US Burn Centers Research Articles

Use of Air Transport for Minor Burns: Is There Room for Improvement?

Since 1981, the number of US burn centers has decreased by 29%, resulting in more long distance referrals to remaining facilities. Air transport is often the only feasible method for remote patients to reach few remaining burn centers. A significant proportion of flown-in patients have minor burns and are discharged within 24 hours, representing potential over-utilization of resources with increased cost to the healthcare system for no perceptible benefit. We explored factors associated with air transport of burns and opportunities for system improvement. Retrospective review of burn patients transferred by air to regional burn center between January 2003 and June 2013. Demographic, injury and clinical outcome data were acquired from the institutional Burn Registry. Minor burns constituted 17.7% of all flown admits (236/1331). Children were more likely to be included in this cohort at 32% vs 21.6% of adults (P = .0004). The overtriaged cohort had significantly lower % total BSA than accurately triaged cohort (3.3% vs 15%; P = .0001). Subjects with electrical burn injury were twice as likely to be overtriaged than accurately triaged (10.6% vs 5%; P = .002). The average % total BSA in the overtriaged group was 3.3%; the face was most common area burned (47.7%). The average estimate of charges for transfer was between $25,000 and 30,000/patient. The incidence of overtriage among flown-in burn patients, approximately 20%, represents substantial unnecessary healthcare expenditure. Improved burn care education, incentives to increase use of telemedicine, and modification of American Burn Association guidelines to include consultation with a burn center rather than automatic transfer are needed to reduce this cost to the healthcare system.

Prediction of multiple infections after severe burn trauma: a prospective cohort study.

To develop predictive models for early triage of burn patients based on hypersusceptibility to repeated infections. Infection remains a major cause of mortality and morbidity after severe trauma, demanding new strategies to combat infections. Models for infection prediction are lacking. Secondary analysis of 459 burn patients (≥16 years old) with 20% or more total body surface area burns recruited from 6 US burn centers. We compared blood transcriptomes with a 180-hour cutoff on the injury-to-transcriptome interval of 47 patients (≤1 infection episode) to those of 66 hypersusceptible patients [multiple (≥2) infection episodes (MIE)]. We used LASSO regression to select biomarkers and multivariate logistic regression to built models, accuracy of which were assessed by area under receiver operating characteristic curve (AUROC) and cross-validation. Three predictive models were developed using covariates of (1) clinical characteristics; (2) expression profiles of 14 genomic probes; (3) combining (1) and (2). The genomic and clinical models were highly predictive of MIE status [AUROCGenomic = 0.946 (95% CI: 0.906-0.986); AUROCClinical = 0.864 (CI: 0.794-0.933); AUROCGenomic/AUROCClinical P = 0.044]. Combined model has an increased AUROCCombined of 0.967 (CI: 0.940-0.993) compared with the individual models (AUROCCombined/AUROCClinical P = 0.0069). Hypersusceptible patients show early alterations in immune-related signaling pathways, epigenetic modulation, and chromatin remodeling. Early triage of burn patients more susceptible to infections can be made using clinical characteristics and/or genomic signatures. Genomic signature suggests new insights into the pathophysiology of hypersusceptibility to infection may lead to novel potential therapeutic or prophylactic targets.

Experience with the use of close-relative allograft for the management of extensive thermal injury in local national casualties during Operation Iraqi Freedom

The care of host nation burn victims in Iraq and Afghanistan has been a significant challenge to US military healthcare providers. To provide burn care in an austere environment is more challenging by limitations in resources such as inadequate medical supplies, infection control issues, and a lack of blood or tissue banking capabilities. Large full thickness burns pose a significant obstacle due to limitations in the casualties' available donor skin, which can be used to achieve wound coverage. In US burn centers, allograft stored in skin banks provides temporary coverage during donor site healing in the management of large total body surface area burns. This report is a study of two severely burned Iraqi children with inadequate donor site surface area to achieve wound coverage that were managed with close-relative allograft harvested from their fathers to achieve temporary wound closure. A brief literature review and future recommendations are included.

Regarding critical care of the burn patient: The first 48 hours

Abstract : Letter to the Editor: We read with much interest the recent review by Dr. Latenser on the care of burn patients in the first 48 hrs (1). Although the review was well-written, concise, and informative, we believe two assertions deserve clarification. First, Dr. Latenser states that the Parkland formula has been renamed the Consensus formula. This is incorrect. It was first used by the authors of the Advanced Burn Life Support course, in which fluid requirements of burn patients during the first 24 hrs after burn were estimated as 2 to 4 mL/kg per percentage total body surface area burn (2). This represents a compromise between physicians who advocated for the Parkland formula (which estimates 4 mL/kg per percentage burn) and those who advocated for the modified Brooke formula (which estimates 2 mL/kg per percentage burn). Although the Parkland formula is most commonly used in US burn centers, there is no consensus regarding which of the two formulas is superior.

Geographic access to burn center hospitals.

The delivery of burn care is a resource-intensive endeavor that requires specialized personnel and equipment. The optimal geographic distribution of burn centers has long been debated; however, the current distribution of centers relative to geographic area and population is unknown. To estimate the proportion of the US population living within 1 and 2 hours by rotary air transport (helicopter) or ground transport of a burn care facility. A cross-sectional analysis of geographic access to US burn centers utilizing the 2000 US census, road and speed limit data, the Atlas and Database of Air Medical Services database, and the 2008 American Burn Association Directory. The proportion of state, regional, and national population living within 1 and 2 hours by air transport or ground transport of a burn care facility. In 2008, there were 128 self-reported burn centers in the United States including 51 American Burn Association-verified centers. An estimated 25.1% and 46.3% of the US population live within 1 and 2 hours by ground transport, respectively, of a verified burn center. By air, 53.9% and 79.0% of the population live within 1 and 2 hours, respectively, of a verified center. There was significant regional variation in access to verified burn centers by both ground and rotary air transport. The greatest proportion of the population with access was highest in the northeast region and lowest in the southern United States. Nearly 80% of the US population lives within 2 hours by ground or rotary air transport of a verified burn center; however, there is both state and regional variation in geographic access to these centers.

Telemedicine Evaluation of Acute Burns Is Accurate and Cost-Effective

As the number of US burn centers has declined, access to burn care is increasingly limited. Inexperience in burn wound assessment by referring physicians often results in overtriage or undertriage. In an effort to improve access to burn care in our region, we instituted a program of telemedicine evaluation of acute burns. We created a telemedicine network linking our burn center to three hospitals located 298 to 350 air miles away. Participants agreed to perform telemedicine consultation for acutely burned patients admitted to their emergency departments. We compared consults and referrals from these facilities during the period July 2005 to August 2007 (TELE) to those during a 2-year period before instituting telemedicine (PRE-TELE). During the TELE period, 80 patients were referred, of whom 70 were seen acutely by telemedicine, compared with 28 PRE-TELE referrals. The groups did not differ in age or burn size. Only 31 patients seen by telemedicine received emergency air transport (44.3%), compared with 100% of PRE-TELE patients (p < 0.05). Nine other TELE patients were transported by family; 30 other patients were treated locally. Ten remaining patients were transported without telemedicine evaluation. TELE patients transported by air had somewhat larger burn sizes (9.0% vs. 6.5% total body surface area; p = NS) and longer length of stay (13.0 days vs. 8.0 days; p = NS) than PRE-TELE patients. Burn size estimates by burn center physicians made either by telemedicine or direct inspection correlated closely but both differed significantly from those of referring physicians. Providers and patients expressed a high level of satisfaction with the telemedicine experience. Acute evaluation of burn patients can be performed accurately by telemedicine. This can reduce undertriage or overtriage for air transport, improve resource utilization, and both enhance and extend burn center expertise to many rural communities at low cost.

Current practice of thromboprophylaxis in the burn population: A survey study of 84 US burn centers

Current practice of thromboprophylaxis in the burn population: A survey study of 84 US burn centers

Current practice of thromboprophylaxis in the burn population: A survey study of 84 US burn centers

While there is limited prospective data on the incidence of venous thromboembolism (VTE) in the burn population, there are no prospective studies on the efficacy and safety of VTE prophylaxis in these patients. Despite lack of such data, we hypothesized that most burn centers practice some form of prophylaxis. Eighty-four US burn centers were contacted regarding their modality of VTE prophylaxis, if any. Of the 84 US burn centers, 71 were enrolled in this survey. 76.1% centers reported routine VTE prophylaxis. Modalities included sequential compression device (SCD) (33), subcutaneous heparin (31), enoxaparin (13), dalteparin (3), and intravenous heparin infusion (1). Twenty-one reported combined modalities of SCD and subcutaneous heparin (19), SCD and enoxaparin (1), or SCD and dalteparin (1). Survey results underscore the need to definitively establish risk factors for VTE in the burn population and to prospectively define an evidence-based standard of care in prophylaxis for those patients.

A Multicenter Review of Toxic Epidermal Necrolysis Treated in US Burn Centers at the End of the Twentieth Century

A Multicenter Review of Toxic Epidermal Necrolysis Treated in US Burn Centers at the End of the Twentieth Century

A Survey of Clinical Pharmacy Services in US Burn Centers

A Survey of Clinical Pharmacy Services in US Burn Centers