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Introduction From the plains of North Dakota to the lakes of Minnesota and beyond, for our patient population, telemedicine has grown to be an important burn care delivery method. Specialized burn care is essential to ensure successful patient outcomes from burn injury. Our institution utilizes an advanced practice provider (APP) either physician assistant or nurse practitioner to lead the telemedicine care instead of the burn surgeon. Given most of the burn care is non-operative management, an APP can deliver burn expertise and high-quality care to the burn patient. Methods A retrospective chart review performed via data extraction from the electronic medical record at a single ABA-verified Burn Center. Dates of review ranged from January 1, 2022, through June 30, 2022. Patient population was Regions Hospital Outpatient Burn Clinic and Telemedicine Clinic volumes. Data review included patient location, mode of visit (in-person or virtual), and time to >95% healed. Inclusion was acute burns of all ages and mechanisms of injury. Exclusion was non-burn wounds, scar management and frostbite patients. Results A total of 1300 (87%) of all outpatient visits performed by APPs with 328 (25%) of these visits conducted via telemedicine. Varying by month, 7-13% of patients were treated exclusively via telemedicine not requiring any in-person burn care. When comparing the patient distance from the burn center (1-50 miles and >50 miles) and time to >95% healed, there was no correlation. Patients who were treated exclusively via telemedicine, lived an average of 205 (5-580) miles from the burn center, had an average TBSA of 2.2 (0.25-55) % and had an average of 18.3 (7-62) days until 95% healed. Compared to patients treated in-person only or combination of in-person and telemedicine, lived an average of 91 (1-631) miles, had an average TBSA of 2.5 (0.25-67) % and had an average of 24.6 (5-80) days until 95% healed. Conclusions A burn telemedicine program led by APPs can facilitate remote expert burn care, all while maintaining standard of care. Limitations were a narrow review window, single center retrospective analysis, and the exact date for time to 95% healed is difficult to determine due to interval follow up windows. Our goal is to further review and analyze our telemedicine and clinic data to optimize burn care delivery with the utilization of APPs, investigate quality of care indicators within telemedicine and reduce transfers and travel for specialized burn care. Applicability of Research to Practice APP led telemedicine improves surgeon availability to do hands on treatment in the Burn Center and allows for outreach and specialized expertise to be delivered across remote distances. It allows for the ability to triage patients and optimize burn clinic resources. Telemedicine can be performed in any location and reduce travel. Telemedicine is reimbursable. Barriers include wound care supply access, technological limitations, state licensing and institutional credentialing.

Land application of wastewater effluent is beneficial for recharging groundwater aquifers and avoiding direct pollutant discharges to surface waters. However, the fate of non-regulated organic wastewater pollutants, such as pharmaceuticals and personal care products (PPCPs), in such wastewater reuse systems is understudied. Here, a 14-month study (October 2016 through December 2017) was conducted to evaluate the fate and potential risks of seven commonly used PPCPs in a local wastewater treatment plant (WWTP) and from 13 groundwater monitoring wells at a spray-irrigation site where effluent has been spray-irrigated since the early 1980s. Acetaminophen and trimethoprim were the most frequently detected (93%) PPCPs in WWTP influent, while in the effluent, caffeine and trimethoprim were detected most frequently (70%). Wastewater treatment generally reduced concentrations of acetaminophen and caffeine by >88%; however, some compounds had low removal or were present at higher concentrations in the effluent compared with influent (e.g. naproxen, sulfamethoxazole, trimethoprim and ofloxacin). Seasonal trends were observed, with higher PPCP concentrations in the WWTP influent and effluent in the winter. Risk calculations conducted on the wastewater effluent suggest that the risk posed by PPCPs that persisted in the effluent are medium to high to aquatic organisms. Detection frequencies of PPCPs were lower in groundwater samples compared to the effluent, with sulfamethoxazole (40%) and caffeine (32%) as the most frequently detected compounds. Similarly, average concentrations of PPCPs in groundwater were found to be nearly two orders of magnitude lower than concentrations in the effluent. Minimal seasonal influence was observed for groundwater samples. Human health risk assessments indicate that concentrations in groundwater, which is used as a drinking water source, appear to pose minimal risk.

Introduction Burn Telemedicine programs are shown to improve care, increase access to specialists, provide real-time education, and reduce rates of missed outpatient visits. Many occur in acute care facilities or outpatient clinics and conducted with video technology. This center has expanded the depth of options for the care team to include a Burn Telemedicine Store and Forward Program. This program is unique in that patients receive an outpatient burn visit from their home. Methods Photographs instead of video are uploaded into the patient’s electronic medical record. The provider reviews the photographs then conducts a phone visit to review the plan of care and recommendations. This program is reserved for patients requiring outpatient evaluation and meet specific criteria including having technology available to upload photographs into the medical record, minor burns not requiring complex dressing changes, or burns located in areas needing range of motion evaluation. Burn telemedicine coordinators assist patients in creating access to their electronic medical record prior to discharge or during their initial clinic visit. Training relating to lighting, camera angles, and number of photos to include is performed. Photographs are uploaded into the medical record within a prescribed timeframe. The phone visit is then scheduled and conducted between the patient and provider. Results Benefits of this program include flexibility for patients to receive follow up care from their home, increased access to burn specialists in areas where healthcare facilities are scarce, and the ability to speak to their providers to review the care plan. Additionally, this program is beneficial to providers who have flexibility to review photographs and formulate the plan within the electronic medical record for this subset of patients instead of having them travel to a busy outpatient burn clinic. The providers bill the patient’s insurance for the phone visit. Finally, this process is fully secure and HIPPA compliant. Challenges have occurred within this program. The telemedicine coordinators have had to assist patients with limited experience with technology to upload photos into the electronic medical record which is time consuming and complex. In addition, some patients are not available during their scheduled phone visit time, resulting in additional time to reschedule their visits. Still this program has helped reduce the number of patients lost to follow up. Conclusions This program is a beneficial option for this subset of patients. Patients comment how much they appreciate the ability to do an outpatient appointment from their home. Applicability of Research to Practice This is applicable as it describes the benefits and challenges of developing a secure option for outpatient burn care. Outpatient visits directly into a patient’s home is unique and innovative.

People use a large variety of chemicals in their everyday lives, including prescription drugs, over-the-counter medications, and personal care products. The chemicals in these products enter the wastewater stream and are not removed completely by wastewater treatment plants (WWTPs), causing these chemicals and their metabolites to persist in the treated effluent. The Pennsylvania State University has spray-irrigated all of its treated wastewater onto ~240 ha of agricultural and forested land known as the “Living Filter” since the early 1980s. Once a week from October 2016 to March 2017, 24-hr composite samples were collected after each treatment process through the WWTP. Water samples were collected monthly from 14 groundwater wells (20 – 100 m) at the Living Filter. Samples were analyzed for seven emerging contaminants: acetaminophen, ampicillin, caffeine, naproxen, ofloxacin, sulfamethoxazole, and trimethoprim. The goal was to track these compounds through the WWTP and ultimately to the wells at the Living Filter to assess: (i) the removal efficiency of the WWTP and (ii) the ability of the Living Filter‘s soil profile to provide further treatment of the compounds that persisted in the effluent. In general, the WWTP effectively removed acetaminophen and caffeine (>90%), and exhibited seasonal variability in the removal efficiency of the other compounds, with activated sludge as the most effective step for reducing contaminant concentrations. Concentrations in the groundwater were typically at least one order of magnitude lower than the concentrations in the WWTP effluent, suggesting that the soil generally acted as an effective biogeochemical filter, except during snowmelt events.