Physical and psychosocial outcomes among burn-injured people with heterotopic ossification: A burn model system study

INTRODUCTION

Heterotopic ossification (HO), or ectopic bone formation in soft tissue, is a not so rare and poorly understood debilitating sequela of burn injury. Individuals developing HO following burn injuries to their hands often experience reductions in mobility, significant contractures, and joint pain. This study identifies demographic characteristics of individuals who develop HO and compares their physical and psychosocial outcomes to the general burn population.

METHODS

Participant demographics, injury characteristics, and PROMIS-29 scores across three time points (discharge, six- and 12- months after injury) were extracted from the Burn Model System National Longitudinal Database representing participants from 2015-2022. Mixed-effects linear regression models were used to compare PROMIS scores across all three longitudinal measurements. Models were adjusted for age, sex, race/ethnicity, HO status, and burn size.

RESULTS

Of the 861 participants with data concerning HO, 33 were diagnosed with HO (3.8% of participants). Most participants with HO were male (n = 24, 73%) and had an average age of 40 + /- 13 years. Participants with HO had significantly larger burn size (49 +/-23% Total Body Surface Area (TBSA)) than those without HO (16 +/-17%). Participants with HO reported significantly worse physical function, depression, pain interference and social integration scores than those without HO. After adjusting for covariables, participants with HO continued to report statistically significantly worse physical function than those without HO. Although physical functioning was consistently lower, the two populations did not differ significantly among psychosocial outcome measures.

CONCLUSIONS

While HO can result in physical limitations, the translation to psychosocial impairments was not evident. Targeted treatment of HO with the goal of maximizing physical function should be a focus of their rehabilitation.

LEVEL OF EVIDENCE

2b TYPE OF STUDY: Symptom Prevalence Study.

Burn Nursing

Burn nurses care for patients throughout the recovery continuum.

Predictors at 6 and 12 Months for Social Participation Outcome at 24 Months in the Adult Burn Injury Population: A Burn Model System National Database Study

OBJECTIVE

To identify clinical factors (physical and psychological symptoms and post-traumatic growth) that predict social participation outcome at 24-month after burn injury.

DESIGN

A prospective cohort study based on Burn Model System National Database.

SETTING

Burn Model System centers.

PARTICIPANTS

181 adult participants less than 2 years after burn injury (N=181).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Demographic and injury variables were collected at discharge. Predictor variables were assessed at 6 and 12 months: Post-Traumatic Growth Inventory Short Form (PTGI-SF), Post-Traumatic Stress Disorder Checklist Civilian Version (PCL-C), Patient-Reported Outcomes Measurement Information System (PROMIS-29) Depression, Anxiety, Sleep Disturbance, Fatigue, and Pain Interference short forms, and self-reported Heat Intolerance. Social participation was measured at 24 months using the Life Impact Burn Recovery Evaluation (LIBRE) Social Interactions and Social Activities short forms.

RESULTS

Linear and multivariable regression models were used to examine predictor variables for social participation outcomes, controlling for demographic and injury variables. For LIBRE Social Interactions, significant predictors included the PCL-C total score at 6 months (β=-0.27, P<.001) and 12 months (β=-0.39, P<.001), and PROMIS-29 Pain Interference at 6 months (β=-0.20, P<.01). For LIBRE Social Activities, significant predictors consisted of the PROMIS-29 Depression at 6 months (β=-0.37, P<.001) and 12 months (β=-0.37, P<.001), PROMIS-29 Pain Interference at 6 months (β=-0.40, P<.001) and 12 months (β=-0.37, P<.001), and Heat Intolerance at 12 months (β=-4.55, P<.01).

CONCLUSIONS

Post-traumatic stress and pain predicted social interactions outcomes, while depression, pain and heat intolerance predicted social activities outcomes in people with burn injury.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Specialty Certification for Burn Nursing: Value, Beliefs, and Benefits

Specialty certification for burn nursing will be available in 2023. This review outlines the path taken from specialty recognition by the American Nurses Association to the Certified Burn Registered Nurse certification. Clinical expertise, knowledge, skill, mastery of professional issues, and competence are hallmark features of a nurse specialty certification. A review of resources will illustrate the evolution of burn nursing practice with the development of burn nursing standards, competencies, and characteristics of the professional burn nurse. Resources are identified which outline the value of specialty certification, providing an overview for the impact of burn nursing certification on professional development, nurse satisfaction, and patient outcomes. Burn nurses play a key role in the care and recovery of the burn-injured patient. Since 2017, members of the burn nurse community have taken steps to confirm the role of the modern burn nurse and document standards. As a community, we are now poised to advance our specialty one step further and support the development of a national burn nurse certification examination. This paper provides a historical account of the path taken for burn nurse specialty recognition and national certification to date. The value and impact of specialty certification in general is outlined, thus providing a comprehensive overview for the value and impact of certification on professional development, nurse satisfaction, and patient outcomes.

Trajectories of physical health-related quality of life among adults living with burn injuries: A burn model system national database investigation to improve early intervention and rehabilitation service delivery

INTRODUCTION

Understanding trajectories of recovery in key domains can be used to guide patients, families, and caregivers. The purpose of this study was to describe common trajectories of physical health over time and to examine predictors of these trajectories.

METHOD

Adults with burn injuries completed self-reported assessments of their health-related quality of life (HRQOL) as measured by the SF-12® Physical Component Summary (PCS) score at distinct time points (preinjury via recall, index hospital discharge, and at 6-, 12-, and 24 months after injury). Growth mixture modeling (GMM) was used to model PCS scores over time. Covariables included burn size, participant characteristics, and scores from the Community Integration Questionnaire (CIQ)/Social Integration portion, Satisfaction With Life Scale (SWLS), and Satisfaction With Appearance Scale (SWAP).

RESULTS

Data from 939 participants were used for complete-case analysis. Participants were 72% male, 64% non-Hispanic White, with an average age of 44 years and an average burn size of 20% of total body surface area (TBSA). The best fitting model suggested three distinct trajectories (Class 1 through 3) for HRQOL. We titled each Class according to the characteristics of their trajectory. Class 1 (recovering; n = 632), Class 2 (static; n = 77), and Class 3 (weakened; n = 205) reported near average HRQOL preinjury, then reported lower scores at discharge, with Class 1 subsequently improving to preinjury levels and Class 3 improving but not reaching their preinjury quality of life. Class 3 experienced the largest decrease in HRQOL. Class 2 reported the lowest preinjury HRQOL and remained low for the next 2 years, showing minimal change in their HRQOL.

CONCLUSIONS

These findings emphasize the importance of early universal screening and sustained intervention for those most at risk for low HRQOL following injury. For Class 2 (static), lower than average HRQOL before their injury is a warning. For Class 3 (weakened), if the scores at 6 months show a large decline, then the person is at risk for not regaining their HRQOL by 24 months and thus needs all available interventions to optimize their outcomes. Results of this study provide guidance for how to identify people with burn injury who would benefit from more intensive rehabilitation to help them achieve or regain better HRQOL. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Impacts of Financial Assistance on Quality of Life Among People Living With Burn Injury: Matched Cohort Analysis of the National Institute on Disability, Independent Living and Rehabilitation Research Burn Model System Database

Disparities in socioeconomic status and minority status affect the risk of burn injury and the severity of that injury, thus affecting the subsequent cost of care. We aimed to characterize the demographic details surrounding receipt of financial assistance due to burn injury and its relationship with health-related quality of life scores. Participants ≥18 from Burn Model System National Longitudinal Database (BMS) with complete demographic data were included (n = 4330). Nonresponders to financial assistance questions were analyzed separately. The remaining sample (n = 1255) was divided into participants who received financial assistance because of burn injury, those who received no financial assistance, and those who received financial assistance before injury and as a result of injury. A demographic and injury-characteristic comparison was conducted. Health-related quality of life metrics (Satisfaction with Life, Short Form-12/Veterans RAND 12-Item Health Survey, Community Integration Questionnaire Social Component, and the Post-Traumatic Growth Inventory) were analyzed preinjury, then 6-months, 1-year, and 2-years postinjury. A matched cohort analysis compared these scores. When compared to their no financial assistance counterparts, participants receiving financial assistance due to burns were more likely to be minorities (19% vs 14%), have more severe injuries (%TBSA burn 21% vs 10%), and receive workers' compensation (24% vs 9%). They also had lower health-related quality of life scores on all metrics except the post-traumatic growth inventory. Financial assistance may aid in combating disparities in posttraumatic growth scores for participants at the greatest risk of financial toxicity but does not improve other health-related quality of life metrics.

Defining numerical cut points for mild, moderate, and severe pain in adult burn survivors: A northwest regional burn model system investigation

INTRODUCTION

Pain is a common and often debilitating sequela of burn injury. Burn pain develops following damage to peripheral sensory nerves and the release of inflammatory mediators from injury. Burn pain is complex and can include background and procedural pain that result from the injury itself, wound care, stretching, and surgery. Clinicians and researchers need valid and reliable pain measures to guide screening, treatment, and research protocols. Unlike other conditions, visual analog, or numeric pain rating scale (VAS/NRS) scores that represent mild, moderate, and severe pain among people with burn injury have not been established. The aim of this study was to identify the most suitable average pain intensity rating scores for mild, moderate, and severe pain in adult burn survivors using a PROMIS Pain Interference (PROMIS-PI) short form.

METHODS

An average pain intensity VAS/NRS score (0-10) and customized PROMIS-PI short form were administered to adults with burn injury treated at a regional burn center at hospital discharge (baseline) and at 6, 12, and 24-months after injury. To identify pain intensity scores that represent mild, moderate, and severe pain, we computed F values and Bayesian Information Criterion (BIC) statistics associated with multiple ANOVA comparisons for mean pain interference scores by various pain intensity cut points. Six possible cut points (CP) were compared: CP 3,6; 3,7; 4,6; 4,7; 2,5; and 3,5. Optimal cut points were considered those with the highest ANOVA F statistics. Models with similar F statistics were also compared with BIC.

RESULTS

Data from a sample of 253 participants (83% white, 66% male, mean age 47 years) with VAS/NRS pain intensity and PROMIS-PI scores at one or more timepoints were analyzed. The optimal classification for mild, moderate, and severe pain was CP 2,5 at baseline and 12-months. Although CP 3,6 had the highest F value at 6-months, there was not strong evidence to support CP 3,6 over CP 2,5 (BIC difference: 2.9); similarly, CP 3,7 had the highest value at 24-months, but the BIC difference over CP 2,5 was only 2.2.

CONCLUSIONS

VAS/NRS scores for pain among adults with burn injury can be categorized as mild (0-2), moderate (3-5), and severe (6-10). These findings advance our understanding regarding the meaning of pain intensity ratings after burn injury, and provide an objective definition for clinical management, quality improvement, and pain research.

Posttraumatic Stress Disorder Symptom Clusters as Predictors of Pain Interference in Burn Survivors: A Burn Model System National Database Study

Individuals who experience burns are at higher risk of developing posttraumatic stress disorder and chronic pain. A synergistic relationship exists between posttraumatic stress disorder and chronic pain. We sought to evaluate the role of individual posttraumatic stress disorder symptom clusters as predictors of pain interference. We hypothesized that the hyperarousal and emotional numbing symptom clusters would be predictive of pain interference, even when accounting for the other two posttraumatic stress disorder symptom clusters, pain intensity, and other covariates. Multivariate linear regression analyses were completed using data from the Burn Model System National Database. A total of 439 adult participants had complete responses on self-report measures assessing posttraumatic stress disorder symptoms, pain intensity, and pain interference at 6-month after discharge and were included in analyses. Results indicate hyperarousal (B = .10, p = .03) and emotional numbing (B = .13, p = .01) posttraumatic stress disorder symptom clusters were each significantly associated with pain interference, even when accounting for pain intensity (B = .64, p < .001). Results highlight the importance of the emotional numbing and hyperarousal posttraumatic stress disorder symptom clusters in explaining pain interference. Findings suggest that when posttraumatic stress disorder symptoms or chronic pain are present, screening for and treating either condition may be warranted to reduce pain interference. Further, psychological interventions that target emotional numbing and hyperarousal posttraumatic stress disorder symptoms may be fruitful for promoting better coping with chronic pain and reducing pain interference.

64 Community Level Disadvantage Negatively Impacts Return to Work After Burn Injury

Introduction

The loss of income from injury, additional health care expenses, and inability to return work can lead to unsatisfactory outcomes. Community level disadvantage (e.g., low high school completion, low home ownership, low income) are more common among minority groups. We hypothesized community level disadvantage would negatively impact the ability to return to work after burn injury. This could serve to identify patients who need focused social, vocational, and financial support during rehabilitation.

Methods

Data from adult participants in a large multicenter database from 1998-2021 were linked by zip-code to three multi-domain community level-indices: i) Distressed Communities Index, ii) Social Vulnerabilities Index (SVI), iii) Social Deprivation Index (SDI). Cohort characteristics, the distribution of each index within cohort, and days to return to work were described. Fit and strength of association between the indices and return to work was assessed with multi-level logistic regression models. A non-responder analysis examining demographic and clinical differences between was performed using Chi-square tests and Wilcoxon rank sum tests to understand potential bias in the findings.

Results

A total of 1960 participants provided both zip code and employment data 6 months after injury. 75% of participants were male. Mean age was 39. Race/Ethnicity Data: 81.4% identified as White, 11% Black, and 7% as “other” race; 84% of the participants as non-Hispanic or Latino. Median burn size was 20% TBSA (IQR 0.1-95.0), and length of hospitalization was 30 days (IQR 0-379). Of the community indices tested, both DCI and SVI were associated with return to work with DCI having the strongest association with return to work after injury, irrespective of indices. However, when DCI and SVI were included in the model to represent community disadvantage, the impact of race on return to work was less. Participants who did not provide employment information were younger, sustained larger burn sizes, and had longer LOS compared to those who did.

Conclusions

DCI and SVI are associated with return to work after burn injury and can be used to focus limited social, vocational, and financial services. Minoritized participants were less likely to return to work but they live in communities with greater disadvantage (e.g. fewer employment opportunities), which highlights the public health impacts of structural racism.

122 PTSD Symptom Clusters as Predictors of Pain Interference in Burn Survivors

Introduction

Individuals who experience burns are at higher risk of developing post-traumatic stress disorder (PTSD) and chronic pain. There exists a synergistic relationship between PTSD and chronic pain in burn survivors. Theories exist about how aspects of each condition may perpetuate one another, or share underlying mechanisms. Both of these conditions are of relevance to pain-related disability. We sought to examine the role of individual PTSD symptom clusters as predictors of pain interference. We hypothesized that the hyperarousal and emotional numbing symptom clusters would be predictive of pain interference, even when accounting for the other two PTSD symptom clusters, pain intensity, and other covariates (burn size, hospital length of stay, age and gender).

Methods

Data were analyzed from the Burn Model System National Database. Inclusion criteria required participants to have a moderate to severe burn injury that required surgery for wound closure. Patient-reported outcome data: PTSD Checklist - Civilian, PROMIS-Pain Interference Short Form 4a, and a 0-10 average Pain Intensity item were analyzed at 6-months after injury. Hierarchical linear regression models were fit to examine the impact of PTSD symptom clusters on pain interference over and above that of pain intensity, and standardized betas were calculated (B).

Results

A total of 439 adult participants had complete responses on the measures of interest (e.g. PTSD symptoms, PROMIS-Pain Interference, and Pain Intensity) and were included in the analysis. Mean age, percent total body surface area burned, and hospital length of stay were 47 years, 18%, and 27 days, respectively. 69% were male and 82% were Caucasian. Results of a linear regression found that hyperarousal (B = .10, p = .03) and emotional numbing (B = .13, p = .01) PTSD symptom clusters were each significant predictors of pain-related disability, even when accounting for pain intensity (B = .64, p < .001). The covariates age, gender, days until discharge, and TBSA were all nonsignificant. The model accounted for 61% of the variance associated with pain-related disability.

Conclusions

Results highlight the importance of the emotional numbing and hyperarousal PTSD symptom clusters in explaining pain interference. Future evaluations parsing out the longitudinal relationships (i.e., beyond 6-months postburn) between PTSD symptom clusters, pain intensity, and pain interference, as well as evaluating other underlying mechanisms, are warranted.

73 Associations Between Pre-burn Occupation Type and Employment Outcomes at One Year

Introduction

Reintegration into the workforce after burn injury is an important issue for survivors. In a 2012 systematic review, 28% of burn survivors never returned to any form of employment. Although pre-burn employment status is strongly associated with post-burn employment, there are little data on the role of pre-injury occupation type on workplace reintegration. The aim of this project was to assess the impact of occupation type on employment outcomes after burn injury.

Methods

Data from the National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System National Longitudinal Database from 2015 to 2021 were used to investigate the association between occupation type and employment outcomes. Occupation type was classified into two groups, Labor and Non-labor, using the U.S. Bureau of Labor Statistics Standard Occupational Classification System. Demographic and clinical data were compared between groups. Mixed regression analyses examined associations between pre-burn occupation type and post-burn employment outcomes (employment at 1 year, days to return to work), controlling for age, gender, race, ethnicity, pre-injury employment, and burn size.

Results

Of the 600 patients who were employed pre-injury, 247 (41%) identified with a non-labor occupation and 353 (59%) with labor occupations. The Labor group was more male (82% vs. 61%) and Hispanic (23% vs. 6%), younger (mean age 42.1 vs. 48.3 years), less educated (high school or less, 25% vs. 11%) and more likely to have been injured at work (28% vs. 14%) compared to the Non-labor group (p< 0.001 for all comparisons). Changes in occupation were seen from pre-injury to post-injury; 16% of working survivors changed from Non-labor to Labor and 13% from Labor to Non-labor occupation types. For those who did return to work after injury, the average time to return to work was greater for Labor compared to the Non-labor group (150 vs 100 days; p=0.003). Additionally, those in the pre-injury Labor group were less likely to be employed at 12 months compared to the Non-labor group (odds ratio = 0.41; p=0.009).

Conclusions

Pre-injury occupation type is associated with employment outcomes after injury. Therefore, occupation type can be used to inform vocational reintegration resources, such as vocational rehabilitation programs, to optimize survivor outcomes.

10 The Impact of Insurance Disparities on Long-term Burn Outcomes: A Burn Model System Investigation

Introduction

Access to healthcare and insurance coverage are associated with quality of life, morbidity, and mortality outcomes. However, most studies have only focused on same-admission and short-term outcomes due to the lack of national longitudinal data and there is limited data on this topic in the burn literature. Our aim was to determine the effect of insurance status on long-term outcomes in a national sample of burn patients.

Methods

This is a retrospective study using the longitudinal Burn Model System National Database from January 2015 to April 2021. The inclusion criteria were all adult patients admitted for burn injury from participating sites. Main outcomes were the physical (PCS) and mental (MCS) health component summary scores of the Veterans RAND 12 (VR-12) score at 6, 12, and 24 months after injury. Multivariable regression was used to examine the association between insurance status and the outcomes, adjusting for demographics (i.e., age, gender, race/ethnicity) and burn injury severity.

Results

A total of 3,698 burn patients were included. Mean age was 43.39 (SD 15.84) years, 72% were male and 76% were white. Most patients had private/commercial insurance (56.37%), followed by Medicare (14.42%) and Medicaid (13.18%). The remaining 16% were uninsured patients (self-pay or philanthropy). Mean PCS scores were 43.64 (SD 10.87), 45.31 (SD 11.04) and 46.45 (SD 10.65) and Mean MCS scores were 47.80 (SD 12.35), 48.18 (SD 12.30) and 48.44 (SD 12.18) at 6, 12 and 24 months, respectively. In adjusted analyses, Medicaid insurance was associated with worse MCS at 6 months (Coefficient -3.90, p=0.001), and worse PCS at 12 and 24 months (Coefficient -3.09, p=0.004 and Coefficient -4.18, p< 0.001, respectively), compared to uninsured status. Medicare insurance was associated with worse PCS scores at 24 months (Coefficient -3.07, p=0.013).

Conclusions

Having Medicaid and Medicare insurance was significantly associated with a lower health-related quality of life at long-term follow up, even after adjusting for demographics and burn injury severity. Further studies need to focus on analyzing the reasons for these disparities and developing strategies to improve the quality of life of this subpopulation.

114 Long Term Impact of Hospital Acquired Multi-drug Resistant Organisms on Health-related Quality of Life

Introduction

MDROs colonize wounds and cause infections for hospitalized burn patients, which may lead to increased infection risk, wound complications, longer (LOS) and more cost. Little is known about the long-term impacts of MDRO colonization and infection on burn survivors. We aimed to describe the impacts of colonization on long-term health-related quality of life (HRQoL), itch, and pain.

Methods

Data from adult participants in a multicenter longitudinal outcome study were used. Data was described and χ ² and Kruskal-Wallis testing was applied to determine differences between the two groups. Outcomes included Veterans RAND 12 (VR-12) physical component summary score (PCS), and PROMIS 29 domains for pain intensity, fatigue, pain interference, physical function, and sleep disturbance. Pruritus was assessed using the 4-D Itch scale for total itch. Multilevel, multiple linear regressions were used for outcome measures at 6 m post-injury. Random effects regression with robust standard errors (SE) were used to evaluate the impacts over time.

Results

The study included 704 individuals and 92 were MDRO colonized (13%). Colonized patients had larger burns (25% TBSA, IQR 9-45 vs. 8% TBSA, IQR 3–20; p < .001), more operations (4, IQR 2-7 vs. 1, IQR 1-3; p < .001), more grafting (17% TBSA, IQR 3-46 vs. 3% TBSA, IQR 1- 9; p < .001), more ventilator days (2, IQR 0–8 vs. 0 IQR 0-0; p < .001), and longer LOS (34 days, IQR 17 – 64 vs. 16, IQR 9 - 27; p < .001). Adjusting for confounding covariables, such as demographics, colonization was associated with a lower PCS score (OR -0.33, 95% CI -0.68, -0.06; p=.018); a higher fatigue score (OR 0.46, 95% CI 0.13, 0.79; p = .007) and worse itch (OR 0.4, 95% CI -0.01, 0.75; p = .036). There was no association with pain intensity, pain interference, or sleep disturbance. Random effects regression indicated that colonization was associated with lower PCS (OR -5.0, 95% CI -8.60, -1.39; p = .007).

Conclusions

Impact of colonization extends beyond the immediate hospitalization and likely has long-term effects on HRQoL. Given our observation of lower physical function after MDRO, more granular research on taxa-specific effects, timing of colonization, and interventions are indicated to elucidate the impact on HRQoL.

78 Classification and Regression Tree Model for Predicting Satisfaction with Life Scale Scores After Burn Injury

Introduction

Current early burn care prognostication models predict in-hospital mortality (e.g., revised Baux Score). However, patients, families and clinicians need more holistic tools in the hours and days after injury to identify specific factors that might affect their quality of life and indicate a need for more intensive services. This project aims to predict Satisfaction with Life (SWL) in survivors of burn injury using patient, injury, and care factors available within 24 hours of admission.

Methods

Two hundred and fourteen participants were identified from a multicenter national longitudinal database and merged with clinical data from a single institution's trauma registry. Patients were randomized into a training dataset (80%) and a testing dataset (20%). A CART algorithm was used to examine the relative contributions of individual predictor variables in classifying low SWL at six-month follow up (SWL ≤ 20). Seventeen covariables obtained within 24 hours of index hospital admission were analyzed from five domains: demographics, comorbidities, injury, care, and host response to injury. Lab values were those closest to but not greater than 24 hours after index hospital admission.

Results

Multiple covariables contributed to the SWL score. CART analysis selected a pre-injury SWL score < 31 as the first node and strongest indicator of low SWL. CART then selected the following subgroups at risk for SWL ≤ 20 at 6 months: (1) hematocrit >55%; (2) lactate >4 mmol/L, age > 59; (3) total body surface area (TBSA) burned >30%, presence of a hand, neck, and/or face burn. The cross-validated predictive accuracy of the CART model was 69.4% with a cross-validated relative error of 0.379. In the validation data set, sensitivity and specificity were 62.5% and 72.0%, respectively.

Conclusions

The findings demonstrate the potential feasibility of creating a model that can predict a clinically meaningful quality of life outcome using covariables gathered within hours of hospital admission after burn injury. Predictive measures suggest that while some of the included covariables may be associated with SWL, they are not consistently and reliably predictive of low SWL alone. With more data and additional refined inputs, a similar model could be used to identify those in need of more intensive services earlier on in the hospitalization.

The Impact of Burn Survivor Preinjury Income and Payer Status on Health-Related Quality of Life

The costs required to provide acute care for patients with serious burn injuries are significant. In the United States, these costs are often shared by patients. However, the impacts of preinjury finances on health-related quality of life (HRQL) have been poorly characterized. We hypothesized that lower income and public payers would be associated with poorer HRQL. Burn survivors with complete data for preinjury personal income and payer status were extracted from the longitudinal Burn Model System National Database. HRQL outcomes were measured with VR-12 scores at 6, 12, and 24 months postinjury. VR-12 scores were evaluated using generalized linear models, adjusting for potential confounders (eg, age, sex, self-identified race, burn injury severity). About 453 participants had complete data for income and payer status. More than one third of BMS participants earned less than $25,000/year (36%), 24% earned $25,000 to 49,000/year, 23% earned $50,000 to 99,000/year, 11% earned $100,000 to 149,000/year, 3% earned $150,000 to 199,000/year, and 4% earned more than $200,000/year. VR-12 mental component summary (MCS) and physical component summary (PCS) scores were highest for those who earned $150,000 to 199,000/year (55.8 and 55.8) and lowest for those who earned less than $25,000/year (49.0 and 46.4). After adjusting for demographics, payer, and burn severity, 12-month MCS and PCS and 24-month PCS scores were negatively associated with Medicare payer (P < .05). Low income was not significantly associated with lower VR-12 scores. There was a peaking relationship between HRQL and middle-class income, but this trend was not significant after adjusting for covariates. Public payers, particularly Medicare, were independently associated with poorer HRQL. The findings might be used to identify those at risk of financial toxicity for targeting assistance during rehabilitation.

77 Impacts of Financial Assistance on Quality of Life Among People Living with Burn Injury

Introduction

Financial toxicity negatively impacts recovery after injury. Financial assistance (FA; e.g., disability income, food stamps, low-income housing voucher) may mitigate the impacts of financial toxicity. We aimed to describe FA after burn injury and its association with health-related quality of life (HRQL) and return to work.

Methods

Data from adult participants participating in a multicenter longitudinal database from 2015 to 2021 were used for complete-case analysis. Participants were separated into two groups: those who received any form of financial assistance due to their burn injury, and those who did not. The cohort and FA were described. Multi-level, mixed-effects, linear regression was performed to assess the associations of FA with VR-12 Physical and Mental Health Component Summary scores (PCS, MCS) and return to work. Lastly, a propensity score analysis matched 3:1 on age, gender, pre-injury PCS and MCS, burn size, length of hospital stay, and the number of operations as a result of burn injury was used to maximally reduce potential confounding.

Results

The analysis included 1,237 participants [725 who received FA, 512 who did not receive FA (NFA)]. Participants who received FA due to their burn injury were more likely to be younger (median 42 FA vs 48 NFA, p-value < 0.001), racially minoritized (19.2% FA vs 14.3% NFA, p-value < 0.001), have larger injuries (21% FA vs. 10% TBSA NFA, p-value < 0.001), longer hospital stays (median 29.5 days FA vs. 17 days NFA, p-value < 0.001), more days before returning to work (median 220 days FA vs 79 days NFA, p-value < 0.001), and have a workers compensation insurance payer (23.6% FA vs. 9.38% NFA, p-value < 0.001) compared to peers who did not receive FA. The number of participants who received new FA decreased after the 6-month time point: 11% at discharge, 33% at 6 months, and 15% at 12 months. Propensity score analysis demonstrated that receiving FA was associated with lower PCS and MCS scores at all time points and longer time to return to work (Table 1).

Conclusions

Given that financial toxicity is associated with unsatisfactory recovery after injury, efforts to reduce financial stressors are needed. FA seems somewhat matched to patients with greater recovery challenges (e.g., larger injuries, more complex hospitalizations). Additionally, most patients do not receive FA for a prolonged period (e.g., >6 months). While FA is associated with lower HRQL and longer return to work, these data may represent improvement compared to what people living with burn injury might have experienced without FA and represent unmeasured confounding.

The relation between satisfaction with appearance and race and ethnicity: A National Institute on Disability, Independent Living, and Rehabilitation Research burn model system study

Research supports that people of color in the U.S. have poorer outcomes after burn injury compared to White individuals. The current study sought to explore burn health disparities by testing the relationship between racial and ethnic minority status, a proxy for systemic discrimination due to race and ethnicity, with two key constructs linked to functional outcomes, satisfaction with appearance and social community integration. Participants included 1318 burn survivors from the Burn Model System National Database (mean age = 40.2, SD = 12.7). Participants completed measures of satisfaction with appearance and social community integration at baseline, 6-, 12-, and 24-months after burn injury. Linear regressions revealed that racial and ethnic minority status significantly related to lower satisfaction with appearance and social community integration compared to White individuals at all time points. In addition, satisfaction with appearance continued to significantly relate to greater social community integration even while accounting for race and ethnicity, age, sex, burn size, and physical disability at 6-, 12-, and 24-month time points. Overall, the study supports that racial and ethnic minority burn survivors report greater dissatisfaction with their appearance and lower social community reintegration after burn injury.

Evaluation of the psychometric properties of the burn specific health scale-brief: A National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System Study

OBJECTIVE

The Burn Specific Health Scale-Brief (BSHS-B) is a commonly used burn specific health outcome measure that includes 40 items across nine subscales. The objective of this study was to use both classical and modern psychometric methods to evaluate psychometric properties of the BSHS-B.

METHODS

Data were collected post burn injury by a multisite federally funded project tracking long term outcomes. We examined dimensionality, local dependence, item fit, and functioning of response categories, homogeneity, and floor and ceiling effects. Items were fit to Item Response Theory models for evaluation.

RESULTS

A total of 653 adults with burn injury completed the BSHS-B. Factor analyses supported unidimensionality for all subscales, but not for a total score based on all 40 items. All nine of the subscales had significant ceiling effects. Six item pairs displayed local dependence suggesting redundance and 11 items did not fit the Item Response Theory models. At least 15 items have too many response options.

CONCLUSIONS

Results identified numerous psychometric issues with the BSHS-B. A single summary score should never be used for any purpose. Psychometric properties of the scale need to be improved by removing redundant items, reducing response categories and modifying or deleting problematic items. Additional conceptual work is needed to, at a minimum, revise the work subscale and optimally to revisit and clearly define the constructs measured by all the subscales. Additional items are needed to address ceiling effects.

Exploring 'Return to Productivity' Among People Living with Burn Injury: a Burn Model System National Database Report

INTRODUCTION

Burn survivors experience barriers to returning to work. For those who do return to work, little is known regarding whether they achieve pre-injury productivity (i.e., equivalent or gain in income compared to pre-injury income). Identifying patients at risk of not achieving pre-injury productivity is important for targeting services that support this population.

METHODS

We extracted occupational and income data through 24 months post-injury from the multi-center, longitudinal Burn Model System National Database. Annual income was reported in six groups: <$25k, $25k-50k, $50k-99k, $100k-149k, $150k-199k, $>199k. Participants were classified by change in income at each follow up (i.e., gain, loss, equivalent). Explanatory variables included demographics, injury characteristics, insurance payer, employment status, and job type. Multi-level, multi-variable logistic regression was used to model return to productivity.

RESULTS

453 participants provided complete income data at discharge and follow up. Of the 302 participants employed pre-injury, 180 (60%) returned to work within 24 months post-injury. Less than half (138) returned to productivity (46% of participants employed pre-injury; 77% of those who returned to work). Characteristics associated with return to productivity included older age (median 46.9 vs 45.9 years, OR 1.03, p=0.006), Hispanic ethnicity (24% vs 11%, OR 1.80, p=0.041), burn size >20% TBSA (33.7% vs 33.0%, OR 2.09, p=0.045), and post-injury employment (54% vs 26%, OR 3.41, p<0.001).

CONCLUSION

More than half of employed people living with burn injury experienced loss in productivity within 24 months post-injury. Even if they return to work, people living with burn injuries face challenges returning to productivity and may benefit from vocational rehabilitation and/or financial assistance.

Temperature sensitivity after burn injury: A Burn Model System National Database Hot Topic

BACKGROUND

People living with burn injury often report temperature sensitivity. However, its epidemiology and associations with health-related quality of life (HRQOL) are unknown. We aimed to characterize temperature sensitivity and determine its impact on HRQOL to inform patient education after recovery from burn injury.

METHODS

We used the multicenter, longitudinal Burn Model System National Database to assess temperature sensitivity at 6, 12 and 24 months after burn injury. Chi-square and Kruskal-Wallis tests determined differences in patient and injury characteristics. Multivariable, multi-level generalized linear regression models determined the association of temperature sensitivity with Satisfaction with Life Scale (SWL) scores and Veterans RAND 12 (VR-12) physical (PCS) and mental health summary (MCS) component scores.

RESULTS

The cohort comprised 637 participants. Two thirds (66%) experienced temperature sensitivity. They had larger burns (12% TBSA, IQR 4-30 vs 5% TBSA, IQR 2-15; p<0.0001), required more grafting (5% TBSA, IQR 1-19 vs 2% TBSA, IQR 0-6; p<0.0001), and had higher intensity of pruritus at discharge (11% severe vs 5% severe; p=0.002). After adjusting for confounding variables, temperature sensitivity was strongly associated with lower SWL (OR -3.2, 95% CI -5.2, -1.1) and MCS (OR -4.0, 95% CI -6.9, -1.2) at 6-months. Temperature sensitivity decreased over time (43% at discharge, 4% at 24-months) and was not associated with poorer HRQOL at 12 and 24 months.

CONCLUSION

Temperature sensitivity is common after burn injury and associated with worse SWL and MCS during the first year after injury. However, temperature sensitivity seems to improve and be less intrusive over time.

"Living Well" After Burn Injury: Using Case Reports to Illustrate Significant Contributions From the Burn Model System Research Program

The Burn Model System (BMS) program of research has been funded since 1993 by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). The overarching aim of this program is to improve outcomes and quality of life for people with burns in the areas of health and function, employment, and community living and participation. This review reports on BMS contributions that have affected the lives of individuals with a significant burn injury using case reports to associate BMS contributions with recovery. In January 2020, current BMS grantee researchers assessed peer-reviewed BMS publications from 1994 to 2020. Using case report methodology, contributions were linked to three individuals treated at one of the four Burn Model System institutions. With over 25 years of NIDILRR funding, unique BMS contributions to patient recovery were identified and categorized into one of several domains: treatment, assessment measures, sequelae, peer support, employment, and long-term functional outcomes. A second review for significant results of BMS research that add to the understanding of burn injury, pathophysiology, and recovery research was identified and categorized as injury recovery research. The case study participants featured in this review identified select NIDILRR research contributions as having direct, personal benefit to their recovery. The knowledge generation and clinical innovation that this research program has contributed to our collective understanding of recovery after burn injury is considerable. Using case study methodology with three adult burn survivors, we highlight the impact and individual significance of program findings and reinforce the recognition that the value of any clinical research must have relevance to the lives of the study population.

Burn model system national longitudinal database representativeness by race, ethnicity, gender, and age

INTRODUCTION

Representativeness of research populations impacts the ability to extrapolate findings. The Burn Model System (BMS) National Database is one of the largest prospective, longitudinal, multi-center research repositories collecting patient-reported outcomes after burn injury.

OBJECTIVE

To assess if the BMS Database is representative of the population that is eligible to participate.

DESIGN

Data on adult burn survivors who were eligible for the BMS Database from 2015 to 2019 were analyzed.

SETTING

Not applicable.

PARTICIPANTS

Burn survivors treated at BMS centers meeting eligibility criteria for the BMS Database. Eligibility for the database is based on burn size and receipt of autografting surgery.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Race, ethnicity, gender, and age were compared between individuals who did and did not enroll. Regression analysis examined the correlation between demographic characteristics and study enrollment. Additional regression analysis examined the association between enrollment and the intersection of race, ethnicity, and gender.

RESULTS

A total of 982 adult burn survivors were eligible for the BMS database during the study period. Of those who were eligible, 72.1% Enrolled and 27.9% were Not Enrolled. The Enrolled group included more female and more younger survivors compared to the Not Enrolled group. In regression analyses, Black/African American burn survivors were less likely and individuals identifying as female were more likely to enroll in the BMS Database. Furthermore, White men and women were more likely to enroll compared to Black/African American men and women, and non-Hispanic/Latino men were more likely to enroll compared to Hispanic/Latino men.

CONCLUSIONS

This study found differences in BMS Database enrollment by race, ethnicity, and gender. Further research is warranted to investigate causes for the disparities found in this study. In addition, strategies are needed to improve enrollment to ensure future representativeness.

T5 The Impact of Burn Survivor Pre-injury Income and Payer on Health-Related Quality of Life Outcomes

Introduction

The critical care, surgery, and rehabilitation required to recover patients with serious burn injuries are associated with high financial costs. In the US, these costs are often borne by patients. However, the relationship between pre-injury finances (personal income and payer) and health-related quality of life (HRQL) of burn survivors has not been reported. We hypothesized that lower income and public payers would be independent predictors of poorer HRQL.

Methods

Burn survivors with complete data for pre-injury personal income and payer were extracted from the NIDILRR Burn Model System National Database. HRQL outcomes included VA-Rand 12 (VR-12) scores at 6-, 12-, and 24-months post-injury. VR-12 scores were evaluated using generalized linear models and adjusted for potential confounders (age, gender, self-identified race, measures of burn injury severity). Model performance was assessed with Akaike Information Coefficient.

Results

453 burn survivors had complete data for income and payer status. 36.4% earned less than $25k/year, 24% earned $25k-49k/year, 23% earned $50k-99k/year, 10% earned $100k-149k/year, 3% earned $150k-199k/year, and 3% earned ≥$200k/year. Mental component summary (MCS) and physical component summary (PCS) scores were highest for those who earned $150-199k/year (55.8, 55.8), and lowest for those who earned &lt; $25k/year (49.0, 46.4). There was a negative relationship between income &lt; $25k/year and MCS scores at 6-, 12-, and 24-months post-injury (p&lt; 0.05). This relationship was not observed with PCS scores. After adjusting for demographics, payer, and burn severity, 24-month PCS scores were negatively associated with Medicare payer (p=0.025), black race (p=0.008) and number of operations during index admission (p=0.026). There were no significant associations with MCS scores.

Conclusions

HRQL was highest for burn survivors earning between $150-199k/year. Participants who earned &lt; $25k/year had the lowest VR-12 scores and particularly MCS scores. On multivariable analysis, most of the differences in HRQL associated with pre-injury income were explained by differences in demographic, payer and burn severity factors.

Burn patients' pain experiences and perceptions

INTRODUCTION

Burns are painful injuries associated with a long recovery. Patients may not be receiving sufficient pain management education to optimize their experience and recovery after burn injury. Therefore, we aimed to obtain patients' perspectives about the effectiveness of current burn pain education to inform future efforts.

METHODS

We used a mixed-methods research design that included both inpatients and outpatients cared for at a single, American Burn Association-verified burn center. Participants were at least 14 years of age with an acute burn who received a minimum of two wound interventions. The interview was designed by clinician stakeholders using a modified Delphi technique and focused on patient respondent's pain experience, understanding and desire to gain knowledge concerning burn pain and its management. Descriptive quantitative analysis was performed on categorical data. Recorded interview segments were transcribed for content analysis.

RESULTS

Twenty-one adult burn patients were interviewed. Participants reported experiencing variable levels of pain and pain management effectiveness. Inpatients reported more severe pain than outpatients. Only 11% of inpatients reported having received enough pain information, compared to 50% of outpatients. Content analysis yielded 3 themes: patient's pain experience, range of expectations, and clinical information/services desired. Mental and physical effects were key factors in respondents' pain experiences, with many participants reporting mental anguish in addition to pain. Of participants who had pain expectations, most were matched by their experience (56%), although many individuals (44%) described higher pain levels than they anticipated. Positive experiences with the burn care team primarily revolved around receiving pain education from a provider, whereas negative experiences focused on wound care events. Participants desired more information on sleep and pain medications, alternative treatments, weaning and addiction risk, realistic expectations of recovery timelines, and available mental health services. Written (pamphlet) education ranked as the most desirable delivery method, followed by in-person and video education.

CONCLUSIONS

Burn patients reported variable pain experiences and a strong desire to receive additional pain education. This project informs key strategies to educate burn patients on pain: leverage the high-level of interest in pain to foster education, describe pharmacologic and alternative therapies, offer weaning plans and explanation of addiction risks.

APPLICABILITY TO PRACTICE

Burn patients' perspectives help inform strategies and content creation for pain-related education materials that burn centers can provide to improve patients' experiences.

EXTERNAL FUNDING

Project was supported in part by the NIH grant for Insight Student Research Program at the Harborview Injury Prevention and Research Center (R25 HD094336).

Impact of the affordable care act's medicaid expansion on burn outcomes and disposition

BACKGROUND

We aimed to analyze the impact of the Affordable Care Act's Medicaid Expansion on clinical outcomes and patient disposition after burn injury. We hypothesized that increased insurance coverage results in improved outcomes and higher rates of discharge to inpatient rehabilitation.

METHODS

We reviewed the University of Washington Regional Burn Center registry data for patients admitted from 2011 to 2018. Patients were grouped into two categories: before (2011-2013) and after (2015-2018) Medicaid expansion; we excluded 2014 data to serve as a washout period. Outcomes assessed included length of hospital stay, patient disposition, and mortality. Multivariable logistic and linear regression models with covariates for sex, age, burn size, ethnicity ethnicity, distance from burn center, etiology of burn, and presence of inhalation injury were used to determine the impact of Medicaid expansion on outcomes.

RESULTS

Rates of uninsured patients decreased while Medicaid coverage increased. Despite increased median burn size after Medicaid expansion, inpatient mortality rates did not change, but average acute care length of stay increased. More patients were discharged to rehabilitation centers.

CONCLUSIONS

Our study corroborates prior findings of increased insurance coverage since Medicaid expansion. Increased insurance coverage is associated with higher rates of discharge to inpatient rehabilitation programs after burn injury.

Nursing Understanding and Perceptions of Delirium: Assessing Current Knowledge, Attitudes, and Beliefs in a Burn ICU

The number of delirium days in hospitalized patients directly correlates with mortality and long-term cognitive dysfunction. Burn patients are at greater risk for delirium due to prolonged mechanical ventilation, high sedative and analgesic medication requirements, and the common need for multiple operations. Limited research exists on nurses' understanding and comfort using delirium screening tools and preventive interventions. A process improvement project was developed in a single, regional burn intensive care unit (BICU) with the goal of increasing RN staff awareness of delirium, delirium assessment, and preventive interventions. A 10-question survey was developed and administered to the BICU RN staff before and after the educational intervention. Both quantitative and qualitative data analyses were performed. Twenty-seven (38%) anonymous surveys were returned. In pre- and postintervention surveys, respondents agreed that nursing interventions were important in preventing delirium. Despite educational intervention, 26% of the respondents reported that a tool is not needed to identify delirium. Survey analysis indicated strong support for nonpharmacologic nursing interventions in preventing delirium as well as reducing pharmacologic interventions, especially benzodiazepines. Mechanical ventilation was perceived as a barrier to performing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in both pre- and postsurveys. Staff compliance with documenting CAM-ICU assessments increased and CAM-positive days decreased over the project timeline. Overall, BICU nurses' awareness and general knowledge about delirium increased and specific knowledge deficits were discovered. Continued education about the CAM-ICU tool is still needed; additionally addressing barriers within the structure of the unit to provide nurses more resources to properly assess and prevent delirium.

Burn survivors' perception of recovery after injury: A Northwest Regional Burn Model System investigation

INTRODUCTION

Previous reports suggest that many factors impact recovery from burn injury. To improve our understanding of these factors, we queried adult burn survivors using a mixed method design during the first year after injury.

METHODS

An anonymous, 2-page survey was developed and administered to adult burn survivors during routine outpatient clinic follow-up visits at a regional burn center. Participants rated issues of concern and their impacts on return to pre-burn activity levels. Both quantitative and qualitative data were obtained. Descriptive statistics were used to analyze quantitative data and thematic analysis was used to identify, analyze and report patterns from open-ended responses.

RESULTS

Over seven months in 2016, 187 patients completed the anonymous survey. Study participants were predominantly male, white, and non-Hispanic. Participants who had not yet returned to pre-burn function reported worse outcomes for all issues queried compared to those who had. Burn survivors from racial and ethnic minority groups reported greater difficulty with accessing medical care and information about their injury as well as higher levels of self-identified posttraumatic stress, issues related to appearance and concerns for loss of strength. Several themes and sub-themes were identified that had both negative and positive impact on early recovery. Such themes included: healing process, psychological recovery and emotional health, and community reintegration/employment.

CONCLUSIONS

Several themes from responses provided insight into challenges as well as key support systems during the first year of recovery after injury. Collectively, these findings can be used to direct clinical outpatient care, patient education and psychosocial support services.

Mortality prognostication scores do not predict long-term, health-related quality of life after burn: A burn model system national database study

OBJECTIVE

Despite improved mortality rates after burn injury, many patients face significant long-term physical and psychosocial disabilities. We aimed to determine whether commonly used mortality prognostication scores predict long-term, health-related quality of life after burn injury. By doing so, we might add evidence to support goals of care discussions and facilitate shared decision-making efforts in the hours and days after a life-changing injury.

METHODS

We used the multicenter National Institute of Disability, Independent Living and Rehabilitation Research Burn Model System database (1994-2019) to analyze SF-12 physical (PCS) and mental component (MCS) scores among survivors one year after major burn injury. Ninety percent of the observations were randomly assigned to a model development dataset. Multilevel, mixed-effects, linear regression models determined the relationship between revised Baux and Ryan Scores and SF-12 measures. Additionally, we tested a model with disaggregated independent and other covariates easily obtained around the time of index admission: age, sex, race, burn size, inhalation injury. Residuals from the remaining 10% of observations in the validation dataset were examined.

RESULTS

The analysis included 1606 respondents (median age 42 years, IQR 28-53 years; 70% male). Median burn size was 16% TBSA (IQR 6-30) and 13% of respondents sustained inhalation injury. Higher revised Baux and Ryan Scores and age, burn size, and inhalation injury were significantly correlated with lower PCS, but were not correlated with MCS. Female sex, black race, burn size, and inhalation injury correlated with lower MCS. All models poorly explained the variance in SF-12 scores (adjusted r² 0.01-0.12).

CONCLUSION

Higher revised Baux and Ryan Scores negatively correlated with long-term physical health, but not mental health, after burn injury. Regardless, the models poorly explained the variance in SF-12 scores one year after injury. More accurate models are needed to predict long-term, health-related quality of life and support shared decision-making during acute burn care.

Pain across traumatic injury groups: A National Institute on Disability, Independent Living, and Rehabilitation Research model systems study

BACKGROUND

Pain is a common problem after traumatic injury. We describe pain intensity and interference at baseline and 1 year postinjury in burn, traumatic brain injury (TBI), and spinal cord injury (SCI) survivors and compare them with the general population (GP). We tested a custom Patient Reported Outcomes Measurement Information System (PROMIS) pain interference short form developed for use in trauma populations.

METHODS

We administered a pain intensity numerical rating scale and custom PROMIS pain interference short forms at baseline and/or 1 year postinjury from participants (≥18 years) at three Model System projects (burn, TBI, and SCI). Scores were compared across injury groups and pain intensity levels, and to the GP. Reliability and floor and ceiling effects of the custom PROMIS pain measures were calculated.

RESULTS

Participants (burn, 161; TBI, 232; SCI, 134) responded to the pain intensity and/or pain interference measures at baseline (n = 432), 1 year (n = 288), or both (n = 193). At baseline, pain interference and intensity were both significantly higher in all three groups than in the GP (all p < 0.01). At 1 year, average pain intensity in SCI and burn (p < 0.01) participants was higher than the GP, but only SCI participants reported higher pain interference (p < 0.01) than the GP. Half of all participants reported clinically significant pain interference (55 or higher) at baseline and one third at 1 year. Reliability of the custom pain interference measure was excellent (>0.9) between T-scores of 48 and 79.

CONCLUSION

The custom pain interference short forms functioned well and demonstrated the utility of the custom PROMIS pain interference short forms in traumatic injury. Results indicate that, for many people with burn, TBI and SCI, pain remains an ongoing concern long after the acute injury phase is over. This suggests a need to continue to assess pain months or years after injury to provide better pain management for those with traumatic injuries.

LEVEL OF EVIDENCE

Epidemiologic/Therapeutic study, level IV.

Inhalation injury is associated with long-term employment outcomes in the burn population: Findings from a cross-sectional examination of the Burn Model System National Database

Introduction

Inhalation injuries carry significant acute care burden including prolonged ventilator days and length of stay. However, few studies have examined post-acute outcomes of inhalation injury survivors. This study compares the long-term outcomes of burn survivors with and without inhalation injury.

Methods

Data collected by the Burn Model System National Database from 1993 to 2019 were analyzed. Demographic and clinical characteristics for adult burn survivors with and without inhalation injury were examined. Outcomes included employment status, Short Form-12/Veterans Rand-12 Physical Composite Score (SF-12/VR-12 PCS), Short Form-12/Veterans Rand-12 Mental Composite Score (SF-12/VR-12 MCS), and Satisfaction With Life Scale (SWLS) at 24 months post-injury. Regression models were used to assess the impacts of sociodemographic and clinical covariates on long-term outcome measures. All models controlled for demographic and clinical characteristics.

Results

Data from 1,871 individuals were analyzed (208 with inhalation injury; 1,663 without inhalation injury). The inhalation injury population had a median age of 40.1 years, 68.8% were male, and 69% were White, non-Hispanic. Individuals that sustained an inhalation injury had larger burn size, more operations, and longer lengths of hospital stay (p<0.001). Individuals with inhalation injury were less likely to be employed at 24 months post-injury compared to survivors without inhalation injury (OR = 0.63, p = 0.028). There were no significant differences in PCS, MCS, or SWLS scores between groups in adjusted regression analyses.

Conclusions

Burn survivors with inhalation injury were significantly less likely to be employed at 24 months post-injury compared to survivors without inhalation injury. However, other health-related quality of life outcomes were similar between groups. This study suggests distinct long-term outcomes in adult burn survivors with inhalation injury which may inform future resource allocation and treatment paradigms.

The Impact of Comorbid Conditions on Long-Term Patient-Reported Outcomes From Burn Survivors

Preburn comorbidities increase the risk of death in the acute phase, and negatively impact quality of life among survivors. Investigations to date have only evaluated comorbidities as indices, limiting the ability to target conditions and develop strategies for risk reduction. Therefore, we aimed to evaluate the differential effects of specific conditions on long-term, patient-reported outcomes after burn injury. A prospectively maintained trauma registry was merged with a longitudinal database of patient-reported outcomes from a regional burn center from 2007 to 2018. Demographic data, injury-specific information, and the prevalence of 20 comorbidities were systematically documented. The impact of comorbidities on responses to Short Form-12/Veterans RAND 12 (SF/VR-12) health surveys at 6, 12, and 24 months postinjury was evaluated with generalized linear models. The merged dataset included 493 adult participants. Median age was 46 years (interquartile range, IQR 32-57 years), and 72% were male. Median burn size was 14% TBSA (IQR 5-28%). Seventy percent of participants had ≥1 comorbidity (median 1 comorbidity/participant; IQR 0-2 comorbidities). SF/VR-12 mental component summary scores at 6 and 12 months postinjury were negatively associated with mental illness (P < .001, P = .013). SF/VR-12 physical component summary (PCS) scores were negatively associated with smoking (P = .019), diabetes (P = .001), and alcohol use disorder (P = .001) at 6-month follow-up. Twelve-month SF/VR-12 PCS scores were negatively associated with prior trauma admission (P = .001) and diabetes (P = .042). Twenty-four-month SF/VR-12 PCS scores were negatively associated with mental illness (P = .003). Smoking, alcohol use disorder, and diabetes were associated with lower PCS scores 6 months after injury; diabetes persisted as a negatively associated covariate at 12 months. Mental component summary scores were negatively associated with mental illness 6 and 12 months postinjury. Integrated models of postdischarge comorbidity management need to be tested in burn patients.

25 Social Integration in the First 2 Years After Moderate to Severe Burn Injury: A Burn Model System National Database Study

Introduction

Feeling a part of community and participating in social life are important aspects of overall quality of life. Burn survivors consider community reintegration one of the most important issues affecting their recovery. Integration, including social integration, has been studied in this population, but longitudinal analyses to examine factors associated with successful integration are lacking. The current study aims to assess variables associated with social integration during the first two years post-burn.

Methods

Adult (18+ years) burn survivors enrolled in the Burn Model System national longitudinal database responded to questionnaires at hospital discharge and 6-, 12-, and 24-months postburn. Social integration was assessed at all follow-up timepoints using the Community Integration Questionnaire Social Integration Component Scale, which has a possible range of scores from 0 (no community integration) to 12 (excellent community integration). To examine variables associated with social integration over time, linear mixed effect models utilizing generalized least squares with maximum likelihood and robust standard errors were used. Independent variables in the model included age, sex, % total body surface area (TBSA) burned, race/ethnicity, living status at time of injury, facial burn, history of psychiatric treatment preburn, employment at follow-up assessment, and SF-12 or VR-12 mental health component scores at the time of each follow-up assessment.

Results

Data from 1,848 adult burn survivors were included in the analyses. Average age of the survivors was 42.9 years, 74.0% were male, 77.7% were white, 47.0% were married or living common-law with a partner, and mean total body surface area burned was 18.2%. Factors associated with better social integration over time included younger age, female sex, lower TBSA (&lt; 40%) burn size, white/non-Hispanic race, no preburn psychiatric treatment, postburn employment, and better mental health. Time was not a significant predictor, indicating that social integration scores remain relatively stable over the 24-month follow-up period.

Conclusions

We identified several factors that contribute to greater social integration including age, gender, burn size, race/ethnicity, employment, and mental health, with the association between age, gender, and employment status and community integration a novel finding in this population.

Applicability of Research to Practice

This study suggests that while most factors associated with social integration are not modifiable, interventions aimed at improving mental health and helping burn survivors return to work could also improve self-reported social integration.

Burn Nurse Competencies: Developing Consensus Using E-Delphi Methodology

Competency standards for nurses who specialize in the care of burn-injured patients are lacking. Currently, there are no nationally agreed on standards that define safe and competent burn nursing practice. In 2014, nurse members of the American Burn Association proposed the Burn Nurse Competency Initiative (BNCI) with the intent of establishing a core set of competency standards for burn nursing. The BNCI used the Delphi technique of consensus building with input from up to 178 registered nurse burn care experts. This article describes the multistaged consensus-building process used and provides a final list of competencies. These newly created competencies now define professional practice standards for burn nurses. Their creation completes one of the essential steps required for burn nursing to be recognized as a specialty.

The impact of discharge contracture on return to work after burn injury: A Burn Model System investigation

INTRODUCTION

Despite many advances in burn care, the development of extremity contracture remains a common and vexing problem. Extremity contractures have been documented in up to one third of severely burned patients at discharge. However, little is known about the long-term impact of these contractures. The purpose of this study was to examine the association of extremity contractures with employment after burn injury.

METHODS

We obtained data from the Burn Model System database from 1994 to 2003. We included in the study cohort all adult patients who were working prior to injury and identified those discharged with and without a contracture in one of the major extremity joints (shoulder, elbow, wrist, hip, knee and ankle). We classified contracture severity according to mild, moderate and severe categories. We performed descriptive analyses and predictive modeling to identify injury and patient factors associated with return to work (RTW) at 6, 12, and 24 months.

RESULTS

A total of 1,203 participant records met criteria for study inclusion. Of these, 415 (35%) had developed a contracture at discharge; 9% mild, 12% moderate, and 14% severe. Among 801 (67%) participants who had complete data at 6 months after discharge, 70% of patients without contracture had returned to work compared to 45% of patients with contractures (p < 0.001). RTW increased at each subsequent follow-up time point for the contracture group, however, it remained significantly lower than in no-contracture group (both p < 0.01). In multivariable analyses, female sex, non-Caucasian ethnicity, larger burn size, alcohol abuse, number of in-hospital operations, amputation, and in-hospital complications were associated with a lower likelihood of employment. In adjusted analyses, discharge contracture was associated with a lower probability of RTW at all 3 time points, although its impact significantly diminished at 24 months.

CONCLUSIONS

This study indicates an association between discharge contracture and reduced employment 6, 12 and 24 months after burn injury. Among many other identified patient, injury, and hospitalization related factors that are barriers to RTW, the presence of a contracture at discharge adds a significant reintegration burden for working-age burn patients.

Factors Associated with Attrition of Adult Participants in a Longitudinal Database: A National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System Study

Participant attrition in longitudinal studies can lead to substantial bias in study results, especially when attrition is nonrandom. A previous study of the Burn Model System (BMS) database prior to 2002 identified participant and study-related factors related to attrition. The purpose of the current study was to examine changes in attrition rates in the BMS longitudinal database since 2002 and to revisit factors associated with attrition. Individuals 18 years and older enrolled in the BMS database between 2002 and 2018 were included in this study. Stepwise logistic regression models identified factors significantly associated with attrition at 6, 12, and 24 months postburn injury. The percentage of individuals lost to follow-up was 26% at 6 months, 33% at 12 months, and 42% at 24 months. Factors associated with increased risk of loss to follow-up across two or more time points include male sex, lower TBSA burn size, being unemployed at the time of burn, shorter duration of acute hospital stay, younger age, not having private health insurance or workers' compensation, and a history of drug abuse. Retention levels in the BMS have improved by at least 10% at all time points since 2002. The BMS and other longitudinal burn research projects can use these results to identify individuals at high risk for attrition who may require additional retention efforts. Results also indicate potential sources of bias in research projects utilizing the BMS database.

Burn Nurse Competency Utilization: Report From the 2019 Annual American Burn Association Meeting

Competence in healthcare is a recognized expectation by consumers. In 2018 following an extensive review and consensus-building process, burn nursing practice competencies were published. Clinical nurse leaders were called upon to use these published competencies in practice as a basis for the requisite knowledge and skills needed in the care of the burn-injured individual. In 2019 at the 51st Annual Meeting of the American Burn Association, nurses from four U.S. burn centers reported on their center's incorporation of the competencies within their educational nursing curriculums. This paper provides a forum for each of the lead authors from Rhode Island Hospital Burn Center, the University of Utah Health Burn Trauma Intensive Care Unit, Parkland Regional Burn Center, and the University of Chicago Medicine Burn Center to outline their current utilization of the new burn nurse competencies and plans for future use.

Exploring the Burn Model System National Database: Burn injuries, substance misuse, and the CAGE questionnaire

Burn survivors who misuse alcohol and/other substances have been associated with poorer long-term outcomes and clinical complications following injury. The self-reported CAGE questionnaire (Cut down, Annoyed, Guilty, and Eye-opener) is an outcomes assessment tool used to screen for potential substance misuse. Understanding the persistence and emergence of potential substance misuse through examination of CAGE scores may provide important information about this population. Using data collected from the Burn Model System National Database, demographic and clinical characteristics of individuals who reported positive CAGE scores (total score of ≥2) and those who reported negative CAGE scores (total score of 0 or 1) for either alcohol or other drugs were compared.

Early patient deaths after transfer to a regional burn center

INTRODUCTION

Patients who sustain burn injuries are frequently transferred to regional burn centers. Severely injured patients, unlikely to survive, may be transported far from home and family to die shortly after arrival. An examination of early deaths, those that happen within a week of transfer, may offer an opportunity to revise the way we think about critical burns and consider the best way to provide regional care.

METHODS

This is a focused review of burn patients who survived ≤1 week after transfer to a regional center from 2013-2017. Originating location data such as city, state, population at origin were obtained. Transfer data, including mode of transport and distance traveled, as well as patient characteristics, Total Body Surface Area (TBSA) burned, inhalation injury, medical history with calculation of revised-Baux (r-Baux) score were analyzed.

RESULTS

25 patients (1.2%) met inclusion criteria. Patients were transferred from a wide geographic area with population ranges of 1000 to 279,000. 21 patients met criteria for burn resuscitation by TBSA; 4 (19%) were placed on comfort care upon arrival, 7 (33%) were placed on comfort care after discussion with the patient's family, and 10 (48%) received full resuscitation efforts. Of these 10 patients, 2 died as "full code", 8 were transitioned to comfort care after failed resuscitation or other events. Code status was not always addressed prior to the decision to transfer. Two patients were transferred after cardiac arrest in the field both of which had significant medical comorbidities in addition to their burn.

CONCLUSIONS

Regional burn centers support a variety of populations. Transferring patients for which care is futile may have a profound impact on resource utilization from a variety of perspectives including transferring centers, receiving centers, regional Emergency Medical Services and families. Referring providers need to be supported in identifying these severely injured, potentially expectant patients. Transfer of patients may negatively impact families as a loved one may die far from home, before family can arrive. With our increasing ability to utilize telemedicine, transfer may not always provide the best support we can offer for providers, patients, and families.

APPLICABILITY OF RESEARCH TO PRACTICE

Early deaths after transfer to a regional burn center, especially those that do not undergo a full resuscitation, should be critically examined to determine the appropriateness of transfer in a palliative, patient and family centered approach.

Prospective observational study comparing burn surgeons' estimations of wound healing after skin grafting to photo-assisted methods

INTRODUCTION

Appropriate graft healing after split-thickness skin graft and early recognition of complications (graft loss) are critical to burn patient management. Larger mesh ratio expansions and Meek micrografting may pose a greater challenge in estimating the percentage of wound healing. This study looks at the reliability of photograph assessments and the concordance of bedside evaluation to photograph assessments of wound healing after skin grafting.

METHODS

Three assessment methods for percentage of wound healing after skin Grafting were assessed: (1) clinicians' bedside rating, (2) clinician assessment of high-definition photographs, and (3) digital image analysis through color subtraction using Adobe Photoshop. We compared each method using a mixed-effects model on absolute agreement using intra-class correlation (ICC) and Bland Altman (BA) plots.

RESULTS

Fourteen burn patients were enrolled with 38 grafted wounds (100 sites). Bedside assessments had a mean ICC of 0.64 (compared to digital image analysis) and 0.69 (compared to photo assessment), with a wide range on BA-plots. Inter-rater reliability of photo assessment was excellent (0.96) among six clinicians. Repeated photo-assisted assessments had good intra-rater reliability (ICC: photo assessment: 0.88; digital analysis: 0.97).

CONCLUSIONS

Bedside wound healing assessments show variability; photograph documentation of sequential wound progression could supplement active clinical management or studies for more reliable assessments.

Outpatient opioid use of burn patients: A retrospective review

INTRODUCTION

Opioid overuse is a growing patient safety issue but continue to be integral to burn pain management. This study aims to characterize opioid use in discharged patients and factors for predictive of long term use.

METHODS

Participants with burns admitted to a single center from 2006 to 2015 were included. Total outpatient morphine equivalent dose (MED) was recorded at discharge and each clinic visit. Burn size, percent grafted, age, sex, and preadmission drug use were collected. For each time point, multivariate logistic regression was performed to examine the relationship of discharge MED and long-term opioid use, adjusting for age, sex, burn size, and percent grafted. MED was divided into low (0-150 mg per day), medium (151-300 mg per day), and high (greater than 301 mg) groups on day of discharge.

RESULTS

At discharge, 366 (90%) patients received opioids. At day 14, both the medium MED (OR 2.72; CI 1.18-6.23) and high MED (OR 2.74; CI 1.02-7.37) groups had an increased risk for continued opioid use. On day 60, only the high MED group (OR 6.06; CI 1.60-22.97) had an increased risk. History of drug use was significant at 60 days (OR 7.67; 1.67-35.26) and alcohol use was significant at 14 days (OR 3.14; CI 1.25-7.93) and 30 days (OR 5.92; CI 1.81-19.36).

CONCLUSIONS

Whereas opioids are widely prescribed upon discharge, most patients no longer use them 30 days later. Higher opiate utilization at discharge increases risk of long term use, as does pre-injury drug and alcohol use, but only temporarily.

Burn Patients' Perceptions of Their Care: What Can We Learn From Postdischarge Satisfaction Surveys?

Little is understood about the inpatient experience from the burn patients' perspectives. Rather, hospitals emphasize quantitative feedback as part of the ongoing process improvement. Comments returned with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) administrative survey may provide important patient perspectives. They analyzed quantitative and qualitative HCAHPS data to identify areas for care improvement. They reviewed our burn center HCAHPS results over 2 years. They analyzed "top-box" result in each defined HCAHPS category, which is the most frequently reported best result in each composite, including survey scores ≥9 (out of 10). They performed qualitative content analysis of open-text responses via a HIPAA-compliant analysis software. They developed a hierarchy of major expressed themes and organized them using HCAHPS-validated satisfaction domains. A total of 610 inpatient HCAHPS surveys (21% response rate) were returned. Seventy-five percent of respondents ranked their burn center as ≥9 (out of 10) in care scores. Content analysis identified three main components of the inpatient experience: 1) provider/nurse communication, 2) hospital environment, and 3) the discharge experience. Caring, respect, handoff coordination, explanations, listening, and confidence in provider constituted the six key communication themes. Patients generally reported that burn providers listened to their concerns, but others requested clearer explanations of their condition and care. Responses about hospital environment highlighted excessive noise and disrupted sleep, and variable responses related to cleanliness. Challenges in the discharge experience included difficulties procuring wound care supplies and discharge medications. Qualitative data from HCAHPS helped identify major target areas for burn center performance improvement. Analysis of HCAHPS direct patient feedback is useful in process improvement, whereas numerical data alone do not provide sufficient actionable information.

Trends 10 years after burn injury: A Burn Model System National Database study

BACKGROUND

The Burn Specific Health Scale-Brief (BSHS-B) evaluates 9 aspects of health and has been validated globally. Existing reports typically focus on outcomes shortly after injury. The purpose of this study is to determine whether quality of life remains a concern for burn survivors ten years after-injury.

METHODS

Cross sectional data of survivors admitted from 1994 to 2006 to four US burn centers were collected in the Burn Model System National Database 10 years after injury. Responses to the items in the nine BSHS-B domains range from 0 to 4. Lower scores indicating poorer quality of life. Median scores are reported and differences were compared using Wilcoxon-Mann-Whitney test.

RESULTS

Ten-year survivor injury characteristics suggest a moderate severity of injury. Survivors scored lower in heat sensitivity, affect, body image, and work (median=3.2, 3.6, 2.8, and 3.6, respectively). Affect, body image, and interpersonal scores were significantly lower for females (median=3.1, 2.8, 3.8, respectively) than males [median=3.6, 3.3, 4, respectively (p=0.008, 0.004, 0.022, respectively)].

CONCLUSIONS

Our results suggest certain domains of burn specific health benefit from support at 10 years after injury, and select populations such as females may necessitate additional treatment to restore burn-specific health. These results support that burn injuries represent a chronic condition and long-term medical and psychosocial support may benefit burn survivor recovery.