The impact of discharge contracture on return to work after burn injury: A Burn Model System investigation

A Meta-Analysis of the Mortality and the Prevalence of Burn Complications in Western Populations

Management of burn injuries is complex, with highly variable outcomes occurring among different populations. This meta-analysis aims to assess the outcomes of burn therapy in North American and European adults, specifically mortality and complications, to guide further therapeutic advances. A systematic review of PubMed, Web of Science, and Cochrane was performed. Random-effect meta-analysis of proportions was conducted to assess the overall prevalence of the defined outcomes. In total, 54 studies were included, pooling 60 269 adult patients. A total of 53 896 patients were in North America (NA, 89.4%), and 6373 were in Europe (10.6%). Both populations experienced similar outcomes. The overall pooled prevalence of mortality was 13% (95% CI, 8%-19%) for moderate burns, 20% (95% CI, 12%-29%) for severe burns in the NA region, and 22% (95% CI, 16%-28%) for severe burns in Europe. Infectious complications were the most common across both regions. European studies showed an infection rate for patients with moderate and severe burns at 8% and 76%, respectively, while NA studies had rates of 35% and 54%. Acute kidney injury (39% vs 37%) and shock (29% vs 35%) were the next most common complications in European and NA studies, respectively. The length of stay was 27.52 days for patients with severe burns in Europe and 31.02 days for patients with severe burns in NA. Burn outcomes are similar between Western populations. While outcomes are reasonably good overall, infectious complications remain high. These findings encourage the development of further therapeutic strategies disclosing respective costs to enable cost/efficiency evaluations in burn management.

Adult Burn Survivors and Burn Care Staff Perceptions Regarding Transitioning From the Burn Unit: A Cross-Country Qualitative Study in Ghana and China

Rehabilitative care for burn patients in developing countries is often wrought with several issues. Post-discharge support is equally challenging as there is often limited rehabilitative care as the burn survivors and their families transition. To inform practice, this study sought to explore the perspectives of adult burn survivors and burn care staff regarding transitioning from the burn unit and the development of a transitional rehabilitation programme. We employed interpretive description for this study. Semi-structured face-to-face interviews were conducted with adult burn survivors and burn care staff across two tertiary healthcare facilities in Lanzhou, Gansu Province of China, and Ghana. The thematic analytical approach was employed to analyse the data. Forty-six participants comprising 26 adult burn survivors and 20 burn care staff participated in this study. Two themes and five subthemes emerged from the data. Transitioning from the burn unit to the home was described as complex with varied biopsychosocial needs emerging. However, available support was not comprehensive to resolve these needs. Existing pre-discharge support is limited across both settings. Burn survivors expressed interest in taking on an active role in the rehabilitation process and being able to self-manage their post-burn symptoms following discharge. Transitional rehabilitative support should include an active follow-up system, ensure patient- and family-centred support, and offer a bundle of comprehensive rehabilitative services using locally available items which do not financially burden burn survivors and their families. In conclusion, transitioning from the burn unit is filled with varied health needs. Transitional rehabilitative care is required to bridge the pre-discharge and post-discharge periods.

Utilizing a Quality Improvement Approach to Improve Positioning of Acute Burn Patients

Patient positioning, using "anti-deformity positioning," is a standard practice in burn rehabilitation to assist with edema management, scar contracture prevention, and wound healing. Consistently providing proper positioning requires the combined effort of the multidisciplinary burn team. Our primary goal was to increase the frequency that patients were correctly positioned to over 90%. At a medium-sized, academic burn unit, random audits were conducted by burn lead therapists on the compliance of proper patient positioning over 6 months. Using this data as a trigger, a quality improvement project was designed using the Plan-Do-Study-Act (PDSA) cycle. Surveys were distributed to therapy and nursing staff to identify barriers to proper positioning. Effects on positioning compliance postintervention were monitored. In the 6 months prior to intervention, the average correct positioning was 76%. Surveys identified the following barriers to care: nursing needed more education and the approach was too heavily reliant on nursing efforts alone. To address this, therapists provided education to all nurses, communicated daily about positioning expectations, shifted the project to a multidisciplinary approach, and made changes in therapy workflow. The median compliance improved from 79% to 91% (P < .05). Coordinating efforts of the entire burn team improve consistency for positioning in burn patients. Utilizing the PDSA cycle allowed us to identify areas for improvement and develop appropriate interventions to increase education for nursing staff and workflow improvements for therapists. Following the completion of our interventions, we were able to obtain an immediate improvement in our patient positioning compliance.

Quality indicators for hospital burn care: a scoping review

BACKGROUND

Burn treatments are complex, and for this reason, a specialised multidisciplinary approach is recommended. Evaluating the quality of care provided to acute burn patients through quality indicators makes it possible to develop and implement measures aiming at better results. There is a lack of information on which indicators to evaluate care in burn patients. The purpose of this scoping review was to identify a list of quality indicators used to evaluate the quality of hospital care provided to acute burn patients and indicate possible aspects of care that do not have specific indicators in the literature.

METHOD

A comprehensive scoping review (PRISMA-ScR) was conducted in four databases (PubMed, Cochrane Library, Embase, and Lilacs/VHL) between July 25 and 30, 2022 and redone on October 6, 2022. Potentially relevant articles were evaluated for eligibility. General data and the identified quality indicators were collected for each included article. Each indicator was classified as a structure, process, or outcome indicator.

RESULTS

A total of 1548 studies were identified, 82 were included, and their reference lists were searched, adding 19 more publications. Thus, data were collected from 101 studies. This review identified eight structure quality indicators, 72 process indicators, and 19 outcome indicators listed and subdivided according to their objectives.

CONCLUSION

This study obtained a list of quality indicators already used to monitor and evaluate the hospital care of acute burn patients. These indicators may be useful for further research or implementation in quality improvement programs.

TRIAL REGISTRATION

Protocol was registered on the Open Science Framework platform on June 27, 2022 ( https://doi.org/10.17605/OSF.IO/NAW85 ).

Risk factors for burn contractures: A cross-sectional study in a lower income country

Risk factors for burn contractures require further study, especially in low and middle-income countries (LMICs); existing research has been predominantly conducted in high income countries (HICs). This study aimed to identify risk factors for burn contractures of major joints in a low-income setting. Potential risk factors (n = 104) for burn contracture were identified from the literature and a survey of clinicians with extensive experience in low and middle-income countries (LMIC). An observational cross-sectional study of adult burn survivors was undertaken in Bangladesh to evaluate as many of these risk factors as were feasible against contracture presence and severity. Forty-eight potential risk factors were examined in 48 adult patients with 126 major joints at risk (median 3 per participant) at a median of 2.5 years after burn injury. Contractures were present in 77% of participants and 52% of joints overall. Contracture severity was determined by measurement of loss of movement at all joints at risk. Person level risk factors were defined as those that were common to all joints at risk for the participant and only documented once, whilst joint level risk factors were documented for each of the participant's included joints at risk. Person level risk factors which were significantly correlated with loss of range of movement (ROM) included employment status, full thickness burns, refusal of skin graft, discharged against medical advice, low frequency of follow up and lack of awareness of contracture development. Significant joint level risk factors for loss of ROM included anatomical location, non-grafted burns, and lack of pressure therapy. This study has examined the largest number of potential contracture risk factors in an LMIC setting to date. A key finding was that risk factors for contracture in low-income settings may differ substantially from those seen in high income countries, which has implications for effective prevention strategies in these countries. Better whole person and joint outcome measures are required for accurate determination of risk factors for burn contracture. Recommendations for planning and reporting on future contracture risk factor studies are made.

A Narrative Review of Outcomes in Burn Rehabilitation Based on the International Classification of Functioning, Disability, and Health

Burn injury commonly causes long-term physical impairments and psychosocial limitations that impact survivorship. This article uses the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) framework to summarize burn rehabilitation outcomes related to body functions and structures and how they relate to activities and participation within the social context. This article will contribute to a better understanding of burn recovery, facilitate the identification of specific and meaningful issues common to burn survivorship that may be under-reported in prior investigations and guide future rehabilitation to advance long-term burn outcomes.

Concepts in soft-tissue reconstruction of the contracted hand and upper extremity after burn injury

Burns and their subsequent contracture result in devastating functional and aesthetic consequences which disproportionally affect the upper extremity. By focusing on reconstruction with analogous tissue and utilizing the reconstructive elevator, function can be restored concomitantly with form and aesthetic appearance. General concepts for soft-tissue reconstruction after burn contracture are presented for different sub-units and joints.

Are burns a chronic condition? Examining patient reported outcomes up to 20 years after burn injury-A Burn Model System National Database investigation

BACKGROUND

People living with burn injury often face long-term physical and psychological sequelae associated with their injuries. Few studies have examined the impacts of burn injuries on long-term health and function, life satisfaction, and community integration beyond 5 years postinjury. The purpose of this study was to examine these outcomes up to 20 years after burn injury.

METHODS

Data from the Burn Model System National Longitudinal Database (1993-2020) were analyzed. Patient-reported outcome measures were collected at discharge (preinjury status recall) and 5 years, 10 years, 15 years, and 20 years after injury. Outcomes examined were the SF-12/VR-12 Physical Component Summary and Mental Component Summary, Satisfaction with Life Scale, and Community Integration Questionnaire. Trajectories were developed using linear mixed models with repeated measures of outcome scores over time, controlling for demographic and clinical variables.

RESULTS

The study population included 421 adult burn survivors with a mean age of 42.4 years. Lower Physical Component Summary scores (worse health) were associated with longer length of hospital stay, older age at injury and greater time since injury. Similarly, lower Mental Component Summary scores were associated with longer length of hospital stay, female sex, and greater time since injury. Satisfaction with Life Scale scores decrease negatively over time. Lower Community Integration Questionnaire scores were associated with burn size and Hispanic/Latino ethnicity.

CONCLUSION

Burn survivors' physical and mental health and satisfaction with life worsened over time up to 20 years after injury. Results strongly suggest that future studies should focus on long-term follow-up where clinical interventions may be necessary.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.