Follow-up After Burn Injury Is Disturbingly Low and Linked With Social Factors

Injury Pattern Analysis to Optimize Burn Injury Prevention in the Unhoused Community

Unhoused patients are an overrepresented group in burn injury, and are a uniquely vulnerable population. Current research focuses on the consequences of homelessness on burn outcomes, with little known about the specific circumstances and behaviors leading to burn injury that may represent specific targets for injury prevention efforts. The burn registry at an urban regional burn center was queried for burn admissions in unhoused adults from 2019 to 2022. Registry data pulled included demographics, urine toxicology, mechanism of injury, and injury subjective history. Subjective injury history was reviewed to determine more specific injury circumstances and activities during which accidental burns occurred. Demographic and mechanistic trends in burn admissions were explored via descriptive statistics. Among 254 admissions for burns from the unhoused community, 58.1% of patients were positive for stimulants on admission. Among accidental injuries (69.7%), common circumstances included preparing food or beverages, cooking or using methamphetamine, smoking cannabis or tobacco, bonfires, and candles. A specific common circumstance was lighting a cigarette while handling accelerants (6.7%). Interventions for stimulant abuse, as well as outreach efforts to educate unhoused patients about situational awareness, safe handling of accelerants, safe smoking practices, and safe cooking practices, may be effective tools in reducing burn admissions in this vulnerable population.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Race and Ethnicity Influences Outcomes of Adult Burn Patients

Outcomes of burn survivors is a growing field of interest; however, there is little data comparing the outcomes of burn survivors by ethnicity. This study seeks to identify any inequities in burn outcomes by racial and ethnic groups. A retrospective chart review of an ABA Certified burn center at a large urban safety net hospital identified adult inpatient admissions from 2015 to 2019. A total of 1142 patients were categorized by primary ethnicity: 142 black or African American, 72 Asian, 479 Hispanic or Latino, 90 white, 215 other, and 144 patients whose race or ethnicity was unrecorded. Multivariable analyses evaluated the relationship between race and ethnicity and outcomes. Covariate confounders were controlled by adjustment of demographic, social, and prehospital clinical factors to isolate differences that might not be explained by other factors. After controlling for covariates, black patients had 29% longer hospital stays (P = .043). Hispanic patients were more likely to be discharged to home or to hospice care (P = .005). Hispanic ethnicity was associated with a 44% decrease in the odds of discharge to acute care, inpatient rehabilitation, or a ward outside the burn unit (P = .022). Black and Hispanic patients had a higher relative chance of having publicly assisted insurance, versus private insurance, than their white counterparts (P = .041, P = .011 respectively). The causes of these inequities are indeterminate. They may stem from socioeconomic status not entirely accounted for, ethnic differences in comorbidity related to stressors, or inequity in health care delivery.

Evaluation of the Role of a Clinical Pharmacist on Medication Management in an Adult Burn Clinic via a Collaborative Drug Therapy Management Protocol

Historically, pharmacists have not been formally involved in managing burn clinic patients. Collaborative Drug Therapy Management (CDTM) protocols allow pharmacists working within a defined context to independently assume responsibility for direct patient care activities. The objective of this study was to evaluate the number and type of medication-related interventions made by a clinical pharmacist, in an adult burn clinic, via a CDTM protocol. The protocol allows pharmacists to independently manage the following disease states: pain, agitation, delirium, insomnia, venous thromboembolism, skin/soft tissue infections, and hypermetabolic complications. All pharmacist visits between 1/1/22 and 9/22/22 were included. A total of 16 patients were seen at 28 visits with a clinical pharmacist for a total of 148 interventions. Patients were mostly males (81%) with a mean ± SD age of 41 ± 15 years. The majority of patients were in-state (94%), with 9 (56%) being from an outlying county. Patients were seen for a median (IQR) of 2 (1,2) visits. Interventions were made at all visits (100%) with a median of 5 (4,6) per visit. Interventions (per visit) included medication reconciliation [28 (100%)], a median of 1 (0,2) medication ordered or adjusted, labs ordered at 7 (25%) visits, with adherence and patient education both reviewed at over 90% of visits. To the best of our knowledge, ours is the first burn center to implement a Clinical Pharmacist CDTM Protocol, with a pharmacist directly impacting transitions of care. This may serve as a framework for other sites. Future directions include continuing to track data for medication adherence and access, billing/reimbursement, and clinical outcomes.

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.

Understanding factors in burn patient follow-up

Follow-up rates (FUR) are concerningly low among burn-injured patients. This study investigates the factors associated with low FUR and missed appointments (MA). We hypothesize that patients who are homeless, use illicit substances, and have psychiatric comorbidities will have lower rates of follow-up (FU) and more MAs. Data from a discharge-planning survey of 281 burn-injured patients discharged from September 2019 - July 2020 was analyzed and matched with patients' EMR records for a retrospective chart review. Data collected included general demographics, burn characteristics, hospitalization details, FU visits, MAs, homeless status, substance use, major psychiatric illness (MPI), and survey responses. Data analysis used Chi-square, Fisher's exact test, Student t-test, Wilcox Rank Sum test, and Multivariate Regression Analysis (MVR). Overall, 37% of patients had no FU in clinic and 46% had one or more MA. On MVR, homeless patients were more likely to never follow up, OR = 0.227 (95% CI = 0.106-0.489), as were patients who anticipated transportation difficulties, OR = 0.275 (95% CI = 0.151-0.501). Homeless patients were more likely to have MA, OR= 0.231 (95% CI = 0.099-0.539). On univariate analysis, patients with one or more documented MPI had lower FUR, with 50.62% having no FU (p = 0.0020). Among patients who responded to the survey that they were current drug users, 52% had no FU as compared to 28% of patients who responded that they did not use drugs (p = 0.0007). Factors associated with lower FUR and more MAs include homeless status, substance use, MPI, and transportation difficulties.