An executive summary of the National Trauma Research Action Plan

ABSTRACT

The National Trauma Research Action Plan project successfully engaged multidisciplinary experts to define opportunities to advance trauma research and has fulfilled the recommendations related to trauma research from the National Academies of Sciences, Engineering and Medicine report. These panels identified more than 4,800 gaps in our knowledge regarding injury prevention and the optimal care of injured patients and laid out a priority framework and tools to support researchers to advance this field. Trauma research funding agencies and researchers can use this executive summary and supporting manuscripts to strategically address and close the highest priority research gaps. Given that this is the most significant public health threat facing our children, young adults, and military service personnel, we must do better in prioritizing these research projects for funding and providing grant support to advance this work. Through the Coalition for National Trauma Research, the trauma community is committed to a coordinated, collaborative approach to address these critical knowledge gaps and ultimately reduce the burden of morbidity and mortality faced by our patients.

Preliminary Exploration of Long-Term Patient Outcomes After Tracheostomy in Burns: A Burn Model System Study

INTRODUCTION

Upper airway management is crucial to burn care. Endotracheal intubation is often performed in the setting of inhalation injury, burns of the face and neck, or large burns requiring significant resuscitation. Tracheostomy may be necessary in patients requiring prolonged ventilatory support. This study compares long-term, patient-reported outcomes in burn patients with and without tracheostomy.

MATERIALS AND METHODS

Data from the Burn Model System Database, collected from 2013 to 2020, were analyzed. Demographic and clinical data were compared between those with and without tracheostomy. The following patient-reported outcomes, collected at 6-, 12-, and 24-mo follow-up, were analyzed: Veterans RAND 12-Item Health Survey (VR-12), Satisfaction with Life, Community Integration Questionnaire, Patient-Reported Outcomes Measurement Information System 29-Item Profile Measure, employment status, and days to return to work. Regression models and propensity-matched analyses were used to assess the associations between tracheostomy and each outcome.

RESULTS

Of 714 patients included in this study, 5.5% received a tracheostomy. Mixed model regression analyses demonstrated that only VR-12 Physical Component Summary scores at 24-mo follow-up were significantly worse among those requiring tracheostomy. Tracheostomy was not associated with VR-12 Mental Component Summary, Satisfaction with Life, Community Integration Questionnaire, or Patient-Reported Outcomes Measurement Information System 29-Item Profile Measure scores. Likewise, tracheostomy was not found to be independently associated with employment status or days to return to work.

CONCLUSIONS

This preliminary exploration suggests that physical and psychosocial recovery, as well as the ability to regain employment, are no worse in burn patients requiring tracheostomy. Future investigations of larger scale are still needed to assess center- and provider-level influences, as well as the influences of various hallmarks of injury severity. Nonetheless, this work should better inform goals of care discussions with patients and families regarding the use of tracheostomy in burn injury.

44 Examining the Impact of the COVID-19 Pandemic on Participants in a Longitudinal Study of Burn Outcomes

Introduction

The COVID-19 pandemic has had widespread effects on healthcare and society at large. There are limited data on the impact of the pandemic on the long-term recovery of the burn survivor. This study aims to compare physical and psychosocial outcomes of the burn survivor population before and during the COVID-19 pandemic.

Methods

Data from the Burn Model System National Database (2015-present) were analyzed. Data were divided into pre- and during-pandemic groups (before and after March 1st, 2020). Outcomes were compared at four cross-sectional time points: 6, 12, 24, and 60 months after burn injury. The following patient reported outcome measures were examined: SF-12 Health Survey, PROMIS-29, Post-Traumatic Growth Indicator, Community Integration Questionnaire, Patient Civilian Checklist, Satisfaction with Life Scale, Burn Specific Health Scale, NeuroQOL Stigma, 4-D Itch, and CAGE Questionnaire (drug/alcohol misuse). Given the cross-sectional design, potential differences in clinical and demographic characteristics were examined for each group at each time point. Adjusted mean outcome scores at each time point were compared between groups using a two stage multi-variable regression model with propensity score matching. For each time point, subjects from each group were matched. The propensity score was calculated using the following matching variables: gender, age, race, ethnicity, etiology, length of stay, and burn size. The mean score difference of outcomes within each matched sample was examined.

Results

Sample sizes varied by time point with a range from 420 at 6 months to 94 at 60 months. The during-COVID group comprised 10% of the total sample size. There were no significant differences in demographic and clinical characteristics between the groups at any time point. There were no significant differences between the groups in adjusted mean outcome scores across the different time points.

Conclusions

This preliminary examination showed no differences in myriad long-term outcomes at multiple time points after injury among burn survivors before and during the start of the COVID-19 pandemic. The results may suggest an element of resilience, however given the sample size and cross-sectional limitations further investigation is required to better understand the impact of COVID-19 on the burn population.

73 Associations Between Pre-burn Occupation Type and Employment Outcomes at One Year

Introduction

Reintegration into the workforce after burn injury is an important issue for survivors. In a 2012 systematic review, 28% of burn survivors never returned to any form of employment. Although pre-burn employment status is strongly associated with post-burn employment, there are little data on the role of pre-injury occupation type on workplace reintegration. The aim of this project was to assess the impact of occupation type on employment outcomes after burn injury.

Methods

Data from the National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System National Longitudinal Database from 2015 to 2021 were used to investigate the association between occupation type and employment outcomes. Occupation type was classified into two groups, Labor and Non-labor, using the U.S. Bureau of Labor Statistics Standard Occupational Classification System. Demographic and clinical data were compared between groups. Mixed regression analyses examined associations between pre-burn occupation type and post-burn employment outcomes (employment at 1 year, days to return to work), controlling for age, gender, race, ethnicity, pre-injury employment, and burn size.

Results

Of the 600 patients who were employed pre-injury, 247 (41%) identified with a non-labor occupation and 353 (59%) with labor occupations. The Labor group was more male (82% vs. 61%) and Hispanic (23% vs. 6%), younger (mean age 42.1 vs. 48.3 years), less educated (high school or less, 25% vs. 11%) and more likely to have been injured at work (28% vs. 14%) compared to the Non-labor group (p< 0.001 for all comparisons). Changes in occupation were seen from pre-injury to post-injury; 16% of working survivors changed from Non-labor to Labor and 13% from Labor to Non-labor occupation types. For those who did return to work after injury, the average time to return to work was greater for Labor compared to the Non-labor group (150 vs 100 days; p=0.003). Additionally, those in the pre-injury Labor group were less likely to be employed at 12 months compared to the Non-labor group (odds ratio = 0.41; p=0.009).

Conclusions

Pre-injury occupation type is associated with employment outcomes after injury. Therefore, occupation type can be used to inform vocational reintegration resources, such as vocational rehabilitation programs, to optimize survivor outcomes.

10 The Impact of Insurance Disparities on Long-term Burn Outcomes: A Burn Model System Investigation

Introduction

Access to healthcare and insurance coverage are associated with quality of life, morbidity, and mortality outcomes. However, most studies have only focused on same-admission and short-term outcomes due to the lack of national longitudinal data and there is limited data on this topic in the burn literature. Our aim was to determine the effect of insurance status on long-term outcomes in a national sample of burn patients.

Methods

This is a retrospective study using the longitudinal Burn Model System National Database from January 2015 to April 2021. The inclusion criteria were all adult patients admitted for burn injury from participating sites. Main outcomes were the physical (PCS) and mental (MCS) health component summary scores of the Veterans RAND 12 (VR-12) score at 6, 12, and 24 months after injury. Multivariable regression was used to examine the association between insurance status and the outcomes, adjusting for demographics (i.e., age, gender, race/ethnicity) and burn injury severity.

Results

A total of 3,698 burn patients were included. Mean age was 43.39 (SD 15.84) years, 72% were male and 76% were white. Most patients had private/commercial insurance (56.37%), followed by Medicare (14.42%) and Medicaid (13.18%). The remaining 16% were uninsured patients (self-pay or philanthropy). Mean PCS scores were 43.64 (SD 10.87), 45.31 (SD 11.04) and 46.45 (SD 10.65) and Mean MCS scores were 47.80 (SD 12.35), 48.18 (SD 12.30) and 48.44 (SD 12.18) at 6, 12 and 24 months, respectively. In adjusted analyses, Medicaid insurance was associated with worse MCS at 6 months (Coefficient -3.90, p=0.001), and worse PCS at 12 and 24 months (Coefficient -3.09, p=0.004 and Coefficient -4.18, p< 0.001, respectively), compared to uninsured status. Medicare insurance was associated with worse PCS scores at 24 months (Coefficient -3.07, p=0.013).

Conclusions

Having Medicaid and Medicare insurance was significantly associated with a lower health-related quality of life at long-term follow up, even after adjusting for demographics and burn injury severity. Further studies need to focus on analyzing the reasons for these disparities and developing strategies to improve the quality of life of this subpopulation.

Current status of burn wound pathophysiology

Healing is a continuum that can be unpredictable. Despite many advances and understanding of the multiple cellular processes and molecules involved in burn wound healing, physicians and patients have yet to reap the full benefit of this knowledge. The advances have occurred in a very short period, and with the exponential growth of molecular biology techniques and transgenic animal models, our understanding and treatment of burn wound healing could change exponentially over the next 10 years. The goal must be to continue to improve functional outcomes for burn survivors just as we have conquered critical care management for acutely injured burn patients.

Engine block burns: Dupuytren's fourth-, fifth-, and sixth-degree burns

We recently treated two patients with engine block-muffler contact burns and greatly underestimated the devastating injuries to bone, deep fascia, and muscle. As a result, each patient required multiple procedures to close their burn wounds. Ten-year data from the University of Washington Burn Unit confirmed our observation that these burns tend to be considerably deeper than suspected. Eighteen patients with contact burns from engine parts were identified from 1980 through 1990. Nine (50%) of these were initially recognized to be fourth-degree and five (28%) were third-degree thermal injuries, showing that these are deep burns. Eight patients required fascial excisions and four required debridement of devascularized bone. The mean burn size was only 6% total body surface area; however, the patients with fourth-degree burns had an average graft take of only 56% and required a mean hospital stay of 44 days. Patients with third-degree burns also had suboptimal graft take and some required prolonged hospitalization. Thirty-six percent of patients required flaps either as the initial procedure or as a second procedure following an autograft. The four patients with partial-thickness burns healed without surgery and their average length of hospital stay was 3 days. Of the entire group, only four healed without surgery and only five healed with a single operation. Our 10-year data indicate that engine block contact burns are usually small, but most are deceptively deep, involving tendon, muscle, or bone. If the burn appears full thickness, suspicion must be very high at the initial surgical procedure that there is deep tissue destruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Establishing a Collaborative Genomic Repository for Adult Burn Survivors: A Burn Model System Feasibility Study

In this study, we aimed to integrate a genetic repository with an existing longitudinal national burn database. We set out two primary objectives, namely (1) to develop standard operating procedures for genetic sample collection and storage, DNA isolation, and data integration into an existing multicenter database; and (2) to demonstrate the feasibility of correlating genetic variation to functional outcomes in a pilot study, using the catechol-O-methyltransferase (COMT) gene. Dubbed the worrier/warrior gene, COMT variants have been associated with varying phenotypes of post-traumatic stress, wellbeing, and resilience. Between August 2018 and July 2020, COMT variants were identified for 111 participants from three sites and correlated with their outcome data. We found no association between COMT variants and functional outcomes, likely due to the inadequate sample size. We also asked all potential participants why they consented to or refused genetic analysis. A thematic analysis of responses revealed altruism and personal interest/enthusiasm in the study as top reasons for consenting. Privacy concerns were the most common reason for refusal. In conclusion, we successfully developed standard operating procedures for genetic sample collection and storage, DNA isolation, and data integration into an existing database, and we demonstrated the feasibility of conducting a multicenter collaborative study using a centralized lab location.

The impact of insurance disparities on long-term burn outcomes: A Burn Model System investigation

INTRODUCTION

Access to healthcare and insurance coverage are associated with quality of life, morbidity, and mortality outcomes. However, most studies have only focused on same-admission and short-term outcomes due to the lack of national longitudinal datalthere are limited data on this topic in the burn literature. Our aim was to determine the effect of insurance status on long-term outcomes in a national sample of burn patients.

METHODS

This retrospective study used the longitudinal Burn Model System National Database from January 1997 to December 2020. The inclusion criteria were all adult patients admitted for burn injury from participating sites. Main outcomes were the physical (PCS) and mental (MCS) health component summary scores of the Veterans RAND 12 (VR-12) score at 6, 12, and 24 months after injury. Adjusting for demographic and clinical characteristics, multivariable regression was used to examine the association between insurance status and the outcomes.

RESULTS

A total of 1809 burn patients were included. Most patients had private/commercial insurance (60.42 %), followed by Medicare (13.99 %) and Medicaid (12.77 %). The remaining 13 % were uninsured patients (self-pay or philanthropy). In adjusted analyses, Medicaid insurance was associated with worse MCS at 6 months (Coefficient -4.24, 95 % CI -6.06 - -2.41) and 12 months (Coefficient -3.62, 95 % CI -5.68 - -1.57), and worse PCS at all timepoints, compared to private/commercial insurance. Medicare insurance was associated with worse MCS scores at 12 months (Coefficient -2.86, 95 % CI -5.06 - -0.66) and worse PCS scores at all timepoints.

CONCLUSION

Having Medicaid and Medicare insurance was significantly associated with a lower health-related quality of life at long-term follow up, even after adjusting for demographics and burn injury severity.

Experiences of Alaska Native people living with burn injury and opportunities for health system strengthening

BACKGROUND

Injuries are a leading cause of death and disability for Alaska Native (AN) people. Alaska Native Tribal Health Consortium (ANTHC) is supporting the development of a burn care system that includes a partnership between Alaska Native Medical Center (ANMC) in Anchorage, AK and UW Medicine Regional Burn Center at Harborview Medical Center (HMC) in Seattle, WA. We aimed to better understand the experiences of AN people with burn injuries across the care continuum to aid development of culturally appropriate care regionalization.

METHODS

We performed focus groups with twelve AN people with burn injury and their caregivers. A multidisciplinary team of burn care providers, qualitative research experts, AN care coordinator, and AN cultural liaison led focus groups to elicit experiences across the burn care continuum. Transcripts were analyzed using a phenomenological approach and inductive coding to understand how AN people and families navigated the medical and community systems for burn care and areas for improvement.

RESULTS

Three themes were identified: 1-Challenges with local burn care in remote communities including limited first aid, triage, pain management, and wound care, as well as long-distance transport to definitive care; 2-Divergence between cultural values and medical practices that generated mistrust in the medical system, isolation from their support systems, and recovery goals that were not aligned with their needs; 3-Difficulty accessing emotional health support and a survivor community that could empower their resilience.

CONCLUSION

Participants reported modifiable barriers to culturally competent treatment for burn injuries among AN people. The findings can inform initiatives that leverage existing resources, including expansion of the Extension for Community Healthcare Outcomes (ECHO) telementoring program, promulgation of the Phoenix Society Survivors Offering Assistance in Recovery (SOAR) to AK, coordination of regionalized care to reduce time away from AK and provide more comfortable community reintegration, and define rehabilitation goals in terms that align with personal goals and subsistence lifestyle skills. Long-distance transport times are non-modifiable, but better pre-hospital care could be achieved by harnessing existing telehealth services and adapting principles of prolonged field care to allow for triage, initial care, and resuscitation in remote environments.

114 Long Term Impact of Hospital Acquired Multi-drug Resistant Organisms on Health-related Quality of Life

Introduction

MDROs colonize wounds and cause infections for hospitalized burn patients, which may lead to increased infection risk, wound complications, longer (LOS) and more cost. Little is known about the long-term impacts of MDRO colonization and infection on burn survivors. We aimed to describe the impacts of colonization on long-term health-related quality of life (HRQoL), itch, and pain.

Methods

Data from adult participants in a multicenter longitudinal outcome study were used. Data was described and χ ² and Kruskal-Wallis testing was applied to determine differences between the two groups. Outcomes included Veterans RAND 12 (VR-12) physical component summary score (PCS), and PROMIS 29 domains for pain intensity, fatigue, pain interference, physical function, and sleep disturbance. Pruritus was assessed using the 4-D Itch scale for total itch. Multilevel, multiple linear regressions were used for outcome measures at 6 m post-injury. Random effects regression with robust standard errors (SE) were used to evaluate the impacts over time.

Results

The study included 704 individuals and 92 were MDRO colonized (13%). Colonized patients had larger burns (25% TBSA, IQR 9-45 vs. 8% TBSA, IQR 3–20; p < .001), more operations (4, IQR 2-7 vs. 1, IQR 1-3; p < .001), more grafting (17% TBSA, IQR 3-46 vs. 3% TBSA, IQR 1- 9; p < .001), more ventilator days (2, IQR 0–8 vs. 0 IQR 0-0; p < .001), and longer LOS (34 days, IQR 17 – 64 vs. 16, IQR 9 - 27; p < .001). Adjusting for confounding covariables, such as demographics, colonization was associated with a lower PCS score (OR -0.33, 95% CI -0.68, -0.06; p=.018); a higher fatigue score (OR 0.46, 95% CI 0.13, 0.79; p = .007) and worse itch (OR 0.4, 95% CI -0.01, 0.75; p = .036). There was no association with pain intensity, pain interference, or sleep disturbance. Random effects regression indicated that colonization was associated with lower PCS (OR -5.0, 95% CI -8.60, -1.39; p = .007).

Conclusions

Impact of colonization extends beyond the immediate hospitalization and likely has long-term effects on HRQoL. Given our observation of lower physical function after MDRO, more granular research on taxa-specific effects, timing of colonization, and interventions are indicated to elucidate the impact on HRQoL.

68 The Association Between Body Mass Index and Physical Function in Adult Burn Survivors

Introduction

An area of rehabilitation research in burns is the impact of co-morbidities. Obesity is one of these, is an increasing public health concern, and its role remains controversial regarding burn injury and physical recovery. Our aim was to evaluate associations between body mass index (BMI) as a measure of obesity, at discharge and self-reported physical function (PF) during recovery of adult burn survivors.

Methods

This study included data that was collected by four American Burn Association-verified burn centers, which contribute to the Burn Model System National Database project. The data included BMI obtained at hospital discharge and self-reported Patient-Reported Outcomes Measurement Information System (PROMIS)-29 PF-mobility and upper extremity scores assessed at 6-, 12-, and 24-months after burn. Mixed linear models for repeated measures and regression models were used to assess associations between BMI and PROMIS-29 PF scores over time. Values are expressed as means ± SD. Significance was set at p&lt; 0.05.

Results

A total of 502 adult patients aged 47 ± 16 years were included, with mean total body surface area burned (TBSA) of 17 ± 18 % (range; 1.0-88%) and mean BMI of 23.1 ± 5.4 kg*m-2 (range; 14.0-64.7 kg*m-2). We found no significant effect at 6 months (beta=-0.045, p= 0.54) nor at 12 months after injury (beta=-0.063, p= 0.44) when adjusted for age, burn size, and sex, however, BMI at discharge had a significant negative effect on self-reported mobility scores 24 months after injury (beta=0.218, p=&lt; 0.05).

Conclusions

Increased weight (i.e. BMI) at discharge was negatively associated with PF during recovery. Benefiting from a large sample size, our analysis suggests that long term recovery and restoration of PF in adult burn survivors is compromized by excess body weight.

Temporal activity of plasminogen activators and matrix metalloproteinases during cutaneous wound repair

BACKGROUND

Response to tissue injury begins with the deposition of a fibrin-rich clot or the provisional matrix. The provisional matrix consists of plasma-borne matrix molecules that serve as scaffolding for the ensuing migration of cells. During wound repair multiple cell types must migrate through the clot-matrix scaffolding. The migration of these cells through the matrix is dependent on the activity of the fibrinolytic and proteolytic systems, which include the plasminogen activator (PA) system and matrix metalloproteinases (MMP). The aim of this study was to better understand the temporal activity of these enzymes during normal wound repair.

METHODS

We used the murine excisional wound model and extracted proteins under nonreducing conditions. With use of gelatin and casein zymography, we determined the activity of the MMPs during the course of wound repair. In addition, we quantified the activity of MMP-2 and MMP-9 by a standardized assay. Plasminogen zymograms were used to detect urokinase PA and tissue PA activity. Western blots were used to detect the natural inhibitor of PAs, plasminogen activator inhibitor type 1.

RESULTS

Our results demonstrate the temporal activity of MMP-2, MMP-3, MMP-7, and MMP-9 during the course of normal dermal repair. The activity of urokinase PA and tissue PA were also determined; it preceded the activity of the MMPs.

CONCLUSIONS

We demonstrate the temporal activity of the 2 protease families, MMPs and PAs, in the normal process of cutaneous wound healing.

The optimal time for early excision in major burn injury

INTRODUCTION

Early excision and grafting (E&G) drastically changed burn care in America by reducing morbidity, mortality and hospital length of stay (LOS). The present study was intended to determine whether an optimal time window exists between resuscitation and wound sepsis for the first E&G in a patient with a large burn.

MATERIAL AND METHOD

The authors conducted a retrospective study of patients admitted between January 1994 and December 2000 with > or = 40% TBSA burns and at least 1 E&G procedure. Patients were grouped according to the day of their first operation. Patients allowed to heal indeterminate burns prior to excision and grafting of deep partial or full thickness burns were grouped as > or = d7 and were excluded from the present study. The authors correlated the time of first excision with infection, mortality and LOS.

RESULTS

Seventy-five patients were identified and 12 patients allowed to heal indeterminate burn prior to excision and grafting of deep partial or full thickness burns were excluded. Sixty-three remaining patients included 51 males and 12 females. Mean burn size was 49% of total body surface area (TBSA) (44% deep partial or full thickness) and the mean age was 36 years. There were 61 flame (2 combined with electrical injuries), 1 scald and 1 chemical burn. Twelve died (19%) and 52 patients developed 121 infections. Whereas there was no statistical difference in mortality for patients operated on different days (p > 0.2), 60% of patients operated within the first 48 hours after injury died; this was not significant due to a small patient number

CONCLUSIONS

The present data suggest that patients who undergo early excision and grafting within seven days following a major burn > or = 40% TBSA have equivalent infection or mortality rates regardless of when the first operation occurs between post burn day(PBD) 2 and PBD 7 (p > 0.2).

Physical and Psychological Recovery Following Toxic Epidermal Necrolysis: A Patient Survey

Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are acute, life-threatening diseases that cause sloughing of the skin and mucous membranes. Despite improved survival rates, few studies focus on long-term outcomes. We conducted a single-center review of all patients with SJS/TEN admitted from January 2008-2014. SJS/TEN survivors were invited to participate in the validated Veterans RAND 12 Item Health Survey (VR-12) to assess health related quality of life using a mental health composite score (MCS) and physical health component score (PCS). The sample was compared to US norms using one sample two tailed t-tests. A second questionnaire addressed potential long-term medical complications related to SJS/TEN. Of 81 treated subjects, 24 (30%) long-term survivors responded. Participants identified cutaneous sequelae most frequently (79%), followed by nail problems (70%), oral (62%) and ocular (58%) sequalae. Thirty-eight percent rated their quality of life to be "unchanged" to "much better" since their episode of SJS/TEN. The average PCS score was lower than US population norms (mean: 36 vs. 50, p=0.006), indicating persistent physical sequelae from SJS/TEN. These results suggest that SJS/TEN survivors continue to suffer from long-term complications that impair their quality of life and warrant ongoing follow-up by a multidisciplinary care team.

Burn Wound Bed Management

Critical to the success of modern burn care is the management of the burn wound. Timely and complete removal of nonviable tissue is complicated by the irreplaceable nature of the tissue lost either through the burn injury or as "collateral damage" as part of the treatment. Challenges in distinguishing between viable and nonviable tissue and "replacing the irreplaceable" are discussed alongside potential disruptive technologies which could fundamentally change how burn care is delivered. Advances in burn wound bed management forms the foundation on which the goal of zero preventable death and disability after burn injury can be achieved.

Mediators in thermal injury

The combined goal of each of the mediators discussed here is homeostasis in a stressful situation. The associated immunosuppression and immunohyperactivity are unfortunate sequelae of massive upregulation of mediators normally produced in miniscule quantities. Perhaps they were once necessary to regulate survival of severely injured patients. However, Stoner's question about whether these mediators are beneficial for modern medical practices is very relevant. Our significant challenge is now to counteract the body's own efforts to heal itself. Understanding the interactions initiates this task; discovering therapeutic control mechanisms must be the next step.

78 Classification and Regression Tree Model for Predicting Satisfaction with Life Scale Scores After Burn Injury

Introduction

Current early burn care prognostication models predict in-hospital mortality (e.g., revised Baux Score). However, patients, families and clinicians need more holistic tools in the hours and days after injury to identify specific factors that might affect their quality of life and indicate a need for more intensive services. This project aims to predict Satisfaction with Life (SWL) in survivors of burn injury using patient, injury, and care factors available within 24 hours of admission.

Methods

Two hundred and fourteen participants were identified from a multicenter national longitudinal database and merged with clinical data from a single institution's trauma registry. Patients were randomized into a training dataset (80%) and a testing dataset (20%). A CART algorithm was used to examine the relative contributions of individual predictor variables in classifying low SWL at six-month follow up (SWL ≤ 20). Seventeen covariables obtained within 24 hours of index hospital admission were analyzed from five domains: demographics, comorbidities, injury, care, and host response to injury. Lab values were those closest to but not greater than 24 hours after index hospital admission.

Results

Multiple covariables contributed to the SWL score. CART analysis selected a pre-injury SWL score < 31 as the first node and strongest indicator of low SWL. CART then selected the following subgroups at risk for SWL ≤ 20 at 6 months: (1) hematocrit >55%; (2) lactate >4 mmol/L, age > 59; (3) total body surface area (TBSA) burned >30%, presence of a hand, neck, and/or face burn. The cross-validated predictive accuracy of the CART model was 69.4% with a cross-validated relative error of 0.379. In the validation data set, sensitivity and specificity were 62.5% and 72.0%, respectively.

Conclusions

The findings demonstrate the potential feasibility of creating a model that can predict a clinically meaningful quality of life outcome using covariables gathered within hours of hospital admission after burn injury. Predictive measures suggest that while some of the included covariables may be associated with SWL, they are not consistently and reliably predictive of low SWL alone. With more data and additional refined inputs, a similar model could be used to identify those in need of more intensive services earlier on in the hospitalization.

83 The Impact of Tracheostomy on Long-term Patient Outcomes: A Burn Model System National Database Study

Introduction

Management of the upper airway is crucial to burn care, especially in the setting of inhalation injury or burns to the face or neck. Endotracheal intubation is often performed to secure the airway; however, tracheostomy may be necessary in patients requiring prolonged ventilatory support. This study compares long-term outcomes of burn patients with and without tracheostomy.

Methods

Data from the Burn Model System National Database, collected from 2013 to 2020, were analyzed. Demographic and clinical data were compared between those with and without tracheostomy. The following patient-reported outcome measures, collected at 6-, 12-, and 24-months, were analyzed: Veterans Rand 12 Physical Component Summary Score (VR-12 PCS), Veterans Rand 12 Mental Component Summary Score (VR-12 MCS), Satisfaction with Life (SWL), Community Integration Questionnaire (CIQ), Patient-Reported Outcomes Measurement Information System (PROMIS-29), employment status, and number of days to return to work. Regression models were used to assess the impact of tracheostomy status on long-term outcome measures, controlling for demographic and clinical variables.

Results

Of the 714 patients included in this study, 39 (5.46%) received a tracheostomy and 675 (94.54%) did not. The two groups were similar across all demographic data collected. Tracheostomy patients were more likely to have flame injury, inhalation injury, larger burn size, more trips to the operating room, longer hospital stay, and greater number of days on a ventilator (p< 0.001). Regression model analyses demonstrated that tracheostomy was associated with worse VR-12 PCS scores at 6-, 12-, and 24-months (6.6 [95% CI 1.5, 11.8], p=0.012; 11.5 [6.2, 16.8], p< 0.001; 10.8 [4.2, 17.5], p=0.001). Tracheostomy was also associated with worse scores in two PROMIS-29 domains, physical function and pain interference. For physical function, the association was seen at 6-, 12-, and 24-months (7.4 [3.0, 11.8], p=0.001; 9.6 [5.2, 14.0], p< 0.001; 11.3 [5.8, 16.9], p< 0.001). For pain interference, the association was only seen at 12-months (-5.3 [-10.0, -0.55], p=0.029).

Conclusions

After burn injury, patient-reported outcome measures of physical function and pain interference were significantly worse with tracheostomy.

Developing a National Trauma Research Action Plan: Results from the long-term outcomes research gap Delphi survey

BACKGROUND

In the National Academies of Sciences, Engineering, and Medicine 2016 report on trauma care, the establishment of a National Trauma Research Action Plan to strengthen and guide future trauma research was recommended. To address this recommendation, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. We describe the gap analysis and high-priority research questions generated from the National Trauma Research Action Plan panel on long-term outcomes.

METHODS

Experts in long-term outcomes were recruited to identify current gaps in long-term trauma outcomes research, generate research questions, and establish the priority for these questions using a consensus-driven, Delphi survey approach from February 2021 to August 2021. Panelists were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability including both military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population, Intervention, Compare/Control, and Outcome model. On subsequent surveys, panelists were asked to prioritize each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category.

RESULTS

Thirty-two subject matter experts generated 482 questions in 17 long-term outcome topic areas. By Round 3 of the Delphi, 359 questions (75%) reached consensus, of which 107 (30%) were determined to be high priority, 252 (70%) medium priority, and 0 (0%) low priority. Substance abuse and pain was the topic area with the highest number of questions. Health services (not including mental health or rehabilitation) (64%), mental health (46%), and geriatric population (43%) were the topic areas with the highest proportion of high-priority questions.

CONCLUSION

This Delphi gap analysis of long-term trauma outcomes research identified 107 high-priority research questions that will help guide investigators in future long-term outcomes research.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level IV.

The Unna 'sleeve': an effective postoperative dressing for pediatric arm burns

The goal of this study was to develop a postoperative plan for sheet grafts that would protect the graft, yet would also eliminate the need for daily wound care. Eleven pediatric patients (13 arms burns) who underwent excision and grafting were included in our study. The total area on the arm ranged from 1% to 5% total body surface area. All grafts were sheet grafts held in place with steri-strips or sutures. The grafts were covered with a layer of greasy gauze, followed by an Unna done paste dressing, and then an elastic bandage. The Unna "sleeve" remained in place for an average of 6 days (range, 3 to 10 days). In eight cases, a second Unna sleeve was applied and removed 6 to 7 days later. In all 13 cases, additional wound care for grafts was unnecessary, and patients did not require extended inpatient hospitalization. Graft take was 100% in all cases, and no reconstruction was required.