Burns Registry Of Australia And New Zealand Research Articles

Bloodstream infections and multidrug resistant bacteria acquisition among burns patients in Australia and New Zealand: A registry-based study

IntroductionThis study interrogates infection related data in the Burns Registry of Australia and New Zealand (BRANZ), to examine associations of multi-drug resistant organisms (MDROs) and blood stream infection (BSI). MethodsData between July 2016 and June 2021 were analysed to determine prevalence, risk factors and outcomes associated with BSIs and MDROs: Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), carbapenem-resistant Pseudomonas spp. (CRP), and carbapenem-resistant Enterobacter (CRE). Data completeness and value for quality improvement activity were assessed. ResultsWe found a low incidence (3.4%) of the resistant organisms of interest, and no change over the study period. Fequency varied between services and increased with age and size of burn. MRSA was the commonest organism in all age groups. A positive BSI result occurred in 1.6% of patients (12.1% of cultures taken) at a median time of 10.2 days post injury. Free text identification of organisms was inconsistently documented. ConclusionsThe low rate and patterns of acquisition of MDROs of interest and BSIs is comparable with reports from countries with low incidence of massive burns. Wider adoption of a standardized laboratory reporting framework would help realise the potential of clinical quality registries to provide data which supports evidence based infection prevention initiatives.

In-hospital outcomes of paediatric burn injuries managed in children’s hospitals compared to general hospitals

IntroductionIn Australia and New Zealand, children with burn injuries are cared for in either general hospitals which cater to both adult and paediatric burn injuries or in children’s hospitals. Few publications have attempted to analyse modern burn care and outcomes as a function of treating facilities. AimThe aim of this study was to compare in-hospital outcomes of paediatric burn injuries managed in children’s hospitals to those treated in general hospitals that regularly treated both adult and paediatric burn patients. MethodsA retrospective cohort study of cases was undertaken using data from the Burns Registry of Australia and New Zealand (BRANZ). All paediatric patients with data for an acute or transfer admission to a BRANZ hospital and registered with BRANZ with a date of admission between 1 July 2016 and 30 June 2020 were included in the study. The primary outcome of interest was the acute admission length of stay. Secondary outcome measures of interest included admission to the intensive care unit and readmission to a specialist burn service within 28 days. The Alfred Hospital Ethics Committee granted ethical approval for this study (project 629/21). ResultsA total of 4630 paediatric burn patients were included in the analysis. Approximately three quarters of this cohort (n = 3510, 75.8%) were admitted to a paediatric only hospital, while the remaining quarter (n = 1120, 24.2%) were admitted to a general hospital. A greater proportion of patients admitted to general hospitals underwent burn wound management procedures in the operating theatre (general hospitals 83.9%, children’s hospitals 71.4%, p < 0.001). Patients admitted to children’s hospitals had a longer median time to their first episode of grafting (children’s hospitals 12.4 days, general hospitals 8.3 days, p < 0.001). The adjusted regression model for hospital LOS indicate that patients admitted to general hospitals had a 23% shorter hospital LOS, compared to patients admitted to children’s hospitals. Neither the unadjusted or adjusted model for intensive care unit admission was significant. After accounting for relevant confounding factors, there was no association between service type and hospital readmission rates. ConclusionsComparing children’s hospitals and general hospitals, different models of care seem to exist. Burn services in children’s hospitals adopted a more conservative approach and were more inclined to facilitate healing by secondary intention rather than surgical debridement and grafting. General hospitals are more “aggressive” in managing burn wounds in theatre early, and debriding and grafting the burn wounds whenever considered necessary.

Concordance between coding sources of burn size and depth across Australian and New Zealand specialist burn services.

The percentage of total body surface area (%TBSA) burned and burn depth provide valuable information on burn injury severity. This study investigated the concordance between The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) codes and expert burn clinicians in assessing burn injury severity. We conducted a retrospective population-based review of all patients who sustained a burn injury between July 1, 2009, and June 30, 2019, requiring admission into a specialist burn service across Australia and New Zealand. The %TBSA burned (including the percentage of full thickness burns) recorded by expert burn clinicians within the Burns Registry of Australia and New Zealand (BRANZ) were compared to ICD-10-AM coding. 20,642 cases (71.5%) with ICD-10-AM code data were recorded. Overall, kappa scores (95% confidence interval [CI]) for burn size ranged from 0.64 (95% CI 0.63-0.66) to 0.86 (95% CI 0.78-0.94) indicating substantial to almost perfect agreement across all %TBSA groups. When stratified by depth, the lowest agreement was observed for < 10% TBSA and < 10% full thickness (kappa 0.03; 95% CI 0.02-0.04) and the highest agreement was observed for burns of ≥ 90% TBSA and ≥ 90% full thickness (kappa 0.72; 95% CI 0.58-0.85). Overall, there was substantial agreement between the BRANZ and ICD-10-AM coded data for %TBSA classification. When %TBSA classification was stratified by burn depth, greater agreement was observed for larger and deeper burns compared with smaller and superficial burns. Greater consistency in the classification of burns is needed.

Examining the patient profile and variance of management and in-hospital outcomes for Australian adult burns patients.

Burn injuries are a common subtype of trauma. Variation in models of care impacts clinical measures of interest, but a nation-wide examination of these measures has not been undertaken. Using data from the Burns Registry of Australia and New Zealand (BRANZ), we explored variation between Australian adult burn services with respect to treatment and clinical measures of interest. Data for admissions July 2016 to June 2020 were extracted. Clinical measures of interest included intensive care admission, skin grafting, in-hospital death, unplanned readmissions, and length of stay (LOS). Estimated probabilities, means, and corresponding 95% confidence intervals (CI) were calculated for each service. The BRANZ recorded 8365 admissions during the study period. Variation between specialist burn services in admissions, demographics, management, and clinical measures of interest were observed. This variation remained after accounting for covariates. Specifically, the adjusted proportion (95% CI) of in-hospital mortality ranged from 0.15% (0.10-0.21%) to 1.22% (0.9-1.5%). The adjusted mean LOS ranged from 3.8 (3.3-4.3) to 8.2 (6.7-9.7) days. A decade after its launch, BRANZ data displays variation between Australian specialist burn services. We suspect differences in models of care between services contributes to this variation. Ongoing research has begun to explore reasons underlying how this variation influences clinical measures of interest. Further engagement with services about models of care will enhance understanding of this variation and develop evidence-based guidelines for burn care in Australia.

Performance of BEAMS Risk of Death Score for Mortality Prediction in Australian and New Zealand Burns Patients.

The BEAMS (Burns Evaluation and Mortality Study) risk of death score was developed in 2013 as a mortality prediction tool for burns patients admitted to an ICU (intensive care unit) in Australia and New Zealand. While it previously performed well, identifying high-risk groups and allowing benchmarking, over time such scores may lose calibration or be superseded by improved scoring systems. Our aim was to assess the performance of the BEAMS score in a modern cohort of burns patient. Data were sourced from the Burns Registry of Australia and New Zealand (BRANZ) and the Australia New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS CORE) databases. Data were linked using probabilistic methodology. BEAMS risk of death scores was calculated for all adult patients. Between 2009 and 2019, there were 2075 patients admitted to an Australian or New Zealand ICU with a burn-related injury. Advanced age, female gender, higher %TBSA burns, and inhalation injury were all associated with increased rate of mortality (P &lt; .05). Overall hospital mortality was 9.4% (n = 195). The predicted risk of death from BEAMS was 8.7% and the score had an area under the receiver operating characteristic curve of 0.934. We found the BEAMS risk of death score continues to have excellent performance in a modern cohort of adult critically ill burns patients. It remains a valid tool for mortality prediction among adult burns patients admitted to ICU across Australia and New Zealand.

Burn wound excision within 24 h: A 9-year review

BackgroundSevere burns are accompanied by an acute and prolonged hypermetabolic response typified by elevated levels of proinflammatory cytokines and acute phase proteins. When persistent, this inflammatory response can result in multi-organ dysfunction and death. Regarded as the standard of care, early removal of devitalised tissue and eschar mitigates this hypermetabolic response. Ascertaining the optimal time point for early excision, which remains controversial, has several clinical implications. MethodsThis retrospective observational study included 836 adult thermal burns patients with total burned surface area ≥20% from all Burns Registry of Australia and New Zealand (BRANZ) Hospital sites, including the Victorian Adult Burns Service (VABS), from July 1 2009 to June 30 2018. Patients were divided into two groups, “early” and “delayed”, based on a 24-hour excision cut-off from when the injury occurred. Outcome measurements included mortality, hospital length of stay, intensive care unit length of stay, ventilation requirements and the incidence of positive blood cultures. ResultsAmong all patients at BRANZ sites, excision within 24 h was associated with reduced mean length of ICU stay (6.6 ± 8.1 vs. 9.2 ± 10.6 days; p = 0.008) and lower mean mechanical ventilator hourly use (94.9 ± 160.8 vs. 159.2 ± 219.1 h; p = 0.001) in the 20−29% TBSA sub-group. Beyond this, no significant differences were observed in outcome measurements. ConclusionsWhile it is physiologically important to perform early burn wound excision to mitigate the inflammatory response, delaying excision beyond 24 h for surgical planning, possibly up to 72 h after injury, may be a reasonable approach for certain patient groups.

Venous thromboembolism in burns patients: Are we underestimating the risk and underdosing our prophylaxis?

Burns patients exhibit all factors of Virchow's triad and are thus at high theoretical risk of venous thromboembolism (VTE). At our tertiary referral burns unit, a standard dose of low molecular weight heparin, which acts primarily by inhibiting Factor Xa, is given for thromboprophylaxis. However, the pharmacokinetics of enoxaparin are altered following a burn injury, and thus burns patients are likely underdosed on their thromboprophylaxis. The objectives of this study were to determine the incidence and risk factors for VTE among burns patients at the Victorian Adult Burns Service (VABS) and to determine the adequacy of the current enoxaparin thromboprophylaxis regimen through measurement of anti-factor Xa (AFXa) levels and comparison with established reference ranges. This study consisted of two parts. In part 1, the Burns Registry of Australia and New Zealand (BRANZ) was reviewed for cases of VTE in burns patients admitted to the VABS from 2013 - 2018. Part 2 was a prospective study that determined peak and trough AFXa levels in patients admitted to the VABS with >10% total body surface area (TBSA) burns. Part 1. Totally, 1,475 patients were admitted to the VABS between 2013 - 2018. There were 20 cases of VTE (1.36%). Percent TBSA of burn (OR = 1.04, 95% CI: 1.03 - 1.06), full thickness burns (OR = 2.78, 95% CI: 1.15 - 6.73), ICU admission (OR = 15.08, 95% CI: 5.01 - 45.44), mechanical ventilation (OR = 10.62, 95% CI: 4.05 - 27.91), operative procedures (OR = 1.43, 95% CI: 1.29 - 1.59), and a longer hospital stay (OR = 1.05, 95% CI: 1.04 - 1.07) were all associated with an increased VTE risk. Part 2. A total of 20 participants with >10% TBSA burns were recruited to the prospective study. Peak anti Factor Xa (AFXa) levels were measured for all 20 participants with 15% recording an initial prophylactic peak AFXa level within reference range. Upon subsequent measurements, 50% of participants reached a prophylactic peak AFXa level. Trough AFXa levels were measured for 17 participants with no participant recording an initial or subsequent trough AFXa level at or above the prophylactic threshold. Our study demonstrates a high incidence of VTE among burns patients at the VABS, especially among the major burns patients, and a thromboprophylaxis protocol that is ineffective in achieving prophylactic levels of AFXa level. The evidence suggests a need to evaluate different dosing protocols among burns patients in order to improve AFXa levels, with the aim of decreasing incidence of VTE in high-risk patients.

Predictors of itch and pain in the 12 months following burn injury: results from the Burns Registry of Australia and New Zealand (BRANZ) Long-Term Outcomes Project.

BackgroundItch and pain are common complaints of patients with burn injuries. This study aimed to describe the prevalence and predictors of itch and moderate to severe pain in the first 12 months following a burn injury, and determine the association between itch, moderate to severe pain, work-related outcomes, and health-related quality of life following a burn injury.MethodsBurn patients aged 18 years and older were recruited from five Australian specialist burn units. Patients completed the 36-item Short Form Health Survey Version 2 (SF-36 V2), the Sickness Impact Profile (SIP) work scale, and a specially developed questionnaire relating to itch at 1, 6, and 12 months post-injury. Moderate to severe pain was defined as a score less than 40 on the bodily pain domain of the SF-36 V2. Multivariate mixed-effects regression models were used to identify patient and burn injury predictors of itch and moderate to severe pain.ResultsThree hundred and twenty-eight patients were included. The prevalence of itch decreased from 50% at 1 month to 27% at 12 months. Similarly, the prevalence of moderate to severe pain decreased from 23% at 1 month to 13% at 12 months. Compared to patients aged 18-34, the adjusted odds of experiencing any itch were 59% (95% CI: 0.20, 0.82) and 55% (95% CI: 0.22, 0.91) lower for patients aged between 35 and 49 and ≥ 50 years, respectively. Compared to patients aged 18-34, the adjusted odds of experiencing moderate to severe pain were 3.12 (95% CI: 1.35, 7.20) and 3.42 (95% CI: 1.47, 7.93) times higher for patients aged 35-49 and ≥ 50 years, respectively.ConclusionsLess than 15% of patients reported moderate or severe pain at 12 months, while approximately one-quarter of the patients reported itch at the same period. The presence of moderate to severe pain was associated with a greater negative impact on health-related quality of life and work outcomes compared to itch. Further research is needed to improve our ability to identify patients at higher risk of persistent itch and pain who would benefit from targeted review and intervention studies.

Variation in documented inhalation injury rates following burn injury in Australia and New Zealand

IntroductionThe negative impact of inhalation injuries on in-hospital outcomes for burn patients is well known, but the burns community is yet to form a consensus on diagnostic criteria and clinical definitions. The diagnosis of inhalation injuries is consequently highly subjective. This study aimed to assess the variation in the rate of documented inhalation injury for adult patients in Australian and New Zealand burn units. MethodsData for sequential admissions collected from eight adult burn centres across Australia and New Zealand between July 2009 and June 2016 were extracted from the Burns Registry of Australia and New Zealand (BRANZ). Inhalation injury was classified in two ways: (i) a field in the BRANZ data dictionary, and (ii) through a series of International Classification of Disease 10th Revision Australian Modification (ICD-10-AM) codes. Variation in inhalation injury prevalence was assessed using descriptive statistics, funnel plots, logistic regression, and predicted probabilities. ResultsThere were 11,206 admissions to BRANZ sites over the study period. Inhalation injury prevalence was the highest at Site D (13.1% for the BRANZ field and 11.8% for the ICD-10-AM codes), but there was significant variation between the contributing sites and the inhalation injury classification methods. ConclusionThere is significant variation in the prevalence of documented inhalation injury among Australian and New Zealand burns units. The variation in the prevalence of documented inhalation injury across Australian and New Zealand sites reinforces the need for a consensus definition in the diagnosis of these injuries. Further work is required to improve data quality and reconcile the differences between clinical and ICD-10-AM coding prevalence before changes in clinical practice can be recommended from these data.

Severe burns in Australian and New Zealand adults: Epidemiology and burn centre care

IntroductionStudies describing the epidemiology of severe burns (>20% total body surface area) in adults are limited despite the extensive associated morbidity and mortality. This study aimed to describe the epidemiology of severe burn injuries admitted to burn centres in Australia and New Zealand. Materials and methodsData from the Burns Registry of Australia and New Zealand (BRANZ) were used in this study. Patients were eligible for inclusion if they were admitted between August 2009 and June 2013, were adults (18-years or older), and had burns of 20% total body surface area (TBSA) or greater. Demographics, burn characteristics and in-hospital mortality risk factors were investigated using multivariable Cox proportional hazards analysis. ResultsThere were 496 BRANZ registered patients who met the inclusion criteria. Over half of the patients were aged 18–40 years and most were male. The median (IQR) TBSA was 31 (25–47). Most (75%) patients had burns involving <50% TBSA, 58% sustained their burn injury at home, and 86% had sustained flame burns. Leisure activities, working for income and preparing food together accounted for over 48% of the activities undertaken at the time of injury. The in-hospital mortality rate was 17% and the median (IQR) length of stay was 24 (12–44) days. Seventy-two percent were admitted to an intensive care unit (ICU) and 40% of patients had an associated inhalation injury. Alcohol and/or drug involvement was suspected in 25% of cases. ConclusionThis study describes the demographics, burn injury characteristics and in-hospital outcomes of severe burn injuries in adults whilst also identifying key predictors of inpatient mortality. Key findings included the over-representation of young males, intentional self-harm injuries and flame as a cause of burns and highlights high risk groups to help aid in the development of targeted prevention strategies.

Burns first aid treatment in remote Northern Australia

Background and objectiveIt is well demonstrated that adequate burns first aid treatment (BFAT) improves clinical outcomes for the injured but adequacy remains low in many studies. This study presents a twelve month assessment of the adequacy of burns first aid treatment for patients managed by the Burns Service, Royal Darwin Hospital (RDH). MethodsProspective study design of all patients managed by the Burns Service, Royal Darwin Hospital. Data were collated from two sources; RDH Burns Registry, and the Burns Registry of Australia and New Zealand (BRANZ). Inclusion criterion was all patients managed by the Burns Service, Royal Darwin Hospital for the period 1 January 2014–31 December 2014. Variables collected and analysed include: demographics, burn mechanism, burn wound depth and adequacy of and circumstances around first aid. ResultsOverall 310 cases were analysed. Most injuries involved adults (68%), 19% Indigenous persons and 70% of all patients had their burn injury occur in the urban region. Adequate BFAT occurred in 41% of cases. Adults, contact burns and those where the burn injury occurred in the remote regions were less likely to receive adequate BFAT. Indigenous persons were less likely to attempt any BFAT at all and when they did receive BFAT it was more likely applied by an emergency responder or health professional. ConclusionOverall adequacy of BFAT is low in the Top End of the Northern Territory. Remote dwellers and Indigenous persons are at increased risk of not applying or receiving adequate BFAT. The poor level of adequate BFAT demonstrated in this study suggests that the Top End community particularly remote and Indigenous persons would benefit from targeted BFAT education programs that are delivered in a culturally and linguistically appropriate fashion.

Predictors of moderate to severe fatigue 12 months following admission to hospital for burn: Results from the Burns Registry of Australia and New Zealand (BRANZ) Long Term Outcomes project

IntroductionFatigue has been identified as an outcome of concern following burn but is rarely captured in outcomes studies. We aimed to: (i) describe the prevalence, and predictors, of moderate to severe fatigue in the first 12 months following burn, and (ii) establish the association between fatigue and health-related quality of life and work outcomes. MethodsAdult burns patients, admitted >24h, were recruited from five BRANZ sites. Participants were followed-up at 1-, 6-, and 12-months after injury using the Brief Fatigue Inventory (BFI), 36-item Short Form Health Survey (SF-36) and the Sickness Impact Profile (SIP)—work scale. Moderate to severe fatigue was defined as a global BFI score of 4–10. Multivariable mixed effects regression modelling was used to identify demographic, socioeconomic, burn size and severity predictors of moderate/severe fatigue at follow-up. ResultsThe mean±SD age of the 328 participants was 42.1±16.7years, 70% were male, 47% were flame burns, and the mean±SD %TBSA was 8.7±11.2. The prevalence of moderate/severe fatigue decreased from 37% at 1-month, to 32% at 6-months and 26% at 12-months. The adjusted odds of moderate/severe fatigue were 2.62 (95% CI: 1.27, 5.42) times higher for women compared to men, and 2.64 (95% CI: 1.03, 6.79) times higher in patients with a %TBSA≥20. Compared to patients in major cities, the adjusted odds of reporting moderate/severe fatigue were 2.48 fold higher (95% CI: 1.17, 5.24) for patients residing in inner regional areas, and 3.60 fold (95% CI: 1.43, 9.05) higher for patients living in remote/very remote areas. At each time point, the physical and mental health summary scores, and each sub-scale score, of the SF-36 were significantly lower in patients reporting moderate/severe fatigue. Patients experiencing moderate to severe fatigue reported higher work-related disability on the SIP work scale at each time point after injury. Discussion and conclusionMore than a quarter of participants reported moderate to severe fatigue on the BFI at 12-months and fatigue was strongly associated with poorer health-related quality of life and greater work-related disability.

The Burns Registry of Australia and New Zealand: progressing the evidence base for burn care.

OBJECTIVE: Analysis of data from the Burns Registry of Australia and New Zealand (BRANZ) to determine the extent of variation between participating units in treatment and in specific outcomes during the first 4 years of its operation. DESIGN: BRANZ, an initiative of the Australian and New Zealand Burn Association, is a clinical quality registry developed in accordance with the Australian Commission on Safety and Quality in Healthcare national operating principles. SETTING: Patients with burn injury who fulfil pre-defined criteria are transferred to and managed in designated burn units. There are 17 adult and paediatric units in Australia and New Zealand that manage almost all patients with significant burn injury. Twelve of these units treat adult patients. PARTICIPANTS: Data on 7184 adult cases were contributed by ten acute adult burn units to the registry between July 2010 and June 2014.Major outcomes: In-hospital mortality, hospital length of stay, skin grafting rates, and rates of admission to intensive care units. RESULTS: Considerable variations in unit profiles (including numbers of patients treated), in treatment and in outcomes were identified. CONCLUSIONS: Despite the highly centralised delivery of care to patients with severe or complex burn injury, and the relatively small number of specialist burn units, we found significant variation between units in clinical management and in outcomes. BRANZ data from its first 4 years of operation support its feasibility and the value of further development of the registry. Based on these results, the focus of ongoing research is to improve understanding of the reasons for variations in practice and of their effect on outcomes for patients, and to develop evidence-informed clinical guidelines for burn management in Australia and New Zealand. Language: en

The Burns Registry of Australia and New Zealand: progressing the evidence base for burn care.

Analysis of data from the Burns Registry of Australia and New Zealand (BRANZ) to determine the extent of variation between participating units in treatment and in specific outcomes during the first 4 years of its operation. BRANZ, an initiative of the Australian and New Zealand Burn Association, is a clinical quality registry developed in accordance with the Australian Commission on Safety and Quality in Healthcare national operating principles. Patients with burn injury who fulfil pre-defined criteria are transferred to and managed in designated burn units. There are 17 adult and paediatric units in Australia and New Zealand that manage almost all patients with significant burn injury. Twelve of these units treat adult patients. Data on 7184 adult cases were contributed by ten acute adult burn units to the registry between July 2010 and June 2014.Major outcomes: In-hospital mortality, hospital length of stay, skin grafting rates, and rates of admission to intensive care units. Considerable variations in unit profiles (including numbers of patients treated), in treatment and in outcomes were identified. Despite the highly centralised delivery of care to patients with severe or complex burn injury, and the relatively small number of specialist burn units, we found significant variation between units in clinical management and in outcomes. BRANZ data from its first 4 years of operation support its feasibility and the value of further development of the registry. Based on these results, the focus of ongoing research is to improve understanding of the reasons for variations in practice and of their effect on outcomes for patients, and to develop evidence-informed clinical guidelines for burn management in Australia and New Zealand.

Long term outcomes data for the Burns Registry of Australia and New Zealand: Is it feasible?

BackgroundIncorporating routine and standardised collection of long term outcomes following burn into burn registries would improve the capacity to quantify burn burden and evaluate care. AimsTo evaluate methods for collecting the long term functional and quality of life outcomes of burns patients and establish the feasibility of implementing these outcomes into a multi-centre burns registry. MethodsFive Burns Registry of Australia and New Zealand (BRANZ) centres participated in this prospective, longitudinal study. Patients admitted to the centres between November 2009 and November 2010 were followed-up at 1, 6, 12 and 24-months after injury using measures of burn specific health, health status, fatigue, itch and return to work. Participants in the study were compared to BRANZ registered patients at the centres over the study timeframe to identify participation bias, predictors of successful follow-up were established using a Generalised Estimating Equation model, and the completion rates by mode of administration were assessed. Results463 patients participated in the study, representing 24% of all BRANZ admissions in the same timeframe. Compared to all BRANZ patients in the same timeframe, the median %TBSA and hospital length of stay was greater in the study participants. The follow-up rates were 63% at 1-month, 47% at 6-months; 40% at 12-months, and 21% at 24-months after injury, and there was marked variation in follow-up rates between the centres. Increasing age, greater %TBSA and opt-in centres were associated with greater follow-up. Centres which predominantly used one mode of administration experienced better follow-up rates. ConclusionsThe low participation rates, high loss to follow-up and responder bias observed indicate that greater consideration needs to be given to alternative models for follow-up, including tailoring the follow-up protocol to burn severity or type.