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Introduction In the U.S., traumatic injuries are the leading cause of death before age 45 and have a significantly lower mortality if routed to a verified trauma center. Burn injuries are included in trauma statistics and represent 1.1 million injured people annually seeking medical assistance. Routing of burn injuries to ABA-recognized burn centers has yet to be assessed as it has in trauma injury. Our goal was to examine the impact of prehospital routing of burn injuries on hospital length of stay, mortality, and potential costs of care through a statewide care coordination center, the Louisiana Emergency Response Network. Methods Our study is a retrospective statewide analysis of burn injuries from 01/01/2017 thru 12/31/2019 using the Louisiana Hospital Inpatient Discharge Database. Routing of burn patients was implemented in 2018 using the ABA burn referral criteria. Data included: total admissions with primary burn diagnosis, region, discharge status, length of stay, and raw mortality by region and state. Descriptive and comparative statistics were performed to assess the impact of routing of burn injured patients. Cost analysis was performed using Louisiana Medicaid per diem rates from 2021 at $1,907.92/day. Results 1,288 patients were treated in Louisiana during the study period with 855 post-routing and 433 pre-routing. The mean length of stay was reduced from 11.84 days in 2017 to 8.82 days in 2018 (p value=0.0988) with a potential savings of 761 inpatient care days or $2.17 million. Overall mortality across the state was unchanged except in the highest volume region where it dropped from 7.9% in 2017 to 3.6% in 2019 (54%). Conclusions Burn injuries meeting ABA referral criteria are a form of time-sensitive trauma. This study marks the first analysis pre and post implementation of routing for burn injuries by a statewide care coordination center. Our study demonstrates improvement in length of stay and mortality but a continued need to examine other contributing factors such as severity of injury and concomitant trauma.

Introduction Healing potential of deep partial thickness burns is not easily determined early after injury. Prolonged and continued inflammation can contribute to burn wound conversion. Early excision compared to a wait and see approach to wound healing decreases inflammation, shortens length of stay, and decreases painful wound procedures. However, early excision is at the expense of removing tissue that may otherwise heal without autografting. Use of a cryopreserved, allogeneic cellularized scaffold living tissue product (CTP) in pediatric deep partial thickness wounds with dermal elements remaining after excision is an alternative approach to wound closure. CTP may allow early excision without compromising healing potential, thereby minimize donor site morbidity, infectious complications and decrease length of stay. This case series describes the expanded access experience of a CTP on pediatric patients with thermal injury. Methods Expanded use approval of a CTP was obtained through the FDA for pediatric patients with burns at three burn centers. Patients were taken to the operating room for excision and grafting of burns at the discretion of the attending surgeon. In wounds with dermal elements present after excision, CTP was grafted to the wound bed (Table 1). Postoperative wound care and follow up was per institutional standards of care. Results Six pediatric patients (9 weeks – 13 years old) with mixed depth burns having dermal elements remaining after excision were treated successfully with a CTP. Donor site surface area was reduced in all patients. No serious adverse events related to the CTP were noted in any of the cases. Average time to heal wounds treated with the CTP was approximately 2-3 weeks. In wounds ultimately deemed to be full thickness, CTP was not detrimental to subsequent autograft take. See Table 1. Conclusions This case series demonstrates that use of a CTP in pediatric patients is donor site sparing without any serious adverse events. Furthermore, use in full thickness burns is not detrimental to subsequent autograft take. The degree of dermal elements necessary to support wound healing is unknown and requires further study. This case series supports the application for a clinical trial investigating the safety and efficacy of CTP as an adjunct to wound healing in pediatric deep partial thickness burns.

Introduction Autograft (AG) is the standard of care for treatment of severe burns. While AG provides effective wound closure (WC), the procedure creates a donor site wound prone to pain and scarring. In a phase 1b trial, no deep partial-thickness (DPT) wound treated with a bioengineered allogeneic cellularized construct (BACC) required AG by Day 28 and WC at the BACC site was achieved in 93% of patients by Month (M) 3. This phase 3 study (NCT03005106) evaluated the efficacy and safety of this BACC in patients with DPT burns. Methods Enrolled patients were aged ≥18 years with 3–49% TBSA thermal burns on the torso or extremities. In each patient, two DPT areas (≤2,000 cm2 total) deemed comparable following excision were randomized to treatment with either cryopreserved BACC or AG. Coprimary endpoints were 1) the difference in percent area of BACC treatment site and AG treatment site autografted at M3 and 2) the proportion of patients achieving durable WC of the BACC treatment site without AG at M3. Ranked secondary endpoints were: 1) the difference between BACC and AG donor sites in average donor site pain intensity through Day 14; 2) the difference between BACC and AG donor site cosmesis at M3; and 3) the difference between BACC and AG treatment site cosmesis at M12. Safety assessments were performed in all patients through M12. Results Seventy-one patients were enrolled. By M3, there was a 96% reduction in mean percent area of BACC treatment sites that required AG, compared with AG treatment sites (4.3% vs 102.1%, respectively; P Conclusions This phase 3 study achieved both coprimary endpoints, including significant autograft sparing and durable WC in DPT burns. Both donor site pain and donor site cosmesis were favorable outcomes of significantly reduced use of AG in BACC-treated patients. M12 POSAS for BACC did not differ significantly from AG. This BACC may offer a new treatment for severe burns to reduce or eliminate the need for AG. Applicability of Research to Practice This BACC has shown clinical benefit in patients with DPT thermal burns, potentially mitigating donor site morbidity. External Funding Stratatech, a Mallinckrodt Company; Funding and technical support for the Phase 3 clinical study were provided by the Biomedical Advanced Research and Development Authority (BARDA), under the Assistant Secretary for Preparedness and Response, within the U.S. Department of Health and Human Services, under Project BioShield Contract No. HHSO100201500027C.

Introduction Autograft (AG) is the standard of care for treatment of severe burns. While AG provides effective wound closure (WC), the procedure creates a donor-site wound prone to dyspigmentation, infection, scarring, and pain. In a phase 1b trial, no deep partial-thickness (DPT) wound treated with a bioengineered regenerative skin construct (BRSC) required AG by Day 28 and WC at the BRSC site was achieved in 93% of patients by Month 3 (Holmes et al 2019). This phase 3 study evaluated the efficacy and safety of this BRSC in patients with DPT burns. Methods This phase 3 study (NCT03005106) enrolled patients aged ≥18 years with 3–49% total body surface area (TBSA) thermal burns on the torso or extremities. In each patient, two DPT areas (≤2,000 cm2 total) deemed comparable following excision were randomized to treatment with either cryopreserved BRSC or AG. Coprimary endpoints were 1) the difference in percent area of BRSC treatment site and AG treatment site autografted at 3 months and 2) the proportion of patients achieving durable WC of the BRSC treatment site without AG at 3 months. Safety assessments were performed in all patients. Efficacy was analyzed at 3 months and safety and scar follow-up continues to one year. Results A total of 71 patients were enrolled (mean [SD] age 44 [16] years; mean [SD] %TBSA 12.0 [8.4]). By Month 3, 4.3% (SD 21.6%) of all BRSC-treated area required AG compared with an additional regrafting of 2.1% of all AG-treated area (total 102.1% SD 13.1%; P< .0001). Three patients subsequently required AG at their BRSC site, 2 of whom also required it at their AG sites; Durable WC without autografting at the BRSC treatment site was achieved at Month 3 in 83% of patients compared with 86% of patients at the AG site. The most common BRSC-related adverse event (AE) was pruritus, occurring in 11 (15%) patients. All BRSC-related AEs were mild or moderate in severity. Conclusions This phase 3 study achieved both coprimary endpoints, including significant autograft sparing and durable WC in DPT burns. This BRSC may offer a new treatment for severe burns to reduce or eliminate the need for AG. Applicability of Research to Practice This BRSC has shown clinical benefit in patients with DPT thermal burns, potentially mitigating donor site morbidity. External Funding Stratatech, a Mallinckrodt Company; Funding and technical support for the Phase 3 clinical study were provided by the Biomedical Advanced Research and Development Authority (BARDA), under the Assistant Secretary for Preparedness and Response, within the U.S. Department of Health and Human Services, under Project BioShield Contract No. HHSO100201500027C.

Epidemiological trends provide a means for targeting efforts in burn prevention. There have been but few regional-specific studies concerning burns in the southern United States. This study describes burn injury trends experienced by a single burn center in Louisiana. We also investigate the temporal relationships of several activities informally known for having a high risk for burn injury among local providers. Data were retrospectively extracted from the records of all patients treated for burn injuries at the regional burn center from 2012 to 2018 in both inpatient and outpatient settings. Demographical data and burn injury characteristics were noted. A total of 6,498 patients were included (1,593 inpatient, 4,905 outpatient). The most common burn etiologies were scald and flame, with flame being associated with more severe injuries. Overall incidence was disproportionally high in males and children less than 4 years of age. Total incidence was highest in Caucasians, though African Americans held the highest annual incidence rate specific to this population. The most common situation at the time of burn injury involved the consumption or preparation of food or beverages. Significant variation was observed in the rates of different injury situations throughout the year. Notably, burns related to seafood, heating, and firework activity occurred more often during crawfish season, colder months, and the months of January and July, respectively. In addition to establishing preliminary trends, these data may be useful in guiding the development of future evidence-based prevention efforts to target the most detrimental burn injuries in this population.

Introduction As a verified burn center, we prepare for mass casualty & constantly strive to remain at the forefront of the burn technology & research. There was nothing that prepared us for a statewide stay-at-home order nor the hospital lockdown that would come with the coronavirus pandemic. The hospital lockdowns resulted in disheartening loneliness that would prohibit the visitation of family to the ill or injured patients. The difficulty of locking down well parents proved challenging. Our new hospital policy restricted parent movements & their anxiety of exposure also heightened the desire to discharge. We questioned whether the peds patient was better suited in the hospital or at home. This shifted our usual practice. During March-May, our hospital restricted parent movements out of the patient’s room, no visitors, no swap outs during the day. This resulted in early debridements, often at the bedside, & application of the polylactic acid polymer substitute. This allowed for a discharge within 24 hrs & return to clinic in 48 hrs. Methods We reviewed the charts of 10 pediatric patients that normally would have remained hospitalized pre-COVID & these patients were admitted underwent debridement & early application of a polylactic acid polymer skin substitute. The charts were reviewed to determine if there were any readmissions, ER visits, delays in wound healing, delays in OR time, if needed, opposition from parents or nurses from about readiness for discharge. Results The charts indicated there was one return admission. The readmit was from a planned split thickness skin graft & the polylactic acid polymer was used to stage the deeper area while allowing the majority to heal. Charts demonstrated satisfaction of the parents that didn’t want to be in the hospital during COVID. No nurses felt uncomfortable & all patients demonstrated stable vitals & good UOP at the time of discharge. This indicates several initial application on admission & was discharged within 24 hours. Conclusions This could at face value be a simple means to an end. The review of records indicates this was successful by most definitions of outcome. The limitation discovered was the ability to optimize outpatient therapy. Burns in the time of COVID, made use reexamine how we have cared for burns & whether there was room to perform more without an inpatient or a decreased inpatient stay. This change in practice also illustrated the ability to the wounds we initially thought may be deeper & possibly need excision actually healed well with no current development of hypertrophic scarring. Our institution will consider the early practice of debridement & lactic acid polymer application even when the restriction are eased. It also forced us to reevaluate how much we are grafting & reexamine what can heal on its own.

Introduction Last year we planned and created our own burn camp. We saw a need not being served and jumped in a created a camp experience that was archived in a documentary and received stellar reviews by all who attended. The kids’ camp expectations was exceeded and everyone was looking forward to 2020. We planned for a great 2020 camp experience and then COVID struck. We debated about the safety to proceed with residential camp as we knew it. Other camps cancelled but our inner need to serve wouldn’t let us do this. Methods Our planning committee quickly shifted and began planning for how we can bring that experience to a virtual platform. We engaged our Facebook group and called every kid on our list to inform the parents of the change. We then created a daily schedule and purchased the items needed for all activities. We then sent or delivered these with a gift card to kids that couldn’t make the pickups. Pickups were scheduled in the cities where most of our kids reside. We conducted daily yoga and meditation, cooking classes, painting and campfire stories. We mixed daily online sessions with 3 tailgating meet ups. We invited guest lectures and left the virtual space open for the kids to hang out. Results At the final tailgate/virtual pizza party, we had an awards ceremony and received testimonials from kids and parents about how for the first-time siblings were able to participate. We delivered to 15 kids and had 20 attend the tailgate pickups. On average, we had 16 kids attend daily. Conclusions Parents could see how their child benefitted from this community and the intent of camp. This event revealed exactly where our patients reside from a socioeconomic standpoint. Deliveries to some homes left our volunteers in tears. This helped explain the discrepancy between interest expressed and the numbers that showed daily for events. It also made us recognize that camp means even more as it is an escape from their realities.

Introduction Our institution has utilized the suspension epidermal autograft solution since a first application with FDA compassionate use protocol. We have since used this commercially available technology for the management of deep partial thickness and full thickness burn wounds. There is a non-adherent dressing in the commercially available kits to cover the suspension in a semi-porous fashion. We often would have beautifully dressed extremities and trunks only to find that in positions of function the non-adherent layer would pop through the intact staples. We then investigated the source of this discrepancy and found the non-elastic property of the dressing the likely culprit. We then began the process to determine an alternative dressing that could work more efficiently. Methods In an effort to determine if the institutional standard of care could be benefitted by this patient-based observation, the charts of patients that underwent simultaneous application of the epidermal autograft suspension and the poly lactic acid polymer dressing were interrogated. The data was identified by the institutional tissue tracker. Once the patient was identified, the chart was then reviewed to determine the desired data points. We evaluated the charts of patients that were recorded as utilizing the suspension epidermal autograft charge as wells charges for the poly lactic acid polymer skin substitute. The charts were then evaluated to determine if there were any deviations from our expected outcomes using the suspension alone. Results Our preliminary results indicate that the patients were able to discharge sooner as the wound care associated with the polymer skin substitute is more streamlined. It did not reflect any areas of graft loss but did in 2 instances remained in place longer than our standard. The wound was healed beneath but the skin substitute remained adhered. Conclusions The simultaneous use of suspension epidermal autografts and poly lactic acid skin substitutes has become common place for our institution. A quick review as a QI project has resulted in the desire to delve further into comparative data points. A formal retrospective review of the charts will be undertaken for a case series of about 20 patients.

Introduction A burn mass casualty incident (BMCI) occurs when a disaster involves many injured patients who have specific burn injuries. For this particular state, there are four burn centers. They range in size from 4–20 beds. The area hazards include: Methods A meeting was arranged for the burn center directors. Burn surgeons, along with burn center nursing staff, evaluated a series of “predefined patients” distributed over a compressed timeline during the hourlong exercise. The participants had not previously seen the “patients” nor were they aware of their injuries until the exercise controller released the information. The exercise controller was provided by a state emergency response coordination agency. The exercise followed a meeting that discussed efforts to standardize emergency medical services (EMS) care in the state, and route burn patients through the state call center to the most appropriate burn center. The final hour of the morning focused on the tabletop exercise, followed by a “hot-wash” (debriefing). Results The scenario included 20 patients staggered over the morning with each surgeon considering capacity and capability to manage the theoretical patients who ranged in age from 1 month to 81 years old (Median 24, Mean 28.2) with a TBSA range of 0 to 73 (Median 6, Mean 12.85). There were 4/20 patients intubated on arrival, and an additional 7/16 had “soot tinged sputum.” 16/20 arrived by EMS. Assuming this was a Type III Burn Disaster (meaning burn event only), all four burn center directors reported under ideal circumstances; they could absorb these patients into their respective hospital systems. However, it was also clear that while all could admit, sustaining all of these patients over an extended period may be problematic and potentially require a transfer. It was also discussed that had the severity of burn injury changed for two or more patients, it could have led to exceeding the capability/capacity for most of the burn centers. Conclusions The key to this event was to identify a trigger point for each facility. Every disaster plan requires a trigger or triggers meaning an activation point to begin treating an event based on their BMCI (or burn surge) plan. The next logical step in this process is to analyze further the capabilities and capacities that will inform the planning process as it evolves. Applicability of Research to Practice A working BMCI plan could improve resource utilization during disasters.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, type IV hypersensitivity reactions of the skin and mucosa. These reactions (SJS/TEN) are frequently managed in burn units; however, no standardized guidelines exist for the treatment and management of SJS/TEN. To gain insight into current SJS/TEN management practices, a survey on admission, diagnosis, and management, was conducted across accredited burn units in the United States. A 28-item question survey on SJS/TEN management, diagnosis, and treatment practices was distributed among medical directors and co-directors of American Burn Association-verified burn centers. Responses were collected over a 6-week period. In total, 31 (48% response rate) burn unit medical directors/co-directors participated in the survey. The majority of responders indicate that acceptance to their burn unit is based on clinical suspicion of SJS/TEN (74%), and biopsy or dermatological evaluation is not required (67 and 87%, respectively). More than half (61%) of the burn units have their own SJS/TEN protocol in place. No consensus was observed on different treatment aspects, such as infection control, systemic treatment, and wound care. Most directors reported their burn units to consult ophthalmology (77%) and dermatology (54%) for the management of patients with SJS/TEN. Large variability in procedures of admission, treatment, and management of SJS/TEN was identified across burn centers. This study demonstrates the urgent need for SJS/TEN standardized guidelines in the United States.