Response of a local hospital to a burn disaster: Contributory factors leading to zero mortality outcomes

Conflict and catastrophe-related severe burn injuries: A challenging setting for antimicrobial decision-making

Severe burns are a major component of conflict-related injuries and can result in high rates of mortality. Conflict and disaster-related severe burn injuries present unique challenges in logistic, diagnostic and treatment options, while wider conflict is associated with driving local antimicrobial resistance. We present a targeted review of available literature over the last 10 years on the use of systemic antimicrobial antibiotics in this setting and, given limited available data, provide an expert consensus discussion. While international guidelines do not tend to recommend routine use of prophylactic systemic antibiotics, the challenges of conflict settings and potential for polytrauma are likely to have ongoing impacts on antimicrobial decision-making and use. Efforts must be made to develop a suitable evidence base in this unique setting. In the interim, a pragmatic approach to balancing selective pressures of antimicrobial use with realistic access is possible.

Association between awareness of vulnerability and disaster preparedness in an infrastructure-resilient city: a population-based study

OBJECTIVES

Factors associated with an individual's awareness of vulnerability can be modified by the infrastructure of a city. These factors may impact disaster preparedness among local populations in an infrastructure-resilient city, which further influences the health risks of various population subgroups.

STUDY DESIGN

This was a population-based study.

METHODS

Four population subgroups, which have previously been reported to be related to awareness of vulnerability (i.e. past experiences, sociodemographic deprivation, poor housing conditions and family medical needs), were analysed for their impacts on disaster preparedness. Validated population-based phone interviews (n = 856) were conducted in Hong Kong. Three types of disaster preparedness were studied: (1) physical preparedness; (2) social preparedness; and (3) education preparedness.

RESULTS

Previous experience of social hazards, accidental hazards and epidemics increased disaster preparedness among the local population. Specifically, experiences of accidental hazards and social hazards were positively associated with physical preparedness (odds ratios 1.626, 95% confidence interval [95% CI] 1.215, 2.172) and 1.501 [95% CI 1.114, 2.024], respectively). However, experiences of natural hazards did not increase preparedness, even in Hong Kong, which is a city with high 'disaster resilience' because of its well-developed infrastructure. Moreover, individuals with a low educational level or low income had lower education preparedness, unmarried individuals had lower social preparedness, and poor housing conditions of non-private-housing households had negative associations with education preparedness. These findings partially align with local disaster responses to the 2018 Typhoon Mangkhut, the 2019 social unrest and the 2020 COVID-19 pandemic, all of which were observed after the 2018 survey reported in this study.

CONCLUSIONS

Social and environmental interventions should be targeted to marginalised subpopulations through location-based community strategies to encourage increased environmental knowledge and participation in disaster preparedness activities.

The relationships between routine admission blood tests and burn size, and length of stay in intensive care unit

BACKGROUND

Although blood test is a routine in major burns, its relationship with burn size and intensive care unit length of stay (ICULOS) remains undetermined. We investigated the feasibility of using these tests as a reference for definite diagnosis of major burn size, burn size >20% of the total body surface area (TBSA), and their relationships with ICULOS.

METHODS

Data of routine laboratory blood tests within 24 h after burns (n = 73) were collected retrospectively. Correlation tests and regression analyses were performed.

RESULTS

Burns ≥20 TBSA had higher incidences of leucocytosis, hypoalbuminaemia, elevated haemoglobin (Hb), and elevated haematocrit (Hct). Burn size was correlated negatively with albumin but positively with Hb, Hct, and white blood cell (WBC) count. For each unit increase in blood urea nitrogen (BUN)/creatinine (Cr), there was an increase of 1.2 days of ICULOS in females, while in males, there was a 6.7 day increase for every unit increase in Hb and a 3.1 day increase for each unit increase in BUN. A female model including Hb and WBC was derived, discriminating burns ≥20 TBSA with sensitivity and specificity 0.94 and 1.0 respectively, and area under the receiver operating characteristic curve (AUROC) 0.96 (95% CI 0.91-1.00). The male model had sensitivity 0.96, specificity 1.0, and AUROC 0.96 (95% CI 0.89-1.00).

CONCLUSION

Admission Hb and WBC could be used as a reference for definite diagnosis of major burn size, especially in borderline cases. BUN/Cr in females, and Hb and BUN in males, were related to ICULOS.

Incidence and Mortality of Acute Respiratory Distress Syndrome in Patients With Burns: A Systematic Review and Meta-Analysis

Objective: We conducted a systematic review and meta-analysis to comprehensively estimate the incidence and mortality of acute respiratory distress syndrome (ARDS) in overall and subgroups of patients with burns. Data sources: Pubmed, Embase, the Cochrane Library, CINAHL databases, and China National Knowledge Infrastructure database were searched until September 1, 2021. Study selection: Articles that report study data on incidence or mortality of ARDS in patients with burns were selected. Data extraction: Two researchers independently screened the literature, extracted data, and assessed the quality. We performed a meta-analysis of the incidence and mortality of ARDS in patients with burns using a random effects model, which made subgroup analysis according to the study type, inclusion (mechanical ventilation, minimal burn surface), definitions of ARDS, geographic location, mean age, burn severity, and inhalation injury. Primary outcomes were the incidence and mortality of burns patients with ARDS, and secondary outcomes were incidence for different subgroups. Data synthesis: Pooled weighted estimate of the incidence and mortality of ARDS in patients with burns was 0.24 [95% confidence interval (CI)0.2-0.28] and 0.31 [95% CI 0.18-0.44]. Incidences of ARDS were obviously higher in patients on mechanical ventilation (incidence = 0.37), diagnosed by Berlin definition (incidence = 0.35), and with over 50% inhalation injury proportion (incidence = 0.41) than in overall patients with burns. Patients with burns who came from western countries and with inhalation injury have a significantly higher incidence of ARDS compared with those who came from Asian/African countries (0.28 vs. 0.25) and without inhalation injury (0.41 vs. 0.24). Conclusion: This systematic review and meta-analysis revealed that the incidence of ARDS in patients with burns is 24% and that mortality is as high as 31%. The incidence rates are related to mechanical ventilation, location, and inhalation injury. The patients with burns from western countries and with inhalation injury have a significantly higher incidence than patients from Asian/African countries and without inhalation injury. Systematic Review Registration: identifier: CRD42021144888.

Ranking hospitals' burn care capacity using cluster analysis on open government data

BACKGROUND AND OBJECTIVE

To deal with burn mass casualty incidents (BMCIs), various countries have established national or regional BMCI emergency response plans (ERPs). A burn care capacity ranking model for hospitals can play an integral role in ERPs by providing essential information to emergency medical services for distributing and handling mass burn patients. Ranking models vary across countries and contexts. However, Taiwan has had no such model. The study aims to develop a ranking model for classifying hospitals' burn care capacity in preparation for the development of a national BMCI ERP.

METHODS

Multiple methods were adopted. An expert panel provided consultations on data selection and clustering validation. Data on 116 variables from 535 hospitals were collected via open data platforms under the Ministry of Health and Welfare. Data selection and streamlining was conducted to determine 42 variables for cluster analysis. SAS 9.4 was used to analyze the data set -via a hierarchical cluster analysis using Ward's method, followed by a tree-based model analysis to identify the criteria for each cluster. Both internal and external cluster validation were performed.

RESULTS

Four clusters of burn care capacity were determined to be a suitable number of clusters. All hospitals were arranged into capacity levels accordingly. Results of the Kruskal-Wallis test showed that the difference between clusters were significant. Tree-based model analysis revealed four determining variables, among which the refined level of emergency care responsibility hospital was found to be most influential on the clustering process. Responses from the questionnaire were used as an external validation tool to corroborate with the cluster analysis results.

CONCLUSION

The use of open government data and cluster analysis was suitable for developing a ranking model to determine hospitals' burn care capacity levels in Taiwan. The proposed ranking model can be used to develop a BMCI emergency response plan and can also serve as a reference for using cluster analysis with open government data to rank care capacity or quality in other domains.

The Wound Microbiology and the Outcomes of the Systemic Antibiotic Prophylaxis in a Mass Burn Casualty Incident

This paper describes the wound microbiology and outcome of using systemic antibiotic prophylaxis (SAP) in mass burn casualties (MBC). The charts of 31 patients (mean age: 21 years, mean burn area: 42% of the total body surface area) injured in a dust explosion were reviewed for 1 month after the burn. Polymicrobial and rare pathogen wound infections (Acinetobacter junii, Aeromonas sobri, et al) were common in MBC due to sterility breech. Following the use of SAP for 2 to 14 days after admission, there was a reduction in wound infection rate from 45% at week 1 postburn to 10% at week 4. In addition, no blood stream infection occurred in the first week after the burns. Multidrug-resistant Acinetobacter baumannii, Klebsiella pneumoniae, and Candida albicans were the top three wound pathogens cultured. Multidrug-resistant microorganism infections were found in 39% of the patients, and the odds ratios for the these infections in burn patients with more than ≥40% total body surface area and in patients receiving two or more classes of antibiotics were 41.7 (95% confidence interval [CI] = 2.1-810.7, P = .01) and 9.9 (95% CI= 1.0-92.7, P = .04), respectively. Although SAP did not prevent wound or blood stream infections, no mortality occurred in our patients. A randomized controlled study is needed to investigate the impact of SAP on burn mortality in MBC.

Assessment and determinants of global outcomes among 445 mass-casualty burn survivors: A 2-year retrospective cohort study in Taiwan

PURPOSE

To study outcomes among survivors of the mass-casualty powder explosion on 27 June 2015, at Formosa Fun Coast Waterpark, New Taipei City, Taiwan.

METHODS

Using retrospective data on Taiwanese survivors, we analyzed prehospital management, burns assessment and prognosis, functional recovery, and medical costs, followed-up through 30 June 2017. We related outcomes to burn extent, categorized according to the percentages of total body surface area with second/third-degree burns (%TBSA) or autologous split-thickness skin grafts (%STSG), and an investigational scale: f{SASG} = (%TBSA + %STSG)/2, stratified by %STSG. Analyses included casualty dispersal, comparisons between %TBSA, %STSG and f{SASG}, and their relationships with length of hospitalization, times to rehabilitation and social/school re-entry, physical/mental disability, and medical costs. We also investigated how burn scars restricting joint mobility affected rehabilitation duration.

RESULTS

445 hospitalized casualties (excluding 16 foreigners, 23 with 0% TBSA and 15 fatalities) aged 12-38 years, had mean TBSA of 41.1%. Hospitalization and functional recovery durations correlated with %TBSA, %STSG and f{SASG} - mean length of stay per %TBSA was 1.5 days; more numerous burn scar contractures prolonged rehabilitation. Females had worse burns than males, longer hospitalization and rehabilitation, and later school/social re-entry; at follow-up, 62.3% versus 37.7% had disabilities and 57.7% versus 42.3% suffered mental trauma (all p ≤ 0.001). Disabilities affecting 225/227 people were skin-related; 34 were severely disabled but 193 had mild/moderate impairments. The prevalence of stress-related and mood disorders increased with burn extent. Treatment costs (mean USD-equivalents ∼$48,977/patient, ∼$1192/%TBSA) increased with burn severity; however, the highest %TBSA, %STSG and f{SASG} categories accounted for <10% of total costs, whereas TBSA 41-80% accounted for 73.2%.

CONCLUSIONS

Besides %TBSA, skin-graft requirements and burn scar contractures are complementary determinants of medium/long-term outcomes. We recommend further elucidation of factors that influence burn survivors' recovery, long-term physical and mental well-being, and quality of life.

Risk Factors for Multidrug-Resistant Acinetobacter baumannii Infections in a Mass Burn Casualty Incident

They investigated the risk factors of multidrug-resistant Acinetobacter baumannii infections in 33 burn patients in a mass burn casualty. The independent variables included sex, burn size, vancomycin, ampicillin/sulbactam, cefazolin, meropenem, third-/fourth-generation cephalosporin, the number of classes of antibiotic used, and the number of days of antibiotic use. Multidrug-resistant A. baumannii infection was the outcome variable. Logistic regressions and structural equation model were used for statistical analysis. The average age was 21.7 years (range, 17-32 years; M = 11 [33%], F = 22 [67%]; mean burn area, 42% of the total body surface area; study period, June 28, 2015 to July 31, 2015). The incidence of infection was 39% (n = 13/33). For every percent increase in burn size, the odds of developing A. baumannii infections increased by 1.1 (P < .05). Similarly, the odds increased by 2.5 in every number increase in the classes of antibiotic used, by 1.2 in everyday increase in the days of antibiotic used, and by 12 in patients treated with vancomycin (P < .05). The correlations of these risk factors were demonstrated in a hypothetical structural equation model (P-value of chi-squared test > .05 and root mean square error of approximation < 0.05) in which burn size was the fundamental risk factor of multidrug-resistant A. baumannii infections. The model did not predict the emergence of multidrug-resistant A. baumannii infections. Conclusively, the risks of multidrug-resistant A. baumannii infections in burns are correlated with burn size, the number of classes of antibiotic used, the number of days of antibiotic use, and the prior use of vancomycin.

The crowd-out effect of a mass casualty incident: Experience from a dust explosion with multiple burn injuries

A mass casualty incident (MCI) can have an enormous impact on an already crowded emergency department (ED), affecting the quality of health care provided to non-MCI ED patients. On June 26, 2015, a burn MCI (BMCI) occurred due to a cornstarch explosion at a party at a water park. The competing needs of the BMCI patients might have crowded out the needs of the non-BMCI patients. Although crowd-out effects have been previously documented in a variety of health care situations, they have not been extensively evaluated during MCIs. We aimed to determine whether the outcomes of the non-MCI patients were compromised during this incident.We conducted a retrospective observational study comparing several health care parameters and outcomes between non-BMCI patients and historical controls during the designated period using institutional electronic records and the National Health Insurance Research Database.On the night of the incident, 53 patients were sent to our ED; most of them arrived within 3 hours after the BMCI. There was a significant increase in the wait time for ICU beds among non-BMCI patients compared to the wait times during the corresponding week of the previous year (8.09 ± 4.21 hours vs 3.77 ± 2.15 hours, P = .008). At the hospital level, there was a significantly increased length of hospital stay (LOS) in the ICU after the MCI compared with the LOS in the ICU in the same week of the preceding year (median days: 15 vs 8, P ≤ .001). At the regional level, there were no significant differences between the 2 periods in the LOS in acute care, LOS in the ICU or mortality rates at the involved medical centers.Crowd-out effects from the MCI occurred in the ED and at the institutional level. Although there was an increased wait time for admission to the ICU and a longer LOS in the ICU, the LOS in acute care beds, treatment of time-sensitive diseases, and mortality rates were not compromised by the current MCI protocol at either the institutional or regional levels.