TRANSPORTING BURN PATIENTS TO REGIONAL BURN CENTERS

Abstract Introduction A burn center is defined by the American College of Surgeons as a program that facilitates the provision of specialized multidisciplinary care in a designated setting. The Children’s Hospital Association states that pediatric patients need age specific health care delivered by specialty trained clinicians in an environment designed just for kids. When these two different specialty areas within one organization cross paths, how does the organization determine all the factors that go into determining the standard of care? One burn center found itself at the heart of this question when asked to determine the best location and how to care for pediatric burn patients. Methods An email survey was sent to burn centers verified with the American Burn Association (ABA) to care for both adult and pediatric patients and located within their region or with a similar volume. The questions included: Results Thirteen burn centers responded. Nine of the thirteen were located within the western region, two in the mid-west, one each in the south and northeast regions. Eight burn centers were categorized as academic and the other five as teaching hospitals. Bed size ranged from 8–44 with an average of 18 beds. Eighty-five percent of the respondents stated they admitted most if not all pediatric burn patients to the burn unit with two of those centers being the only location within their hospital for pediatric patients. Over seventy-five percent provided 24/7 provider coverage. There was more variability in answers regarding rate of pediatrician consultation, code blue team response, and geographic proximity to a children’s hospital however pediatric consultation was obtained in the majority of cases. Conclusions The survey responses were helpful to communicate some degree of burn center community standard although more centers and increased specificity would have strengthened the argument for a burn center remaining the preferred location for all pediatric burn admissions. Applicability of Research to Practice Sharing of our experience and recommendation that the ABA establish a burn community standard, especially one that takes how to manage competing specialties into consideration, will be helpful to all burn centers who could face this same challenge.

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562 Burn Bed Availability in the Northeast Region During the COVID-19 Pandemic

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.212 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

pp. S131-S131

Author(s):

Christina Lee ◽

Kathe M Conlon ◽

Michael A Marano ◽

Margaret A Dimler ◽

Robin Lee ◽

...

Keyword(s):

Mass Casualty Incident ◽

Mass Casualty ◽

Published Data ◽

Burn Patients ◽

Northeast Region ◽

Burn Centers ◽

State Hospitals ◽

Burn Center ◽

Mass Casualty Event ◽

Local Trauma

Abstract Introduction The coronavirus disease pandemic has placed enormous strain on all medical services with ICU capabilities throughout the Northeast region. The surge in ICU beds might severely limit burn centers to accept burn patients in a regional mass casualty incident. Methods Burn bed data was collected by a regional burn disaster consortium. Open burn bed census was collected via telephone from each burn center in the consortium on April 15th, May 7th, May 21st, June 4th and June 18th of 2020. This data was compared to published data from 2009 to 2016. Results The results are listed in Table 1. Lowest available burn bed was 35 beds on April 15th, 2020. Conclusions Although a disaster may impact surrounding local and state hospitals, it does not always impact a burn center’s ability to transfer patients from a local trauma center or nearby burn center. A pandemic however affects a larger region and impacts all hospitals within that region. Peak ICU utilization in the Northeast was between the second and third week of April. During the peak utilization time, burn bed census was about 50% of the historical average. Burn bed census did not return to historical average until May 7, 2020. If a mass casualty event occurred in the pandemic region, the Northeast region would have to reach out to other ABA designated regions for assistance. Historically, burn mass casualty plans are based on the capacity to move burn patients to other burn centers in order to relieve surge capacity at the affected center. This data illustrates that, in a pandemic, burn beds are being utilized for non-burn patients. The ability to follow these plans will be greatly impacted.

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Sedation and Analgesia for Adult Outpatient Burn Dressing Change: A Survey of American Burn Association Centers

Journal of Burn Care & Research ◽

10.1093/jbcr/irz164 ◽

2019 ◽

Vol 41 (2) ◽

pp. 322-327 ◽

Cited By ~ 1

Author(s):

Jordan K Voss ◽

Jeanette Lozenski ◽

Jennifer K Hansen ◽

Shannon Salerno ◽

Aaron Lackamp ◽

...

Keyword(s):

The United States ◽

Outpatient Setting ◽

Burn Patients ◽

Medication Regimen ◽

Burn Centers ◽

Pain Medications ◽

Oral Pain ◽

Wide Variability ◽

Sedation And Analgesia ◽

Dressing Change

Abstract The management of pain and sedation during burn dressing change is challenging. Previous reviews and studies have identified wide variability in such practices in hospitalized burn patients. This survey-based study aimed to determine the most commonly utilized sedation and analgesia practices in adult burn patients treated in the outpatient setting. The goal was to identify opportunities for improvement and to assist burn centers in optimizing sedation procedures. A 23-question survey was sent to members of the American Burn Association. Nonpharmacological interventions including music, television, games, and virtual reality were used by 68% of survey respondents. Eighty-one percent reported premedicating with oral opioids, 32% with intravenous opioids, and 45% with anxiolytics. Fifty-nine percentage of respondents indicated that the initial medication regimen for outpatient dressing changes consisted of the patient's existing oral pain medications. Forty-three percent indicated that there were no additional options if this regimen provided inadequate analgesia. Fifty-six percentage of respondents felt that pain during dressing change was adequately controlled 75% to 100% of the time, and 32% felt it was adequately controlled 50% to 75% of the time. Nitrous oxide was used by 8%. Anesthesia providers and an acute pain service are available in a minority of cases (13.7% and 28%, respectively) and are rarely consulted. Procedural burn pain remains significantly undertreated in the outpatient setting and the approach to treatment is variable among burn centers in the United States. Such variation likely represents an opportunity for identifying and implementing optimal practices and developing guidelines for burn pain management in the outpatient setting.

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Reimbursement for Out-of-State Burn Patients Is Not Always Lower Than That for In-State Patients at Regional Burn Centers

Journal of Burn Care & Research ◽

10.1097/bcr.0b013e3181e4d6dd ◽

2010 ◽

Vol 31 (4) ◽

pp. 603-609 ◽

Cited By ~ 1

Author(s):

Michael D. Peck ◽

Melissa A. Pressman ◽

Daniel M. Caruso ◽

Linda S. Edelman ◽

James H. Holmes ◽

...

Keyword(s):

Burn Patients ◽

Burn Centers

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89 The Effect of Trauma Center Status and Burn Verification Process on Burn Patient Outcomes

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.093 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

pp. S61-S62

Author(s):

Manuel Castillo-Angeles ◽

Christopher J Burns ◽

John C Kubasiak ◽

Anupama Mehta ◽

Robert Riviello ◽

...

Keyword(s):

Hospital Mortality ◽

Patient Outcomes ◽

Trauma Center ◽

Burn Patients ◽

Trauma Centers ◽

Burn Centers ◽

Adjusted Analysis ◽

Burn Care ◽

Burn Center ◽

Burn Patient

Abstract Introduction Burn center verification was implemented to ensure burn patients receive the best quality of care. As part of the of the organized burn care system, trauma centers that do not have a burn center within the hospital should refer burn patients to a designated burn center. However, more than 30% of burn patients are still being taken care of in non-verified burn centers. Our aim was to determine if trauma center status conferred a benefit in outcomes in a national sample of burn patients. Methods This is a retrospective study using State Inpatient Databases of 22 states in 2014. The inclusion criteria were all patients admitted for burn injury (ICD-9 codes 940–949). Hospitals were categorized as ABA verified centers (VBC) and non-verified burn centers (NVBC), as well as trauma centers (TC) and non-trauma centers (NTC) based on verification status at the time of admission. Main Outcomes were in-hospital mortality and length of hospitalization (LOS). Stratifying by burn center verification status, multivariable regression was used to identify the association between trauma center status and the outcomes. Results A total of 15,982 burn patients were identified. The overall in-hospital mortality rate was 2.45%. In our sample, we only had 26 hospitals that were both a TC and VBC (Table 1). The majority of patients (54%) were treated at a NVBC/TC. In unadjusted analysis, amongst verified centers, there was no difference in mortality between TC and NTCs (3.2% vs. 3.0%, p=0.877), but NTCs had longer LOS (14.7 vs. 10 d, p< 0.001). Amongst non-verified centers, TCs had higher mortality when compared with NTCs (2.4% vs. 1.1%, p< 0.001), but TCs had longer LOS (8.3 vs. 7.2 d, p=0.007). After adjusted analysis, within VBC, TC status was associated with shorter LOS (Coef -3.28, 95% CI -5.37 – -1.19, p=0.002), but not associated with mortality (OR 1.21, 95% CI 0.50 – 2.89, p=0.667). After adjusted analysis, within NVBC, TC status was associated with longer LOS (Coef 2.37, 95% CI 1.70 – 3.04, p< 0.001) and with mortality (OR 3.70, 95% CI 2.10 – 6.51). Conclusions Trauma center status does not confer any benefit for burn patient outcomes within the burn care verification system. Despite the regionalization of burn care through the development of verified burn centers, the majority of burn patients are receiving care at trauma centers with a non-verified burn center within the hospital.

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Referral Patterns in Pediatric Burn Patients

The American Surgeon ◽

10.1177/000313481408000911 ◽

2014 ◽

Vol 80 (9) ◽

pp. 836-840 ◽

Cited By ~ 6

Author(s):

Andrea N. Doud ◽

John M. Swanson ◽

Mitchell R. Ladd ◽

Lucas P. Neff ◽

Jeff E. Carter ◽

...

Keyword(s):

Treatment Center ◽

Burn Patients ◽

Severely Injured Patients ◽

Referral Patterns ◽

Burn Centers ◽

International Classification Of Disease ◽

Referral Criteria ◽

Patient Database ◽

Injured 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 cross-referenced 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.

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Analgesia and Sedation in the Intensive Care of Burn Patients

Journal of Intensive Care Medicine ◽

10.1177/0885066610393442 ◽

2011 ◽

Vol 26 (6) ◽

pp. 397-407 ◽

Cited By ~ 20

Author(s):

Tomislav Trupkovic ◽

Michael Kinn ◽

Stefan Kleinschmidt

Keyword(s):

Intensive Care ◽

Intensive Care Units ◽

Neuromuscular Blocking ◽

Scientific Data ◽

Neuromuscular Blocking Agents ◽

Burn Patients ◽

National Guidelines ◽

Burn Centers ◽

Blocking Agents ◽

Sedation And Analgesia

Objective: A variety of agents and techniques are employed in different countries, settings, and medical specialities in order to provide analgesia and sedation in intensive care. Several national guidelines have been published in recent years regarding sedation and analgesia in a general intensive care patient population; however, to date no data exist for patients with burn injuries. The aim of the study was to evaluate analgesia and sedation practice in the intensive care of burn patients in Europe. Design: A postal survey was sent to 188 burn centers in Europe. The addresses were provided by the European Burn Association. The heads of the intensive care units were asked to fill in a structured questionnaire concerning the use of analgesia and sedation in their units. Results: The overall response rate was 27.04%; 63% of European burn centers reported standard operating procedures for sedation and analgesia. A regular score-based assessment of sedation, analgesia, and delirium is carried out by 58%, 60%, and 5%, respectively, of the units. Propofol is the sedative most frequently used for short-term sedation and the weaning phase, whereas benzodiazepines are the preferred substances for medium- and long-term sedation. α2-agonists are widely used during weaning. Opioids are the analgesics of choice for approximately two thirds of the patients. Ketamine is preferred for analgesia in 12% and for sedation in 13% of all substances used. For painful procedures (eg, dressing changes), a large variety of different combinations of analgesics and sedatives are used. Half of the responding intensive care units use neuromuscular blocking agents and supportive nonpharmacological techniques. Two thirds of the European burn centers perceive the need for change in their concepts of analgesia and sedation. Conclusion: A wide variety of drugs are used for analgesia and sedation in European burn centers. This would appear to be due to lack of guidelines or scientific evidence. The implementation of regular assessment of sedation, analgesia, and delirium must be improved. The widespread use of neuromuscular blocking agents should be restricted or even abandoned. Two thirds of the units identify a need for change in their concepts. Valid scientific data are needed to develop guidelines for sedation and analgesia of burn patients.

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The Use of Extracorporeal Membrane Oxygenation in Severely Burned Patients: A Survey of North American Burn Centers

Journal of Burn Care & Research ◽

10.1093/jbcr/irab103 ◽

2021 ◽

Author(s):

Sebastien Hebert ◽

Mete Erdogan ◽

Robert S Green ◽

Jack Rasmussen

Keyword(s):

Respiratory Failure ◽

Perioperative Management ◽

Case Reports ◽

The United States ◽

Burn Patients ◽

Burn Centers ◽

Burn Care ◽

Consensus Statements ◽

The Status ◽

Ecmo Therapy

Abstract Respiratory failure and acute respiratory distress syndrome can occur in burn patients with or without inhalational injury, and can significantly increase mortality. For patients with severe respiratory failure who fail conventional therapy with mechanical ventilation, the use of veno-venous extracorporeal membrane oxygen (ECMO) may be a lifesaving salvage therapy. There have been a series of case reports detailing the use of ECMO in burn patients over the last twenty years, but very little is currently known about the status of ECMO use at burn centers in North America. Using a web-based survey of burn center directors in Canada and the United States, we examined the rate of usage of ECMO in burn care, barriers to its use, and the perioperative management of burn patients receiving ECMO therapy. Our findings indicate that approximately half of burn centers have used ECMO in the care of burn patients, but patient volume is very low on average (less than 1 per year). Of centers that do use ECMO in burn care, only 40% have a specified protocol for doing so. Approximately half have operated on patients being actively treated with ECMO therapy, but perioperative management of anticoagulation varies widely. A lack of experience and institutional support, and a perceived lack of evidence to support ECMO use in burn patients were the most commonly identified barriers to more widespread uptake. Better collaboration between burn centers will allow for the creation of consensus statements and protocols to improve outcomes for burn patients who require ECMO.

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Burn patients find relief in a virtual world

PsycEXTRA Dataset ◽

10.1037/e300082003-045 ◽

2002 ◽

Author(s):

Siri Carpenter

Keyword(s):

Virtual World ◽

Burn Patients

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