Development of a Unified National Database of Burn Centers with Co-located Emergency Departments, 2020

The care of severely burned patients comes with unique requirements for specialized burn centers. The American Burn Association sets guidelines for burn centers and provides a voluntary program to verify their quality of care. However, not all burn centers are verified, and it is unclear which nonverified centers have met requirements set by their state health departments. To compile a complete database of all United States emergency departments in facilities with confirmed burn centers, we investigated state requirements to supplement data from the American Burn Association verification process. In 2020, only 13 states set requirements for burn centers; 3 states explicitly required American Burn Association verification, 4 used modified American Burn Association criteria, and 6 used alternate criteria. Only 2 states had separate requirements for pediatric burn centers. Based on adherence to state and American Burn Association criteria, we identified 90 confirmed burn centers in 2020, 85 of which had emergency departments. Of these 85, 45 (53%) were only verified, 17 (20%) were only state-confirmed, and 23 (27%) were both. Emergency departments in a confirmed burn center were more likely—than those without—to have higher adult and pediatric visit volumes, be academic, be a stroke or trauma (adult or pediatric) center, have a dedicated pediatric area, and have a pediatric emergency care coordinator. We compiled the first unified burn center database that incorporates state and American Burn Association lists. This database can be utilized in future health services research and is available to the public through a smartphone application.

Electronic Cigarette-Related Injuries Presenting to Five Large Burn Centers, 2015-2019

Electronic cigarettes are advertised as safer alternatives to traditional cigarettes yet cause serious injury. US burn centers have witnessed a rise in both inpatient and outpatient visits to treat thermal injuries related to their use. A multicenter retrospective chart review of American Burn Association burn registry data from 5 large burn centers was performed from January 2015 to July 2019 to identify patients with electronic cigarette-related injuries. A total of 127 patients were identified. Most sustained less than 10% total body surface area burns (mean 3.8%). Sixty-six percent sustained 2nd degree burns. Most patients (78%) were injured while using their device. Eighteen percent of patients reported spontaneous device combustion. Two patients were injured while changing their device battery, and two were injured modifying their device. Three percent were injured by second-hand mechanism. Burn injury was the most common injury pattern (100%), followed by blast injury (3.93%). Flame burns were the most common (70%) type of thermal injury; however, most patients sustained a combination-type injury secondary to multiple burn mechanisms. The most injured body region was the extremities. Silver sulfadiazine was the most common agent used in initial management of thermal injuries. Sixty-three percent of patients did not require surgery. Of the 36% requiring surgery, 43.4% required skin grafting. Multiple surgeries were uncommon. Our data recognizes electronic cigarette use as a public health problem with potential to cause thermal injury and secondary trauma. Most patients are treated on an inpatient basis although most patients treated on outpatient basis have good outcomes.

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

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.

100 Use of the PHQ-2 as a Depression Screening Tool to Meet BQUIP Guidelines

Introduction In 2015, the Burn Quality Improvement Program (BQUIP) guidelines were established with recommendations for systematic screening of Major Depressive Disorder at all verified burn centers. Our level one trauma center rolled out a program to screen all patients entering the burn service starting in June 2018. After a year of collecting data, we have been able to evaluate the program and make recommendations for other burn centers. Methods All patients admitted to the inpatient burn service who were over 12 years of age were screened by bedside nurses using the 2-item Patient Health Questionnaire (PHQ-2). Exclusion for screening included those who were intubated and sedated and/or not alert or oriented. A reminder automatically popped up in the nursing task list in the electronic medical record until it was given, or patient was coded as not appropriate for screening. Results A total of 509 patients were admitted to the Burn Service between June 2018 and May 2019. Of those, 40 were identified as not being appropriate for screening due to inability to regain consciousness, and 116 (24%) were not screened for unknown reasons. The remaining patients, 353 (77%) were screened with the PHQ-2 and 94% of these patients were screened on the same day of admit. Of the patients screened, 28 (8%) scored above the clinical cut-off for probable depression (PHQ-2 ³ 3) and 265 (75.1%) did not endorse any symptoms on the PHQ-2. Of the 28 that screened positive, 16 (57.1%) received psychological services. Of those that did not receive psychology services, the majority were admitted for less than 3 days (n=10, 76.9%). Conclusions In the first year of the program the vast majority of eligible patients were able to be screened by nursing staff with a 2-item measure. A 77% screening rate is high for a trauma setting. This success is likely due to the automation of the task in the electronic medical record, the ease of use of the PHQ-2 and the dedication of the nursing staff. The 8% rate of a positive screen is higher than the general population (4%) but a similar rate to what is reported in the literature of burn survivors who are 5- and 10-years post burn injury. Given that most patients were screened within 24 hours of admission, we are capturing depressive symptoms that predate the injury. We know that depression can impair burn recovery (e.g., affect participation in therapy, impede wound healing) and lead to poorer long-term outcomes. Systematic screening of depressive symptoms upon admission will allow us to intervene earlier and potentially reduce barriers to optimal recovery. We will be discussing utilization of resources for providing inpatient services to patients with a positive screen.

79 Electronic Cigarette-Related Injuries Presenting to Five Large Burn Centers, 2015–2019

Introduction Electronic cigarettes are advertised as safer alternatives to smoking cigarettes yet can cause serious injury. As consumer use of electronic cigarettes has increased, burn centers have witnessed a rise in both inpatient and outpatient visits to treat thermal and blast injuries related to their use. Methods A multicenter retrospective chart review of ABA burn registry data from 5 large burn centers was performed from January 2015 to July 2019 to identify patients who sustained Electronic Nicotine Delivery Systems (ENDS)-related injuries. Results A total of 127 patients with electronic cigarette-related injuries were identified, of which 113 were male (89%) and 14 were female (11%). Mean age was 34.0 years (SD 13.5%, range 1–75 years). The majority of patients (n=92, 72%) were treated on an inpatient basis, and average length of stay was 6.7 days. Most patients sustained less than 10% total body surface area burns (mean 3.8%, SD 2.6%, range 0.1% to 16.5%). 66% (n=85) sustained 2nd degree burns, and 36% (n=46) sustained 3rd degree burns. Most patients were injured while using the ENDS (n=100, 78%), while 18% (n=24) of patients reported spontaneous combustion. 2 patients (1.5%) were injured while changing their device battery, and 2 patients (1.5%) were injured while modifying the device. 3% (n=4) were injured by second-hand mechanism. Burn injury was the most common injury pattern (100%), followed by blast injury (n=81, 63%). Flame burns were the most common (n=89, 70%) type of thermal injury, followed by contact burns (n= 70, 55%), flash burns (n=47, 37%), chemical burns (n=2, 1.5%), and electrical burns (n=1, 0.7%). The most commonly injured body region was the extremities. There were no ENDS-related deaths. Silvadene was the most common topical agent used in the initial management of thermal injuries, followed by Bacitracin and Xeroform. 63% (n=80) of patients did not require surgery, while 36% (n=46) required surgical excision, and 15% (n=20) required split-thickness skin grafting. Multiple surgeries were uncommon. 22% of patients required one operation, 12% required two operations, and 2% required 3 operations. Conclusions Our data recognizes use of ENDS as a growing public health problem with potential to cause thermal injury and secondary trauma. Most injuries occur during use, however many result from spontaneous combustion while the device is not being used. Treatment of ENDS-related injuries is institution-dependent. Most patients are treated on an inpatient basis however the majority of patients treated on outpatient basis have good outcomes.

47 COVID-19 Impact on Burn Care- A Summary of Weekly Bed Counts and Surge Capacity

Introduction The COVID-19 pandemic has raised global awareness of healthcare resource limitations. Specifically, the pandemic has demonstrated that burn disaster planning should involve non-burn disasters that threaten staff, supplies, or space. The ABA facilitated bed counts with the assistance of regional disaster coordinators from April through August of 2020. Our analysis examines the impact of the pandemic on burn surge and bed capacity in the U.S. Methods Bed availability was obtained by the ABA regional disaster coordinators through an initiative by the Organization and Delivery of Burn Care Committee. Bed availability was defined as immediately available burn beds and categorized as adult, pediatric, or flexible. Surge capacity was defined as the maximum number of patients that a burn center could admit in a surge situation. Data was deidentified by the central office with descriptive statistics to determine bed availability and surge capacity trends regionally and nationally. Results Bed counts were performed 6 times from 04/17/2020 through 08/14/2020. Response rates from the 137 North American burn centers varied from 86–96%. At least 6 burn centers (5%) were either closed or converted for COVID patients during the initial two bed counts. The total number of adult or pediatric burn beds was 2,082. Total bed availability decreased from 845 at the first survey down to 572 beds at the last survey. Surge capacity baseline was 1,668 beds and decreased from 1,132 beds in the initial survey down to 833 beds in the final survey. Conclusions Our study demonstrates a significant impact on burn bed availability due to the COVID-19 pandemic with a 37% reduction in available burn beds from April to August and a 26% reduction in surge capacity. This study demonstrates a substantial reduction in bed availability during the pandemic with additional analysis in process to examine regional trends.

541 72 Facial Burns Treated with Autologous Skin Cell Suspension- A Real World Data Analysis Across 5 U.S. Burn Centers

Introduction Optimal management of facial burn injuries remains a significant challenge in burn care. Acute surgical intervention is often coupled with delayed reconstructive procedures as an essential option for burn care. Experience with new surgical technologies could challenge historic reconstructive ladders. Our goal was to pragmatically assess the rate of successful intervention with autologous skin cell suspension (ASCS) for the treatment of facial burn injuries from real-world data. Methods A retrospective review from five burn centers over a three-year period was performed from deidentified registry data for facial burn injuries initially treated with ASCS. Cases of non-acute thermal burn and burns not involving the face were excluded. Data collection included: date of surgery, last follow-up date, need for grafting (split or full thickness skin graft, STSG or FTSG, respectively) or reapplication of ASCS within the same hospitalization, and reconstruction not including laser procedures due to scarring during the follow-up period. Descriptive statistics were calculated and data are reported as median with interquartile ranges where appropriate. Results A total of 72 burn injuries were treated with ASCS for facial burn injuries. Two burn centers treated 4 patients each, one treated 18, and the remaining two treated 22 and 24 patients. The median follow-up was 199 days (range 9 -1,150 days). Acute failure requiring a second treatment with ASCS or application of a full-thickness or split-thickness autograft occurred in 12 (16%) of the patients with 5 undergoing re-application of ASCS and 7 undergoing FTSG or STSG. reconstruction secondary to scarring during the follow-up period occurred in 10 (14%) of patients. Reconstruction was required in 1 of 5 patients that underwent a second treatment with ASCS as opposed to 4 of 5 patients treated with FTSG or STSG. Conclusions This study represents the largest experience with the use of ASCS for the management of facial burn injury in the reported literature. Use of ASCS from real-world data indicated that ASCS successfully resulted in definitive wound closure in 90% of the patients treated with facial burn injuries, with 10% requiring secondary intervention. This failure rate is below the previously published rate of 33%, indicating the disruptive potential of this technology for the management of facial burn injuries.

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

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.

603 Evaluating real-world national and regional trends in definitive closure in US burn care: A survey of US Burn Centers

Introduction Real-world data is observational data gathered outside of the experimental setting from diverse sources which is analyzed to produce real-world evidence. To better understand the impact of burn center treatment patterns, a national sample survey for real-world data sought to benchmark key burn center practice patterns, resource utilization, and clinical outcomes with national data contained within NBR version 8.0 (NBR). Methods A survey was developed by healthcare economists and burn specialists and administered to a representative sample of US burn centers. The survey collected information across several domains, including: burn center characteristics; patient characteristics including number of patients, and burn size and depth; aggregate number of types of procedures; and resource use such as autograft procedure time, length of stay (LOS), and dressing changes; and costs. Nuanced information was collected on care practices and patient outcomes for TBSA burns under 20%. Survey findings were aggregated by key outcomes (LOS, number of procedures, costs) nationally and regionally. Aggregated burn center data were also compared to the NBR to identify trends relative to current treatment patterns. Results Benchmarking survey results demonstrated shifts in burn center patient mix, with more severe cases being seen in the inpatient setting and less severe burns moving to the outpatient setting. Additionally, an overall reduction in the number of autograft procedures was observed compared to NBR, and time efficiencies improved as the intervention time per TBSA decreases with TBSA increases. Both nationally and regionally, an increase in costs were observed. Conclusions The results suggest resource use estimates from NBR version 8.0 may be higher than current practices, thus highlighting the importance of improved NBR reporting and further research on burn center standard of care practices. This study demonstrates significant variations in burn center characteristics, practice patterns, and resource utilization thus increasing our understanding of burn center operations and behavior.