Development and implementation of prospective outcome monitoring in a regional burns service using cumulative sum (CUSUM) techniques

Introduction

Real-time monitoring of mortality in burns units has the potential to immediately mark when mortality rates are significantly higher or lower than predicted. Rapid feedback from targeted internal audit allows early intervention, to reinforce positive practices, and improve systems where outcomes are unsatisfactory.This is the first study to describe prospective use of cumulative sum (CUSUM) methodology in mortality monitoring outside of cardiac surgery.

Methods

An eight-year retrospective study of mortality was performed on all admissions to a regional burns intensive care unit in the UK. Risk-adjusted CUSUM charts, variable life adjusted displays (VLADs) and zeroed VLADs were produced to track mortality against that predicted by the Belgium burns score. The same techniques were implemented prospectively for one year (76 admissions) using the Osler modification of the Baux score for risk adjustment.

Results

Internal audit would have been triggered on nine occasions using zeroed VLAD monitoring in the retrospective study. The Belgium score overpredicts mortality in the elderly.Internal audit was triggered for better than predicted outcomes on two occasions in the prospective study.

Discussion

This study describes a successful design for an early-warning system to monitor outcomes in a burns intensive care setting.     

Pediatric facial burns: Is facial transplantation the new reconstructive psychosurgery?

INTRODUCTION:

Current pediatric burn care has resulted in survival being the expectation for most children. Composite tissue allotransplantation in the form of face or hand transplantation may present opportunities for reconstructive surgery of patients with burns. The present paper addresses the question “Could facial transplantation be of therapeutic benefit in the treatment of pediatric burns associated with facial disfigurement?”

METHODS:

Therapeutic benefit of facial transplantation was defined in terms of psychiatric adjustment and quality of life (QOL). To ascertain therapeutic benefit, studies of pediatric burn injury and associated psychiatric adjustment and QOL in children, adolescents and adults with pediatric burns, were reviewed.

RESULTS:

Pediatric burn injury is associated with anxiety disorders, including post-traumatic stress disorder and depressive disorders. Many patients with pediatric burns do not routinely access psychiatric care for these disorders, including those for psychiatric assessment of suicidal risk. A range of QOL outcomes were reported; four were predominantly satisfactory and one was predominantly unsatisfactory.

DISCUSSION:

Facial transplantation may reduce the risk of depressive and anxiety disorders other than post-traumatic stress disorder. Facial transplantation promises to be the new reconstructive psychosurgery, because it may be a surgical intervention with the potential to reduce the psychiatric suffering associated with pediatric burns. Furthermore, patients with pediatric burns may experience the stigma of disfigurement and psychiatric conditions. The potential for improved appearance with facial transplantation may reduce this ‘dual stigmata’. Studies combining surgical and psychiatric research are warranted.     

Mental disorders among acute burn patients

Objective

To investigate mental disorders among acute hospitalized burn patients.

Method

Consecutive acute adult burn patients (n = 107) admitted to Helsinki Burn Centre were interviewed by an experienced psychiatrist with the Structured Clinical Interview for DSM-IV-TR for Axis I and II mental disorders assessed in three time frames (lifetime, the month prior to burn, and in acute care). Information on clinical features, psychiatric symptoms, personality traits, and burn severity (total body surface area, TBSA) was gathered.

Results

The mean TBSA was 9%. Most (61%) acute burn patients had at least one lifetime Axis I or II mental disorder. Prevalences of lifetime substance-related disorders (47%), psychotic disorders (10%), and Axis II personality disorders (23%) were high. The overall prevalence of Axis I mental disorders increased significantly (Q = 6.40, df = 1, p = 0.011) from the month prior to burn (40%) to acute care (48%). The prevalence of delirium for this period was significantly higher (0.9% vs. 13%; Q = 13.00, df = 1, p < 0.001) in acute care.

Conclusions

Mental disorders, particularly substance use disorders, psychotic disorders, and personality disorders are common among acute burn patients before injury. These disorders may predispose to burns. Burn itself may also predispose to mental disorders, particularly delirium.     

Relationships between the Quality of Life Questionnaire (QLQ) and the SF-36 among young adults burned as children

Objective

To examine the relationship between two measures that can be used to examine quality life among pediatric burn survivors.

Design

Prospective, correlational study.

Setting

Acute and rehabilitation pediatric burn care facility.

Participants

Eighty young adult survivors of pediatric burns, who were 18–28 years of age, with burns of 30% or greater, and were at least 2 years after burn.

Interventions

Not applicable.

Main outcome measures

The SF-36 and the Quality of Life Questionnaire (QLQ) were used to assess participant's self-reported general health and long-term adjustment.

Results

Significant correlations (p ≤ 0.001) were found between the total quality of life score of the QLQ and the mental component scale of the SF-36. However, no significant correlations were found between the total quality of life score of the QLQ and the SF-36 physical component scale.

Conclusions

Approximately 100,000 children are treated for burns annually, with a high percentage surviving, creating a challenge for health care professionals who need to prepare burn survivors with their psychosocial and physical well-being as adults. This study found that the SF-36 and QLQ are measuring somewhat different aspects of psychosocial and physical adjustment. It is recommended that both tools could be useful to the burn practitioner in assessing quality of life.     

Management of electrical and chemical burns in children

Background

Pediatric electrical and chemical burns are rare injuries, and the care of these patients varies significantly. We reviewed our experience in management of electrical and chemical burns to analyze the clinical course, management, and outcomes.

Methods

A retrospective review was conducted on children with chemical and electrical burns presenting to two large regional pediatric burn centers over a 10-y period (2002–2012). Clinical data including patient demographics, nature of burns, management, and outcomes were collected and analyzed.

Results

There were 50 cases, 25 chemical and electrical burns each. Overall, the mean ± standard deviation age was 6.2 ± 5.6 y, and the mean total body surface area burn was 4.3 ± 3.2%. Chemical burns were larger, had less depth, and shorter length of stay, whereas electrical burns were smaller, deeper, and had a longer length of stay. Two chemical burns and six electrical burns required grafting. Twelve percent of electrical burns required rehabilitation, and 20% required compression garments for hypertrophic scars. Six percent required late surgeries.

Conclusions

Pediatric electric and chemical burns are rare and require specialized care. Graft rates are not high but are mostly noted in electrical burns.     

Prevalence and co-morbidity of psychiatric disorders 1-4 years after burn

Objective

Currently, little is known about psychiatric disorders in the period following on the first year after burn. We examined the prevalence of DSM-IV Axis I disorders in burn patients 1-4 years after burn, using a standardized structured clinical interview and comparing findings with a representative general population sample.

Methods

Ninety patients admitted to five burn centres were assessed with the 12-month Composite International Diagnostic Interview. Results were compared to an age and gender matched nation based norm group.

Results

Twelve-month prevalence for any DSM-IV study disorder was 39%.Prevalence for any after burn onset disorder was 28%. Most prevailing were major depression (10%), generalized anxiety disorder (10%), and PTSD (7%). The comorbidity-proportions for PTSD and generalized anxiety disorder where the highest. Fifty-seven percent of all burn onset disorders started within 1 year after the trauma and 21% within the next year. Burn patients had significantly higher prevalence rates for DSM-IV disorders than people from the general population sample.

Conclusion

Psychiatric morbidity among burn patients, 1-4 years after burn, is considerable and higher than what may be expected in the general population. A 2-year follow-up for anxiety and depression disorder is warranted.     

In the media: Burns as a method of assault

Aim

The aims of this study were to determine whether a change occurred in the pattern of assault burn injury cases hospitalised to the adult state burns unit, Western Australia, from 2004 to mid-year of 2012, and to compare patient and burn characteristics of adult assault burns with those admitted for unintentional burns.

Methods

Study data were obtained from the Royal Perth Hospital (RPH) Burns Minimum Dataset (BMDS). Aggregated data of unintentional burn admissions during the same period were provided by the BMDS data manager to enable comparisons with assault burn patients.

Results

Assault burn admissions during 2004–2012 accounted for approximately 1% of all adult burn hospitalisations. All assault victims were burned by either thermal or scald agents. A high rate of intubation (24%) and ICU admission (1 in 3 cases) was observed in the fire assault group. The six assault cases undergoing intubation were severe burns, median TBSA 50%, most commonly affecting the face, head and torso, half of these cases had inhalational injuries and also required escharotomies.Comparison of admissions by calendar period showed no statistically significant differences in demographic, burn cause or TBSA%. However, statistically significant differences were found for pre-morbid psychiatric history (15% vs. 58%, p = 0.025) and concomitant fractures or dislocations (46% vs. 2%), p = 0.011).

Conclusions

While the proportion of assault burn admissions per total burn admissions steadily increased from 0.4% in 2009 to 1.5% in mid-2012, this proportion did not exceed that peak level observed of 2.1% for 2004.     

Preoperative evaluation of thyroglossal duct cysts: children versus adults—is there a difference?

Background

Thyroglossal duct cysts (TGDCs) are common in children but also present in adults. This study evaluates the preoperative management and postoperative outcomes in patients with a resected TGDC.

Methods

A retrospective analysis was performed on patients with a surgically treated TGDC. Clinicopathologic variables and treatment outcomes were obtained by chart review.

Results

A total of 79 patients (44 pediatric and 35 adult) were identified. The majority of patients in both groups presented with a neck mass. Compared with children, adults were significantly more likely to undergo preoperative imaging and fine-needle aspiration biopsy. Malignancy was not identified in any patient on preoperative workup or postoperative pathology.

Conclusions

Adults with a TGDC are more likely to undergo preoperative imaging and biopsy. The infrequent occurrence of TGDC cancer or concurrent thyroid pathology suggests that the diagnosis of a TGDC may be made on clinical grounds in adult patients although ultrasound (±fine-needle aspiration biopsy) may be a useful supplementary modality.     

Epidemiologic investigation of geriatric burns in Southwest China

Objective

To study the epidemiologic characteristics of burns in the elderly patients to reduce risks.

Methods

Features, including causes, seasonality, co-morbidities and mortality among 280 burned patients over 60 years old, admitted to Burn Unit, Southwest Hospital from 1999 to 2006, were analyzed retrospectively.

Results

The incidence of burns in the elderly has been decreasing gradually from 4.35% in 1999 to 3.81% in 2006. The geriatric burns could happen any time during a year, but most frequently in summer and winter. Seventy percent of the geriatric burns were related to activities of daily life. The co-morbid conditions in the elderly, which comprised 83.9% of the victims, contributed to the burn outcomes. No difference in morbidity was found between rural and urban patients. However, mortality was significantly higher in the rural patients with 30% over TBSA burns.

Conclusion

The incidence of geriatric burns has been decreasing associated with social and individual living levels in China. However, the disparity in the mortality rates between rural and urban suggests investment in rural China is needed to reduce health inequalities.     

Effect of 12-week isokinetic training on muscle strength in adult with healed thermal burn

Introduction

Severe burns result in marked and prolonged skeletal muscle catabolism and weakness, which persist despite ‘standard” rehabilitation programmes of occupational and physical therapy. Therefore, the objectives of this study were of twofold: to quantify the long-term effects of burns on leg muscle strength and to assess whether adults with thermal burn would benefit from the isokinetic training programme.

Materials and methods

Burned adult patients, with 35–55% total body surface area (TBSA) burned, were assessed at 6 months after burn in respect to leg muscle strength at 150° s⁻¹, using isokinetic dynamometry. Non-burned adults were assessed similarly, and served as controls. The burned adults participated in the resistance training programme 3 times weekly. The isokinetic exercise programme was begun with 60% of the average peak torque. Intensity of isokinetic exercise was increased from one set to five sets during the first through fifth sessions and remained at six sets for the remaining 6th to 24th sessions. Finally, a dose of 10 sets was applied for the 25th to the 36th sessions. Each set consisted of five repetitions of concentric contraction in angular velocities of 150° s⁻¹ for knee extensors, and flexors. All exercise sessions were preceded by a 5-min warm-up period on the treadmill.

Results

Subjects with burns more than 35% of TBSA produced significantly less torque, work, and power in the quadriceps and hamstring than control subjects (20.5%, 15.2%, p < 0.05). Three months after isokinetic programme, muscle strength further increased by 17.9% ± 10.1% compared to the baseline measurement for burned patients but continued to be below the concurrent age-matched, non-burned adult.

Conclusion

We found that adults with severe burns, relative to non-burned adults, had significantly lower peak torque as well as total work performance using the extensors and flexors muscles of the thigh. Participation in isokinetic training resulted in a greater improvement in extensor and flexor muscle strength in adults with held thermal burn compared to base line values.     

The application of glycerol-preserved skin allograft in the treatment of burn injuries: An analysis based on indications

Introduction

Glycerol-preserved skin allograft (GPA) plays a crucial role in the management of burns. Its indications include wound-bed preparation, definitive dressing and sandwich grafting technique.

Objective

We analysed the experience of using GPA and its efficacy in burn treatment in our burn centre.

Methods

All burns managed with GPA in our burn centre from October 2001 to May 2008 were analysed.

Results

Mean total body surface area (TBSA) of 43 consecutive cases was 28.7%. GPA adhered to the wound for an average of 8.4 days before rejection. The length of hospital stay of the survivors was 42.5 days. The autograft take after wound-bed preparation with GPA was 88.4%. For sandwich grafting technique, the autograft take was 74.4%. When GPA was applied for partial-thickness burn as definitive dressing, all patients achieved complete healing within an average of 19 days without further surgical intervention. Despite colonisation of burn wounds after application of skin allograft, the outcomes of autograft take and wound healing were not significantly different.

Conclusion

The selective and strategic use of the GPA in major burn patients ensures optimal benefits in the management of burns. It is versatile in various categories of burn wounds with minimal morbidity.     

Laser Doppler imaging in a paediatric burns population

Objective

Laser Doppler imaging (LDI) was compared to wound outcomes in children's burns, to determine if the technology could be used to predict these outcomes.

Methods

Forty-eight patients with a total of 85 burns were included in the study. Patient median age was 4 years 10 months and scans were taken 0–186 h post-burn using the fast, low-resolution setting on the Moor LDI2 laser Doppler imager. Wounds were managed by standard practice, without taking into account the scan results. Time until complete re-epithelialisation and whether or not grafting and scar management were required were recorded for each wound. If wounds were treated with Silvazine™ or Acticoat™ prior to the scan, this was also recorded.

Results

The predominant colour of the scan was found to be significantly related to the re-epithelialisation, grafting and scar management outcomes and could be used to predict those outcomes. The prior use of Acticoat™ did not affect the scan relationship to outcomes, however, the use of Silvazine™ did complicate the relationship for light blue and green scanned partial thickness wounds. Scans taken within the 24-h window after-burn also appeared to be accurate predictors of wound outcome.

Conclusion

Laser Doppler imaging is accurate and effective in a paediatric population with a low-resolution fast-scan.     

Characteristics of fatal and hospital admissions for burns in Fiji: a population-based study (TRIP Project-2)

Background

Over 95% of burn deaths are estimated to occur in low-and-middle-income countries. However, the epidemiology of burn-related injuries in Pacific Island Countries is unclear. This study investigated the incidence and demographic characteristics associated with fatal and hospitalised burns in Fiji.

Methods

This cross-sectional study utilised the Fiji Injury Surveillance in Hospital database to estimate the population-based incidence and contextual characteristics associated with burns resulting in death or hospital admission (≥12 h) during a 12-month period commencing 1st October 2005.

Results

116 people were admitted to hospital or died as a result of burns during the study period accounting for an overall annual incidence of 17.8/100,000 population, and mortality rate of 3.4/100,000. Most (92.2%) burns occurred at home, and 85.3% were recorded as unintentional. Burns were disproportionately higher among Fijian children compared with Fijian–Indian children with the converse occurring in adulthood. In adults, Indian women were at particularly high risk of death from self-inflicted burns as a consequence of ‘conflict situations’.

Conclusion

Burns are a significant public health burden in Fiji requiring prevention and management strategies informed by important differences in the context of these injuries among the major ethic groups of the country.     

Perineal burn care: French working group recommendations

Objectives

Burns to the perineum are frequently exposed to faeces. Diverting colostomy is often described to prevent faecal soiling. Because this technique is invasive with frequent complications, use of non-surgical devices including specifically designed faecal management systems has been reported in perineal burns.

Methods

In order to standardise the faecal management strategy in patients with perineal burns, a group of French experts was assembled. This group first evaluated the ongoing practice in France by analysing a questionnaire sent to every French burn centre. Based on the results of this study and on literature data, the experts proposed recommendations on the management of perineal burns in adults.

Results

Specifically designed faecal management systems are the first-line method to divert faeces in perineal burns. The working group proposed recommendations and an algorithm to assist in decisions in the management of perineal burns in four categories of patients, depending on total burn skin area, depth and extent of the perineal burn.

Conclusion

In France, non-surgical devices are the leading means of faecal diversion in perineal burns. The proposed algorithm may assist in decisions in the management of perineal burns. The expert group emphasises that large clinical studies are needed to better evaluate these devices.     

The effects of splinting on shoulder function in adult burns

Introduction

Exercises are commonly prescribed to improve shoulder range following axillary burns, but the effect of additional splinting is unclear.

Aim

To compare splinting and exercise to exercise alone in adults with axillary burns.

Method

Prospective randomised study allocating participants to a splinting (n = 27) or no splinting group (n = 25). Outcomes measured at six and twelve weeks were shoulder abduction and flexion range, quality of life using the Burn Specific Health Scale-Brief (BSHS-B) questionnaire and upper limb function using the Upper Extremity Functional Index (UEFI) and the Grocery Shelving Task (GST).

Results

At week twelve, there was no difference between groups for shoulder abduction (mean difference 0°, 95% CI −22 to 22°), flexion (mean difference 2°, 95% CI −18 to 23°), BSHS-B (mean difference −2 points, 95% CI −23 to 18 points), UEFI (mean difference −3 points, 95% CI −19 to 14 points) and GST (mean difference −9 s, 95% CI −20 to 3 s). Adherence to splinting decreased from 77% of participants at week one to 16% at week twelve.

Conclusion

Shoulder splints did not improve clinical outcomes in this study population and low adherence rates suggest splinting may be unacceptable to patients and makes drawing firm conclusions difficult.     

Air ambulance transfer of adult patients to a UK regional burns centre: Who needs to fly?

Introduction

Helicopter emergency medical services play a valuable role in the transfer of critically ill patients. This paper reviews the role of air ambulance services in the provision of regional burns care and suggests guidelines for their use.

Methods

A retrospective review of patients treated at the Midlands Adult Burns Centre over a 3-year period.

Results

27 adult burns patients were transported by air ambulance during the study period. Patients were aged 19–89 years (average 41.3 years) with an estimated burn size of 5–70% TBSA. Distance travelled was 11–79 miles (average 41.2 miles). All patients were appropriately referred to the burns centre according to national referral guidelines but in 7 cases (26%) it was felt that transport by air ambulance was not clinically indicated and land transfer would have been safe and appropriate.

Conclusion

Air ambulances offer a fast and effective means of transferring patients to a regional burns centre in selected cases. There is limited data for the beneficial effects of helicopters and survival benefit is seen only in the most severely injured patients. We suggest criteria for the use of air ambulances in burns patients in order to maximise the benefit and reduce unnecessary flights.     

Methylated spirit burns: an ongoing problem

Objective

Despite many educational campaigns we still see burns caused by methylated spirit every year. We undertook a retrospective study to analyse the impact of this problem.

Methods

We retrospectively collected data of all patients with burns caused by methylated spirit over twelve years from 1996 to 2008. Our main endpoints were: incidence, age, mechanism of injury, total body surface area (TBSA) burned, burn depth, need for surgery and length of hospital stay.

Results

Ninety-seven patients with methylated spirit burns were included. During the study period there was no decrease in the number of patients annually admitted to the burn unit with methylated spirit burns. 28% of the patients (n = 27) were younger than eighteen years old, 15% (n = 15) were ten years old or younger. The most common cause of burns was carelessness in activities involving barbecues, campfires and fondues. Mean TBSA burned was 16% (SD 12.4). 70% (n = 68) had full thickness burns. 66% (n = 64) needed grafting. Mean length of hospital stay was 23 days (SD 24.7).

Conclusions

The use of methylated spirit is an ongoing problem, which continues to cause severe burns in adults and children. Therefore methylated spirit should be banned in households. We suggest sale only in specialised shops, clear labelling and mandatory warnings.     

A systematic review of the features that indicate intentional scalds in children

Background

Most intentional burns are scalds, and distinguishing these from unintentional causes is challenging.

Aim

To conduct a systematic review to identify distinguishing features of intentional and unintentional scalds.

Methods

We performed an all language literature search of 12 databases1950–2006. Studies were reviewed by two paediatric/burns specialists, using standardised methodology. Included: Primary studies of validated intentional or accidental scalds in children 0–18 years and ranked by confirmation of intentional or unintentional origin. Excluded: neglectful scalds; management or complications; studies of mixed burn type or mixed adult and child data.

Results

258 studies were reviewed, and 26 included. Five comparative studies ranked highly for confirmation of intentional/unintentional cause of injury. The distinguishing characteristics were defined based on best evidence. Intentional scalds were commonly immersion injuries, caused by hot tap water, affecting the extremities, buttocks or perineum or both. The scalds were symmetrical with clear upper margins, and associated with old fractures and unrelated injuries. Unintentional scalds were more commonly due to spill injuries of other hot liquids, affecting the upper body with irregular margins and depth.

Conclusions

We propose an evidence based triage tool to aid in distinguishing intentional from unintentional scalds, requiring prospective validation.     

Objective evaluation of the effect of autologous platelet concentrate on post-operative scarring in deep burns

Introduction

The healing of grafted areas after surgical treatment of deep burns frequently generates mutilating scars, and rises the risk of subsequent scar hypertrophy. Scar assessment based on clinical evaluation is inherently subjective, which stimulates search for objective means of evaluation.

Objective

The aim of this study was to objectively evaluate the effect of using autologous platelet concentrate (APC) in combination with split thickness skin grafting (STSG) on scarring processes following surgery of deep burns as compared with application of STSG alone.

Method

Selected viscoelastic properties of 38 scars on 23 patients in total were examined using the Cutometer MPA 580 under controlled conditions for long-term outcomes 1, 3, 6 and 12 months after surgery following deep burns.

Results

The findings of this study suggest that the STSG + APC combination reduces the time of scar viscoelastic properties recovery as compared with application of STSG alone. This was statistically significant for viscoelastic parameters R₂ and Q₁.

Conclusion

APC has been advocated to enhance scarring after surgery of deep dermal and full thickness burns. We objectively demonstrated that the viscoelastic properties of scars treated with STSG + APC combination return more rapidly to the plateau state than areas treated with STSG only.