Severe burn injury: Body Mass Index and the Baux score

Objective: The revised Baux score (age total body surface area (TBSA) burned and inhalation injury)) is predictive of mortality in burn patients. Our study objective was to assess whether the addition of body mass index (BMI) to the revised Baux score would be of value. We posited that increasing BMI follows a pattern similar to age and TBSA in the revised Baux score after severe burn injury. Methods: Patient data from the burn registry was queried for patients admitted between 1/1/2013 to 8/31/2019. Patients 12 years or older with a TBSA of 20% or greater burn were included. Inpatient outcomes were analyzed based on BMI. Results: 56 of 1365 patients met inclusion criteria. Mean age of the study population was 48.25 years and 64.3% of patients were male. Median BMI was 25.8 and median TBSA was 26.5. Inhalation injury was present in 44.6% (25/56) of patients. Median hospital length of stay (LOS) and ICU LOS were 21.5 and 17 days respectively. On bivariate analysis, non-survivors had higher TBSA (41.5% vs 25.5%, p = 0.034), more inhalation injury (83.3%, 10/12 vs 34.8%, 15/43 p = 0.003) and higher complication rates (91.6%, 11/12 vs 59.1 %, 25/43, p = 0.043). Survivors also had higher BMI (28.2 vs 23, p = 0.003) and increased hospital LOS (24 vs 5.5, p = 0.003). Automatic model fit in binary logistic regression showed a negative relationship between BMI and mortality. Conclusion: We found a negative relationship between BMI and mortality. Pre-obesity appears to have a protective role, but BMI was not found to be a useful addition to the revised Baux score. Larger sample sizes may be of benefit a for a for a more definitive understanding of the role of BMI with regards to burn survival.     

Dysphagia in the burn patient: Experience in a National Burn Reference Centre

IntroductionMajor burn patients are exposed to different invasive procedures for wound management or medical stabilization. Dysphagia is a frequent adverse effect of burns in the presence of invasive airway procedures and facial wounds.ObjectiveTo estimate the prevalence of dysphagia, to determine the degree of severity, and to report clinical characteristics that could contribute to the appearance of dysphagia in patients admitted to a National Burn Reference Centre.MethodsAn observational cross-sectional study was conducted in a burn reference centre over a 6-month period. All patients admitted to the burn service of a National Reference Centre were included. A clinical bedside swallowing assessment was performed in patients referred to a Speech-Language Pathologist (SLP). The presence or absence of dysphagia was evaluated, and the degree of severity was measured according to the Dysphagia Outcome and Severity Scale (DOSS).ResultsFifty-four participants were recruited. The prevalence of dysphagia over a 6-month period was 27.78% (n = 15) of the total burn patients admitted to the Burn Unit. The severity of dysphagia varied from mild (26.7%), mild-moderate (33.3%), moderate (20%), moderate-severe (13.3%), to severe (6.7%). All dysphagia patients had orotracheal intubation history with an average length of 18 days, as opposed to the non-dysphagia group, of which 75% of the participants had orotracheal intubation history for an average of 8.5 days. Statistically non-significant associations were found between dysphagia and demographic aspects or clinical characteristics (p > 0.05).Conclusion27.78% of burn patients presented dysphagia, with differences in the degree of severity. Presence and duration of orotracheal intubation stands out as a condition of interest. The SLP inclusion in the burn team is presented as a valuable input in order to minimize risks associated with swallowing impairment.     

Burn care in relation to burn epidemiology in Italy

Aim

Burn centres are ‘hubs’ of referral for large areas and should be organised in a network optimised for the needs of their area. Burn centres’ organisation and activity in Italy are analysed with reference to burn epidemiology in the country.

Methods

A questionnaire was submitted to Italian burn centres concerning organisation, activity and epidemiology of burns treated in 2008.

Results

A total of 2067 patients were admitted to a burn centre in 2008; 50% of burns were due to flames (21% alcohol); and 25% of patients were <14 years old. Overall mortality was 5.3%. 144 beds in 15 burn centres were available (seven reserved for children; bed/inhabitants ratio, 1/414,.023). However, distribution is not uniform in the country. Bed rotation was 14.4 patients/bed, and hospital stay varied from 11.7 days for <20% total body surface area (TBSA) burns to >120 days for burns >70%. About half (57%) of patients admitted had less than 20%TBSA burns, 32% had 20-50% TBSA burns, 7% from 50% to 70% and 4% over 70% TBSA. A national network coordinating burn centre activity is lacking.

Conclusions

Italy seems to have less availability of beds for burn care than other countries, and distribution and organisation of the network may be improved. The high prevalence of child burns should be noticed and this makes prevention campaigns advisable.     

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

Background

The 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.

Developing a burn injury severity score (BISS): Adding age and total body surface area burned to the injury severity score (ISS) improves mortality concordance

Background

There is limited research validating the injury severity score (ISS) in burns. We examined the concordance of ISS with burn mortality. We hypothesized that combining age and total body surface area (TBSA) burned to the ISS gives a more accurate mortality risk estimate.

Methods

Data from the Royal Perth Hospital Trauma Registry and the Royal Perth Hospital Burns Minimum Data Set were linked. Area under the receiver operating characteristic curve (AUC) measured concordance of ISS with mortality. Using logistic regression models with death as the dependent variable we developed a burn-specific injury severity score (BISS).

Results

There were 1344 burns with 24 (1.8%) deaths, median TBSA 5% (IQR 2–10), and median age 36 years (IQR 23–50). The results show ISS is a good predictor of death for burns when ISS ≤ 15 (OR 1.29, p = 0.02), but not for ISS > 15 (ISS 16–24: OR 1.09, p = 0.81; ISS 25–49: OR 0.81, p = 0.19). Comparing the AUCs adjusted for age, gender and cause, ISS of 84% (95% CI 82–85%) and BISS of 95% (95% CI 92–98%), demonstrated superior performance of BISS as a mortality predictor for burns.

Conclusion

ISS is a poor predictor of death in severe burns. The BISS combines ISS with age and TBSA and performs significantly better than the ISS.     

Use of the burn intervention score to calculate the charges of the care of burns

Background

To our knowledge this is the first published estimate of the charges of the care of burns in Sweden. The Linköping Burn Interventional Score has been used to calculate the charges for each burned patient since 1993. The treatment of burns is versatile, and depends on the depth and extension of the burn. This requires a flexible system to detect the actual differences in the care provided. We aimed to describe the model of burn care that we used to calculate the charges incurred during the acute phase until discharge, so it could be reproduced and applied in other burn centres, which would facilitate a future objective comparison of the expenses in burn care.

Burn healing is dependent on burn site: a quantitative analysis from a porcine burn model

This retrospective review examines healing in different sites on a porcine burn model; 24 pairs of burns on 18 pigs from other animal trials were selected for analysis. Each pair of burns was located on the either the cranial or the caudal part of the thoracic ribs region, on the same side of the animal. The burns were 40-50 cm(2) in size and of uniform deep-dermal partial thickness. Caudal burns healed significantly better than cranial burns, demonstrated by earlier closure of wounds, less scar formation and better cosmesis. To our knowledge, this is the first detailed study reporting that burn healing is affected by location on a porcine burn model. We recommend that similar symmetrical burns should be used for future comparative assessments of burn healing.     

The accuracy of burn diagnosis codes in health administrative data: A validation study

Background

Health administrative databases may provide rich sources of data for the study of outcomes following burn. We aimed to determine the accuracy of International Classification of Diseases diagnoses codes for burn in a population-based administrative database.

Working time and workload of nurses: The experience of a burn center in a high income country

We conducted a one-month study of the working time and workload of nurses in a 15 beds burn center (including 8 intensive care beds). Nurses’ tasks were categorized according to their nature (medical care, local treatments, post anesthetic monitoring, administrative time related to health care, administrative time unrelated to health care, cleaning, rest). The time taken to complete a given task was measured for each task. The time devoted to walk and unavailable for patients care was also measured.     

Assessment of a quality improvement intervention to improve the consistency of total body surface area burn estimates between referring facilities and a pediatric burn center

BackgroundBurns are a significant source of pediatric morbidity and frequently result in transfer of care to a pediatric burn center. Data suggest that referring facilities often overestimate the total body surface area (%TBSA) of burns in comparison to the subsequent assessment at the pediatric burn center. Such discrepancies may trigger inappropriately aggressive interventions with potential for patient harm. Our baseline assessment of data from 106 patients transferred to our pediatric burn center over a one-year period showed that 59/106 (56%) patients had a %TBSA recorded at the time of transfer and 18/59 (31%) had clinically significant differences (>5% difference) in estimates between the referring facility and the pediatric burn center.MethodsInformed by this clinical audit and a root cause analysis, we implemented practices to enhance consistency of clinical assessments between referring facilities and our pediatric burn center. These practices included the use of a common clinical assessment instrument (a standardized Lund and Browder form) that was integrated into the interfacility transfer process as well as educational outreach at referring facilities for providers who treat children with burns, prioritizing facilities with the highest number of discrepancies.ResultsFollow up data was reviewed 16–23 months after initiating the intervention. Cumulatively, we found significant improvement in the proportion of patients with %TBSA recorded (94% vs 56%, p < 0.001) that achieved our goal to exceed 90% and a reduction in clinically significant discrepancies that exceeded our goal of 15% (10% vs 31%, p = 0.002).ConclusionsReferring facilities often overestimate the %TBSA in comparison to the subsequent assessment at the pediatric burn center. The consistency of the %TBSA estimates can be improved by interventions that utilize the sharing of a common clinical assessment instrument and standardization of the transfer intake process.     

Exploring the Burn Model System National Database: Burn injuries,substance misuse,and the CAGE questionnaire

Burn survivors who misuse alcohol and/other substances have been associated with poorer long-term outcomes and clinical complications following injury. The self-reported CAGE questionnaire (Cut down, Annoyed, Guilty, and Eye-opener) is an outcomes assessment tool used to screen for potential substance misuse. Understanding the persistence and emergence of potential substance misuse through examination of CAGE scores may provide important information about this population. Using data collected from the Burn Model System National Database, demographic and clinical characteristics of individuals who reported positive CAGE scores (total score of ≥2) and those who reported negative CAGE scores (total score of 0 or 1) for either alcohol or other drugs were compared.     

Improving burn care and preventing burns by establishing a burn database in Ukraine

Background

Burns are a challenge for trauma care and a contribution to the surgical burden. The former Soviet republic of Ukraine has a foundation for burn care; however data concerning burns in Ukraine has historically been scant. The objective of this paper was to compare a new burn database to identify problems and implement improvements in burn care and prevention in this country.

Methods

Retrospective analyses of demographic and clinical data of burn patients including Tukey's post hoc test, analysis of variance, and chi square analyses, and Fisher's exact test were used. Data were compared to the American Burn Association (ABA) burn repository.

Results

This study included 1752 thermally injured patients treated in 20 hospitals including Specialized Burn Unit in Municipal Hospital #8 Lviv, Lviv province in Ukraine. Scald burns were the primary etiology of burns injuries (70%) and burns were more common among children less than five years of age (34%). Length of stay, mechanical ventilation use, infection rates, and morbidity increased with greater burn size. Mortality was significantly related to burn size, inhalation injury, age, and length of stay. Wound infections were associated with burn size and older age. Compared to ABA data, Ukrainian patients had double the length of stay and a higher rate of wound infections (16% vs. 2.4%).

Conclusion

We created one of the first burn databases from a region of the former Soviet Union in an effort to bring attention to burn injury and improve burn care.     

A retrospective review of burn dressings on a porcine burn model

This is a study to compare wound healing among three types of dressings on a porcine model with deep-dermal-partial-thickness burns. The burns in this study were from eight animal trials conducted in the past for other purposes and only burns with a uniform pale appearance that had served as controls in original experiments were selected. In total, there were 57 burns in 33 pigs, using one of following three dressings: Acticoat (Silver) (3 trials), Jelonet (Gauze) (3 trials), and Solosite Gel/Jelonet (Gel/Gauze) (2 trials). The wound healing assessments included wound re-epithelialisation during a 6-week period, clinical and histological scar assessments at week 6 after burn. Of all wound healing/scar assessments, only re-epithelialisation showed statistical difference between dressings. Earlier re-epithelialisation was observed in Gel/Gauze dressings compared to Silver and/or Gauze dressings. However, this study revealed huge variation in wound healing outcome between 3 trials within both Silver and/or Gauze dressings, supported by significant differences on re-epithelialisation, clinical and histological scar measurements. In addition, it was found that larger animals healed better than smaller ones, based on weights from 21 pigs. Of all dressings, Silver delivers the best protection for wound colonization/infection. Wound colonization/infection was found to confine wound healing and lead to thinner RND in scars. From this study, we cannot find enough evidence to suggest the beneficial effect of one dressing(s) over others on burn wound healing outcome on a porcine model with small deep-dermal-partial-thickness burns with a relative small sample size.     

Alcohol use and smoking in burn patients at the Helsinki Burn Center

Objective

We investigated alcohol use and smoking at time of burn and their relationships with severity of burn and presence of mental disorders.

Adherence to National Burn Care Review referral criteria in a paediatric Emergency Department

Introduction

The National Burn Care Review (NBCR) gives guidance on the recognition of potentially complex burns requiring assessment and management in a burn unit. This guidance provides a referral framework for those initiating assessment and management of burns. The effect of close adherence to NBCR guidance on workload is at present unknown.

Objectives

To audit referral patterns of burns in our paediatric Emergency Department (ED) in comparison to NBCR referral criteria. To identify the type of injuries not referred despite meeting criteria, and their outcomes, to assess whether these patients come to any harm short-term. To estimate the effect that closer adherence would have on workload and how our unit proposes to work with the ED to improve its distribution and our patients care.

Methods

A retrospective case-note audit of patients presenting to a paediatric ED with a triage diagnosis of “burn/scald” over a 6-month period between 1st April and 29th September 2008.

Results

190 patients presented with burns during this period, of which 126 (66%) had potentially complex burns. Of these, 93 (74%) were not referred to the burns unit i.e. were “under-referred”. In this group burns to specialized areas in patients under 5 years of age were particularly prevalent. 78 (84%) were reviewed in the ED and received no specialist input. Seven patients suffered minor complications. Only three of these patients (3.2%) required subsequent referral to the burns unit for opinion. None required any further specialist intervention.

Conclusion

Strict adherence to NBCR referral criteria could result in a significant increase in workload for regional burn units with as yet unquantifiable benefit in patient outcomes. Many minor injuries appear to be safely managed in the ED with little adverse outcome. Even small improvements in practice could result in a considerable workload increase for a burns unit. Further prospective research is required, particularly looking at longer-term outcomes. We are hoping to improve educational and clinical links between our EDs and burn unit to improve patient care and distribution of clinical workload. Further national guidance maybe necessary.     

Evaluation of Burn Wound Infection in a Referral Center in Colombia

Introduction  Burn wound infection (BWI) is the second most important cause of death in burn patients. There is currently limited data about the incidence and clinical presentation of BWI using quantitative techniques as quantitative biopsy culture (QBC) to prevent progress to burn wound sepsis (BWS). Methods  This is a prospective cohort study of patients diagnosed with BWI, confirmed by QBC, from February 2018 to July 2019 at University Hospital of Santander (HUS). The primary outcome was to determine clinical, microbiological, and histopathological characteristics of patients diagnosed with BWI along with a positive QBC and their relationship with early diagnosis and progression to BWS. Results  525 patients were admitted to HUS Burn Center. Of those, 44/525 (8.23%) presented a clinical diagnosis of BWI (median age, 20.5 years [1–67 years]; 25/44 [56.8%] male). QBC was positive in 26/44 (59%), Staphylococcus aureus 14/44 (31.8%), and Pseudomonas aeruginosa 7/44 (15.9%) were the mainly etiological agents isolated. Bacterial resistance to antibiotics was mostly to beta-lactams in 14/44 (31.8%), corresponding to methicillin-resistant Staphylococcus aureus (MRSA). Clinical signs more related to infection were erythema in 33/44 (61.3%). As many as 10/44 (22.7%) progressed to sepsis and 2/44 (6%) died. Conclusion  BWI increases hospitalization time and number of surgeries, increasing the risk of sepsis and death. The QBC allows an accurate diagnosis with lesser false-positive cases that impact antibiotic resistance and mortality. Protocols targeting this problem are needed to decrease the impact of this.     

Catheter-related infections in burn patients at the Burn Centre of the University Hospital in Ostrava

We need central venous catheters (CVCs) in management of critically ill patients with severe burns, either for the administration of fluids or monitoring hemodynamic status. Central venous catheterization may cause different early or late complications, which depend on the physician's erudition, the quality of the catheters and quality of Intensive Care Unit (ICU) nursing care for insertion. 272 CVCs were inserted in 114 both adult and pediatric patients from 2004 to 2006 in the ICU of the Burn Centre in Ostrava. The average insertion length of the catheter was 10.2 days, and the average total length of catheterization was 24 days. The total number of catheter-days was 2768. All catheter tips removed were routinely cultured. The most frequent infecting pathogens were coagulase-negative Staphylococci. Peripheral blood cultures were examined in case of fever. Bacterial findings from wounds, sputa and urine were monitored in all patients. No exogenous catheter sepsis according to Maki's criteria occurred in our study group. Endogenous catheter colonization with positive peripheral blood culture and bacteraemia occurred in 4 cases, which means an incidence density of 1.44 endogenous colonizations per 1000 catheter-days. The quality of used catheters and particularly the technique of placement and maintenance of catheters are considered crucial for good results in the ICU of Burn centre in Ostrava.     

Epidemiology of infections in a Burn Unit,Albania

Background

Many types of nosocomial infections (NIs) can be present in the burned patient. The purpose of this study is to calculate the rates for NI in the Intensive Care Unit of the Service of Burns and Plastic Surgery in University Hospital Centre (UHC) in Tirana, Albania.

Method

The study is prospective, clinical and analytical. The study is continued/longitudinal because monitors all patients with severe burns during a specified time period (1 year). For data analysis was used SPSS 19.0.

Results

The infection prevalence rate was 12 infected patients per 100 patients. The colonisation prevalence rate was 43 colonised patients for 100 patients. The most frequent infection microorganisms were Pseudomonas aeruginosa and Staphylococcus aureus (67% and 24%). Incidence of BSI was 3 BSI for 1000 hospitalization days. Incidence of catheter-related bloodstream infection (CRBSI) was 11.7 BSI for 1000 catheter days. Colonisation of the tip of the central catheter (CTC) was 15.6 for 1000 catheter days.

Conclusions

The epidemiology of burn wound infections as well as the definitions have changed due to important changes in burn wound treatment but further studies should be done documented the factors that can reduce the burn wound infection rates.