donor sites (normal scar) and normal skin in different anatomical locations between 2 and 7 months post-burn using objective instrumentation. A secondary objective was to compare this data with anatomic-specific normative data using the same objective instrumentation.

Methods
Skin characteristics of HSc, D and N in 44 burn survivors were measured at 2, 3, 4, 5, 6 and 7 months post-burn using validated instrumentation: high-frequency ultrasound for thickness, Cutometer® to measure pliability and Mexameter® to measure erythema and pigmentation. Up to five sites were assessed on the same participant if their scar was located on the upper extremity (UE), lower extremity (LE) and trunk. A mixed model two-way analysis of variance was used to investigate the differences in means between sites at each time point and between time points at each site.

Results
The results revealed that HSc sites were thicker than D and N at all time points and UE and trunk HSc were thicker than LE HSc at 7 months post-burn, pliability of trunk HSc did not improve over time, and UE HSc was more erythematous at 7 months compared to other anatomical sites whereas D erythema decreases from 2 to 7 months.

Conclusions
Scar management treatments should prioritize the UE and trunk sites which developed HSc during the first two months post-burn and continues to vary significantly from normal scar and normal skin at 7 months. Furthermore, these results provide preliminary evidence that the recovery profile of HSc varies at different anatomical sites and that thickness is the characteristic that distinguishes HSc from normal scar and normal skin.
546 Health Disparities Among Rural Burn Patients
Authors: Duggan Robert P , Brondeel Kimberley C , Mahony William L , Torres Grant , Palackic Alen , Branski Ludwik K 
Published: March 2022

Abstract

Introduction
Socioeconomic status is a risk factor for sustaining a burn and for burn mortality. Patients from rural areas make up a minority of the population but are frequently more isolated from life-saving care and burn centers. Lower socioeconomic status patients may delay seeking treatment of their burns for concern over medical costs, time away from work, and overall distance from accredited burn centers. We aim to explore disparities in burn outcomes at our institution based on patient socioeconomic status.

Methods
Between January 2020 and January 2021, patients presenting for management of acute burns were reviewed. Patient demographics and outcomes were collected, including time to presentation, total body surface area burned, presence of inhalational injury, and mortality. Patient socioeconomic status and rural designations were assigned based on a validated metric derived from Census endpoints, with higher scores reflecting lower socioeconomic status.

Results
A total of 524 patients were identified. Overall, 30% of our patients were from areas defined as being small towns or rural by the Census. Racial demographics did not differ between rural and urban areas (p = 0.099), but Hispanic ethnicity was less common (16% vs. 29%, p = 0.002). Rates of alcohol, tobacco, and illicit drug use did not differ between groups. Compared to the urban/suburban cohort, rural patients were from less affluent areas (63.6 vs. 58.5, p = 0.001) and traveled farther to our center (112 miles vs. 70 miles, p = 0.029). Despite these distances, rural patients did not have a higher rate of delayed presentation (35.7% vs. 43.3%, p = 0.105), or longer average time to presentation (3.4 days vs 4.4 days, p = 0.222). Flame burns were the most common mechanism overall (44.3%) and were significantly more common in the rural population (59.2% vs. 37.8%, p &lt; 0.001), Scalds, the second most common burn mechanism (25.9%), occurred less frequently in rural patients (18.5% vs. 29.2%, p = 0.011). Controlling for age, TBSA, inhalational injury, and ventilator requirement, patients from rural areas were at a significantly higher risk of mortality (OR 24, p = 0.024).

Conclusions
Rural burn patients face many challenges receiving appropriate care following a burn. They frequently come from less affluent backgrounds, limiting their ability to access care, and they must travel greater distances to a qualified burn surgeon. Despite these barriers, our rural patient population did not present any later following a burn compared to our more urban patients. Rural patients sustained more extensive burns but were not hospitalized at a greater rate. Even when controlling for numerous factors associated with burn mortality, rural patients were still at an increased risk. Burn prevention strategies targeting rural communities should address the unique challenges facing these areas.
558 Nurse-driven fluid resuscitation protocol - a quality improvement initiative
Authors: Linticum Kim , Fagan Shawn P , Homsombath Bounthavy F , Dowling Lynn , Rhodes Mandy 
Published: March 2022

Abstract

Introduction
The migration of paper medical records to electronic health record (EHR) has been in process for a few years now and most facilities have achieved this successfully. EHR has streamlined care and documentation. Further developments such as Computerized Physician Order Entry (CPOE) has been noted as one of the most promising functionalities of Health Information Technology (HIT), as it allows providers to enter orders, medications, diagnostic tests, and procedures, with the intent of improving the clarity and specificity of physician orders, facilitating the rapid communication of orders to pharmacies, and providing significantly enhanced decision support capabilities compared to traditional handwritten orders.1
In our experience, initiation of CPOE has been beneficial in many ways, namely in decreasing medication errors related to handwritten orders. However, in the clinical scenario of acute resuscitation of a critically injured burn patient, the CPOE structure did not address each and every need that would arise, especially if fluid titration was necessary. Nursing staff were left unsure of what to do in terms of their role in adjusting fluids and assessing for adequacy of resuscitation. This led to gaps in care in which potential critical situations needed to be addressed. For instance, the possible development of abdominal compartment syndrome and how to respond to it was not part of CPOE set that was implemented. This was placing the patient at risk by delaying initiation of hemodynamic monitoring and delaying electrolyte replacement as well.
The goal of this study is to report the outcomes of this quality improvement initiative and to describe the resultant research that is in place to evaluate its effectiveness.

Methods
This is a QI project that will identify and describe how a protocol was developed post- CPOE implementation to address gaps in nursing care during fluid resuscitation of critically ill burned patients

Results
We created a protocol that allows the nurse to have better insight into what is happening with the patient and what physician orders are most pertinent at any particular time. The protocol sets parameters that alerts the nurse when additional intervention is necessary. For instance, monitoring for abdominal compartment syndrome begins once resuscitation exceeds 6 mL/kg/TBSA and allowing for the nurse to call the primary physician for hypotension that is refractory to fluid bolus. This was not clear before and nurses were not intervening appropriately, which resulted in gaps in delivery of care. We have not had to report any adverse or sentinel event related to fluid resuscitation since the implementation of this protocol.

Conclusions
A nurse-driven protocol helped address gaps in care for nurses at the bedside during fluid resuscitation
577 Expanding Outpatient Burn Therapy Services to Address Social Determinants of Health
Authors: Smith Susan L , Gonzalez Rachel B , Mayorga Cindy , Smith Howard G 
Published: March 2022

Abstract

Introduction
Occupational and Physical Therapist provide acute services to burn-injured patients and continue treatment well into their functional recovery for mobility, strengthening, scar management, contracture prevention and return of independence. Unfortunately, we recognized that patients encountered obstacles when attempting to access these services in the outpatient setting. It was evident that these impediments frequently coincided with social determinants of health (SDOH). According to Healthy People 2020, SDOH represent the cumulative influences of individual, cultural, community and societal attributes on health and quality-of-life. Self-pay patients accounted for 12% of clinic patients. However, patients with coverage were not always receiving adequate therapy due to lack of burn knowledge among community-based therapist. By expanding outpatient burn clinic services, we are better positioned to meet the needs of all burn-injured patients in our community.

Methods
A plan was outlined to increase the presence of Occupational and Physical Therapy (OT/PT) in the outpatient burn clinic. Pertinent literature was reviewed, and a presentation was developed to establish need and outline a model for integration of services. The inpatient OT/PT department managers collaborated with the Burn Director and Burn APRN on projecting staffing and equipment needs. Multidisciplinary cost analysis was completed. Guidelines for outpatient burn rehabilitative therapy staffing and a description of services were developed.

Results
After much collaboration and effort, and with community support, our PT/OT inpatient burn staff provide rehabilitative therapy to all patients attending outpatient burn clinic two days weekly. Additionally, educational material, hands on range of motion training and free new and donated compression garments are readily available during all four burn clinics weekly. The new outpatient burn clinic opened in 2021, equipped with two large showers and a designated therapy room, ready to wear compression garments, putty, and assistive devices designed to further support burn recovery. Attendance for burn outpatient visits increased significantly from 2015 to 2018.

Conclusions
Transportation, childcare, employment restrictions, individual health and wellness beliefs, lack of funding and access to technology represent examples of blockades to healthcare care. This multidisciplinary effort increased the availability and scope of rehabilitative services in the outpatient burn clinic patient, allowing patients to receive comprehensive burn wound care and rehabilitative therapy in one location to promote healing, manage pain, improved function, maximizes independence and reintegrate into their family and community.
581 Sustained Multidisciplinary CLABSI Bundle in the Burn Center
Authors: Dao Sylvia H , Heffernan Jamie M , Greenway Andrew , Libraro Kaitlyn M , Twohig Deirdre , Gallagher Jim 
Published: March 2022

Abstract

Introduction
Central line-associated bloodstream infections (CLABSI) remains a high risk for burn patients due to their compromised integumentary system. Additionally, identifying bloodstream infections secondary to a burn infection versus a central line remains a challenge. Literature review suggests multidisciplinary CLABSI bundles (MCB) demonstrate reduction of CLABSIs. This research looks at the use of a MCB compared to the application of the standard CLABSI bundle alone reduce CLABSI incidence and standardized infection ratios over the past two years in the Burn Center. We hypothesize a MCB will have sustained CLABSI SIR and incidence reduction over time.

Methods
Infection Prevention & Control CLABSI data collection on all burn patients pre-intervention (2017-2018) and post-intervention (2019-2020) were performed as a quality improvement project; IRB was not obtained. In addition to the CLABSI Bundle (optimal site, aseptic insertion, aseptic maintenance, timely removal, & education), MCB was also implemented in Qtr. 1, 2019. MCB includes necessity of line discussion during daily and multidisciplinary rounds, strategic blood culture collection upon admission/transfers for patients with existing central line, improved nursing and provider documentation of burn infection per CDC definitions, integration of CLABSI reviews in tiered Burn Quality Improvement Program, and universal zero CLABSI goal setting for RNs. Two-sample t-test will be used to compare results pre-intervention (2017-18) & post-intervention (2019-20). CLABSI incidence and standardized Infection ratio will be illustrated per year.

Results
The post-intervention CLABSI SIR data (M= 0.08, SD=0.11) significantly improved when compared to the pre-intervention CLABSI SIR data (M= 0.77, SD= 0.169), t(2)=4.72, p=0.02. The post-intervention CLABSI incidence data (M=0.5, SD=0.70) significantly improved when compared to the pre-intervention CLABSI incidence data (M=4.5, SD= 0.70), t(2)= 5.65, p= 0.01

Conclusions
The combination of the CLABSI bundle with the MCB demonstrated favorable CLABSI SIR and incidence reduction, as literature suggests. Implementing multimodal, multidisciplinary interventions must be a priority for sustained CLABSI reduction. Considerations for future studies should measure length of catheter days, incidence of positive blood cultures on admission/transfers for patients with existing central lines, and incidence of burn infection rates with positive blood culture and an existing central line.
597 Reconstruction of Lop Ear Deformities After Severe Burn Injury in Pediatric Patients: An 11-year Experience
Authors: Ehrlichman Richard J , Sadeq Farzin , Driscoll Daniel N 
Published: March 2022

Abstract

Introduction
The ear is one of the most highly visible structures on the face. One or both ears are frequently involved in panfacial burns. Because they are bilateral structures, asymmetries are clearly visible. Reconstruction of burned ear deformity often requires replacement or modification of skin and/or cartilage. Even these are successfully replaced, scar contractile forces can cause deformation of the ear. One of these deformities is lop or cup ear, in which the helical rim is either folded over, wrinkled or tight. We describe the necessity of applying otoplasty techniques to address this problem.

Methods
A retrospective chart review analysis was performed to assess demographic variables, procedural indications and procedural outcomes in pediatric patients treated at our hospital for complex ear reconstruction for ear deformities after her surgery. Inclusion criteria were pediatric patients aged 0 to 21 years admitted to Shriners Hospital for Children-Boston from January 1, 2010 to January 1, 2021 for burn injury, who subsequently required follow-up complex ear reconstruction for ear deformities after burn injury. Of these patients, those with lop ear deformities who required construction were examined. Using the Trauma Registry of the American College of Surgeons (TRACS) and Shriners Hospital for Children Information Source (SHCIS) databases, we identified 12 eligible patients. Surgical procedure data was obtained from the SHCIS electronic medical records. Surgical photographs were obtained with patient informed consent. Those patients who required Medpor or cartilage frame reconstructions were excluded.

Results
12 patients required an otoplasty-type procedure to obtain desired results or symmetry with the contralateral ear. This technique involved a posterior incision in the auriculomastoidmastoid sulcus, are you a year and cartilage modification with sutures to to re-create the antihelical fold an superior crus as well as conchal setback sutures.

Conclusions
Because ears are bilateral structures, symmetry is extremely poor. Because of multiple contractile forces on the external ear from secondary healing or contraction of skin grafts, the ear is often displaced anteriorly and the upper portions become folded. Treatment requires reconstruction of the natural folds of the ear and shortening of the helical rim to mastoid distance. this requires an otoplasty approach with a posterior incision,, exposure of the cartilaginous framework and modification of the cartilage with incisions and sutures. This technique however requires adequate soft tissue coverage of the ear.