Verified Burn Center Research Articles

786 Guardian Refusal for Pediatric Burn Surgery, What Providers Need to Understand

Abstract Introduction Pediatric patients, between the age of newborn and 18 years, require legal guardian consent for any surgical procedure. In some cases, despite medical advisement, guardians refuse excision and skin graft for a minor in their care. In these cases, extended healing times, re-admission, scaring, contracture and physical disability may ensue. Our study aims to review contributing factors of guardian refusal and explore the outcomes of such refusals. Methods Retrospective chart review of all pediatric patients admitted to a large verified burn center between January 2018 through May 2019 were reviewed for total body surface area (TBSA) burned, age, depth of wound, mechanism, MD recommendation for surgical procedure, operative procedures conducted and length of hospital stay (LOS). Results Of the 265 pediatric patients admitted to the Burn Service, 32 (12%) were recommended surgical intervention during their hospitalization. Of these, 25 (78%) guardians consented for surgical skin grafting procedures following recommendation; 3 (9%) guardians delayed treatment consent by an average of 5 days; and 4 (13%) refused surgical consent for skin grafting procedures entirely. The average TBSA for patients recommended for surgical intervention was 8.7, those who accepted surgical intervention had an average TBSA of 8.35, compared to the 11.25 TBSA who refused surgical intervention. Average inpatient length of stay for patients whose guardians consented to surgical intervention promptly was 15.8 days. Despite an average 5 day delay in consent, guardians who deferred consent for surgical intervention doubled their length of stay (31.1 inpatient days). The four guardians who refused recommended surgical intervention had an average inpatient stay of 8.25 days. This finding is consistent with multi-day dressing use and outpatient clinic management. Of note, the four patients that did not receive surgical intervention for burn wound management were linked by common cultural background. Conclusions Pediatric burn injury is both acute and chronic, and the shock of initial injury is often overwhelming for both the patient and the guardian. Furthermore, guardians are then asked to make surgical decisions for a minor in their care. The burn team needs to have a heightened awareness of the cultural norms in the communities they serve to ensure quality care deliverance and patient safety. Applicability of Research to Practice Directly Applicable.

Gender Disparities Among Burn Surgery Leadership.

Gender disparities have been described in the plastic surgery and general surgery literature, but no data have been reported in burn surgery. The aim of this study is to determine gender disparities among burn surgery leadership. A cross-sectional study was performed. Burn surgeons included were directors of American Burn Association (ABA)-verified burn centers, past presidents of the ABA, and International Society for Burn Injuries (ISBI), and editors of the Journal of Burn Care & Research, Burns, Burns & Trauma, Annals of Burns & Fire Disasters, and the International Journal of Burns and Trauma. Training, age, H-index, and academic level and leadership position were compared among surgeons identified. Among the 69 ABA and ISBI past presidents, 203 burn journals' editorial board members, and 71 burn unit directors, females represented only 2.9%, 10.5%, and 17%, respectively. Among burn unit directors, females completed fellowship training more recently than males (female = 2006, male = 1999, P < .02), have lower H-indexes (female = 8.6, male = 17.3, P = .03), and are less represented as full professors (female = 8.3%, male = 42.4%, P = .026). There were no differences in age, residency, research fellowship, or number of fellowships. Gender disparities exist in burn surgery and are highlighted at the leadership level, even though female surgeons have a similar age, residency training, and other background factors. However, gender diversity in burn surgery may improve as females in junior faculty positions advance in their careers.

Obesity Paradox in the Burn Patient.

Despite the fact that obesity is a known risk factor for comorbidities and complications, there is evidence suggesting a survival advantage for patients classified by body mass index (BMI) as overweight or obese. Investigated in various clinical areas, this "Obesity Paradox" has yet to be explored in the burn patient population. We sought to clarify whether this paradigm exists in burn patients. Data collected on 519 adult patients admitted to an American Burn Association Verified Burn Center between 2009 and 2017 was utilized. Univariable and multivariable logistic regression were used to determine the association between in-hospital mortality and BMI classifications (underweight <18.5 kg/m2, normal 18.5 to 24.9 kg/m2, overweight 25-29.9 kg/m2, obesity class I 30 to 34.9 kg/m2, obesity class II 35 to 39.9 kg/m2, and extreme obesity >40 kg/m2). For every kg/m2 increase in BMI, the odds of death decreased, with an adjusted odds ratio of 0.856 (95% confidence interval [CI] 0.767 to 0.956). When adjusted for total BSA (TBSA), being obesity class I was associated with an adjusted odds ratio of mortality of 0.0166 (95% CI 0.000332 to 0.833). The adjusted odds ratio for mortality for underweight patients was 4.13 (95% CI 0.416 to 41.055). There was no statistically significant difference in odds of mortality between the normal and overweight BMI categories. In conclusion, the obesity paradox exists in burn care: further investigation is needed to elucidate what specific phenotypic aspects confer this benefit and how these can enhance the care of burn patients.

Initial management of severe burn injury.

Patients with severe burn injuries pose significant challenges for the intensivist. Though average burn sizes have decreased over time, severe burn injuries involving greater than 20% of the total body surface area still occur. Verified burn centers are limited, making the management of severely burn injured patients at nonspecialized ICUs likely. Current practices in burn care have increased survivability even from massive burns. It is important for intensivists to be aware of the unique complications and therapeutic options in burn critical care management. This review critically discusses current practices and recently published data regarding the evaluation and management of severe burn injury. Burn patients have long, complex ICU stays with accompanying multiorgan dysfunction. Recent advances in burn intensive care have focused on acute respiratory distress syndrome from inhalation injury, acute kidney injury (AKI), and transfusion, resulting in new strategies for organ failure, including renal replacement therapy and extracorporeal life support. Initial evaluation and treatment of acute severe burn injury remains an ongoing area of study. This manuscript reviews current practices and considerations in the acute management of the severely burn injured patient.

Prognostic Indicators for Upper and Lower Extremity Amputations in a Verified Burn Center

Prognostic Indicators for Upper and Lower Extremity Amputations in a Verified Burn Center

Effects of Intraoperative Dexamethasone Administration in Adult Diabetic Burn Patients.

The steroid dexamethasone is used intraoperatively to prevent postoperative nausea. Studies of intraoperative steroid use in diabetic patients have shown conflicting effects on blood glucose and complications, and their use has not yet been studied in the burn population. A review of adult diabetic acute burn patients undergoing surgery at a verified burn center from 2012 to 2017 was conducted. Statistical analysis compared those who did and did not receive an intraoperative steroid. A total of 74 patients who underwent 121 operations were identified; steroid was administered in 14.0% of cases. There were no statistically significant differences in preoperative glucose, insulin requirements, TBSA, or hemoglobin A1C. Postoperatively, the steroid group had a 16.7 mg/dl (SD = 11.1) increase in blood glucose (P = .042) and 53.5 unit/24 hour (SD = 28.4) increase in insulin requirement (P = .019), compared with no change in controls. The complication rate in the steroid group was 52.9% compared with 20.1% in controls (P = .003); partial graft loss was the most common complication. Diabetic burn patients who receive intraoperative steroid have increased postoperative blood glucose levels, insulin requirements, and complication rates compared with patients who do not receive steroids. Discussion is warranted to avoid intraoperative steroid in this population.

Safety and efficacy of intraoperative gastric feeding during burn surgery

BackgroundLarge burns are associated with a dramatic increase in metabolic demand, and adequate nutrition is vital to prevent poor wound healing and septic complications. However, enteral nutrition (EN) support is frequently withheld perioperatively, risking nutritional deficits. We retrospectively examined the safety and feasibility of continuing EN during surgery in patients with an established airway, and estimated the impact of perioperative fasting on overall caloric intake. MethodsMechanically ventilated patients admitted to our urban, verified burn center between January 2012 and July 2017 with greater than 20% total body surface area (TBSA) burns were included in this retrospective analysis. The total volume of EN received by the patient during each 24-h period and goal EN volume as determined by a clinical dietitian were collected. ResultsA total of 45 patients met criteria with mean TBSA of 44% (range 20–84%). Most patients had a gastric feeding tube (86%). Each patient underwent a median of 4 operations (range 1–33) for a total of 249 operative days and 991 non-operative days. There were no aspiration events. On non-operative days, patients met 85% of estimated caloric needs. EN was held on 170 operative days (69%), and on these days, only 34% of total caloric needs were met. EN was continued on 77 operative days (31%), and on these days, 95% of total caloric needs were met (p<0.001). Patients who had EN held for at least 50% of operative procedures (n=30) met only 69% of caloric goals while intubated. By comparison, patients who had EN continued for a majority of procedures (n=15) met 81% of caloric goals (p=0.002). ConclusionsContinuing EN intraoperatively in patients with an established airway appears to be a safe and efficacious way to meet patients’ nutritional needs, including when feeding is delivered via a gastric route. This is particularly important given that placement of nasojejunal feeding tubes can be difficult, particularly in resource-poor settings where endoscopic or fluoroscopic-guided placement may not be practical.

Regional disparities in access to verified burn center care in the United States.

Burn injuries result in 50,000 annual admissions. Despite joint referral criteria from the American College of Surgeons (ACS) and American Burn Association (ABA), many severely injured patients are not treated at verified centers with specialized care. Only one prior study explores regional variation in access to burn centers, focusing on flight or driving distance without considering the size of the population accessing that center. We hypothesize that disparities exist in access to verified centers, measured at a population level. We aim to identify a subset of nonverified centers that, if verified, would most impact access to the highest level of burn care. We collected ABA data for all verified and nonverified adult burn centers and geocoded their locations. We used county-level population data and a two-step floating catchment method to determine weighted access in terms of total beds available locally per population. We compared regions, as defined by the ABA, in terms of overall access. Low access was calculated to be less than 0.3 beds per 100,000 people using a conservative estimate. We identified 113 centers, 59 verified and 54 nonverified. Only 2.9% of the population lives in areas with no verified center in 300 miles; however, 24.7% live in areas with low access. Significant regional disparities exist, with 37.3% of the population in the Southern Region having low access as compared with just 10.5% in the Northeastern Region. We identified 8 nonverified centers that would most impact access in areas with no or low access. We found significant disparities in access to verified center burn care and determined nonverified centers with the greatest potential to increase access, if verified. Our future directions include identifying barriers to verification, such as lack of fellowship-trained burn surgeons or lack of hospital commitment. Epidemiological, level III.

21 A Case-Controlled Retrospective Review of Burn Patients Meeting American Burn Association’s Verified Burn Center Referral Criteria

Regulatory and advisory bodies have published guidelines that trigger patient referral to a verified burn center. Despite these easily referenced resources, non-verified burn units admit and manage patients who meet burn center referral criteria. This may deny patients access to appropriate multidisciplinary care, increase their risk of complications, and increase the cost of care. The purpose of this study was to describe several characteristics and sequelae of patients with delayed referral (DR) to a verified burn center compared to patients who were immediately referred. This was a matched case-controlled retrospective study of inpatients who met 1 or more referral criteria to a verified burn center but were delayed in their referral from 2012–2017. Patients who had DR were compared to those who were referred within 3 days (IR). Cases were matched on age, total body surface area (TBSA) and ABA referral criteria. Basic descriptive statistics were calculated. Of the 3,759 patients who were admitted during the study period, 60 had delayed referrals and all were successfully matched. There was no significant difference in past medical history. DR were seen on average at 7.6 days post-injury as compared to 0.45 days IR (p < .0001). There was no significant difference for the specific referral criteria, burn location, discharge disposition or between those with a payor source and those who were uninsured. However, for patients with a payor source those with private insurance were more likely to have a DR (p = .045). Flame/flash injuries were more likely to be immediately referred (p < .001) and contact burns were more often delayed (p < 0.001). Females were more often DR than males (p = 0.009) as were non-minorities (p = 0.042). DR had longer hospitalizations 17.67 days vs 10.83 (p = .023) and required surgery more often 47 vs. 28 (p = .0003). DR suffered more acute complications 27 vs 7 (p < .001) and more long-term complications 20 vs 10 (p = .034). Based on our data, DR results in increased surgeries, increased lengths of stay, and more complications. All these factors are associated with increased cost of care and increased nosocomial risk for patients. Eliminating DR may have a significant positive impact on the cost and morbidity of burn care.

329 Prognostic Indicators for Upper and Lower Extremity Amputations in a Verified Burn Center

Patients with burns or necrotizing soft tissue infections are at risk for significant morbidity. Extremities with extensive complex skin defects are at increased jeopardy. This may be increased by co-morbid conditions, yet prognostic indicators are not well defined in the literature. The purpose of this study was to identify and describe those potential prognostic factors found in the burn population patients requiring either upper or lower extremity amputation. This is a retrospective chart review of patients requiring amputation from 2000 - 2017. The co-morbidities of these patients were compared to patients that did not require amputation. Descriptive statistics and the relative risk of amputation for certain co-morbidities were calculated. During the study period there were a total of 110 patients requiring amputation versus 12,997 that did not. For those requiring amputations, burn injury was the most common precipitating event (59%) and flame flash was the most common mechanism (25%). The most frequent level of amputation was at the digit level (39%) followed by the transtibial level (33%). When amputees (AP) were compared to non-amputees (NA) there were significant differences between average (median) age, AP 49.9 (54.1) years vs. NA 34.3 (33.8) years (p < 0.001), TBSA AP 19.9% (6%) vs. NA 8.1% (4%, p=0.003) and length of stay AP 33.4 (26) days vs. NA 11.0 (7) days (p<0.001). Conditions associated with increased risk of amputation included cardiovascular disease (RR 4.3, p<0.001), liver disease (RR 4.8, p<0.001), renal insufficiency (RR 19.1, p<0.001), diabetes (RR 5.0, p <0.001), alcohol abuse (RR4.3, p<0.001) and smoking history (RR 4.1, p<0.001). Several comorbidities are associated with higher risk of amputation. Burn patients at higher risk of amputation are not only systematically different from non-amputees, but more specifically have greater restriction of blood flow from diabetes, cardiovascular disease and end stage renal disease which are the greatest afflictions leading to the need for an amputation. Future studies should investigate the role of circumferential burn injury, escharotomies / fasciotomies, as well as, the differences in amputation level between the upper versus lower extremity. This study gives providers quantified data to identify those patients at higher risk of amputation.

415 Development of a Comprehensive Clinical Outreach Coordinator Role at an ABA Verified Burn Center

415 Development of a Comprehensive Clinical Outreach Coordinator Role at an ABA Verified Burn Center

15 Trends in Pediatric Acuity at a Single Verified Burn Center

15 Trends in Pediatric Acuity at a Single Verified Burn Center

93 The BMI Paradox in Burn Patients

Despite the fact that obesity is a known risk factor for comorbidities and complications, there is evidence suggesting a survival advantage for patients classified by body mass index (BMI) as overweight or obese. Investigated in various clinical areas, this “BMI paradox” has yet to be explored in the burn patient population. We sought to clarify whether this paradigm exists in burn patients. Data collected on 519 adult patients admitted to an American Burn Association/American College of Surgeons Verified Burn Center between 2009 and 2017 was utilized. Univariable and multivariable logistic regression were used to determine the association between in-hospital mortality and the National Heart, Lung and Blood Institute(NIH) BMI classifications (underweight <18.5 kg/m2, normal 18.5–24.9 kg/m2, overweight 25–29.9 kg/m2, obesity class I 30–34.9 kg/m2, obesity class II 35–39.9 kg/m2 and extreme obesity >40 kg/m2). The mean BMI of inpatients treated for burns was 29.56 (SD 10.64). For every kg/m2 increase in BMI, the odds of death decreased, with an adjusted odds ratio 0.82 (95% CI 0.71–0.96; p<0.01). When adjusted for total burn surface area, being in the obese class I rather than the normal classification was associated with an adjusted odds ratio of mortality of 0.032 (95% CI 0.0012 - 0.92; p<0.05), whereas having a BMI >40 kg/m2 had an odds ratio of 0.00. The adjusted odds ratio if underweight was 12.11 (95%CI 1.55–94.62; p<0.05). There was no statistically significant difference in odds of mortality between a normal and an overweight BMI. The “BMI paradox” exists in burn care. Further investigation is needed to elucidate what specific phenotypic aspects confer this benefit and how these can enhance the care of burn patients. Alters understanding of predictors of outcome.

16 A Framework for a Successful Pressure Injury Prevention Program in a Regional Burn Center

Burn-injured patients are inherently at-risk for pressure injuries. Little evidence exists regarding pressure ulcer prevention practices for burn centers. Our verified burn center sought to decrease the incidence of hospital-acquired pressure injury (HAPI) by reducing device and positioning related pressure injuries. A key part of our plan includes education for all staff. We conducted the study at a verified regional burn center serving adult and pediatric populations. While on our journey to Magnet designation, we tracked National Database of Nursing Quality Indicators (NDNQI) data quarterly. Preliminary data indicated our rate of HAPI was above the national benchmark. We currently employ interventions such as turning every 2 hours, padding of bony prominences, use of pressure reducing or air circulating beds, proper skin care, nutritional assessment, measures that decrease length of stay, use of the Braden Scale to assess risk, and early mobilization. In addition to, we elevated some of these practices by frequent reposition of catheter securement and other invasive devices to prevent mucosal injury, elimination of supine laying in turning schedule, and improved nutritional management. The risk reduction strategy includes an improved method for securing nasogastric tubes, moisture management of wounds, standardizing heel protection, padding securement ties for endotracheal tubes, restricted use of touch fasteners on all ace bandages, regulating c-collar care, directing splint checks and addition of a stretch bandage training protocol. We collected data from monthly surveys reported to NDNQI for a total of 8 quarters. All HAPIs are reported to NDNQI specifically as the total number of HAPIs, number of patients with a HAPI, and HAPIs identified per patient. Our findings demonstrate a decrease in the overall number of HAPIs occurring in our unit since the introduction of our prevention program (p= 0.037). The number of patients with HAPIs and the number of HAPIs adjusted for unit census also dropped (p= 0.021 and p= 0.040 respectively). In addition to the decrease in the number of overall HAPIs, we have seen historically low incidence of HAPI. The burn center has experienced a dramatic decline in the incidence of hospital-acquired pressure injury due to prevention initiatives and risk reduction strategies. Burn centers should adopt programs to prevent hospital-acquired harm rather than maintain a reactive approach. Involving bedside nursing staff increases effectiveness of programs. Research is ongoing to evaluate the impact of various prevention strategies for hospital-acquired pressure injury specific to the burn population. A coalescence of practices is needed to establish industry standards of care.

253 Increasing Incidence and Severity of Electronic Cigarette Burns: Two Year Experience at a Single Verified Burn Center

253 Increasing Incidence and Severity of Electronic Cigarette Burns: Two Year Experience at a Single Verified Burn Center

274 Occurrence of Psychiatric Illness and Problematic Substance Use among Frostbite Patients in an Urban Verified Burn Center

High concordance rates of frostbite injury, substance abuse, and psychiatric illnesses among patients receiving specialized burn treatment have been acknowledged in both scientific literature and clinical lore. Despite this, no recent study has been conducted documenting this phenomenon, and there are no published protocols to guide management of psychiatric comorbidities. Review of the literature shows the last such study was published in 1997. Although understood to be a problem, the challenge of effectively addressing psychosocial factors related to frostbite injury and care has received little attention. To explore the frequency of identified psychiatric diagnoses among patients, this study examined a limited time course (2012-2018) of both inpatient and outpatient clinical records of adult patients treated at an urban verified Regional Burn Center for frostbite injury. A total of 39 patients met inclusion criteria. The patient population was predominately male (77%), with a mean age of 42.5 years (range 22-74 years). Twenty-two patients (56%) were admitted to the burn center and 17 patients (44%) were treated as outpatients. Of the 39 patients reviewed, 65% self-reported substance abuse and/or a preexisting psychiatric illness. Consistent with previous findings, high rates of preexisting psychiatric illness and substance abuse were identified. Results highlight the importance of initial psychiatric and substance abuse screening for identified frostbite patients. If further indicated by screening, full utilization of available social work, psychological, and/or psychiatric services for clinical assessment and treatment recommendations (both while hospitalized and post discharge) is strongly recommended. This study supports a routine psychology and/or psychiatry consult for frostbite patients due to high concordance rates of substance abuse and psychiatric illness.

407 Variations in Practice Among Registered Dietitians at Pediatric Verified Burn Centers

407 Variations in Practice Among Registered Dietitians at Pediatric Verified Burn Centers

451 Stakeholder Experiences and Student Perceptions following Implementation of New Advance Burn Life Support Curriculum

Management of patients with severe burn injuries can be overwhelming to emergency medical providers and hospital staff clinicians. The Advance Burn Life Support (ABLS) courses offer a way to alleviate fears and uncertainty with the initial care needed for the burn-injured patient. The ABLS Course was updated between 2015 and 2016. Several new guidelines were included with a special emphasis on initial fluid resuscitation and modification of the Parkland Formula. This study aims to evaluate ABLS students’ perceptions and retention of the new ABLS course format in comparison to a prior study conducted in 2014. An online survey regarding perceptions of burn knowledge, skills and burn disaster preparedness was emailed to all participants who were certified in ABLS from January 2017 to July 2017. This online survey included students’ perceptions regarding estimating TBSA, fluid resuscitation, initial pain medication, inhalation injuries, and the role of a verified burn center. North Carolina state medical disaster officials as well as the North Carolina Office of Emergency Medical Services previously approved a student’s perceptions survey in 2014 for assessing ABLS courses. The knowledge gained from that survey was outline in a 2015 research article “Advance Burn Life Support for Day-to-Day Burn Injury Management and Disaster Preparedness: Stakeholder Experiences and Student Perceptions Following 56 Advanced Burn Life Support Courses”. We compared the 2014 ABLS student responses to 2017 ABLS student responses as a means of evaluating the new ABLS curriculum. There was a 42% response rate to the 2017 ABLS students’ perception survey. Demographics and work experiences were similar to the 2014 students’ perception survey. The 2017 student survey results were compared to results outlined in the ABLS research article. An improved or equally positive response were noted to seven main perception questions identified in the 2014 survey. This small study offers support to the effectiveness of the new ABLS course format • Supports the new ABLS curriculum as compared to the previous ABLS content • Reports student’s perceptions and retention of the new ABLS curriculum • Provide suggested parameters to the ABLS Committee for consideration during the next course revision

Increased mortality in women: sex differences in burn outcomes

BackgroundThere is increasing evidence that sex differences may influence responses after thermal injury and affect clinical outcomes. The objective of this study was to evaluate the relationships between sex, thermal injury, body size, and inpatient mortality in burn patients.MethodsMedical records of adults with >20% total body surface area (TBSA) burn injury admitted to two American Burn Association (ABA)-verified burn centers between 2008 and 2014 were retrospectively reviewed. Injury details and baseline characteristics, including body size as estimated by body surface area (BSA) and body mass index (BMI) were recorded, along with details of the hospital course. The primary outcome of inpatient mortality was compared between sexes.ResultsOut of 334 subjects, 60 were women (18%). Median TBSA was 33% (IQR 25–49) in this cohort, with 19% full thickness burns and 30% inhalation injury. Despite no significant difference in age, presence of inhalation injury, TBSA, or depth of burn, women had significantly higher rates of inpatient mortality (45 vs. 29%, P = 0.01). BSA was significantly lower in women vs. men (P < 0.001), but this difference was not more pronounced among non-survivors. There was no difference in BMI between men and women non-survivors. Although not significant (P = 0.28), women succumbed to their injuries sooner than men (day 4 vs. 10 post-injury).ConclusionsWomen are less likely to survive burn injuries and die sooner than men with similar injuries. Body size does not appear to modulate this effect. Burn centers should be aware of the higher mortality risk in women with large burns.

Referral Patterns in Pediatric Burn Patients

Though multiple studies have demonstrated superior outcomes amongst adult burn patients at verified burn centers (VBCs) relative to nondedicated burn centers (NBCs), roughly half of such patients meeting American Burn Association (ABA) referral guidelines are not sent to these centers. We sought examine referral patterns amongst pediatric burn patients. Retrospective review of a statewide patient database identified pediatric burn patients from 2000 to 2007 using International Classification of Disease (ICD-9) discharge codes. These injuries were crossreferenced with ABA referral criteria to determine compliance with the ABA guidelines. 1831 children sustained burns requiring hospitalization during the study period, of which 1274 (70%) met ABA referral criteria. Of 557 treated at NBCs, 306 (55%) met criteria for transfer. Neither age, gender, nor payer status demonstrated significant association with treatment center. VBCs treated more severely injured patients, but there was no difference in survival or rate of discharge home from NBCs versus VBCs. Studies to evaluate differences in functional outcomes between pediatric burn patients treated at VBCs versus NBCs would be beneficial to ensure optimization of outcomes in this population.