Burn Intensive Care Unit Research Articles

Spectral Reflectance as a Unique Tissue Identifier in Healthy Humans and Inhalation Injury Subjects.

Tracheal intubation is the preferred method of airway management, a common emergency trauma medicine problem. Currently, methods for confirming tracheal tube placement are lacking, and we propose a novel technology, spectral reflectance, which may be incorporated into the tracheal tube for verification of placement. Previous work demonstrated a unique spectral profile in the trachea, which allowed differentiation from esophageal tissue in ex vivo swine, in vivo swine, and human cadavers. The goal of this study is to determine if spectral reflectance can differentiate between trachea and other airway tissues in living humans and whether the unique tracheal spectral profile persists in the presence of an inhalation injury. Reflectance spectra were captured using a custom fiber-optic probe from the buccal mucosa, posterior oropharynx, and trachea of healthy humans intubated for third molar extraction and from the trachea of patients admitted to a burn intensive care unit with and without inhalation injury. Using ratio comparisons, we found that the tracheal spectral profile was significantly different from buccal mucosa or posterior oropharynx, but the area under the curve values are not high enough to be used clinically. In addition, inhalation injury did not significantly alter the spectral reflectance of the trachea. Further studies are needed to determine the utility of this technology in a clinical setting and to develop an algorithm for tissue differentiation.

The effects of short bouts of ergometric exercise for severely burned children in intensive care: A randomized controlled trial

Objective To determine the effects of short bouts of ergometric exercises on the number of days in the burn intensive care unit (ICU), body mass, and functional ambulation. Design Multi-center, randomized controlled trial. Setting Burn intensive care unit. Participants Children ages 7–17 with severe burns covering over 30% total body surface area (TBSA). Intervention All patients received standard of care (Control) with the experimental group receiving additional exercise with a cycle ergometer (Exercise). Main measures The number of days in the ICU, total weight, lean body mass (LBM), and functional ambulation were taken shortly after randomization and again within one week of the scheduled hospital discharge. Results of outcomes are expressed as median ± interquartile range (IQR), unless otherwise noted (e.g. demographics). Results Fifty-four severely burned children (n = 18 Control, n = 36 Exercise) were included. The average ± standard deviation for age was 12 ± 3 years and TBSA was 48 ± 16%. The median ± IQR ICU days for Control was 46 ± 51 days vs 31 ± 29 days for Exercise. The median total weight loss for Control was 2.2 ± 1.2 kg vs 1.8 ± 1.4 kg in Exercise. Control lost 0.75 ± 0.8 kg of LBM vs 0.46 ± 0.43 kg in Exercise. Both groups showed significant improvement in functional ambulation (p < 0.01). However, exercise did not add additional benefits. Conclusion Short bouts of ergometric exercises are feasible for severely burned patients while receiving care in the ICU but did not add additional benefits.

Genomic Insights Into the Mechanism of Carbapenem Resistance Dissemination in Enterobacterales From a Tertiary Public Heath Setting in South Asia.

10.6% patients were CRE positive. Only 27% patients were prescribed at least 1 antibiotic to which infecting pathogen was susceptible. Burn and ICU admission and antibiotics exposures facilitate CRE acquisition. Escherichia coli ST167 was the dominant CRE clone. Given the high prevalence of multidrug resistance (MDR) across South Asian (SA) hospitals, we documented the epidemiology of carbapenem-resistant Enterobacterales (CRE) infections at Dhaka Medical College Hospital between October 2016 and September 2017. We enrolled patients and collected epidemiology and outcome data. All Enterobacterales were characterized phenotypically and by whole-genome sequencing. Risk assessment for the patients with CRE was performed compared with patients with carbapenem-susceptible Enterobacterales (CSE). 10.6% of all 1831 patients with a clinical specimen collected had CRE. In-hospital 30-day mortality was significantly higher with CRE [50/180 (27.8%)] than CSE [42/312 (13.5%)] (P = .001); however, for bloodstream infections, this was nonsignificant. Of 643 Enterobacterales isolated, 210 were CRE; blaNDM was present in 180 isolates, blaOXA-232 in 26, blaOXA-181 in 24, and blaKPC-2 in 5. Despite this, ceftriaxone was the most commonly prescribed empirical antibiotic and only 27% of patients were prescribed at least 1 antibiotic to which their infecting pathogen was susceptible. Significant risk factors for CRE isolation included burns unit and intensive care unit admission, and prior exposure to levofloxacin, amikacin, clindamycin, and meropenem. Escherichia coli ST167 was the dominant CRE clone. Clustering suggested clonal transmission of Klebsiella pneumoniae ST15 and the MDR hypervirulent clone, ST23. The major trajectories involved in horizontal gene transfer were IncFII and IncX3, IS26, and Tn3. This is the largest study from an SA public hospital combining outcome, microbiology, and genomics. The findings indicate the urgent implementation of targeted diagnostics, appropriate antibiotic use, and infection-control interventions in SA public institutions.

Diencephalic storm in trauma patients: Is it really that rare

Introduction: Diencephalic storm is characterized by extreme episodic catecholamine release in the presence of a stressor and it is usually refractory to standard antihypertensives. The treatment of choice during the crisis is propofol and the best preventative measure is to remove the stressor (i.e. ventilator). Case presentation: A 32-year-old male sustained 2nd and 3rd degree burn to 25 percent of the body surface area that included a severe inhalation component. The patient was admitted to the Burn Intensive Care Unit at the Arnold Luterman Regional Burn Center in Mobile, AL. The patient had frequent episodes (3-5 per day) of severe agitation that were accompanied by extreme tachycardia of &gt; 200 beats per minute and hypertension (280/140). The inciting event was often endotracheal suctioning, but less noxious stimulation also resulted in similar episodes. During these episodes, the patient had significantly elevated catecholamine levels that improved after extubation. The patient’s symptoms were refractor to standard antihypertensives but immediately resolved when given propofol. Further episodes of the diencephalic storm were treated successfully with propofol. Once the patient was removed from mechanical ventilation, there were no further episodes. Conclusion: Diencephalic Storm may be difficult to diagnose due to a lack of familiarity with this rare entity. Any patient with severe agitation combined with the effects of episodic large catecholamine surges should be considered to have Diencephalic Storm. The standard immediate treatment is propofol due to the lack of responsiveness of standard antihypertensives and the removal of the stressor.

71 Burn Intensive Care Unit Early Mobility Competency Based Orientation

IntroductionCompetencies in healthcare are used to teach practice standards, to establish expectations for professional growth, and to evaluate and improve the effectiveness of educational programs. Benefits of early mobilization of Burn Intensive Care Unit (BICU) patients include improved ICU related weakness and delirium, range of motion, and decreased length of stay while promoting functional independence. A rehabilitation competency was developed for early mobility with the patient in the BICU using nationally agreed-upon standards for competence. By design this competency for BICU early mobility is part of a tiered training structure, with the burn rehabilitation and pediatric competencies serving as additional tiers of burn therapist training at our organization. The goal of this competency is to provide direct therapist training, including alignment with the inter-professional team involved with this intervention.MethodsA pretest was issued regarding BICU early mobility competency. The pretest asked the therapist to indicate their perceived level of competence in the areas of functional mobility, indications and contraindications of BICU early mobility, Respiratory Care Provider (RCP) protocols and documentation of BICU early mobility. Based on the results of this pretest, it was identified that BICU early mobility would be prioritized as the next training tier. The BICU Early Mobility Competency was created in Competency Based Orientation (CBO) format, including nationally agreed-upon standards for burn therapist competence. The method of this training is designed to occur with an ongoing patient case study for validation, with the CBO as the teaching tool.ResultsCreation of this competency as part of a tiered training allows our burn center to have an educational program which aligns with the nationally agreed-upon standards for burn therapist competence. Creation of this competency resulted in direct communication channels between rehabilitation, RCP, nursing and physician teams.ConclusionsThis tiered system allows for time management of the validator signing off on competencies, and encourages use of current resources and literature in the areas of burn therapist competence and professional development.

518 Prescribing practices of atypical antipsychotics in the burn ICU

IntroductionAtypical antipsychotics are commonly used in the management of agitation and delirium in the intensive care unit (ICU). Patients admitted to the burn intensive care unit (BICU) with burns with large total body surface involvement ( >20%) require prolonged mechanical ventilation and prolonged ICU stay, putting them at risk of ICU delirium. Furthermore, patients with burn injuries often have underlying psychiatric conditions, and some can develop new psychiatric disorders secondary to the trauma associated with their burn. Due to these factors many burn patients receive scheduled oral atypical antipsychotics during their ICU stay. The purpose of this study was to retrospectively characterize the prescribing practices of atypical antipsychotics in the BICU.MethodsThis was a single-center, retrospective chart review of adults admitted to the BICU with a burn injury who received scheduled oral atypical antipsychotics. Prescribing patterns in the ICU and on all transitions of care were analyzed. Additionally, the appropriateness of AAP prescribing at discharge was evaluated. AAPs were considered to be appropriately prescribed at discharge if a patient was continuing a home medication, or if psychiatric consult services recommended continuing at discharge.ResultsDuring the five year study period, 440 adults were admitted to the BICU with a burn injury, 18.2% of which were prescribed an AAP during their ICU course. Of those prescribed an AAP, 28.8% had a documented underlying psychiatric condition. Most patients were male (70%) with an average age of 41 years, and a mean total body surface area burn of 32%. The average ICU length of stay was 32 days. AAPs were primarily used to treat agitation/delirium (72.5% of patients). Quetiapine was the most commonly prescribed AAP. On transfer to stepdown, AAPs were continued in 78.4% of patients. Additionally, 67.7% were discharged on an AAP. Of these patients, continuation was considered appropriate in 54% of patients.ConclusionsDespite overall lower AAP prescribing in the burn ICU compared to other ICUs, over two thirds of patients initiated on AAPs in the BICU were prescribed AAPs at discharge. AAPs should be evaluated for appropriateness at each transition of care.

528 Evaluation of phosphate replacement practices in burn patients

IntroductionBurn injury causes acute shifts in phosphorus leading to hypophosphatemia and negative sequelae, such as motor neuropathy, muscle weakness, cardiac failure, and respiratory failure. These patients require frequent phosphorus level monitoring and repletion beyond the needs of a general critical care patient. Data suggests patients with normal phosphorus levels have lower incidence of ventilator wean failure and positive clinical outcomes. There is limited data evaluating phosphate replacement practices in burn patients for their intensive care unit (ICU) length of stay while also evaluating those who concomitantly receive continuous renal replacement therapy (CRRT) as it is the primary mode of renal replacement therapy in this population and further depletes phosphorus levels.MethodsThis was a single-center, retrospective, observational study of patients with a burn injury admitted and discharged from a burn intensive care unit (BICU) from January 1, 2016 to June 30, 2020 who received phosphate. Patients less than 18 years of age and those admitted to the BICU for non-burn injuries were excluded. Burn injury type, number of phosphorus doses per day, and phosphorus levels were collected. Normal phosphorus was defined as 2.5-4.9 mg/dL and hypophosphatemia as < 2.5mg/dL. Patient data was evaluated in 24-hour time intervals as defined as midnight to midnight. Phosphorus lab values were included in data analysis if there was corresponding phosphate administration in that 24-hour interval. The primary objective was to assess the temporal dose-response to phosphate replacement in burn patients.ResultsThere were 291 patients who met criteria, 116 were selected in chronological order by admission date and were included in data analysis. The mean age was 51.51 years and the mean total body surface area burned was 21.48%. Flame burn accounted for 83.6 % (n=97) of patients and 37.06% (n=43) of patients had concomitant inhalation injury. The mean amount of phosphate given to a patient per day was 28.38 mmol and patients on CRRT received a mean amount of phosphate of 33.34 mmol per day. In response to phosphate administration, the mean change in phosphorus was 0.334 ± 1.08 mg/dL. In patients on CRRT, the mean change in phosphorus was 1.4 ± 1.89 mg/dL. Patients experienced hypophosphatemia 69.63% of the days that they received phosphate repletion and patients on CRRT had hypophosphatemia 87.39% of the days they received phosphate repletion.ConclusionsHypophosphatemia is common in the burn injury population and current phosphate replacement practices are insufficient to replete phosphorus in burn injury patients.

746 Nurse Driven Fluid Resuscitation in the Burn Center

IntroductionThe prior practice of the burn center was to resuscitate burn injuries over 20% total body surface area (TBSA) using a provider led modified Brooke fluid resuscitation formula. In that model of fluid resuscitation, the burn center provider ordered an initial fluid rate and adjusted hourly, where appropriate based on nurse recorded outputs. In Q4 2020 a nurse-driven fluid resuscitation was implemented in the adult Burn Intensive Care Unit (BICU). The primary purpose of the survey research is to evaluate the effect of the nurse-driven fluid resuscitation on nurse and physician communication.MethodsSurvey research was initiated in Q3 2020 with a pre-practice change survey for BICU staff. The 3-part survey included 10 questions. The post survey will be repeated in August and remain open through October or until 70% of participants have completed the survey, whichever comes first.ResultsPaired t-tests will be used compare survey research results pre and post-protocol implementation. In the pre-implementation survey there was a response rate of 44% (11/25). The average years of experience in the burn center was 11.64 years (median 7, SD 10.66). All survey questions were asked based on a 5-point Likert scale with anchors of 1 “strongly disagree” and 5 “strongly agree.” Question 1 the average score was 3.67. Question 2 the average score was 3.5. Question 3 the average score was 3.58. Question 4 the average score was 3.33. Question 5 the average score was 3.5. Content analysis was used to explore responses to open-ended questions. Three themes were identified: training, lack of communication, and over-resuscitation.ConclusionsThe pre-implementation survey revealed highest scores on nurses and physicians having a good map of each other’s skills and lowest on providers and nurses discussing ways to prevent errors. Content analysis also revealed common concerns about miscommunication and lack of resuscitation training leading to over resuscitation. Upon completion of the post-implementation survey, we anticipate reporting changes in low scoring questions. We look forward to reporting these results as part of this abstract.

744 Integrative Nursing framework in Burn ICU

IntroductionPatient and staff experiences are enhanced through a holistic and relationship-based approach of care. An integrative nursing (IN) framework was created utilizing various therapeutic modalities to augment healing for patients. Additionally, staff RNs were encouraged to utilize some IN modalities to aid in their own well-being. In 2019, the Burn ICU (BICU) was selected as one of five pilot units in the hospital to implement the IN framework. Post-implementation, staff were surveyed on their attitudes regarding the IN framework.MethodsThe IN framework was created utilizing the IN principles and hospital policies. Two selected RN champions promoted this framework for staff and patients. In the BICU, over 95% of the RNs completed all five IN training modules: IN in Action, Acupressure, Clinical Massage, Aromatherapy, and Mind-Body skills. BICU was stocked with supplies, not limited to aromatherapy products, breathing ball, and massager chair. Additional resources were added including virtual reality (VR) and spiritual care. RNs documented interventions for pain/stress, anxiety/sleep, and nausea in the patient record. Post implementation, a self-report survey by RNs was utilized evaluated the IN framework.ResultsA total of 27 surveys were collected from 29 available RNs. Aromatherapy, VR, therapeutic touch were the most utilized patient modalities, while staff mostly utilized the massage chair, aromatherapy, and deep tissue massager. Lack of time and personal discomfort were the highest reported barriers to utilization of the IN modalities.ConclusionsCreating and implementing an IN framework is achievable and can assist with improving patient and staff experiences in the hospital. Most staff and patients who utilized IN tools believed it provided benefits. Addition of IN modalities is the next step in providing patients with holistic care that treats not only the physical wounds but the whole patient.

105 Nursing Theory and Burn Competency Training Practices to Address Gaps in Post-covid Trained Graduate Nurses

IntroductionRecruitment efforts just after the recent COVID crises brought in several new graduate nurses. They had limited clinical exposure during COVID-19 resulting in difficulty transitioning into practice providing safe patient care. As a result, these nurses lacked the fundamental knowledge needed to care for acutely ill burn and wound patients resulting in the new graduate registered nurses (NGRNs) feeling overwhelmed at the bedside. These findings coincide with assessments noted in Kavanagh and Sharpnack’s (2021), article identifying only 9% of NGRNs were practice ready, with 7% failing to recognize urgency or a change in a patient’s condition.MethodsIn order to achieve the designated American Burn Association (ABA) competencies, our center designed a program based on Patricia Benner’s Novice to Expert nursing theory. Additionally, we divided the competencies into achievable goals and domains using the Donna Wright's nursing competency model.StaRN program: didactics/simulation/skills/unit orientation one on one with a preceptorCompetency based staged orientation program for new staffBurn Specific Education includes:1) Burn and complex wound care didactic2) Burn specific High-fidelity simulation scenario utilizing critical care equipment promoting critical thinking and critical reasoning skills3) Task trainers4) On-going preceptor education5) Nurse Extern programResultsNGRNS arriving at our unit in early 2020 were found to be incapable of performing clinical tasks in the burn ICU (BICU) setting at the level of competency recommended by the ABA. We immediately placed this cohort into the revised training program incorporating Benners Novice to Expert Theory and Wright’s Competency Model. Of the 25, 17 were able to be placed in the BICU (68%), and 8 were able to transfer to a lower level of care (progressive care/med-surg). All 25 were given extended orientation (12 weeks instead of the normal 8, as recommended by our facility). We will follow this group to determine retention rates.ConclusionsCurrent levels of competencies by the ABA creates gaps in care for graduate nurses entering the workforce with deficits. Applying Benner's Novice to Expert Theory and Wright’s Competency Model to modify approaches to training helps identify gaps in care, addresses areas that are weak for the nurse, and help guide the graduate nurse through stages of expertise to arrive more confidently at the level of competency expected by the ABA.

713 Mortality Benefit After Addition of Mid-level Support in Burn Intensive Care Unit

IntroductionBurn Intensive Care Units (BICU)s are resource-heavy and labor-intensive units with very sick patients. The removal of burns as a requirement from the surgical curriculum has decreased the number of rotating surgical trainees, but did not impact patient care needs. Our unit adopted an Advanced Practice Provider (APP) service model in fiscal year 2018 to provide consistent standardized clinical care, with surgical trainees rotating monthly, to mitigate the loss of residents over time. We aimed to critically evaluate the impact of an APP run BICU on mortality and quality improvement initiatives.MethodsPatients were identified using Institutional Burn Center registry, and linked to the clinical and administrative data. All patients admitted to the BICU between July 1, 2016 and June 30, 2020 were eligible for inclusion. All central line associated blood stream infections (CLABSI), catheter associated urinary tract infections (CAUTI), ventilator associated pneumonias (VAP) and mortality rates were compared. Demographics, length of stay (LOS), co-morbid conditions and mortality were evaluated. Statistical analysis was performed with Students’ t-test, and chi-squared tests. Significance was accepted as p< 0.05.ResultsThere were no significant differences in admission rates over the study period. The number of CLABSIs significantly decreased each year (15 (2017), 6 (2018), 5 (2019), 3 (2020)). The number of CAUTIs significantly decreased ((13 (2017), 6 (2018), 1 (2019), 3 (2020)). The number of VAPs significantly decreased ((15(2017), 12 (2018), 7 (2019), 3 (2020)). Mortality was unchanged from 2017-2019 but significantly decreased in 2020 ((2.2% (2017), 2.4% (2018), 2.5% (2019), 0.9% (2020)).ConclusionsThere were no significant differences in admission rates over the study period. The number of CLABSIs significantly decreased each year (15 (2017), 6 (2018), 5 (2019), 3 (2020)). The number of CAUTIs significantly decreased ((13 (2017), 6 (2018), 1 (2019), 3 (2020)). The number of VAPs significantly decreased ((15(2017), 12 (2018), 7 (2019), 3 (2020)). Mortality was unchanged from 2017-2019 but significantly decreased in 2020 ((2.2% (2017), 2.4% (2018), 2.5% (2019), 0.9% (2020)).

720 Intensive Insulin Therapy in the Burn Intensive Care Unit: A Systematic Review of Literature

IntroductionThe significant burden of burn-related morbidity and mortality is partly due to the complex pathophysiological derangements that occur in the acute post-burn period. Critical care literature has pushed for tighter glycemic control, but these studies often use heterogenous groups of medical and surgical patients. Furthermore, some of these studies present conflicting evidence of whether there is true mortality benefit. Providers must balance the risks associated with hyperglycemia such as infection, inflammation, and pour wound healing against the risks associated with severe hypoglycemia, most notably coma and death. This study aims to review the literature on outcomes in tight glucose control regimens (glucose < 150mg/dL) in the burn ICU population to help guide further research and practice guidelines.MethodsA systematic review of literature utilizing PubMed was conducted for any article published at any time. Searches used the AND function to identify articles with a burn term (burn injury OR burn care OR burn ICU OR burn OR thermal injury OR burned) and a glucose control related term (glucose control OR glycemic control OR glucose management OR insulin OR metformin OR glipizide). Inclusion criteria were English studies that describe intensive care unit (ICU) glucose management in adult burn patients. Exclusion criteria were involvement of children, animals, and settings outside of the ICU. Case reports, editorials, and position pieces were also excluded.ResultsThe search identified 2,154 articles. Full text review of 61 articles identified 8 that met inclusion criteria. Two randomized control trials, 3 retrospective case-control studies, 2 retrospective cohort studies, and 1 systematic literature review. Only 1 study showed mortality benefit of tighter glucose control (< 150 mg/dL) compared to controls (< 200 mg/dL), while 3 studies showed no difference in mortality between cases and controls. Three studies demonstrated a reduction in infectious complications including sepsis, pneumonia, urinary tract infection, and bacteremia. Nearly all studies (6/8) showed increased rates of hypoglycemia with tight control, but very few instances of adverse sequela following hypoglycemia were noted.ConclusionsLike the broader critical care population, tighter glucose control may be beneficial to burn patients but with some variability. Balancing the complications of hypoglycemia with hyperglycemia continues to be a challenge with no clear guidelines. Further research in a burn specific population would help create a safe and effective treatment algorithm which could be adapted widely.

554 Preventing accidental central line removal: Early success through a novel securement device

IntroductionCentral Venous Catheter (CVC) placement and maintenance can be difficult due to non-intact skin and possible surrounding weeping wounds. In addition, routinely used products require intact skin for the adherence of the central line dressing along with sutures or securement devices. With the increased number of line dislodgements, the Burn Intensive Care Unit (BICU) searched for alternative means of line securement. A subcutaneously anchored sutureless system (SASS) was found that could secure the line and allow for improved cleaning around the insertion site. The SASS is a device made of metal which resides in subcutaneous portion of the skin and anchors the CVC while allowing lifting of the catheter to clean underneath.MethodsAfter identification of the SASS product, a trial was implemented. Nurses (RN) and providers were trained virtually by the product representative. Nursing champions were selected to be a liaison between the product representative and the staff. Patients included burn patients or Steven Johnsons (SJS) patients, with large open total body surface area, who had a CVC placed peripherally or centrally between September 2020 to June 2021. A survey was conducted upon insertion of the device, with dressing changes, and upon removal.ResultsIn 2018, there were a total of 14 CVC dislodgements and 12 in the year 2019. For the year 2020, there were 4 dislodgements and 2 in 2021. Both adult and pediatric patients utilized approximately 12 SASS. From the nurses who cared for the patients, 19 responses were obtained regarding the SASS. Overall, 94% of staff recommended this product for use. No accidental removal of the CVC was reported with use of the SASS. With cleaning around the catheter insertion site, 53% believed that they were able to clean better while 47% felt that it was the same with the previous practice. In terms of duration of changing the dressing and maintaining the catheter, 53% felt that it was the same while 47% thought it was faster. During maintenance, the most discomfort reported by patients was 4/10.ConclusionsThe SASS can be implemented as another viable method to prevent accidental dislodgement of the CVC while securing CVC without sutures. In addition, RNs believed it allows for faster cleaning around the insertion site and faster dressing changes with minimal discomfort to the patient. More data can be collected over longer periods of time and to look at its efficacy in non-burn patients.

703 Evaluation of a Stress Ulcer Prophylaxis Protocol in an Burn Intensive Care Unit

IntroductionPatients suffering from large burn injuries have an increased risk of gastrointestinal mucosal damage from stress ulcers. Proton pump inhibitors (PPIs) and histamine H2-receptor antagonists (H2RAs) are routinely used for stress ulcer prophylaxis in burn patients, however there are few comparative trials evaluating the efficacy of these therapies in the burn population. Our burn center uses a stress ulcer prophylaxis protocol that incorporates both classes in a step-wise manner. The objective of this study was to evaluate the protocol by comparing the incidence of uncontrolled gastric pH, positive gastric occult blood, and gastrointestinal bleed (GIB) while on famotidine or pantoprazole prophylaxis.MethodsThis was a single-center retrospective observational study conducted at an academic medical center and was approved by the hospital’s Institutional Review Board. Patients were included if they were at least 18 years of age, admitted to the burn intensive care unit (BICU) from June 2017 to August 2020 with burns involving at least 1% TBSA, and had at least one documented gastric pH and/or occult blood test while receiving famotidine or pantoprazole. The primary endpoint was a composite of gastric pH less than 5, a positive occult blood test, or occurrence of GIB.ResultsIn total, 107 patients with a mean age of 55 yo were included in the study. The median TBSA burn was 16% and length of stay was 23 days. Seventy seven (72%) patients received famotidine and 93 (87%) of patients received pantoprazole. The incidence of the primary endpoint in all patients receiving famotidine and pantoprazole were 69 (90%) and 86 (92%), respectively (p = 0.513). During famotidine prophylaxis, 256 (43%) gastric pH tests were less than 5 and 397 (47%) gastric occult blood tests were positive, with no reports of GI bleeding. During pantoprazole prophylaxis, 751 (33%) gastric pH tests were less than 5 and 1220 (47%) gastric occult blood tests were positive, and 4 (4%) were diagnosed with a GI bleed. A total of 91 (85%) patients had deviations from the protocol, which included 42 (46%) patients who did not receive the recommended dose or agent, 27 (30%) patients who were not initiated on the recommended initial agent, and 22 (24%) patients who did not receive a recommended increase in dose or switch agents when recommended.ConclusionsIn the setting of burn injuries of at least 1% TBSA, no difference was detected in uncontrolled gastric pH, positive occult blood tests, or GIB when using famotidine or pantoprazole in our stress ulcer prophylaxis protocol. The overall incidence of gastric pH less than 5 and positive gastric occult blood was high for both agents, while the incidence of GIB was low in both groups.

578 A Multi-pronged Approach to Improving Communication, Collaboration and Outcomes in the Burn ICU

IntroductionEffective communication between members of the burn healthcare team is vital as it impacts both patient outcomes and staff satisfaction. Discontinuity is a consistent barrier to communication. Fragmented communication may occur for a variety of reasons, including delineated shifts for staff, a decreased presence of physicians and allied health professionals at night, and variable levels of collaboration between nursing, therapy, allied health professionals and physicians. The purpose of this quality improvement project (QI) was to evaluate 3 interventions aimed at improving communication, collaboration, and ultimately patient outcomes.MethodsThe 3 interventions included the use of daily goal cards, increased frequency of interdisciplinary bedside rounds from once daily to twice daily and expanded in-house burn team coverage to include a burn-specific Physician Assistant/Nurse Practitioner (PA/NP) staffed in the center from 3:00pm to 11:00 pm. A 12-item survey consisting of a 5-point Likert scale and open-ended questions was distributed to team members to evaluate effectiveness of the interventions. Incidence of code events were evaluated as an indicator of patient outcomes.ResultsThere were a total of 29 respondents, including physicians, allied healthcare professionals, therapists, and nurses. Sixty-nine percent of participants felt that the daily goal cards were an effective means of communication however only 45 % strongly agreed/agreed that achievement of daily goals had increased. The expanded coverage by a burn PA/NP was viewed as an improvement to patient care by 90 % of respondents, with 79 % strongly agreeing/agreeing that the expanded coverage prevented errors. When evaluating afternoon rounds 69 % of respondents either strongly agreed/agreed that it improved patient care and 52% found it to prevent errors. Nocturnal code events decreased by 56% over the one-year period following the institution of expanded coverage. There was no added expense associated with any of the three interventions.ConclusionsWhile the results of this QI project were overwhelmingly positive, the expanded coverage by a dedicated burn PA or NP was viewed to be the most beneficial change. Temporally, the expanded coverage was also associated with a marked decrease in nocturnal code events. The addition of afternoon rounds was the next most beneficial change noted with positive findings in both effectiveness and improvement of patient care. There was a dichotomy between the effectiveness of the daily goal cards and the accomplishment of the goals that were set forth that needs further exploration.

510 5-Year Retrospective Analysis of a Vented Early Mobility Algorithm in the Burn ICU

IntroductionThe practice of early mobilization on mechanically ventilated patients in ICU settings has received significant attention within recent literature, however limited research to date has focused specifically on the burn population. The purpose of this single center retrospective analysis was to review the use of a burn critical care mobility algorithm, to determine the safety and feasibility of early mobility programs in the burn population, expose limitations preventing mobility progression at our facility, and discuss unique challenges to early mobility with burn patients.MethodsA retrospective review was completed for all intubated burn center admissions between January 2015 to December 2019. Burn Therapy notes were then reviewed for all intubated patients from initial evaluation until each patient was either extubated or underwent a tracheostomy. Data was collected using the stages of the mobility algorithm.ResultsIn the 5 years following initial implementation, the vented mobility algorithm was utilized on 127 patients with an average TBSA of 22.8%. Of these patients, 25 were transitioned to comfort care measures due to the extent of their burn injuries but were included in the review. The average intubated days were 8.05 days and the average length of stay was 26 days. No adverse events occurred during treatment with the algorithm. Stage 1: PROM/AROM was completed with 100% of patients (n=127). Chair mode of bed, stage 2a, was utilized in 39.4%(n=50) of patients, while 15.8% (n=20) of patients were dependently transferred to the cardiac chair in stage 2b. Stage 3 (sitting on the edge-of-bed) was completed with 25% (n=32) of patients, with only 11% (n=14) progressing to stage 5 (standing), and 3.9% (n=5) actively transferring to a chair. In 5 years, only 4.7% (n=6) reached stage 6 (ambulation). The most common treatment limitations were medical complications (33%) including: unstable medical status, agitation, sedation, cultured epithelial autograft placement, and orthopedic restrictions. Line placement, including femoral and pedal catheters , was also found to be a barrier to the use of our algorithm in 21% of held patient treatments.ConclusionsRetrospective analysis demonstrates that early mobilization during mechanical ventilation is safe and feasible with in the burn population despite challenges including airway stability, sedation, and line limitations. Dedicated burn therapy staff and team coordination is required to optimize management during the critical care stage of recovery and improve outcomes for survivors.

557 Introduction of a Pediatric Burn Education Program in an Adult Hospital

IntroductionAt a newly developed burn unit, the program decided to expand further and start admitting pediatric patients. While there are many working parts to this endeavor, we will primarily address staff preparedness. Prior to the introduction of a burn education course entitled Burns in the Pediatric Population, only a handful of nurses had received any hospital-based education for caring for pediatric patients. A previous pediatric course had been taught, however, this course focused primarily on illnesses of childhood. Staff had voiced on many occasions that they felt the education they received was not adequate and felt uncomfortable taking care of pediatric burn patients.MethodsAll Burn Intensive Care (BICU) nurses, regardless of having received the prior pediatric education, were required to take Burns in the Pediatric Population (n=42). The course content was based on the Burn Nurse Competencies. The course consisted of didactic lectures and hands-on sessions. Each participant was required to take a pre-test before the class and a post-test at the conclusion. The test included knowledge-based questions and self-rated confidence level questions. In addition, each participant was sent a survey three months after the completion of the class to evaluate their knowledge and confidence level.ResultsAt the conclusion of the class, the average test score went from 49.3% to 92.7%. Both the pre-test and post-test had each nurse evaluate their own confidence level for caring for a pediatric patient. Initially, 19.5% of the nurses stated that they had no confidence in caring for a pediatric patient. At the conclusion of the class, all nurses expressed some confidence with caring for a pediatric patient, with the majority, 72.7%, stating they had moderate or high confidence.The return rate of the three-month evaluation was 81% (n=34). The knowledge-based test had an average score of 71%. 30.3% of the staff stated that their confidence in caring for a pediatric patient increased, 54.5% stated their confidence level remained the same, and 15.1% of those returning the survey stated that their confidence level decreased in the three month time period.ConclusionsThe results from the three-month survey have been utilized to edit and make our pediatric mock codes and course more specific to the needs of the bedside nurses. In addition, we are planning to increase the frequency and the level of participation in our pediatric mock codes. All Burn ICU nurses will need to participate in a pediatric mock code on a semi-annual basis. In addition, there will be a section that is added to each Burn ICU nurse’s annual competency specifically covering pediatric burns.

570 Burn-Related Injuries Treated at Two Gulf Coast Hospitals During Following a Category 4 Hurricane

IntroductionNatural disasters are commonly associated with mass destruction and severe injuries. On August 29th, 2021 a category 4 hurricane made landfall before mandatory evacuations were ordered in a major metropolitan community. The powerful storm challenged disaster management teams and first responders as communities struggled to recover. Our study analyzes the demographics of those injured and the injury patterns treated at our state’s only verified burn/trauma center and the adjacent children’s hospital in the aftermath of the hurricane.MethodsA retrospective chart review was performed on patients seeking emergent care following the hurricane. Demographic data was abstracted from the medical records along with injury pattern including age, gender, mechanism of injury, total body surface area (TBSA), surgical interventions, and length of stay. In addition, brief surveys of fire chiefs from the two most impacted regions were performed to assess prehospital challenges.Results41 patients (76% male) presented to our ER with a median age of 44 (7 patients < 12 years of age). 85% of injuries occurred at home while 15% occurred at work. Of the 78% requiring admission, 66% underwent excision and autograft with a mean TBSA of 17% (range 1-80%). Power outages resulted in increased gas generator usage across the region. Most of the burn injuries following the storm were due to generator and cooking accidents (56%). Each fire chief reported up to 91 calls/day due to suspected carbon monoxide poisoning for the two weeks following the storm. A single event resulted in 8 inhalation injuries treated in our ER with one burn ICU admission. The mean hospital length of stay was 1.11 days/%TBSA for those undergoing surgery.ConclusionsHurricanes are more common today with many coastal cities as risk for similar natural disasters. Despite our generator safety media outreach efforts prior to the storm, this remains an opportunity for improved injury prevention. Many patients suffered delays in discharge as their homes/nursing facilities suffered structural damages and were without power and water. Disaster planning should account for limited disposition options during severe storms. Our study is the first to describe burn-related injuries from a category 4 storm and our communities’ response.

509 Why do elderly burn patients die? Analysis of early versus delayed ICU deaths, from 2014-2021

IntroductionDespite continued improvements in critical care, nutrition, and surgical technique, elderly patients with burn injury remain a vulnerable population, with increased mortality. The purpose of this study was to compare early versus late deaths in elderly burn patients admitted to the intensive care unit, to identify potential interventions that might improve survival.MethodsWe conducted a retrospective review of elderly patients (age >=60 years), who were admitted to an urban burn center ICU, with thermal and/or inhalation injury, over an 8-year period. Data were extracted from a prospectively maintained registry and verified through our electronic medical record. Patients who died less than 1 week after admission were compared with those who died after the first week. Univariate analysis was performed by 2-tailed Student’s T test and chi-square, with statistical significance assigned to p values < 0.05.ResultsFrom 2014-2021, we admitted 1322 patients to the burn ICU for thermal and/or inhalation injury. Mortality was 9.4% for patients >= 60 years of age, compared to 2.0% for patients < 60 (p< 0.001). The elderly patients who succumbed to their injury had a mean age of 75.3 years, TBSA 27.7%, modified Baux score of 111.3, and survival of 13.8 days. We observed a bimodal distribution of deaths, peaking on the first day after injury, and in the third week after admission, the most common cause of which, for both groups, was multisystem organ failure. Compared to the delayed deaths (n=21), patients who died within the first week (n=16) had an increased incidence of inhalation injury, a higher modified Baux score but similar age and TBSA, and lower baseline comorbidities and complications (TABLE). ConclusionsPresence of inhalation injury and high modified Baux score, not necessarily age or %TBSA, was associated with early mortality in the elderly, after burn injury. Older patients who survive their initial resuscitation often succumb to complications related to baseline comorbidities. Improved management of these comorbidities, via the active involvement of geriatric medicine and palliative care, represents an opportunity to increase survival.

Tranexamic acid reduced blood transfusions in acute burn surgery: A retrospective case-controlled trial

ObjectiveEarly excision and grafting of burn wounds are key for reducing prevalence of infection and sepsis. However, it is associated with massive blood loss and patients frequently require large numbers of blood transfusions. This study aimed to evaluate the effect of tranexamic acid (TXA) on blood transfusion requirements in acute burn surgery. MethodsPatients admitted to the burn intensive care unit between January 2018 and May 2021 and received TXA before first surgery for wound excision and grafting were matched in a 1:2 ratio to patients that did not receive TXA (confounders age,sex,total body surface area (TBSA) burned). Primary endpoint of the analysis was the total number of transfused units of red blood cells (RBC) intra- and postoperatively up to 48 h. Fresh frozen plasma (FFP) and platelets were evaluated. Endpoints were compared between groups using van Elteren tests adjusting for strata variable age, gender, TBSA. ResultsTwenty-six TXA patients were matched with 52 control patients resulting in similar distributions of gender (77.9%(TXA)vs. 82.7%(control) males, p=0.542), age (51.7±21.3vs.48.3 ±17.4years,p = 0.459) and %TBSA burned (33.5%(IQR34)vs. 38.5% (IQR 30.5),p = 1.000). TXA group received significantly less RBC units intraoperatively (2.5(IQR 2.0)vs.4.0 units (IQR4.0), p = 0.038) and in total (4.0(IQR3.0)vs.6.0(IQR4.0),p = 0.017). TXA patients also received less blood products in general (RBC, FFP, platelets) in each period and in total. We found no significant difference in length of stay (24.0(IQR26.0)vs.33.0 days (IQR 0.5),p = 0.367) or mortality (15.4%vs.21.2%, p = 0.542). DiscussionThis study shows that necessity for blood transfusions in acute burn surgery may be reduced significantly by administration of TXA perioperatively. Randomized-controlled trials are needed to prove these findings.