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An understanding of population-specific variation in pediatric burn injuries is essential to the development of effective prevention strategies. The purpose of this study was to examine the etiology of pediatric burn injury considering age and race categories using the National Burn Repository. The authors reviewed the records of all pediatric patients (age

Although comprehensive burn care requires significant resources, patients may be treated at verified burn centers, nonverified burn centers, or other facilities due to a variety of factors. The purpose of this study was to evaluate the association between patient and injury characteristics and treatment location using a national database.We performed an analysis of all burn patients admitted to United States hospitals participating in the Healthcare Cost and Utilization Project over 2 years. Univariate and multivariate analyses were performed to identify patient and injury factors associated with the likelihood of treatment at designated burn care facilities. Definitive care facilities were categorized as American Burn Association-verified centers, nonverified burn centers, or other facilities.During the 2 years of the study, 29,971 burn patients were treated in 1,376 hospitals located in 19 participating states. A total of 6,712 (22%) patients were treated at verified centers, with 26% and 52% treated at nonverified or other facilities, respectively. Patients treated at verified centers were younger than those treated at nonverified or other facilities (33.1 years versus 33.7 years versus 41.9 years; p0.001) and had a higher rate of inhalation injury (3.4% versus 3.2% versus 2.2%; p0.001). Independent factors associated with treatment at verified centers include burns to the head or neck (relative risk [RR], 2.4; CI, 2.1 to 2.7), hand (RR, 1.8; CI, 1.6 to 1.9), electrical injury (RR, 1.4; CI, 1.2 to 1.7), and fewer comorbidities (RR, 0.55; CI, 0.5 to 0.6).More than two-thirds of significantly burned patients are treated at nonverified burn centers in the United States. Many patients meeting American Burn Association criteria for transfer to a burn center are being treated at nonburn center facilities.

Older adults with burns are at risk for worse outcomes because of factors related to age, comorbidities, and response to treatment. Although the impact of pneumonia has been previously described in burn patients, less is known in the older adult population. In this study, we used the National Burn Repository to characterize patient and injury factors associated with pneumonia development in older adults with burns. We examined the records of all patients in the National Burn Repository aged 55 years and older from 1995 to 2007. To better characterize the effects of age on outcomes, patients were stratified into three categories: 55 to 64 years, 65 to 74 years, and 75 years and older. Pneumonia was identified by listed complications and ICD-9 codes. Comorbidities were classified by Charlson Comorbidity Index Score. Unadjusted and multivariate regression analyses were performed to distinguish the impact of age, comorbidities, and injury factors on pneumonia development and mortality. A total of 23,794 patient records met inclusion criteria during the study period, and 2,052 (8.6%) had pneumonia. Patients who developed pneumonia were more likely to be men (65 vs 56%, P < .001), have higher TBSA (21 vs 13%, P < .001), have sustained inhalation injury (21 vs 7%, P < .001), and have comorbid condition (34 vs 13%, P < .001). On multivariate analysis, factors significantly associated with pneumonia development were male sex, percent TBSA, inhalation injury, and presence of comorbidity. Specifically, chronic lung and heart disease had adjusted odds ratio (OR) of 2.70 and 3.48, respectively, for development of pneumonia (P < .001). By logistic regression, adjusted OR for pneumonia were 0.89 (95% CI 0.74–1.06, P = 18) in the 65 to 74 years age group and 1.26 (95% CI 1.07–1.48, P = 005) in the oldest group compared with the 55 to 64 years age group. Pneumonia during hospitalization was associated with an adjusted OR of 1.91 for death (95% CI 1.61–2.27, P < .001) after controlling for the factors of age, sex, comorbidity, TBSA, and inhalation injury. Injury factors and the presence of comorbidities consistently predicted the development of pneumonia in this large national patient sample. Higher age category also predicted higher pneumonia risk, although this association was only significant in the highest age group. This study, thus, highlights the importance of comorbidities over chronological age in pneumonia development in older adults with burn injuries. (J Burn Care Res 2010;31:105–110)

The provision of optimal burn care is a resource-intensive endeavor. The American Burn Association has developed criteria to help guide the decision to refer a patient to a burn center for definitive injury care. The purpose of this study was to compare the patient and injury characteristics of patients admitted to the single verified burn center in Washington State with those treated at other facilities in the state. We performed a retrospective review of all patients admitted to a hospital with a burn injury in Washington State from 1987 to 2005 using the state's discharge database (Comprehensive Hospital Abstract Reporting System). Patient and injury factors of patients admitted to the state's single verified burn center or at other hospitals were compared. Multivariate poisson regression was used to calculate the relative risk of injury and patient factors that were significantly associated with admission to the verified burn center. From 1987 to 2005, a total of 16,531 patients were admitted to a Washington State hospital after burn injury. Of these patients, 8624 (52.2%) were treated definitively at the University of Washington Burn Center. Patients treated at this verified center had larger overall burn size (7.4% vs 4.5% TBSA, P < .001), higher percent full-thickness burn (4.3% vs 1.2%, P < .001), and higher rates of inhalation injury (2.3% vs 1.5%, P = .005). Uninsured status (relative risk = 1.46, 95% confidence interval = 1.4-1.5) was also significantly associated with treatment at the verified burn center. Injury severity and payer status were both found to be independent predictors of treatment at the single verified burn center in Washington. Language: en

The homeless are at an increased risk for traumatic injury, but little is known about the injury etiology and outcome of homeless persons who sustain burn injuries. In this study, we analyze patient and injury characteristics of homeless persons admitted to a regional burn center. This is a retrospective cohort study of patients admitted to our burn center between 1994 and 2005. A total of 3700 adult patients were admitted during the study period and, of these, 72 (1.9%) were homeless. The cohort of homeless patients was compared with domiciled adult patients admitted during the same time period, analyzing baseline patient and injury characteristics and injury outcomes. Overall, homeless patients had more extensive burn injuries than domiciled patients (17.8% vs 11.2%TBSA, P < .001) and overall longer lengths of hospital stay (22 vs 12 days, P < .001). The homeless population also had significantly higher rates of alcohol (80.6% vs 12.8%, P < .001) and drug abuse (59.4% vs 12.8%, P < .001), history of mental illness (45.2% vs 11.0%, P < .001), and injury by assault (13.9% vs 2.0%, P < .001). Homeless patients tended to have more severe injuries; higher rates of substance abuse and mental illness; increased incidence of assault by burning; and longer lengths of hospital stay. Hospitalization of a homeless patient following injury may provide a unique opportunity to address co-occurring substance abuse and mental illness and approach injury prevention to improve patients’ outcomes and reduce injury recidivism.

BACKGROUND: With unprecedented survival rates in modern burn care, there is increasing focus on optimizing long-term functional outcomes. However, 3% to 8% of patients admitted to burn centers still die of injury. Patterns in which these patients progress to death remain poorly characterized. We hypothesized that burn nonsurvivors will follow distinct temporal distributions and patterns of decline, parallel to the trimodality of deaths previously described for trauma. METHODS: We retrospectively identified all adult deaths from 1995 to 2007 in the National Burn Repository database (n = 5,975) and at our regional burn center (n = 237). We stratified patients by age and analyzed injury and death characteristics. We used objective criteria to allocate nonsurvivors to one of four trajectories: early rapid decline, early organ failure, late sudden death, or late-onset decline. RESULTS: The greatest concentration of deaths in both samples and age groups occurred within 72 hours of injury and decreased subsequently with no later mortality peak. Death was most often caused by burn shock within the first week of injury, cardiogenic shock or lung injury in Weeks 1 to 2, and sepsis/multiorgan failure after Week 2. In decreasing frequency, trajectories to death fit the pattern of early rapid decline (58%), early organ failure (20%), late-onset decline (16%), and late sudden death (6%). CONCLUSION: Most burn deaths follow a pattern of early rapid decline or early organ failure manifested by death or critical illness within several days of the burn. These findings indicate that more than three quarters of burn deaths are attributable to failure or significant decompensation beginning in the resuscitation phase. Sporadic deaths later in hospitalization are uncommon. Despite significant advances in burn resuscitation, our data indicate that ongoing efforts to mitigate deaths in modern burn care should still focus on care improvements in the resuscitation phase. LEVEL OF EVIDENCE: Epidemiologic study, level III. Language: en

Despite many advances in modern burn care, deaths still occur in the burn intensive care unit. For patients with severe burns, providers may advocate to withdraw life support early during hospitalization when the extent of injury makes survival highly unlikely or when the patient's condition deteriorates during resuscitation. Our regional burn center has implemented a stepwise withdrawal protocol since 2001 in an effort to standardize symptoms palliation at the end of life. In this study, the authors evaluated the frequency of early withdrawal and the protocol impact on end-of-life processes of care in burn patients who died within 72 hours of hospitalization. A 13-year review of all burn patients aged ≥18 years admitted to our burn center to identify all patients who died within 72 hours of hospitalization was performed. Patients were dichotomized to the periods before (1995 to mid-2001) and after implementation of standardized withdrawal protocol (mid-2001 to 2007). Descriptive analyses were performed to compare end-of-life care processes between the two periods. A total of 4374 adult patients with acute burns were admitted during the 13-year study period, of which 252 (6%) died during hospitalization. Of the patients who died within 72 hours, 106 (84%) had withdrawal of life support compared with 20 (16%) who died with ongoing life support. Higher mean TBSA distinguished patients who died by withdrawal (61 vs 48%, P = .06). Since mid-2001, all 61 patients who had life support withdrawn were by protocol. Implementation of the protocol has led to more frequent use of opioid infusion (98 vs 87%, P = .07) and benzodiazepine infusion (95 vs 49%, P < .01), without hastening time to death (median 5.0 vs 5.5 hours, P = .70). The large majority of early burn deaths at our regional center occur via withdrawal of life support. Implementation of a protocolized withdrawal has resulted in more consistent provision of analgesia and sedation without hastening death. Burn centers should consider using a protocol for withdrawal of life support to improve consistency in end-of-life symptoms palliation.

Severe burn injury results in a systemic inflammatory response that leads to increased capillary permeability and fluid leak into the interstitium. This global systemic capillary leak can be attributed, at least in part, to inflammatory mediators produced as a result of cellular injury. Plasma exchange has been used in the management of a number of illnesses with a significant inflammatory component, and, therefore, may have a role in the early management of burn injury. The purpose of this study was to review our institutional experience using plasma exchange in the management of severe burn injury. We performed a retrospective review of all patients receiving plasma exchange at our burn center between 2001 and 2005. Data collected included the following: burn size, presence of inhalation injury, resuscitation fluid received, urine output, lactate levels, base deficit levels, and hematocrit before and after the exchange procedure. A total of 37 patients underwent plasma exchange during the 5-year study period and seven patients underwent two plasma exchange treatments. Average TBSA burned was 48.6% (range 18-82) and 73% of patients sustained an inhalation injury. After plasma exchange, hourly fluid volume received significantly decreased (P < .05) and base deficit, lactate, and hematocrit levels significantly improved. Plasma exchange in the early resuscitation period was associated with decreased fluid administration, as well as increased urine output in the period during and immediately after the procedure. These data suggest that plasma exchange may provide a useful tool in the management of severe burn injury.

Improvements in outcomes for older adults sustaining burn injuries have lagged far behind those of younger patients. As this segment of the population grows, there has been an increasing interest in better understanding the epidemiology and outcomes of injury in older adults. The National Burn Repository (NBR) provides a unique opportunity to examine burn injuries on a national level. We aimed to characterize specific injury and outcome trends in older adult with burns through analysis of the NBR. We examined the records of all patients in the NBR aged 55 and older. To characterize age effects on injury and outcomes, patients were stratified into three age categories: 55 to 64 years, 65 to 74 years, and 75 years and older. Baseline characteristics, details of hospital treatment, mortality, and disposition were compared among these three age groups using chi or analysis of variance. Logistic regression analysis was performed to assess the impact of age on burn mortality. A total of 180,401 patient records were available from 1991 to 2005, of which 23,180 (14%) met age inclusion criteria. Mean burn size (9.6% TBSA) and percent with inhalation injury (11.3%) did not markedly differ by age. Men predominated overall (ratio 1.4:1), although women (4290) outnumbered men (3439) in the oldest age category. Length of stay per TBSA and median hospital charges increased with increasing age category, suggesting higher resource consumption with aging. Mean number of operations per patient, however, decreased with age. Mortality rates and discharge to nonindependent status increased with age. By logistic regression, the adjusted odds ratio for mortality was 2.3 (95% CI 2.1-2.7) in the 65 to 74 age group, and 5.4 (95% CI 4.8-6.1) in the oldest group when compared with the 55 to 64 age group. Mortality rates decreased significantly after 2001 across all age groups. This analysis demonstrates age-dependent differences in resource utilization and mortality risk within the older burn population and highlights the need for a national research agenda focused on management practices and outcomes in older adult with burns.

Modern burn care is a resource intensive endeavor requiring specialized equipment, personnel, and facilities in order to provide optimum care. The costs associated with burn injury to both patients and society as a whole can be multifaceted and large. The purpose of this study was to evaluate the association between hospital costs, patient characteristics, and injury factors in a cohort of pediatric patients admitted to a regional burn center. We performed a review of the hospital charges accrued by pediatric patients (age

Returning to school is an important indicator of functional aptitude and emotional adjustment in school-aged patients after burn injury. Only two reports in the burn literature provide objective data on time to school re-entry. However, these analyses did not address the impact of patient and burn injury characteristics on time to return to school. The purpose of this study was to determine the time for school re-entry and to identify the factors associated with re-entry time in a cohort of burned children treated at our burn center. We performed a retrospective review of all school age children treated at our burn center from 1997 to 2003 who were entered into a federally funded longitudinal research database for patients with severe burn injury. Time to school re-entry after discharge was calculated for each patient, and multivariate regression was used to identify the factors associated with longer time to return to school. A total of 64 patients were included in this study. The average time to school re-entry was 10.5 days (range, 0-40) and the median time was 7.5 days. Gender (male), age, and length of hospital stay were significantly associated (P < .05) with longer time to return to school. The average time to school return is quite short. Further studies are needed to increase understanding of the factors influencing longer time to re-entry and also to examine children's experiences upon re-entry.

To study factors related to breast cosmetic outcome in patients treated with an interstitial implant as part of breast-conservation therapy.One hundred fifty-six patients with stage I or II breast carcinoma who received 50 Gy of external-beam irradiation followed by a 20-Gy interstitial boost were examined. The dose homogeneity index (DHI) was calculated for each evaluable implant and was examined in light of other patient-, treatment-, and tumor-related variables previously demonstrated to affect cosmesis.Of the variables examined, both the DHI (P = .021) and the total excision volume (P = .019) were significantly related to cosmetic outcome (excellent vs less than excellent) in a univariate model. In the multivariate analysis, only the total excision volume remained significant (P = .032). The mean total excision volume +/- SD in patients with excellent cosmetic outcome (81.8 cm3 +/- 84.0) was significantly less than that in patients with less than excellent cosmetic outcome (120 cm3 +/- 84). The probability of excellent cosmetic outcome linearly increased with an increase in DHI. The mean DHI was 0.74 +/- 0.12 for the cases with excellent cosmetic outcome and 0.68 +/- 0.10 for those with less than excellent cosmetic outcome.To achieve optimal cosmesis, DHI should be maximized. The volume of tissue removed, however, remains the most significant determinant.

To evaluate the relative utility of interstitial implant as a technique for tumor bed dose escalation and assess technical factors related to outcome.From 1982-1994, a prospectively applied institutional policy of margin-directed boost dose escalation to the tumor bed was followed whereby interstitial implantation was commonly employed for a final margin status (FMS)or = 2 mm. There were 509 treated breasts, of which 127 received an implant boost. For purposes of comparison, cases were broadly classed as "implant" (all FMSor = 2 mm) and "nonimplant" (FMSor = 2 mm or FMS2 mm). The implant target volume was determined at completion of whole breast irradiation by clinical assessment. All implants were constructed in accordance with a preplanning algorithm designed to maximize dose homogeneity within a prescription isodose goal of 0.50 Gy/h for 40 h. Local control and cosmetic outcome were evaluated with respect to extent of tumor, histopathology, FMS, extent of surgery, and systemic adjuvant therapy. Implant quality was assessed using four calculated parameters: strand separation quotient (SSQ), planar separation quotient (PSQ), global separation quotient (GSQ), and dose homogeneity index (DHI). The mean implant volume was 48.3 +/- 20 cc, the mean prescribed dose rate was 0.46 +/- 0.08 Gy/h, and the mean total implant dose was 19.94 +/- 1.52 Gy.Cosmetic outcome was good/excellent in 90% of implant and 83% of all nonimplant cases, which was not statistically different. Cosmesis was significantly superior with implant when compared to nonimplant cases receiving an external boost of 20 Gy. Logistic regression analyses of implant cases revealed that reexcision volume and decreased DHI were associated with adverse cosmesis. There were 10 local failures in the implanted patients (4 within the prescribed isodose volume, 5 at the periphery, and 1 elsewhere in the breast). The local failure rate at 5 and 7 years in the implanted group was 3.9 and 9.0%, respectively, compared to nonimplant cases with a marginor = 2 mm of 3.2 and 3.2%, respectively. These differences were not significant. The crude local failure rate in patients with an associated DCIS component was 12% a compared to 3% in patients with pure invasive histology (p = 0.06). A proportional hazards survival model revealed a significant association of local failure with the performance of a reexcision and young age.We conclude that interstitial implant boost for breast conserving irradiation is associated with cosmesis that is superior than the same nominal dose of external beam boost, although this is highly dependent upon the technical quality of the source position and the relative uniformity of dose deposition. Breast implantation results in a rate of local control no better than dose-matched external beam boost in patients with a final marginor = 2 mm. Local control with implantation might be further enhanced by increasing implant volume and/or improved target localization.