Search

One of the most significant data collection efforts undertaken by the American Burn Association, the National Burn Repository (NBR) now encompasses more than 180,000 admissions. The Government Affairs Committee designated the prevalence of across-state-line burn admissions as one of its initial major inquiries to be made of the NBR. This line of inquiry could have bearings on healthcare access, legislative advocacy, and burn center solvency. The NBR Advisory Committee provided a specifically abstracted report after the 2005 call for data. Because of patient confidentiality concerns the file only contained admission frequencies by state-of-injury:state-of-care pairs. Nevertheless we were able to produce suggestive summary statistics and national maps for interpretations. This abstracted data encompasses records between 1995 and 2005, during which 8157 cross-state border admissions occurred, 6714 of which were to non-Shriner's hospitals. The rate of border crossing ranged from 0 to 202 patients annually. The highest rates were from the northernmost western states, northernmost New England states, and several southern states. Utah, West coast, and Great Lakes states sent relatively few admissions to other states. Twenty-seven states received no out-of-state admissions whereas several states had very high hosting rates. Although mapping cross-state burn admissions is an elementary exercise it demonstrated the value of the NBR for the Committees on Organization and Delivery, Government Affairs, and other facets of the American Burn Association. Anticipated access to ZIP Code data will permit: 1) granular identification of underserved areas, 2) documentation and prediction of reimbursement challenges, 3) mapping of de facto burn center referral markets, 4) mass disaster capacity planning, and 5) community-level burn risk factor analyses.

A multicenter clinical study assessed the ability of an acellular allograft dermal matrix to function as a permanent dermal transplant in full-thickness and deep partial-thickness burns. The study consisted of a pilot phase (24 patients) to identify the optimum protocol and a study phase (43 patients) to evaluate graft performance. Each patient had both a test and a mirror-image or contiguous control site. At the test site, the dermal matrix was grafted to the excised wound base and a split-thickness autograft was simultaneously applied over it. The control site was grafted with a split-thickness autograft alone. Fourteen-day take rates of the dermal matrix were statistically equivalent to the control autografts. Histology of the dermal matrix showed fibroblast infiltration, neovascularization, and neoepithelialization without evidence of rejection. Wound assessment over time showed that thin split-thickness autografts plus allograft dermal matrix were equivalent to thicker split-thickness autografts.

This article attempts to predict the federal government’s response to the cost of burn care in the 1990s by examining the explosive growth of health care costs in the 1980s and the impact that this had on hospitals with burn centers. The Prospective Payment System (PPS) was enacted in 1983, which limited the government’s liability to hospitals by effectively capping the amount of federal dollars in the system. The inequities of the classification of burn patients by the PPS is discussed and a proposal for modification is outlined.

A 2-year experience with laboratory and clinical applications of fibrin glue is presented. An autologous technique, which eliminates the danger of multidonor preparations, has been developed in our blood bank. While one can obtain different fibrinogen concentrations from the same amount of a patient's blood, in vitro mechanical testing demonstrated that at higher fibrinogen concentrations there is an increase in shear adhesive strength. Evaluation of skin-graft take in 16 Sprague-Dawley rats did not demonstrate significant differences in healing when adhesive use was compared with suture technique. In a clinical study, four different groups of patients (facial burns, hand burns, difficult graft sites, and miscellaneous surgical applications) benefited from autologous or single-donor fibrin glue for a total of 82 cases. There are several distinct advantages to the use of fibrin adhesive: The autologous technique eliminates the risk of transmissible viral diseases (AIDS, hepatitis); it can be used as a sealant in the treatment of seromas, dural leaks, and lymphoceles; and it improves hemostasis and early graft adherence. Face and hands are resurfaced with sheet grafts in a single procedure, obtaining a better aesthetic result with complete graft take and immediate start of physical therapy. Neither sutures nor pressure dressings are required. The minimal postoperative care associated with early return to normal activities seems to increase the satisfaction of patients and nurse personnel.

This historical review documents the establishment and current status of specialized burn care facilities opened in the United States since 1947, describes trends in their physical configuration and burn bed availability and discusses the terms used to classify those facilities. Lists of active burn care facilities were reviewed, including primarily the Burn Care Resource directories of the American Burn Association, which date back to 1976, along with the results of special surveys carried out by the authors in 1992 and 2006. Of the burn facilities at 175 US hospitals which had reported the presence of specialized burn beds since 1947, 25 had closed before 1992, 153 have been active as recently as 1992, and 125 were active as of early 2007. Between 1979 and 2007, total burn beds listed as available in annual surveys of hospitals reporting specialized burn care facilities ranged between about 1700 and 1800 beds. Average burn beds in those facilities increased from approximately 11.2 to 14.4. Specialized burn care facilities provide burn care in various configurations of units dedicated primarily to burns and those shared with other patients. Despite the closing of 50 such facilities in recent decades, total reported burn beds in the United States have remained essentially stable during the past 30 years. Issues related to concentrating burn beds in a smaller number of facilities and external factors affecting their past and future operations merit additional review.

This study was designed to test the hypothesis that auricular acupuncture-like transcutaneous electrical nerve stimulation would significantly reduce the pain experienced by patients with burns immediately after wound debridement, other wound care, and dressing changes. Subjects were 11 inpatients at the University of Alabama Hospital Burn Unit. A two-period crossover design was used, and each patient received one experimental treatment consisting of bilateral acupuncture-like transcutaneous electrical nerve stimulation to six ear points and one control treatment consisting of a placebo pill. The Visual Analogue Scale was used as a measure of pain and was completed immediately before and after treatments and at 15, 30, and 60 minutes after treatment. A two-factor repeated measures ANOVA indicated significant effects of measurement time (p less than 0.001) and treatment by time (p = 0.002). Post hoc analysis revealed significant differences (p less than 0.05) between experimental and control conditions at all times after treatment but not at pretreatment baseline. These results indicate that auricular acupuncture-like transcutaneous electrical nerve stimulation may be an effective pain management technique in patients with burns.

The safety and effectiveness of Integra® Dermal Regeneration Template was evaluated in a postapproval study involving 216 burn injury patients who were treated at 13 burn care facilities in the United States. The mean total body surface area burned was 36.5% (range, 1–95%). Integra® was applied to fresh, clean, surgically excised burn wounds. Within 2 to 3 weeks, the dermal layer regenerated, and a thin epidermal autograft was placed. The incidence of invasive infection at Integra®-treated sites was 3.1% (95% confidence interval, 2.0–4.5%) and that of superficial infection 13.2% (95% confidence interval, 11.0–15.7%). Mean take rate of Integra® was 76.2%; the median take rate was 95%. The mean take rate of epidermal autograft was 87.7%; the median take rate was 98%. This postapproval study further supports the conclusion that Integra® is a safe and effective treatment modality in the hands of properly trained clinicians under conditions of routine clinical use at burn centers.

The Baxter formula is commonly used to calculate fluid requirements. Baxter reported that 12% of patients would require more than 4.3 mL/kg per percentage of total body surface area (%TBSA). We anecdotally observed that we frequently exceeded the predictions of the formula, and we wondered if this was unique to our practice. We studied our last 11 burn-related resuscitations and collected fluid resuscitation data from US burn centers. Twenty-eight centers were queried, and 6 centers shared data. We were therefore able to study the resuscitation data of 50 adult patients. For 29 patients (58%), 4.3 mL/kg/%TBSA was exceeded compared with the 12% reported by Baxter. These findings suggest that in actual practice, fluid volumes administered are larger than the Baxter formula predicts. This survey does not explain why. Possible reasons for the larger fluid volumes are as follows: (1) the sample is not representative; (2) the formula is used improperly; (3) burns have changed and require more fluids; (4) burn care has changed.

This study examined the influence of various factors on the probability that 225 persons with severe burns would return to work 12 months after being discharged from the acute care setting. By use of multivariate analysis, 4 out of 15 variables significantly increased the probability of being employed: (1) being white, (2) not blaming oneself, (3) receiving workmen's compensation, and (4) being employed before the injury. With controls for burn severity and other variables, premorbid employment accounted for a person being 171 times more likely to return to work than one who was not employed before injury. Our findings suggest that some traditionally held impressions regarding factors related to return to work after a severe burn should be revisited. Moreover, despite earlier reports concluding that burn severity was the primary predictor of return to work, we found no factors in the acute care environment or patient characteristics that were statistically significant. Instead, findings from this series underscore the importance of the preinjury environment--especially being employed at the time of injury--as the strongest predictor of return to work after a severe burn.

OBJECTIVE: The use of hypertonic sodium solutions (HSS) and lactated Ringer's (LR) solution in the resuscitation of patients with major burns was compared. SUMMARY BACKGROUND DATA: Hypertonic sodium solutions have been recommended for burn resuscitation to reduce the large total volumes required with isotonic LR solution and their attendant complications. METHODS: To evaluate the efficacy of this therapy in our adult burn center, we resuscitated 65 consecutive patients with HSS (290 mEq/L Na) between July 1991 and June 1993 and compared them with 109 burn patients resuscitated with LR (130 mEq/L Na) between July 1986 and June 1988 (LR-1). A subsequent 39 patients were resuscitated with LR between September 1993 and August 1994 (LR-2). RESULTS: Patients receiving hypertonic sodium solutions versus LR-1 were similar with respect to age (46.0 vs. 43.6 years), total burn size (39.2% vs. 39.9%), incidence of inhalation injury (41.5% vs. 47.7%), and predicted mortality (34.6% vs. 30.2%). Total resuscitation volumes during the first 24 hours were lower among patients treated with HSS than those in the LR-1 group (3.9 +/- 0.3 vs. 5.3 +/- 0.2 mL/kg/% body surface area [BSA], p < 0.05). After 48 hours, however, cumulative fluid loads were similar (6.6 +/- 0.6 vs. 7.5 +/- 0.3 mL/kg/%BSA), and total sodium load was greater with the HSS group (1.3 +/- 0.1 vs. 0.9 +/- 0.1 mEq/kg/%BSA, p < 0.002). During the first 3 days after burn, serum sodium concentrations were moderately elevated in the HSS patients (153 +/- 2 vs. 135 +/- 1 mEq/L, p < 0.001). Patients resuscitated with HSS had a fourfold increase in renal failure (40.0 vs. 10.1%, p < 0.001) and twice the mortality of LR-1 patients (53.8 vs. 26.6%, p < 0.001). In patients resuscitated with HSS, renal failure was an independent risk factor (p < 0.001, by logistic regression). Analysis of these results prompted a return to LR resuscitation (LR-2). Age (41.6 +/- 2.9 years), burn size (37.8 +/- 3.9 %BSA), and incidence of inhalation injury (51.3%) were similar to the earlier groups. Total sodium load was less among LR-2 patients than the HSS group (0.7 +/- 0.1 mEq/kg/%BSA, p < 0.01), but similar to the LR-1 patients. Renal failure developed in only 15.4%, and 33.3% died, similar to the LR-1 group and significantly lower than patients treated with HSS (p < 0.001 and p < 0.05, respectively). CONCLUSION: Hypertonic sodium solution resuscitation of burn patients did not reduce the total resuscitation volume required. Furthermore, it was associated with an increased incidence of renal failure and death. The use of HSS for burn resuscitation may be ill advised.

This study was designed to evaluate the relative severity and resource consumption of hospitalized patients with burns in a national cross section of hospitals, both with and without burn centers. We investigated to determine whether clinical variables or severity of illness measures not recorded in the Uniform Hospital Discharge Data Set are significant in explaining variation in length of stay, total cost, and mortality for patients with burns. The ability of the six burn diagnosis-related groups (DRGs) to explain variation in patients' length of stay was 20% and their ability to predict total costs was 24%. For the same patient population, the explanatory power of the DRGs improved to 54% for length of stay and 44% for costs when these variables were adjusted by the Severity of Illness Index. We also investigated whether hospitals with burn centers treated a more severely ill population of patients with burns than did hospitals without such centers. Significantly higher levels of severely ill patients with burns (p less than or equal to 0.0001) were found at burn center hospitals. Other patients or treatment variables, combined with a case-mix severity measure, were evaluated for their ability to further increase the explanatory power of DRGs. We also discuss here the use of the study results for reevaluating reimbursement policy.

With the subcutaneous injection of a saline-vasopressor solution under donor sites and debrided areas, a significant reduction in intraoperative blood transfusions was accomplished. No problems in healing of donor sites or skin grafts were encountered. Vasodilating anesthetics and ketamine can overcome the local vasopressor action. Discontinuing or reducing the concentration of these agents results in less bleeding from the wound.

An acute microwave oven burn injury to the hand resulting in second- and third-degree burns to the left long finger is presented. Excision and coverage using a cross-finger flap resulted in full return of function. Because of the difficulty in evaluating the extent of tissue necrosis, we recommend hospitalization for most microwave injuries where obvious soft tissue damage has been sustained.

Biological adhesive fixation of skin grafts has been performed successfully on patients with facial burns and burns at difficult sites by using autologous human fibrin adhesive, which eliminates the danger of multidonor pool preparations. There are several distinct advantages to the use of fibrin glue: There is no danger of multidonor pool preparations. Wounds do not require any sutures or pressure dressings in the immediate postoperative period. Grafts demonstrate excellent take with minimal postoperative care. The patients can maintain normal ambulation. Fibrin glue seems to be an important factor in the application of skin grafts to burned areas in these two groups of patients.

In an effort to find an enzyme preparation for chemical debridement of burns, we treated 463 burn patients with Sutilains ointment (Travase) from 1972 through 1975. This method allowed earlier application of the first skin graft and resulted in a shorter hospital stay without significantly altering mortality compared with results obtained before 1972 and with national results. Travase appears to be effective in the treatment of burn patients when used in this method.

Of the estimated two million thermal injuries which occur in the United States annually, approximately 5% will require hospital care. The acutely burned patient requires comprehensive management, beginning with classification based on a “Rule of Nines” estimate of the body area involved. Percentage of second and third degree burns is used as a criterion for determining the need to hospitalize a burn patient. Tetanus prophylaxis is recommended in all acute burn cases. The Brooke and Dallas formulas may be used as means of determining fluid therapy requirements. When eschar constriction causes circulatory problems, escharotomy should be performed. Tracheostomy may be considered only when other methods of respiratory care, including endotracheal intubation, are inapplicable. Analgesia administration is done intravenously during early post-burn treatment. Other aspects of burn patient management to be considered are wound care, inhalation injury, and deep-structure damage often resulting from electrical burns.

The high cost of health care has become a nationwide concern and there are several national initiatives under way to reduce the rate of increase of these costs. Among the most recent initiatives has been the introduction of Medicare reimbursement based upon Diagnostic Related Groups (DRGs). This paper presents a retrospective analysis of the costs of care of burned patients admitted to the University of Alabama at Birmingham Burn Center and a profile of the financial impact of DRGs. Costs for burned patients were twice as high as for the average patient in the hospital and increased at a faster rate. Since 1977 the proportion of indigent patients and patients with very poor third-party coverage has greatly increased and those with good or excellent third-party coverage has decreased. If the care for Medicare patients had been reimbursed on the bases of DRG rates in 1982, payments would have exceeded costs by $2,981 but would have been $88,399 less than charges. In 1983, if the care for Medicare patients had been reimbursed on the bases of DRG rates, the payment would have been $409,629 less than costs and $634,583 less than charges. This very unfavorable reimbursement is because DRG reimbursement is essentially a flat rate and for long lengths of stay costs are much greater than reimbursements. Specific policies on methods to correct this discrepancy are suggested.

Because of basic differences in pathophysiology, patients with electrical injury require therapeutic measures quite separate and distinct from patients with flame burns. Fluid requirements are much greater for the electrical-injured patient due to the depth of the injury and frequent occurrence of pigment in the urine. Fasciotomy with surgical exploration for determination of tissue viability is usually required in areas of obvious or questionable viability in patients with electrical injury. Sulfamylon is preferred for topical antibacterial therapy in electrical injury, because of its excellent penetration into deeper tissues. With this regimen of conservative surgical debridement of necrotic tissue, in many patients we have been able to salvage limbs and, in particular, preserve function. Language: en

Transcutaneous electric nerve stimulation (TENS) was found to be as effective as morphine in reducing the pain associated with enzymatic debridement in burn patients. Twenty-four patients who were scheduled for Travase enzymatic debridement were randomly assigned to receive TENS or morphine for pain relief immediately following debridement. Patients reported their pain level on both a visual analogue scale and a verbal categorical scale at 15-minute intervals during the first hour and at hourly intervals through four hours after Travase application. There was no significant difference in the pain reported between the TENS and morphine groups. A statistical difference in pain report was found (ANOVA) over time, but no statistical difference was shown by group assignment. TENS appears to be a nonadditive alternative to morphine in burn patients for reduction of pain associated with enzymatic debridement.

The seriously injured patient seen in the hospital's emergency department presents a special set of problems. The physician responsible for his care must be able to recognize and treat any and all types and combinations of injuries. Top priority, of course, goes to ventilation and circulation. Simple maneuvers are often lifesaving if respiratory or circulatory failure is recognized immediately.

Because of disadvantages associated with the use of the Hubbard tank in the management of burn patients, the burn team at the University of Alabama replaced the tank with a trauma table that had been manufactured to their specifications. The trauma table is capable of being hydraulically raised or lowered, and maneuvered into Trendelenburg's position or its reverse. Another feature of the table is side rails that can be lowered. In contrast to the Hubbard tank, the trauma table has the following associated advantages: (1) quicker treatment sessions; (2) less pain to the patient; (3) elimination of patient exposure to contaminated water; (4) more comfort for the therapist; and (5) greater ease in patient handling, for example, rolling the patient onto a stretcher or bringing the patient into a sitting position.

The effects of enflurane anesthesia on the oxygen supply-demand balance have been studied in nine hypermetabolic-hyperdynamic burned patients undergoing debridement and skin-grafting procedures. Mean burn size was 55% of total body surface area. The patients were without cardiac, lung, hepatic, and kidney dysfunction and were not septic. Anesthesia was induced with sodium pentothal and maintained with enflurane and nitrous oxide in oxygen. Ventilation was controlled to maintain PaCO2 within normal limits. Crystalloid solutions and blood were administered to maintain adequate heart filling pressures. Serial measurements of cardiac output, arterial and mixed venous blood gases, and oxygen content were made before, during, and after anesthesia. Following induction of anesthesia and enflurane administration, cardiac output, oxygen delivery, and oxygen consumption decreased in a parallel fashion to approximately 60% of control. These variables did not change significantly throughout the procedure and returned to control values when enflurane was discontinued. Arteriovenous oxygen content difference did not increase and metabolic acidosis did not develop, suggesting that tissue perfusion remained adequate. Under anesthesia, oxygen consumption in burned patients was similar to that observed in normal subjects, indicating that enflurane blunts the hypermetabolic effects of thermal injury. It is concluded that in burned patients enflurane decreases metabolic rate and cardiac output, and maintains an adequate oxygen supply-demand balance.

The high cardiac output (CO) observed during the chronic phase in burned patients has been ascribed, among other factors, to the elevated blood flow in the burn wound. The hemodynamic effects of wound excision to fascia have been studied in eight patients with second- and third-degree burns ranging from 42% to 70% total body surface area (TBSA) undergoing debridement and skin-grafting procedures. The study was performed on the 4th to the 51st postburn day when all patients were in a hyperdynamic state. Serial hemodynamic measurements, including arterial and mixed-venous blood O2 saturation and content, were made before induction of anesthesia, during surgery both before and after wound excision, and in the recovery room a few hours after surgery. During anesthesia, the elevated CO decreased probably as a consequence of decreased metabolic requirements, but no further hemodynamic change was observed following wound excision. The size of burn wound excised to fascia averaged 24% TBSA and ranged from one-third to more than one-half of the initial burn. With discontinuation of anesthesia, CO rose rapidly above preoperative values, apparently to meet a similar increase in oxygen consumption. The excision of large areas of burned tissue did not attenuate the hyperdynamic circulation in burned patients, at least during and immediately after surgery. The data suggest that the elevated blood flow in the burn wound does not play a significant role in the pathogenesis of the hyperdynamic state.

Delayed wound closure should be used in wounds that are contaminated or contain devitalized tissue. The wound should be left open for three to four days for observation to determine if infection is present or if the tissues are devitalized. This management technique allows the physician to control infection and provide surgical debridement. Leaving the wound open provides the opportunity to inspect and evaluate the wound to determine if a problem is present. The wound then can be repaired with minimal risk. It is beneficial that the wound healing process is not delayed using this technique of wound closure.