The Effect of Burn Center Volume on Mortality in a Pediatric Population: An Analysis of the National Burn Repository

Evaluation of a National Sample of 16,671 Pediatric Burn Admissions: Identifying Predictors of Non-accidental Pediatric Burns

BACKGROUND

Burn injuries remain one of the leading causes of injury and death in children. Studies have demonstrated a higher mortality for pediatric burns associated with non-accidental injury. Using data from a burn registry, our study aimed to discern potential factors associated with non-accidental burn injuries.

METHODS

We utilized the American Burn Association database from 2016 to 2018, which collects data from over one hundred burn centers across the United States, to evaluate a large pediatric burn population. Patients aged ≤14 years were analyzed. The population was then divided into suspected non-accidental versus accidental burn injuries. A multivariable logistic regression model was utilized to evaluate for predictors of burn injuries. Additional models were used to assess the relationship between suspected non-accidental burn injury and mortality, intensive care unit (ICU) stay, and hospital length of stay.

RESULTS

16,671 pediatric patients were included. Of those, 1228 (7.4%) patients suffered non-accidental burn injury. A majority of children who sustained non-accidental burn injury were younger, non-white, and sustained scald burns. The regression model demonstrated predictors for non-accidental burn injuries included younger age, Black race, chemical/corrosion burns, government insurance, and increased total body surface area (TBSA) burn. Overall mortality for the population was 0.5%.

CONCLUSION

This evaluation of a national burn registry reveals differences in pediatric patients sustaining non-accidental burns compared to accidental burns. The findings in this study identify pediatric populations at risk for suspected non-accidental burn injuries which may assist in preparing the families for expectations after admission for a burn injury.

LEVEL OF EVIDENCE

III.

Pediatric Burn Injuries: Risk Factors for Increased Mortality

INTRODUCTION

Burn injuries are among the top ten leading causes of unintentional death in pediatric patients and are encountered by pediatric surgeons in all practice settings. There is a lack of literature evaluating mortality in pediatric burn injuries in regard to nonaccidental burns and potential disparities. Our study aims to determine the risk factors associated with mortality in pediatric burn injuries and highlight the characteristics of this patient population.

METHODS

We utilized the Trauma Quality Improvement Program database from 2017 to 2019 to identify primary burn injuries in children ≤14 y old. Physical abuse descriptors were used to identify patients with suspected nonaccidental injuries. Further demographics, including age, race, ethnicity, and insurance type, were evaluated. Descriptive statistics were generated and a multivariable logistic regression analysis was utilized to evaluate risk factors for mortality.

RESULTS

13,472 pediatric burn patients (≤14 y old) were identified. The overall mortality was low (<1%). Children with burns to multiple body regions had the highest independent risk of mortality in this cohort. All older age groups had an independent risk of mortality compared to the youngest patients, but those from ages 5 to <10 y old had the highest risk of mortality (OR = 11.40; 95% confidence interval: 4.41-29.43, P < 0.001). Black children had a significantly higher mortality compared to White children. Nonaccidental burns carried a mortality that was twice that of accidental burns. Government insurance type was the primary insurance type for a majority of patients who died.

CONCLUSIONS

Risk factors for mortality in pediatric burn include Black race, multiple affected body regions, and nonaccidental burns. This study identified an increased mortality risk in the older age groups in contrast to previous studies that showed increased mortality in younger patients suffering from burn injuries.

An eighteen-year review of intensive care requirements for paediatric burns in a regional burns service

INTRODUCTION

Advances in burns management have reduced mortality. Consequently, efficient resource management plays an increasingly important role in improving paediatric burns care. This study aims to assess the support requirements and outcomes of paediatric burns patients admitted to a burns centre intensive care unit in comparison to established benchmarks in burns care.

METHOD

A retrospective review of burns patients under the age of 16 years old, admitted to a regional burns service intensive care unit between March 1998 and March 2016 was conducted.

RESULTS

Our analysis included 234 patients, with the percentage of TBSA affected by burn injury ranging from 1.5% to 95.0%. The median (IQR) %TBSA was 20.0% (11.0-30.0), and the observed mortality rate was 2.6% (6/234). The median (IQR) length of stay was 0.7 days/%TBSA burn (0.4-1.2), 17.9% (41/229) required circulatory support and 2.6% (6/234) required renal replacement. Mortality correlated with smoke inhalation injury (P < 0.001), %TBSA burn (P = 0.049) and complications (P = 0.004) including infections (P = 0.013).

CONCLUSIONS

Among children with burn injuries who require intensive care, the presence of inhalational injury and the diagnosis of infection are positively correlated with mortality. Understanding the requirements for organ support can facilitate a more effective allocation of resources within a burns service.

Facility Size and Risk Factors for Mortality in Pediatric Trauma

BACKGROUND

Pediatric trauma outcomes can vary across facilities, yet evidence on the relationship between facility bed size and pediatric trauma outcomes has been mixed. We aimed to identify how facility bed size might modify the impact of patient-level risk factors on mortality in pediatric trauma. We hypothesized that patient-level risk factors would have a stronger association with mortality at smaller trauma centers, and a weaker association with mortality at larger centers.

METHODS

We used deidentified data obtained from the 2017-2018 Trauma Quality Programs registry, including patients ages 0-18 years of age who were admitted to the hospital. The primary outcome was in-hospital mortality. Facility bed size was dichotomized as large (>600 beds) vs small/medium (≤600 beds). Sensitivity analyses used 200 and 400 beds as alternative cutoffs. Interaction between facility bed size and patient characteristics was assessed using unadjusted logistic regression, with statistically significant interactions entered in a final, fully adjusted model.

RESULTS

The analysis included 171 810 patients (mean age 10 ± 5 years; 65%/35% male/female), including 28% treated in a large hospital and 1.2% who died during the hospitalization. Controlling for trauma center level (or subsetting to pediatric trauma centers only), larger bed size did not reduce mortality risk associated with patient characteristics such as injury mechanism, injury severity, or patient demographics.

CONCLUSIONS

Contrary to our hypothesis, greater facility bed size was not associated with reduced mortality risk associated with patient characteristics. Future studies are needed to identify hospital practices or characteristics that can attenuate the excess risk of known patient-level risk factors.

In-hospital outcomes of paediatric burn injuries managed in children's hospitals compared to general hospitals

INTRODUCTION

In Australia and New Zealand, children with burn injuries are cared for in either general hospitals which cater to both adult and paediatric burn injuries or in children's hospitals. Few publications have attempted to analyse modern burn care and outcomes as a function of treating facilities.

AIM

The aim of this study was to compare in-hospital outcomes of paediatric burn injuries managed in children's hospitals to those treated in general hospitals that regularly treated both adult and paediatric burn patients.

METHODS

A retrospective cohort study of cases was undertaken using data from the Burns Registry of Australia and New Zealand (BRANZ). All paediatric patients with data for an acute or transfer admission to a BRANZ hospital and registered with BRANZ with a date of admission between 1 July 2016 and 30 June 2020 were included in the study. The primary outcome of interest was the acute admission length of stay. Secondary outcome measures of interest included admission to the intensive care unit and readmission to a specialist burn service within 28 days. The Alfred Hospital Ethics Committee granted ethical approval for this study (project 629/21).

RESULTS

A total of 4630 paediatric burn patients were included in the analysis. Approximately three quarters of this cohort (n = 3510, 75.8%) were admitted to a paediatric only hospital, while the remaining quarter (n = 1120, 24.2%) were admitted to a general hospital. A greater proportion of patients admitted to general hospitals underwent burn wound management procedures in the operating theatre (general hospitals 83.9%, children's hospitals 71.4%, p < 0.001). Patients admitted to children's hospitals had a longer median time to their first episode of grafting (children's hospitals 12.4 days, general hospitals 8.3 days, p < 0.001). The adjusted regression model for hospital LOS indicate that patients admitted to general hospitals had a 23% shorter hospital LOS, compared to patients admitted to children's hospitals. Neither the unadjusted or adjusted model for intensive care unit admission was significant. After accounting for relevant confounding factors, there was no association between service type and hospital readmission rates.

CONCLUSIONS

Comparing children's hospitals and general hospitals, different models of care seem to exist. Burn services in children's hospitals adopted a more conservative approach and were more inclined to facilitate healing by secondary intention rather than surgical debridement and grafting. General hospitals are more "aggressive" in managing burn wounds in theatre early, and debriding and grafting the burn wounds whenever considered necessary.

Setting the Standard: Using the ABA Burn Registry to Benchmark Risk Adjusted Mortality

Reports of single center experience and studies of larger databases have identified several predictors of burn center mortality, including age, burn size, and inhalation injury. None of these analyses has been broad enough to allow benchmarking across burn centers. The purpose of this study was to derive a reliable, risk-adjusted, statistical model of mortality based on real-life experience at many burn centers in the U.S. We used the American Burn Association 2020 Full Burn Research Dataset, from the Burn Center Quality Platform (BCQP) to identify 130,729 subjects from July 2015 through June 2020 across 103 unique burn centers. We selected 22 predictor variables, from over 50 recorded in the dataset, based on completeness (at least 75% complete required) and clinical significance. We used gradient-boosted regression, a form of machine learning, to predict mortality and compared this to traditional logistic regression. Model performance was evaluated with AUC and PR curves. The CatBoost model achieved a test AUC of 0.980 with an average precision of 0.800. The logistic regression produced an AUC of 0.951 with an average precision of 0.664. While AUC, the measure most reported in the literature, is high for both models, the CatBoost model is markedly more sensitive, leading to a substantial improvement in precision. Using BCQP data, we can predict burn mortality allowing comparison across burn centers participating in BCQP.

Factors Associated With Mechanical Ventilation Duration in Pediatric Burn Patients in a Regional Burn Center in the United States

OBJECTIVES

Among burned children who arrive at a burn center and require invasive mechanical ventilation (IMV), some may have prolonged IMV needs. This has implications for patient-centered outcomes as well as triage and resource allocation decisions. Our objective was to identify factors associated with the duration of mechanical ventilation in pediatric patients with acute burn injury in this setting.

DESIGN

Single-center, retrospective cohort study.

SETTING

Registry data from a regional, pediatric burn center in the United States.

PATIENTS

Children less than or equal to 18 years old admitted with acute burn injury who received IMV between January 2005 and December 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Ventilator days were defined as any full or partial day having received IMV via an endotracheal tube or tracheostomy, not inclusive of time spent ventilated for procedures. Of 5,766 admissions for acute burn care, 4.3% ( n = 249) required IMV with a median duration of 10 days. A multivariable model for freedom from mechanical ventilation showed that the presence of inhalational injury (subhazard ratio [sHR], 0.62; 95% CI, 0.46-0.85) and burns to the head and neck region (sHR, 0.94; 95% CI, 0.90-0.98) were associated with increased risk of remaining mechanically ventilated at any time point. Older (sHR, 1.03; 95% CI, 1.01-1.04) and male children (sHR, 1.39; 95% CI, 1.05-1.84) were more likely to discontinue mechanical ventilation. A majority of children (94.8%) survived to hospital discharge.

CONCLUSIONS

The presence of inhalational injury and burns to the head and neck region were associated with a longer duration of mechanical ventilation. Older age and male gender were associated with a shorter duration of mechanical ventilation. These factors should help clinicians better estimate a burned child's expected trajectory and resource-intensive needs upon arrival to a burn center.

Adherence with early allied health assessments in specialist burn services

Appropriate multidisciplinary allied health assessment during the early stages of admission following burn injury positively influences recovery and quality of life. Variation in allied health care may affect patient outcomes. We aimed to explore adherence in providing early allied health assessments in accordance with local parameters. Associations between the number of assessments and hospital length of stay (LOS) were also explored. The Burns Registry of Australia and New Zealand was queried for adult (≥ 16 years) burn injured patients admitted to a specialist burn service for > 48 hours between July 2016 and June 2020. Quality indicator data relating to allied health assessment processes were examined; patients were grouped according to the number of assessments they received within 48 hours of admission. Of the 5789 patients included in the study, 5598 (97%) received at least one allied health assessment within 48 hours of admission and 3976 (69%) received all three assessments. A greater proportion of patients who received no assessments were admitted on a Saturday. Patients receiving three assessments had more severe injuries compared to their counterparts who received fewer assessments. Hospital LOS was not associated with the number of allied health assessments during an acute admission following burn injury after accounting for confounding factors, particularly TBSA. Multidisciplinary allied health teams provide routine burn care to Australian and New Zealand burns patients at a consistent level. Further, this study provides evidence that allied health input is prioritised towards patients with increasing severity of burn injury, playing an integral role in early rehabilitation.

Burn Registries State of Affairs: A Scoping review

Registry science allows for the interpretation of disease-specific patient data from secondary databases. It can be utilized to understand disease and injury, answer research questions, and engender benchmarking of quality-of-care indicators. Numerous burn registries exist globally, however, their contributions to burn care have not been summarized. The objective of this study is to characterize the available literature on burn registries. The authors conducted a scoping review, having registered the protocol a priori. A thorough search of the English literature, including grey literature, was carried out. Publications of all study designs were eligible for inclusion provided they utilized, analyzed, and/or critiqued data from a burn registry. Three hundred twenty studies were included, encompassing 16 existing burn registries. The most frequently used registries for peer-reviewed publications were the American Burn Association Burn Registry, Burn Model System National Database, and the Burns Registry of Australia and New Zealand. The main limitations of existing registries are the inclusion of patients admitted to burn centers only, deficient capture of outpatient and long-term outcome data, lack of data standardization across registries, and the paucity of studies on burn prevention and quality improvement methodology. Registries are an invaluable source of information for research, delivery of care planning, and benchmarking of processes and outcomes. Efforts should be made to stimulate other jurisdictions to build burn registries and for existing registries to be improved through data linkage with administrative databases, and by standardizing one international minimum dataset, in order to maximize the potential of registry science in burn care.

Does patient load affect clinical outcome of burn patients in specialized centers? An analysis of the German Burn Registry

Hospital volume has been identified as an independent outcome parameter for a number of medical fields and surgical procedures, and there is a tendency to increase required patient numbers for center verification. However, the existing literature does not support a clear correlation between patient load and clinical outcome in adult burn care and recent data from Germany does not exist. We therefore evaluated the effect of patient volume in German burn centers on clinical outcome. Patient data was extracted from the German Burn Registry from 2015 to 2018. For better inter-center comparability, solely burn patients with a TBSA ≥ 10% were included. Mortality, number of surgeries and length of stay (LOS) were evaluated with respect to burn center patient volume. Burn center volume was divided into two and three groups. A total of 2718 patients with a TBSA ≥ 10% were admitted to the participating 17 burn centers. Independent from the division of patient data into either 2 or 3 groups, the TBSA and ABSI score-related severity of burn injuries were comparable between groups. There was no significant difference in mortality due to center size. Nevertheless, patients treated in large volume burn centers showed a significantly increased LOS (+4.5 days, [1.9-7.2] CI, p = 0.001) and required significantly more surgeries (+0.5 surgeries [0.2-0.8] CI, p = 0.002) when compared to the small volume centers. A similar phenomenon regarding mortality and LOS (p 0.001) was observed after dividing the centers into two groups. Interestingly a division into three groups showed significant differences with the best outcome for patients in medium-volume centers. Nevertheless, mortality did not differ significantly. Therefore, our data demonstrates that in contrast to many other medical fields, outcome and mortality are not automatically improved in burn care by simply increasing the patient load, at least in centers treating 20-100 BICU patients/year.

Pediatric major burns: a monocentric retrospective review of etiology and outcomes (2008–2020)

Background

Burns are one of the most common causes of mortality and morbidity among children. This study aims to assess the epidemiology of pediatric major burns in a third level hospital in Spain to evaluate demographics, etiology, and outcomes.

Methods

A retrospective study was held by the Plastic, Reconstructive and Burn Surgery department of the hospital. We included 147 patients under 18 admitted to hospital between January 2008 and December 2020 who meet the inclusion criteria: partial thickness burns > 10% total body surface area (TBSA) in patients < 18 years old. Clinical data extracted included age, gender, date of admission, %TBSA, burn types, severity and sites of burn, length of stay, length of ventilator support, intensive care admission, blood transfusion, surgical interventions, and complications.

Results

Three groups of age were analyzed. The average %TBSA was 18.7 (SE 0.9). Scalds were the main mechanism of injury (70.1%) and upper extremity was the most frequent location affected (68%). The 28.6% of patients suffered some complication, but the mortality rate was low (0.7%). In our series, the group aged 13–18 showed significantly higher %TBSA, more number of surgeries and blood transfusions.

Conclusions

Scald burns are the most frequent mechanism of injury in pediatric burns. However, teenagers suffer more severe burns and complications, usually caused by flame. Despite the low mortality rates, more measures of prevention should be taken to increase children security.

Level of evidence: Level IV, Risk/Prognostic.

The Impact of Plastic Surgery Volume on Inpatient Burn Outcomes

BACKGROUND

Acute burn care involves multiple types of physicians. Plastic surgery offers the full spectrum of acute burn care and reconstructive surgery. The authors hypothesize that access to plastic surgery will be associated with improved inpatient outcomes in the treatment of acute burns.

METHODS

Acute burn encounters with known percentage total body surface area were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Edition, codes. Plastic surgery volume per facility was determined based on procedure codes for flaps, breast reconstruction, and complex hand reconstruction. Outcomes included odds of receiving a flap, patient safety indicators, and mortality. Regression models included the following variables: age, percentage total body surface area, gender, inhalation injury, comorbidities, hospital size, and urban/teaching status of hospital.

RESULTS

The weighted sample included 99,510 burn admissions with a mean percentage total body surface area of 15.5 percent. The weighted median plastic surgery volume by facility was 245 cases per year. Compared with the lowest quartile, the upper three quartiles of plastic surgery volume were associated with increased likelihood of undergoing flap procedures (p < 0.03). The top quartile of plastic surgery volume was also associated with decreased odds of patient safety indicator events (p < 0.001). Plastic surgery facility volume was not significantly associated with a difference in the likelihood of inpatient death.

CONCLUSIONS

Burn encounters treated at high-volume plastic surgery facilities were more likely to undergo flap operations. High-volume plastic surgery centers were also associated with a lower likelihood of inpatient complications. Therefore, where feasible, acute burn patients should be triaged to high-volume centers.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Characteristics of Burn-Injured Children in 117 U.S. PICUs (2009-2017): A Retrospective Virtual Pediatric Systems Database Study

OBJECTIVES

To describe characteristics and outcomes of children with burn injury treated in U.S. PICUs.

DESIGN

Retrospective study of admissions in the Virtual Pediatric Systems, LLC, database from 2009 to 2017.

SETTING

One hundred and seventeen PICUs in the United States.

PATIENTS

Patients less than 18 years old admitted with an active diagnosis of burn at admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 2,056 patients were included. They were predominantly male (62.6%) and less than 6 years old (66.7%). Cutaneous burns were recorded in 92.1% of patients, mouth/pharynx burns in 5.8%, inhalation injury in 5.1%, and larynx/trachea/lung burns in 4.5%. Among those with an etiology recorded (n = 861), scald was most common (38.6%), particularly in children less than 2 years old (67.8%). Fire/flame burns were most common (46.6%) in children greater than or equal to 2 years. Multiple organ failure was present in 26.2% of patients. Most patients (89%) were at facilities without American Burn Association pediatric verification. PICU mortality occurred in 4.5% of patients. On multivariable analysis using Pediatric Index of Mortality 2, greater than or equal to 30% total body surface area burned was significantly associated with mortality (odds ratio, 5.40; 95% CI, 2.16-13.51; p = 0.0003). When Pediatric Risk of Mortality III was used, greater than or equal to 30% total body surface area burned (odds ratio, 5.45; 95% CI, 1.95-15.26; p = 0.001) and inhalation injury (odds ratio, 5.39; 95% CI, 1.58-18.42; p = 0.007) were significantly associated with mortality. Among 366 survivors (18.6%) with Pediatric Cerebral Performance Category or Pediatric Overall Performance Category data, 190 (51.9%) had a greater than or equal to 1 point increase in Pediatric Cerebral Performance Category or Pediatric Overall Performance Category disability category and 80 (21.9%) had a new designation of moderate or severe disability, or persistent vegetative state.

CONCLUSIONS

Burn-injured patients in U.S. PICUs have a substantial burden of organ failure, morbidity, and mortality. Coordination among specialized facilities may be particularly important in this population, especially for those with higher % total body surface area burned or inhalation injury.

Analysis of 12,661 pediatric burns in Wuhan institute of burns: A retrospective study of fifteen years

BACKGROUND

By analyzing the epidemic characteristics of pediatric burns in a burn center serving large areas of Hubei Provence and partly surrounding provinces around Wuhan City, the aim of this study is to provide better strategies for the prevention and care for pediatric burns.

METHODS

Pediatric burn patients who were younger than 13 years old in Wuhan Third Hospital from 2004 to 2018 were included. Demographic and clinical data were collected, analyzed and compared among groups.

RESULTS

12,661 pediatric burns, mean aged 2.37 ± 2.30 y, were admitted during the 15 years, with 7973 boys (62.97%) and 4688 girls (37.03%). By age groups, infant (<3y), preschool (>3-6y) and school children (>6-13y) accounted for 81.12% (10,270 cases), 12.08% (1530 cases) and 6.80% (861 cases) respectively. The most cause of injury was scalds (11,232, 88.71%), followed by flame burns (917, 7.24%), electric burns (201, 1.59%), contact burns (127, 1.00%), firework or firecracker (124, 0.98%), chemical burns (40, 0.32%) and hot crush injury (20, 0.16%). The mean age of firework or firecracker burns was 6.19 ± 2.83y, electric burns 5.18 ± 3.31y, flame burns 4.73 ± 3.53y, hot crush injury 3.85 ± 2.37 y, contact burns 3.66 ± 3.35y, chemical burns 3.03 ± 2.50y, and scald 2.06 ± 1.91y. Over half cases (57.34%) were small burns less than 10% total burn surface area (TBSA) and the larger TBSA, the fewer number of patients. The mortality rate was 0.11% and correlated with TBSA, age and etiology. The mean length of stay (LOS) was 12.63 ± 11.91 days and highly correlated with etiology and TBSA. The mean hospital cost was 11210.76 ± 21248.87 RMB (about 1600 USD) or 1626.91 ± 3957.59 RMB (about 230 USD) per % TBSA, which was correlated with depth of burn, TBSA, etiology, LOS and age.

CONCLUSION

Pediatric burns in central China was still common and even increasing. Majority of the pediatric burn victims were boys under three years old, while the mean ages of different etiologies varied from about 2-6 years old. Education and prevention aiming the high risks are the key point to decrease pediatric burns.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TYPE OF STUDY

Retrospective analysis.

LEVEL OF EVIDENCE

Level III.

Nurse Staffing, the Clinical Work Environment, and Burn Patient Mortality

The complexity of modern burn care requires an integrated team of specialty providers working together to achieve the best possible outcome for each burn survivor. Nurses are central to many aspects of a burn survivor's care, including physiologic monitoring, fluid resuscitation, pain management, infection prevention, complex wound care, and rehabilitation. Research suggests that in general, hospital nursing resources, defined as nurse staffing and the quality of the work environment, relate to patient mortality. Still, the relationship between those resources and burn mortality has not been previously examined. This study used a multivariable risk-adjusted regression model and a linked, cross-sectional claims database of more than 14,000 adults (≥18 years) thermal burn patients admitted to 653 hospitals to evaluate these relationships. Hospital nursing resources were independently reported by more than 29,000 bedside nurses working in the study hospitals. In the high burn patient-volume hospitals (≥100/y) that care for the most severe burn injuries, each additional patient added to a nurse's workload is associated with 30% higher odds of mortality (P < .05, 95% CI: 1.02-1.94), and improving the work environment is associated with 28% lower odds of death (P < .05, 95% CI: 0.07-0.99). Nursing resources are vital in the care of burn patients and are a critical, yet previously omitted, variable in the evaluation of burn outcomes. Attention to nurse staffing and improvement to the nurse work environment is warranted to promote optimal recovery for burn survivors. Given the influence of nursing on mortality, future research evaluating burn patient outcomes should account for nursing resources.

Pediatric burn-trauma patients have increased length of stay compared to trauma-only patients: A propensity matched analysis

BACKGROUND

Trauma is the leading cause of mortality in children. Burn injury involves intensive resources, especially in pediatric patients. We hypothesized that among pediatric trauma patients, combined burn-trauma (BT) patients have increased length of stay (LOS) and mortality compared to trauma-only (T) patients.

METHODS

The Pediatric Trauma Quality Improvement Program (2014-2016) was queried and BT patients were 1:2 propensity-score-matched to T patients based on age, gender, hypotension on admission, injury type and severity.

RESULTS

93 BT patients were matched to 186 T patients. There were no differences in matched characteristics. BT patients had a longer median LOS (4 vs 2 days, p<0.001) with no difference in mortality (1.1% vs 1.1%, p=1.00), intensive care unit (ICU) LOS (3 vs 3 days, p=0.55), or complications including decubitus ulcer (0% vs 1.1%, p=0.32), deep vein thrombosis (0% vs 0.5%, p=0.48), extremity compartment syndrome (1.1% vs 0%, p=0.16), and urinary tract infection (1.1% vs 1.1%, p=1.00).

CONCLUSION

Pediatric BT patients had twice the LOS compared to a matched group of pediatric T patients. There was no difference between the cohorts in ICU LOS, complications or mortality rate. When evaluating risk-stratified quality metrics such as LOS, concomitant burn injury should be incorporated.

A Decade Epidemiological Study of Pediatric Burns in South West of Iran

BACKGROUND

Burn is one of the most traumatic injuries and life-threatening states which expose children at a higher risk. The aim of this study was evaluating the epidemiology of pediatric burns in age less than eighteen years old during the last decade.

METHODS

This cross-sectional study was carried out during 2008-2017 in Amir-al Momenin Burn Center, affiliated by Shiraz University of Medical Sciences, Shiraz, Iran. The subjects consisted of burn victims under 18 years old who were registered as outpatients and inpatients.

RESULTS

During the study period, 1893 and 12431 patient were registered as inpatients and outpatients of the hospital. The burn victims were males. Children under 5 years old were prone to scald injuries more than children in any other age. More than 90% of inpatients children burned accidentally, while 116 (6.12%) burn injuries were suicidal; which was mostly seen in girls (75%, 87 out of 116).

CONCLUSION

Most burns involved scalds from hot liquids especially in children age less than 5 years. Different strategies can be executed by means of broadcast flashes in mass media and educational programs through schools to show risk situation and statements calling attention to prevent childhood burn injuries.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

One center's experience developing a burn outpatient registry

INTRODUCTION

Recent advances in burn care have resulted in the transition of care from inpatient to outpatient. There is a growing appreciation that with improved survival, meaningful markers of quality need to include recovery of form, function, and reconstruction. Capture of the data describing care delivered in the outpatient setting is being missed.

METHODS

Development of our outpatient database included providers, registrar, program manager, and outpatient nursing staff. Data points were included if they described the population, and epidemiology of our patients, were useful for programmatic changes and improvements as well as anticipated research focus areas.

RESULTS

The database platform chosen was Midas+™ because it was in use by hospital quality and integrated with the electronic medical record. Fields were customized based on changing program needs and are updated for new programs or outcomes measures. Reports can be easily built and both outpatients and inpatients are included. This allows for longitudinal tracking of burn patients. Ongoing additions to original data points include variables to track outcomes related to laser therapy for scar management, time to custom garment donning, and to track functional outcomes. Epidemiologic data collected is used to target high-risk populations for prevention and outreach efforts. Outcome data is used for evaluation of programs and care.

CONCLUSIONS

High quality databases serve to measure effectiveness of care and offer insight for areas of improvement. There is a clear need for inclusion of outpatient activity in the National Burn Registry (NBR).

Does Increased Patient Load Improve Mortality in Burns?: Identifying Benchmark Parameters Defining Quality of Burn Care

INTRODUCTION

In burn care, as in other medical fields, there is a tendency to increase the required number of patients for center certifications. Does the increase in patient load automatically improve the quality of burn care? What are the benchmark parameters that have been shown to improve burn care?

METHODS

To answer these questions, Medline, Cochrane Library, and Livivo were searched from inception through January 2018 for all studies evaluating the influence of treatment parameters on outcomes in different burn care settings.

RESULTS

Fifteen studies were included in this systematic review. In adults, not a single study showed a decreased mortality due to a higher patient load. However, in children, 2 studies demonstrated a further decrease of the already low mortality due to an increase in patient load. In contrast to patient load, benchmark parameters that had a significant influence on the outcome of burn care for adults and children were: single bed isolation, residency programs, American Burn Association certifications of burn centers, speed of wound closure, and standard operating procedures for burn care.

CONCLUSIONS

This systematic review demonstrates that a clear correlation between patient load and mortality reduction in adult burn treatment is not supported by the existing literature, requiring future studies. In contrast, all efforts aiming to improve the quality of burn care, such as isolation of burn patients, speed of wound closure, American Burn Association verification and especially standard operating procedures for burn care improve survival and quality of burn care.

Volume-outcome relationship on survival and cost benefits in severe burn injury: a retrospective analysis of a Japanese nationwide administrative database

Background

Although it has been reported that high hospital patient volume results in survival and cost benefits for several diseases, it is uncertain whether this association is applicable in burn care.

Methods

We conducted a retrospective observational study on severe burn patients, defined by a burn index ≥ 10, using 2010–2015 data from a Japanese national administrative claim database. A generalized additive mixed-effect model (GAMM) was used to evaluate the nonlinear associations between patient volume and the outcomes (in-hospital mortality, healthcare costs per admission, and hospital-free days at 90 days). Generalized linear mixed-effect regression models (GLMMs) in which patient volume was incorporated as a continuous or categorical variable (≤ 5 or > 5) were also performed. Patient severity was adjusted using the prognostic burn index (PBI) or the risk adjustment model developed in this study, simultaneously controlling for hospital-level clustering. Sensitivity analyses evaluating patients who were directly transported, those with PBI ≤ 120 and those excluding patients who died within 2 days of admission, were also performed.

Results

We analyzed 5250 eligible severe burn patients from 737 hospitals. The PBI and the developed risk adjustment model had good discriminative ability with areas under the receiver operating characteristic curves of 0.86 and 0.89, respectively. The GAMM plots showed that in-hospital mortality and healthcare costs increased according to the increase in patient volumes; then, they reached a plateau. Fewer hospital-free days were observed in the higher volume hospitals. The GLMM model showed that patient volume (incorporated as a continuous variable) was significantly associated with increased in-hospital mortality (adjusted odds ratio [95% confidence interval (CI)] = 1.14 [1.09–1.19]), high healthcare costs (adjusted difference [95% CI] = $4876 [4436–5316]), and few hospital-free days (adjusted difference [95% CI] = − 3.1 days [− 3.4 to − 2.8]). Similar trends were observed in the analyses in which patient volume was incorporated as a categorical variable. The results of sensitivity analyses showed comparable results.

Conclusions

Analysis of Japanese nationwide administrative database demonstrated that high burn patient volume was significantly associated with increased in-hospital mortality, high healthcare costs, and few hospital-free days. Further studies are needed to validate our results.

Electronic supplementary material

The online version of this article (10.1186/s40560-019-0363-7) contains supplementary material, which is available to authorized users.

Characteristics and outcome of burned children admitted to a pediatric intensive care unit

Objective

To analyze the characteristics and outcomes of children hospitalized for burns in a pediatric trauma intensive care unit for burn patients.

Methods

An observational study was conducted through the retrospective analysis of children (< 16 years) admitted to the pediatric trauma intensive care unit for burn victims between January 2013 and December 2015. Sociodemographic and clinical variables were analyzed including the causal agent, burned body surface, presence of inhalation injury, length of hospital stay and mortality.

Results

The study analyzed a sum of 140 patients; 61.8% were male, with a median age of 24 months and an overall mortality of 5%. The main cause of burns was scalding (51.4%), followed by accidents involving fire (38.6%) and electric shock (6.4%). Mechanical ventilation was used in 20.7% of the cases. Associated inhalation injury presented a relative risk of 6.1 (3.5 - 10.7) of needing ventilatory support and a relative risk of mortality of 14.1 (2.9 - 68.3) compared to patients without this associated injury. A significant connection was found between burned body surface and mortality (p < 0.002), reaching 80% in patients with a burned area greater than 50%. Patients who died had a significantly higher Tobiasen Abbreviated Burn Severity Index than survivors (9.6 ± 2.2 versus 4.4 ± 1.1; p < 0.001). A Tobiasen Abbreviated Burn Severity Index ≥ 7 represented a relative risk of death of 68.4 (95%CI 9.1 - 513.5).

Conclusion

Scalding burns are quite frequent and are associated with high morbidity. Mortality is associated with the amount of burned body surface and the presence of inhalation injury. Special emphasis should be given to accidents involving fire, reinforcing proper diagnosis and treatment of inhalation injury.

Emergency Care of Pediatric Burns

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

Creation of a decision aid for goal setting after geriatric burns: a study from the prognostic assessment of life and limitations after trauma in the elderly [PALLIATE] consortium

OBJECTIVES

We hypothesized that a decision-support aid to predict index admission mortality and discharge disposition for geriatric burns could be constructed using the well-accepted Baux score (age +total body surface area burned) in a geriatric-specific cohort.

METHODS

National Burn Repository version 8.0 (2002-2011) was queried for all subjects aged 65 years or older. Baux scores were calculated and patients grouped into deciles. Three discharge outcomes (death,home, discharge to nonhome setting) were measured per decile. A receiver operating characteristic analysis was used to determine optimal Baux score cutpoints based on the Youden Index. The odds of mortality at various Baux score cutoffs were estimated using logistic regression.

RESULTS

The sample was composed of 8,001 subjects. Withdrawal of care was documented in 264 deaths; median time to withdrawal was three days. As Baux score increased, three peaks in disposition were seen. Less than 50% of patients with a Baux score of 80 or greater were discharged home. Patients with a moderate Baux score (80-130) had an increased likelihood of discharge to a nonhome setting. Baux scores of 130 or greater were nearly uniformly fatal (mortality, 94-100%). Baux score of 86.15 or less was predictive of discharge home (area under the curve, 0.698; sensitivity, 75.28%; specificity, 54.64%), and a score greater than 93.3 was predictive of mortality (area under the curve, 0.779; sensitivity, 57.46%; specificity, 87.08%).

CONCLUSION

For geriatric patients whose Baux scores exceed 86, return-to-home rates drop drastically; mortality increases at a score greater than 93, and mortality is nearly universal at a score ≥130 or greater. We are piloting a display of these findings as a decision-making aid when setting goals of care with stakeholders after geriatric burns.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level III; therapeutic/care management, level IV.