Perspective on Contemporary Burn Surgery and Burn Care in Sweden

Abstract 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.

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746 Racial and Ethnic Disparities Among Burn Surgery Leadership

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.328 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S206-S206

Author(s):

Francesco M Egro ◽

Caroline E Kettering ◽

Anisha Konanur ◽

Alain C Corcos ◽

Guy M Stofman ◽

...

Keyword(s):

Group Representation ◽

Minority Group ◽

Ethnic Disparities ◽

Full Professor ◽

Academic Rank ◽

H Index ◽

Burn Care ◽

Burn Center ◽

Major Burn ◽

Burn Surgery

Abstract Introduction The underrepresentation of racial and ethnic minority groups has existed and been well documented in general and plastic surgery literature but has not been described in burn surgery. The aim of this study is to evaluate current minority group representation among burn surgery leadership. Methods A cross-sectional study was performed in January 2019 to evaluate minority group representation among burn surgery leadership. Burn surgeons included were directors of American Burn Association (ABA)-verified burn centers in the US, past and current presidents of the ABA and International Society of Burn Injuries (ISBI), and editorial board members of five major burn journals (Journal of Burn Care & Research, Burns, Burns & Trauma, Annals of Burns & Fire Disasters, and the International Journal of Burns and Trauma). Surgeons were compared based on factors including age, gender, training, academic rank, and h-index. Results Among 71 burn center directors, 68 societal presidents, and 197 journal editors, minority ethnic groups represented 18.3, 7.4, and 34.5 percent, respectively. Among US burn center directors, the group classified collectively as non-white was significantly younger (white = 56 years, non-white = 49 years; p< 0.01), graduated more recently (white = 1996, non-white = 2003; p < 0.01), and had a lower h-index (white = 17.4, non-white = 9.5; p < 0.05) than white colleagues. There were no significant differences in gender, type of residency training, advanced degrees obtained, and fellowships completed between white and non-white groups.The were no significant differences in the likelihood of white and non-white directors in academia to be full professor, residency or fellowship director, or chair of the department.When compared to the 2018 US National Census, burn unit directors had a 5.1 percent decrease in non-white representation. Specifically, Asians had an 8.3 percent increase in representation, while there was a decrease in both Black (12.0%) and Hispanic (15.3%) representation. Conclusions Disparities in representation of ethnic and racial minorities exist in burn surgery leadership. The most extreme disparities were seen with Black and Hispanic surgeons. However, because these surgeons are younger and graduated more recently, it is promising that minority representation will continue to rise in the future. Applicability of Research to Practice Programs should be initiated in burn surgery that address the implicit biases of burn surgeons and increase mentorship opportunities for underrepresented minorities.

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870 Delineation of Burn Surgery Coaching Trees: Describing Generational Influences of Leadership in Burn Care

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.436 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S274-S274

Author(s):

Victor C Joe

Keyword(s):

National Football League ◽

Head Coach ◽

Adaptive Network ◽

Burn Care ◽

Complex Adaptive ◽

Burn Surgery ◽

Fellowship Programs ◽

History Of ◽

Assistant Coach ◽

Surgical Coaching

Abstract Introduction Genealogies, or family trees, provide graphic representations of family history, tracing lines of decent among its members. Professional sports, most notably the National Football League (NFL), have borrowed this concept in delineating “coaching trees”. Connections among coaches can be described by the head coach-assistant coach relationships and utilized to demonstrate philosophical influences among coaches. This project was an attempt to explore the application of this concept to the profession of burn surgery and see if it could provide insight into the relationships (i.e., mentorship) that have influenced generations of burn surgeons over the past fifty years. Methods The first step in the process was to examine data sources. This consisted of gleaning information from the American Burn Association (ABA) archives (1976–1996) housed at the National Library of Medicine, the digital archives of the ABA, relevant review of the peer-reviewed literature, the public domain (world wide web), and documentation from various burn programs. The next step was to consider varying methodological approaches to the construction of the tree. Results While coaching relationships in the NFL represent a complex adaptive network, the relationships in an burn surgical coaching tree represent an even more complex network and the analogies between the two systems break down. As an exploratory project, the decision was made to construct several different trees with relative simple relational lines, concentrating central nodes on various past association presidents, prominent burn directors, and robust burn fellowship programs. This was done to illustrate proof-of-concept and inform future iterations of the project. Conclusions Creating burn surgery coaching trees can be done demonstrating relatively simple relational lines and provide basic illustrations of the influences of leadership among generations and institutions. More advanced mathematical and social science methodologies can be applied to explore these relationships in greater depth and elucidate a more thorough understanding of successful relationships, mentorship, and leadership dynamics in this complex adaptive network. Applicability of Research to Practice The description of coaching trees provides important insights into the history of burn surgery and the process can be replicated for other professions represented on the burn care team. It validates the importance of maintaining robust archives for our posterity. The information thus organized may inform the approach of the organization and/or inclined individual leaders on how mentorship occurs within our profession.

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57 Safety and Cost Effectiveness of Outpatient Surgery in Acute Burn Care

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.061 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

pp. S41-S41

Author(s):

Zach Z Zhang ◽

Andrew Golin ◽

Anthony Papp

Keyword(s):

Surface Area ◽

Body Surface Area ◽

Body Surface ◽

Outpatient Surgery ◽

Graft Loss ◽

Total Body Surface Area ◽

Split Thickness Skin Graft ◽

Burn Care ◽

Burn Surgery ◽

Total Body

Abstract Introduction Outpatient burn surgery is increasingly utilized for delivery of acute burn care. Reports of its safety and efficacy are limited. The purpose of our study was to evaluate the safety and cost reduction associated with outpatient burn surgery and to describe our centre’s experience. Methods This was a single centre, retrospective cohort study of consecutive patients who underwent outpatient acute burn surgery requiring split thickness skin graft or dermal regenerative template from January 2010 - December 2018. Patients with insufficient follow up to evaluate operative site healing were excluded. Patient demographics, comorbidities, burn etiologies, operative data and postoperative care were reviewed. The primary outcome is complication involving major graft loss requiring reoperation. Results 165 patients and 173 procedures met the inclusion criteria. The average age was 44 years and 60.6% (100/165) were male. The number of annual outpatient procedures increased 48% from 23 to 34 cases over the 9-year period. The mean grafted total body surface area was 1.0 ± 0.9%. Rate of major graft loss requiring reoperation was 5.2% (9/172). Greater than 95% graft take was achieved in 80.9% of patients. Age, sex, co-morbidities, total body surface area, and procedure types were not significantly associated with postoperative complication rate. Outpatient burn surgery model was estimated to save CA$7,875 per patient from inpatient costs. This extrapolates to a total of over CA$1.36 million in savings over the 9-year study period. Conclusions Acute burn care at our centre is increasingly being delivered through an outpatient day surgery model. Our demonstration of its safety and considerable cost savings is compelling for further utilization. Our experience found the adoption of improved dressing care, appropriate patient selection, increased patient education, adequate pain control, and regimented outpatient multidisciplinary care to be fundamental for effective outpatient surgical burn care.

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541 Gender Disparities Among Burn Surgery Leadership

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.169 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S108-S109

Author(s):

Francesco M Egro ◽

Anisha Konanur ◽

Caroline E Kettering ◽

Alain C Corcos ◽

Guy M Stofman ◽

...

Keyword(s):

Gender Diversity ◽

National Level ◽

Junior Faculty ◽

Fellowship Training ◽

Gender Disparities ◽

Cross Sectional ◽

Burn Care ◽

Burn Unit ◽

Burn Surgery

Abstract Introduction Gender disparities have been described in the plastic surgery and general surgery literature, but no data has been reported in burn surgery. The aim of this study is to determine gender disparities among burn surgery leadership. Methods 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. Results Among the 69 ABA and ISBI past presidents, 203 burn journals’ editorial board members, and 71 burn unit directors, females represented only2.9 percent, 10.5 percent, and 17 percent, respectively. Among burn unit directors, females completed fellowship training more recently than males (female = 2006, male = 1999, p < 0.02), have lower H-indexes (female = 8.6, male = 17.3, p = 0.03), and are less represented asfull professors (female = 8.3 percent, male = 42.4 percent, p = 0.026). There were no differences in age, residency, research fellowship, or number of fellowships. Conclusions 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. Applicability of Research to Practice Gender disparities are a significant issue in burn leadership, which needs further discussion at national level and should be addressed more proactively through programs that emphasize leadership opportunities and mentorship for women.

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591 Cost Savings in Operative Burn Care

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.217 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S137-S138

Author(s):

Tracy L Williams ◽

Meaghan Voycik ◽

Jenny A Ziembicki

Keyword(s):

Blood Loss ◽

Surface Area ◽

Body Surface Area ◽

Body Surface ◽

Surgical Intervention ◽

Cost Savings ◽

The Body ◽

Effective Measure ◽

Burn Care ◽

Burn Surgery

Abstract Introduction “Over the past 30 years, techniques of early excision and grafting along with enhancement of critical care have significantly improved survival following severe burn. Despite these advancements, large volume blood loss associated with surgical intervention continues to be a challenging aspect of burn surgery.” (Sterling, 2011) “Estimates of blood loss in adults during burn surgery range from 196 to 269 ml for each percent of the body surface area excised and grafted.” (Cartotto, 2000) A gold standard to achieve hemostasis does not exist. Therefore, institutions rely on their habit, practices, and FDA guidelines to formulate a standard of care. (Groenewold et al, 2011) In multiple comparison studies, “telfa pads soaked in epinephrine solution are a mainstay of hemostasis.” (Sterling, 2010) In 2018, an epinephrine shortage led to an increase cost to the operating room (OR) during the surgical treatment of burn wounds. This prompted the pharmacy and OR to collaborate on a more cost-effective measure without compromising patient care. Methods In November 2018, the epinephrine dosages were modified. Dosages were changed from Epinephrine 1;1000, 1mg/ml, 60mg/L for adults and 30mg/L for pediatrics to Epinephrine 1:1000, 1mg/ml, 30mg/L for adults and 15mg/L for pediatric patient’s. Parameters were set as to the amount of product that would be preordered from the pharmacy for each patient based on the total body surface area to be excised and or grafted: Should additional quantities be needed, an arrangement was made that the pharmacy would prepare and deliver the solution to the OR within 15 minutes of order to avoid delays in treatment. The time periods examined were: June 1, 2018 though November 7, 2018 and November 8, 2018 through June 20, 2019. Total burn patients requiring surgical intervention admitted during this time frame were 180 and 184 patients. June 2018-November 2018 represents previous practice. November 2018-June 2019 represents the implementation of changes in epinephrine dosage and establishing parameters for ordering. Results The overall Cost Savings In Operative Burn Care in relation to decreasing the dosage of Epinephrine from November 2018 to June 2019 was $100,952.25. Setting parameters provided better estimation of need and resulted in a 26% decrease in ordered product. Better estimation of product led to a 9.3% decrease in waste. Decreasing waste led to a savings of $28,463.61. Monthly cost to the OR for Epinephrine solution decreased to $9708.30 per month indicating a savings of $26,291.70 per month. Conclusions Operative costs decreased therefore leading to departmental savings. Applicability of Research to Practice Burn wound hemostasis was accomplished using reduced doses of Epinephrine solution. Nurses have a clearer picture on the amount of Epinephrine solution to order for each patient. The amount of product waste was reduced.

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A Qualitative Survey Study of United States Burn Units: Pathways to a Career in Burn Surgery

Journal of Burn Care & Research ◽

10.1093/jbcr/irz071 ◽

2019 ◽

Vol 40 (5) ◽

pp. 595-600

Author(s):

Francesco M Egro ◽

Erica D Johnson ◽

Elizabeth M Kenny ◽

Aaron M Foglio ◽

Brandon T Smith ◽

...

Keyword(s):

United States ◽

Critical Care ◽

Wound Care ◽

The United States ◽

Fellowship Training ◽

Training Requirements ◽

Burn Care ◽

Burn Unit ◽

Burn Units ◽

Burn Surgery

Abstract With current changes in training requirements, it is important to understand the venues in the United States for a general surgery (GS) and plastic surgery (PS) resident interested in pursuing a burn surgery career. The study aims to evaluate the pathways to a career in burn surgery and the current state of leadership. A cross-sectional study was conducted between August and September 2017. A 12-question survey was sent to all burn unit directors in the United States, asking about their background, who manages various aspects of burn care and the hiring requirements. Responses were received from 55 burn unit directors (47% response rate). Burn units are lead most commonly by physicians who received GS training (69%), but the majority either did not undergo fellowship training (31%) or completed a burn surgery fellowship (29%). While surgical care (GS = 51%, PS = 42%) and wound care (GS = 51%, PS = 42%) were predominantly managed by GS- or PS-trained burn teams, management of other aspects of burn care varied depending on the institution, demonstrating that a shift in burn care management. The desired hiring characteristics, including GS (67%) or PS residency (44%) and a burn surgery (55%), trauma surgery (15%), or critical care (44%) fellowship. Directors’ training significantly influenced their preferences for hiring requirements. While leadership in burn surgery is dominated by GS-trained physicians, the surgical and wound care responsibilities are shared among PS and GS. Although one third of current directors did not undergo fellowship training, aspiring surgeons are advised to obtain a burn surgery and/or critical care fellowship.

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The role of enzymatic debridement in burn care in the COVID-19 pandemic. Commentary by the Italian Society of Burn Surgery (SIUST)

Burns ◽

10.1016/j.burns.2020.04.009 ◽

2020 ◽

Vol 46 (4) ◽

pp. 984-985 ◽

Cited By ~ 2

Author(s):

Rosario Ranno ◽

Michelangelo Vestita ◽

Pasquale Verrienti ◽

Davide Melandri ◽

Giuseppe Perniciaro ◽

...

Keyword(s):

Italian Society ◽

Burn Care ◽

Burn Surgery ◽

Enzymatic Debridement

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Safety and Cost Effectiveness of Outpatient Surgery in Acute Burn Care

Journal of Burn Care & Research ◽

10.1093/jbcr/irab183 ◽

2021 ◽

Author(s):

Zach Zhang ◽

Andrew P Golin ◽

Anthony Papp

Keyword(s):

Surface Area ◽

Body Surface Area ◽

Body Surface ◽

Outpatient Surgery ◽

Graft Loss ◽

Total Body Surface Area ◽

Complication Rates ◽

Burn Care ◽

Burn Surgery ◽

Total Body

Abstract Introduction Outpatient burn surgery is increasingly utilized in acute burn care. Reports of its safety and efficacy are limited. This study aims to evaluate the safety and cost reduction associated with outpatient burn surgery and to describe our centre’s experience. Methods This was a single centre, retrospective cohort study of consecutive patients who underwent outpatient burn surgery requiring split thickness skin graft or dermal regenerative template from January 2010 - December 2018. Patient demographics, comorbidities, burn etiologies, operative data and postoperative care were reviewed. The primary outcome is complications involving major graft loss requiring reoperation. Results One hundred and sixty-five patients and 173 procedures met the inclusion criteria. The average age was 44 years and 60.6% (100/165) were male. Annual outpatient procedure volume increased 48% from 23 to 34 cases over the 9-year period. The median (IQR) grafted percentage total body surface area was 1.0 (1.0)%. Rate of major graft loss requiring reoperation was 5.2% (9/172) and the most common site was the lower extremity (8/9, 88.9%). Age, sex, co-morbidities, total body surface area, and procedure types were not significantly associated with postoperative complication rates. The outpatient burn surgery model was estimated to save CA$8,170 per patient from inpatient costs. Conclusion Demonstration of the safety and cost savings associated with outpatient acute burn surgery is compelling for further utilization. Our experience found the adoption of improved dressing care, appropriate patient selection, increased patient education, adequate pain control, and regimented outpatient multidisciplinary care to be fundamental for effective outpatient surgical burn care.

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Racial and Ethnic Disparities Among Burn Surgery Leadership

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa026 ◽

2020 ◽

Vol 41 (3) ◽

pp. 714-721 ◽

Cited By ~ 2

Author(s):

Caroline E Kettering ◽

Francesco M Egro ◽

Anisha Konanur ◽

Brandon T Smith ◽

Alain C Corcos ◽

...

Keyword(s):

Minority Groups ◽

Minority Group ◽

Ethnic Disparities ◽

The United States ◽

Academic Rank ◽

H Index ◽

Burn Care ◽

Burn Center ◽

Major Burn ◽

Burn Surgery

Abstract The underrepresentation of racial and ethnic minority groups has been well-documented in general and plastic surgery but not in burn surgery. The aim of this study is to evaluate current minority group disparities among burn surgery leadership. A cross-sectional analysis was performed. Burn surgeons included directors of American Burn Association-verified burn centers in the United States, past and current presidents of the American Burn Association, and editorial board members of five major burn journals (Journal of Burn Care & Research, Burns, Burns & Trauma, Annals of Burns & Fire Disasters, and the International Journal of Burns and Trauma). Surgeons were compared based on factors including age, gender, training, academic rank, and Hirsch index (h-index). Among 71 burn center directors, 50 societal presidents, and 197 journal editors, minority groups represented 18.3, 2.0, and 34.5%, respectively. Among burn center directors, the group classified collectively as nonwhite was significantly younger (49 vs 56; P < .01), graduated more recently (2003 vs 1996; P < .01), and had a lower h-index (9.5 vs 17.4; P < .05). There were no significant differences in gender, type of residency training, advanced degrees obtained, fellowships, academic rank, and academic leadership positions between white and nonwhite groups. When compared with the 2018 U.S. National Census, burn unit directors had a 5.1% decrease in nonwhite representation. Disparities in representation of ethnic and racial minorities exist in burn surgery despite having similar qualifying factors.

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