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Choong E, Jurat D, Sandeep B, Rainnie B, Manzanero S, Dowsey M, McPhail S, Choong PF, Wood F. The impact of infection on length of stay in adult burns: A scoping review. Burns 2024; 50:797-807. [PMID: 38307765 DOI: 10.1016/j.burns.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/29/2023] [Accepted: 01/10/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND The disruption to the immune system and profound metabolic response to burn injury gives rise to a unique susceptibility to infection. Indeed, infection is one of the most frequently encountered post-burns complications placing significant burden on patients and healthcare system. Advancements in burn care have led to marked improvements in burn-related mortality and morbidity; however, scarce hospital resources hamper adequate burn-related care, and patient length of stay (LOS) in hospital is an important drain on such resources. The aim of this review was to assess and evaluate the existing literature relating to the impact of infections on LOS in hospitalised, adult burn patients. METHODS Electronic searches were performed in Medline and Embase. Eligible studies were those reporting on LOS and infection in adult burn populations. Articles published before 2000 were excluded to ensure that the analysis was focused on contemporary literature that reflects current, clinical management of burn patients. RESULTS Nineteen studies (54,397 burn patients) were included in the review. All studies were retrospective, with the majority undertaken in North America (14 studies). The mean age range was 38-67 years and the majority of patients were male. Inhalation injury was recorded in eleven studies. The most common types of infection included pneumonia, blood stream infections (BSI) and burn wound infections. Overall, there was a trend towards a positive association between infection and LOS. CONCLUSION The results of this scoping review provide an overview of the existing literature on the relationship between infection and LOS in adult burn populations. However, significant gaps remain in knowledge which call for further high-quality research. Standardised definitions for the collection of infection data and the use of burns specific infection control guidelines are also critical to understanding and improving patient outcomes.
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Affiliation(s)
- Emma Choong
- Infection Collaboration in trAuma, orthopaedics and burns (ICARAUS), Australia; St Vincent's Hospital Melbourne, Fitzroy 3065, Victoria, Australia; University of Melbourne, Department of Surgery, St. Vincent's Hospital Melbourne, Victoria, Australia.
| | - Danika Jurat
- Infection Collaboration in trAuma, orthopaedics and burns (ICARAUS), Australia; State Burns Unit, Fiona Stanley Hospital, Murdoch 6150, Western Australia, Australia
| | - B Sandeep
- Infection Collaboration in trAuma, orthopaedics and burns (ICARAUS), Australia; State Burns Unit, Fiona Stanley Hospital, Murdoch 6150, Western Australia, Australia
| | - Briana Rainnie
- Infection Collaboration in trAuma, orthopaedics and burns (ICARAUS), Australia; Royal Brisbane and Women's Hospital, Herston 4029, Queensland, Australia
| | - Silvia Manzanero
- Infection Collaboration in trAuma, orthopaedics and burns (ICARAUS), Australia; Jamieson Trauma Institute, Metro North Health, Butterfield Street, Herston, Brisbane, QLD 4029, Australia; School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD 4059, Australia
| | - Michelle Dowsey
- Infection Collaboration in trAuma, orthopaedics and burns (ICARAUS), Australia; University of Melbourne, Department of Surgery, St. Vincent's Hospital Melbourne, Victoria, Australia
| | - Steven McPhail
- Infection Collaboration in trAuma, orthopaedics and burns (ICARAUS), Australia; Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove 4059, Queensland, Australia; Digital Health and Informatics Directorate, Metro South Health, Woolloongabba 4102, Queensland, Australia
| | - Peter Fm Choong
- Infection Collaboration in trAuma, orthopaedics and burns (ICARAUS), Australia; University of Melbourne, Department of Surgery, St. Vincent's Hospital Melbourne, Victoria, Australia
| | - Fiona Wood
- Infection Collaboration in trAuma, orthopaedics and burns (ICARAUS), Australia; State Burns Unit, Fiona Stanley Hospital, Murdoch 6150, Western Australia, Australia
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Elrod J, Adathal A, Mohr C, Neuhaus K, Schiestl C, Böttcher-Haberzeth S. As time goes by - Overlooking 40 years of inpatient burn treatment at a national pediatric burn center in Switzerland. Burns 2024; 50:236-243. [PMID: 37690964 DOI: 10.1016/j.burns.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 08/12/2023] [Accepted: 08/18/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Despite extensive prevention programs, burns remain a frequent cause of injury in Switzerland with a known age peak in children. Pediatric burns may cause substantial morbidity, a psyochological burden and therapy related high economic costs. To improve preventive measures, precise knowledge of etiology and treatment of pediatric burns in Switzerland as well as their temporal evolution is indispensable. METHODS The present retrospective analysis included pediatric burn patients admitted for acute treatment to the Pediatric Burn Center of the University Children`s Hospital Zurich over the last four decades. Sociodemographic, injury related, and treatment related data were extracted from medical records. Linear regression analysis was applied to determine temporal changes during the past four decades and chi-square and t-tests were applied wherever applicable. RESULTS A total of 3425 acute burn patients were included in the study between 1977 and 2020, corresponding to a mean of 89 patients/year. Mean age was 3.60 ± 4.12 years, three quarters of all patients were preschool children (0-5 years) and mean total body surface area (TBSA) burned was 8.01% ± 9.57%, however only around one fifth had severe burns (>10% TBSA). Scald burns (65.31%) and flame burns (32.99%) were most commonly seen. Linear regression analysis showed the total number of thermal injuries treated at our center to have increased significantly as of 2004 (p < 0.001). Separate analysis showed the same for small and medium (<10% TBSA) burns (p < 0.001), whereas the number of severe burns did not increase significantly. Length of stay (LOS) was highly associated with %TBSA burned. The percentage of female patients amongst all patients increased over time (p = 0.012). LOS per TBSA burned decreased significantly (p < 0.001). CONCLUSION The present data show pediatric burns to remain a major health burden in Switzerland, especially small and medium burns in preschool children. Prevention programs should focus on this age population as well as on scald and flame burns as most common etiologies. The observed decrease in length of stay suggests a major improvement in overall quality of care in pediatric burns and supports centralization of care.
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Affiliation(s)
- Julia Elrod
- Pediatric Burn Center, Children's Skin Center, Department of Surgery, University Children's Hospital Zurich; University of Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland; Department of Pediatric Surgery, University Medical Center Mannheim, Heidelberg University, Heidelberg, Germany
| | - Ashal Adathal
- Pediatric Burn Center, Children's Skin Center, Department of Surgery, University Children's Hospital Zurich; University of Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland
| | - Christoph Mohr
- Pediatric Burn Center, Children's Skin Center, Department of Surgery, University Children's Hospital Zurich; University of Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland; Department of Pediatric Surgery, University Medical Center Mannheim, Heidelberg University, Heidelberg, Germany
| | - Kathrin Neuhaus
- Pediatric Burn Center, Children's Skin Center, Department of Surgery, University Children's Hospital Zurich; University of Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland
| | - Clemens Schiestl
- Pediatric Burn Center, Children's Skin Center, Department of Surgery, University Children's Hospital Zurich; University of Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland
| | - Sophie Böttcher-Haberzeth
- Pediatric Burn Center, Children's Skin Center, Department of Surgery, University Children's Hospital Zurich; University of Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland.
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3
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Thompson CM, Phillips MH, Bessey PQ, Higginson S, Hoarle K, Hsu N, Phillips B, Weber JM, Weichmann-Murata E, Mandell SP. Using a National Burn Registry to Develop a Model for Risk-Adjusted Length of Stay Benchmarking. J Burn Care Res 2023; 44:22-26. [PMID: 35986490 DOI: 10.1093/jbcr/irac103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Indexed: 01/11/2023]
Abstract
Length of stay (LOS) is a frequently reported outcome after a burn injury. LOS benchmarking will benefit individual burn centers as a way to measure their performance and set expectations for patients. We sought to create a nationwide, risk-adjusted model to allow for LOS benchmarking based on the data from a national burn registry. Using data from the American Burn Association's Burn Care Quality Platform, we queried admissions from 7/2015 to 6/2020 and identified 130,729 records reported by 103 centers. Using 22 predictor variables, comparisons of unpenalized linear regression and Gradient boosted (CatBoost) regressor models were performed by measuring the R2 and concordance correlation coefficient on the application of the model to the test dataset. The CatBoost model applied to the bootstrapped versions of the entire dataset was used to calculate O/E ratios for individual burn centers. Analyses were run on 3 cohorts: all patients, 10-20% TBSA, >20% TBSA. The CatBoost model outperformed the linear regression model with a test R2 of 0.67 and CCC of 0.81 compared with the linear model with R2=0.50, CCC=0.68. The CatBoost was also less biased for higher and lower LOS durations. Gradient-boosted regression models provided greater model performance than traditional regression analysis. Using national burn data, we can predict LOS across contributing burn centers while accounting for patient and center characteristics, producing more meaningful O/E ratios. These models provide a risk-adjusted LOS benchmarking using a robust data source, the first of its kind, for burn centers.
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Affiliation(s)
- Callie M Thompson
- Department of Surgery, University of Utah Health, Salt Lake City, UT, USA
| | | | - Palmer Q Bessey
- Department of Surgery Weil-Cornell Medicine, New York City, NY, USA
| | - Sara Higginson
- Department of Surgery, University of California, Fresno, Fresno, CA, USA
| | | | - Naiwei Hsu
- Torrence Memorial Burn Center, Torrence, CA, USA
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Bajwa MS, Sohail M, Ali H, Nazir U, Bashir MM. Predicting Thermal Injury Patient Outcomes in a Tertiary-Care Burn Center, Pakistan. J Surg Res 2022; 279:575-585. [DOI: 10.1016/j.jss.2022.06.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 12/01/2022]
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Crandall CG, Cramer MN, Kowalske KJ. Edward F. Adolph Distinguished Lecture. It's more than skin deep: thermoregulatory and cardiovascular consequences of severe burn injuries in humans. J Appl Physiol (1985) 2021; 131:1852-1866. [PMID: 34734782 PMCID: PMC8714984 DOI: 10.1152/japplphysiol.00620.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/27/2021] [Accepted: 11/01/2021] [Indexed: 11/22/2022] Open
Abstract
Each year, within the United States, tens of thousands of individuals are hospitalized for burn-related injuries. The treatment of deep burns often involves skin grafts to accelerate healing and reduce the risk of infection. The grafting procedure results in a physical disruption between the injured and subsequently debrided host site and the skin graft placed on top of that site. Both neural and vascular connections must occur between the host site and the graft for neural modulation of skin blood flow to take place. Furthermore, evaporative cooling from such burn injured areas is effectively absent, leading to greatly impaired thermoregulatory responses in individuals with large portions of their body surface area burned. Hospitalization following a burn injury can last weeks to months, with cardiovascular and metabolic consequences of such injuries having the potential to adversely affect the burn survivor for years postdischarge. With that background, the objectives of this article are to discuss 1) our current understanding of the physiology and associated consequences of skin grafting, 2) the effects of skin grafts on efferent thermoregulatory responses and the associated consequences pertaining to whole body thermoregulation, 3) approaches that may reduce the risk of excessive hyperthermia in burn survivors, 4) the long-term cardiovascular consequences of burn injuries, and 5) the extent to which burn survivors can "normalize" otherwise compromised cardiovascular responses. Our primary objective is to guide the reader toward an understanding that severe burn injuries result in significant physiological consequences that can persist for years after the injury.
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Affiliation(s)
- Craig G Crandall
- University of Texas Southwestern Medical Center and Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas
| | - Matthew N Cramer
- University of Texas Southwestern Medical Center and Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas
| | - Karen J Kowalske
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
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6
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Zhang C, Chang M, Zhou Z, Yi L, Huang X, Gao C, Guo F, Huan J. Factors Influencing Length of Hospital Stay and Predictors Affecting Probability of Requiring Surgery in Severely Pediatric Burn Patients. J Burn Care Res 2020; 41:1165-1171. [PMID: 32163568 DOI: 10.1093/jbcr/irz202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Although many researches have explored the prognostic factors associated with length of hospital stay (LOS) of adult burn patients, fewer reports concerning pediatric burn patients have been conducted. The present study employed pediatric burn data to identify factors related to LOS and developed a novel model to assess the possibility of requiring surgery. A total of 750 children admitted for burns met the criteria for enrollment. We have analyzed the medical records using multivariable linear regression and logistic regression. The pediatric patients were stratified into medical (nonsurgical) and surgical groups, respectively. The median LOS was 27.11 ± 17.91 days (range: 6-107 days). Following multiple linear regression, surgery (P < .001; 95% confidence interval [CI]: 6.485, 11.918), percent total BSA (%TBSA) (P < .001; 95% CI: 0.271, 0.459), days to surgery (P < .001; 95% CI: 0.349, 0.648), etiology (P < .001; 95% CI: -15.801, -9.422), infection (P < .001; 95% CI: 4.163, 8.329), and erythrocyte loss (P < .001; 95% CI: 1.923, 4.017) were significantly associated with LOS. After logistic regression, the percent full thickness (%FT) (P < .001; odds ratio [OR]: 2.358; 95% CI: 1.680, 3.311), infection (P < .001; OR: 2.935; 95% CI: 2.014, 4.278), and erythrocyte loss (P < .001; OR: 0.572; 95% CI: 0.470, 0.696) within 5 days postadmission were independently related to the probability of requiring surgery. In conclusion, in pediatric patients admitted with burn size of TBSA ≥20%, factors independently influencing LOS were surgery, %TBSA, days to surgery, etiology, erythrocyte loss, and infection. Furthermore, the pivotal predictors of probability requiring surgery were %FT, infection, and erythrocyte loss.
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Affiliation(s)
- Chuankai Zhang
- Department of Burn and Plastic Surgery, Shanghai Jiao Tong University, School of Medicine, Rui Jin Hospital, China
| | - Mengling Chang
- Department of Burn and Plastic Surgery, Shanghai Jiao Tong University, School of Medicine, Rui Jin Hospital, China
| | - Zengding Zhou
- Department of Burn and Plastic Surgery, Shanghai Jiao Tong University, School of Medicine, Rui Jin Hospital, China
| | - Lei Yi
- Department of Burn and Plastic Surgery, Shanghai Jiao Tong University, School of Medicine, Rui Jin Hospital, China
| | - Xiaoqin Huang
- Department of Burn and Plastic Surgery, Shanghai Jiao Tong University, School of Medicine, Rui Jin Hospital, China
| | - Chengjin Gao
- Emergency Department, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, China
| | - Feng Guo
- Department of Burn and Plastic Surgery, Shanghai Jiao Tong University, School of Medicine, Rui Jin Hospital, China.,Department of Plastic Surgery, Affiliated Sixth People's Hospital of Shanghai, Shanghai jiaotong University, China
| | - Jingning Huan
- Department of Burn and Plastic Surgery, Shanghai Jiao Tong University, School of Medicine, Rui Jin Hospital, China
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Cavallaro DC, Chipp E. Letter to Burns in Response to Letter to the Editor in response to the impact of serum zinc normalization on clinical outcomes in severe burn patients (Article in Press) by Olsen, Coffey and Porter et al. Burns 2020; 46:1234. [DOI: 10.1016/j.burns.2020.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/23/2020] [Indexed: 10/24/2022]
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8
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Neil DL. Hospital stay per percent TBSA: Fact-checks on false trails. Burns 2020; 47:481-484. [PMID: 33010969 DOI: 10.1016/j.burns.2020.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 04/09/2020] [Indexed: 10/24/2022]
Affiliation(s)
- David L Neil
- Dr. Word Ltd., 7F-11, No. 57, Sec. 1, Chongqing S. Rd., Taipei 10045, Taiwan.
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9
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Elrod J, Mohr C, Wolff R, Boettcher M, Reinshagen K, Bartels P, Koenigs I. Using Artificial Intelligence to Obtain More Evidence? Prediction of Length of Hospitalization in Pediatric Burn Patients. Front Pediatr 2020; 8:613736. [PMID: 33537267 PMCID: PMC7849450 DOI: 10.3389/fped.2020.613736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 11/26/2020] [Indexed: 12/05/2022] Open
Abstract
Background: It is not only important for counseling purposes and for healthcare management. This study investigates the prediction accuracy of an artificial intelligence (AI)-based approach and a linear model. The heuristic expecting 1 day of stay per percentage of total body surface area (TBSA) serves as the performance benchmark. Methods: The study is based on pediatric burn patient's data sets from an international burn registry (N = 8,542). Mean absolute error and standard error are calculated for each prediction model (rule of thumb, linear regression, and random forest). Factors contributing to a prolonged stay and the relationship between TBSA and the residual error are analyzed. Results: The random forest-based approach and the linear model are statistically superior to the rule of thumb (p < 0.001, resp. p = 0.009). The residual error rises as TBSA increases for all methods. Factors associated with a prolonged LOS are particularly TBSA, depth of burn, and inhalation trauma. Conclusion: Applying AI-based algorithms to data from large international registries constitutes a promising tool for the purpose of prediction in medicine in the future; however, certain prerequisites concerning the underlying data sets and certain shortcomings must be considered.
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Affiliation(s)
- Julia Elrod
- Department of Paediatric Surgery, University Medical Centre Eppendorf, Hamburg, Germany.,Burn Unit, Plastic and Reconstructive Surgery, Department of Paediatric Surgery, Altona Children's Hospital, Hamburg, Germany
| | - Christoph Mohr
- Department of Paediatric Surgery, University Medical Centre Eppendorf, Hamburg, Germany
| | | | - Michael Boettcher
- Department of Paediatric Surgery, University Medical Centre Eppendorf, Hamburg, Germany.,Burn Unit, Plastic and Reconstructive Surgery, Department of Paediatric Surgery, Altona Children's Hospital, Hamburg, Germany
| | - Konrad Reinshagen
- Department of Paediatric Surgery, University Medical Centre Eppendorf, Hamburg, Germany.,Burn Unit, Plastic and Reconstructive Surgery, Department of Paediatric Surgery, Altona Children's Hospital, Hamburg, Germany
| | - Pia Bartels
- Department of Paediatric Surgery, University Medical Centre Eppendorf, Hamburg, Germany
| | | | - Ingo Koenigs
- Department of Paediatric Surgery, University Medical Centre Eppendorf, Hamburg, Germany.,Burn Unit, Plastic and Reconstructive Surgery, Department of Paediatric Surgery, Altona Children's Hospital, Hamburg, Germany
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Smith RR, Hill DM, Hickerson WL, Velamuri SR. Analysis of factors impacting length of stay in thermal and inhalation injury. Burns 2019; 45:1593-1599. [PMID: 31130323 DOI: 10.1016/j.burns.2019.04.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 04/16/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Several studies have analyzed single or combinations of variables for impact on length of stay (LOS) in thermally-injured patients. The objective of this study was to evaluate a multitude of established variables and potentially identify novel variables associated with LOS in a single study. METHODS This two-year, retrospective study included all patients admitted to the burn center between January 2015 and December 2016. Exclusions included death during admission, lack of thermal or inhalation injury, age less than 18 years, readmission(s), and if pregnant or incarcerated. Baseline demographics and pertinent data were collected using electronic medical records. Regression analysis was used to determine the most predictive variables. RESULTS Six hundred twenty-nine patients were admitted during the inclusion period and 354 patients remained for analysis after exclusion. Univariable analysis revealed 32 variables significantly associated with LOS. Using multivariable regression, the best-fit baseline demographic model included: percent total body surface area (TBSA) injured, lower/middle socioeconomic status, clotting disorders, anemia, admission serum creatinine, and percent third degree injured (r2 = 0.557). The best-fit combined model (incorporating baseline demographics and early in-hospital variables) included: acute kidney injury, infection and received vasopressor(s), percent TBSA injured, admission serum ethanol level, maximum C-reactive protein, and maximum total bilirubin (r2 = 0.828). CONCLUSIONS There are multiple factors associated with the increased LOS seen in patients with thermal and inhalation injury. This study confirmed and identified novel factors not previously discussed in the literature that were significantly associated with LOS. Expansion of the data submitted to the National Burn Repository and the Burn Quality Improvement Program may be warranted. This study confirms claims from previous studies on inadequacy of current data submitted for benchmarking and under-reimbursement for the care of such a complex population.
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Affiliation(s)
- Rebecca R Smith
- Department of Clinical Pharmacy, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA.
| | - David M Hill
- Department of Clinical Pharmacy, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Department of Burn Research, Firefighters Regional Burn Center, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, 881 Madison Avenue, Memphis, TN 38103, USA.
| | - William L Hickerson
- Department of Plastic Surgery, Firefighters Regional Burn Center, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Department of Plastic Surgery, College of Medicine, University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, TN 38103, USA.
| | - Sai R Velamuri
- Department of Plastic Surgery, Firefighters Regional Burn Center, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Department of Plastic Surgery, College of Medicine, University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, TN 38103, USA.
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11
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Dolp R, Rehou S, McCann MR, Jeschke MG. Contributors to the length-of-stay trajectory in burn-injured patients. Burns 2018; 44:2011-2017. [PMID: 30104050 DOI: 10.1016/j.burns.2018.07.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 07/16/2018] [Accepted: 07/20/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Burn patients have a highly variable length-of-stay (LOS) due to the complexity of the injury itself. The LOS for burn patients is estimated as one day per percent total body surface area (TBSA) burn. To focus care expectation and prognosis we aimed to identify key factors that contribute to prolonged LOS. METHODS This was a retrospective cohort-study (2006-2016) in an adult burn-centre that included patients with ≥10% TBSA burn. Patients were stratified into expected-LOS (<2 days LOS/%TBSA) and longer-than-expected-LOS (≥2 days LOS/%TBSA). We assessed demographics, comorbidities, and in-hospital complications. Logistic regression and propensity matching was utilized. RESULTS Of the 583 total patients, 477 had an expected-LOS whereas 106 a longer-than-expected-LOS. Non-modifiable factors such as age, 3rd degree TBSA%, inhalation injuries and comorbidities were greater in the exceeded LOS patients. Subsequent matched analysis revealed factors like number of procedures performed, days ventilated and in-hospital complications (bacteremia, pneumonia, sepsis, graft loss, and respiratory failure) were significantly increased in the longer-than-expected-LOS group. CONCLUSIONS Progress has been made to update the conventional one day/%TBSA to better aid health care providers in giving appropriate outcomes for patients and their families and to supply intensive care units with valuable data to assess quality of care and to improve patient prognosis.
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Affiliation(s)
- Reinhard Dolp
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Rehou
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Marc G Jeschke
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Immunology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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12
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Nosanov LB, McLawhorn MM, Hassan L, Travis TE, Tejiram S, Johnson LS, Moffatt LT, Shupp JW. Graft loss: Review of a single burn center's experience and proposal of a graft loss grading scale. J Surg Res 2017; 216:185-190. [PMID: 28807206 DOI: 10.1016/j.jss.2017.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 04/19/2017] [Accepted: 05/01/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND There exists neither a consensus definition of burn "graft loss" nor a scale with which to grade severity. We introduced an institutional scale in 2014 for quality improvement. MATERIALS AND METHODS We reviewed all burned patients with graft loss on departmental Morbidity and Mortality reports between July 2014 and July 2016. Graft loss grades were assigned during the course of clinical care per institutional scale. Chronic nonhealing wounds and nonburn wounds were excluded. Data abstracted included demographics, medical history, injury details, surgical procedures, graft loss, and lengths of stay (LOS). Photos of affected areas were graded by two blinded surgeons, and a linear weighted κ was calculated to assess interrater agreement. RESULTS Graft loss was noted in 50 patients, with 43 remaining after exclusions. Mean age was 50.1 y. The majority were male (58.1%) and African American (41.9%). Smoking (30.2%) and diabetes (27.9%) were prevalent. Total body surface area involvement ranged from 0.5% to 51.0% (11.8 ± 12.3%). Grade I graft loss was documented on one patient (2.3%), Grade II in 15 (34.9%), Grade III in 12 (27.9%), and Grade IV in 15 (34.9%). Reoperation was performed in 20 (46.5%). Hospital LOS was longer than predicted in 38 patients (88.4%). Seven had significant morbidity, including two amputations. Moderate agreement was reached between blinded surgeons (κ = 0.44, P = 0.004). CONCLUSIONS Graft loss is a major source of morbidity in burn patients. In this cohort, reoperation was common and hospital LOS was extended. Use of a grading scale improves dialog among providers and enables improved understanding of risk factors.
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Affiliation(s)
- Lauren B Nosanov
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC
| | | | - Lamisa Hassan
- Firefighters' Burn and Surgical Research Laboratory, Washington, DC
| | - Taryn E Travis
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC
| | - Shawn Tejiram
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC
| | - Laura S Johnson
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC
| | - Lauren T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, Washington, DC
| | - Jeffrey W Shupp
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC.
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Not all patients meet the 1 day per percent burn rule: A simple method for predicting hospital length of stay in patients with burn. Burns 2017; 43:282-289. [DOI: 10.1016/j.burns.2016.10.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 10/19/2016] [Accepted: 10/24/2016] [Indexed: 11/24/2022]
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Mathews AL, Cheng MH, Muller JM, Lin MCY, Chang KWC, Chung KC. Cost Analysis of 48 Burn Patients in a Mass Casualty Explosion Treated at Chang Gung Memorial Hospital. Injury 2017; 48:80-86. [PMID: 27553390 PMCID: PMC5186334 DOI: 10.1016/j.injury.2016.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/04/2016] [Accepted: 08/15/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Little is known about the costs of treating burn patients after a mass casualty event. A devastating Color Dust explosion that injured 499 patients occurred on June 27, 2015 in Taiwan. This study was performed to investigate the economic effects of treating burn patients at a single medical center after an explosion disaster. METHODS A detailed retrospective analysis on 48 patient expense records at Chang Gung Memorial Hospital after the Color Dust explosion was performed. Data were collected during the acute treatment period between June 27, 2015 and September 30, 2015. The distribution of cost drivers for the entire patient cohort (n=48), patients with a percent total body surface area burn (%TBSA)≥50 (n=20), and those with %TBSA <50 (n=28) were analyzed. RESULTS The total cost of 48 burn patients over the acute 3-month time period was $2,440,688, with a mean cost per patient of $50,848 ±36,438. Inpatient ward fees (30%), therapeutic treatment fees (22%), and medication fees (11%) were found to be the three highest cost drivers. The 20 patients with a %TBSA ≥50 consumed $1,559,300 (63.8%) of the total expenses, at an average cost of $77,965±34,226 per patient. The 28 patients with a %TBSA <50 consumed $881,387 (36.1%) of care expenses, at an average cost of $31,478±23,518 per patient. CONCLUSIONS In response to this mass casualty event, inpatient ward fees represented the largest expense. Hospitals can reduce this fee by ensuring wound dressing and skin substitute materials are regionally stocked and accessible. Medication fees may be higher than expected when treating a mass burn cohort. In preparation for a future event, hospitals should anticipate patients with a %TBSA≥50 will contribute the majority of inpatient expenses.
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Affiliation(s)
- Alexandra L Mathews
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical School, United States
| | - Ming-Huei Cheng
- Department of Plastic and Reconstructive Surgery, Center for Tissue Engineering, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taiwan
| | | | - Miffy Chia-Yu Lin
- Department of Plastic and Reconstructive Surgery, Center for Tissue Engineering, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taiwan
| | - Kate W C Chang
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, United States
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical School, United States.
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Taylor SL, Sen S, Greenhalgh DG, Lawless M, Curri T, Palmieri TL. Real-Time Prediction for Burn Length of Stay Via Median Residual Hospital Length of Stay Methodology. J Burn Care Res 2016; 37:e476-82. [PMID: 27355650 PMCID: PMC5014656 DOI: 10.1097/bcr.0000000000000332] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hospital length of stay (LOS) after burn injury is commonly estimated as 1 day per percent burn, but LOS often exceeds that estimate. The purpose of this study is to develop a novel method for estimating burn hospital LOS at any time during hospitalization. The authors used the American Burn Association National Burn Repository from 2000 to 2009 to directly estimate the median residual LOS (MRLOS) of patients hospitalized for burn injuries and who survived to discharge. The MRLOS is the median of how many more days a burn patient will be hospitalized given that the person has been in hospital for a specified time period. The authors also estimated the 25th and 75th percentiles of residual life and quantified the relationship between MRLOS and LOS with ordinary least squares for all burn patients, by burn size and by presence of inhalation injury. MRLOS increased with increasing LOS, confirming that discharge estimates change over time. Patients with inhalation injury had longer MRLOS than patients without inhalation injury in the first 100 hospital days. Patients with large burns (>25%) had large MRLOS consistent with prolonged hospitalization, but patients with small burns (<25%) also had steadily increasing MRLOS during hospitalization (ie, the longer the patient was in the hospital, the longer the predicted LOS regardless of initial LOS estimate). Estimating remaining hospital LOS at any time during admission has been problematic; MRLOS can be used to provide an estimate of remaining hospital LOS and resource utilization to families, administrators, and other medical professionals.
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Affiliation(s)
- Sandra L. Taylor
- University of California Davis Medical Center Department of Public Health Sciences, Sacramento, CA
| | - Soman Sen
- Department of Surgery, Sacramento, CA
- Burn Department, Shriners Hospitals for Children Northern California, Sacramento, CA
| | - David G. Greenhalgh
- Department of Surgery, Sacramento, CA
- Burn Department, Shriners Hospitals for Children Northern California, Sacramento, CA
| | | | | | - Tina L. Palmieri
- Department of Surgery, Sacramento, CA
- Burn Department, Shriners Hospitals for Children Northern California, Sacramento, CA
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Is the Target of 1 Day of Stay per 1% Total Body Surface Area Burned Achieved in Chemical Burns? Ann Plast Surg 2016; 77 Suppl 1:S39-42. [DOI: 10.1097/sap.0000000000000716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Walker TLJ, Rodriguez DU, Coy K, Hollén LI, Greenwood R, Young AER. Impact of reduced resuscitation fluid on outcomes of children with 10-20% body surface area scalds. Burns 2014; 40:1581-6. [PMID: 24793046 DOI: 10.1016/j.burns.2014.02.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 01/19/2014] [Accepted: 02/14/2014] [Indexed: 11/18/2022]
Abstract
'Permissive hypovolaemia' fluid regimes in adult burn care are suggested to improve outcomes. Effects in paediatric burn care are less well understood. In a retrospective audit, outcomes of children from the South West Children's Burn Centre (SWCBC) less than 16 years of age with scalds of 10-20% burn surface area (BSA) managed with a reduced volume fluid resuscitation regime (post-2007) were compared to (a) an historical local protocol (pre-2007) and (b) current regimes in burn services across England and Wales (E&W). Outcomes included length of stay per percent burn surface area (LOS/%BSA), skin graft requirement and re-admission rates. 92 SWCBC patients and 475 patients treated in 15 other E&W burn services were included. Median LOS/%BSA for patients managed with the reduced fluid regime was 0.27 days: significantly less than pre-2007 and other E&W burn services (0.54 days, 0.50 days, p<0.001). Skin grafting to achieve healing reduced post-2007 compared to pre-2007 and remains comparable with other E&W services. Re-admission rates were comparable between all groups. A reduced fluid regime has significantly shortened LOS/%BSA without compromising burn depth as measured by skin grafting to achieve healing. A prospective trial comparing permissive hypovolaemia to current regimes for moderate paediatric scald injuries would help clarify.
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Affiliation(s)
- T L J Walker
- Frenchay Hospital, North Bristol NHS Trust, United Kingdom
| | | | - K Coy
- Frenchay Hospital, North Bristol NHS Trust, United Kingdom
| | | | - R Greenwood
- University Hospitals Bristol NHS Foundation Trust, United Kingdom
| | - A E R Young
- Frenchay Hospital, North Bristol NHS Trust, United Kingdom.
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den Hollander D, Albert M, Strand A, Hardcastle TC. Epidemiology and referral patterns of burns admitted to the Burns Centre at Inkosi Albert Luthuli Central Hospital, Durban. Burns 2014; 40:1201-8. [PMID: 24439933 DOI: 10.1016/j.burns.2013.12.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 12/10/2013] [Accepted: 12/17/2013] [Indexed: 10/25/2022]
Abstract
RATIONALE The epidemiology, referral patterns and outcome of patients admitted to a tertiary burns unit in southern Africa were reviewed. MATERIALS AND METHODS The charts of all patients with thermal injury presenting to the Burns Centre at Inkosi Albert Luthuli Central Hospital (IALCH) between 1 January 2008 and 31 December 2010 were reviewed. Information collected included age, gender, past medical history, cause of burn, size of burn, presence of inhalation injury, time before admission, time to excision, length of hospital stay, complications and mortality. FINDINGS Four hundred and sixty two patients were admitted, 296 (58%) children and 193 (42%) adults. The female-male ratio was 1:1.13. The mean total body surface area (TBSA) burned was 12% (interquartile range 8-25%) for children and 18% (interquartile range 10-35%) for adults. Common causes for the burns were in children: hot liquids (71%) and open flame (24%). Major causes in adults were: open fire (68%) and hot liquids (25%). Epilepsy was a contributing factor in 12.7%. Inhalation injury was seen in 13.6% of adults and 14.3% of children with a flame burn. Forty-four percent of referrals from general surgical units were for burns <30% in adults, and 30% for burns <10% in children. More than one in four patients was referred between 1 and 6 weeks post-injury. Overall mortality was 9.1% (5.7% in children and 15.1% in adults). Complications occurred in 21.6% of children and 36.7% in adults, the most common being lung complications such as ARDS and infection, severe sepsis, skin graft failure and contractures. The length of stay was 1 day/% TBSA burn for all burns in children and for burns between 10 and 49% in adults. CONCLUSIONS The epidemiology and outcome of severe burns referred to the Burns Centre at IALCH is similar to those in other units in Africa. The management and referral of burns patients by other hospitals are inappropriate in a significant number of patients.
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Affiliation(s)
- Daan den Hollander
- Regional Burns Centre, Inkosi Albert Luthuli Central Hospital, Durban, KwaZulu-Natal, Republic of South Africa; Level I Trauma Centre, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, Durban, KwaZulu-Natal, Republic of South Africa.
| | - Malin Albert
- Regional Burns Centre, Inkosi Albert Luthuli Central Hospital, Durban, KwaZulu-Natal, Republic of South Africa; Medical Students, Faculty of Medicine, Lund University, Lund, Sweden
| | - Anna Strand
- Regional Burns Centre, Inkosi Albert Luthuli Central Hospital, Durban, KwaZulu-Natal, Republic of South Africa; Medical Students, Faculty of Medicine, Lund University, Lund, Sweden
| | - Timothy C Hardcastle
- Level I Trauma Centre, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, Durban, KwaZulu-Natal, Republic of South Africa
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Hussain A, Dunn KW. Predicting length of stay in thermal burns: a systematic review of prognostic factors. Burns 2013; 39:1331-40. [PMID: 23768707 DOI: 10.1016/j.burns.2013.04.026] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 03/14/2013] [Accepted: 04/23/2013] [Indexed: 01/07/2023]
Abstract
BACKGROUND Continued improvement in all aspects of the management of thermal injury has resulted in marked improvements in the traditionally reported outcome of mortality. This has resulted in the search for alternative parameters that can be monitored to indicate the performance of burn services. Length of stay (LOS) in hospitalised burn patients has long been considered reflective of injury-associated morbidity, cost and the quality of care, which can be monitored consistently across services. AIM We undertook a systematic review of published literature pertaining to LOS prognostication in thermal burns to identify the relevant factors, quantify the risk associated with these factors and identify predictive prognostic models. METHODS Electronic searches were performed on MEDLINE, CINHAL, EMBASE, Web of Science, the Cochrane collection and a general web search was performed using Google. The searches were complemented by a manual search of the contents of leading burns journals. Quality of the studies included in the review was evaluated against published standards for prognostic studies. RESULTS Fourteen studies were included in the review after meeting the inclusion/exclusion criteria. Age and %TBSA were the strongest predictors of LOS in these studies. Other significant predictors included % full thickness burn, female gender, inhalation injury, surgery including escharotomy and the depth of burn. Nine studies reported multivariate models for predicting LOS in patients sustaining thermal injury. None of these models were validated and the goodness-of-fit statistic (R2) ranged from 0.15 to 0.75. CONCLUSION This review has demonstrated that %TBSA and age are the best predictors of LOS in published literature. Current prognostic models do not explain a significant proportion of variation in LOS.
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Affiliation(s)
- Amer Hussain
- University Hospital South Manchester, Southmoor Road, Manchester M23 9LT, United Kingdom.
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Abstract
The Balanced Scorecard provides a model that can be adapted to the management of any burn center, burn service or burn program. This model enables an organization to translate its mission and vision into specific strategic objectives across the four perspective: (1) the financial perspective; (2) the customer service perspective; (3) the internal business perspective; and (4) the growth and learning perspective. Once the appropriate objectives are identified, the Balanced Scorecard guides the organization to develop reasonable performance measures and establishes targets, initiatives and alternatives to meet programmatic goals and pursue longer-term visionary improvements. We used the burn center at the University of Colorado Health Sciences Center to test whether the Balanced Scorecard methodology was appropriate for the core business plan of a healthcare strategic business unit (i.e. a burn center).
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Affiliation(s)
- T L Wachtel
- Centura Health St. Anthony Central Hospital, University of Colorado Health Sciences Center, Department of Surgery, Denver, USA
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Abstract
A 17-year-old male sustained 95 per cent body surface area burns (87 per cent full thickness skin loss). He was hospitalized in the Department of Plastic Surgery that also treats burns. After 232 days he was discharged home when he was functionally independent. He had 16 surgical procedures for excision of burn eschar and skin grafting; received a total of 128 units of blood; 899 units of fresh frozen plasma and had enteral hyperalimentation for 175 days. About 1000 physician-hours, 3000 nurse-hours, 1000 physiotherapy and occupational therapy-hours and about 250 dietician-hours were needed for his treatment. More than 1850 laboratory tests and 120 X-rays were performed, and more than 600 kg of ointment and creams were used, as well as half a ton of topical antimicrobial solutions. Ten different antibiotics were used for a total of 85 treatment days. Some 8500 m of dressing were applied with more than 6000 pieces of petroleum jelly gauze dressing. Hospitalization costs were found to be US$141,750, only 37.5 per cent of which were salaries. An analysis of these costs is given.
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Affiliation(s)
- A Eldad
- Burns Unit, Hadassah University Hospital, Ein Kerem, Jerusalem, Israel
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