Burn Admissions Research Articles

Burden of burns in Portugal, 2000–2013: A clinical and economic analysis of 26,447 hospitalisations

IntroductionThere is a lack of recent and nation-wide epidemiological studies of burns in Europe, mainly in southern Europe. There are no recent studies describing the clinical and economic burden of burns in this European area. Hence, this research aimed to describe the clinical and economic burden of burn hospitalisations in Portugal. MethodsA retrospective observational study was performed and the Portuguese hospitalisation database of public hospitals was used; all inpatients, discharged between 2000 and 2013, with a main or secondary diagnosis of burns (ICD-9-CM: 940.xx-949.xx) were taken into account. Furthermore, admissions to hospitals with and without burn centres were compared. ResultsA total of 26,447 burn hospitalisations were registered (mean of 1889burn admissions/year). The total hospitalisation rate was of 18.9hospitalisations/100,000inhabitants/year, and there was a higher incidence of male patients. Burn hospitalisations and hospitalisation rates are significantly decreasing – mostly in 0–14-year-old patients – and children below the age of 5 years represented a fifth of all admissions. Besides the important morbidity, the in-hospital mortality rate was of 4.4%. With a total annual charge of almost 13million Euros, the average cost per burn admission is increasing, and reached 8032Euros in 2013. Additionally, more than half of the patients admitted to hospitals without burn centres were not transferred to hospitals with burn centres, not following the European Burns Association transferral criteria. ConclusionsAs the largest southern European nation-wide epidemiological study of burn patients, this research highlights that burn admissions, as well as hospitalisation rates, are decreasing significantly. This was particularly obvious among the youngest patients despite the fact that the numbers still remain very high. Moreover, the in-hospital mortality rate is still excessively high and the burn transferral criteria are not being followed. Thus, it is important to improve preventive measures, reach out to and educate providers about the burn transferral criteria, and develop specific health care strategies for children with these injuries.

Pediatric Burns: A Single Institution Retrospective Review of Incidence, Etiology, and Outcomes in 2273 Burn Patients (1995-2013).

Unintentional burn injury is the third most common cause of death in the U.S. for children age 5 to 9, and accounts for major morbidity in the pediatric population. Pediatric burn admission data from U.S. institutions has not been reported recently. This study assesses all pediatric burn admissions to a State wide Certified Burn Treatment Center to evaluate trends in demographics, burn incidence, and cause across different age groups. Demographic and clinical data were collected on 2273 pediatric burn patients during an 18-year period (1995-2013). Pediatric patients were stratified by age into "age 0 to 6," "age 7 to 12," and "age 13 to 18." Data were obtained from National Trauma Registry of the American College of Surgeons and analyzed using standard statistical methodology. A total of 2273 burn patients under age 18 were treated between 1995 and 2013. A total of 1663 (73.2%) patients were ages 0 to 6, 294 (12.9%) were 7 to 12, and 316 (13.9%) were age 13 to 18. A total of 1400 (61.6%) were male and 873 (38.4%) were female (male:female ratio of 1.6:1). Caucasians had the highest burn incidence across all age groups (40.9%), followed by African-Americans (33.6%), P < .001. Caucasian teenagers formed 62.1% of patients age 13-18, P < .001. A total of 66.3% of all pediatric burns occurred at home, P < .001. Mean TBSA burned was 8.9%, with lower extremity being the most common site (38.5%). Scald burns constituted the majority of cases (71.1%, n = 1617), with 53% attributable to hot liquids related to cooking, including coffee or tea, P < .001. In the teenage group, flame burns were the dominant cause (53.8%). Overall mean length of stay was 10.5 ± 10.8 days for all patients, and15.5 ± 12 for those admitted to the intensive care unit, P < .005. One hundred (4.4%) patients required ventilator support (P = .02), and average duration of mechanical ventilation was 11.9 ± 14.5 days. Skin grafting was performed for 520 (22.9%) patients, P < .001. Overall mortality was 0.9% (n = 20), with mean TBSA involved of 61.5%. The majority of pediatric burn injuries are scald burns that occur at home and primarily affect the lower extremities in Caucasian and African-American males. Among Caucasian teenagers flame burns predominate. Mean length of stay was 10 days, 23% of patients required skin grafting surgery, and mortality was 0.9%. The results of this study highlight the need for primary prevention programs focusing on avoiding home scald injuries in the very young, as well as fire safety training for teenagers.

Epidemiology and outcomes of pediatric burns over 35 years at Parkland Hospital

BackgroundSince opening its doors in 1962, the Parkland Burn Center has played an important role in improving the care of burned children through basic and clinical research while also sponsoring community prevention programs. The aim of our study was to retrospectively analyze the characteristics and outcomes of pediatric burns at a single institution over 35 years. Study designThe institutional burn database, which contains data from January 1974 until August 2010, was retrospectively reviewed. Patients older than 18 years of age were excluded. Patient age, cause of burn, total body surface area (TBSA), depth of burn, and patient outcomes were collected. Demographics were compared with regional census data. ResultsOver 35 years, 5748 pediatric patients were admitted with a thermal injury. Males comprised roughly two-thirds (66.2%) of admissions. Although the annual admission rate has risen, the incidence of pediatric burn admissions, particularly among Hispanic and African American children has declined. The most common causes of admission were scald (42%), flame (29%), and contact burns (10%). Both the median length of hospitalization and burn size have decreased over time (r2=0.75 and 0.62, respectively). Mortality was significantly correlated with inhalation injury, size of burn, and history of abuse. It was negatively correlated with year of admission. ConclusionsOver 35 years in North Texas, the median burn size and incidence of pediatric burn admissions has decreased. Concomitantly, length of stay and mortality have also decreased.

Chemical Burn Injury in Kumasi: The Trend and Complications following and Their Management.

Background:A chemical burn refers to irritation and destruction of human tissue caused by exposure to a chemical, usually by direct contact with the chemical or its fumes. The study investigated the trend and complications following chemical burns and their management.Methods:The study involved a retrospective review of Burns Registry at the Burns Intensive Care Unit of the Komfo Anokye Teaching Hospital on patients who were admitted for burns from May 1, 2009 to April 30, 2013.Results:Chemical burns admissions accounted for 3.5% (n = 17) out of the total 487 burns cases, consisting of 12 males (70.6%) and 5 females (29.4%). Mean total burns surface area was 21.9%; mean length of stay in Burns Intensive Care Unit was 9.5 days. The etiological agents for the chemical burns included the following: hot caustic soda 1 (5.9%); acid 9 (53.9%)—the most common; hot ethanol 3 (17.6%); and other chemicals such as other bases, oxidizers, solvents, etc. accounted for 4 (23.5%) etiological agents. Outcome included 11 discharges (64.7%), 6 transferred out to other wards (35.3%), and 0 deaths (0.0%). The complications included severe scar contractures in 5 patients (29.4%), loss of vision: partial/total = 2 (11.8%), gross keloidal/hypertrophic scars = 10 (58.8%).Conclusions:Chemical burns are severe and often cause severe debilitating sequelae including partial/total loss of vision. But the current study showed that only a small population (3.5%) were affected by chemical burns and no death was recorded; society has to be continually conscious of chemicals, especially caustic agents, and hence take the necessary precautions so as to prevent these avoidable complications.

Descriptive Epidemiology of Unintentional Burn Injuries Admitted to a Tertiary-Level Government Hospital in Nepal: Gender-Specific Patterns.

This study describes the epidemiology of unintentional adult burn injury admissions in a tertiary hospital in Nepal, from 2002 to 2013, focusing on gender-specific patterns. Chi-square tests and Wilcoxon Rank Sum tests were performed. There were 819 unintentional burn admissions: 52% were male and 58% younger than 35 years. The median percentage total body surface area burned (interquartile range) was greater in females than in males (P < .001): 28% (17-40) versus 20% (12-35), and female mortality was higher (32% vs 11%). A higher proportion females were illiterate than males (48% vs 17%). Burns occurred at home (67%), work (28%), and public places (5%); gender-specific patterns were observed. Flame burns accounted for 77%, electricity 13%, and scalds 8%. Kerosene (31%) and biomass (27%) were the major fuels. Cooking, heating, and lighting were the main activities associated with burn injury. Results support interventions to reduce the use of open fires and kerosene and to promote electrical safety.

Burn center volume makes a difference for burned children.

Determine the relationship between the volume of burn admissions and outcomes for children with burns. Retrospective review of the National Burn Repository from 2000-2009 using mixed effect logistic regression modeling. Tertiary burn centers in the United States. All children <18 years of age admitted with burn injury to a burn center submitting data to the National Burn Repository. None. Of the 210,683 records in the NBR from 2000-2009, 33,115 records for children ≤ 18 years of age met criteria for analysis; 26,280 had burn sizes smaller than 10%; only 32 of these children died. Volume of children treated varied greatly among facilities. Age, total body surface area burn, inhalation injury, and burn center volume influenced mortality (p < 0.05) An increase in the median yearly admissions of 100 decreased the odds of mortality by approximately 40%. High volume centers (admitting >200 pediatric patients/year) had the lowest mortality when adjusting for age and injury characteristics (p < 0.05). Higher volume pediatric burn centers had lower mortality, particularly at larger burn sizes. The lower mortality of children a high volume centers could reflect greater experience, resource, and specialized expertise in treating pediatric patients.

Body protective compound-157 enhances alkali-burn wound healing in vivo and promotes proliferation, migration, and angiogenesis in vitro.

Chemical burns take up a high proportion of burns admissions and can penetrate deep into tissues. Various reagents have been applied in the treatment of skin chemical burns; however, no optimal reagent for skin chemical burns currently exists. The present study investigated the effect of topical body protective compound (BPC)-157 treatment on skin wound healing, using an alkali burn rat model. Topical treatment with BPC-157 was shown to accelerate wound closure following an alkali burn. Histological examination of skin sections with hematoxylin–eosin and Masson staining showed better granulation tissue formation, reepithelialization, dermal remodeling, and a higher extent of collagen deposition when compared to the model control group on the 18th day postwounding. BPC-157 could promote vascular endothelial growth factor expression in wounded skin tissues. Furthermore, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide and cell cycle analysis demonstrated that BPC-157 enhanced the proliferation of human umbilical vein endothelial cells (HUVECs). Transwell assay and wound healing assay showed that BPC-157 significantly promoted migration of HUVECs. We also observed that BPC-157 upregulated the expression of VEGF-a and accelerated vascular tube formation in vitro. Moreover, further studies suggested that BPC-157 regulated the phosphorylation level of extracellular signal-regulated kinases 1 and 2 (ERK1/2) as well as its downstream targets, including c-Fos, c-Jun, and Egr-1, which are key molecules involved in cell growth, migration, and angiogenesis. Altogether, our results indicated that BPC-157 treatment may accelerate wound healing in a model of alkali burn-induced skin injury. The therapeutic mechanism may be associated with accelerated granulation tissue formation, reepithelialization, dermal remodeling, and collagen deposition through ERK1/2 signaling pathway.

Intentional burns in Nepal: A comparative study

AimsIntentional burns injuries are associated with high mortality rates, and for survivors, high levels of physical and psychological morbidity. This study provides a comprehensive assessment of intentional burn admissions to the adult Burns Unit at Bir Hospital, Kathmandu, Nepal, during the period 2002–2013. MethodsA secondary data analysis of de-identified data of patients hospitalized at Bir Hospital, Kathmandu, with a burn during the period of 1 January 2002 to 31 August 2013. Socio-demographic, injury and psychosocial factors of patients with intentional and unintentional burns are described and compared. Chi-square tests, Fisher's exact test and Wilcoxon rank sum tests were used to determine statistical significance. ResultsThere were a total of 1148 burn admissions of which 329 (29%) were for intentional burn, 293 (26%) were self-inflicted and 36 (3%) were due to assault. Mortality rates for intentional burns were approximately three times those for unintentional burns (60 vs. 22%). When compared to unintentional burns, patients with intentional burns were more likely to be female (79 vs. 48%), married (84 vs. 67%), younger (25 vs. 30 years), have more extensive burns (total body surface area, %: 55 vs. 25) and higher mortality (60 vs. 22%). Intentional burns were more likely to occur at home (95 vs. 67%), be caused by fire (96 vs. 77%), and kerosene was the most common accelerant (91 vs. 31%). A primary psychosocial risk factor was identified in the majority of intentional burn cases, with 60% experiencing adjustment problems/interpersonal conflict and 32% with evidence of a pre-existing psychological condition. A record of alcohol/substance abuse related to the patient or other was associated with a greater proportion of intentional burns when compared with unintentional burns (17 vs. 4%). ConclusionsThe majority of intentional burn patients were female. Almost all intentional burns occurred in the home and were caused by fire, with kerosene the most common accelerant used. Underlying psychosocial risk factors were identified in most cases. Intentional burns resulted in severe burns with high mortality. Intentional burns are not only a serious medical issue; they represent significant public health and gender issues in Nepal.

Impact of the introduction of real-time therapeutic drug monitoring on empirical doses of carbapenems in critically ill burn patients

PurposeAdequate empirical antibiotic dose selection for critically ill burn patients is difficult due to extreme variability in drug pharmacokinetics. Therapeutic drug monitoring (TDM) may aid antibiotic prescription and implementation of initial empirical antimicrobial dosage recommendations. This study evaluated how gradual TDM introduction altered empirical dosages of meropenem and imipenem/cilastatin in our burn ICU. MethodsImipenem/cilastatin and meropenem use and daily empirical dosage at a five-bed burn ICU were analyzed retrospectively. Data for all burn admissions between 2001 and 2011 were extracted from the hospital's computerized information system. For each patient receiving a carbapenem, episodes of infection were reviewed and scored according to predefined criteria. Carbapenem trough serum levels were characterized. Prior to May 2007, TDM was available only by special request. Real-time carbapenem TDM was introduced in June 2007; it was initially available weekly and has been available 4 days a week since 2010. ResultsOf 365 patients, 229 (63%) received antibiotics (109 received carbapenems). Of 23 TDM determinations for imipenem/cilastatin, none exceeded the predefined upper limit and 11 (47.8%) were insufficient; the number of TDM requests was correlated with daily dose (r=0.7). Similar numbers of inappropriate meropenem trough levels (30.4%) were below and above the upper limit. Real-time TDM introduction increased the empirical dose of imipenem/cilastatin, but not meropenem. ConclusionsReal-time carbapenem TDM availability significantly altered the empirical daily dosage of imipenem/cilastatin at our burn ICU. Further studies are needed to evaluate the individual impact of TDM-based antibiotic adjustment on infection outcomes in these patients.

National trends in burn and inhalation injury in burn patients: results of analysis of the nationwide inpatient sample database.

The aim of this study was describe national trends in prevalence, demographics, hospital length of stay (LOS), hospital charges, and mortality for burn patients with and without inhalational injury and to compare to the National Burn Repository. Burns and inhalation injury cause considerable mortality and morbidity in the United States. There remains insufficient reporting of the demographics and outcomes surrounding such injuries. The National Inpatient Sample database, the nation's largest all-payer inpatient care data repository, was utilized to select 506,628 admissions for burns from 1988 to 2008 based on ICD-9-CM recording. The data were stratified based on the extent of injury (%TBSA) and presence or absence of inhalational injury. Inhalation injury was observed in only 2.2% of burns with <20% TBSA but 14% of burns with 80 to 99% TBSA. Burn patients with inhalation injury were more likely to expire in-hospital compared to those without (odds ratio, 3.6; 95% confidence interval, 2.7-5.0; P < .001). Other factors associated with higher mortality were African-American race, female sex, and urban practice setting. Patients treated at rural facilities and patients with hyperglycemia had lower mortality rates. Each increase in percent of TBSA of burns increased LOS by 2.5%. Patients with burns covering 50 to 59% of TBSA had the longest hospital stay at a median of 24 days (range, 17-55). The median in-hospital charge for a burn patient with inhalation injury was US$32,070, compared to US$17,600 for those without. Overall, patients who expired from burn injury accrued higher in-hospital charges (median, US$50,690 vs US$17,510). Geographically, California and New Jersey were the states with the highest charges, whereas Vermont and Maryland were states with the lowest charges. The study analysis provides a broad sampling of nationwide demographics, LOS, and in-hospital charges for patients with burns and inhalation injury.

A 365-day view of the difficult patients treated in an Australian adult burn center.

Although the effect of burns on mental health has been well examined, the aims of this study were to determine the prevalence of pre-existing mental health, drug and alcohol, and forensic problems in an Australian burn patient population; examine differences between these groups in terms of burns characteristics and healing; and also establish any patterns of presentation amongst these groups. Retrospective case notes of all the acute burn admissions, 273 patients, into a busy tertiary adults burn center in a full year were reviewed. Almost half of the patients admitted had underlying complex issues. Those with psychotic, forensic, and/or drug and alcohol problems tended to stay longer in hospital and required more procedures, despite burn sizes comparable with those in the general population. These patients also tended to sustain their burn injuries, and present to hospital, on a Saturday, Sunday, or Monday, rarely coming later in the week. Those with depression/anxiety had similar lengths of stay, number of procedures and random temporal presentations to the general burns population. Burn centers should be well staffed and educated in how to deal with patients with complex needs; this staffing should be actively structured to deal with a clear pattern of presentation over the weekend and Monday.

Scald Burns in Children. An Analysis with Special Attention to the Roma Ethnic Group in East Slovakia

Objectives: A retrospective analysis of scald burns in children in a region with a significant prevalence of Roma ethnicity living in poor socioeconomic situation. Patients: During 3 year period 273 children were admitted to the Clinic of Burns and Reconstructive Surgery of our hospital; 201 of them were with scald burns accounting for 73.6% of all pediatric burn admissions. More than half (58.7%) of the 201 children with scald burns were of Roma ethnicity. Results: The average BSAB of the children with scald burns was 10.8%; mean length of hospital stay 11.5 days. 58.7% of the children with scald burns was of Roma ethnicity. The non-scald admissions of children had a similar pattern but these children were older and with an even higher prevalence of Roma patients (75%), a slightly lower average BSAB (9.8%) and a significantly longer need of hospital treatment (average 15.7 days). Conclusion: The frequency of scald burn injuries in very young Roma children in our region is very high. Prevention of scald burns is possible only through targeted and well-organized education of this vulnerable population.

Epidemiology and Outcome of Chemical Burn Patients Admitted in Burn Unit of JNMC Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India: A 5-year Experience.

Aims and Objective:The objectives of this study were to evaluate the epidemiology, clinical variable of chemical burns, and their outcomes to prevent or reduce the frequency and morbidity of such injuries.Materials and Methods:A retrospective analysis was performed on all the patients with chemical burns admitted at author's center between November 2008 and December 2013. All the patients were evaluated in terms of age, sex, total body surface area, etiology, treatment given, morbidity, mortality, final outcome, and then educated regarding specific preventive measures.Results:A total of 96 patients (2.4% of total burn admissions) (42 males and 54 females) were admitted to our hospital with chemical burn injuries. Most of the patients were in the age group of 16–30 years. Incidence in females was slightly higher than in males. Acid was found to be the most common cause of injury. We found 55% patients admitted had <10% total body surface area (TBSA) involvement, 35% had burns involving between 11 and 20% TBSA, and 4% had burns involving 21–30% TBSA, and 6% had burns in >30% TBSA. Morbidity was noticed in the form of skin defect in 80% of cases, soft tissue defect with exposed tendon, bone, or vessels in 16% of cases, and 4% of patients developed contracture and hypertrophic scar. Eighty-six percent of patients required operative intervention. A total of three deaths (3%) were recorded.Conclusion:It was found that chemical burns, though not very common, are deeper burns and can be accidental or non-accidental, and the high-risk age group is 16–25 years. Chemical burns are largely preventable and if properly managed have a good outcome.

Operative utilization following severe combat-related burns.

The goal of burn surgical therapy is to minimize mortality and to return survivors to their preinjury state. Prompt removal of the burn eschar, early durable coverage, and late corrections of functional deformities are the basic surgical principles. The operative burden, while presumed to be substantial and significant, is neither well described nor quantified. The burn registry at the U.S. Institute of Surgical Research Burn Center was queried from March 2003 to August 2011 for all active duty burn admissions; active duty subjects were chosen to eliminate subject follow-up as a significant variable. Subject demographics including age, sex, branch of service, injury type, injury severity score, transfusion, allograft use, length of stay, mechanism of injury, and survival were tabulated as were their percentage TBSA, specific body region involvement, and nature and dates of operations performed. Univariate analysis and multiple logistic regressions were performed to determine independent factors which predict early and late operative burden. In the 8-year study period, 864 active duty patients were admitted to the burn center. Among them, 569 (66%) were operative in nature. The operations that were performed during acute hospitalization were 62%, while the remaining 38% were performed following discharge. A linear relationship exists between TBSA and the number of acute operations with an average of one acute operation required per 5% TBSA. No direct relationships however were found between TBSA and the number of reconstructive operations. Based on multiple logistic regression, battle vs nonbattle (odds ratio [OR], 0.559; 95% confidence interval [CI], 0.298-1.050; P = .0706), injury severity score (OR, 1.021; 95% CI, 1.003-1.039; P = .0222), intensive care unit length of stay (OR, 1.076; 95% CI, 1.053-1.099; P ≤ .0001), allograft use (OR, 2.610; 95% CI, 1.472-4.628; P = .0010), and TBSA of the trunk (OR, 0.982; 95% CI, 0.965-1.000; P = .0439) (but not overall TBSA) were associated with a high acute operative burden. Battle vs nonbattle (OR, 0.546; 95% CI, 0.360-0.829; P = .0045), and TBSA of the upper extremities (OR, 1.008; 95% CI, 1.002-1.013; P = .0042) were noted to be significant variables in predicting late reconstruction operations. The operative burden of burn, not previously well characterized, consists of operations performed during as well as after the initial hospitalization. While injury severity and truncal involvement are significant determinants of acute surgical therapy, the presence of upper extremity burns is a significant determinant of reconstruction following discharge.

Too hot to handle? Hot water bottle injuries in Sydney, Australia

ObjectiveHot water bottles are frequently used in the community as a source of warmth, and to alleviate a number of medical symptoms. In Australia it is believed that over 500,000 water bottles are sold annually (Whittam et al., 2010). This simple treatment is known to result in significant burns and has led to mandatory labeling requirements on hot water bottles in Australia. Despite this, few published studies have documented the incidence and nature of burns sustained through their use. This study aimed to assess the incidence, causation and outcome of hot water bottle burns presenting to a major burn trauma unit in Sydney (Australia). MethodsThe New South Wales Agency for Clinical Innovation Statewide Burn Injury database and admission data to the Concord Hospital Burns Injury Unit (major treatment unit) provided information on hot water bottle burns occurring between 2005 and 2013. Demographic details, cause of burn, burn depth, total burn surface area (%TBSA), and outcome of burn were ascertained. In order to assess the burn potential of hot water bottles, a separate study examined the thermic properties of hot water bottles in ‘real life’ scenarios. FindingsThere were 155 hot water bottle burn presentations resulting in 41 admissions and 24 grafts. The majority of patients were female, and most burns resulted from appliance rupture when used for local pain relief. Patients had an average TBSA of 2.4%. Burns patients were slightly more likely to reside in areas with greater socio-economic disadvantage. In real life scenarios, hot water bottles were shown to retain heat over 50°C for at least 3hours (h). ConclusionsHot water bottles are a source of common and preventable burns in the community, with women being more at risk than men. Hot water bottles may retain harmful levels of heat over an extended period of time. Additional labeling requirements pertaining to the longevity of hot water bottles and their use among people especially at risk of burns (i.e. children, the elderly, patients who have undergone recent surgery and/or those with conditions associated with sensory impairment) may further reduce the incidence and severity of hot water bottle burns in the community.

In view of standardization: Comparison and analysis of initial management of severely burned patients in Germany, Austria and Switzerland

IntroductionInitial treatment of severely injured patients in German speaking trauma centers follows precise sequences. Several guidelines and training courses ensure a constant quality in providing evidence-based treatment for these patients.Similar standards, algorithms and guidelines for the treatment of severely burned patients are lacking. This raises the question about the current standard of care for burn victims in German speaking burn centers. In order to achieve standardization, as a first step this study surveys principles of burn room organization and management in these burn centers. Material and methodsA questionnaire including 40 questions regarding burn room organization, personnel structure and qualification, infrastructural conditions and quality management was developed and sent to 21 level one burn centers in Germany, Austria and Switzerland. ResultsThe rate of returned questionnaires was 81%. The analysis revealed varying personnel and infrastructural conditions in participating burn centers. Indications for admission to the burn room and admission procedures itself are different throughout surveyed hospitals. Individual standard operating procedure (SOP) for burn trauma admissions was available in most burn centers and nearly all participants register their burn trauma cases using an in-house burn register. ConclusionThe survey suggests a lack of standardization in personnel structure, infrastructure and treatment approach for the initial clinical care of severely burned patients in burn centers across the German speaking countries. Further evaluation of existing protocols and international standards in burn care is inevitable to develop standardized guidelines for burn care and to improve quality of care.

Optimizing Feedback from a Designated Level 1 Trauma/Burn Center to Referring Hospitals

The American College of Surgeons Committee on Trauma (ACS-COT) is dedicated to improving the quality of care for severely injured patients. The ACS-COT charges designated centers with providing feedback to referring hospitals. There are no guidelines or recommendations as to what should be included in the feedback or how it should be used. The objectives of this study were to evaluate current feedback efforts regarding patients transferred to Harborview Medical Center (HMC), a regional level 1 trauma and burn center, to better understand how the feedback is used, and to evaluate what types of feedback are most useful to the referring hospitals. An analysis of U-link (password-protected access to patient's electronic medical record) and other forms of feedback was performed. A survey was sent to 82 Washington State hospitals in the regionalized trauma system to evaluate the current feedback process and its utility. During 1 year, HMC admitted 5,988 trauma and 763 burn patients; 54.8% of trauma and 66.5% of burn admissions were transferred from referring hospitals. Currently, 90 different referring hospitals have acquired a U-link account to follow their patients. Discharge summaries were the primary source of information used. When hospitals were asked how this information is used, education (100%), systems analysis (98.5%), and quality assurance (92%) were most common. There is significant interest on the part of referring hospitals to receive feedback from a designated level 1 trauma/burn center to improve quality of care. A system like U-link can allow secure access to review patient charts for quality improvement and feedback purposes, in a manner that is efficient for the referring and receiving hospitals.

Combat-Related Facial Burns: Analysis of Strategic Pitfalls

Burns constitute approximately 10% of all combat-related injuries to the head and neck region. We postulated that the combat environment presents unique challenges not commonly encountered among civilian injuries. The purpose of the present study was to determine the features commonly seen among combat facial burns that will result in therapeutic challenges and might contribute to undesired outcomes. The present study was a retrospective study performed using a query of the Burn Registry at the US Army Institute of Surgical Research Burn Center for all active duty facial burn admissions from October 2001 to February 2011. The demographic data, total body surface area of the burn, facial region body surface area involvement, and dates of injury, first operation, and first facial operation were tabulated and compared. A subset analysis of severe facial burns, defined by a greater than 7% facial region body surface area, was performed with a thorough medical record review to determine the presence of associated injuries. Of all the military burn injuries, 67.1% (n = 558) involved the face. Of these, 81.3% (n = 454) were combat related. The combat facial burns had a mean total body surface area of 21.4% and a mean facial region body surface area of 3.2%. The interval from the date of the injury to the first operative encounter was 6.6 ± 0.8 days and was 19.8 ± 2.0 days to the first facial operation. A subset analysis of the severe facial burns revealed that the first facial operation and the definitive coverage operation was performed at 13.45 ± 2.6 days and 31.9 ± 4.1 days after the injury, respectively. The mortality rate for this subset of patients was 32% (n = 10), with a high rate of associated inhalational injuries (61%, n = 19), limb amputations (29%, n = 9), and facial allograft usage (48%, n = 15) and a mean facial autograft thickness of 10.5/1,000th in. Combat-related facial burns present multiple challenges, which can contribute to suboptimal long-term outcomes. These challenges include prolonged transport to the burn center, delayed initial intervention and definitive coverage, and a lack of available high-quality color-matched donor skin. These gaps all highlight the need for novel anti-inflammatory and skin replacement strategies to more adequately address these unique combat-related obstacles.

Merits and challenges in the development of a dedicated burn service at a regional hospital in South Africa

IntroductionThe Edendale Hospital Burn Service was initiated in 2011 to improve the quality of burn care at a regional hospital. This audit reviews the merits and challenges in developing such a service and identifies areas on which to focus quality improvement initiatives. MethodologyThe burn admission records were retrospectively interrogated for the years 2012–2013. ResultsThis audit covers an 18-month period in which 490 patients were admitted. Admitted days per percentage burn were 2.6 days per percentage total body surface area burnt. The mortality rate was 13%. Fourteen percent of patients met the criteria for referral to the provincial burn centre but for a variety of logistical reasons only 3% were transferred. ConclusionWe have redesigned the process of care without alteration of resources. Outcomes of burns less than 30% total body surface area are not acceptable which we believe reflects the lack of infrastructure and systems development. This audit has revealed a number of areas, which are suitable for dedicated quality improvement initiatives.

A clinician's guide to the treatment of foot burns occurring in diabetic patients

IntroductionDiabetes mellitus affects 25.8 million Americans and is predicted to almost double by 2050. The presence of diabetes complicates hospital courses because of the microvascular complications associated with disease progression. Patients with diabetes represent 18.3% of annual burn admissions to our unit and 27% have burns to the feet. The purpose of this project was to develop an evidence-based guideline for care of the patient with diabetes and foot burns MethodsA multidisciplinary group was charged with developing an evidence-based guideline for the treatment of foot burns in patients with diabetes. Evidence was evaluated in the areas of diabetes, burn care, hyperbaric medicine, care of diabetic foot wounds and physical therapy. After guideline development and approval, key aspects were incorporated into order sets. ResultsKey aspects of this guideline are the ability to identify patients with undiagnosed diabetes, assess diabetic control, optimize glycemic and metabolic control, optimize burn wound management, treat microvascular disease, and provide education and a discharge plan. Evaluated outcomes are glycemic control, length of stay, complication rates, amputation rates, infection rates and the use of hyperbaric oxygen. ConclusionsBest outcomes for this high risk population will be attainable with an evidence based guideline.