A Rationale for Significant Cost Savings in Patients Suffering Home Oxygen Burns: Despite Many Comorbid Conditions, Only Modest Care Is Necessary

Outcomes of Patients with Burns Associated with Home Oxygen Therapy: An Institutional Retrospective Review

Home oxygen therapy (HOT) burns carry high morbidity and mortality. Many patients are active smokers, which is the most frequent cause of oxygen ignition. We conducted a retrospective review at our institution to characterize demographics and outcomes in this patient population. An IRB-approved single-institution retrospective review was conducted for home oxygen therapy burn patients between July 2016 and January 2021. Demographic and clinical outcome data were compared between groups. We identified 100 patients with oxygen therapy burns. Mean age was 66.6 years with a male to female ratio of 1.3:1 and median burn surface area of 1%. In these patients, 97% were on oxygen for COPD and smoking caused 83% of burns. Thirteen were discharged from the emergency department, 35 observed for less than 24 hours, and 52 admitted. For admitted patients, 69.2% were admitted to the ICU, 37% required intubation, and 11.5% required debridement and grafting. Inhalational injury was found in 26.9% of patients, 3.9% underwent tracheostomy, and 17.3% experienced hospital complications. In-hospital mortality was 9.6% and 7.7% were discharged to hospice. 13.5% required readmission within 30 days. Admitted patients had significantly higher rates of admission to the ICU, intubation, and inhalational injury compared to those that were not admitted (p < .01). Most HOT-related burns are caused by smoking and can result in significant morbidity and mortality. Efforts to educate and encourage smoking cessation with more judicious HOT allocation would assist in preventing these unnecessary highly morbid injuries.

Nexobrid Treatment for Burn Injuries in Patients With Chronic Obstructive Pulmonary Disease and Home Oxygen Therapy

There is an increased risk for burn injuries associated with home oxygen therapy of patients with chronic obstructive pulmonary disease since 10 to 50 % of these patients continue to smoke. Enzymatic eschar removal of facial burns is gaining popularity but intubation of this specific patient group often leads to prolonged weaning and can require tracheostomy. This study dealt with the question if enzymatic debridement in these patients can also be performed in analgosedation. A selective review of the literature regarding burn trauma associated with home oxygen use in patients with COPD was performed, as well as a retrospective analysis of all patients with burn injuries associated with home oxygen use and chronic obstructive pulmonary disease that were admitted to the study clinic. In the literature 1746 patients with burns associated with home oxygen use are described, but none of them received enzymatic debridement. In this study seventeen patients were included. All three patients in this study with facial full-thickness burn injuries received enzymatic debridement. The mortality rate in this cohort was 17.6 % (3/17). Up to date, there is limited experience performing regional anesthesia debridement in patients with COPD. This is the first manuscript describing the use of enzymatic debridement in patients with COPD and home oxygen therapy. We could confirm other studies that intubation of these patients leads to prolonged ventilation hours and increases the probability for poor prognosis. Therefore, we described the treatment of enzymatic debridement in analgosedation without intubation.

Western Trauma Association critical decisions in trauma: Preferred triage and initial management of the burned patient

This is a recommended management algorithm from the Western Trauma Association addressing the management of victims of burn injury. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published retrospective studies, clinical guidelines, and the expert opinion of members of the Western Trauma Association in conjunction with partner members of the American Burn Association. The algorithm and accompanying comments represent one safe and sensible approach that can be followed at most trauma centers. We recognize that there may be patient or institutional factors that warrant deviation from the published algorithm. We would encourage institutions to use this document as a starting point toward a dialog with local burn centers to collaboratively create a patient-centered care experience for the victims of minor burn injuries arriving at local trauma centers.

Overutilization of Helicopter Transport in the Minimally Burned—A Healthcare System Problem That Should Be Corrected

Eighty-eight percent of all patients burned in North America suffer burns of less than 20% TBSA. These patients may need care at a burn center, but barring any inhalation injury or polytrauma, these patients do not require helicopter transport (HEMS). We sought to identify a cohort of patients suffering smaller burns who do not benefit from HEMS to establish significant health care system savings. A 5-year retrospective analysis of data collected from our trauma registry was performed. Patients were separated into two groups: HEMS and ground transport (EMS). A subanalysis was performed between those with smaller burns (<20% TBSA and no ICU/OR requirement). ED disposition, hospital length of stay, distance transported, and cost was analyzed. Of 616 burn patients presenting to our center, 13% were transported by HEMS, 46% by ambulance, and 61% by private vehicle. Of those transported via HEMS, 38% had been evaluated and treated at an outside hospital before transfer. Patients transported via HEMS had larger burns (13 vs 9 %TBSA; P = .002) and deeper burns (P < .001), longer hospital stays (P = .003), higher ICU admission rates (P < .001), and mortality rates (P = .003) compared with those transported by EMS. Transport distance was a mean 5.5 times greater (88 vs 16 mi) in the HEMS group (P < .001). Within this cohort, 53% of patients transported via HEMS suffered smaller burns, compared with 73% transported by EMS. A subanalysis of the smaller burns cohort showed increased distances of transport via HEMS (91 vs 18 mi; P < .001) and increased rates of admission from the ED in the EMS group (93% vs 68% by HEMS; P = .005), yet no difference in length of stay, or rates of early discharge, defined as <24-hour hospital stay. Fully 1/4 of those transported via HEMS with smaller burns were discharged from the ED after burn consultation, debridement, and dressing. Mortality in both was nil. Average cost per helicopter transport was US$29K. Accurate triage and burn center consultation before scene transport or hospital transfer could help identify patients not benefiting from HEMS yet safely transferrable by ground, or better served by early clinic follow-up, which would reduce cost without compromising care in this cohort. Annual patient savings approximating US$444K could be multiplied were non-HEMS transport universally adopted for smaller burns.

Burn injury during long-term oxygen therapy in Denmark and Sweden: the potential role of smoking

Background

Long-term oxygen therapy (LTOT) increases life expectancy in patients with COPD and severe hypoxemia. Smoking is the main cause of burn injury during LTOT. Policy regarding smoking while on LTOT varies between countries. In this study, we compare the incidence of burn injury that required contact with a health care specialist, between Sweden (a country with a strict policy regarding smoking while on LTOT) and Denmark (a country with less strict smoking policy).

Methods

This was a population-based, cohort study of patients initiating LTOT due to any cause in Sweden and Denmark. Data on diagnoses, external causes, and procedures were obtained from the Swedish and Danish National Patient Registers for inpatient and outpatient care. Patients were followed from January 1, 2000, until the first of the following: LTOT withdrawal, death, or study end (December 31, 2009). The primary end point was burn injury during LTOT.

Results

A total of 23,741 patients received LTOT in Denmark and 7,754 patients in Sweden. Most patients started LTOT due to COPD, both in Sweden (74%) and in Denmark (62%). The rate of burn injury while on LTOT was higher in Denmark than in Sweden; 170 (95% confidence interval [CI], 126–225) vs 85 (95% CI, 44–148) per 100,000 person-years; rate ratio 2.0 (95% CI, 1.0–4.1). The risk remained higher after adjustment for gender, age, and diagnosis in multivariate Cox regression, hazard ratio 1.8 (95% CI, 1.0−3.5). Thirty-day mortality after burn injury was 8% in both countries.

Conclusion

Compared to Sweden, the rate of burn injury was twice as high in Denmark where smoking is not a contraindication for prescribing LTOT.

Smoking-Related Home Oxygen Burn Injuries: Continued Cause for Alarm

BACKGROUND

Home oxygen therapy is a mainstay of treatment for patients with various cardiopulmonary diseases. In spite of warnings against smoking while using home oxygen, many patients sustain burn injuries.

OBJECTIVES

We aimed to quantify the morbidity and mortality of such patients admitted to our regional burn unit over a 6-year period.

METHODS

A retrospective chart review of all patients admitted to a regional burn center from 2008 through 2013 was completed. Admitted patients sustaining burns secondary to smoking while using home oxygen therapy were selected as the study population to determine morbidity.

RESULTS

Fifty-five subjects were admitted to the burn unit for smoking-related home oxygen injuries. The age range was 40-84 years. Almost all subjects were on home oxygen for chronic obstructive pulmonary disease (96%). Seventy-two percent of burns involved <5% of the total body surface area, 51% of patients were intubated, and of those 33% had evidence of inhalation injury. The hospital mortality rate was 14.5%. The mean length of hospital stay was 8.6 days, and 54.5% were discharged to a nursing home or another advanced facility. Finally, concomitant substance abuse was found in 27%, and a previous history of injury from smoking while on home oxygen was discovered in 14.5%.

CONCLUSIONS

This single-center analysis is one of the largest describing burn injuries stemming from smoking while using home oxygen therapy. We identified the morbidity and mortality associated with these injuries. Ongoing education and careful consideration of prescribing home oxygen therapy for known smokers is highly encouraged.

Burn injury associated with home oxygen use in patients with chronic obstructive pulmonary disease

OBJECTIVES

To quantify the risk of burn injury associated with home oxygen use and to examine the risk factors associated with the development of this injury.

PATIENTS AND METHODS

We used a nested case-control and a retrospective cohort design to study enrollment and claims data from a national sample of Medicare beneficiaries 66 years and older with a diagnosis of chronic obstructive pulmonary disease (COPD) from January 1, 2001, through December 31, 2010. The primary outcome was burn injury in patients with COPD prescribed home oxygen.

RESULTS

In the nested case-control method, patients with burn injury were twice (odds ratio, 2.43; 95% CI, 1.57-3.78) as likely to be prescribed oxygen in the preceding 90 days compared with those without burn injury. In the retrospective cohort study, the absolute risk of burn injury in patients prescribed oxygen therapy was 2.98 per 1000 patients compared with 1.69 per 1000 patients not prescribed oxygen during a 22-month period. The excess risk of a burn injury associated with oxygen was 0.704 per 1000 patients per year, and the number needed to harm was 1421. In multivariable analysis, factors associated with burn injury included male sex, low socioeconomic status, oxygen therapy use, and the presence of 3 or more comorbidities.

CONCLUSION

The benefits of oxygen therapy in patients with COPD outweigh the modest risk of burn injury associated with home oxygen use. However, with the increasing number of patients being prescribed oxygen, health care professionals must educate and counsel patients regarding the potential risk of burn injury.