US Burn Centers Research Articles

Burn-Related Violence Against Women in the United States: Findings From the ABA Burn Registry.

Violence against women is a global public health problem. Centers for Disease Control and Precention (CDC) data show 41% of US women have experienced intimate partner violence. Burn-related violence against women is an extremely confronting form of physical violence. The aim of this study was to describe the frequency, demographics, injury characteristics, and outcomes of women admitted to US burn centers who have experienced burn violence compared to those with accidental burn injuries. 2008-2018 data were comparative statistics were used to describe/compare groups. 54 523 women met study inclusion criteria. 956 (2%) experienced burn violence. Women who experienced burn violence had a younger median [IQR] age (36 [27,48] vs 47 [32,61], P < .0001), were Black/African American (44.5% vs 22.4%, P < .0001), were covered by Medicaid (38.8% vs 21.6%, P < .0001), had a higher median [IQR] %TBSA extent (6.0% [3,15.2] vs 3.0% [1,7.3], P < .0001), a higher proportion with third-degree burns (35.4% vs 28.9%, P < .0001), and a higher proportion with TBSA > 20% (18.2% vs 6.7%, P < .0001). Scald/flame injuries were the most frequent mechanism of injury. Women who experienced violence had a higher median [IQR] length of hospital stay (7.0 [2,18] vs 4.0 [1,11] days, P <.0001), Intensive Care Unit (ICU) stay (8.5 [2,27] vs 4 [2,13] days, P < .0001), and mortality rate (5.7% vs 4.3%, P < .04). The frequency of women who sustained burn violence appears small yet experience worse outcomes. Clinicians should be aware of these demographic/clinical characteristics to provide optimal care to this vulnerable population.

The association between body mass index and physical function in adult burn survivors: A Burn Model System National Database study

IntroductionAn area of rehabilitation research in burns is the impact of co-morbidities on disease trajectory. Obesity is a comorbidity of increasing public health concern, but its role remains controversial regarding burn injury and physical recovery. Our aim was to evaluate the association between body mass index (BMI) categories as a measure of obesity at discharge and self-reported physical function (PF) during recovery of adult burn survivors. MethodsThis is a retrospective study on data collected by four major US burn centers, which contribute to the Burn Model System National Database. The data included BMI obtained at hospital discharge and self-reported PF-mobility, using the PROMIS measures assessed at 6, 12, and 24 months after burn. Subjects were classified into weight status categories based on BMI: underweight (BMI <18.5), normal weight (18.5 ≤ BMI <25), overweight (25 ≤ BMI <30), obesity class 1 (30 ≤ BMI <35), obesity class 2 (35 ≤ BMI <40), and obesity class 3 (BMI ≥40). Mixed-effects linear regression models were used to assess the association between BMI categories and PF scores over time, adjusted for patient and injury characteristics. ResultsA total of 496 adult burn patients aged 47 ± 16 years were included, with mean total body surface area (TBSA) burned of 18 ± 19 % and mean BMI at discharge of 28 ± 7 kg/m2. PROMIS PF scores significantly improved over time in the recovery phase after burn (time effect, p < 0.001). Compared to overweight burn patients, normal-underweights exhibited lower PF score by an average of 4.06 units (p = 0.001) but scores increased linearly by an estimated 0.17 units per month (p = 0.01) over the 24 months after discharge. Similarly, compared to overweight burn patients, class 1 obese reported lower PF score by a mean 2.67 units (p = 0.07) but PF increased linearly by 0.15 units per month (p = 0.07) over the 24 months after discharge. These findings were independent of the effects of age at discharge, sex, TBSA burned, and hand and leg burn. ConclusionBeing overweight was associated with improved and faster recovery of PF scores compared to normal, underweight, and obese burn patients during long-term recovery. Hence, our data suggests that long-term recovery and restoration of PF in adult burn survivors is not compromised by a small excess in body weight.

Precursors to oliguria during major burn resuscitation: An analysis of a prospective observational trial at 5 major US burn centers

Currently, urine output is the leading variable used to tailor fluid resuscitation in patients with large TBSA burns. However, this metric often lags with respect to resuscitation. Our group sought to identify derangements in variables that precede development of oliguria (<30 cc/hr) that we hypothesize will aid in more efficient resuscitation. We performed a retrospective analysis of 146 adult patients admitted within 4 h of a large TBSA (>20%) burn. We then divided them into two cohorts: those who developed oliguria within 6 h of admission and those who did not. Patients who experienced early oliguria had a higher incidence of invasive SBP < 90 (p = 0.02) or DBP < 40 (p = 0.009), lower minimum bicarbonate level (p = 0.04), more full thickness burns (p = 0.004), and higher TBSA (p = 0.01). More female patients were found in the oliguric group (p = 0.003). Multivariate analysis was used to develop a model to predict development of oliguria. When evaluated together, minimum DBP, sex, TBSA (or percent full thickness burn), and maximum base deficit constituted the most parsimonious model that significantly predicted oliguria (AUC = 0.92). Interestingly, the model lost significance when DBP was omitted, highlighting the importance of diastolic pressure in the development of oliguria.

Development of the national injury resource database (NIRD)

IntroductionLack of an accurate, publicly available database of burn/trauma resources creates challenges in providing burn care. In response to this gap, our group developed the National Injury Resource Database (NIRD), a comprehensive database of all US burn centers (BC) and trauma centers (TC) and their capabilities. MethodsLists of all national BC and TC were obtained from the American Burn Association (ABA), the American College of Surgeons, and every state department of health. Data was cross-checked and included BC/TC were linked with a 7-digit identification number using the American Hospital Association Quick Search guide. Each center’s resources and verification status were validated with electronic or telephonic communications. ResultsThe final database includes 135 BC and 617 TC, of which 18 are BC-only, 500 are TC-only, and 117 are combined BC/TC. ABA-verified BC (n = 76) are only found in Washington DC and 31 states, and 8 states have no BC. In the last 10 years, a net increase of 7 burn centers was found nationally. The ABA’s online BC directory is outdated. ConclusionsNIRD represents the only up-to-date, comprehensive listing of BC and TC in existence. It categorizes all currently operating BC and TC across myriad classifications of designation and capabilities.

Pilot randomized clinical trial of virtual reality pain management during adult burn dressing changes: Lessons learned.

Opioids are the most frequently used pain medications by US burn centers to control severe procedural pain during wound care. Concerns for long-term opioid use have prompted the exploration of non-pharmaceutical interventions, such as virtual reality (VR), for procedural pain management. The primary objective of this pilot study was to evaluate the feasibility and efficacy of VR pain alleviation treatment in reducing adult burn patients' perceived pain during burn dressing changes. Adult patients aged 18-70 years were recruited from the inpatient unit of a single American Burn Association-verified burn center between May 2019 and February 2020 and randomly assigned to one of three arms. Active VR participants played four VR games; passive VR participants were immersed in the same VR environment without the interaction elements; and a standard of care control group. 71 patients were screened for eligibility and 33 were deemed eligible to approach for informed consent, with 14 agreeing to participate in this study. Of these 14 patients, 4 were randomly assigned to the active VR, 4 to the passive VR, and 6 to the control group. Self-reported overall pain was lowest among participants in the active VR (dressing 1 = 41.3, dressing 2 = 61.0, and dressing 3 = 72.7) and highest among participants in the passive VR (dressing 1 = 58.3, dressing 2 = 74.5, and dressing 3 = 89.0) across all three dressing changes. Self-reported worst pain was lowest among the active VR at the first and last dressing (64.3 and 92.2, respectively), but the control group has the lowest self-reported worst pain at the second dressing (71.3). VR is a useful non-pharmacological tool for pain distraction but designing and implementing clinical research studies face many challenges in real-world medical settings. Lessons from this study have important implications for future VR studies by other researchers. Trial Registration: ClinicalTrials.gov Identifier: NCT04545229.

738 Access to Burn Care: A 10 Year Perspective of Burn Centers in the U.S.

Abstract Introduction Only 2% of US hospitals have designated burn centers (BC), of which 57% are verified by the American Burn Association (ABA). Further, of the non-verified burn centers, it is unclear which ones meet requirements set by their state departments of health. This gap in knowledge of BC verification and/or designation status combined with the lack of an accurate, publicly available database to route patients and characterize BC resources creates challenges in burn care, especially in disaster preparedness. The goal of our study was to characterize the net effect of domestic BC openings and closings over the last decade on US burn resources and, thus, access to care. Methods Our group has recently created the National Injury Resource Database (NIRD), a comprehensive list of every US Level I and II trauma center and/or burn center. NIRD was created by culling these facilities from 1) the current ABA burn center directory, 2) the current ABA burn center regional map, 3) the American Hospital Association database, 4) the American College of Surgeons Committee on Trauma database, and 5) data from all 50 State Departments of Health. Redundant entries were omitted, and 100% of the remaining institutions were then personally contacted by one of the study investigators to confirm or clarify the status of each center as well as the resources listed in the various databases. The NIRD database was then compared to the ABA’s 2012 burn center directory to compare the number, identities, and characteristics of those US BCs which had either closed or opened in the intervening ten years. Results In 2012, there were 127 total BC, 63 of which were ABA verified. Currently, NIRD shows that there are 134 total BC recognized by the ABA, 76 of which are verified. Since 2012, 11 BC have been removed from the ABA’s burn center directory after either closing or failing to maintain ABA recognition, while 18 BC have been added. In the same time frame, there have been changes in BC verification status across the US, with 14 BC gaining ABA verification and 1 BC losing verification. In comparing the ABA’s current BC directory to their burn center regional map, we found variability in 18 centers across 15 states (CA, DC, IL, IN, KS, MD, ME, MI, MS, MO, NY, TN, TX, VA, VT), i.e., instances in which 1 or more BC found on the ABA’s BC regional map were not found on the ABA’s BC directory list. Conclusions The last 10 years have shown an upward trend in the number of US BC. Further, we found variability in the ABA’s online resources in 15 states, suggesting that their resources are outdated. NIRD can serve as a resource for the construction of publicly available real-time tools to aid in routing burn patients. Applicability of Research to Practice NIRD can serve as a resource for the construction of publicly available real-time tools to aid in routing burn patients.

701 Impact of Alcohol and Methamphetamine Use on Burn Resuscitation

Abstract Introduction Mortality associated with burn injuries is declining with improved critical care, including resuscitation. However, patients admitted with concurrent substance use have increased risk of complications and poor outcomes. The impact of alcohol and methamphetamine use on acute burn resuscitation has been described in single center studies, however, has not been studied since implementation of computerized decision support for resuscitation. The purpose of this study was to evaluate resuscitation volumes for patients with alcohol and methamphetamine use within a large prospective observational trial at 5 major US burn centers. Methods We performed an observational trial across five institutions with &amp;gt; 20% total body surface area (TBSA) burn, weighing &amp;gt;40kg that were resuscitated utilizing computerized decision support. Patients were evaluated based presence of alcohol, with a minimum blood alcohol level of 0.10, or positive methamphetamines on urine drug screen. Fluid volumes and urine output were examined over 48 hours and Wilcoxon Method was utilized to compare patient groups. Results A total of 296 patients were analyzed. 37 (12.5%) were positive for methamphetamine use, 50 (16.9%) were positive for alcohol use, and 209 (70.1%) with negative for both. Patients positive for methamphetamine received a mean of 5.30 ±2.63 cc/kg/TBSA, patients positive for alcohol received a mean of 5.41 ± 2.49 cc/kg/TBSA, and patients with neither received a mean 4.33 ± 1.79 cc/kg/TBSA. Patients with methamphetamine or alcohol use had significantly higher fluid requirements than those who were negative for both substances. In the first 6 hours patients with alcohol use had significantly higher urinary output in comparison to patients with methamphetamine use which had similar output to patients negative for both substances. Conclusions This study demonstrated that patients with alcohol and methamphetamine use had statistically significantly larger fluid resuscitation requirements compared to patients without. The effects of alcohol as a diuretic align with previous literature. However, patients with methamphetamine lack the increased urinary output as a cause for their increased fluid requirements. Methamphetamine’s neurologic and cardiovascular effects due to increased release of dopamine, serotonin, and norepinephrine are known. Further investigation is required to better understand the mechanism underlying the need for increased resuscitation after burn injury in patients positive for methamphetamines. Applicability of Research to Practice The impact of alcohol and illicit substances on burn care, especially during the initial resuscitation, aids providers in guiding early critical care.

538 Demographic and Injury Differences Between Children with Burn Injury from the United States and Mexico

Abstract Introduction A large burn data set is being used to evaluate outcomes of pediatric burn survivors, but questions remain whether this data set is generalizable to the typical population of US burn centers as only 62% of enrollees are from the US. A better understanding of similarities and differences within this data set will help in the applicability of findings from it. Methods This is a retrospective cohort study using data from children enrolled in a burn database. Data from 2043 children admitted for burn injury from 1994 to 2020 were analyzed. Data were stratified into children who were US residents and Mexico residents at the time of injury, all treated in US hospitals, and grouped by age into “&amp;lt; 5 years”, “5-10 years” and “ &amp;gt;10 years”. Sex, race, ethnicity, injury etiology, total body surface area injured (TBSA), and circumstances of injury were compared. Fisher’s exact test and Kruskal–Wallis one-way analysis of variance were used to test for differences in categorical and continuous variables, respectively. Results Both US and Mexico populations showed increased incidence among males as they aged. In the US population, as expected the most frequent cause of burns in patients &amp;lt; 5 years was scald. In the Mexico population, fire/flame burns were more frequent in all ages and electric burns were more common among children &amp;gt; 5 years. In both populations, indoor injuries were more common among children &amp;lt; 5 years and outdoor injuries were more common as children aged. Children from Mexico had larger burns and longer lengths of hospital stay than US children across all ages. Conclusions Children from Mexico who were referred to the US for burn care were similar in demographic patterns to US children. While differences were seen in extent and mechanism, the difference is likely influenced by larger, more severe burns being transferred to the US for care, while low severity burns were treated locally. This suggests that children from Mexico in the database are not representative of the pediatric burn injury population of the US or Mexico more broadly. When studying datasets from US hospitals containing non-US residents, it is recommended that these populations be separately analyzed, otherwise, findings cannot be generalized to the US pediatric burn injury population. Applicability of Research to Practice In addition to identifying prevention needs, differences among US and Mexico resident children cared for in the US limit the utility of analyzing this population in the burn dataset.

Health Equity Ratings of US Burn Centers: Does For-Profit Status Matter?

Health Equity Ratings of US Burn Centers: Does For-Profit Status Matter?

Sexual Function after Burn Injury: “The Bystander Effect” and Other Results from a Survey of Active Medical Providers from the Canadian Burn Association

ABSTRACT Introduction The prevalence of new onset sexual dysfunction amongst burn survivors may be as high as 53%. Unsurprisingly, patients consistently report intimacy and sexual function in romantic relationships as something that lowers their quality of life. Other groups have reported that the topic of sexual health and new onset erectile difficulties was not adequately addressed in 83% of responding patients cared for at major US burn centers. It is unknown how well healthcare providers themselves feel they address the topic of sexual health in patients who survive major burn injuries. Objective The goal of this project was to survey current practice patterns, views and beliefs on sexual function of burn survivors in a population of medical providers providing direct care to patients. Ideally, the goal of this study was to describe existing biases and communication barriers that prevent discussions of sexual function during recovery. The results of this survey will identify blind-spots in the care of burn victims as it pertains to improving their quality of life. Methods A 24-item survey; modified from a survey created by Rimmer et al, 2010, was distributed to active members of the Canadian Burn Association (nurses, physicians and nurse practitioners) across 23 centers. The Survey was divided into 3 sections, aiming to collect information on participant demographics, on how participants’ burn centers address the topic of intimacy and sexuality with burn survivors, and on how individual participants address this important topic. Participation was voluntary, and no personal identifiers were collected. Results 32 health care providers participated in our survey. When asked “Who on your burn team is primarily responsible for discussing sexuality and intimacy with burn survivors and/or partners”, 47% (n=15) and 36% (n=11) of participants indicated that “it is not anyone's responsibility” in respective inpatient and outpatient units. Furthermore, when asked “In your opinion, does your burn team do a good job of addressing sexuality and intimacy with your burn survivors?”, 84% (n=26) participants responded “no”. Conclusions Health care providers are often not addressing sexuality and intimacy in the care of survivors of burn injuries. Multiple barriers work together to inhibit health care providers from initiating these important conversations with patients. This includes a high prevalence of the well-described “bystander effect”, where no single person is responsible for addressing the issue of sexual health. Cultural, gender, and sexual orientation-sensitive education programs and incorporation of sexual health discussions into standardized admission discharge processes should be explored further. Finally, specification of which provider is responsible to initiate and follow-up on discussions of sexuality/intimacy is a specific intervention that can improve the care provided to burn survivors moving forward. Disclosure No

1 The Battle of the Titans: Comparing Resuscitation Between 5 Centers Using the Burn Navigator

IntroductionThe goal of burn resuscitation is to provide the least amount of fluid necessary to maintain end-organ perfusion and prevent burn shock. The objective of this analysis was to examine how the Burn Navigator (BN), a clinical decision support tool in burn resuscitation, was utilized across 5 major burn centers in the United States.MethodsA non-interventional, observational trial of 300 adult patients with embedded prospective and retrospective components was undertaken to examine the effectiveness of the BN in burn resuscitation. 5 ABA-verified burn centers enrolled patients. Data examining patient demographics, burn characteristics, fluid volumes, and resuscitation-related complications were examined. Statistical analysis compared the 5 sites in terms of these variables.ResultsA total of 285 patients were eligible for analysis. There was no difference among the centers in terms of average age (45.5 + 16.8 years), BMI (29.2 + 6.9), ISS (21.2 + 12.8), or median TBSA (34 [25.8, 47]). Primary crystalloid infusion volumes at 24 hours differed significantly when measured in ml/kg/TBSA (median 3.7 [2.9, 8.8], range 1.3 to 12.3). Similarly, total fluids, which includes colloid adjuncts, drip medications and enteral fluids, differed between groups when measured in both ml/kg (median 149.8 [106.5, 224.1], range 38.4 to 536.2) and ml/kg/TBSA (4.2 [3.3, 5.5], 1.7 to 15.3) at 24 hours. Post-hoc adjustment for pairwise comparisons resulted in a loss of significance between most of the sites. There was a total of 156 resuscitation-related complications reported across the 5 sites with an average incidence of 44.4 % incidence.ConclusionsThe Burn Navigator appeared to standardize fluid resuscitations across 5 major US burn centers. With primary fluid volumes near the Parkland formula, the device can be utilized effectively in burn centers, and further study should exam the utility of this device in facilities that do not commonly treat burn injuries, as well as the battlefield.

544 Southern US Burn Centers, Surge Capacity and 15 Months of the COVID19 Pandemic

IntroductionBurn mass casualty incident (BMCI) planning efforts have been in practice and publication for 40+ years. Through these ongoing efforts, we know there are measurable limits to burn center capacity and capability through modeling and real-world events relying on conventional and contingency standards of care, even when the only focus is those patients with burn injuries. The southern region of the American Burn Association (ABA) includes 37 burn centers and continues to play a critical role in the BMCI preparedness process.COVID-19 has emerged as the greatest pandemic in terms of morbidity and mortality since the 1918 influenza pandemic. While COVID-19 has no direct connection to burn injuries, the impact of COVID-19 on the American Healthcare System to include burn care was and remains significant.MethodsWe conducted a retrospective analysis of (southern) regional data voluntarily submitted to the ABA from March 2020 to June 2021 and generally coincides with the first three waves of the pandemic. We focused on the self-reported data specific to the three critical components in managing a surge of patients: staffing, space, and supplies (to include pharmaceuticals and equipment).ResultsStaff: These data were collected over a period that coincided with the first three waves seen in the region. Staffing shortages were noted during each of the surges but were most excessive when a regional surge paralleled surges in other parts of the country (November-December 2020).SpaceLate November and early December 2020, space was in short supply with the surge of patients for more of the region than at any other time during the 28 weeks of reporting. While single facilities reported other episodes of limited space or supplemented with temporary structures, the peak was early December.SuppliesAs the first surge began to subside, the supply shortages were abated. However, as additional surges occurred, the supply chain had not recovered. Supply shortages were reported in greater numbers than either space or staffing needs through the multiple waves of the pandemic.ConclusionsThe surge of patients that had to be managed by the greater healthcare community placed a substantial strain on the burn centers to keep beds dedicated for patients with burn injuries. The pandemic directly led to a diminished available capacity for burn care in such a way that it could have compromised our ability to confront a surge of burn-injured patients. Future BMCI planning efforts must consider this aspect of the process. Crisis Standards of Care may come into play during such an event.

603 Evaluating real-world national and regional trends in definitive closure in US burn care: A survey of US Burn Centers

Abstract Introduction Real-world data is observational data gathered outside of the experimental setting from diverse sources which is analyzed to produce real-world evidence. To better understand the impact of burn center treatment patterns, a national sample survey for real-world data sought to benchmark key burn center practice patterns, resource utilization, and clinical outcomes with national data contained within NBR version 8.0 (NBR). Methods A survey was developed by healthcare economists and burn specialists and administered to a representative sample of US burn centers. The survey collected information across several domains, including: burn center characteristics; patient characteristics including number of patients, and burn size and depth; aggregate number of types of procedures; and resource use such as autograft procedure time, length of stay (LOS), and dressing changes; and costs. Nuanced information was collected on care practices and patient outcomes for TBSA burns under 20%. Survey findings were aggregated by key outcomes (LOS, number of procedures, costs) nationally and regionally. Aggregated burn center data were also compared to the NBR to identify trends relative to current treatment patterns. Results Benchmarking survey results demonstrated shifts in burn center patient mix, with more severe cases being seen in the inpatient setting and less severe burns moving to the outpatient setting. Additionally, an overall reduction in the number of autograft procedures was observed compared to NBR, and time efficiencies improved as the intervention time per TBSA decreases with TBSA increases. Both nationally and regionally, an increase in costs were observed. Conclusions The results suggest resource use estimates from NBR version 8.0 may be higher than current practices, thus highlighting the importance of improved NBR reporting and further research on burn center standard of care practices. This study demonstrates significant variations in burn center characteristics, practice patterns, and resource utilization thus increasing our understanding of burn center operations and behavior.

The association of burn patient volume with patient safety indicators and mortality in the US

IntroductionClinical volume has been associated with rate of complications and mortality for various conditions and procedures. We aim to analyze the relationship between annual hospital burn admission, patient safety indicators (PSI), line infections, and inpatient mortality. We hypothesize that high facility volume will correlate with better outcomes. MethodsAll burn admissions with complete data for total body surface area (TBSA) and depth were extracted from the Nationwide Inpatient Sample from 2002–2011. Predictor variables included age, gender, comorbidities, %TBSA, burn depth, and inhalation injury. Surgically relevant PSIs were drawn from the Healthcare Cost & Utilization Project and included: sepsis, venous thromboembolic disease, hemorrhage, pneumonia, and wound complications. Outcomes were analyzed with regression models. ResultsOf the 57,468 encounters included, 3.1% died, 6.3% experienced >1 PSI event, and 0.3% experienced a catheter-associated urinary tract infections or central line associated blood stream infections. The most frequent PSI was pneumonia followed by sepsis and VTE. Annual hospital burn admission volume was independently associated with decreased odds of mortality (OR 0.99, 95% CI 0.99–0.99, p < 0.001) and PSIs (OR 0.99, 95% CI 0.99–0.99, p = 0.031). There was no significant correlation with line infections. In both mortality and PSI models, age, %TBSA, inhalation injuries, and Elixhauser comorbidity score were significantly associated with adverse outcomes (p < 0.05). ConclusionThere was a significant association between higher hospital volume and decreased likelihood of patient safety indicators and mortality. There was no observed relationship with line infections. These findings could inform future verification policies of US burn centers.

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

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

51 Patient Reported Outcomes Following Rehabilitative Surgery in Burn Survivors

Burn survivors have surgical needs after their incident hospitalization. Little is understood regarding what predicts these operations and their effect on patient reported outcomes (PROs). We aim to characterize the use of burn-related operations post-hospitalization and determine whether PROs change during this time. We hypothesized improvement in PROs following surgery adjusting for patient and burn factors. Adult burn survivors with complete data through 2 years post-hospitalization were extracted from the Burn Model Systems, a prospective observational database from 4 US burn centers. Surgical and non-surgical patients were compared. Predictor variables included patient and injury characteristics and inpatient procedures; these were modeled with logistic regression. Health states were measured with Veterans RAND 12 item health survey (VR-12). Burn-related operations were organized into 3 categories: wound, scar, and contracture. The average treatment effect of surgery was modeled with propensity score matching. 372 of 1,359 patients (27.4%) underwent ≥ 1 burn-related operation within 2 years of discharge. Factors that increased the likelihood of operations included number of operations at incident hospitalization (p<0.001), hand and perineal involvement (p=0.001 & 0.042), and range of motion limitation (p<0.001). VR-12 physical health scores rose for all cohorts except those needing wound operations. VR-12 mental health scores rose for those not receiving surgery, but stagnated or declined for surgical cohorts. After adjustment, scar related operations showed no significant changes in physical or mental component scores. Contracture operations were not significantly associated with changes to physical component scores, but showed a decline in mental component scores at 12-month visits (p<0.001). The number of operations at incident hospitalization was the strongest predictor of needing later surgery. Patients with ongoing surgical needs for wounds appear to have poorer quality of life than matched peers. Contracture and scar surgeries were not associated with gains in global well-being compared to matched non-surgical peers. Additional qualitative studies are needed to understand why these data suggest a discrepancy to what is observed in the clinical setting with regard to reconstructive surgery. Better informed shared decision making with patients when deciding on rehabilitative burn surgery.

Trends 10 years after burn injury: A Burn Model System National Database study

BackgroundThe Burn Specific Health Scale-Brief (BSHS-B) evaluates 9 aspects of health and has been validated globally. Existing reports typically focus on outcomes shortly after injury. The purpose of this study is to determine whether quality of life remains a concern for burn survivors ten years after-injury. MethodsCross sectional data of survivors admitted from 1994 to 2006 to four US burn centers were collected in the Burn Model System National Database 10 years after injury. Responses to the items in the nine BSHS-B domains range from 0 to 4. Lower scores indicating poorer quality of life. Median scores are reported and differences were compared using Wilcoxon–Mann–Whitney test. ResultsTen-year survivor injury characteristics suggest a moderate severity of injury. Survivors scored lower in heat sensitivity, affect, body image, and work (median=3.2, 3.6, 2.8, and 3.6, respectively). Affect, body image, and interpersonal scores were significantly lower for females (median=3.1, 2.8, 3.8, respectively) than males [median=3.6, 3.3, 4, respectively (p=0.008, 0.004, 0.022, respectively)]. ConclusionsOur results suggest certain domains of burn specific health benefit from support at 10 years after injury, and select populations such as females may necessitate additional treatment to restore burn-specific health. These results support that burn injuries represent a chronic condition and long-term medical and psychosocial support may benefit burn survivor recovery.

T1 A Comparative Study of Autologous Skin Cell Suspension to Split-thickness Autografting in the Treatment of Acute Burns

Split-thickness autografts (STAG) are the current standard of care for the permanent coverage of deep partial-thickness (DPT) burns. However, grafting is often complicated by hypertrophic scarring and dyspigmentation. Non-cultured, autologous, cell suspension systems are potential alternatives to autografting appropriately selected burn wounds. ReCell® is a device for the rapid, point-of-care preparation and application of non-cultured, autologous skin cells that provides an expansion ratio of 80:1 but is currently limited by US law to investigational use only. We present the results of the initial FDA approval trial for ReCell®. This was a prospective, randomized, within-patient controlled, GCP-compliant, FDA IDE trial comparing ReCell® to STAG for the treatment of acute, DPT burns in adults suffering 1–20% TBSA thermal burns. Comparable burn wounds measuring 100–320 cm2 were randomized to treatment with ReCell® vs. 2:1 meshed STAG. The co-primary effectiveness endpoints were donor site healing at 1 week (superiority) and recipient site healing at 4 weeks (non-inferiority) between the ReCell®-treated and autografted wounds. Secondary effectiveness endpoints included percent epithelialization over time, pain, and patient satisfaction. Safety endpoints included graft loss, infection, scarring, and adverse events. Data were analysed by intention-to-treat (ITT) and modified per-protocol (MPP) populations, as appropriate. A total of 101 subjects across 12 US Burn Centers were enrolled (n=101 ITT, n=83 MPP). The superiority effectiveness endpoint was met for ReCell® donor site healing in the ITT population (p=0.004), and the non-inferiority effectiveness endpoint was met at -2.4% [-8.4 to 2.3%] in the MPP population for ReCell® recipient site healing vs. STAG healing. Secondary effectiveness endpoints demonstrated similar rates of epithelialization and patient satisfaction with respect to the recipient wounds, while there was significantly reduced pain and significantly higher patient satisfaction with respect to the ReCell® donor site wounds. No demonstrable safety signal was generated. ReCell® can be used to safely treat acute, DPT, thermal burns in adults with comparable wound closure and scarring outcomes, but with significantly smaller and less painful donor sites that patients clearly prefer, when compared to conventional STAG. Using ReCell® allows the burn surgeon to “graft” a DPT burn with ~98% less skin than with conventional STAG, resulting in comparable healing, reduced pain, improved aesthetics, and increased overall patient satisfaction.

Work-Related Burn Injuries Hospitalized in US Burn Centers: 2002 to 2011.

To develop a comprehensive definition to identify work-related burns in the National Burn Repository (NBR) based on multiple fields and describes injuries by occupation. The NBR, which is an inpatient dataset, was used to compare type and severity of burn injuries by occupation. Using the definition developed for this analysis, 22,969 burn injuries were identified as work-related. In contrast, the single work-related field intended to capture occupational injuries only captured 4696 cases. The highest numbers of burns were observed in construction/extraction, food preparation, and durable goods production occupations. Occupations with a mean total body surface area (TBSA) burned greater than 10% include transportation and material-moving, architecture and engineering, and arts/design/entertainment/sports/media occupations. The NBR dataset should be further utilized for occupational burn injury investigations and multiple fields should be considered for case ascertainment.

Early leukocyte gene expression associated with age, burn size, and inhalation injury in severely burned adults.

In the patient with burn injury, older age, larger percentage of total body surface area (TBS) burned, and inhalation injury are established risk factors for death, which typically results from multisystem organ failure and sepsis, implicating burn-induced immune dysregulation as a contributory mechanism. We sought to identify early transcriptomic changes in circulating leukocytes underlying increased mortality associated with these three risk factors. We performed a retrospective analysis of the Glue Grant database. From 2003 to 2010, 324 adults with 20% or greater TBS burned were prospectively enrolled at five US burn centers, and 112 provided blood samples within 1 week after burn. RNA was extracted from pooled leukocytes for hybridization onto Affymetrix HU133 Plus 2.0 GeneChips. A multivariate regression model was constructed to determine risk factors for mortality. Testing for differential gene association associated with age, burn size, and inhalation injury was based on linear models using a fold change threshold of 1.5 and false discovery rate of 0.05. After adjusting for potential confounders, age greater than 60 years (relative risk [RR], 4.53; 95% confidence interval [CI], 2.93-6.99), burn size greater than 40% TBS (RR, 4.24; 95% CI, 2.61-6.91), and inhalation injury (RR, 2.08; 95% CI, 1.35-3.21) were independently associated with mortality. No genes were differentially expressed in association with age greater than 60 years or inhalation injury. Fifty-one probe sets representing 39 unique genes were differentially expressed in leukocytes from patients with burn size greater than 40% TBS; these genes were associated with platelet activation and degranulation/exocytosis, and gene-set enrichment analysis suggested increased cellular proliferation and down-regulation of proinflammatory cytokines. Among adults with large burns, older age, increasing burn size, and inhalation injury have a modest effect on the leukocyte transcriptome in the context of the "genomic storm" induced by a 20% or greater than TBS burned. The 39-gene signature we identified may provide novel targets for the development of therapies to reduce morbidity and mortality associated with burns greater than 40% TBS. Epidemiologic study, level III.