Acute Burn Care Research Articles

389 Limited Volume Resuscitation with 5% Albumin Exacerbates Liver Injury in a 40% TBSA Swine Burn Model

Acute burn care (>30% TBSA) requires IV resuscitation with large volumes of fluids. Lactated Ringer’s (LR) is the most commonly utilized fluid however, other crystalloids (PlasmaLyte; PL) and colloids (fresh frozen plasma [FFP]; 5% Albumin [ALB]) have been suggested. While resuscitation maintains hemodynamics, limited volumes may suffice in resource-poor environments or mass casualty scenarios. This study compares limited IV resuscitation to the modified Brooke (MB) formula, with emphasis on liver function. Thirty anesthetized swine were subjected to 40% TBSA contact burns and randomized to one of five groups (n=6/group): 15mL/kg/d with LR; PL; FFP; ALB; was compared to 2ml/kg/%TBSA LR (MB). Animals recovered in metabolic cages for urine and blood collection (baseline (BL), 6, 12, 24, 32, and 48h post-burn) to quantify biochemical markers. Following euthanasia (48h) liver tissue samples were snap frozen for analysis. Four non-thermally injured animals (sham) served as tissue controls. Plasma protein was elevated at 48h with colloids (p≤0.002) and albumin levels were elevated throughout the study in the ALB group (p<0.0001). When compared with BL levels, liver enzymes alanine (68.3±1.3 vs 84.0±2.9 mg/dL; p<0.0001) and aspartate (31.0±1.0 vs 90.2±4.3 mg/dL; p<0.0001) aminotransferases were elevated by 6h post burn and remained high regardless of treatment. In the ALB group levels of bilirubin (p<0.0001) were higher throughout the course of the experiment when compared with all other treatments. Total urine output was greater in animals receiving MB (1703±245 mL) when compared with LR (1050±61 mL; p=0.07), PL (797±160 mL; p=0.007), and ALB (933±160 mL; p=0.09), but not FFP (1330±181 mL; p=0.61). Caspase was significantly up regulated in MB, LR, PL, and ALB when compared with sham animals (p≤ 0.019). Heat shock protein 70 tended to be greater in MB and L-LR than sham animals (p≤0.066). Histology revealed reduced intracellular glycogen reduced due to burn (p≤0.01) and a significantly higher level of edema in ALB when compared with other treatment groups (p≤0.16) as demonstrated by histology. Results from these experiments suggest that in this model, resuscitation with ALB early post-burn negatively impacts liver function. No abnormal changes in liver damage markers were detected in animals receiving FFP. Data from these studies can help inform limited volume resuscitative efforts for patients with burns. Limited IV fluid resuscitation is common in resource poor environments. Any available IV fluid would be effective to buy time in prolonged field care, however physicians should monitor liver function if using ALB.

216 Risk Stratification of Orbital Compartment Syndrome: A Comparison of Intra-Ocular Pressure and the Baux Score

Early fluid resuscitation is a mainstay in acute burn care. Aggressive fluid therapy in significant thermal burns can lead to third spacing of fluid into the orbit thus increasing the risk of orbital compartment syndrome. The Baux score is a simple tool often used in burn care to help predict mortality and thus indicate severity of the burn. This study aims to quantify the intra-ocular pressures (IOP) as it relates to the patient’s Baux score, in an effort to stratify the risk for orbital compartment syndrome. This study is a retrospective analysis of 70 patients with thermal burns at a level one burn center. The initial Baux score was noted for each patient as well as the highest measured IOP within the first 72 hour period. Linear regression was used to test for an association between peak intraocular pressure and the Baux score. Patients requiring orbital decompression were compared with those who did not, using the Fisher exact test. Eleven of 70 patients required emergent orbital decompression with a lateral canthotomy and cantholysis and had a higher Baux score than patients who did not receive the procedure (p = 0.03). The average IOP was 18.7 +/- 5mmHg but patients who underwent an orbital decompression all had IOP greater than 40. There was a positive relationship between the Baux score and IOP for Baux scores greater than 70; however, this was no longer statistically significant when adjusted for periocular burns. The risk of orbital compartment syndrome linearly increases with beaux scores greater than 70 and additionally in patients with periocular burns. As such, a high index of suspicion and early evaluation by an ophthalmologist is warranted in these patients to preserve vision. An elevated Beaux score can predict the necessity for ophthalmic intervention in patients at a high risk for vision loss secondary orbital compartment syndrome

431 Through the Eyes of Burn-Injured Youth - How Burn Camp Helps Survivors Thrive

Improvement in acute burn care has increased the probability of survival of severely burned children who often experience disfigurement and physical/emotional pain. Recreational camps whose goal is to help them deal with their burn injuries have existed for several decades. This includes helping burned children cope with disfigurement and the psycho/social challenges of burn survival. Few studies have delineated the actual benefits of camp from the participants’ point of view. This study asked attendees to identify and rank reasons they would recommend camp attendance to a burn-injured peer. Burn-injured youth attending four regional burn camps completed a survey asking, “If you were to invite a burn survivor to burn camp how would you rate the following 10 items recently identified by your burn peers as benefits of attending?” Items included Increased Confidence, Making Friends, Help with Scarring, No Judgement Zone, Supportive Counselors, Trying New Things, Being Part of a Community, Getting Away from Home and Being Outside. Participants rated each item on a scale of 1(Not at all) to 4 (Really a lot) and then chose the 3 most important benefits they get from burn camp. Participants (n=164) had a mean age of 13.7 years; female (n=88), male (n=74). The main cause of injury was fire/flame (40%) and scald (42%). The average age at burn was 6.1 yrs.; average years of attending camp was 4.6 and 76% had visible scars. All items received an average score of 3 or higher. The highest rated items were Increasing My Confidence (3.63) and Supportive Counselors (3.59). The lowest were, Time Away from Home (3.08) and Spending Time Outside (3.21). All items were ranked significantly higher than the two lowest ranking items (p=<001). The three responses endorsed as most important included Increasing My Confidence (46%), Making Friends-Building Connections (45%) and Helping Me Accept My Scars (44%). Campers endorsed many aspects of burn camp as positive. Importantly, the highest rated items support the development of meaningful relationships, which has been shown to buffer children from developmental disruption and help them adjust to trauma. The high levels of endorsement suggest that camp is helping children adjust to their burns in many ways, the key goal of burn camps. Burn care professionals should be proactive in encouraging pediatric patients to attend burn camp as it provides multiple reported benefits. Coordination between health care providers, survivors and parents in promoting attendance at burn camp is highly recommended by the very youth who espouse the benefits of attending.

84 Acute Burn Care May Reduce Future Vascularized Composite Allotransplantation Candidacy: Anti-HLA Immune Sensitization Effects of Allograft &amp; Blood Transfusion

84 Acute Burn Care May Reduce Future Vascularized Composite Allotransplantation Candidacy: Anti-HLA Immune Sensitization Effects of Allograft &amp; Blood Transfusion

Clinical profile of patients with post burn contracture

Background: Burns are a major, global public health problem, resulting in an estimated 195,000 deaths annually. Most burns occur in low-and middle-income countries, with almost half occurring in the south-east Asia region. The reasons for the high incidence include widespread ignorance of fire prevention, the rapid increase of poor socio-economic conditions, and the persistence of old traditions and customs.Methods: The study was carried out in Department of Surgery, Himalayan Institute of Medical Sciences, SRH University, Swami Ram Nagar, Dehradun over a period of 12months. Cases of the post burn contractures attended in the O.P.D were included in the study.Results: A total of 45 patients were included in the study. Of these, 22 (48.8%) were males and 23 (51.2%) were females. Ages ranged from 1 to 55year. Flame burn (20 cases = 44.4%) was the most common type of initial burn insult followed by scald burns (14 cases=31.1%).Conclusions: The pitfalls in initial burn care that lead to contractures in the patients include the failure to institute adequate surgical management of deep burns, the lack of physiotherapy/ROM exercises, and failure to provide proper anti-deformity splint age. There is need to revisit the prevalent acute burn care practices and establish focused preventive strategies.

Effects of a restrictive blood transfusion protocol on acute pediatric burn care: Transfusion threshold in pediatric burns.

Blood transfusion is costly and associated with various medical risks. Studies in critically ill adult and pediatric patients suggest that implementation of more restrictive transfusion protocols based on lower threshold hemoglobin concentrations can be medically and economically advantageous. The purpose of this study was to evaluate the implications of a hemoglobin threshold change in pediatric burn patients. We implemented a change in hemoglobin threshold from 10 g/dL to 7 g/dL and compared data from patients before and after this protocol change in a retrospective review. Primary endpoints were hemoglobin concentration at baseline, before transfusion, and after transfusion; amount of blood product administered; and mortality. Secondary endpoints were the incidence of sepsis based on the American Burn Association physiological criteria for sepsis and mean number of septic days per patient. All endpoint analyses were adjusted for relevant clinical covariates via generalized additive models or Cox proportional hazard model. Statistical significance was accepted at p less than 0.05. Patient characteristics and baseline hemoglobin concentrations (pre, 13.5 g/dL; post, 13.3 g/dL; p > 0.05) were comparable between groups. The group transfused based on the more restrictive hemoglobin threshold had lower hemoglobin concentrations before and after transfusion throughout acute hospitalization, received lower volumes of blood during operations (pre, 1012 mL; post, 824 mL; p < 0.001) and on days without surgical procedures (pre, 602 mL; post, 353 mL; p < 0.001), and had a lower mortality (pre, 8.0%; post, 3.9%; mortality hazard decline, 0.55 [45%]; p < 0.05). Both groups had a comparable incidence of physiological sepsis, though the more restrictive threshold group had a lower number of sepsis days per patient. More restrictive transfusion protocols are safe and efficacious in pediatric burn patients. The associated reduction of transfused blood may lessen medical risks of blood transfusion and lower economic burden. Therapeutic, level IV.

What do emergency medicine and burns specialists from resource constrained settings expect from mHealth-based diagnostic support? A qualitative study examining the case of acute burn care

BackgroundTraumatic injury is a serious global health burden, particularly in low- and middle-income countries where medical care often lacks resources and expertise. In these contexts, diagnostic telemedicine could prove a cost effective tool, yet it remains largely underused here, and knowledge on its potential impact is limited. Particularly scarce is the view of the expert user physicians, and how they themselves relate to this technology.MethodsThis qualitative study investigated tele-experts’ (n = 15) views on the potential for image based teleconsultation to be integrated in trauma and emergency care services. A semi-structured interview guide was used to gather data concerning an mHealth app for burns diagnostics in the acute care setting, in the Western Cape, South Africa. Questions examined challenges and opportunities in user acceptance and outcomes, in specific case management and in the wider healthcare system. Resulting data were subject to qualitative content analysis.ResultsExperts perceived remote diagnostic support through mHealth as linking directly to several key ideas in medicine, including barriers to care, medical culture and hierarchy, and medical ethics within a society. Ideas running through the data pertained to the widening and narrowing of inherent gaps in the healthcare system, and the formalisation of processes, practices and relationships, effected by the introduction of an app. Wide consensus was stated on positive outcomes such as increased education opportunities, improved professional relationships and a better ability to advise and diagnose, all further facilitated through greater ease of access. The belief was that these could achieve a narrowing of systemic divides within healthcare, although it was acknowledged that the possibility to induce the opposite effect also arose. Differing opinions were voiced relating to the involvement of allied health professionals and feedback.ConclusionExperts see several aspects to an mHealth app for remote diagnostic support which could enhance provision of trauma and emergency care in a resource poor setting, relating to reduced delays, streamlined care and improved outcomes. Attention is also drawn, however, to specifics of the environment which would demand further and careful consideration for success – time pressure, intensity and the wide range of subspecialties to be considered.

The SILKIE (Skin graftIng Low friKtIon Environment) study: a non-randomised proof-of-concept and feasibility study on the impact of low-friction nursing environment on skin grafting success rates in adult and paediatric burns

ObjectivesTo evaluate the impact of low-friction (LF) bedding on graft loss in an acute burn care setting, and to examine the feasibility and costs of using LF bedding compared with...

Screening of HLA sensitization during acute burn care

BackgroundSince the inception of clinical VCA almost two decades ago, burn victims have been identified as immunologically complex patients owing to preformed HLA antibodies. However, it remains unclear whether the detected HLA antibodies are the result of former alloantigenic events or if their de novo formation occurs during primary burn care. MethodsPatients with burns >20% of total body surface area (TBSA) admitted to Zurich Burn Centre between May 2015 and September 2016 were screened for HLA antibodies at admission and 6 months post trauma. The influence of glycerol-preserved donor skin and red blood cell transfusion on HLA antibody formation was investigated. ResultsThirty-seven patients (7 females and 30 males) with an average age of 45.2±19.1 years and average affected TBSA of 38.5%±18.9% were screened for HLA antibodies. Five patients (13.5%) showed preformed HLA antibodies at admission. Only 3 patients demonstrated verified de novo sensitization during acute burn care. Six patients treated with donor skin and blood transfusions showed no occurrence of HLA antibodies after 6 months. One patient died after 2 weeks due to infectious and thromboembolic complications – however, HLA antibodies were already detected. ConclusionFormation of HLA antibodies during acute burn care might be lower than that previously expected by using glycerol-preserved donor skin and restrictive administration of blood products. Modern concepts of burn care may contribute to a revised outlook on burn patients as potential candidates for VCA.

Clinical Epidemiology of Acute Burn Injuries at Nepal Cleft and Burn Centre, Kathmandu, Nepal.

Burn injury is a global health problem mainly occurring in developing countries. The Nepal Cleft and Burn Centre at Kirtipur Hospital, Kathmandu, has been providing the acute burn care since 2013 with 7 intensive care unit beds, 30 general beds, and 2 dedicated operating rooms. A similar descriptive study was performed in this center in 2014. These studies will be helpful for developing prevention strategies and monitoring the progress in the standard of care of acute burn patients. This is a descriptive retrospective study of the clinical data of acute burn patients admitted from January 1, 2015 to December 31, 2016. There were a total of 567 patients who came from 63 of 75 total districts of Nepal. Two hundred ninety-six (52.2%) patients were females and 271 (47.8%) were males. Two thirds of the patients were young adults. Most of the injuries occurred inside the house (72.1%). Flame burn was the most common mode of injury (66%) followed by scald (21.6%). Only 64 (11.3%) patients arrived on the same day of the injury. The longest time elapsed was 60 days with a median of 4.3 days. Range of total body surface area (TBSA) involved was 1% to 95%. The mean and median TBSAs were 25% and 15%, respectively. Range of hospital stay was 1 to 105 days with a median of 13.3 days.A total of 448 surgical procedures were performed in 384 patients (67.7%). A total of 110 (19.4%) patients died at the hospital. Only 13 patients (3%) survived deep burn injury involving 40% or more TBSA with either cadaveric skin allograft or with skin allograft from the live relatives. The outcome of burn injuries in Nepal is very poor. Children and females are at high risk. There is a lack of knowledge about burn prevention, proper first aid, and skin donation among the Nepalese population. Delay in presentation and extensive burns are poor prognostic factors. Awareness programs about the proper first aid and the need of a skin bank has to be done to improve the burn scenario in Nepal. Availability of allograft can increase the chances of survivability of patients with extensive burns in Nepal.

The Effect of Burn Trauma on Lipid and Glucose Metabolism: Implications for Insulin Sensitivity.

Severe burns represent a unique form of trauma in terms of the magnitude and persistence of the stress response they incur. Given advances in acute burn care in the last quarter of a century and the resultant reduction in mortality rates, even for those with massive burns, greater emphasis is now placed on understanding the metabolic stress response to severe burn trauma in order to devise strategies that promote recovery and reduce morbidity. Derangements in metabolism including protein and lipid redistribution and altered glucose handling are hallmarks of the pathophysiological response to burn trauma. In this review article, we aim to distill and discuss the c urrent literature concerning the effect of burn trauma on lipid and glucose metabolism. Furthermore, we will discuss the implications of altered lipid metabolism with regards to insulin sensitivity and glucose control, while discussing the utility of agents and strategies aimed at restoring normal lipid and glucose metabolism in burned patients.

Multicenter Randomized Controlled Trial to Assess an e-Learning on Acute Burns Management

An e-learning tutorial was developed to cover the basic aspects of acute burns management. The aim of this study was to provide objective educational evidence supporting the role of an e-learning on acute burns management ("basic burns management" or BBM) when compared with traditional teaching methods when introduced in different medical school settings around the world. A multicenter randomized controlled trial was conducted at the University of Pittsburgh, Peninsula College of Medicine and Dentistry, and St. George's University of London comparing the learning experience of medical students with the BBM e-learning tool (intervention) and a traditional lecture (control). A group of medical students was randomly allocated to the e-learning or lecture arms. Both groups were subjected to a 10-question pre-intervention and post-intervention tests assessing burns knowledge, and were asked to fill out a satisfaction survey. A total of 79 medical students of varying years of study participated. As a whole, students demonstrated a significant gain in knowledge after intervention (overall = 47.6%, P < .001), regardless of medical school year of study or interest in surgery. Participants undertaking the BBM e-learning had a greater exam score improvement and satisfaction compared with the traditional lecture even though they were not statistically significant. BBM e-learning is a free tool that provides comparable acute burn care learning opportunity and satisfaction outcomes to a traditional lecture, allowing convenient and standardized incorporation of burns teaching within an educational setting, regardless of geographical location, level of experience, or interest in surgery.

In view of standardization Part 2: Management of challenges in the initial treatment of burn patients in Burn Centers in Germany, Austria and Switzerland

IntroductionInitial therapy of severe burns in specialized burn trauma centers is a challenging task faced by the treating multi-professional and interdisciplinary team. A lack of consistent operating procedures and varying structural conditions was recently demonstrated in preliminary data of our group. These results raised the question on how specific treatment measures in acute burn care are met in the absence of standardized guidelines. Material and methodsA specific questionnaire containing 57 multiple-choice questions was sent to all 22 major burn centers in Germany, Austria and Switzerland. The survey included standards of airway management and ventilation, fluid management and circulation, body temperature monitoring and management, topical burn wound treatment and a microbiological surveillance. Additionally, the distribution of standardized course systems was covered. Results17 out of 22 questionnaires (77%) were returned completed. Regarding volume resuscitation, results showed a similar approach in estimating initial fluid while discrepancies persisted in the use of colloidal fluid and human albumin. Elective tracheostomy and the need for bronchoscopy with suspected inhalation injury were the most controversial issues revealed by the survey. Topical treatment of burned body surface also followed different principles regarding the use of synthetic epidermal skin substitutes or enzymatic wound debridement. Less discrepancy was found in basic diagnostic measures, body temperature management, estimation of the extent of burns and microbiological surveillance. ConclusionWhile many burn-related issues are clearly not questionable and managed in a similar way in most participating facilities, we were able to show that the most contentious issues in burn trauma management involve initial volume resuscitation, management of inhalation trauma and topical burn wound treatment. Further research is required to address these topics and evaluate a potential superiority of a regime in order to increase the level of evidence.

Cutaneous Imaging Technologies in Acute Burn and Chronic Wound Care.

Wound assessment relies on visual evaluation by physicians. Such assessment is largely subjective and presents the opportunity to explore the use of emergent technologies. Emergent and powerful noninvasive imaging technologies applicable to assess burn and chronic wounds are reviewed. The need to estimate wound depth is critical in both chronic wound and burn injury settings. Harmonic ultrasound technology is powerful to study wound depth. It addresses the limitations of optical imaging with limited depth of penetration. What if a wound appears epithelialized by visual inspection, which shows no discharge yet is covered by repaired skin that lacks barrier function? In this case although the wound is closed as defined by current standards, it remains functionally open, presenting the risk of infection and other postclosure complications. Thus, assessment of skin barrier function is valuable in the context of assessing wound closure. Options for the study of tissue vascularization are many. If noncontact and noninvasive criteria are of importance, laser speckle imaging is powerful. Fluorescence imaging is standard in several clinical settings and is likely to serve the wound clinics well as long as indocyanine green injection is not of concern. A major advantage of harmonic ultrasound imaging of wound depth is that the same system is capable of providing information on blood flow dynamics in arterial perforators. With many productive imaging platforms to choose from, wound care is about to be transformed by technology that would help assess wound severity.

Bone markers during acute burn care: Relevance to clinical practice?

ObjectiveBone changes are increasingly described after burn. How bone markers could help to detect early bone changes or to screen burn patients at higher risk of demineralization is still not made clear. We performed an observational study assessing the changes in serum bone markers after moderate burn. MethodsAdults admitted in the first 24h following burn extended on >10% body surface area were included. Serum levels of collagen type 1 cross-linked C-telopeptide (CTX), tartrate-resistant acid phosphatase 5b (TRAP), type 1 procollagen N-terminal (P1NP) and bone alkaline phosphatase (b-ALP) were measured at admission and every week during the first month. Data are expressed as median [min-max]. ResultsBone markers were measured in 20 patients: 18 men, 2 women (including one post-menopausal). Age was 46 [19–86] years old, burn surface area reached 15 [7–85] %. Twelve patients completed the study. All biomarkers mainly remained into normal ranges during evolution. A huge variability was observed regarding biomarkers evolution. Patient's evolution was not linear and could fluctuate from a decrease to an increase of blood concentrations. There was not necessarily a consistency between the two formation or the two resorption markers. Variations observed between two consecutive measurements were lesser than the accepted critical difference in almost one third of the cases. ConclusionsConsidering available data, role and interest of bone markers in management of burn related bone disease remain unclear.

Is the Target of 1 Day of Stay per 1% Total Body Surface Area Burned Achieved in Chemical Burns?

The length of hospital stay (LOS) is a standard parameter used to reflect quality and evaluate outcomes in acute burn care. This study aims to assess whether the target of 1 day of stay per 1% total body surface area (TBSA) burned was achieved in acute chemical burns management and factors affecting the LOS. A retrospective analysis of the records of patients who suffered from chemical burn injuries admitted to a university burn center over a continuous 14-year period was performed.A total of 118 patients were admitted over the period for chemical burns. Only 14% of cases achieved the target stated. Factors associated with lengthening of the hospital stay included TBSA, ocular involvement, the cause of injury, and the need for surgery during the same admission.The LOS in chemical burns frequently exceeds 1 day of stay per 1% TBSA burned. Many factors can contribute to a patient's LOS and are worth exploring in order to see if the impact of these factors could be minimized. Early surgical intervention should help to reduce the LOS if reliable methods of burn wound depth assessment are available.

Measuring the Burden of Pediatric Burn Injury for Parents and Caregivers

This study sought to identify which commonly experienced burn-related issues parents/caregivers of burn-injured youth deemed most stressful, difficult, and disruptive during their child's initial acute burn care hospitalization, and following the child's discharge. Parents completed an 11-item survey, asking them to rate the difficulty of items regarding their child's burn injury. The scale was created by burn doctors, nurses, and psychologists with an average of 10.5 (SD ± 4.8) years of experience. Items selected were among common parental problems reported in the burn literature. Respondents included 69 parents/caregivers of previously hospitalized, burn-injured youth. The majority were mothers, n = 51 (74%), and n = 34 (49%) were Caucasian. The most represented age group was 37 to 45 years, n = 31 (45%). Children were on average, 6.04 years out from their initial injury. All parents reported their child's pain as the most difficult part of the injury, n = 69 (100%). The second most common issue was the child's first hospital stay. The other two items found to be "very hard" or "pretty hard" were the time spent away from their other children, and feelings of hopelessness in being unable to fix everything for their child. In this study, key parental problems occurred during the child's initial hospitalization. Burn staff cannot alleviate all problems, however, staff education regarding distressing problems faced by parents, as well as possible solutions, can be made available.

Vitamin D status after a high dose of cholecalciferol in healthy and burn subjects

BackgroundBurn patients are at risk of vitamin D (VD) deficiency and may benefit from its pleiotropic effects as soon as acute phase. Aim of this observational study was to assess effects of a cholecalciferol (VD3) bolus on VD status in adult burn patients (Group B, GB) after admission, compared to healthy subjects (Group H, GH). MethodsBoth groups received an oral dose of 100,000IU VD3. Blood samples were collected before (D0) and 7 days (D7) after bolus to measure 250H-D, 1,25(OH)2-D, parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF23). Albumin (ALB) and VD binding protein (DBP) were measured and used to calculate free 25OH-D level. Data were expressed as median (min–max) or proportions. ResultsA total of 49 subjects were included: 29 in GH and 20 in GB. At D0, prevalence of VD deficiency was higher in GB: 25OH-D was 21.5 (10.1–46.3) ng/ml in GH vs 11 (1.8–31.4) ng/ml in GB. DBP and ALB were lower in GB. At D7, DBP was stable in both groups while ALB decreased in GB. 25OH-D increased by 66.6 (13.5–260.3)% in GH. In GB, changes in 25OH-D extended from −36.7% to 333.3% with a median increase of 33.1%. Similar changes were observed in each group for free 25OH-D. High FGF23 levels were observed in GB. ConclusionsThis study highlighted the differences in VD status and in response to a high dose VD3 in burn patients when compared to healthy patients. Pitfalls in VD status assessment are numerous during acute burn care: 25OH-D measurement needs cautious interpretation and interest of free 25OH-D is still questionable. They should not prevent burn patients to receive VD supplements during acute care. Higher doses than general recommendations should probably be considered.

Burns education for non-burn specialist clinicians in Western Australia

BackgroundBurn patients often receive their initial care by non-burn specialist clinicians, with increasingly collaborative burn models of care. The provision of relevant and accessible education for these clinicians is therefore vital for optimal patient care. Design/methodsA two phase design was used. A state-wide survey of multidisciplinary non-burn specialist clinicians throughout Western Australia identified learning needs related to paediatric burn care. A targeted education programme was developed and delivered live via videoconference. Pre-post-test analysis evaluated changes in knowledge as a result of attendance at each education session. ResultsNon-burn specialist clinicians identified numerous areas of burn care relevant to their practice. Statistically significant differences between perceived relevance of care and confidence in care provision were reported for aspects of acute burn care. Following attendance at the education sessions, statistically significant increases in knowledge were noted for most areas of acute burn care. ConclusionsIdentification of learning needs facilitated the development of a targeted education programme for non-burn specialist clinicians. Increased non-burn specialist clinician knowledge following attendance at most education sessions supports the use of videoconferencing as an acceptable and effective method of delivering burns education in Western Australia.

A Systematic Review of Advance Practice Providers in Acute Care

Accreditation Council for Graduate Medical Education mandated work-hour restrictions have negatively impacted many areas of clinical care, including management of burn patients, who require intensive monitoring, resuscitation, and procedural interventions. As surgery residents become less available to meet service needs, new models integrating advanced practice providers (APPs) into the burn team must emerge. We performed a systematic review of APPs in critical care questioning, how best to use all providers to solve these workforce challenges? We performed a systematic review of PubMed, CINAHL, Ovid, and Google Scholar, from 2002 to 2012, using the key words: nurse practitioner, physician assistant, critical care, and burn care. After applying inclusion/exclusion criteria, 18 relevant articles were selected for review. In addition, throughput and financial models were developed to examine provider staffing patterns. Advanced practice providers in critical care settings function in various models, both with and without residents, reporting to either an intensivist or an attending physician. When APPs participated, patient outcomes were similar or improved compared across provider models. Several studies reported considerable cost-savings due to decrease length of stay, decreased ventilator days, and fewer urinary tract infections when nurse practitioners were included in the provider mix. Restrictions in resident work-hours and changing health care environments require that new provider models be created for acute burn care. This article reviews current utilization of APPs in critical care units and proposes a new provider model for burn centers.