scholarly journals Updating the Burn Center Referral Criteria: Results From the 2018 eDelphi Consensus Study

2020 ◽  
Vol 41 (5) ◽  
pp. 1052-1062 ◽  
Author(s):  
Amanda P Bettencourt ◽  
Kathleen S Romanowski ◽  
Victor Joe ◽  
James Jeng ◽  
Jeffrey E Carter ◽  
...  
Keyword(s):  
Injury Severity ◽  
Burn Injury ◽  
Clinical Trial Data ◽  
Patient Characteristics ◽  
Stevens Johnson Syndrome ◽  
Burn Care ◽  
Medical Needs ◽  
Burn Center ◽  
Referral Criteria ◽  
Johnson Syndrome

Abstract Existing burn center referral criteria were developed several years ago, and subsequent innovations in burn care have occurred. Coupled with frequent errors in the estimation of extent of burn injury and depth by referring providers, patients are both over and under-triaged when the existing criteria are used to support patient care decisions. In the absence of compelling clinical trial data on appropriate burn patient triage, we convened a multidisciplinary panel of experts to execute an iterative eDelphi consensus process to facilitate a revision. The eDelphi process panel consisted of n = 61 burn stakeholders and experts and progressed through four rounds before reaching consensus on key clinical domains. The major findings are that 1) burn center consultation is strongly recommended for all patients with deep partial-thickness or deeper burns ≥ 10% TBSA burned, for full-thickness burns ≥ 5% TBSA burned, for children and older adults with specific dressing and medical needs, and for special burn circumstances including electrical, chemical, and radiation injuries; 2) smaller burns are ideally followed in burn center outpatient settings as soon as possible after injury, preferably without delays of a week or more; 3) frostbite, Stevens–Johnson syndrome/TENS, and necrotizing soft-tissue infection patients benefit from burn center treatment; and 4) telemedicine and technological solutions are of likely benefit in achieving this standard. Unlike the original criteria, the revised consensus-based guidelines create a framework promoting communication so that triage and treatment are specifically tailored to individual patient characteristics, injury severity, geography, and the capabilities of referring institutions.

Differences in Treatment of Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis at Burn Centers and Nonburn Centers

2020 ◽  
Vol 41 (5) ◽  
pp. 945-950
Author(s):  
Rachel M Nygaard ◽  
Frederick W Endorf
Keyword(s):  
Toxic Epidermal Necrolysis ◽  
Severe Disease ◽  
Definitive Treatment ◽  
Stevens Johnson Syndrome ◽  
Skin Disorders ◽  
National Inpatient Sample ◽  
Term Care ◽  
Burn Centers ◽  
Burn Center ◽  
Johnson Syndrome

Abstract Stevens–Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and Stevens–Johnson/TEN overlap syndrome (SJS/TEN) are severe exfoliative skin disorders resulting primarily from allergic drug reactions and sometimes from viral causes. Because of the significant epidermal loss in many of these patients, many of them end up receiving treatment at a burn center for expertise in the care of large wounds. Previous work on the treatment of this disease focused only on the differences in care of the same patients treated at nonburn centers and then transferred to burn centers. We wanted to explore whether patients had any differences in care or outcomes when they received definitive treatment at burn centers and nonburn centers. We queried the National Inpatient Sample database from 2016 for patients with SJS, SJS/TEN, and TEN diagnoses. We considered burn centers as those with greater than 10 burn transfers to their center and fewer than 5 burn transfers out of their center in a year. Multivariable logistic regression assessed factors associated with treatment at a burn center and mortality. Using the National Inpatient Sample, a total of 1164 patients were identified. These were divided into two groups, nonburn centers vs burn centers, and those groups were compared for demographic characteristics as well as variables in their hospital course and outcome. Patients treated at nonburn centers were more likely to have SJS and patients treated at burn centers were more likely to have both SJS/TEN and TEN. Demographics were similar between treatment locations, though African-Americans were more likely to be treated at a burn center. Burn centers had higher rates of patients with extreme severity and mortality risks and a longer length of stay. However, burn centers had similar actual mortality compared to nonburn centers. Patients treated at burn centers had higher charges and were more likely to be transferred to long-term care after their hospital stay. The majority of patients with exfoliative skin disorders are still treated at nonburn centers. Patients with SJS/TEN and TEN were more likely to be treated at a burn center. Patients treated at burn centers appear to have more severe disease but similar mortality to those treated at nonburn centers. Further study is needed to determine whether patients with these disorders do indeed benefit from transfer to a burn center.

scholarly journals Drug-induced liver injury associated with stevens-Johnson syndrome/toxic epidermal necrolysis: Patient characteristics, causes, and outcome in 36 cases

Hepatology ◽  
2015 ◽  
Vol 63 (3) ◽  
pp. 993-999 ◽  
Author(s):  
Harshad Devarbhavi ◽  
Sujata Raj ◽  
Venu H. Aradya ◽  
Vijaykumar T. Rangegowda ◽  
Girish P. Veeranna ◽  
...  
Keyword(s):  
Liver Injury ◽  
Toxic Epidermal Necrolysis ◽  
Patient Characteristics ◽  
Stevens Johnson Syndrome ◽  
Drug Induced ◽  
Drug Induced Liver Injury ◽  
Johnson Syndrome

517 ALDEN Based Determination of Culprit Drugs in Stevens-Johnson Syndrome: A 15-year Single Center Review

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S96-S96
Author(s):  
Paul M de Bustros ◽  
Anthony J Baldea ◽  
Arthur Sanford ◽  
Charles Bouchard ◽  
Cara Joyce
Keyword(s):  
Statistical Significance ◽  
Total Body Surface Area ◽  
Overlap Syndrome ◽  
Stevens Johnson Syndrome ◽  
Single Center ◽  
Drug Reactions ◽  
Sulfa Drug ◽  
Burn Center ◽  
Johnson Syndrome ◽  
Culprit Drug

Abstract Introduction Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis Syndrome (TENS) are severe and potentially lethal adverse drug reactions characterized by acute inflammation and subsequent necrosis of the skin, mucous membranes, and ocular surface. SJS/TENS is defined on a spectrum based on the percent of total body surface area (%TBSA) with epidermal detachment: SJS (< 10% TBSA), Overlap Syndrome (10–30%), and TENS (>30%). The purpose of our study was to perform a systemic retrospective trend analysis of SJS spectrum diagnoses and culprit drugs in 147 patients admitted to the burn center over the past 15 years with the final diagnosis of SJS/TENS. The burn center serves as a regional referral center for patients with suspected or confirmed SJS/TENS. These referrals came from the five other academic medical centers as well as private hospitals in the area. Methods The electronic medical records of patients with a confirmed diagnosis of SJS/TENS admitted to the burn center from 2002 to 2017 were reviewed. Clinical data and the algorithm of drug causality for epidermal necrolysis (ALDEN) were used to identify the single most probable culprit drug. The following data were reviewed: date of admission, %TBSA with detachment, biopsy confirmation, and possible inciting agents. Chi-square tests were used to assess statistical significance for group comparisons. Results Over 15 years, 147 patients had a biopsy-confirmed diagnosis of SJS/TENS, of which 67% (n =98) had a culprit drug identified. The most common spectrum classification was TENS (n=73), followed by SJS (n=46) and Overlap Syndrome (n=27). Anticonvulsants (n=24), fluoroquinolones (n=14), allopurinol (n=11), sulfa drugs (n=9), and NSAIDs (n=9) were the most common inciting agents. Between 2006–2017, the proportion of patients presenting with SJS increased as compared to TENS and Overlap syndrome (10% in 2002–2009 vs. 42% in 2010–2017, p< 0.01). Sulfa drug reactions were more prevalent in recent years (0% in 2002–2009 vs. 18% in 2010–2017, p=0.065) and fluoroquinolone-induced reactions in earlier years (21% in 2002–2009 vs. 6% in 2010–2017, p=0.068). Conclusions This is one of the largest single center series of SJS/TENS/Overlap cases in the US. Our data supports trends presented in the EuroSCAR (1997–2001) and RegiSCAR (2003–2012) studies. Applicability of Research to Practice The ALDEN algorithm provides an important and validated method for determining the probable culprit drug in SJS/TENS spectrum reactions. Trends in culprit drugs can shift over time based on changes in prescribing practices. Therefore, these trends need to be monitored in order to advise providers on which agents present the greatest risk to patients.

581 Basecamp: Burn Efficiency Care Pathway

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S132-S132
Author(s):  
Carolyn B Blayney ◽  
Nicole S Gibran
Keyword(s):  
Burn Injury ◽  
Care Pathway ◽  
Wound Care ◽  
Medical Center ◽  
Patient Specific ◽  
Improvement Project ◽  
Burn Care ◽  
Burn Center ◽  
Resuscitation Guidelines ◽  
Standard Operating

Abstract Introduction Standardizing care has shown in the literature to be a means to improving the culture of safety in any field. Aligning burn surgeons, staff and ancillary services in the Burn ICU, Burn Acute Care floor, Burn Clinic who all have varying ideas, and plans of care creates toxic variation and communication challenges for bedside staff. While attending a medical center leadership development session, Burn Center Leadership collaborated on a project regarding burn center standardization. Methods A multidisciplinary Burn Center retreat in September 2017, launched the effort with a special emphasis on patient and family participation.We elicited feedback on what we did well and areas we could improve on. Using crowdsourcing methodology, the group selected 5 core QI/PI areas: resuscitation, wound care, pain/anxiety/delirium, physical mobility and psychosocial needs.Each multidisciplinary group, led by a non-physician chair and a Physician liaison established assigned tasks, rules of engagement and time frames. Work groups met weekly and reported progress to the Burn center QI committee.The project concluded with dissemination of the work products to staff. Patients and families were updated on the progress made to ensure we were still in alignment with our original goals. Results Burn Center orientation materials, standard operating practice documents and a Burn Center Standard of Care packet was developed. Documents were uploaded to a commonly accessible Burn Center Sharepoint website so there was one central source of information. The final BasECamP output was a daily checklist packet started on all BICU admits, that addressed key QI indicators and directives for care goals; 24 hr resuscitation guidelines, time to TF vs PO within 4 hrs of admit, daily weights, IV vs PO medication for wound care, time to first active mobility and a review of ICU and Hospital LOS per %TBSA. 71 adult burn patients >18 years admitted to the BICU between November 2018 and May 2019 were started on the pathway. Of the 71, 58 were admitted with a burn injury, 4 with TEN, 6 were burn post-ops and there were 3 deaths. The 58 new burn admits are reviewed below. Conclusions The BaSeCamP packet is turned in and reviewed with the team. Data shows significant improvement in knowledge of standard operating procedures, expectations and resource availability. With improved communication across the burn team, staff more clearly understand patient-specific expectations in burn care and are more easily able to educate patients and families about the plan. Applicability of Research to Practice This Process improvement project responds to patient and family feedback that burn teams must coordinate communication and eliminate variability in delivery of care.

Geospatial Mapping as a Guide for Resource Allocation Among Burn Centers in India

2019 ◽  
Vol 41 (4) ◽  
pp. 853-858
Author(s):  
Kavitha Ranganathan ◽  
Charles A Mouch ◽  
Michael Chung ◽  
Ian B Mathews ◽  
Paul S Cederna ◽  
...  
Keyword(s):  
Burn Injury ◽  
Cross Sectional ◽  
Burn Centers ◽  
Optimal Outcomes ◽  
Burn Care ◽  
Burn Center ◽  
Level Data ◽  
Burn Units ◽  
Time Required ◽  
Reallocation Of Resources

Abstract Timely treatment is essential for optimal outcomes after burn injury, but the method of resource distribution to ensure access to proper care in developing countries remains unclear. We therefore sought to examine access to burn care and the presence/absence of resources for burn care in India. We surveyed all eligible burn centers (n = 67) in India to evaluate burn care resources at each facility. We then performed a cross-sectional geospatial analysis using geocoding software (ArcGIS 10.3) and publicly available hospital-level data (WorldStreetMap, WorldPop database) to predict the time required to access care at the nearest burn center. Our primary outcome was the time required to reach a burn facility within India. Descriptive statistics were used to present our results. Of the 67 burn centers that completed the survey, 45% were government funded. More than 1 billion (75.1%) Indian citizens live within 2 hours of a burn center, but only 221.9 million (15.9%) live within 2 hours of a burn center with both an intensive care unit (ICU) and a skin bank. Burn units are staffed primarily by plastic surgeons (n = 62, 93%) with an average of 5.8 physicians per unit. Most burn units (n = 53, 79%) have access to hemodialysis. While many Indian citizens live within 2 hours of a burn center, most centers do not offer ICU and skin bank services that are essential for modern burn care. Reallocation of resources to improve transportation and availability of ICU and skin bank services is necessary to improve burn care in India.

546 Impact of the Affordable Care Act on Burn Outcomes

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S112-S113
Author(s):  
Jamie Oh ◽  
Amali Fernando ◽  
Stephen Sibbett ◽  
Gretchen J Carrougher ◽  
Barclay T Stewart ◽  
...  
Keyword(s):  
Affordable Care Act ◽  
Injury Severity ◽  
Burn Injury ◽  
Insurance Coverage ◽  
Complication Rates ◽  
Patient Disposition ◽  
Burn Center ◽  
The Affordable Care Act ◽  
Chi Square Analysis ◽  
The Impact

Abstract Introduction With changes in insurance coverage after the implementation of the Affordable Care Act (ACA) in 2014, we aim to analyze the impact of Medicaid expansion on clinical outcomes and patient disposition after burn injury. We hypothesize that with increased insurance coverage, more patients are discharged to a skilled nursing facility (SNF) or rehabilitation center. Methods Under IRB approval, we reviewed trauma registry data for patients with burn injuries admitted to a regional burn center from 2011 to 2018. Patients were grouped into two categories: before (2011–2014) and after (2015–2018) ACA; we excluded data from 2014 to serve as a washout period. Outcomes of interest were length of hospital stay controlled for burn size (LOS/TBSA), number of complications, patient disposition (Home, SNF, or Rehab), and mortality. Chi square analysis and student t-tests were performed to determine differences between the two groups. Multivariate logistic regression including age, sex, race, distance from medical center, burn size, and etiology of the burn as covariates were used to determine the impact of ACA implementation on patient disposition. Results Inpatient mortality rates did not change following ACA implementation. Average LOS/TBSA and number of complications increased, which may be due to increased average age, burn size, and distance from the burn center after ACA. Fewer patients were discharged home and more patients were sent to rehabilitation centers and SNF, which may relate to more patients being insured. Even after adjusting for covariates, discharge to inpatient rehabilitation was significantly increased and discharge to a SNF approached significance. Conclusions Since ACA implementation, there has been no change in mortality after a burn injury, but an increase in average LOS and complication rates, consistent with increased injury severity. Rates of discharge to rehab centers and SNF improved with the increase in overall insurance coverage in the burn population. Applicability of Research to Practice This work highlights changes in patient outcomes with ACA implementation and can help to guide understanding of health disparity and resource utilization in this population.

760 Patients with Pre-existing Mental Illness Who Developed Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Lessons Learned at a Large Tertiary Burn Center and the Importance of Accurately Diagnosing Psychiatric Disorders

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S213-S214
Author(s):  
Sarah L Laughon ◽  
Michael Duplisea ◽  
Carolyn Ziemer ◽  
Lori Chrisco ◽  
Felicia N Williams ◽  
...  
Keyword(s):  
Bipolar Disorder ◽  
Psychiatric Disorder ◽  
Toxic Epidermal Necrolysis ◽  
Psychiatric Disorders ◽  
Skin Diseases ◽  
Case Series ◽  
Lessons Learned ◽  
Stevens Johnson Syndrome ◽  
Burn Center ◽  
Johnson Syndrome

Abstract Introduction In recent years, burn centers are managing more patients with exfoliative skin disorders including Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN), and SJS/TEN overlap. While it is well known that burn patients have higher rates of co-morbid psychiatric disorders than the general population, the incidence of pre-existing psychiatric disorders among patients who develop SJS, SJS/TEN overlap, and TEN is unknown. This study aimed to characterize a cohort of patients with pre-existing psychiatric disorders admitted to a tertiary burn center for treatment of SJS, SJS/TEN overlap, and TEN with specific focus on those who received the offending agent for a psychiatric indication. Methods A retrospective descriptive case series using an institutional burn center registry was performed. All patients admitted to a single verified burn center between January 1, 2009 and December 31, 2018 with biopsy-proven SJS, SJS/TEN overlap, or TEN and the presence of a co-morbid psychiatric disorder were identified. Demographic, hospital, and clinical information were extracted from the burn registry and verified through review of the electronic medical record. Results Among 168 patients with biopsy-proven SJS, SJS/TEN overlap, or TEN, 18% (30/168) had a pre-existing psychiatric disorder, with the offending agent being prescribed for a psychiatric indication in 30% (10/30) of patients. Lamotrigine was the offending agent in 80% of cases and prescribed 100% of the time for a psychiatric indication. Of those who received lamotrigine, patients were 100% female, 63% black, and had an average age of 38 years. The mean length of stay was 24 days and 88% received a psychiatric consultation. While 75% of patients were started on lamotrigine for a diagnosis of bipolar disorder, none of these patients met criteria for bipolar disorder. Conclusions Pre-existing psychiatric comorbidity is less common among patients that develop SJS, SJS/TEN overlap, and TEN than in burn-injured patients. For patients with pre-existing psychiatric disorders who develop these potentially fatal skin diseases from an offending agent that was prescribed for a psychiatric indication, early involvement of psychiatry colleagues is recommended to ensure proper psychiatric diagnosis and management moving forward. Applicability of Research to Practice This study highlights the importance of accurate assessment for and diagnosis of bipolar disorder prior to determining treatment approach. For the burn surgeon treating these patients, early involvement of psychiatric consultants is recommended and extremely important.

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