American Burn Association Research Articles

American Burn Association 52nd Annual Meeting

American Burn Association 52nd Annual Meeting

596 ICU Sedation Practices for Mechanically Ventilated Burn Patients Following Guideline Implementation

Abstract Introduction Our American Burn Association verified regional burn center has approximately 700 admissions for burn injury per year, 200 of which are admitted to the burn intensive care unit (BICU). Sedation practices during acute burn resuscitations remain variable. In order to standardize our sedation practices, we developed a Background Pain and Anxiety Decision Tree for Mechanically Intubated Adults in March 2017. Concern over hypotension led to the removal of propofol as the sedative of choice. The new protocol made midazolam the primary choice and recommended the use of adjunct analgesics, including acetaminophen, for background pain. It uses the Richmond Agitation Sedation Scale (RASS) to determine whether patients were oversedated (RASS< 0) or anxious (RASS >1+). Methods We conducted a single center retrospective chart review on intubated patients admitted to the BICU from November 2017 through November 2018. Data collection focused primarily on sedation practices during this time to determine whether our protocol had the desired effects. Highest and lowest RASS were collected, and the difference between the two (delta RASS) was used to determine changes in patient agitation and sedation. Results Thirty three adult patients requiring mechanical ventilation were admitted to the BICU between November 2017 and November 2018. Of these patients, 21 (66%) received propofol on hospital day one, and 12 (38%) received propofol on hospital day two. Eleven patients received both propofol and midazolam on hospital day one. Of these patients, the average propofol dose was 511 micrograms per day and the average midazolam dose was 13.3mg per day (p=0.02). Eighteen (56%) and twenty five (78%) patients received acetaminophen on hospital days one and two, respectively. Twenty four patients had a RASS recorded during their first hospital day. The average highest RASS recorded was 1.3 and the average lowest recorded RASS was -3.2. Patients who received both propofol and midazolam had a higher peak RASS (2.4) and a lower minimum RASS (3.4), creating a larger delta RASS for this group. Conclusions Despite eliminating propofol from our sedation guidelines, its use remains the predominant mode of sedation for burn patients throughout the first forty eight hours of hospitalization. There is also room for improvement for administration of non-opioid analgesics, including acetaminophen. Finally, our ventilated patients tend to be more oversedated than undersedated, and a combination of midazolam and propofol creates the largest swings in patients’ sedation and agitation status. Applicability of Research to Practice Changing sedation and pain management practices in the ICU is a multifactorial process that requires more than ICU guideline implementation. The use of two sedatives during the first hospital day can result in larger swings in RASS as opposed to use of a single agent.

Racial and Ethnic Disparities Among Burn Surgery Leadership.

The underrepresentation of racial and ethnic minority groups has been well-documented in general and plastic surgery but not in burn surgery. The aim of this study is to evaluate current minority group disparities among burn surgery leadership. A cross-sectional analysis was performed. Burn surgeons included directors of American Burn Association-verified burn centers in the United States, past and current presidents of the American Burn Association, and editorial board members of five major burn journals (Journal of Burn Care & Research, Burns, Burns & Trauma, Annals of Burns & Fire Disasters, and the International Journal of Burns and Trauma). Surgeons were compared based on factors including age, gender, training, academic rank, and Hirsch index (h-index). Among 71 burn center directors, 50 societal presidents, and 197 journal editors, minority groups represented 18.3, 2.0, and 34.5%, respectively. Among burn center directors, the group classified collectively as nonwhite was significantly younger (49 vs 56; P < .01), graduated more recently (2003 vs 1996; P < .01), and had a lower h-index (9.5 vs 17.4; P < .05). There were no significant differences in gender, type of residency training, advanced degrees obtained, fellowships, academic rank, and academic leadership positions between white and nonwhite groups. When compared with the 2018 U.S. National Census, burn unit directors had a 5.1% decrease in nonwhite representation. Disparities in representation of ethnic and racial minorities exist in burn surgery despite having similar qualifying factors.

Standards in Biologic Lesions: Cutaneous Thermal Injury and Inhalation Injury Working Group 2018 Meeting Proceedings.

On August 27 and 28, 2018, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn and inhalation injury in Washington, DC. The goal of the meeting was to identify and discuss the existing knowledge, data, and modeling gaps related to understanding cutaneous thermal injury and inhalation injury due to exposure from a fire environment, and in addition, address two more areas proposed by the American Burn Association Research Committee that are critical to burn care but may have current translational research gaps (inflammatory response and hypermetabolic response). Representatives from the Underwriters Laboratories Firefighter Safety Research Institute and the Bureau of Alcohol, Tobacco, Firearms and Explosives Fire Research Laboratory presented the state of the science in their fields, highlighting areas that required further investigation and guidance from the burn community. Four areas were discussed by the full 24 participant group and in smaller groups: Basic and Translational Understanding of Inhalation Injury, Thermal Contact and Resulting Injury, Systemic Inflammatory Response and Resuscitation, and Hypermetabolic Response and Healing. A primary finding was the need for validating historic models to develop a set of reliable data on contact time and temperature and resulting injury. The working groups identified common areas of focus across each subtopic, including gaining an understanding of individual response to injury that would allow for precision medicine approaches. Predisposed phenotype in response to insult, the effects of age and sex, and the role of microbiomes could all be studied by employing multi-omic (systems biology) approaches.

Full thickness genital burns independently increase the odds of death among pediatric burn patients

There are limited published data characterizing pediatric burn patients with genital burns (GB). Assess prevalence of GB in pediatric burn patients and analyze clinical characteristics including predictors of mortality. We queried American Burn Association's National Burn Repository to identify all pediatric burn patients who presented to North American burn centers over a 10-year period. We excluded all patients aged ≥18 years and patients with unknown sex, race, and/or mortality. We also excluded subsequent encounters for patients with multiple visits. Demographic and clinical characteristics were compared between patients with and without GB. Univariable and multivariable logistic regression analyses were performed to identify predictors of mortality. Among 38211 pediatric burn patients, 1244 (3.3%) suffered from second- or third-degree GB. Patients who suffered from third-degree GB (GB3) were significantly older than patients who suffered from second-degree GB (GB2) or patients without GB. Of the patients, 32.3% were aged 0-2 years. Scalding was the most common mechanism of injury for pediatric GB patients at 73.8%. Compared to non-GB patients, GB patients had significantly higher total body surface area (TBSA) burned (16.5% vs 7.0%), higher rates of associated inhalation injury (4.1% vs 2.6%), longer length of stay (LOS) (14.3 days vs 6.7 days), higher rates of urinary tract infection (UTI) (13.0% vs 2.8%) and sepsis (14.1% vs 2.3%), and higher mortality (3.5% vs 0.7%) (P<0.0001 for all). The differences were more pronounced for the subset of patients who suffered from GB3 (TBSA 43.5%, associated inhalation injury 19.9%, LOS 42.9 days, 21.3% UTI, 33.3% sepsis, and 19.3% mortality). On multivariable analysis, the presence of GB3, TBSA, non-white ethnicity, and the presence of associated inhalation injury were significant predictors of mortality. Only 4.5% of pediatric GB patients underwent genital surgery, with the majority consisting of excision, reconstruction, or repair of the penis, vulva, or perineum. No patient required orchiectomy or suprapubic catheter placement. This is the largest study to date of pediatric GB patients. A minority of pediatric burn patients present with GB. However, when they occur, GB are associated with significantly worse clinical outcomes. Importantly, the presence of GB3 is an independent predictor of mortality in pediatric burn patients. The presence of GB appears to be a strong marker of severe burn injury. Pediatric GB patients need to be carefully assessed and aggressively managed for additional injuries, complications, surgical needs, and mortality risk.

Gender Disparities Among Burn Surgery Leadership.

Gender disparities have been described in the plastic surgery and general surgery literature, but no data have been reported in burn surgery. The aim of this study is to determine gender disparities among burn surgery leadership. A cross-sectional study was performed. Burn surgeons included were directors of American Burn Association (ABA)-verified burn centers, past presidents of the ABA, and International Society for Burn Injuries (ISBI), and editors of the Journal of Burn Care & Research, Burns, Burns & Trauma, Annals of Burns & Fire Disasters, and the International Journal of Burns and Trauma. Training, age, H-index, and academic level and leadership position were compared among surgeons identified. Among the 69 ABA and ISBI past presidents, 203 burn journals' editorial board members, and 71 burn unit directors, females represented only 2.9%, 10.5%, and 17%, respectively. Among burn unit directors, females completed fellowship training more recently than males (female = 2006, male = 1999, P < .02), have lower H-indexes (female = 8.6, male = 17.3, P = .03), and are less represented as full professors (female = 8.3%, male = 42.4%, P = .026). There were no differences in age, residency, research fellowship, or number of fellowships. Gender disparities exist in burn surgery and are highlighted at the leadership level, even though female surgeons have a similar age, residency training, and other background factors. However, gender diversity in burn surgery may improve as females in junior faculty positions advance in their careers.

Obesity Paradox in the Burn Patient.

Despite the fact that obesity is a known risk factor for comorbidities and complications, there is evidence suggesting a survival advantage for patients classified by body mass index (BMI) as overweight or obese. Investigated in various clinical areas, this "Obesity Paradox" has yet to be explored in the burn patient population. We sought to clarify whether this paradigm exists in burn patients. Data collected on 519 adult patients admitted to an American Burn Association Verified Burn Center between 2009 and 2017 was utilized. Univariable and multivariable logistic regression were used to determine the association between in-hospital mortality and BMI classifications (underweight <18.5 kg/m2, normal 18.5 to 24.9 kg/m2, overweight 25-29.9 kg/m2, obesity class I 30 to 34.9 kg/m2, obesity class II 35 to 39.9 kg/m2, and extreme obesity >40 kg/m2). For every kg/m2 increase in BMI, the odds of death decreased, with an adjusted odds ratio of 0.856 (95% confidence interval [CI] 0.767 to 0.956). When adjusted for total BSA (TBSA), being obesity class I was associated with an adjusted odds ratio of mortality of 0.0166 (95% CI 0.000332 to 0.833). The adjusted odds ratio for mortality for underweight patients was 4.13 (95% CI 0.416 to 41.055). There was no statistically significant difference in odds of mortality between the normal and overweight BMI categories. In conclusion, the obesity paradox exists in burn care: further investigation is needed to elucidate what specific phenotypic aspects confer this benefit and how these can enhance the care of burn patients.

Impact of insufficient admission vitamin D serum concentrations on sepsis incidence and clinical outcomes in patients with thermal injury

IntroductionIn burn patients, vitamin D has been studied primarily in the pediatric population and focused mainly on the correlation with bone marker measurements and incidence of fractures. There is an association between vitamin D deficiency and the development of sepsis in non-burn critically-ill patients. However, there is limited data on vitamin D concentrations and clinical outcomes in burn patients, such as sepsis. The objective of this study is to evaluate the impact of vitamin D concentrations on the incidence of sepsis in adult burn patients. MethodsThis was a retrospective cohort of patients 18 years of age and older admitted between February 1, 2016 and February 28, 2018 to an American Burn Association (ABA) verified burn center with diagnosis of burn injury. The primary endpoint was incidence of sepsis using the ABA 2007 Sepsis Consensus Criteria between patients with adequate vitamin D concentrations (25[OH]D > 20 ng/mL) and insufficient vitamin D (25[OH]D < 20 ng/mL) concentrations measured on admission. Descriptive statistics were used for baseline demographics. Univariate analysis was conducted using Chi-square, Fisher’s exact test or Mann–Whitney U test, as appropriate. ResultsA total of 115 patients were screened and 107 patients were included in this study. Sixty three patients (58.9%) had insufficient vitamin D concentrations. Patient demographics were overall similar between groups. The median total body surface area burned was 14.6% in the insufficient vitamin D group, and 12.1% in the adequate vitamin D group (p = 0.2). There was a trend towards greater incidence of sepsis in the insufficient vitamin D group in the univariate analysis (15.9% vs. 4.5%, p = 0.07). The multivariable logistic regression analysis found that adequate vitamin D concentrations was associated with a reduction in the incidence of sepsis (OR 0.10, 95% CI 0.01–0.88). The insufficient vitamin D group had a longer median hospital LOS (19 [IQR 11–37] vs 11.5 [IQR 7–20] days, p < 0.05), longer intensive care unit LOS (17 [IQR 10–37] vs 5 [IQR 2–19.5] days, p < 0.05) and fewer ventilator free days (26 [IQR 18–28] vs 28 [IQR 27–28] days, p < 0.05). There was no difference in mortality between groups (p = 0.69). ConclusionsPatients with adequate vitamin D concentrations on admission had a reduction in the incidence of sepsis as compared to patients with insufficient vitamin D concentrations. Insufficient vitamin D concentrations may contribute to other worsened clinical outcomes in burn patients. Our findings set the stage for future, multicenter studies to determine the role of vitamin D supplementation in burn patients.

Burn Nurse Competency Utilization: Report From the 2019 Annual American Burn Association Meeting

Competence in healthcare is a recognized expectation by consumers. In 2018 following an extensive review and consensus-building process, burn nursing practice competencies were published. Clinical nurse leaders were called upon to use these published competencies in practice as a basis for the requisite knowledge and skills needed in the care of the burn-injured individual. In 2019 at the 51st Annual Meeting of the American Burn Association, nurses from four U.S. burn centers reported on their center's incorporation of the competencies within their educational nursing curriculums. This paper provides a forum for each of the lead authors from Rhode Island Hospital Burn Center, the University of Utah Health Burn Trauma Intensive Care Unit, Parkland Regional Burn Center, and the University of Chicago Medicine Burn Center to outline their current utilization of the new burn nurse competencies and plans for future use.

Extremity Mobilization After Split-Thickness Skin Graft Application: A Survey of Current Burn Surgeon Practices.

To determine the current postoperative mobilization care practice patterns of burn surgeons after split-thickness skin grafting and to assess potential inconsistencies in management strategies. A cross-sectional study of active burn surgeons was conducted with an online questionnaire (SurveyMonkey) comprising 7 demographic and 22 mobilization-related questions. Seventy-three (22%) of the 337 members of the American Burn Association mailing list consented to participate in the study, of whom 71 completed the demographic questions and 59 completed the mobilization-related questions. The majority of respondents had more than 10 years of burn care experience (68%) and practiced in an American Burn Association-verified center (70%). Standardized postoperative autograft mobilization protocols were used by 68% of respondents. Most (66%) never or rarely immobilized the upper extremity without joint involvement. When the elbow or wrist was involved, 73% always or very often immobilized. Similarly, 63% never or rarely immobilized the lower extremity without joint involvement. Most immobilized when the knee (70%) or ankle (63%) was involved. Immobilization duration was most commonly 3 or 5 days. Most respondents (71%) reported following Nedelec and colleagues' recommendation that "early postoperative ambulation protocol should be initiated immediately after lower extremity grafting," although there was practice variability. Our findings reveal that the majority of survey respondents do not immobilize the extremities after autograft without joint involvement. When grafts cross major joints, most surgeons immobilize for 3 or 5 days. Despite some practice variability, surveyed burn surgeons' current lower extremity ambulation practices generally align with the 2012 guidelines of Nedelec et al.

Outcomes of Inhalation Injuries in Lesser Burns Still a Deadly Injury

Although it has been widely proposed that inhalation injuries worsen burn outcomes, large-scale studies have yet to demonstrate the exact relationship. This study proposes inhalation injuries as an independent risk factor that worsens burn outcomes.A retrospective review of the American Burn Association Registry from 2002 to 2011 was conducted. Inclusion criteria included burn patients with a total body surface area (TBSA) of less than 15% and adequate data recording of the inhalation injury within the registry. Patients were stratified into 2 groups: inhalation injuries (group 1) vs non-inhalation injuries (group 2). Outcome measures included in-hospital mortality rate, hospital length of stay (LOS), intensive care unit (ICU) LOS, and days on a ventilator.A total of 93781 burn patients met the inclusion criteria. There were 4204 patients in group 1 and 89577 patients in group 2. There was no statistically significant difference between the 2 groups in terms of TBSA, with 3.50% in group 1 and 3.58% in group 2. There was a significantly higher ICU LOS at 8.55 days in group 1 compared to 6.27 days in group 2. There was a significantly higher hospital LOS at 11.48 days in group 1 compared to 6.27 days in group 2. The in-hospital mortality was significantly higher in group 1 at 8.54% vs group 2 at 1.42%.The presence of inhalation injury may be a predictor of increased mortality and poor outcome in burn patients, even in those with small sized burns.

Sedation and Analgesia for Adult Outpatient Burn Dressing Change: A Survey of American Burn Association Centers.

The management of pain and sedation during burn dressing change is challenging. Previous reviews and studies have identified wide variability in such practices in hospitalized burn patients. This survey-based study aimed to determine the most commonly utilized sedation and analgesia practices in adult burn patients treated in the outpatient setting. The goal was to identify opportunities for improvement and to assist burn centers in optimizing sedation procedures. A 23-question survey was sent to members of the American Burn Association. Nonpharmacological interventions including music, television, games, and virtual reality were used by 68% of survey respondents. Eighty-one percent reported premedicating with oral opioids, 32% with intravenous opioids, and 45% with anxiolytics. Fifty-nine percentage of respondents indicated that the initial medication regimen for outpatient dressing changes consisted of the patient's existing oral pain medications. Forty-three percent indicated that there were no additional options if this regimen provided inadequate analgesia. Fifty-six percentage of respondents felt that pain during dressing change was adequately controlled 75% to 100% of the time, and 32% felt it was adequately controlled 50% to 75% of the time. Nitrous oxide was used by 8%. Anesthesia providers and an acute pain service are available in a minority of cases (13.7% and 28%, respectively) and are rarely consulted. Procedural burn pain remains significantly undertreated in the outpatient setting and the approach to treatment is variable among burn centers in the United States. Such variation likely represents an opportunity for identifying and implementing optimal practices and developing guidelines for burn pain management in the outpatient setting.

Factors Affecting Research Productivity of Burn Surgeons: Results from a Survey of American Burn Association Members.

While previous studies have examined factors that affect research productivity for surgeons in general, few studies address research productivity specifically of burn specialists. This study aimed to identify factors that promote and impede research participation and productivity of burn surgeons and help elucidate what changes can be made by departments/divisions to improve the research productivity. A 44-question anonymous research survey tool was administered to burn surgeons who are members of the American Burn Association (ABA). The questions analyzed factors such as demographics, career accomplishments, current institution type, educational background, research background, barriers to conducting research, and current research productivity. Chi-square tests were used to analyze significance at P < .05. Most respondents reported not having any protected research time (71.4%) or resources provided by their institution (84.5%). A majority believed increasing regulatory policies/institutional review board restrictions have negatively impacted productivity (65.1%). Factors associated with positive impact on research productivity included having a mentor, conducting research prior to completing residency, and provision of research resources from the institution such as statistical support, start-up funds, grant writing support, and laboratory space. Age and sex had no statistical impact on research productivity. Burn surgeons are more likely to publish research and to receive grants when they have mentors, a history of research prior to completion of residency, and research resources from their institution. Barriers to research productivity include lack of institutional support, lack of protected research time, and increased regulatory policy.

Variations in access to specialty care for children with severe burns

BackgroundPediatric burns account for 120,000 emergency department visits and 10,000 hospitalizations annually. The American Burn Association has guidelines regarding referrals to burn centers; however there is variation in burn center distribution. We hypothesized that disparity in access would be related to burn center access. MethodsUsing weighted discharge data from the Nationwide Inpatient Sample 2001–2011, we identified pediatric patients with International Classification of Diseases-9th Revision codes for burns that also met American Burn Association criteria. Key characteristics were compared between pediatric patients treated at burn centers and those that were not. ResultsOf 54,529 patients meeting criteria, 82.0% (n = 44,632) were treated at burn centers. Patients treated at burn centers were younger (5.6 versus 6.7 years old; p < 0.0001) and more likely to have burn injuries on multiple body regions (88% versus 12%; p < 0.0001). In urban areas, 84% of care was provided at burn centers versus 0% in rural areas (p < 0.0001), a difference attributable to the lack of burn centers in rural areas. Both length of stay and number of procedures were significantly higher for patients treated at burn centers (7.3 versus 4.4 days, p < 0.0001 and 2.3 versus 1.1 procedures, p < 0.0001; respectively). There were no significant differences in mortality (0.7% versus 0.8%, p = 0.692). ConclusionThe majority of children who met criteria were treated at burn centers. There was no significant difference between geographical regions. Of those who were treated at burn centers, more severe injury patterns were noted, but there was no significant mortality difference. Further study of optimal referral of pediatric burn patients is needed.

Impact of diagnostic bronchoscopy in burned adults with suspected inhalation injury

IntroductionInhalation injury is a common complication of thermal trauma. Fiberoptic bronchoscopy (FOB) is regarded as current standard practice in diagnosing and grading inhalation injury. Nonetheless, its predictive value in terms of therapeutic decision-making and clinical outcome is controversial. MethodsAdult burn patients with inhalation injury (InI) were selected from the National Burn Repository of the American Burn Association. Subjects were propensity score pair-matched based on injury severity and grouped based on whether or not FOB had been performed (FOB, CTR, respectively). Mortality, incidence of pneumonia, length of hospitalization, length of ICU stay and dependency on mechanical ventilation were compared between the two groups. Results3014 patients were matched in two groups with a mean TBSA of 22.4%. There was no significant difference in carboxyhemoglobin fraction at admission. Patients, who underwent FOB on admission had a significantly increased incidence of pneumonia (p < 0.001), mortality (p < 0.05), length of hospitalization (p = 0.002), ICU stay (p < 0.001) and duration of mechanical ventilation (p = 0.006). In a subgroup analysis of patients with TBSA of at least 20%, incidence of pneumonia was significantly higher in the FOB group (p < 0.001) and longer mechanical ventilation was required (p = 0.036). DiscussionDiagnosis and grading of InI through FOB is the current standard, although its predictive value regarding key outcome parameters and therapeutic decision-making, remains unclear. The potential procedural risk of FOB itself should be considered. This study demonstrates correlations of FOB with major clinical outcomes in both a general collective of burned adults as well as severely burned adults. Although these findings must be interpreted with caution, they may induce further research into potential harm of FOB and critical review of routine diagnostic FOB in suspected inhalation injury in thermally injured patients.

Rehabilitation of the Burn Patient

Burn rehabilitation begins the moment the patient contacts the healthcare system and, for many patients, it never truly ends. Returning severely burned patients to their pre-injury level of function has become more challenging, as more severely burned patients survive their injury. The need for rehabilitation does not simply correspond with burn depth, total body surface area involved, or injury severity. Other factors also impact need for rehabilitation, such as anatomic location of injury (eg, across finger joints, face), additional psychosocial strain from a house fire or having an injured loved one, or body image concerns related to visible scarring. To meet these and other challenges posed by burn injuries, rehabilitation requires a multidisciplinary team including, but not limited to, nursing, surgery, burn therapy, rehabilitation medicine, vocational counseling, rehabilitation psychology, psychiatry, and nutrition. Accord­ingly, verification as a burn center by the American Burn Association requires a goal-oriented, multidisciplinary rehabilitation program. This chapter broadly discusses the spectrum and integral components of burn rehabilitation. This review contains 13 figures, 8 tables, and 71 references. Key Words: burn, community integration, function, mental health, multidisciplinary, outcome, pain, quality of life, reconstruction, rehabilitation, therapy.

Rehabilitation of the Burn Patient

Burn rehabilitation begins the moment the patient contacts the healthcare system and, for many patients, it never truly ends. Returning severely burned patients to their pre-injury level of function has become more challenging, as more severely burned patients survive their injury. The need for rehabilitation does not simply correspond with burn depth, total body surface area involved, or injury severity. Other factors also impact need for rehabilitation, such as anatomic location of injury (eg, across finger joints, face), additional psychosocial strain from a house fire or having an injured loved one, or body image concerns related to visible scarring. To meet these and other challenges posed by burn injuries, rehabilitation requires a multidisciplinary team including, but not limited to, nursing, surgery, burn therapy, rehabilitation medicine, vocational counseling, rehabilitation psychology, psychiatry, and nutrition. Accord­ingly, verification as a burn center by the American Burn Association requires a goal-oriented, multidisciplinary rehabilitation program. This chapter broadly discusses the spectrum and integral components of burn rehabilitation. This review contains 13 figures, 8 tables, and 71 references. Key Words: burn, community integration, function, mental health, multidisciplinary, outcome, pain, quality of life, reconstruction, rehabilitation, therapy.

Cost-Effectiveness of the Use of Autologous Cell Harvesting Device Compared to Standard of Care for Treatment of Severe Burns in the United States.

IntroductionWhen introducing a new intervention into burn care, it is important to consider both clinical and economic impacts, as the financial burden of burns in the USA is significant. This study utilizes a health economic modeling approach to estimate cost-effectiveness and burn center budget-impact for the use of the RECELL® Autologous Cell Harvesting Device to prepare autologous skin cell suspension (ASCS) compared to standard of care (SOC) split-thickness skin graft (STSG) for the treatment of severe burn injuries requiring surgical intervention for definitive closure.MethodsA hospital-perspective model using sequential decision trees depicts the acute burn care pathway (wound assessment, debridement/excision, temporary coverage, definitive closure) and predicts the relative differences between use of ASCS compared to SOC. Clinical inputs and ASCS impact on length of stay (LOS) were derived from clinical trials and real-world use data, American Burn Association National Burn Repository database analyses, and burn surgeon interviews. Hospital resource use and unit costs were derived from three US burn centers. A budget impact calculation leverages Monte Carlo simulation to estimate the overall impact to a burn center.ResultsASCS treatment is cost-saving or cost-neutral (< 2% difference) and results in lower LOS compared to SOC across expected patient profiles and scenarios. In aggregate, ASCS treatment saves a burn center 14–17.3% annually. Results are sensitive to, but remain robust across, changing assumptions for relative impact of ASCS use on LOS, procedure time, and number of procedures.ConclusionsUse of ASCS compared to SOC reduces hospital costs and LOS of severe burns in the USA.FundingAVITA Medical.Electronic supplementary materialThe online version of this article (10.1007/s12325-019-00961-2) contains supplementary material, which is available to authorized users.

Western Trauma Association critical decisions in trauma: Preferred triage and initial management of the burned patient.

This is a recommended management algorithm from the Western Trauma Association addressing the management of victims of burn injury. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published retrospective studies, clinical guidelines, and the expert opinion of members of the Western Trauma Association in conjunction with partner members of the American Burn Association. The algorithm and accompanying comments represent one safe and sensible approach that can be followed at most trauma centers. We recognize that there may be patient or institutional factors that warrant deviation from the published algorithm. We would encourage institutions to use this document as a starting point toward a dialog with local burn centers to collaboratively create a patient-centered care experience for the victims of minor burn injuries arriving at local trauma centers.

Inhalation Injury: Unmet Clinical Needs and Future Research.

Pulmonary and systemic insults from inhalation injury can complicate the care of burn patients and contribute to significant morbidity and mortality. However, recent progress in diagnosis and treatment of inhalation injury has not kept pace with the care of cutaneous thermal injury. There are many challenges unique to inhalation injury that have slowed advancement, including deficiencies in our understanding of its pathophysiology, the relative difficulty and subjectivity of bronchoscopic diagnosis, the lack of diagnostic biomarkers, the necessarily urgent manner in which decisions are made about intubation, and the lack of universal recommendations for the application of mucolytics, anticoagulants, bronchodilators, modified ventilator strategies, and other measures. This review represents a summary of critical shortcomings in our understanding and management of inhalation injury identified by the American Burn Association's working group on Cutaneous Thermal Injury and Inhalation Injury in 2018. It addresses our current understanding of the diagnosis, pathophysiology, and treatment of inhalation injury and highlights topics in need of additional research, including 1) airway repair mechanisms; 2) the airway microbiome in health and after injury; and 3) candidate biomarkers of inhalation injury.