The Burden of Burns: An Analysis of Public Health Measures

Accurate analysis of injuries is paramount when allocating resources for prevention, research, education, and legislation. As burn mortality has improved over recent decades, the societal burden of burn injuries has grown ambiguous to the public while a scarcity of investigational funding for survivors has led to a gap in understanding lifelong sequela. We aim to compare national references reporting the incidence of burn injuries in the United States. The American Burn Association Burn Injury Summary Report (ABA-BISR), American Burn Association Fact Sheet, Centers for Disease Control and Prevention (CDC) Web-based Injury Statistics Query and Reporting (WISQARS) database, the CDC National Center for Health Statistics' National Hospital Ambulatory Medical Care Survey (NHAMCS), National Inpatient Sample (NIS), National Emergency Department Sample (NEDS), and commercially available claims databases were queried for 2020 or the most recent data available. The BISR estimated 30,135 burn admissions in 2022. The 2016 ABA Fact Sheet reported 486,000 burns presented to US emergency departments (ED). In 2020, CDC's WISQARS database reported 3,529 fatal, and 287,926 non-fatal, burn injuries. The 2020 NEDS reported 438,185 ED visits while the 2020 NIS estimated 103,235 inpatients. The NHAMCS reported 359,000 ED visits for burn injuries in the same period, and an analysis of ICD-10 burn codes demonstrated over 698,555 claims. Our study demonstrates a large variability in the reported incidence of burn injury by the ABA, CDC, national samples, and claims databases. Per our analyses, we estimate that 600,000 individuals annually suffer a burn injury which merits emergent care in the United States.

Development of the national injury resource database (NIRD)

INTRODUCTION

Lack of an accurate, publicly available database of burn/trauma resources creates challenges in providing burn care. In response to this gap, our group developed the National Injury Resource Database (NIRD), a comprehensive database of all US burn centers (BC) and trauma centers (TC) and their capabilities.

METHODS

Lists of all national BC and TC were obtained from the American Burn Association (ABA), the American College of Surgeons, and every state department of health. Data was cross-checked and included BC/TC were linked with a 7-digit identification number using the American Hospital Association Quick Search guide. Each center's resources and verification status were validated with electronic or telephonic communications.

RESULTS

The final database includes 135 BC and 617 TC, of which 18 are BC-only, 500 are TC-only, and 117 are combined BC/TC. ABA-verified BC (n = 76) are only found in Washington DC and 31 states, and 8 states have no BC. In the last 10 years, a net increase of 7 burn centers was found nationally. The ABA's online BC directory is outdated.

CONCLUSIONS

NIRD represents the only up-to-date, comprehensive listing of BC and TC in existence. It categorizes all currently operating BC and TC across myriad classifications of designation and capabilities.

Autologous Skin Cell Suspension for Full-Thickness Skin Defect Reconstruction: Current Evidence and Health Economic Expectations

Despite differing etiologies, acute thermal burn injuries and full-thickness (FT) skin defects are associated with similar therapeutic challenges. When not amenable to primary or secondary closure, the conventional standard of care (SoC) treatment for these wound types is split-thickness skin grafting (STSG). This invasive procedure requires adequate availability of donor skin and is associated with donor site morbidity, high healthcare resource use (HCRU), and costs related to prolonged hospitalization. As such, treatment options that can facilitate effective healing and donor skin sparing have been highly anticipated. The RECELL® Autologous Cell Harvesting Device facilitates preparation of an autologous skin cell suspension (ASCS) for the treatment of acute thermal burns and FT skin defects. In initial clinical trials, the approach showed superior donor skin-sparing benefits and comparable wound healing to SoC STSG among patients with acute thermal burn injuries. These findings led to approval of RECELL for this indication by the US Food and Drug Administration (FDA) in 2018. Subsequent clinical evaluation in non-thermal FT skin wounds showed that RECELL, when used in combination with widely meshed STSG, provides donor skin-sparing advantages and comparable healing outcomes compared with SoC STSG. As a result, the device received FDA approval in June of 2023 for treatment of FT skin defects caused by traumatic avulsion or surgical excision or resection. Given that health economic advantages have been demonstrated for RECELL ± STSG versus STSG alone when used for burn therapy, it is prudent to examine similarities in the burn and FT skin defect treatment pathways to forecast the potential health economic advantages for RECELL when used in FT skin defects. This article discusses the parallels between the two indications, the clinical outcomes reported for RECELL, and the HCRU and cost benefits that may be anticipated with use of the device for non-thermal FT skin defects.

Iterative refinement of a histologic algorithm for burn depth categorization based on 798 consecutive burn wound biopsies

INTRODUCTION

Our group previously reported a burn biopsy algorithm (BBA-V1) for categorizing burn wound depth. Here, we sought to promulgate a newer, simpler version of the BBA (BBA-V2).

METHODS

Burn wounds undergoing excision underwent 4 mm biopsies procured every 25 cm2. Serial still photos were obtained at enrollment and at excision intraoperatively. Burn wounds assessed as likely to heal by 21 days were imaged within 72 h of injury and at 21 days. A sample of 798 burn wound biopsies were classified by both BBAV1 and BBAV2 algorithms. For nonoperative burn wounds, the proportion of healing versus nonhealing pixels at 21 days after injury were compared.

RESULTS

The 798 biopsies were classified by BBAV1 as 24% SPT, 47% DPT, 28% FT and by BBAV2 as 3% SPT, 67% DPT, and 30% FT (p < 0.0001). Overall, the proportion of biopsies whose wound reclassification changed from a nonoperative to operative pathway was 21% (95% CI: 18-24%). Nonoperative wounds judged at injury as being SPT contained 12.8 million pixels. Repeat 21-day imaging revealed 11.3 million healed pixels (accuracy = 89.6% (95% CI: 89.59-89.62)).

CONCLUSIONS

BBA-V2 was associated with a significantly higher concordance with visual assessment for burn wounds clinically judged as deep partial and full thickness.

Scientific Opinion on the Risks of Drug Shortages on Burn Care

Introduction

Autologous skin cell suspensions (ASCS) minimize the donor site required for addressing partial and full thickness burns. ASCS is currently FDA approved for use in combination with meshed split thickness skin grafts (STSGs) for full-thickness thermal burns in pediatric and adult patients. Besides the initial clinical trials of ASCS and STSG use for burn wounds, there are minimal studies reporting outcomes of their use. Here, we present our experience using ASCS in the past six years. We hypothesized that ASCS and STSG would result in a low reoperation and infection rate.

Methods

Retrospective review of patients seen at an American Burn Association verified burn center between 2017 and 2023 identified 15 patients treated with ASCS overlying STSG. Data collected included patient demographics, burn characteristics, surface area of ASCS usage, and patient outcomes. The primary outcome of interest was the requirement for reoperation following ASCS use. Secondary outcomes included hospital length of stay (LOS), ICU LOS, infection, and the necessity for scar revision via surgery or laser treatment. Data was analyzed using descriptive statistics with categorical variables presented as frequencies and percentages and continuous variables reported as medians and ranges.

Results

The median age of patients treated with ASCS was 36 years (13-67 years). The median BMI was 27.4 (17.7-35.4) and median total body surface area (TBSA) affected by burn was 18% (5.75-69.5%). Six patients (40%) had full thickness in addition to partial thickness burns. Most burns, 11 (73%) were the result of flames, although there were three grease burns and one friction burn. The median time to ASCS application was 10 days (1-39 days) and the median number of ASCS application sites was 2 (1-6). Most ASCS sites were on the upper or lower extremities or the torso; however, two patients had ASCS applied to their feet while another patient had it applied to their genitalia. Median ASCS surface area was 2,464 cm2 (289-20,000 cm2). Median LOS was 23 days (8-125 days) and median ICU LOS was 3 days (0-94 days). Four patients (26.7%) required reoperation on sites of ASCS application with the median time to reoperation being 40.5 days (28-66 days). Three patients (20%) required scar contracture surgery and three (20%) received laser treatments. There were no cutaneous infections in our cohort.

Conclusions

ASCS was effectively used to treat both partial thickness and full thickness burns and burns due to flame, grease, and friction. There did not seem to be any relationship between the necessity for reoperation after ASCS and the burn depth, etiology, surface area, or location.

Applicability of Research to Practice

Clinicians can look to our study for potential outcomes when using ASCS with STSG in a variety of situations.

Development of Prepositioned Burn Care-specific Disaster Resources for a Burn Mass Casualty Incident

Disaster preparedness for a burn mass casualty incident (BMCI) must consider the needs of the first responders and community hospitals, who may be the first to receive those patients. Developing a more comprehensive statewide burn disaster program includes meeting with regional healthcare coalitions (HCCs) to identify gaps in care. Quarterly HCC meetings, which link local hospitals, emergency medical services (EMS) agencies, and other interested parties, are held around the state. We rely on the HCC's regional meetings to serve as a platform for conducting focus group research to identify gaps specific to a BMCI and to inform strategy development. One of the deficiencies identified, particularly in rural areas that infrequently manage burn injuries, was a lack of burn-specific wound care dressings that could support the initial response. Relying on this process, a consensus was created for equipment types and quantities, including a kit for storage. Furthermore, maintenance, supply replacement, and scene delivery processes were developed for these kits that could augment a BMCI response. The feedback from the focus groups reminded us that many systems report having infrequent opportunities to provide care for patients with burn injuries. In addition, several types of burn-specific dressings are expensive. With the infrequent occurrence, EMS agencies and rural hospitals reported that it was doubtful their agency/hospital would have more than a minimal stock of burn injury supplies. Therefore, developing supply caches that can be quickly mobilized and deployed to the impacted area was one of the deficiencies we identified and addressed through this process.

A Risk-Benefit Review of Currently Used Dermal Substitutes for Burn Wounds

While split-thickness autologous skin grafts remain the most common method of definitive burn wound closure, dermal substitutes have emerged as an attractive option. There are many advantages of utilizing a dermal substitute, notably reducing the need for donor tissue and subsequent iatrogenic creation of a secondary wound. However, there are disadvantages with each that most be weighed and factored into the decision. And most come at a high initial financial cost. There is little comparative literature of the various available and emerging products. This analysis was performed to objectively present risks and benefits of each option.

Analysis of real-world length of stay data and costs associated with use of autologous skin cell suspension for the treatment of small burns in U.S. centers

BACKGROUND

Autologous skin cell suspension (ASCS) is a treatment for acute thermal burn injuries associated with significantly lower donor skin requirements than conventional split-thickness skin grafts (STSG). Projections using the BEACON model suggest that among patients with small burns (total body surface area [TBSA]<20 %), use of ASCS± STSG leads to a shorter length of stay (LOS) in hospital and cost savings compared with use of STSG alone. This study evaluated whether data from real-world clinical practice corroborate these findings.

MATERIALS AND METHODS

Electronic medical record data were collected from January 2019 through August 2020 from 500 healthcare facilities in the United States. Adult patients receiving inpatient treatment with ASCS± STSG for small burns were identified and matched to patients receiving STSG using baseline characteristics. LOS was assumed to cost $7554/day and to account for 70 % of overall costs. Mean LOS and costs were calculated for the ASCS± STSG and STSG cohorts.

RESULTS

A total of 151 ASCS± STSG and 2243 STSG cases were identified; 63.0 % of patients were male and the average age was 44.2 years. Sixty-three matches were made between cohorts. LOS was 18.5 days with ASCS± STSG and 20.6 days with STSG (difference: 2.1 days [10.2 %]). This difference led to bed cost savings of $15,587.62 per ASCS± STSG patient. Overall cost savings with ASCS± STSG were $22,268.03 per patient.

CONCLUSIONS

Analysis of real-world data shows that treatment of small burn injuries with ASCS± STSG provides reduced LOS and substantial cost savings compared with STSG, supporting the validity of the BEACON model projections.

Proceedings of the 2021 American Burn Association State and Future of Burn Science Meeting

Periodically, the American Burn Association (ABA) has convened a State of the Science meeting on various topics representing multiple disciplines within burn care and research. In 2021 at the request of the ABA President, meeting development was guided by the ABA's Burn Science Advisory Panel (BSAP) and a subgroup of meeting chairs. The goal of the meeting was to produce both an evaluation of the current literature and ongoing studies, and to produce a research agenda and/or define subject matter-relevant next steps to advance the field(s). Members of the BSAP defined the topics to be addressed and subsequently solicited for nominations of expert speakers and topic leaders from the ABA's Research Committee. Current background literature for each topic was compiled by the meeting chairs and the library then enhanced by the invited topic and breakout discussion leaders. The meeting was held in New Orleans, LA on November 2nd and 3rd and was formatted to allow for 12 different topics, each with two subtopics, to be addressed. Topic leaders provided a brief overview of each topic to approximately 100 attendees, followed by expert-lead breakout sessions for each topic that allowed for focused discussion among subject matter experts and interested participants. The breakout and topic group leaders worked with the participants to determine research needs and associated next steps including white papers, reviews and in some cases collaborative grant proposals. Here, summaries from each topic area will be presented to highlight the main foci of discussion and associated conclusions.

50 Rise of the (Learning) Machines: Artificial Intelligence for the Assessment of Adult Thermal Burns

Introduction

Burn depth assessment (BDA) is an essential component of the physical exam used in the treatment and triage of burn injured patients. And while many specialties incorporate labs and imaging to determine diagnoses, burn professionals must rely on a physical exam that is accurate in only 70-80% of cases. Our goal was to assess the accuracy of a new imaging technology called Multispectral imaging (MSI) combined with a machine learning algorithm to aid in rapid BDA. We present the results of the first multi-center study using this technology in adult burn injuries.

Methods

In a multi-center IRB-approved study, an MSI device was used to image subjects >18 years of age with thermal burn injuries. The imaging device captured a set of images measuring the reflectance of visible and near-IR light. Subjects were enrolled and imaged within 72 hours of injury with serial imaging as permitted. The images were used to develop a type of machine learning algorithm called a convolutional neural network (CNN) that could identify the regions of non-healing burn within an image. Non-healing burn areas were determined by a panel of three burn surgeons using two standards: a) images confirming 21-day spontaneous healing; or b) pathology reports detailing histologic changes from multiple punch biopsies taken prior to burn excision. From this data, an ensemble of eight separate CNN algorithms was used to automatically identify non-healing burn tissue. Training and test accuracies of the ensemble CNN were calculated using cross-validation at the level of the subject.

Results

One hundred (100) adults were enrolled and imaged. The population had a mean age 45.6 ± 16.7; mean TBSA 13.0 ± 9.3; and was 31% female. From these adults, 210 burn regions were serially imaged. The estimated performance result from the ensemble CNN for identification of non-healing burn regions was AUC of 0.96. Based on the ROC curve, an ideal threshold showed an accuracy of 92.0%, sensitivity 91.9%, and specificity 92.0%.

Conclusions

Our study demonstrates a non-invasive technology that rapidly determines an accurate DBA relative to traditional bedside exam. More accurate burn wound assessment could lead to avoiding unnecessary surgeries or delays in treatment and dramatic cost savings. Use of such a device in a disaster has additional value to better align a patient’s burn care needs and available resources.

86 Outcomes for 43 Hand Burns Treated with 2:1 Meshed and Epidermal Autografts with Abundant Donors

Introduction

Our group has previously reported our experience in treating hand burns with 2:1 meshed autografting and simultaneous application of autologous skin cell suspension (ASCS) even when donor sites are abundant. Here, we sought to expand on this experience. We hypothesized that the use of 2:1 meshed autografting and ASCS (MA/ASCS) would provide comparable outcomes to hand burns treated with sheet graft.

Methods

A retrospective review was conducted of all subjects operated on for deep 2^nd and 3^rd degree hand burns at our ABA-verified burn center from April, 2018 to May, 2021. Exclusion criterion was a burn of >20% TBSA. The cohorts were those subjects treated with MA/ASCS versus those treated with split thickness sheet, pie-crust, or 1:1 meshed autograft alone (STAG). Outcomes included proportion returning to work (RTW), length of time for RTW, and time to wound closure. Mann-Whitney U test was used for comparisons of continuous variables, and Fishers Exact test for categorical variables. Values are reported as median and interquartile range.

Results

Sixty-eight subjects fit the study criteria (MA/ASCS n=43, STAG n=25). The MA/ASCS group was significantly older than the STAG cohort (45.5 yrs [32, 59.25] vs 35 [28, 45], p=0.013) with larger %TBSA burns overall (11.5% [7, 16.25] vs 2% [1, 3], p < 0.0001), and larger hand burns (186 cm2 [124.75, 330.5] vs 104 cm2 [56, 164], p=0.001). Comparable results were seen between MA/ASCS and STAG, respectively, for time to wound closure (8 days [7, 13] vs 8 [6, 14], p=0.48), proportion RTW (51% vs 64%, p=0.33), and days for RTW among those returning (38 [29.25, 62.75] vs 34.5 [20.75, 57], p=0.471). Fractional ablations were performed in 14% of the MA/ASCS group and 12% of the STAG group.

Conclusions

Despite being significantly older, having larger hand wounds, and larger overall wounds within the parameters of the study criteria, patients with 20% TBSA burns or smaller whose hand burns were treated with 2:1 mesh and ASCS overspray had comparable time to wound closure and return to work as subjects treated with 1:1, pie-crust, or sheet STAG.

544 Southern US Burn Centers, Surge Capacity and 15 Months of the COVID19 Pandemic

Introduction

Burn mass casualty incident (BMCI) planning efforts have been in practice and publication for 40+ years. Through these ongoing efforts, we know there are measurable limits to burn center capacity and capability through modeling and real-world events relying on conventional and contingency standards of care, even when the only focus is those patients with burn injuries. The southern region of the American Burn Association (ABA) includes 37 burn centers and continues to play a critical role in the BMCI preparedness process.

COVID-19 has emerged as the greatest pandemic in terms of morbidity and mortality since the 1918 influenza pandemic. While COVID-19 has no direct connection to burn injuries, the impact of COVID-19 on the American Healthcare System to include burn care was and remains significant.

Methods

We conducted a retrospective analysis of (southern) regional data voluntarily submitted to the ABA from March 2020 to June 2021 and generally coincides with the first three waves of the pandemic. We focused on the self-reported data specific to the three critical components in managing a surge of patients: staffing, space, and supplies (to include pharmaceuticals and equipment).

Results

Staff: These data were collected over a period that coincided with the first three waves seen in the region. Staffing shortages were noted during each of the surges but were most excessive when a regional surge paralleled surges in other parts of the country (November-December 2020).

Space

Late November and early December 2020, space was in short supply with the surge of patients for more of the region than at any other time during the 28 weeks of reporting. While single facilities reported other episodes of limited space or supplemented with temporary structures, the peak was early December.

Supplies

As the first surge began to subside, the supply shortages were abated. However, as additional surges occurred, the supply chain had not recovered. Supply shortages were reported in greater numbers than either space or staffing needs through the multiple waves of the pandemic.

Conclusions

The surge of patients that had to be managed by the greater healthcare community placed a substantial strain on the burn centers to keep beds dedicated for patients with burn injuries. The pandemic directly led to a diminished available capacity for burn care in such a way that it could have compromised our ability to confront a surge of burn-injured patients. Future BMCI planning efforts must consider this aspect of the process. Crisis Standards of Care may come into play during such an event.

538 Partial Thickness Pediatric Burn Injuries Treated with Autologous Skin Cell Suspension

Introduction

Management of pediatric burn injuries resulting in optimal aesthetic remains a significant challenge in burn care. Wound care and acute surgical intervention coupled with reconstructive interventions is an essential component of burn care. Incorporation of new technologies in burn care has challenged historic paradigms. Our goal was to evaluate the use of autologous skin cell suspension (ASCS) for the treatment of partial-thickness pediatric burn injuries.

Methods

A retrospective chart review from a single pediatric institution over a 10-month period was performed on patients undergoing treatment with ASCS. Patients with full-thickness injuries treated with autografting were excluded. Demographics and data collection included total burn surface area (TBSA), location of burn, mechanism of burn, time to ASCS application, time to &gt;90% re-epithelization, hospital length of stay, ASCS failure requiring repeat operation, and reconstructive procedures or laser interventions.

Results

26 pediatric patients ≤13 years of age charts were reviewed. 14 patients received ASCS and met inclusion criteria. 8 faces were included in our study along with 11 upper extremity burns, 5 lower extremity burns, and 8 torso burns or some combination of the above. The most common etiology was scald injury from hot water followed by noodle soup burns and grease burns. Other etiologies included road rash, flame burn, and a steam burn. ASCS was applied 2 days (range 1-4) after injuries and patients only required 1 operation. The average length of hospital stay was 4 days (range 1-10) and the average TBSA was 10% (range 4-17). The average time to &gt;90% re-epithelization was 7 days with one outlier with healing at day 24. This is the only patient in the ASCS group that required laser interventions. No patients required repeat procedures, subsequent autografting, or reconstructive procedures.

Conclusions

Pediatric patients with partial-thickness burns benefitted from the ASCS by having limited donor sites, short hospitalizations compared to %TBSA, improved time to &gt;90% re-epithelization, and no repeat surgical interventions. The fast-healing time and good cosmetic outcome decreases the need for compression garments and subsequent laser interventions. Key factors include patient selection and appropriate wound preparation.

504 Starting a Pediatric Burn Center: Challenges Faced in an Underserved Patient Population

Introduction

Burn injury is the third most common cause of childhood injury resulting in death. The CDC recognizing the South as having the highest rate of pediatric burn deaths in the U.S. Unfortunately, 10% of all child abuse cases involve burn injuries and 20% of all pediatric burn admissions are due to nonaccidental trauma. Our study demonstrated that aftercare was a major challenge in starting a pediatric burn center. We analyzed the rate of lost to follow-up in burn-injured children following surgery and our steps to address this need in our community through key partnerships within our state.

Methods

Our study is a single center review of pediatric burn-injured children undergoing surgery from 01/01/2021 through 09/30/2021. Lost to follow-up was defined as three or more consecutive months without clinic or telemedicine visits despite three of more documented communication attempts by attending surgeons and/or clinic staff. Children requiring child protective services (CPS) for suspected nonaccidental trauma were compared to those where nonaccidental trauma was not suspected. All children sustained burn injuries of sufficient severity to require excision and autograft with follow-up in the outpatient clinic. Families were provided with an after-visit summary reviewing the clinic appointment, transportation and meal assistance, and they received a call prior to clinic to remind them of the scheduled appointment.

Results

A total of 35 children required surgery with outpatient follow-up per protocol. 23% of the patients required CPS investigations. We reviewed 151 subsequent clinic visits and the associated cancellations, rescheduled appointments, and no-show visits. Children under the care of CPS had a higher rate of being lost to follow-up (50%) compared to other children (17%). Parents undergoing CPS investigation were 4x less likely to provide cancellation notice. Children placed in foster care had no cancellations, reschedules appointments, or missed visits despite a higher number of clinic visits overall.

Conclusions

Children suffering nonaccidental injuries represent an exceptionally vulnerable portion of our population. Burn injuries often are a public and personal reminder of severe trauma. CPS works to find a balance in securing a safe home while attempting to maintain a family unit. Our work demonstrated an unacceptably high rate of loss to follow-up for children requiring surgical intervention after injury especially in those with concerns for nonaccidental etiologies. As a result, our burn surgeons led an initiative with statewide burn directors and our state’s emergency response network to engage the state’s CPS department. Our goal was to raise awareness and increase education for CPS social workers and foster families on burn injury and aftercare needs.

592 Strategy for Improving Wound Care Compliance in the Outpatient Setting by using Take-home Visual Aids

Introduction

Wound care compliance is a critical component in the success of treating burns in the outpatient setting. Patients and caregivers are educated with demonstration and written materials which have demonstrated a 24-hour retention rate of 30% and 10% respectively. This can leave the patient at higher risk for infection, increased pain from suboptimal dressings, and feelings of frustration. Research has shown that visual learners make up 65% of the population, with auditory learners at 30%, and tactile learners at 5%. We assessed that a combination of demonstration and visual aids could better assist different learning styles and improve wound care compliance. Our study goal was to assess the efficacy of the visual aids component through new patient encounters in the emergency department and outpatient setting using a six-question survey at subsequent encounters.

Methods

The study design is a prospective analysis with comparison to historical controls. Visual aids were designed by the burn physician assistants with assistance at an ABA-verified burn center. We created four double-sided cards made out of a water-resistant synthetic paper, with one for each of our most used dressings. The content of the cards included one of the following: bacitracin/fine mesh gauze with bismuth tribromophenate, bacitracin with low-adherent acetate gauze, silver nylon dressings, and silver foam dressings. Each card contains moulage wounds, step-by-step, and corresponding written instructions at a 4^th grade education reading level. These visual aids were given to patients being discharged from the emergency department, or to new patients in the burn clinic. A six-question survey was administered at one week follow-up encounters with a scale of 1-10 (one being least helpful, and ten being the most helpful) assessing patients understanding of burn wound care and compliance. Compliance rates were abstracted from historical controls with similar burn wound severity.

Results

Limited data is available at the time of submission as the study is currently in-progress and anticipated to be completed by March 2021. We will be using descriptive statistics and comparative analysis to evaluate the results.

Conclusions

Patients initial feedback has been overall positive with a corresponding compliance rate that is successful. Our patients verbalized their approval, with multiple patients stating that they plan to keep the wound care card for any burn injuries that might occur in the future. Additional research is needed to examine the impact of combined demonstration, tactile, and auditory learning aids. In addition, we plan to further expand our engagement effort to include similar wound care cards for pediatric patients as well as language alternative cards to meet our surrounding community's needs.

596 Implementation of a Burn Laser Program at a Children’s Hospital

Introduction

Carbon dioxide ablative fractional laser (CO2-AFL) therapy has become standard of care for adult burn hypertrophic scars (HTS). This therapy option has not been widely adopted in pediatric burn care and no established guidelines for treatment protocols have been published. We sought to modify our American Burn Associated Adult Verified Burn Centers laser protocol at our Children’s Hospital with hopes to provide optimal care to our pediatric burn population. We present our protocol and early experience of CO2-AFL therapy for pediatric burn HTS.

Methods

We conducted a retrospective chart review of pediatric burn patients undergoing CO2-AFL treatment of HTS during the study period of Jan 2021-Oct 2021. Pediatric burn patients were offered laser treatment if their scars were symptomatic with patient complaints of HTS, pruritis, neuropathic pain, and scar contractures. 37 pediatric patients ≤13 years of age were included in our review.

Results

We treated 13 pediatric patients for a total of 40 laser sessions with each patient averaging 3 sessions. Of the 13 patients that were treated with laser, 62% (8 of the 13 patients) had split-thickness skin grafting with 38% (3 of the 8 patients) of those having a staged grafting procedure with dermal substitute. 15% (2 of the 13 patients) healed primarily and 15% (2 of the 13 patients) required excision and closure. Only 1 patient treated with ASCS alone required laser therapy. Our protocol requires patients to receive pre-operative Tylenol, Benadryl, Pepcid, and Oxycodone. The patients then received MAC anesthesia with Toradol, Dexamethasone, Ketamine or Propofol, and Zofran. Patients with extensive HTS on the face or neck were intubated for the procedures. Oxycodone and/or Dilaudid were provided if needed in the post-operative phase. All patients were discharged with Tylenol or Motrin and Triamcinolone 0.1% ointment to be applied daily for 48 hours and then 3-4x/day until the follow-up clinic appointment at one week. Patients were able to resume normal activities the day following the procedure.

Conclusions

Patients and their parents have reported improvements in pigment, pliability, thickness, and pruritis following laser treatments. We created a protocol that allows on average 8 pediatric patients per day to receive laser treatment without it over burdening the pre-operative and post-operative recovery room nursing staff. We are currently tracking outliers of patients requiring increased post-operative analgesia and/or greater than 1 hour in the recovery phase. With the implementation of a laser protocol, we have successfully introduced laser therapy as a viable option for our pediatric burn survivors.

793 "Minimally Invasive" Skin Grafting with Enzymatic Debridement and Autologous Skin Cell Suspension

Introduction

Minimally invasive surgery has become standard of care across numerous subspecialties. However, burn surgery has lagged behind; as the mainstay of treatment still involves excision with a knife and a split thickness skin graft (STSG) with a painful donor site. Enzymatic debridement with bromelain and autologous skin cell spray (ASCS) have independently been STSG use and decrease the donor site size. Due to constraints with the time course of these products only being available via studies before one was FDA approved, these technologies have not been utilized together in the United States until recently. Little literature exists regarding their use in combination. The current study characterizes a series of patients who received “minimally invasive” skin grafts with enzymatic debridement and ASCS as proof of concept.

Methods

This was a retrospective study of a single academic burn center’s experience using bromelain and ASCS together. Data collection included demographics, injury characteristics, length of stay, complications, and measurements of donor sites, STSGs, and ASCS treatment. Donor site size:total area treated with ASCS and/or STSG was calculated. Length of stay (LOS) was qualitatively compared to expected using a factor of 1.1days:%TBSA, and O/E LOS ratio was calculated. Data was reported in medians with interquartile ranges. Patients with 1-30%TBSA qualified for the bromelain study and were treated according to protocol. Those deemed to have enough residual dermis were treated with ASCS, while 3rd degree areas received meshed split thickness skin patch grafts with ASCS overspray.

Results

Eleven patients were included in the study. Four patients received ASCS alone, while 7 patients received a meshed STSG on portions of their burn. Median burn size was 13% TBSA (IQR:5,20), while DPT+FT size was 9% TBSA (IQR:5,16). Patients had a median of 1067 sq cm (IQR:772,2183) of burn operatively treated with ASCS, and 351 sq cm (IQR:0,457) treated with meshed autograft. Donor site size (ASCS and STSG) was 225 sq cm (IQR:72,315), and ratio of donor site are to total treatment area was 0.0125 (IQR:0.01,0.32), suggesting an expansion of 80:1. Median LOS was 11 days (IQR:7,21), 0.84 days per %TBSA (IQR:0.5,1.16). Expected LOS was 14.3 days, with an O/E ratio of 0.77. Two patients developed infection; one required reoperation with STSG on half of his burned areas (5% TBSA).

Conclusions

Enzymatic debridement and ASCS can be used to treat burn injury with a “minimally invasive” approach. Donor sites were much smaller than expected had they been treated with a conventional meshed STSG on deep 2nd degree and 3rd degree areas. The data also suggests that length of stay was lower than expected. Further study is needed to determine which subsets of patients and burn wounds are optimal for this combination of technologies.

607 Use of Autologous Skin Cell Suspension (ASCS) for Full-thickness Burn Injuries Reduces Autograft Procedures

Introduction

Pediatric burn patients and patients with large TBSA injuries are vulnerable to morbidity and mortality, requiring multiple autograft (AG) procedures to obtain definitive closure due to limited donor site availability. The primary objective of this study was to understand the impact of ASCS, as an AG-sparing technology, on the number of AG procedures required to achieve definitive closure of full-thickness (FT) acute thermal burns.

Methods

Retrospective analyses of real-world data were conducted, evaluating clinical outcomes of ASCS-treated patients in prospective, uncontrolled observational studies compared to control data from patients in the National Burn Repository version 8.0 (NBR) who had conventional AG (SOC). The pediatric population consisted of patients < 18 years of age, inclusive of any size TBSA, and the adult cohort included patients ≥ 18 years of age with >50% TBSA injury. Propensity score stratification was used to reduce bias attributable to potential differences in age, sex, %TBSA, and Baux scores between nonrandomized cohorts. Clinical outcomes evaluated included number of AG treatments, length of stay (LOS), healing, and mortality. Additional adverse events were evaluated and compared to historical SOC data sets.

Results

The median number of AG procedures for pediatric patients treated with ASCS and control NBR cohorts was 1.0 (1.0-5.0) and 2.0 (1.0-20.0), respectively. For adult patients, the ASCS-treated and NBR cohorts had medians of 2.0 (1.0-6.0) and 5.0 (1.0-32.0) treatments, respectively. Overall, ASCS lead to approximately 60% fewer mean AG procedures for both populations. By week 8, re-epithelialization was observed in 91.8% and 90.6% of wounds in the pediatric and adult ASCS-treated cohorts. Median LOS for both cohorts were not different between the treatment groups. No significant differences were observed for mortality between cohorts and no adverse events attributed to ASCS were reported.

Conclusions

ASCS treatment reduced the number of AG procedures needed to achieve closure, benefiting patients and offering burn centers reduced complexity and cost in the patient care pathway. While LOS was not significantly reduced in this study as seen in other reports, this finding may be confounded due to potential differences in the patient cohorts relative comorbidities and polytrauma, as well as variability in clinical site inpatient/outpatient management strategies for OT/PT.

813 Histologic Changes of Skin Biopsies After Autologous Skin Cell Suspension

Introduction

Over 10,000 cases of autologous skin cell suspension have been performed around the world for the treatment of burn and soft tissue injuries. A key component of the procedure is the harvest of skin biopsies which are exposed to enzymatic degradation. In some regions, epidermal graft harvest has been attempted manually without enzymatic degradation. Our study goal was to examine the histologic changes of the skin biopsies in manual versus enzymatic degradation.

Methods

Our study was an IRB-approved, prospective controlled analysis of residual skin harvested from 10 patients undergoing hernia repair. Two specimens from each patient were procured intraoperatively with each measuring 2x3cm. Each specimen produced two 4mm punch biopsies from three regions (control, mechanical, and enzymatic) for a total of 12 specimens per patient. Enzymatic specimens were prepared using the Avita Medical ReCell® system per manufacture instructions for use. Mechanical specimens were prepared using an abrasive pad until epidermis was macroscopically removed. Histologic analysis was performed with hematoxylin and eosin stain and whole slide scanning. Two or more investigators reviewed each biopsy concurrently with consensus agreement on the remaining epidermis and evidence of degraded reticular dermis. Descriptive statistics were used to assess the variances in the three groups.

Results

The mean residual epidermis was 9% in the enzymatic group, 35% in the mechanical, and 98% in the control. Epidermal harvest was higher in the enzymatic group relative to the mechanical group (two tailed t-test = 0.0008). Reticular dermis was degraded in 10% of the mechanical specimens and none of the enzymatic specimens.

Conclusions

Epidermal harvest was more consistent in the enzymatic group with less trauma to the dermis. Our study suggest that mechanical harvest requires larger donor sites given the decreased epidermal harvest. Further research is needed to determine impact of cell isolation technique on autograft cell suspension viability and distribution of cell types harvested.

570 Burn-Related Injuries Treated at Two Gulf Coast Hospitals During Following a Category 4 Hurricane

Introduction

Natural disasters are commonly associated with mass destruction and severe injuries. On August 29th, 2021 a category 4 hurricane made landfall before mandatory evacuations were ordered in a major metropolitan community. The powerful storm challenged disaster management teams and first responders as communities struggled to recover. Our study analyzes the demographics of those injured and the injury patterns treated at our state’s only verified burn/trauma center and the adjacent children’s hospital in the aftermath of the hurricane.

Methods

A retrospective chart review was performed on patients seeking emergent care following the hurricane. Demographic data was abstracted from the medical records along with injury pattern including age, gender, mechanism of injury, total body surface area (TBSA), surgical interventions, and length of stay. In addition, brief surveys of fire chiefs from the two most impacted regions were performed to assess prehospital challenges.

Results

41 patients (76% male) presented to our ER with a median age of 44 (7 patients &lt; 12 years of age). 85% of injuries occurred at home while 15% occurred at work. Of the 78% requiring admission, 66% underwent excision and autograft with a mean TBSA of 17% (range 1-80%). Power outages resulted in increased gas generator usage across the region. Most of the burn injuries following the storm were due to generator and cooking accidents (56%). Each fire chief reported up to 91 calls/day due to suspected carbon monoxide poisoning for the two weeks following the storm. A single event resulted in 8 inhalation injuries treated in our ER with one burn ICU admission. The mean hospital length of stay was 1.11 days/%TBSA for those undergoing surgery.

Conclusions

Hurricanes are more common today with many coastal cities as risk for similar natural disasters. Despite our generator safety media outreach efforts prior to the storm, this remains an opportunity for improved injury prevention. Many patients suffered delays in discharge as their homes/nursing facilities suffered structural damages and were without power and water. Disaster planning should account for limited disposition options during severe storms. Our study is the first to describe burn-related injuries from a category 4 storm and our communities’ response.

55 Initial Experience Using Artificial Intelligence for the Assessment of Pediatric Burn Depth

Introduction

Estimation of burn depth, and hence severity, is critical for burn management. Burn depth estimates vary widely, and these inaccuracies can be compounded in pediatric burns. A reliable, objective, non-invasive device for the accurate assessment of burn depth is needed. A non-invasive imaging technology, using multispectral imaging (MSI) combined with a machine learning algorithm (MLA), is being developed as a tool for burn depth assessment. The results of the initial multi-center study using this artificial intelligence (AI) technology in pediatric burns are presented.

Methods

The MSI device was used to image subjects &lt; 18y of age with thermal burns &lt; 50% TBSA. It captured a set of images measuring the reflectance of visible and near-IR light, within a 23x23 cm field-of-view. Images were collected from up to 2 separate burned regions within 72 hours of injury that were then serially imaged for up to 7d post-injury. Burns that the investigator believed would heal spontaneously (superficial or superficial partial-thickness) were managed per institutional standard of care (SOC) and assessed at 21d post-injury for complete healing. Burns that the investigator felt would not heal by 21d post-injury (deep partial-thickness or full-thickness) were excised and grafted per institutional SOC, with multiple biopsies being taken prior to excision.

Regions of non-healing burn within every MSI image were identified by a panel of 3 burn surgeons. To accurately identify these non-healing regions, the panel of surgeons was given access to 1 of 2 clinical reference standards: a) the 21-day healing assessments for burns allowed to heal spontaneously; or b) pathology reports detailing histologic analyses from the biopsies.

This information was then used to develop a type of MLA called a convolutional neural network (CNN) that could automatically identify the regions of non-healing burn within an image. From these data, an ensemble of 8 separate CNN algorithms was used to automatically identify non-healing burn tissue. Training and test accuracies of the ensemble CNN were calculated using cross-validation at the level of the subject.

Results

Twenty-four (24) pediatric burn patients were enrolled, with 26 burned areas being serially imaged. The age range of the subjects was 7 months - 17y, with a mean age of 5.7y. Subjects had a mean burn size of 8.0 ± 4.2% TBSA, and 70% of the subjects were male. The AI performance results showed an accuracy of 88.2 ± 3.7%, sensitivity of 80.0 ± 14.6%, specificity of 88.0% ± 3.7%, and an area under the curve (AUC) of 0.92.

Conclusions

Our study demonstrates an improvement in the accuracy of burn depth assessment over the traditional exam, which could lead to improved burn care.

52 Refinement of a Histologic Algorithm for Burn Depth Categorization Using 1142 Consecutive Burn Wound Biopsies

Introduction

Our group previously reported a theoretical burn biopsy algorithm (BBA-V1) for the categorization of burn wound depth based on histologic analysis, and informed it with the largest series of burn wound biopsies in the literature. That iteration of the BBA resulted in clinical misclassification rates consistent with past literature. Since our last report of that process, we have refined the algorithm with new criteria and a larger repository of burn wound biopsies. Here, we sought to promulgate this newer, simpler version of the BBA (BBA-V2).

Methods

This was an IRB-approved, prospective, multicenter study. Patients with burn wounds assessed by burn experts as requiring excision and autograft underwent 4mm biopsies procured every 25cm². Serial still photos were obtained at enrollment and at excision intraoperatively.

Using H&E with whole slide scanning, a board-certified dermatopathologist assessed each burn biopsy. The criteria used for categorization of burn wound depth in BBA-V1 were: 1) proportion of necrotic adnexal structures, and 2) presence/absence of each of epidermis, papillary dermis, and reticular dermis. The criteria used for BBA-V2 were: 1) magnitude of reticular dermal degeneration, 2) proportion of necrotic adnexal structures, and 3) magnitude of vessel thrombosis.

Biopsy pathology results were correlated with still photos by 3 burn experts for consensus of final burn depth diagnosis. Superficial partial thickness (SPT) wounds were considered to be burn wounds likely to have healed without surgery, while deep partial thickness (DPT) and full thickness (FT) were considered unlikely to heal by 21 days.

Results

The development of BBA V-1 was previously informed by 66 subjects with 117 wounds and 816 biopsies, and resulted in wound categorizations as follows: SPT (20%), DPT (43%), and FT (37%). Therefore, according to BBA-V1, 20% of burn wounds were incorrectly judged as needing excision and grafting by the clinical team. The overall cohort was enlarged to 162 subjects with 294 wounds and 1142 biopsies. The most recent 838 burn wound biopsies were then re-reviewed and re-categorized according to the new BBA-V2 criteria and algorithm. Under BBA-V2, 3% of all burn wound biopsies were categorized as superficial partial thickness, 69% were categorized as deep partial thickness, and 29% were categorized as full thickness.

Conclusions

Our study demonstrates that by adding dermal degeneration severity and vessel thrombosis to our previous criterion of adnexal structure necrosis, BBA-V2 had a much higher rate of concordance with visual clinical assessment for burn wounds clinically judged as needing surgical excision. This study serves as the largest analysis of burn biopsies by modern day burn experts.

725 Case Series: New Porcine Placental ECM for Burn Injuries

Introduction

Human amniotic membrane (HAM) has been used as a biologic dressing for burn wounds since 1955 but limited due to availability, size, and processing costs. In 2021 a new porcine placental product was FDA-approved overcoming challenges with human-sourced products. Our study is the first case series to report outcomes using porcine placental extracellular matrix (PPECM) in the use of adult burn patients.

Methods

Adults with thermal burns resulting in partial-thickness burn wounds (PTBW) were consented and included in the study from 03/2021 to 09/2021. Patients with full-thickness injures, concomitant trauma, or adverse beliefs to porcine products were not included in the study. Serial still images and initial wound measurements were obtained intraoperatively and post-operatively. PPECM trial product processed with a proprietary decellularization method to produce single sheets up to 15x20cm was approved by the facility value assessment committee. Adverse events were defined a priori as infection, increased pain or itching relative to adjacent autografts, or failure to heal. Infection was defined as a PPECM treatment site requiring any change from standard of care or initiation of local or systemic antibiotics. Pain was assessed using a visual analogue scale. Itching was assessed at discharge and follow-up. Healing was assessed using the FDA guidance for wound closure with 2 consecutive visits 2 weeks apart demonstrating 100% epithelialization without drainage or dressing requirements.

Results

Four patients were treated during the study period with wounds involving the torso and major joints such as the hands/wrists and knees. None of the PPECM wounds demonstrated failure to heal or required revision excision, or autograft. None of the PPECM wounds had evidence of infection. PPECM wounds had decreased pain/itching relative to adjacent burn wounds which were treated with split-thickness autograft, autologous skin cell suspension, or allogeneic cultured skin substitute (VAS mean 1 vs 3.1). Healing was noted in all wounds at 1-week primary dressing removal with confirmation at 2-week interval follow-up.

Conclusions

PPECM treatment of PTBW was not associated with adverse events and resulted in favorable outcomes clinically. The large size, ease of use, and lower costs relative to HAM is an intriguing alternative for PTBW. Comparative studies are needed in the field to determine best practices and overall value.

92 ASCS Treatment Impact on Length of Stay Data and Costs for Patients with Small Burns

Introduction

Introduction: Small burns with a total body surface area (TBSA) of &lt; 20% account for the large majority (92%) of burn injury hospital admissions. Autologous skin cell suspension (ASCS) is a novel treatment for acute thermal burn injuries – including small burns -- that is associated with significantly lower donor skin requirements than split-thickness skin grafts, the traditional standard of care (SOC). The ASCS treatment indication was recently expanded from adult patients to include pediatric patients. Previously modeled analyses suggested that ASCS use is associated with a lower hospital length of stay (LOS) and costs savings versus SOC. This study evaluated whether real-world data (RWD) corroborate these findings in small burns and in both adult and pediatric populations.

Methods

Methods: Data were collected from January 2019 through August 2020 from 500 facilities in the United States. Adult patients (age ≥ 21) and pediatric patients (&lt; age 21) receiving inpatient burn treatment with ASCS were identified and matched to patients receiving SOC based on sex, age, TBSA &lt; 20%, and comorbidities. Based on typical BEACON model outcomes, LOS was assumed to account for 70% of total costs and was used as a proxy to assess the data. LOS was assumed to cost $7,554 per day. Mean LOS and costs were calculated for the ASCS and SOC adult and pediatric cohorts. The incremental revenue associated with changes in inpatient capacity was also analyzed.

Results

Results: A total of 151 ASCS and 2,243 SOC adult cases and 19 ASCS and 341 SOC pediatric cases were identified. In adults, the SOC cohort had a higher percentage of patients with TBSA &lt; 20% than the ASCS cohort (82.9% vs. 55.0%). For small burns, sixty-three matches were made for each adult cohort, and seven matches were made for each pediatric cohort. For adults, LOS was 18.5 days with ASCS use and 20.6 days with SOC use (difference: 2.1 days [10.2%]). For pediatrics, the ASCS LOS was 18.6 days, and the SOC LOS was 21.4 days (difference: 2.9 days [15.4%]). This difference led to cost savings of $15,587.62 per adult ASCS patient. Total cost savings with ASCS adult patients were $22,268.03 per patient. The reduced LOS with ASCS adult patients resulted in an increased capacity of 2.0 inpatients per bed per year, which was estimated to increase hospital revenue by $83,894 per burn unit bed annually. Pediatric cost results and savings were similar.

Conclusions

Conclusion: This RWD analysis shows that small burn treatment with ASCS is associated with reduced LOS and substantial cost savings compared with SOC in both adult and pediatric populations, supporting the validity of previous model projections. ASCS use may also significantly increase hospital revenue related to increased inpatient capacity.

543 Challenges in Burn Nurse and Therapy Staffing During and After a Category 4 Hurricane

Introduction

Burn nurse/therapy staffing has been stretched for months by the pandemic. Along the Gulf Coast, Hurricane Ida recently taxed these resources further as regional burn centers saw a weeks-long surge in serious burn injuries in the setting of prolonged power and water outages. We reviewed the execution of a plan for the provision of burn nurse/therapist staffing at an ABA-verified adult burn center that experienced a direct hit by a Category 4 storm.

Methods

Hospital leadership planned to activate Code Gray on 8/29/21 at which time the hospital would be placed on lockdown with no one allowed in or out until Code Gray was lifted.

Our burn leadership subsequently designed a plan to have ten burn nurses and one Occupational Therapist (TEAM A) in house from the inception of Code Gray at 7am on 8/29 thru 7am on 9/1. If Code Gray conditions persisted, nine dedicated burn nurses (TEAM B) were to relieve TEAM A. TEAM B was planned to remain in-house until 7am on 9/4. If Code Gray conditions continued, the plan was to be reassessed at that time. The same burn therapist was planned to remain in-house throughout. Physician coverage was to be provided by the in-house trauma team during Code Gray. No housing or bedding was provided for in-house personnel, and the hospital generator system ostensibly had a 30-day fuel supply.

Results

TEAM A day/night staffing was 6/4 with the off crew sleeping in conference rooms and clinic spaces. An unexpected event occurred when a mission-critical tower for the city’s grid toppled into a river resulting in delays for restoration of the grid, and city-wide boil-water and burn-ban policies. As generators came into widespread use, our pre-storm census of 9 increased to a mean of 12.7 + 1.4. Due to this increase, on the morning of 9/1 six TEAM A nurses elected to stay and be absorbed into Team B with day/night staffing of 6/6.

The rapid influx in number and complexity of burn patients made it clear a burn surgeon presence was needed during Code Gray. One burn attending was able to make it to the hospital at 7am on 8/30 and worked until being relieved at 7am on 9/5. An informal triage strategy was enacted in which only burns of >10% TBSA would be considered for admission. OR availability went down to 2 + 1 at the inception of Code Gray and 3 + 1 on 9/6. Eleven cases were done during this time with a mean TBSA of 20.2 + 10.7%.

Hospital generators were found to consume fuel at a rate almost twice predicted. Due to prioritization, the hospital went back on city power on 9/2. Code Gray was lifted at 7am on 9/4 and normal operations resumed at 7am on 9/11.

Conclusions

The successful provision of care required a willingness for nurses and one therapist to remain in the hospital for six consecutive days and for hospital administration to approve the overtime.

Length of Stay and Costs with Autologous Skin Cell Suspension Versus Split-Thickness Skin Grafts: Burn Care Data from US Centers

INTRODUCTION

Autologous skin cell suspension (ASCS) significantly reduces donor skin requirements versus conventional split-thickness skin grafts (STSG) for thermal burn treatment. In analyses using the Burn-medical counter measure Effectiveness Assessment Cost Outcomes Nexus (BEACON) model, ASCS was associated with shorter hospital length of stay (LOS) and cost savings versus STSG. This study hypothesized that daily practice data from the USA would support these findings.

METHODS

Electronic medical record data from 500 healthcare facilities (January 2019-August 2020) were used to match adult patients who received inpatient burn treatment with ASCS (± STSG) to patients treated with STSG alone on the basis of sex, age, percent total body surface area (TBSA), and comorbidities. Based on BEACON analyses, LOS was assumed to represent 70% of total costs and used as a proxy to assess the data. Mean LOS, costs, and the incremental revenue associated with inpatient capacity changes were calculated.

RESULTS

A total of 151 ASCS and 2443 STSG patients were identified: 63.0% were male and average age was 44.5 years. Eight-one matches were made between cohorts. LOS was 21.7 days with ASCS and 25.0 days with STSG alone (difference 3.3 days [13.2%]). LOS was lower with ASCS than STSG in four of five TBSA intervals. The LOS difference led to hospital bed cost savings of $25,864 per ASCS patient; overall cost savings were $36,949 per patient. Similar cost savings were observed in TBSA groupings < 20% and ≥ 20%. The reduced LOS with ASCS translated into an increased capacity of 2.2 inpatients/bed annually, which increased hospital revenue by $92,283/burn unit bed annually.

CONCLUSIONS

Real-world data show that ASCS (± STSG) is associated with reduced LOS and cost savings versus STSG alone across all burn sizes, supporting the validity of the BEACON analyses. ASCS use may also increase patient capacity and throughput, leading to increased hospital revenue.

Use of 816 consecutive burn wound biopsies to inform a histologic algorithm for burn depth categorization

INTRODUCTION

Burn experts are only 77% accurate when subjectively assessing burn depth, leaving almost a quarter of patients to undergo unnecessary surgery or conversely suffer a delay in treatment. To aid clinicians in burn depth assessment (BDA), new technologies are being studied with machine learning algorithms calibrated to histologic standards. Our group has iteratively created a theoretical burn biopsy algorithm (BBA) based on histologic analysis, and subsequently informed it with the largest burn wound biopsy repository in the literature. Here, we sought to report that process.

METHODS

The was an IRB-approved, prospective, multicenter study. A BBA was created a priori and refined in an iterative manner. Patients with burn wounds assessed by burn experts as requiring excision and autograft underwent 4mm biopsies procured every 25cm 2. Serial still photos were obtained at enrollment and at excision intraoperatively. Burn biopsies were histologically assessed for presence/absence of epidermis, papillary dermis, reticular dermis, and proportion of necrotic adnexal structures by a dermatopathologist using H&E with whole slide scanning. First degree and superficial 2 nd degree were considered to be burn wounds likely to have healed without surgery, while deep 2 nd and 3 rd degree burns were considered unlikely to heal by 21 days. Biopsy pathology results were correlated with still photos by five burn experts for consensus of final burn depth diagnosis.

RESULTS

Sixty-six subjects were enrolled with 117 wounds and 816 biopsies. The BBA was used to categorize subjects' wounds into 4 categories: 7% of burns were categorized as 1 st degree, 13% as superficial 2 nd degree, 43% as deep 2 nd degree, and 37% as 3 rd degree. Therefore 20% of burn wounds were incorrectly judged as needing excision and grafting by the clinical team as per the BBA. As H&E is unable to assess the viability of papillary and reticular dermis, with time our team came to appreciate the greater importance of adnexal structure necrosis over dermal appearance in assessing healing potential.

CONCLUSIONS

Our study demonstrates that a BBA with objective histologic criteria can be used to categorize BDA with clinical misclassification rates consistent with past literature. This study serves as the largest analysis of burn biopsies by modern day burn experts and the first to define histologic parameters for BDA.

Evaluating real-world national and regional trends in definitive closure in US burn care: A survey of US Burn Centers

To better understand trends in burn treatment patterns related to definitive closure, this study sought to benchmark real-world survey data with national data contained within the National Burn Repository version 8.0 (NBR v8.0) across key burn center practice patterns, resource utilization, and clinical outcomes. A survey, administered to a representative sample of U.S. burn surgeons, collected information across several domains: burn center characteristics, patient characteristics including number of patients and burn size and depth, aggregate number of procedures, resource use such as autograft procedure time and dressing changes, and costs. Survey findings were aggregated by key outcomes (number of procedures, costs) nationally and regionally. Aggregated burn center data were also compared to the NBR to identify trends relative to current treatment patterns. Benchmarking survey results against the NBR v8.0 demonstrated shifts in burn center patient mix, with more severe cases being seen in the inpatient setting and less severe burns moving to the outpatient setting. An overall reduction in the number of autograft procedures was observed compared to NBR v8.0, and time efficiencies improved as the intervention time per TBSA decreases as TBSA increases. Both nationally and regionally, an increase in costs was observed. The results suggest resource use estimates from NBR v8.0 may be higher than current practices, thus highlighting the importance of improved and timely NBR reporting and further research on burn center standard of care practices. This study demonstrates significant variations in burn center characteristics, practice patterns, and resource utilization, thus increasing our understanding of burn center operations and behavior.

Surgical Escharotomy and Decompressive Therapies in Burns

Early recognition of the need for escharotomy and other decompressive therapies is imperative for experienced burn providers, as to avoid reversible tissue ischemia and necrosis. With full-thickness burns, the eschar that develops is largely noncompliant. The predictable edema that develops during resuscitation of larger burns increases the likelihood ischemia-inducing pressure, as the underlying tissues swell within noncompliant skin, resulting in burn-induced compartment syndrome. Conventionally, this has been treated with decompressive therapies, such as escharotomy. The most recent surveys have identified that the United States and Canada both face a shortage of practicing burn surgeons. In the event of a burn disaster, many nonburn surgeons would need to provide burn care, including decompressive therapies. We reviewed the literature to provide accurate, accessible, and applicable recommendations regarding this practice following burn injury for both the practicing burn surgeon and those that would provide care in the burn disaster.

A phase 3, open-label, controlled, randomized, multicenter trial evaluating the efficacy and safety of StrataGraft® construct in patients with deep partial-thickness thermal burns

OBJECTIVE

This phase 3 study evaluated StrataGraft construct as a donor-site sparing alternative to autograft in patients with deep partial-thickness (DPT) burns.

METHODS

Patients aged ≥18 years with 3-49% total body surface area (TBSA) thermal burns were enrolled. In each patient, 2 DPT areas (≤2000cm² total) of comparable depth after excision were randomized to either cryopreserved StrataGraft or autograft. Coprimary endpoints were: the difference in percent area of StrataGraft treatment site and autograft treatment site autografted at Month 3 (M3), and the proportion of patients achieving durable wound closure of the StrataGraft site without autograft at M3. Safety assessments were performed in all patients. Efficacy and safety follow-up continued to 1 year.

RESULTS

Seventy-one patients were enrolled. By M3, there was a 96% reduction in mean percent area of StrataGraft treatment sites that required autografting, compared with autograft treatment sites (4.3% vs 102.1%, respectively; P<.0001). StrataGraft treatment resulted in durable wound closure at M3 without autografting in 92% (95% CI: 85.6, 98.8; n/n 59/64) of patients for whom data were available. The most common StrataGraft-related adverse event was pruritus (15%).

CONCLUSIONS

Both coprimary endpoints were achieved. StrataGraft may offer a new treatment for DPT burns to reduce the need for autografting.

CLINICAL TRIAL IDENTIFIER

NCT03005106.

47 COVID-19 Impact on Burn Care- A Summary of Weekly Bed Counts and Surge Capacity

Introduction

The COVID-19 pandemic has raised global awareness of healthcare resource limitations. Specifically, the pandemic has demonstrated that burn disaster planning should involve non-burn disasters that threaten staff, supplies, or space. The ABA facilitated bed counts with the assistance of regional disaster coordinators from April through August of 2020. Our analysis examines the impact of the pandemic on burn surge and bed capacity in the U.S.

Methods

Bed availability was obtained by the ABA regional disaster coordinators through an initiative by the Organization and Delivery of Burn Care Committee. Bed availability was defined as immediately available burn beds and categorized as adult, pediatric, or flexible. Surge capacity was defined as the maximum number of patients that a burn center could admit in a surge situation. Data was deidentified by the central office with descriptive statistics to determine bed availability and surge capacity trends regionally and nationally.

Results

Bed counts were performed 6 times from 04/17/2020 through 08/14/2020. Response rates from the 137 North American burn centers varied from 86–96%. At least 6 burn centers (5%) were either closed or converted for COVID patients during the initial two bed counts. The total number of adult or pediatric burn beds was 2,082. Total bed availability decreased from 845 at the first survey down to 572 beds at the last survey. Surge capacity baseline was 1,668 beds and decreased from 1,132 beds in the initial survey down to 833 beds in the final survey.

Conclusions

Our study demonstrates a significant impact on burn bed availability due to the COVID-19 pandemic with a 37% reduction in available burn beds from April to August and a 26% reduction in surge capacity. This study demonstrates a substantial reduction in bed availability during the pandemic with additional analysis in process to examine regional trends.

615 The Effects of the COVID-19 Pandemic on Implementation of a Psychological Distress Screening Program after Burn Injury

Introduction

The relationship between psychiatric conditions and burn injury is complex, as disorders in thought or mood can both predispose to as well as result from thermal injury. We sought to describe our center’s experience with implementation of a psychological distress screening program in the run-up to and during the COVID-19 pandemic.

Methods

We undertook an analysis of de-identified data as part of a quality improvement review focusing on the results of psychological screening of our outpatient burn population. In the spring of 2019, our verified burn center implemented an outpatient screening program consisting of a registered nurse administering three validated test to screen for Post-Traumatic Stress Disorder screen, depression and anxiety, and problematic alcohol consumption to all patients at the time of physically checking in for their first burn clinic appointment. All outpatients triggering a positive screen are subsequently referred to the burn unit PsyD while a negative screen results in monthly repeat screenings until discharge from the burn clinic or a positive screen, whichever comes first. We analyzed data from the last twelve months of normal outpatient workflow. Loess regression was used to analyze the monthly proportions of patients screening positive.

Results

During the peak of COVID-19 in our region, clinic staff were reduced, and screening procedures suspended for the months of March and April 2020. Therefore, the study period consisted of 01 July 2019 to 31 August 2020. A median of 36.5 screens were conducted per month [interquartile range 27.75, 44.75]. Of these screens, 26.5% were positive, with 94.2% successfully referred to the burn unit’s postdoctoral fellow. The Loess regression showed the proportion of patients screening positive for psychological stressors from July 2019 until a peak in November 2019. A downtrend was then noted in the proportion screening positive from December 2019 to date (Figure).

Conclusions

Psychological stressors are prevalent in burn outpatients. We attribute the decrease in positive responses beginning in December 2019 to a combination of a decrease in the frequency of repeat administrations of the screening test in patients after screening positive, and a reluctance of anxious patients to present to the burn clinic for fear of COVID exposure while at the facility.

56 Reduced Length of Stay with Autologous Skin Cell Suspension Reduces Burn Injuries

Introduction

Burn injuries remain a surgical challenge with few recent innovations. Grafting with split-thickness skin grafts (STSGs) has been the standard of care for decades. Although shown to have mortality benefits, STSGs are associated with significant morbidity in the form of pain and additional open wounds. For years, surgeons have looked for ways to decrease this associated morbidity. To that end, autologous skin cell suspension (ASCS) is a recently FDA-approved point of care regenerative medicine technology that reduces donor skin requirements without compromising clinical outcomes. Our study evaluated the cost and length of stay comparing STSG alone versus ASCS.

Methods

We obtained IRB-approval for single institution, retrospective chart review of patients age &gt;14 years admitted with burn injuries from March 2018 – September 2018. Primary outcome was length of stay/%TBSA for patients undergoing STSG alone as compared to patients undergoing ASCS. The 2016 American Burn Association National Burn Repository (NBR) was used to benchmark LOS/%TBSA. Age, percentage burn injury (TBSA), LOS, mortality, and number of surgeries were reviewed. Student’s t-test was used to assess statistical significance of intragroup analysis.

Results

36 patients were treated with ASCS in combination with meshed autografts for full-thickness acute burn injuries. 37 patients were treated with STSGs at our center. Mean age and %TBSA was 45.2 years and 6.6% for the STSG group and 46.0 years and 18.6% for the ASCS group. The LOS/%TBSA for the STSG was 1.72 versus 1.19 for the ASCS patients (p-value=0.02). The NBR predicts a LOS/%TBSA of 3.38 and 3.42 for the STSG and ASCS groups. Patients in the STSG group and ASCS group had statistically similar surgeries and mortalities.

Conclusions

Burn injured patients treated with ASCS had a decreased LOS/%TBSA when compared to both the STSGs and NBR predictions. ASCS is a novel technology allowing for point-of-care treatment that may decrease LOS for burn injured patients and should be considered as an adjunct to traditional techniques for burn patients.

Applicability of Research to Practice

Reduced length of stay compared to traditional burn care.

T5 Preliminary Analysis of a Phase 3 Open-label, Controlled, Randomized Trial Evaluating the Efficacy and Safety of a Bioengineered Regenerative Skin Construct in Patients with Deep Partial-thickness Thermal Burns

Introduction

Autograft (AG) is the standard of care for treatment of severe burns. While AG provides effective wound closure (WC), the procedure creates a donor-site wound prone to dyspigmentation, infection, scarring, and pain. In a phase 1b trial, no deep partial-thickness (DPT) wound treated with a bioengineered regenerative skin construct (BRSC) required AG by Day 28 and WC at the BRSC site was achieved in 93% of patients by Month 3 (Holmes et al 2019). This phase 3 study evaluated the efficacy and safety of this BRSC in patients with DPT burns.

Methods

This phase 3 study (NCT03005106) enrolled patients aged ≥18 years with 3–49% total body surface area (TBSA) thermal burns on the torso or extremities. In each patient, two DPT areas (≤2,000 cm2 total) deemed comparable following excision were randomized to treatment with either cryopreserved BRSC or AG. Coprimary endpoints were 1) the difference in percent area of BRSC treatment site and AG treatment site autografted at 3 months and 2) the proportion of patients achieving durable WC of the BRSC treatment site without AG at 3 months. Safety assessments were performed in all patients. Efficacy was analyzed at 3 months and safety and scar follow-up continues to one year.

Results

A total of 71 patients were enrolled (mean [SD] age 44 [16] years; mean [SD] %TBSA 12.0 [8.4]). By Month 3, 4.3% (SD 21.6%) of all BRSC-treated area required AG compared with an additional regrafting of 2.1% of all AG-treated area (total 102.1% SD 13.1%; P&lt; .0001). Three patients subsequently required AG at their BRSC site, 2 of whom also required it at their AG sites; Durable WC without autografting at the BRSC treatment site was achieved at Month 3 in 83% of patients compared with 86% of patients at the AG site. The most common BRSC-related adverse event (AE) was pruritus, occurring in 11 (15%) patients. All BRSC-related AEs were mild or moderate in severity.

Conclusions

This phase 3 study achieved both coprimary endpoints, including significant autograft sparing and durable WC in DPT burns. This BRSC may offer a new treatment for severe burns to reduce or eliminate the need for AG.

Applicability of Research to Practice

This BRSC has shown clinical benefit in patients with DPT thermal burns, potentially mitigating donor site morbidity.

External Funding

Stratatech, a Mallinckrodt Company; Funding and technical support for the Phase 3 clinical study were provided by the Biomedical Advanced Research and Development Authority (BARDA), under the Assistant Secretary for Preparedness and Response, within the U.S. Department of Health and Human Services, under Project BioShield Contract No. HHSO100201500027C.

Updating the Burn Center Referral Criteria: Results From the 2018 eDelphi Consensus Study

Existing burn center referral criteria were developed several years ago, and subsequent innovations in burn care have occurred. Coupled with frequent errors in the estimation of extent of burn injury and depth by referring providers, patients are both over and under-triaged when the existing criteria are used to support patient care decisions. In the absence of compelling clinical trial data on appropriate burn patient triage, we convened a multidisciplinary panel of experts to execute an iterative eDelphi consensus process to facilitate a revision. The eDelphi process panel consisted of n = 61 burn stakeholders and experts and progressed through four rounds before reaching consensus on key clinical domains. The major findings are that 1) burn center consultation is strongly recommended for all patients with deep partial-thickness or deeper burns ≥ 10% TBSA burned, for full-thickness burns ≥ 5% TBSA burned, for children and older adults with specific dressing and medical needs, and for special burn circumstances including electrical, chemical, and radiation injuries; 2) smaller burns are ideally followed in burn center outpatient settings as soon as possible after injury, preferably without delays of a week or more; 3) frostbite, Stevens-Johnson syndrome/TENS, and necrotizing soft-tissue infection patients benefit from burn center treatment; and 4) telemedicine and technological solutions are of likely benefit in achieving this standard. Unlike the original criteria, the revised consensus-based guidelines create a framework promoting communication so that triage and treatment are specifically tailored to individual patient characteristics, injury severity, geography, and the capabilities of referring institutions.

Initial Experience With Autologous Skin Cell Suspension for Treatment of Deep Partial-Thickness Facial Burns

Facial burns present a challenge in burn care, as hypertrophic scarring and dyspigmentation can interfere with patients’ personal identities, ocular and oral functional outcomes, and have long-term deleterious effects. The purpose of this study is to evaluate our initial experience with non-cultured, autologous skin cell suspension (ASCS) for the treatment of deep partial-thickness (DPT) facial burns. Patients were enrolled at a single burn center during a multicenter, prospective, single-arm, observational study involving the compassionate use of ASCS for the treatment of large total BSA (TBSA) burns. Treatment decisions concerning facial burns were made by the senior author. Facial burns were initially excised and treated with allograft. The timing of ASCS application was influenced by an individual’s clinical status; however, all patients were treated within 30 days of injury. Outcomes included subjective cosmetic parameters and the number of reoperations within 3 months. Five patients (4 males, 1 female) were treated with ASCS for DPT facial burns. Age ranged from 2.1 to 40.7 years (mean 18.2 ± 17.3 years). Average follow-up was 231.2 ± 173.1 days (range 63–424 days). Two patients required reoperation for partial graft loss within 3 months in areas of full-thickness injury. There were no major complications and one superficial hematoma. Healing and cosmetic outcomes were equivalent to, and sometimes substantially better than, outcomes typical of split-thickness autografting. Non-cultured, ASCS was successfully used to treat DPT facial burns containing confluent dermis with remarkable cosmetic outcomes. Treatment of DPT burns with ASCS may be an alternative to current treatments, particularly in patients prone to dyspigmentation, scarring sequelae, and with limited donor sites.

A Comparative Study of the ReCell® Device and Autologous Spit-Thickness Meshed Skin Graft in the Treatment of Acute Burn Injuries

Early excision and autografting are standard care for deeper burns. However, donor sites are a source of significant morbidity. To address this, the ReCell^® Autologous Cell Harvesting Device (ReCell) was designed for use at the point-of-care to prepare a noncultured, autologous skin cell suspension (ASCS) capable of epidermal regeneration using minimal donor skin. A prospective study was conducted to evaluate the clinical performance of ReCell vs meshed split-thickness skin grafts (STSG, Control) for the treatment of deep partial-thickness burns. Effectiveness measures were assessed to 1 year for both ASCS and Control treatment sites and donor sites, including the incidence of healing, scarring, and pain. At 4 weeks, 98% of the ASCS-treated sites were healed compared with 100% of the Controls. Pain and assessments of scarring at the treatment sites were reported to be similar between groups. Significant differences were observed between ReCell and Control donor sites. The mean ReCell donor area was approximately 40 times smaller than that of the Control (P < .0001), and after 1 week, significantly more ReCell donor sites were healed than Controls (P = .04). Over the first 16 weeks, patients reported significantly less pain at the ReCell donor sites compared with Controls (P ≤ .05 at each time point). Long-term patients reported higher satisfaction with ReCell donor site outcomes compared with the Controls. This study provides evidence that the treatment of deep partial-thickness burns with ASCS results in comparable healing, with significantly reduced donor site size and pain and improved appearance relative to STSG.

The Golden Opportunity: Multidisciplinary Simulation Training Improves Trauma Team Efficiency

OBJECTIVE

Every trauma patient has a golden hour, and resuscitation efficiency within that hour has large implications for patients. We instituted simulation based trauma resuscitation training with the hypothesis that it would improve trauma team efficiency.

METHODS

Five simulation training sessions were conducted with immediate debriefing. Metrics collected in actual trauma resuscitations before and after simulation training included time of primary and secondary surveys and time to computed tomography (CT) scan. Study participants were from multidisciplinary specialties involved in trauma resuscitations as well as former trauma patients from the Trauma Survivors Network.

RESULTS

Seventy-three patients undergoing trauma resuscitations were screened and 67 patients were included. Time to CT scan and secondary survey completion were significantly reduced in actual trauma patient activations following implementation of the curriculum (reduction of 23 to 16 minutes for CT scan p < 0.05, and reduction from 14 to 6 minutes for secondary survey, p < 0.05). Time to primary survey completion did not change (5 minutes).

CONCLUSIONS

Multidisciplinary simulation training was associated with improved trauma team efficiency in the form of reduced assessment time. As emergency department length of stay is an independent predictor of hospital mortality following trauma activation, team-based simulation training has the potential to improve patient outcomes. Multidisciplinary involvement was a key factor, and Trauma Survivors Network involvement brought credibility from the patient perspective.

Young-onset dementia and the need for specialist care: a national and international perspective

OBJECTIVES

Receiving a timely and accurate diagnosis and gaining access to age-appropriate support for younger people living with dementia (YPD) remains a challenge both in the UK and internationally because the focus of most dementia services is primarily upon the needs of older people. The political case to improve services for YPD depends upon the establishment of an understanding of the clinical symptoms, an unequivocal evidence base about need and an accurate evaluation of the size of the population affected. This short report assesses the evidence base from international studies regarding service design and delivery. The goal is to raise awareness, advance best practice and galvanise the international community to address the serious underfunding and underprovision of care for this marginalised group.

CONCLUSION

The current evidence suggests that there are universal problems, regardless of continent, with delays to diagnosis and poor understanding of optimum models for service provision and long-term care.

Nitroglycerin: An unusual solution to intraoperative hypothermia in a 4-year-old burn patient

We describe the case of a 4-year-old child undergoing extensive burn surgery with refractory intraoperative hypothermia. A low-dose nitroglycerin infusion was initiated to reverse vasoconstriction and improve heat absorption, after which the child's temperature steadily improved. In hypothermic burn patients, topical vasoconstrictors may hinder surface warming efforts. A vasodilator infusion may aid in warming the pediatric patient undergoing extensive excision and grafting.

Predicting Mortality and Independence at Discharge in the Aging Traumatic Brain Injury Population Using Data Available at Admission

BACKGROUND

Aging worsens outcome in traumatic brain injury (TBI), but available studies may not provide accurate outcomes predictions due to confounding associated injuries. Our goal was to develop a predictive tool using variables available at admission to predict outcomes related to severity of brain injury in aging patients.

STUDY DESIGN

Characteristics and outcomes of blunt trauma patients, aged 50 or older, with isolated TBI, in the National Trauma Data Bank (NTDB), were evaluated. Equations predicting survival and independence at discharge (IDC) were developed and validated using patients from our trauma registry, comparing predicted with actual outcomes.

RESULTS

Logistic regression for survival and IDC was performed in 57,588 patients using age, sex, Glasgow Coma Scale score (GCS), and Revised Trauma Score (RTS). All variables were independent predictors of outcome. Two models were developed using these data. The first included age, sex, and GCS. The second substituted RTS for GCS. C statistics from the models for survival and IDC were 0.90 and 0.82 in the GCS model. In the RTS model, C statistics were 0.80 and 0.67. The use of GCS provided better discrimination and was chosen for further examination. Using a predictive equation derived from the logistic regression model, outcome probabilities were calculated for 894 similar patients from our trauma registry (January 2012 to March 2016). The survival and IDC models both showed excellent discrimination (p < 0.0001). Survival and IDC generally decreased by decade: age 50 to 59 (80% IDC, 6.5% mortality), 60 to 69 (82% IDC, 7.0% mortality), 70 to 79 (76% IDC, 8.9% mortality), and 80 to 89 (67% IDC, 13.4% mortality).

CONCLUSIONS

These models can assist in predicting the probability of survival and IDC for aging patients with TBI. This provides important data for loved ones of these patients when addressing goals of care.

For Love, Not Money: The Financial Implications of Surgical Fellowship Training

Surgical residents cite “increased income potential” as a motivation for pursuing fellowship training, despite little evidence supporting this perception. Thus, our goal is to quantify the financial impact of surgical fellowship training on financial career value. By using Medical Group Management Association and Association of American Medical Colleges physician income data, and accounting for resident salary, student debt, a progressive tax structure, and forgone wages associated with prolonged training, we generated a net present value (NPV) for both generalist and subspecialist surgeons. By comparing generalist and subspecialist career values, we determined that cardiovascular (ANPV = $698,931), pediatric ($430,964), thoracic ($239,189), bariatric ($166,493), vascular ($96,071), and transplant ($46,669) fellowships improve career value. Alternatively, trauma (-$11,374), colorectal (-$44,622), surgical oncology (-$203,021), and breast surgery (-$326,465) fellowships all reduce career value. In orthopedic surgery, spine ($505,198), trauma ($123,250), hip and joint ($60,372), and sport medicine ($56,167) fellowships improve career value, whereas shoulder and elbow (-$4,539), foot and ankle (-$173,766), hand (-$366,300), and pediatric (-$489,683) fellowships reduce career NPV. In obstetrics and gynecology, reproductive endocrinology ($352,854), and maternal and fetal medicine ($322,511) fellowships improve career value, whereas gynecology oncology (-$28,101) and urogynecology (-$206,171) fellowships reduce career value. These data indicate that the financial return of fellowship is highly variable.

For Love, Not Money: The Financial Implications of Surgical Fellowship Training

Surgical residents cite increased income potential as a motivation for pursuing fellowship training, despite little evidence supporting this perception. Thus, our goal is to quantify the financial impact of surgical fellowship training on financial career value. By using Medical Group Management Association and Association of American Medical Colleges physician income data, and accounting for resident salary, student debt, a progressive tax structure, and forgone wages associated with prolonged training, we generated a net present value (NPV) for both generalist and subspecialist surgeons. By comparing generalist and subspecialist career values, we determined that cardiovascular (NPV = 698,931), pediatric (430,964), thoracic (239,189), bariatric (166,493), vascular (96,071), and transplant (46,669) fellowships improve career value. Alternatively, trauma (11,374), colorectal (44,622), surgical oncology (203,021), and breast surgery (326,465) fellowships all reduce career value. In orthopedic surgery, spine (505,198), trauma (123,250), hip and joint (60,372), and sport medicine (56,167) fellowships improve career value, whereas shoulder and elbow (4,539), foot and ankle (173,766), hand (366,300), and pediatric (489,683) fellowships reduce career NPV. In obstetrics and gynecology, reproductive endocrinology (352,854), and maternal and fetal medicine (322,511) fellowships improve career value, whereas gynecology oncology (28,101) and urogynecology (206,171) fellowships reduce career value. These data indicate that the financial return of fellowship is highly variable.

A case of Tannerite(®) target mixture causing severe blast injury

Tannerite(®) is a proprietary blend of an oxidizer, ammonium nitrate, and aluminum powder catalyst used to make homemade exploding targets. While it is currently approved for unrestricted sale in the United States, it can be used to form devices capable of inflicting major blast injury. We present here a case of close proximity exposure to detonation of the mixed Tannerite(®) blend. In our patient, the exposure lead to injuries typical of blast injury, such as tympanic membrane rupture, globe injury, and severe burns. We review here the sequelae of blast injuries that one must consider when treating a patient with close proximity exposure to Tannerite, with considerations unique to this product.