Belgian Outcome Research Articles

Risk Factors in Hospitalized Patients With Burn Injuries for Developing Heterotopic Ossification--A Retrospective Analysis.

The aims of this study were to identify the risk factors for developing heterotopic ossification in patients with burns injuries and, second, to review the outcomes associated with the treatment disodium etidronate. Patients with heterotopic ossification were identified using the burns unit computer database. The control group was the patients who were the next admission after admission of the patient who subsequently developed heterotopic ossification. Demographic and clinical data were collected. Univariate and multivariate techniques were used to identify risk factors for heterotopic ossification. We reviewed 337 patients admitted over a 5-year period and identified 19 patients with heterotopic ossification (5.6%). A further 19 burn injury patients were included as controls. Heterotopic ossification developed clinically and radiologically after a median time of 37 days (interquartile range [IQR], 30-40) and 49 days (IQR, 38-118), respectively. In univariate analysis, heterotopic ossification was associated with a greater %TBSA, inhalation injury, use of mechanical ventilation, number of surgical procedures, sepsis, and longer time to active movement. In a multivariate analysis that adjusted for severity of burn injury by means of the Belgian Outcome in Burn Injury score, time to active movement was recognized as an independent risk factor for heterotopic ossification (odds ratio 1.48, 95% confidence interval 1.09-2.01). Elevations in serum calcium concentrations were the only observed adverse effects for disodium etidonrate. This study has demonstrated that %TBSA, inhalation injury, and the need for ventilatory support and the use of multiple surgical procedures are predictive of the development of heterotopic ossification.

Comparison of mortality prediction models in burns ICU patients in Pinderfields Hospital over 3 years

BackgroundMany different burns mortality prediction models exist; however most agree that important factors that can be weighted include the age of the patient, the total percentage of body surface area burned and the presence or absence of smoke inhalation. MethodsA retrospective review of all burns primarily admitted to Pinderfields Burns ICU under joint care of burns surgeons and intensivists for the past 3 years was completed. Predicted mortality was calculated using the revised Baux score (2010), the Belgian Outcome in Burn Injury score (2009) and the Boston group score by Ryan et al. (1998). Additionally 28 of the 48 patients had APACHE II scores recorded on admission and the predicted and actual mortality of this group were compared. ResultsThe Belgian score had the highest sensitivity and negative predictive value (72%/85%); followed by the Boston score (66%/78%) and then the revised Baux score (53%/70%). APACHE II scores had higher sensitivity (81%) and NPV (92%) than any of the burns scores. DiscussionIn our group of burns ICU patients the Belgian model was the most sensitive and specific predictor of mortality. In our subgroup of patients with APACHE II data, this score more accurately predicted survival and mortality.

Accuracy of commercial reporting systems to monitor quality of care in burns

IntroductionCapse Healthcare Knowledge Systems (CHKS) is a global commercial organisation that operates health benchmarking programmes in the UK and internationally. In absence of a specialty-specific quality monitoring programme for burn services, CHKS has been producing comparative quality data for burn services for a number of years. The major quality indicator reported by CHKS is mortality as a Risk Adjusted Mortality Index (RAMI). The accuracy of RAMI is unknown in comparison to published burn-specific mortality prediction models. MethodsA retrospective study design was used to collect data for patients admitted to the Adult Burn Service at University Hospital South Manchester (UHSM) between January 2006 and December 2010. Data was collected from two sources, CHKS and Manchester Burn Injury Database (MBID). The demographic and injury characteristics of survivors and non-survivors were compared and Receiver Operator Curve (ROC), equivalence and non-inferiority analyses were used to assess accuracy of RAMI in comparison to Abbreviated Burn Severity Index (ABSI), Belgian Outcome of Burn Injury (BOBI) score, Baux score (Baux) and McGwin score (McGwin). ResultsThe accuracy of RAMI to discriminate between survivors and non-survivors (area under curve=0.79, 95% CI 0.50–0.81) was significantly inferior to that of ABSI, BOBI, Baux and McGwin scores. Equivalence and non-inferiority testing of ROC curves also showed RAMI score to be inferior to ABSI, BOBI, Baux and McGwin scores at 5% significance level. ConclusionCHKS RAMI provides an inaccurate and inferior monitoring of mortality as a quality indicator in burn patients compared to burn specific mortality prediction models. This study raises concerns about the ability of commercially reported systems to accurately monitor quality indicators of relevance to burn care.

Assessment of mortality prediction models in a Ghanaian burn population

PurposeOver 40 new or modified outcome prediction models have been developed for severe burns; with age, total burned surface area (TBSA) and inhalation area as major determinants of mortality. The objective of this study was to assess their applicability in a developing country. ProceduresData were collected retrospectively of a consecutive series of 261 patients (2009–2011) admitted to a Burns Intensive Care. Five outcome prediction models based on admission criteria were evaluated: Bull grid, Abbreviated Burn Severity Index – ABSI, Ryan-model, Belgian Outcome in Burn Injury – BOBI and revised Baux. Discriminative power and goodness-of-fit were assessed by receiver operating characteristic analyses (area under the curve – AUC) and Hosmer–Lemeshow tests. FindingsMedian age was 10.5 years (IQR: 2.5–27 years), median TBSA 21% (IQR: 11–34%); 55.2% were male, 28 patients died (10.7%). Only 2 patients were intubated (0.8%). The AUC were between 77 and 86%. The ABSI model showed the best calibration (28.7 expected deaths). Ryan, BOBI and rBaux significantly underestimated mortality, whereas Bull showed an overestimation. ConclusionThis study on a young group of burn patients showed moderate to good discriminative power using all five prediction models. The expected number of deaths tended to be underestimated in the three most recent prediction models.

O6-5.4 Ventilator-associated pneumonia in patients with severe burn injury: the predictive value of routine surveillance cultures to predict multidrug resistance

IntroductionBurn patients with inhalation injury requiring mechanical ventilation (MV) are at particular risk for ventilator-associated pneumonia (VAP), which is associated with increased morbidity and mortality. Routine endotracheal surveillance cultures (SC)...

Morbidity and Mortality of Bloodstream Infections in Patients With Severe Burn Injury

Bloodstream infections are common in burn patients. To evaluate the effects of bloodstream infections in patients with severe burn injuries. A retrospective, pairwise-matched, risk-adjusted cohort study in a 6-bed burn unit was done. "Exposed" patients with microbiological evidence of bloodstream infections (n = 76) were compared with nonexposed patients (n = 103) matched for burn severity (identical Belgian Outcome in Burn Injury score) and length of hospitalization (≥time-to-event in exposed patients). Main outcome measures were length of hospitalization and mortality. Predominant pathogens were Staphylococcus aureus, enterococci, Pseudomonas aeruginosa, Escherichia coli, coagulase-negative staphylococci, and Candida species. Median patient age was 42 years (interquartile range [IQR], 31-52). Median total burned surface area was 40% (IQR, 25%-50%). Inhalation injury occurred in 54%. Median burn injury score was 4 (IQR, 2-5). Median length of stay before onset of bacteremia was 11 days (IQR, 5.3-19.8). Appropriate antimicrobial therapy was initiated within the first 48 hours in 76%. The exposed group had a higher need for vasopressive/inotropic support (P = .02); need for ventilatory assistance and renal replacement therapy did not differ significantly between groups. Hospital mortality did not differ (P = .30). However, bloodstream infection was associated with longer durations of hospitalization (P < .001) and mechanical ventilation (P < .001). In this cohort of burn patients, bloodstream infections did not adversely affect survival, but greater durations of ventilator dependency and hospital stay increased costs of care.