Geographic access to burn center hospitals

Initial management of patients with burns and combined injuries for acute care surgeons: What you need to know

ABSTRACT

There are nearly 700,000 adults and children with burn injuries who seek care in America each year. While most patients with major burn injuries are cared for at American Burn Association-verified burn centers, many of them present to nonburn centers initially or present with combined burns and other injuries. Despite this, burn surgery is no longer mandated by the Accreditation Council for Graduate Medical Education for general surgery residency and is rarely a meaningful component of surgical critical care fellowships. However, general surgeons are called to participate in and, occasionally, lead the care of adults and children with burn injuries when burn expertise is not available, for patients with combined burns and other injuries, when procedures are required, in intensive care units, and/or during multiple casualty incidents and disasters. Fundamental burn care knowledge and skills deployed during these moments can radically impact patients' chances of survival and future quality of life. This clinical review covers burn-specific aspects of the primary survey and follows the ABCDE approach. Additional details about core burn care principles (e.g., inhalation injury, resuscitation, wound care) and special considerations in combined burns and other injuries are also presented (e.g., burns with concomitant abdominal, thoracic, skeletal, and/or intracranial injury(ies)).

LEVEL OF EVIDENCE

Expert Opinion; Level V.

Advanced Practice Providers in Burn Care, 2013-2022

This study evaluated the prevalence and characteristics of advanced practice providers, including nurse practitioners and physician assistants, who provide care related to burns in the United States from 2013 to 2022 using national claims data. Our analysis was a retrospective, large cohort study evaluating debridement, wound care, and office-based services provided by advanced practice providers from 2013 to 2022 using the Medicare Provider Utilization and Payment Data Public Use Files from the CMS. The reported provider type and billing codes were used to identify healthcare professionals providing burn care. Trends over the study period and available data about care provided were analyzed. From 2013 to 2022, burn care providers included 6918 (43.3%) surgeons, 4264 (26.7%) other physicians, and 4783 (30.0%) advanced practice providers. Overall, the number of advanced practice providers who billed for burn care increased by 250.4% from 714 in 2013 to 2502 in 2022. Compared with physicians, advanced practice providers were more likely to be female and provide care in micropolitan areas with less than 50,000 people. Based on these trends, we project that the number of advanced practice providers providing services related to burns will increase by 56.7% from 2502 in 2022 to 3921 (95% CI, 3541-4303; R2 = 0.97) in 2030. With a growing need for burn care and predicted shortages in the surgeon workforce, the scope of practice and integration of advanced practice providers merits further discussion and evaluation.

Concordance of ChatGPT With American Burn Association Guidelines on Acute Burns

ABSTRACT

Burn injuries often require immediate assistance and specialized care for optimal management and outcomes. The emergence of accessible artificial intelligence technology has just recently started being applied to healthcare decision making and patient education. However, its role in clinical recommendations is still under scrutiny. This study aims to evaluate ChatGPT's outputs and the appropriateness of its responses to commonly asked questions regarding acute burn care when compared to the American Burn Association Guidelines. Twelve commonly asked questions were formulated by a fellowship-trained burn surgeon to address the American Burn Association's recommendations on burn injuries, management, and patient referral. These questions were prompted into ChatGPT, and each response was compared with the aforementioned guidelines, the gold standard for accurate and evidence-based burn care recommendations. Three burn surgeons independently evaluated the appropriateness and comprehensiveness of each ChatGPT response based on the guidelines according to the modified Global Quality Score scale. The average score for ChatGPT-generated responses was 4.56 ± 0.65, indicating the responses were exceptional quality with the most important topics covered and in high concordance with the guidelines. This initial comparison of ChatGPT-generated responses and the American Burn Association guidelines demonstrates that ChatGPT can accurately and comprehensibly describe appropriate treatment and management plans for acute burn injuries. We foresee that ChatGPT may play a role as a complementary tool in medical decision making and patient education, having a profound impact on clinical practice, research, and education.

An integrative literature review of factors contributing to hypothermia in adults during the emergent (ebb) phase of a severe burn injury

BACKGROUND

During the emergent (ebb) phase (first 72 h), the adult person with a severe burn experiences loss of body heat, decreased metabolism, and poor tissue perfusion putting them at risk of hypothermia, increased morbidity, and mortality. Therefore, timely and targeted care is imperative.

AIM

The aim of this integrative literature review was to develop a framework of the factors contributing to hypothermia in adults with a severe burn injury during the emergent (ebb) phase.

METHODS

An integrative review of research literature was undertaken as it provides an orderly process in the sourcing and evaluation of the literature. Only peer reviewed research articles, published in scholarly journals were selected for inclusion (n = 26). Research rigor and quality for each research article was determined using JBI Global appraisal tools relevant to the methodology of the selected study.

FINDINGS

Contributing factors were classified under three key themes: Individual, Pre-hospital, and In-hospital factors.

CONCLUSION

The structured approach enabled the development of an evidence-based framework identifying factors contributing to hypothermia in adults with a severe burn injury during the emergent (ebb) phase and adds knowledge to improve standardized care of the adult person with a severe burn injury.

The role of multiplatform messaging applications in burns care and rehabilitation: A systematic review

BACKGROUND

Multiplatform messaging applications also referred to as cross-platform instant messaging play an important role in delivery of healthcare and education with its low cost, ease of use and accessibility.

AIM

To evaluate the existing evidence regarding the use of multiplatform messaging applications in facilitating consultations and decision-making processes in the context of burns care, as well as to assess the impact of such applications on burns care and rehabilitation.

METHOD

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and PROSPERO protocol CRD42021265203. The CASP and JBI tools were used to evaluate the quality of the studies. Eight hundred fifty-three papers were retrieved from PubMed, CINAHL, Scopus, EMBASE and LILACS published up to July 2022 (updated August 2023) with no time restrictions applied.

RESULTS

An analysis of the seven studies included in this review, inclusive of 16 Multiplatform messaging applications, revealed six themes. These encompassed the utilization of social media for directing and managing clinical practice, as a mode of communication, for evaluating the quality-of-care provision, for investigating available platforms and their technological features, measuring quality of life and for examining issues related to confidentiality.

CONCLUSION

Multiplatform messaging applications offer a solution for individuals with burn injuries to stay in direct contact with burn specialist clinicians for their follow-up and subsequent rehabilitation phase of recovery.

Access to Burn Care in the US

This cross-sectional study examines burn incidence rates and accessibility of American Burn Association–verified or self-designated burn centers from 2013 to 2019.

Towards more realistic measures of accessibility to emergency departments in Sweden

BACKGROUND

Assuring that emergency health care (EHC) is accessible is a key objective for health care planners. Conventional accessibility analysis commonly relies on resident population data. However, the allocation of resources based on stationary population data may lead to erroneous assumptions of population accessibility to EHC.

METHOD

Therefore, in this paper, we calculate population accessibility to emergency departments in Sweden with a geographical information system based network analysis. Utilizing static population data and dynamic population data, we investigate spatiotemporal patterns of how static population data over- or underestimates population sizes derived from temporally dynamic population data.

RESULTS

Our findings show that conventional measures of population accessibility tend to underestimate population sizes particularly in rural areas and in smaller ED's catchment areas compared to urban, larger ED's-especially during vacation time in the summer.

CONCLUSIONS

Planning based on static population data may thus lead to inequitable distributions of resources. This study is motivated in light of the ongoing centralization of ED's in Sweden, which largely depends on population sizes in ED's catchment areas.

Optimizing an Outpatient mHealth Intervention for Children with Burns: A Convergent Mixed-Methods Study

Burn injury is one of the most common traumatic injuries in childhood. Fortunately, 90% of pediatric burns may be treated in the outpatient setting after appropriate burn triage. Patients with burns face significant geographic disparities in accessing expert burn care due to regionalized care. To aid patients and their families during acute outpatient burn recovery, we developed a smartphone app, Telemedicine Optimized Burn Intervention (TOBI). With this app, we aimed to increase access to care by allowing secure, streamlined communication between patients and burn providers, including messaging and wound image transfer. The purpose of this study was to systematically evaluate user feedback to optimize the patient and provider experience. TOBI was evaluated using a convergent mixed-methods approach consisting of qualitative semi-structured interviews and quantitative measurements of app usability via the mHealth App Usability Questionnaire. Participants included 15 caregivers of pediatric patients with burns who used TOBI during treatment and ten burn providers. Users found TOBI to be a highly usable application in terms of usefulness, ease of use, satisfaction, and functionality. Qualitative data provided insight into user experience, satisfaction and preferences, difficulty navigating, usability and acceptability, and potential improvements. Although most users were highly satisfied, improvements were needed to optimize the burn app. We systematically made these improvements before we released TOBI for routine patient use. This study uncovered helpful recommendations for app improvements that can be generalized to other mobile health apps to increase their appeal and adoption.

A Bayesian MultiLayer Record Linkage Procedure to Analyze Post-Acute Care Recovery of Patients with Traumatic Brain Injury

Understanding associations between injury severity and postacute care recovery for patients with traumatic brain injury (TBI) is crucial to improving care. Estimating these associations requires information on patients' injury, demographics, and healthcare utilization, which are dispersed across multiple data sets. Because of privacy regulations, unique identifiers are not available to link records across these data sets. Record linkage methods identify records that represent the same patient across data sets in the absence of unique identifiers. With a large number of records, these methods may result in many false links. Health providers are a natural grouping scheme for patients, because only records that receive care from the same provider can represent the same patient. In some cases, providers are defined within each data set, but they are not uniquely identified across data sets. We propose a Bayesian record linkage procedure that simultaneously links providers and patients. The procedure improves the accuracy of the estimated links compared to current methods. We use this procedure to merge a trauma registry with Medicare claims to estimate the association between TBI patients' injury severity and postacute care recovery.

Hospital-Level Implementation Barriers, Facilitators, and Willingness to Use a New Regional Disaster Teleconsultation System: Cross-Sectional Survey Study

BACKGROUND

The Region 1 Disaster Health Response System project is developing new telehealth capabilities to provide rapid, temporary access to clinical experts across US jurisdictions to support regional disaster health response.

OBJECTIVE

To guide future implementation, we identified hospital-level barriers, facilitators, and willingness to use a novel regional peer-to-peer disaster teleconsultation system for disaster health response.

METHODS

We used the National Emergency Department Inventory-USA database to identify all 189 hospital-based and freestanding emergency departments (EDs) in New England states. We digitally or telephonically surveyed emergency managers regarding notification systems used for large-scale no-notice emergency events, access to consultants in 6 disaster-relevant specialties, disaster credentialing requirements before system use, reliability and redundancy of internet or cellular service, and willingness to use a disaster teleconsultation system. We examined state-wise hospital and ED disaster response capability.

RESULTS

Overall, 164 (87%) hospitals and EDs responded-126 (77%) completed telephone surveys. Most (n=148, 90%) receive emergency notifications from state-based systems. Forty (24%) hospitals and EDs lacked access to burn specialists; toxicologists, 30 (18%); radiation specialists, 25 (15%); and trauma specialists, 20 (12%). Among critical access hospitals (CAHs) or EDs with <10,000 annual visits (n=36), 92% received routine nondisaster telehealth services but lacked toxicologist (25%), burn (22%), and radiation (17%) specialist access. Most hospitals and EDs (n=115, 70%) require disaster credentialing of teleconsultants before system use. Among 113 hospitals and EDs with written disaster credentialing procedures, 28% expected completing disaster credentialing within 24 hours, and 55% within 25-72 hours, which varied by state. Most (n=154, 94%) reported adequate internet or cellular service for video-streaming; 81% maintained cellular service despite internet disruption. Fewer rural hospitals and EDs reported reliable internet or cellular service (19/22, 86% vs 135/142, 95%) and ability to maintain cellular service with internet disruption (11/19, 58% vs 113/135, 84%) than urban hospitals and EDs. Overall, 133 (81%) were somewhat or very likely to use a regional disaster teleconsultation system. Large-volume EDs (annual visits ≥40,000) were less likely to use the service than smaller ones; all CAHs and nearly all rural hospitals or freestanding EDs were likely to use disaster consultation services. Among hospitals and EDs somewhat or very unlikely to use the system (n=26), sufficient consultant access (69%) and reluctance to use new technology or systems (27%) were common barriers. Potential delays (19%), liability (19%), privacy (15%), and hospital information system security restrictions (15%) were infrequent concerns.

CONCLUSIONS

Most New England hospitals and EDs have access to state emergency notification systems, telecommunication infrastructure, and willingness to use a new regional disaster teleconsultation system. System developers should focus on ways to improve telecommunication redundancy in rural areas and use low-bandwidth technology to maintain service availability to CAHs and rural hospitals and EDs. Policies and procedures to accelerate and standardize disaster credentialing are needed for implementation across jurisdictions.

The Geographical Impact of Plastic Surgery Residency to Fellowship and Residency/Fellowship to First Job Placement

INTRODUCTION

The location of trainees' plastic surgery residency or fellowship has implications on their subsequent careers, which can inform future trainees and faculty decisions, and may affect access to care nationwide. This study explores historic geographic trends of the location where trainees complete residency or fellowship and where they pursue a fellowship program or first job.

METHODS

Graduates from US integrated plastic surgery residency or fellowship programs from 2015 to 2021 were identified along with their proximity to fellowship or first job. Location was categorized based on whether the graduate's fellowship/first job location to residency/fellowship was within 100 miles, the same state, the same geographic region, the United States, or international. A χ2 value was calculated to determine the significance of relative geographical location after training.

RESULTS

Three hundred sixty-five graduates that attended fellowship were included, representing 76.5% (65/85) of integrated plastic surgery residency programs. There were 47.7% (n = 174) that stayed within the same geographic region and 3.6% (n = 13) pursued training internationally. The location of the residency or fellowship program appears to have an influence on the location of the graduate's fellowship or first job.

CONCLUSION

Graduates who completed integrated residency or fellowship in a certain geographic location were more likely to stay in that area for their fellowship or first job. This may be explained by graduates continuing training with their original program, the established network, and personal factors such as family and friends.

The Effect of Distance to Treatment Center on Long-Term Outcomes of Burn Patients

Geospatial proximity to American Burn Association (ABA)-verified burn centers or self-designated burn care facilities varies across the country. This study evaluates the effect of distance to treatment center on long-term, patient-reported outcomes. Data from the Burn Model System (BMS) National Longitudinal Database were analyzed. Demographic and clinical data were compared between three cohorts stratified by distance to BMS center (<20, 20-49.9, ≥50 miles). Distance to BMS center was calculated as driving distance between discharge and BMS center ZIP code centroids. The following patient-reported outcomes, collected at 12-months follow-up, were examined: Veterans RAND 12-Item Health Survey (VR-12), Satisfaction with Life (SWL) scale, employment status, and days to return to work. Mixed model regression analyses were used to examine the associations between distance to BMS center and each outcome, controlling for demographic and clinical variables. Of 726 patients included in this study, 26.3% and 28.1% were <20 and between 20 and 49.9 miles to a BMS center, respectively; 46.6% were ≥50 miles to a BMS center. Greater distance was associated with white/non-Hispanic race/ethnicity, preinjury employment, flame injury, and larger burn size (P < .001). Regression analyses did not identify significant associations between distance to BMS center and any patient-reported outcomes. This study suggests that patients treated at BMS centers have similar long-term, patient-reported outcomes of physical and psychosocial function, as well as employment, despite centralization of burn care and rehabilitation services. Given a steady decline in the incidence of burn injury, continued concentration of key resources is logical and safe.

The Impact of Obesity on Early Complications Following Tracheostomy: An Evaluation of a Nationwide Registry

INTRODUCTION

The obesity epidemic is an important public health problem in the United States. Previous studies have revealed the association between obesity and various surgical complications. Tracheostomy which is an important lifesaving procedure may prove technically challenging in an obese patient. This study sought to evaluate the association between obesity and early complications following standard tracheostomy using a national registry.

METHODS

Adult patients who underwent tracheostomy from 2007 to 2017 were analyzed using the Nationwide Inpatient Sample (NIS). The population was stratified into obese and non-obese groups. Early complications following standard tracheostomy were identified and compared between the two groups. Multivariable logistic regression analyses were performed to assess the association between obesity and early complications following tracheostomy.

RESULTS

Data pertaining to 205 032 adult patients were evaluated. Obese patients accounted for 12.1% (n = 21 816) of the entire cohort. The most common complication in the cohort was perioperative bleeding (4316 [2.1%]). A total of 1382 (0.67%), 949 (0.46%), and 134 (0.07%) patients developed pneumothorax/pneumomediastinum, stoma/surgical site infection, and tracheal injury following standard tracheostomy, respectively. There was no difference in the odds of tracheal injury, perioperative bleeding, and pneumomediastinum/pneumothorax following standard tracheostomy in the obese and non-obese group in multivariable analysis. However, obesity was associated with 60% increased odds of developing stoma/surgical site infection following standard tracheostomy (OR 1.60 [1.33-1.92], P < 0.01).

CONCLUSION

Obesity is associated with an increased risk of developing stoma/surgical site infection following standard tracheostomy. This adds to the growing need for measures to help curb the obesity epidemic in a bid to improve surgical outcomes.

Impact of lifting the mandatory evacuation order after the Fukushima Daiichi Nuclear Power Plant accident on the emergency medical system: a retrospective observational study at Minamisoma City with machine learning analysis

OBJECTIVES

This study aimed to identify factors that delayed emergency medical services (EMS) in evacuation order zones after the 2011 Great East Japan Earthquake and Fukushima Daiichi Nuclear Power Plant accident and to investigate how the lifting of the evacuation affected these factors over time.

DESIGN

This research was a retrospective observational study. The primary outcome measure was onsite EMS time. A gradient boosting model and a decision tree were used to find the boundary values for factors that reduce EMS.

SETTING

The target area was Minamisoma City, Fukushima, Japan that was partly designated as an evacuation order zone after the 2011 Fukushima disaster, which was lifted due to decreased radiation.

PARTICIPANTS

This study included patients transferred by EMS from 1 January 2013 through 31 October 2018. Patients who were not transported and those transported for community events, interhospital patient transfer and natural disasters were excluded.

OUTCOME MEASURES

This study evaluated the total EMS time using on-site time which is the time from arrival at the scene to departure to the destination, and other independent factors.

RESULTS

The total number of transports was 12 043. The decision tree revealed that the major factors that prolonged onsite time were time of day and latitude, except for differences by year. While latitude was a major factor in extending on-site time until 2016, the effect of latitude decreased and that of time of day became more significant since 2017. The boundary was located at N37.695° latitude.

CONCLUSIONS

The onsite time delay in EMS in evacuation order zones is largely due to regional factors from north to south and the time of day. However, the north-south regional factor decreased with the lifting of evacuation orders.

European Burns Association guidelines for the management of burn mass casualty incidents within a European response plan

BACKGROUND

A European response plan to burn mass casualty incidents has been jointly developed by the European Commission and the European Burn Association. Upon request for assistance by an affected country, the plan outlines a mechanism for coordinated international assistance, aiming to alleviate the burden of care in the affected country and to offer adequate specialized care to all patients who can benefit from it. To that aim, Burn Assessment Teams are deployed to assess and triage patients. Their transportation priority recommendations are used to distribute outnumbering burn casualties to foreign burn centers. Following an appropriate medical evacuation, these casualties receive specialized care in those facilities.

METHODS

The European Burns Association's disaster committee developed medical-organizational guidelines to support this European plan. The experts identified fields of interest, defined questions to be addressed, performed relevant literature searches, and added their expertise in burn disaster preparedness and response. Due to the lack of high-level evidence in the available literature, recommendations and specially designed implementation tools were provided from expert opinion. The European Burns Association officially endorsed the draft recommendations in 2019, and the final full text was approved by the EBA executive committee in 2022.

RECOMMENDATIONS

The resulting 46 recommendations address four fields. Field 1 underlines the need for national preparedness plans and the necessary core items within such plans, including coordination and integration with an international response. Field 2 describes Burn Assessment Teams' roles, composition, training requirements, and reporting goals. Field 3 addresses the goals of specialized in-hospital triage, appropriate severity criteria, and their effects on priorities and triage. Finally, field 4 covers medical evacuations, including their timing and organization, the composition of evacuation teams and their assets, preparation, and the principles of en route care.

Activation and On-Scene Intervals for Severe Trauma EMS Interventions: An Analysis of the NEMSIS Database

Objective: Time to care is a determinant of trauma patient outcomes, and timely delivery of trauma care to severely injured patients is critical in reducing mortality. Numerous studies have analyzed access to care using prehospital intervals from a Carr et al. meta-analysis of studies from 1975 to 2005. Carr et al.'s research sought to determine national mean activation and on-scene intervals for trauma patients using contemporary emergency medical services (EMS) records. Since the Carr et al. meta-analysis was published, the National Highway Traffic Safety Administration (NHTSA) created and refined the National Emergency Medical Services Information System (NEMSIS) database. We sought to perform a modern analysis of prehospital intervals to establish current standards and temporal patterns.Methods: We utilized NEMSIS to analyze EMS data of trauma patients from 2016 to 2019. The dataset comprises more than 94 million EMS records, which we filtered to select for severe trauma and stratified by type of transport and rurality to calculate mean activation and on-scene intervals. Furthermore, we explored the impact of basic life support (BLS) and advanced life support (ALS) of ground units on activation and on-scene time intervals.Results: Mean activation and on-scene intervals for ground transport were statistically different when stratified by rurality. Urban, suburban, and rural ground activation intervals were 2.60 ± 3.94, 2.88 ± 3.89, and 3.33 ± 4.58 minutes, respectively. On-scene intervals were 15.50 ± 10.46, 17.56 ± 11.27, and 18.07 ± 16.13 minutes, respectively. Mean helicopter transport activation time was 13.75 ± 7.44 minutes and on-scene time was 19.42 ± 16.09 minutes. This analysis provides an empirically defined mean for activation and on-scene times for trauma patients based on transport type and rurality. Results from this analysis proved to be significantly longer than the previous analysis, except for helicopter transport on-scene time. Shorter mean intervals were seen in ALS compared to BLS for activation intervals, however ALS on-scene intervals were marginally longer than BLS.Conclusions: With the increasing sophistication of geospatial technologies employed to analyze access to care, these intervals are the most accurate and up-to-date and should be included in access to care models.

Burn related injuries: a nationwide analysis of adult inter-facility transfers over a six-year period in the United States

Background

US emergency department (ED) visits for burns and factors associated with inter-facility transfer are unknown and described in this manuscript.

Methods

We conducted a retrospective analysis of burn-related injuries from 2009–2014 using the Nationwide Emergency Department Sample (NEDS), the largest sample of all-payer datasets. We included all ED visits by adults with a burn related ICD-9 code and used a weighted multivariable logistic regression model to predict transfer adjusting for covariates.

Results

Between 2009–2014, 3,047,701 (0.4%) ED visits were for burn related injuries. A total of 108,583 (3.6%) burn visits resulted in inter-facility transfers occurred during the study period, representing approximately 18,097 inter-facility transfers per year. Burns with greater than 10% total body surface area (TBSA) resulted in a 10-fold increase in the probability of transfer, compared to burn visits with less than 10% TBSA burns. In the multivariable model, male sex (adjusted odds ratio [aOR] 2.4, 95% CI 2.3–2.6) was associated with increased odds of transfer. Older adults were more likely to be transferred compared to all other age groups. Odds of transfer were increased for Medicare and self-pay patients (vs. private pay) but there was a significant interaction of sex and payer and the effect of insurance varied by sex.

Conclusions

In a national sample of ED visits, burn visits were more than twice as likely to have an inter-facility transfer compared to the general ED patient population. Substantial sex differences exist in U.S. EDs that impact the location of care for patients with burn injuries and warrants further investigation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00705-6.

What Fuels the Fire: A Narrative Review of the Role Social Determinants of Health Play in Burn Injuries

Social determinants of health (SDOH) are the conditions where people live, learn, work, and play that affect their health and quality of life. There has been an increasing focus on the SDOH in the field of medicine to both explain and address health outcomes. Both the risk of burn injuries and outcomes after burns have been found to be associated with multiple aspects of the SDOH. This narrative review seeks to explore the main domains of the social determinants of health, reiterate their importance to the general and burn injury population, examine each's association with risks of burn injuries and burn-related outcomes, and provide an overview of the current burn research landscape that describes the social determinants of health.

Geographic barriers to establishing a successful hospital referral system in rural Madagascar

Background

The provision of emergency and hospital care has become an integral part of the global vision for universal health coverage. To strengthen secondary care systems, we need to accurately understand the time necessary for populations to reach a hospital. The goal of this study was to develop methods that accurately estimate referral and prehospital time for rural districts in low and middle-income countries. We used these estimates to assess how local geography can limit the impact of a strengthened referral programme in a rural district of Madagascar.

Methods

We developed a database containing: travel speed by foot and motorised vehicles in Ifanadiana district; a full mapping of all roads, footpaths and households; and remotely sensed data on terrain, land cover and climatic characteristics. We used this information to calibrate estimates of referral and prehospital time based on the shortest route algorithms and statistical models of local travel speed. We predict the impact on referral numbers of strategies aimed at reducing referral time for underserved populations via generalised linear mixed models.

Results

About 10% of the population lived less than 2 hours from the hospital, and more than half lived over 4 hours away, with variable access depending on climatic conditions. Only the four health centres located near the paved road had referral times to the hospital within 1 hour. Referral time remained the main barrier limiting the number of referrals despite health system strengthening efforts. The addition of two new referral centres is estimated to triple the population living within 2 hours from a centre with better emergency care capacity and nearly double the number of expected referrals.

Conclusion

This study demonstrates how adapting geographic accessibility modelling methods to local scales can occur through improving the precision of travel time estimates and pairing them with data on health facility use.

Virtual Visits for Outpatient Burn Care during the COVID-19 Pandemic

Burn-injured patients must frequently travel long distances to regional burn centers, creating a burden on families and impairing clinical outcomes. Recent federal policies in response to the coronavirus pandemic have relaxed major barriers to conducting synchronous videoconference visits in the home. However, the efficacy and benefits of virtual visits relative to in-person visits remained unclear for burn patients. Accordingly, a clinical quality assurance database maintained during the coronavirus pandemic (3/3/2020 to 9/8/2020) for virtual and/or in-person visits at a comprehensive adult and pediatric burn center was queried for demographics, burn severity, visit quality, and distance data. A total of 143 patients were included in this study with 317 total outpatient encounters (61 virtual and 256 in-person). The savings associated with the average virtual visit were 130 ± 125 miles (mean ± standard deviation), 164 ± 134 travel minutes, &104 ± 99 driving costs, and &81 ± 66 foregone wage earnings. Virtual visit technical issues were experienced by 23% of patients and were significantly lower in pediatric (5%) than in adult patients (44%; p=0.006). This study is the first to assess the efficacy of synchronous videoconference visits in the home setting for outpatient burn care. The findings demonstrate major financial and temporal benefits for burn patients and their families. Technical issues remain an important barrier, particularly for the adult population. A clear understanding of these and other barriers may inform future studies as healthcare systems and payors move toward improving access to burn care through remote healthcare delivery services.

Sparsity of burn centers and prolonged length of hospital stay: A nationwide study

INTRODUCTION

The optimal distribution of burn centers remains unclear. We aimed to determine the appropriate number of burn centers per population (density) and examined a nationwide registry with the hypothesis that low-density burn centers would be associated with unfavorable outcomes.

PATIENTS AND METHODS

A retrospective study was conducted using the Japanese Society of Burn Injury registry (2011-2021). Burn center density was defined as the number of burn centers per one million population in each prefecture, and centers were trisected on the basis of density. Hospital-free days until day 30 were compared between patients at high-, middle-, and low-density centers. Inverse probability weighting was conducted to adjust baseline characteristics, including age, burn mechanism, and burn severity.

RESULTS

We included 6764, 6209, and 2200 patients at high-, middle-, and low-density burn centers, respectively. After adjusting for patient demographics and burn severity, patients at high- and middle-density centers (≥0.4 centers per one million population) had longer hospital-free days compared with those at low-density centers (11 [0-23] vs 11 [0-23] vs 8 [0-22] days; p < 0.001).

CONCLUSIONS

Low burn center density (<0.4 centers per one million population) was associated with longer hospital stay, whereas no higher limit was determined.

Evaluation of the emergency medical system in an area following lifting of the mandatory evacuation order after the Fukushima Daiichi Nuclear Power Plant accident: A retrospective cross-sectional observational study

Following the lifting of the evacuation order due to the Fukushima Daiichi Nuclear Power Plant accident, the medical demand and emergency medical system (EMS) in the area where the evacuation orders were lifted have not been well-investigated. This study aimed to evaluate the emergency transportation in such areas and compare the differences with areas that had minimal impact.Using the local EMS transport records, the characteristics of patients who were transferred by an EMS vehicle in Minamisoma City were collected between July 12, 2016 and July 31, 2018, and were compared between former evacuation zones and outside the evacuation zones in the city.The number of emergency transports in the study period in Minamisoma City were 325 cases in the area where the evacuation orders were lifted and 4307 cases in the other areas. The total EMS time was significantly longer in the area where the evacuation order was lifted (48 ± 16 minutes) than in the other areas (40 ± 15 minutes) (P < .001). In the analysis of each component of EMS times, the transport time, which is the time from departure from the patient's location to arrival at a hospital, was significantly longer in the former evacuation zone than in the other areas (16 ± 9 vs 9 ± 9 minutes, P < .001), suggesting that transport time contributed to the longer EMS response times.In areas where the evacuation orders were lifted, the EMS transport time was significantly longer than that in the area outside the former evacuation zone; correspondingly, the total EMS time significantly increased in the former evacuation zone. A plausible reason for this may be the closure of local medical facilities following the evacuation order after the nuclear accident.

Factors contributing to the restoration of normothermia after hypothermia in people with a major burn injury in the first 24 h of hospital admission

BACKGROUND

People with burn injury experiencing hypothermia are at risk of serious complications such as shock, multisystem organ failure, and death. There is limited information available for health professionals with regard to factors that contribute to restoration of normothermia after hypothermia in people with a major burn injury.

OBJECTIVE

The aim of the study was to identify factors that contribute to normothermia restoration after hypothermia in people with 10% or more total body surface area (TBSA) burn in the first 24 h of admission to a burn care hospital.

METHODS

The study was guided by the Gearing Framework for retrospective chart audit. The sample comprised medical charts of all adult people (n = 113) with a burn injury more than 10% of their TBSA admitted to a single-site burn care hospital intensive care unit in Victoria, Australia, between May 31, 2013, and June 1, 2015. Descriptive statistics were used to describe the sample, and logistic regression was conducted to predict variables contributing to return to normothermia in people with burn injury. Charts with incomplete data were excluded.

FINDINGS

The sample (n = 50) recorded a median initial temperature on admission to the emergency department (ED) of 35.4°C (range = 31.9-37.2°C) and took on an average of 6.2 (standard deviation [SD] = 4.96) hours to return to normothermia (36.5°C). Women took around 6 h longer than men to return to normothermia (mean = 11.14 h, SD = 5.58; mean = 5.38 h, SD = 4.41). Positive correlations were noted between TBSA%, the length of time between admission to the ED and the intensive care unit, and the hours taken to reach normothermia. Regression analysis suggests the initial recorded temperature on admission to the ED was the main predictor of the time body temperature takes to return to normothermia (β = .513, p < .001).

CONCLUSION

This study provides information for practice changes by highlighting the need for guidelines and education programs for health professionals to ensure the delivery of optimum care to people with burn injury.

Smartphone-based optical palpation: towards elastography of skin for telehealth applications

Smartphones are now integral to many telehealth services that provide remote patients with an improved diagnostic standard of care. The ongoing management of burn wounds and scars is one area in which telehealth has been adopted, using video and photography to assess the repair process over time. However, a current limitation is the inability to evaluate scar stiffness objectively and repeatedly: an essential measurement for classifying the degree of inflammation and fibrosis. Optical elastography detects mechanical contrast on a micrometer- to millimeter-scale, however, typically requires expensive optics and bulky imaging systems, making it prohibitive for wide-spread adoption in telehealth. More recently, a new variant of optical elastography, camera-based optical palpation, has demonstrated the capability to perform elastography at low cost using a standard digital camera. In this paper, we propose smartphone-based optical palpation, adapting camera-based optical palpation by utilizing a commercially available smartphone camera to provide sub-millimeter resolution imaging of mechanical contrast in scar tissue in a form factor that is amenable to telehealth. We first validate this technique on a silicone phantom containing a 5 × 5 × 1 mm³ embedded inclusion, demonstrating comparative image quality between mounted and handheld implementations. We then demonstrate preliminary in vivo smartphone-based optical palpation by imaging a region of healthy skin and two scars on a burns patient, showing clear mechanical contrast between regions of scar tissue and healthy tissue. This study represents the first implementation of elastography on a smartphone device, extending the potential application of elastography to telehealth.

Practice Diversity and Burn Center Growth: A 10-Year Profile of a State's Only Burn Center

BACKGROUND

Growth and sustainability of burn practices can be impaired by irregular patterns of patient presentations, resulting in uneven utilization of facilities and staff. Burn care itself may not engage the full capacities of members of burn care teams. To address these problems, we organized a burn and reconstruction center to provide statewide acute care as Mississippi's only burn unit, to fully integrate reconstructive surgery into management of burn patients, and to diversify practice based on plastic surgery scope of practice. The first 10 years of this unit were reviewed to evaluate the performance of this scheme.

METHODS

Burn admissions to and surgical procedures at this unit between July 2009 and June 2019 were analyzed to quantify acute burn care, secondary reconstructive burn care, and categories of practice growth.

RESULTS

The unit admitted 5469 acute burn patients with a mortality rate of 1.49%. Comparing year 10 to year 1 of practice, acute burn admissions increased 58%. Total operations increased 276%. Acute burn procedures increased 176%. Secondary burn procedures increased 405%. Nonburn procedures increased 352%, with the subset of nonburn hand surgery increasing 1062%.

CONCLUSION

Acute burn admissions and procedures increased over this period, but greater growth was seen in secondary burn procedures and nonburn procedures, especially hand cases. Expansion of practice into areas within the overall skill sets of burn team members was an effective growth strategy.

Social workers as members of burn care teams: A qualitative thematic analysis

BACKGROUND

Social workers on interprofessional teams contribute to treating the psychosocial sequelae of burn trauma patients in cooperation with many other burn-treatment team members. However, the roles and skills exercised by social workers can vary between burn units as well as the skills social work students are taught in their academic programs.

METHODS

A purposive sample of 13 burn unit social workers were interviewed online using semi-structured questions. This qualitative thematic analysis of data was conducted to identify how social workers perceive their roles, responsibilities, and knowledge as they relate to their work with patients and their families in a burn unit.

RESULTS

Skills, challenges and barriers to rehabilitation, and resources were identified during thematic analysis within and across participant data as factors social workers found to be important for their work in burn units.

CONCLUSION

By expanding the body of knowledge about factors that impact social work care for burn patients, Social work academic programs may better understand how to prepare medical social work students for best practices in the care of burn-injured patients, survivors, and families at inpatient and community levels.

Factors Associated with Pediatric Burn Clinic Follow-up after Emergency Department Discharge

Attrition between emergency department discharge and outpatient follow-up is well documented across a variety of pediatric ailments. Given the importance of outpatient medical care and the lack of related research in pediatric burn populations, we examined sociodemographic factors and burn characteristics associated with outpatient follow-up adherence among pediatric burn patients. A retrospective review of medical records was conducted on patient data extracted from a burn registry database at an urban academic children's hospital over a 2-year period (January 2018-December 2019). All patients were treated in the emergency department and discharged with instructions to follow-up in an outpatient burn clinic within one week. A total of 196 patients (Mage=5.5 years; 54% male) were included in analyses. Average percent total body surface area was 1.9 (SD=1.5%). One-third of pediatric burn patients (33%) did not attend outpatient follow-up as instructed. Older patients (OR=1.00; 95% CI: [.99-1.00], p=.045), patients with superficial burns (OR=9.37; 95% CI: [2.50-35.16], p=.001), patients with smaller percent total body surface area (OR=1.37; 95% CI: [1.07-1.76], p=.014), and patients with Medicaid insurance (OR=.22; 95% CI: [.09-.57], p=.002) or uninsured/unknown insurance (OR=.07; 95% CI: [.02-.26], p=.000) were less likely to follow up, respectively. Patient gender, race, ethnicity, and distance to clinic were not associated with follow-up. Follow-up attrition in our sample suggests a need for additional research identifying factors associated with adherence to follow-up care. Identifying factors associated with follow-up adherence is an essential step in developing targeted interventions to improve health outcomes in this at-risk population.

Early physiotherapy experience with a biodegradable polyurethane dermal substitute: Therapy guidelines for use

OBJECTIVE

The purpose of this study was to investigate and develop range of motion (ROM) and mobilisation guidelines in adult patients where a newly developed synthetic dermal substitute was applied in our adult burn centre.

METHOD

A retrospective case note audit was conducted on the first 20 acute burn injured patients who had a synthetic dermal substitute applied. Data collected included days to commencement of ROM, days to clearance for mobilisation, and joint ROM achieved after dermal substitute application (prior to delamination) and after split skin grafting (SSG) for the elbow, knee and shoulder joints. Scar assessments were completed at 12 months after injury using two scar assessment scales.

RESULTS

Clearance to mobilise occurred at mean 10.4 and 4.9 days after dermal substitute and after skin graft application to lower limbs respectively. ROM commenced at a mean of 9.9 (upper limbs) and 12.7 (lower limbs) days after dermal substitute application. Following skin grafting, ROM commenced at a mean of 6.6 and 6.5 days for upper limbs and lower limbs respectively. Prior to dermal substitute delamination mean flexion at the knee (86.3°), elbow (114.0°) and shoulder (143.4°) was achieved. Mean ROM continued to improve after grafting with knee (133.2°), elbow (126.1°) and shoulder (151.0°) flexion approaching normal ROM in most cases. Mean extension of the elbow (-4.6°) was maintained close to normal levels after skin grafting. There were no recorded instances of knee extension contracture. Patient and Observer Scar Assessment Scale and Matching Assessment of Photographs of Scars scores indicated good cosmetic outcomes with relatively low levels of itch and minimal pain reported at 12 months after injury.

CONCLUSION

A steep learning curve was encountered in providing therapy treatment for patients managed with this relatively new synthetic dermal substitute. Trends indicated that as experience with this new dermal substitute grew, patients progressed toward active therapy earlier. A guideline for therapy treatment has been developed but will continue to be evaluated and adjusted when required.

Interhospital variation of inpatient versus outpatient pediatric burn treatment after emergency department evaluation

BACKGROUND

Approaches to burn care in the pediatric population are highly variable and can be targeted as a potential measure in cost-reduction. We hypothesized that institutions vary significantly in treatment allocation of nonsevere burns to either inpatient or outpatient care.

METHODS

We queried the PHIS database for fiscal year 2017 to quantify small pediatric burn admissions and Emergency Department visits (ED). The ICD-10 code T31.0 was used to identify burns involving <10% of total body surface area (TBSA). Centers were categorized by burn center status and length of stay, readmissions, and charges were compared.

RESULTS

Inpatient versus outpatient management distribution was significantly different across the included pediatric children's hospitals (n = 34, p < 0.00001). When data were analyzed with respect to outpatient care, a bimodal distribution distinguished two groups: high hospital utilizers with an average of 30% outpatient burn care and low-utilizers averaging 87%. Median inpatient charge per patient was greater than 31-fold compared to ED burn management (p < 0.0001).

CONCLUSIONS

Variability of inpatient versus outpatient pediatric burn management in small burns was significant. Compared to outpatient burn care, inpatient care is significantly more costly. Implementing protocols and personnel to provide adequate attention to small burns in the ED could be an important cost-saving measure.

TYPE OF STUDY

Retrospective analysis.

LEVEL OF EVIDENCE

Level III.

Trends of Burn Injury in the United States: 1990 to 2016

OBJECTIVE

The aim of this study is to report patterns of burn injury within the United States from 1990 to 2016 with regard to age, sex, geography, and year.

SUMMARY BACKGROUND DATA

Advances in the management of burn injuries as well as successful public health efforts have contributed to reductions in the annual incidence and mortality of burns. However, several studies suggest that these reductions are not equally distributed throughout the US population.

MAIN OUTCOMES AND MEASURES

The Global Burden of Disease Study 2016 was utilized to collect incidence, mortality, disability-adjusted life years (DALYs), and years lived with disability (YLD) from 1990 to 2016. All measures were computed with 95% uncertainty intervals (UI).

RESULTS

The overall incidence of burn injury in the United States has decreased from 215 (95% UI, 183-246) to 140 (95% UI, 117-161) per 100,000. However, the relative mortality of burn injury has been fixed over the 26-year study period. Alaska had the highest rates of burn incidence in 1990 and 2016, closely followed by southeastern states. When adjusted for incidence, relative mortality in 1990 was highest in Alabama and Mississippi and the mortality-incidence ratio increased for these states in 2016. In addition, 35 states also demonstrated an increase in the relative mortality of burn injury during the study period.

CONCLUSIONS

Regional trends of burn incidence and mortality are highly variable and are likely due to a multitude of factors. Addressing these disparities will require close examination of the contributing factors of burn injury and severity.

Expert Outpatient Burn Care in the Home Through Mobile Health Technology

Access to care for pediatric burns remsains a major public health problem in the United States. Telemedicine has an opportunity to improve access to care, but current models are expensive and inefficient. They have developed and pilot-tested the TeleBurn App, a novel smartphone application, to treat partial thickness burns while outpatient. The app allows the provision of expert clinical burn care directly in the patient's home through text and image messaging, video conferencing, and instructional videos. They retrospectively reviewed clinical outcomes and usability in pediatric partial thickness burn patients treated using the TeleBurn App compared with standard therapy alone. Standard therapy is considered to be face-to-face delivery of care. Burn wound care was provided to 32 patients via the app and 35 patients with standard therapy. Most (74%) patients offered the app, used it as their primary source of follow-up care. This group had no wound infections or unexpected returns to clinic or hospital. Both TeleBurn App and standard therapy groups had similar burn severity, age, and burn mechanism. Mean healing time was shorter in the app group (mean ± standard deviation: 11.6 ± 4.7 days versus standard therapy: 14.3 ± 5.4 [P = .03]) with fewer clinical encounters (0.93 ± 0.6 vs standard therapy: 3.3 ± 1.0 [P = .001]). Adherence with completion of therapy in patients using the app was 80 vs 64 per cent with standard therapy. They describe a functional, scalable mobile health application in clinical use in a pediatric burn program. Further prospective, randomized studies may validate this mobile health platform, improving access to expert burn care for a vulnerable population.

Burn injury

Burn injuries are under-appreciated injuries that are associated with substantial morbidity and mortality. Burn injuries, particularly severe burns, are accompanied by an immune and inflammatory response, metabolic changes and distributive shock that can be challenging to manage and can lead to multiple organ failure. Of great importance is that the injury affects not only the physical health, but also the mental health and quality of life of the patient. Accordingly, patients with burn injury cannot be considered recovered when the wounds have healed; instead, burn injury leads to long-term profound alterations that must be addressed to optimize quality of life. Burn care providers are, therefore, faced with a plethora of challenges including acute and critical care management, long-term care and rehabilitation. The aim of this Primer is not only to give an overview and update about burn care, but also to raise awareness of the ongoing challenges and stigmata associated with burn injuries.

Geographic Variation in Outcomes After Burn Injury: A Burn Model System National Database Study

BACKGROUND

Geography is an important yet underexplored factor that may influence the care and outcomes of burn survivors. This study aims to examine the impact of geography on physical and psychosocial function after burn injury.

METHODS

Data from the Burn Model Systems National Database (1997-2015) were analyzed. Individuals 18 years and older who were alive at discharge were included. Physical and psychosocial functions were assessed at 6, 12, and 24 months postinjury using the following patient-reported outcome measures: Community Integration Questionnaire, Physical Composite Scale and Mental Composite Scale of the 12-Item Short Form Health Survey, Satisfaction with Appearance Scale, and Satisfaction with Life Scale. Descriptive statistics were generated for demographic and medical data, and mixed regression models were used to assess the impact of geography on long-term outcomes.

RESULTS

The study included 469 burn survivors from the Centers for Medicare and Medicaid Services regions 10, 31 from region 8, 477 from region 6, 267 from region 3, and 41 from region 1. Participants differed significantly by region in terms of race/ethnicity, burn size, burn etiology, and acute care length of stay (P < 0.001). In adjusted mixed model regression analyses, scores of all 5 evaluated outcome measures were found to differ significantly by region (P < 0.05).

CONCLUSIONS

Several long-term physical and psychosocial outcomes of burn survivors vary significantly by region. This variation is not completely explained by differences in population characteristics. Understanding these geographical differences may improve care for burn survivors and inform future policy and resource allocation.

Geospatial Mapping as a Guide for Resource Allocation Among Burn Centers in India

Timely treatment is essential for optimal outcomes after burn injury, but the method of resource distribution to ensure access to proper care in developing countries remains unclear. We therefore sought to examine access to burn care and the presence/absence of resources for burn care in India. We surveyed all eligible burn centers (n = 67) in India to evaluate burn care resources at each facility. We then performed a cross-sectional geospatial analysis using geocoding software (ArcGIS 10.3) and publicly available hospital-level data (WorldStreetMap, WorldPop database) to predict the time required to access care at the nearest burn center. Our primary outcome was the time required to reach a burn facility within India. Descriptive statistics were used to present our results. Of the 67 burn centers that completed the survey, 45% were government funded. More than 1 billion (75.1%) Indian citizens live within 2 hours of a burn center, but only 221.9 million (15.9%) live within 2 hours of a burn center with both an intensive care unit (ICU) and a skin bank. Burn units are staffed primarily by plastic surgeons (n = 62, 93%) with an average of 5.8 physicians per unit. Most burn units (n = 53, 79%) have access to hemodialysis. While many Indian citizens live within 2 hours of a burn center, most centers do not offer ICU and skin bank services that are essential for modern burn care. Reallocation of resources to improve transportation and availability of ICU and skin bank services is necessary to improve burn care in India.

Early patient deaths after transfer to a regional burn center

INTRODUCTION

Patients who sustain burn injuries are frequently transferred to regional burn centers. Severely injured patients, unlikely to survive, may be transported far from home and family to die shortly after arrival. An examination of early deaths, those that happen within a week of transfer, may offer an opportunity to revise the way we think about critical burns and consider the best way to provide regional care.

METHODS

This is a focused review of burn patients who survived ≤1 week after transfer to a regional center from 2013-2017. Originating location data such as city, state, population at origin were obtained. Transfer data, including mode of transport and distance traveled, as well as patient characteristics, Total Body Surface Area (TBSA) burned, inhalation injury, medical history with calculation of revised-Baux (r-Baux) score were analyzed.

RESULTS

25 patients (1.2%) met inclusion criteria. Patients were transferred from a wide geographic area with population ranges of 1000 to 279,000. 21 patients met criteria for burn resuscitation by TBSA; 4 (19%) were placed on comfort care upon arrival, 7 (33%) were placed on comfort care after discussion with the patient's family, and 10 (48%) received full resuscitation efforts. Of these 10 patients, 2 died as "full code", 8 were transitioned to comfort care after failed resuscitation or other events. Code status was not always addressed prior to the decision to transfer. Two patients were transferred after cardiac arrest in the field both of which had significant medical comorbidities in addition to their burn.

CONCLUSIONS

Regional burn centers support a variety of populations. Transferring patients for which care is futile may have a profound impact on resource utilization from a variety of perspectives including transferring centers, receiving centers, regional Emergency Medical Services and families. Referring providers need to be supported in identifying these severely injured, potentially expectant patients. Transfer of patients may negatively impact families as a loved one may die far from home, before family can arrive. With our increasing ability to utilize telemedicine, transfer may not always provide the best support we can offer for providers, patients, and families.

APPLICABILITY OF RESEARCH TO PRACTICE

Early deaths after transfer to a regional burn center, especially those that do not undergo a full resuscitation, should be critically examined to determine the appropriateness of transfer in a palliative, patient and family centered approach.

The association of burn patient volume with patient safety indicators and mortality in the US

INTRODUCTION

Clinical volume has been associated with rate of complications and mortality for various conditions and procedures. We aim to analyze the relationship between annual hospital burn admission, patient safety indicators (PSI), line infections, and inpatient mortality. We hypothesize that high facility volume will correlate with better outcomes.

METHODS

All burn admissions with complete data for total body surface area (TBSA) and depth were extracted from the Nationwide Inpatient Sample from 2002-2011. Predictor variables included age, gender, comorbidities, %TBSA, burn depth, and inhalation injury. Surgically relevant PSIs were drawn from the Healthcare Cost & Utilization Project and included: sepsis, venous thromboembolic disease, hemorrhage, pneumonia, and wound complications. Outcomes were analyzed with regression models.

RESULTS

Of the 57,468 encounters included, 3.1% died, 6.3% experienced >1 PSI event, and 0.3% experienced a catheter-associated urinary tract infections or central line associated blood stream infections. The most frequent PSI was pneumonia followed by sepsis and VTE. Annual hospital burn admission volume was independently associated with decreased odds of mortality (OR 0.99, 95% CI 0.99-0.99, p < 0.001) and PSIs (OR 0.99, 95% CI 0.99-0.99, p = 0.031). There was no significant correlation with line infections. In both mortality and PSI models, age, %TBSA, inhalation injuries, and Elixhauser comorbidity score were significantly associated with adverse outcomes (p < 0.05).

CONCLUSION

There was a significant association between higher hospital volume and decreased likelihood of patient safety indicators and mortality. There was no observed relationship with line infections. These findings could inform future verification policies of US burn centers.

Implication of Burn Disaster Planning and Management: Coverage and Accessibility of Burn Centers in Belgium

INTRODUCTION

Burn disasters represent a real challenge to burn centers worldwide. Several burn disasters with a considerable number of casualties happened in Belgium in the past. The positioning of burn centers is a significant issue to account for in a burn disaster preparedness and response. The objectives of this study are to identify the geographic coverage and accessibility of the burn centers in Belgium in the realm of a burn disaster scenario.

METHOD

Cross-sectional secondary analysis was performed using data from the Belgian Burn Association and Belgian Department of the Statistic. Data were analyzed using ArcGIS, a geographic information system tool to identify the coverage of burn centers within half an hour driving time, and access time of both populations in the districts and the disaster-prone areas to the individual burn centers.

RESULTS

Around 7.3 million (65%) people are covered by a half an hour driving time window from the burn centers. However, the accessibility to the individual burn centers is varied across different regions and provinces.

CONCLUSION

There is a slightly over-supply of burn centers in the mid part of the country, contrasted by an under-supply and poor accessibility for the population living near the borders, particularly in the south part of the country. This study would provide a benchmark for stakeholders in Belgium and other industrial countries to consider the coverage and accessibility of the burn centers as part of preparation and planning for burn disasters in the future.

Impact of traffic variability on geographic accessibility to 24/7 emergency healthcare for the urban poor: A GIS study in Dhaka, Bangladesh

Ensuring access to healthcare in emergency health situations is a persistent concern for health system planners. Emergency services, including critical care units for severe burns and coronary events, are amongst those for which travel time is the most crucial, potentially making a difference between life and death. Although it is generally assumed that access to healthcare is not an issue in densely populated urban areas due to short distances, we prove otherwise by applying improved methods of assessing accessibility to emergency services by the urban poor that take traffic variability into account. Combining unique data on emergency health service locations, traffic flow variability and informal settlements boundaries, we generated time-cost based service areas to assess the extent to which emergency health services are reachable by urban slum dwellers when realistic traffic conditions and their variability in time are considered. Variability in traffic congestion is found to have significant impact on the measurement of timely access to, and availability of, healthcare services for slum populations. While under moderate traffic conditions all slums in Dhaka City are within 60-minutes travel time from an emergency service, in congested traffic conditions only 63% of the city's slum population is within 60-minutes reach of most emergency services, and only 32% are within 60-minutes reach of a Burn Unit. Moreover, under congested traffic conditions only 12% of slums in Dhaka City Corporation comply with Bangladesh's policy guidelines that call for access to 1 health service per 50,000 population for most emergency service types, and not a single slum achieved this target for Burn Units. Emergency Obstetric Care (EmOC) and First Aid & Casualty services provide the best coverage, with nearly 100% of the slum population having timely access within 60-minutes in any traffic condition. Ignoring variability in traffic conditions results in a 3-fold overestimation of geographic coverage and masks intra-urban inequities in accessibility to emergency care, by overestimating geographic accessibility in peripheral areas and underestimating the same for central city areas. The evidence provided can help policy makers and urban planners improve health service delivery for the urban poor. We recommend that taking traffic conditions be taken into account in future GIS-based analysis and planning for healthcare service accessibility in urban areas.

Variations in access to specialty care for children with severe burns

BACKGROUND

Pediatric burns account for 120,000 emergency department visits and 10,000 hospitalizations annually. The American Burn Association has guidelines regarding referrals to burn centers; however there is variation in burn center distribution. We hypothesized that disparity in access would be related to burn center access.

METHODS

Using weighted discharge data from the Nationwide Inpatient Sample 2001-2011, we identified pediatric patients with International Classification of Diseases-9th Revision codes for burns that also met American Burn Association criteria. Key characteristics were compared between pediatric patients treated at burn centers and those that were not.

RESULTS

Of 54,529 patients meeting criteria, 82.0% (n = 44,632) were treated at burn centers. Patients treated at burn centers were younger (5.6 versus 6.7 years old; p < 0.0001) and more likely to have burn injuries on multiple body regions (88% versus 12%; p < 0.0001). In urban areas, 84% of care was provided at burn centers versus 0% in rural areas (p < 0.0001), a difference attributable to the lack of burn centers in rural areas. Both length of stay and number of procedures were significantly higher for patients treated at burn centers (7.3 versus 4.4 days, p < 0.0001 and 2.3 versus 1.1 procedures, p < 0.0001; respectively). There were no significant differences in mortality (0.7% versus 0.8%, p = 0.692).

CONCLUSION

The majority of children who met criteria were treated at burn centers. There was no significant difference between geographical regions. Of those who were treated at burn centers, more severe injury patterns were noted, but there was no significant mortality difference. Further study of optimal referral of pediatric burn patients is needed.

Quality Through Coopetition: An Empiric Approach to Measure Population Outcomes for Emergency Care-Sensitive Conditions

STUDY OBJECTIVE

We develop a novel approach for measuring regional outcomes for emergency care-sensitive conditions.

METHODS

We used statewide inpatient hospital discharge data from the Pennsylvania Healthcare Cost Containment Council. This cross-sectional, retrospective, population-based analysis used International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes to identify admissions for emergency care-sensitive conditions (ischemic stroke, ST-segment elevation myocardial infarction, out-of-hospital cardiac arrest, severe sepsis, and trauma). We analyzed the origin and destination patterns of patients, grouped hospitals with a hierarchical cluster analysis, and defined boundary shapefiles for emergency care service regions.

RESULTS

Optimal clustering configurations determined 10 emergency care service regions for Pennsylvania.

CONCLUSION

We used cluster analysis to empirically identify regional use patterns for emergency conditions requiring a communitywide system response. This method of attribution allows regional performance to be benchmarked and could be used to develop population-based outcome measures after life-threatening illness and injury.

Homelessness and Inpatient Burn Outcomes in the United States

Burn injuries are common in the homeless population. Little is known regarding whether homeless patients experience different outcomes when admitted for burns. We aim to 1) characterize the admitted homeless burn population, and 2) investigate differences in inpatient outcomes between the homeless and non-homeless populations. A retrospective cohort study was performed utilizing the Nationwide Inpatient Sample. Adult patients with complete data for burn characteristics were extracted. Variables included demographic, burn, and facility characteristics. Homelessness was identified with International Classification of Disease 9th edition codes. Outcomes were modeled with regression analysis and included length of stay, total operations, charges, disposition, and Patient Safety Indicators (PSIs). 43,872 encounters were included of which 0.76% were homeless. Homeless encounters were more likely to be male (P < .001) and Medicaid-insured (P < .001). Flame and frostbite injuries were more likely (P < .001), and the mean %TBSA was smaller (15.0 vs 16.8, P < .001). After adjustment, homeless patients had greater lengths of stay (11.5 vs 9.6, P = .046), greater charges ($73,597 vs $66,909, P = .030), fewer operations (P = .016), and three times higher likelihood leaving against medical advice (P = .002). There was no difference in PSIs or mortality. Homeless burn admissions represent a unique cohort that carries a higher comorbidity burden and experiences longer lengths of stay with greater difficulty in disposition. Ironically, these patients accumulate more charges with limited means to pay. Even though no differences were observed in PSIs or mortality, further research is needed to understand how the challenges within this population affect their recovery.

Change of access to emergency care in a repopulated village after the 2011 Fukushima nuclear disaster: a retrospective observational study

OBJECTIVES

Sustaining emergency care access is of great concern. The aim of this study is to evaluate access to emergency care in a repopulated village following the 2011 Fukushima disaster.

DESIGN

This research was a retrospective observational study. The primary outcome measure was total emergency medical services (EMS) time. A Bayesian time series analysis was performed to consider local time series trend and seasonality.

SETTING

The residents in Kawauchi Village, Fukushima, Japan were forced to evacuate after the 2011 Fukushima disaster. As the radiation dose was an acceptable level, the residents began the process of repopulation in April 2012.

PARTICIPANTS

This study included patients transported by EMS from January 2009 to October 2015. Patients transported during the evacuation period (from March 2011 to March 2012) were excluded.

RESULTS

A total of 781 patients were transferred by EMS (281 patients before the disaster, 416 after repopulation and 84 during the evacuation period). A Bayesian time series analysis revealed an increase in total EMS time, from the first request call to arrival at a hospital of 21.85 min (95% credible interval 14.2-29.0, Bayesian one-sided tail-area probability p=0.001). After the disaster, 42.3% of patients were transported to a partner hospital.

CONCLUSIONS

Total EMS time increased after repopulation of the area affected because of a massive number of hospital closures. Proactive partnerships would be a possible countermeasure in the affected areas after a major disaster.

Emergency Care of Pediatric Burns

Although the overall incidence of and mortality rate associated with burn injury have decreased in recent decades, burns remain a significant source of morbidity and mortality in children. Children with major burns require emergent resuscitation. Resuscitation is similar to that for adults, including pain control, airway management, and administration of intravenous fluid. However, in pediatrics, fluid resuscitation is needed for burns greater than or equal to 15% of total body surface area (TBSA) compared with burns greater than or equal to 20% TBSA for adults. Unique to pediatrics is the additional assessment for non-accidental injury and accurate calculation of the percentage of total burned surface area (TBSA) in children with changing body proportions are crucial to determine resuscitation parameters, prognosis, and disposition.

Review of Recent Large-Scale Burn Disasters Worldwide in Comparison to Preparedness Guidelines

The US National Bioterrorism Hospital Preparedness Program indicates that each care facility must have "a plan to care for at least 50 cases per million people for patients suffering burns or trauma" to receive national funding disaster preparedness. The purpose of this study is to evaluate whether this directive is commensurate with the severity recent burn disasters, both nationally and internationally. We conducted a review of medical journal articles, investigative fire reports, and media news sources for major burn disasters dating from 1990 to present day. We defined a major burn disaster as any incident with ≥50 burn injuries and/or ≥ 30 burn-related deaths. We compared existing preparedness guidelines with the magnitude of recent burn disasters using as reference the 2005 U.S. Health and Human Services directive that each locale must "have a plan to care for at least 50 cases per million people for patients suffering burns or trauma." We reported the number of actual casualties for each incident, and estimated the number of burn beds theoretically available if the "50 [burn-injury] cases per million people" directive were to be applied to metropolitan areas outside the United States. Seven hundred fifty-two burn disaster incidents met our inclusion criteria. The majority of burn disasters occurred in Asia/Middle East. The incidence of major burn disasters from structural fires and industrial blasts remains constant in high-income and resource-restricted countries during this study period. The incidence of terrorist attacks increased 20-fold from 2001 to 2015 compared with 1990 to 2000. Recent incidents demonstrate that if current preparedness guidelines were to be adopted internationally, local resources including burn-bed availability would be insufficient to care for the total number of burn casualties. These findings underscore an urgent need to organize better regional, national, and international collaboration in burn disaster response.

Viable placental allograft as a biological dressing in the clinical management of full-thickness thermal occupational burns: Two case reports

RATIONALE

Occupational burn injuries can be detrimental and difficult to manage. The majority of complex cases are referred and managed at regional burn centers where access to specialized care is available. As an alternative to hospitalization with staged surgical procedures, placental products may be used for outpatient medical management of these common burn injuries, especially if access to a regional burn center is limited or restricted.Fresh amnion has been a treatment of choice in burns for more than 100 years. As a biological covering with a broad scope of potential uses, human placental membranes represent a dressing that is particularly advantageous for burn therapy. Recent advances in tissue-preservation technology have allowed for the commercialization of placental amnion products.

PATIENT CONCERNS

To address several complications associated with burn injuries-contractures, scar formation, and pain-a viable cryopreserved placental membrane (vCPM) (Grafix-PRIME, Osiris Therapeutics, Inc., MD) retaining the anti-inflammatory, anti-fibrotic, and antimicrobial properties of fresh placental tissues was chosen for clinical use in the 2 cases reported, where both patients had restricted access to the regional burn center.

DIAGNOSES

Two cases of work-related extremity burns presented to a local rural hospital for immediate post-injury assessment. The 1 case was of a man who sustained a 55.4 cm full-thickness 3 degree thermal burn with exposed bone and tendon, to the left dorsal forefoot after having an industrial pressure washer caught on his work boot. The 2 case was of a female who sustained a 4.7 cm full-thickness 3 degree crush burn to the dorsum extensor surface of her dominant hand's index finger after applying 80-pounds per square inch of heated pressure from a hydraulic press.

INTERVENTIONS

Both burn patients elected to continue their care at the outpatient-based wound and hyperbaric center, receiving a combination of weekly ad libitum debridement, applications of vCPM, and occupational therapy.

OUTCOMES

Both burns reached timely wound closure, and patients regained full range of motion of the affected limb, allowing for early return to work. The average number of allograft applications was 7.5, allowing both patients to return to work in an average of 63.5 days without adverse events or post-treatment complications.

LESSONS

The incorporation of this product in the treatment of these complex burns prevented amputation in one patient, and skin autografting and potential index finger contracture-formation in the second patient. The incorporation of vCPM in burn management may offer a new approach to outpatient burn management and may mitigate several of the complications seen post burn injury, leading to favorable patient outcomes.