Burn recidivism: a 10-year retrospective study characterizing patients with repeated burn injuries at a large tertiary referral burn center in the United States

Trauma recidivism is reduced with engagement in psychosocial programming following orthopaedic trauma

INTRODUCTION

Recidivism is common following injury. Interventions to enhance patient engagement may reduce trauma recidivism. Education, counseling, peer mentorship, and other resources are known as Trauma Recovery Services (TRS). The authors hypothesized that TRS use would reduce trauma recidivism.

METHODS

Over five years at a level 1 trauma center, 954 adults treated operatively for pelvic, spine, and femoral fractures were reviewed. Recidivism was defined as return to trauma center for new injury within 30-months. All patients were offered TRS. Multivariate logistic regression statistical analysis was used to identify predictors of recidivism.

RESULTS

Three hundred and ninety-seven of all patients (42 %) utilized TRS, including educational materials (n = 293), peer visits (n = 360), coaching (n = 284), posttraumatic stress disorder (PTSD) screening (n = 74), and other services. Within the entire sample, 136 patients (14 %) returned to the emergency department for an unrelated trauma event after mean 21 months. 13 % of TRS users became recidivists. Overall, 49 % of recidivists had history of pre-existing mental illness. High rates of TRS engagement between recidivists and non-recidivists were seen (75 %); however, non-recidivists were more likely to use multiple types of recovery services (49 % vs 34 %, p = 0.002), and were more likely to engage with trauma peer mentors (former trauma survivors) more than once (91 % vs 81 %, p = 0.03). After multivariable analysis, patients using multiple different recovery services had a lower risk of recidivism (p = 0.04, OR 0.42, 95 % CI [0.19-0.96]).

CONCLUSIONS

Multifaceted engagement with recovery programming is associated with less recidivism following trauma. Future study of resultant reductions in healthcare costs are warranted.

LEVEL OF EVIDENCE

Level II; Prognostic.

Trauma recidivism is pervasive and is associated with mental and social health opportunities

INTRODUCTION

Recidivism after orthopedic trauma results in greater morbidity and costs. Prior studies explored the effects of social and medical factors affecting the frequency of return to the hospital with new, unrelated injury. Identification of mental, social and other risk factors for trauma recidivism may provide opportunities for mitigation. The purposes of this study are to determine the rates of subsequent, unrelated injury noted among orthopedic trauma patients at a large urban trauma center and to evaluate what patient and injury features are associated with greater rates of trauma recidivism. We hypothesize higher rates of new injuries will be related to ballistic trauma and other forms of assault, alcohol and recreational drug use, unemployment, and unmarried status among our trauma patients.

METHODS

A series of 954 skeletally mature patients at a level 1 trauma center over a 5 year period were included in the study. All were treated operatively for thoracolumbar, pelvic ring, acetabulum, and/or proximal or shaft femoral fractures from a high energy mechanism. Retrospective review of demographic, injury, medical, and social factors, and subsequent care was performed. Trauma recidivism was defined as returning to the emergency department for treatment of any new injury. A backward stepwise logistic regression statistical analysis was used to identify independent predictors of recidivism.

RESULTS

Mean age of all patients was 41.2 years, and 73.2% were male. 136 patients (14.3%) returned with a new injury within a mean of 21 months. These trauma recidivists were more likely to sustain a GSW (22.1% vs 11.4%, p = 0.001). They had higher rates of substance use, including tobacco (57.4% vs 41.8%, p = 0.001) and recreational drugs (50.7% vs 34.4%, p = 0.001), and were less likely to be married (10% vs 25.9%, p<0.001). Mental illness was pervasive, noted in 56.6% of patients with new injury (vs 32.8%, p<0.001). Medicaid insurance was most common in the trauma recidivist population (58.1% vs 35.0%, p = 0.001), and 12.5% were uninsured. Completing high school or more education was protective (93% non-recidivist (vs 79%, p = 0.001). Sixty-nine patients (50.7%) were repeat trauma recidivists within the study period. Independent predictors of new injury included recreational drug use (OR 1.64, p = 0.05) and history of assault due to GSW or other means (OR 1.67, p = 0.05). History of pre-existing mental illness represented the greatest risk factor for trauma recidivism (OR 2.55, p<0.001).

DISCUSSION

New injuries resulting in emergency department presentation after prior orthopedic trauma occurred in 14.3% and were associated with history of assault, lower education, Medicaid insurance, tobacco smoking and recreational drug use. Mental illness was the greatest risk factor. Over half of patients with these additional injuries were repeat trauma recidivists, returning for another new injury within less than 2 years. Awareness of risk factors may promote focused education and other interventions to mitigate this burden.

LEVEL OF EVIDENCE

Level 3 retrospective, prognostic.

The Role of Alcohol and Drug Intoxication in Fire-Related Incidents in Africa: A Systematic Review

Fire-related burns contribute significantly to the global burden of burn injury and mortality. Alcohol and/or drug intoxication poses a risk to burn and fire-related injury, whether intentional or unintentional, but such evidence is scarce in the African context. This review aimed to fill the knowledge gap on health determinants of fire-related morbidity and mortality regionally by investigating the role of alcohol and drug intoxication in such events. Using key concepts, an extensive search was performed on 25 databases for relevant publications. Eligible articles were critically appraised using the appraisal tool for cross-sectional studies (AXIS tool), adapted to the review's objectives and outcomes. A total of 42 articles were included, of which less than half were solely investigating burn/fire-related events. Others indirectly mentioned burn injuries as part of larger health burdens such as injury, trauma, violence and other diseases. The measurement of alcohol and/or drug intoxication was inconsistent between studies with varying results. Alcohol and drug impairment in burn incidents in Africa requires evidence-based epidemiological research, and this review illustrated the limited scope of this topic in current literature. Routine toxicological results from post-mortem examinations were identified as important data sources and several research recommendations were provided.

Socioeconomic and comorbid factors associated with frostbite injury in the United States

Frostbite largely impacts the extremities and often results in long term disability due to amputation. More regions are experiencing extremes in temperature which increases risk of frostbite injury. The aim of this study is to detail social and comorbid factors associated with frostbite injury compared to isolated hand or foot burns. We used the National Inpatient Sample from years 2016 to 2018 to identify admissions included in this study. Weighted incidence and multivariable analysis assessed characteristics and outcomes of frostbite and isolated hand or foot burn injury. In the United States, the estimated incidence of frostbite injury in those aged 15 and over was 0.95 per 100,000 persons and 4.44 per 100,000 persons with isolated hand and foot burns. Homelessness, mental health disorder, drug or alcohol abuse, and peripheral vascular disease were all associated with risk of frostbite injury when compared to burn injury. We found that other insurance was associated with amputation following burn injury, while Black race and homelessness were associated with amputation during a non-elective primary admission following frostbite injury. The differing risk factors associated with early amputation in frostbite and burn patients warrant a multicenter study including burn centers in North America.

Association Between Alcohol, Substance Use, and Inpatient Burn Outcomes

The use of alcohol and illicit substances has been associated with impaired judgment and health, but the effect on inpatient outcomes after burn injury remains unsettled. Our objective was to evaluate the effect of alcohol and illicit substance use on our inpatient burn outcomes. Adult patients admitted with burn injury-including inhalation injury only-between January 1, 2014 and June 30, 2019 were eligible for inclusion. Alcohol use and illicit drug use were identified on admission. Outcomes of interest included requiring mechanical ventilation, admission to the intensive care unit, length of stay, and inpatient mortality. Multivariable linear and logistic regression models were used to estimate the effects of use on inpatient outcomes. A total of 3476 patients were included in our analyses; 8% (n = 284) tested positive for alcohol, 10% (n = 364) tested positive for cocaine, and 27% (n = 930) tested positive for marijuana and at admission. Two hundred and eighty adults (18% of all positive patients) tested positive for at least two substances. Patients who tested positive for alcohol had longer lengths of stay and were more likely to be admitted to the intensive care unit. Patients who tested positive for cocaine had longer overall and intensive care unit lengths of stay. No differences in inpatient outcomes were seen among patients who tested positive for marijuana. Neither alcohol nor illicit substance use appears to affect inpatient mortality after burns. Alcohol and cocaine use significantly increased overall length of stay. Marijuana use had no impact on inpatient outcomes.

Understanding and Addressing Psychiatric Comorbidities and Upper-Extremity Trauma: Surgeons in a Multidisciplinary Care Model

Psychiatric disorders are a common cause of disability and represent an important risk factor for upper-extremity trauma. The review provides an overview of psychiatric illnesses as both contributors and sequelae of 4 major injury patterns: self-inflicted wrist lacerations, self-amputation, upper-extremity fractures, and burns. The authors develop a multidisciplinary model for upper-extremity surgeons to care for patients with psychiatric disorders, with an overview of capacity assessment, optimal psychiatric comanagement, and collaboration with allied health professionals.

Bias in alcohol and drug screening in adult burn patients

Alcohol and illicit drug use are common among burn-injured patients. Urine toxicology and alcohol screens are a part of our admission order sets and automatically ordered for all adult patients. Our objective was to determine the impact of bias in screening compliance and compare those results to patients who test positive. All adult patients admitted between January 1^st, 2014 and December 31^st, 2018 were eligible for inclusion. Multivariable logistic regression was used to identify potential predictors for compliance in obtaining samples for screens, and patient characteristics associated with testing positive. Four thousand nine hundred ninety-eight patients were included in the study. The biggest predictors for compliance in obtaining samples for screens were inhalation injury, intensive care unit stay, length of stay, burn size, and current smoking status. No differences in compliance with screens were seen across age, race, or ethnicity. Current smokers and patients with a history of major psychiatric illness were more likely to test positive for alcohol and illicit drugs. Non-Hispanic Black patients were more likely to test positive for illicit drugs. Male sex and pre-existing psychiatric conditions were significant predictors for compliance for alcohol screens, and, positive tests. Implicit bias based on age, race, or ethnicity played no predictive role in compliance for either screen, however, non-Hispanic Blacks were more likely to test positive for illicit drugs. More studies are needed to understand the effect of selection bias related to sample collection, and the significance of positive test results.