Patient outcomes vs. service workload: an analysis of outcomes in the burn service of England and Wales.

BACKGROUND: Patient outcomes in specialist burns units have been used as a metric of care needs and quality. Besides patient factors there are service factors that might influence Length of Stay (LOS) and mortality, e.g. pressure on beds. Although the bed needs of UK hospitals have dropped significantly over the past three decades, with changes in policies and practices, recent reports suggest that hospitals have 90% bed occupancy for 48 weeks of the year. In the UK, the specialist burn injury service is organised so that patients are assessed on arrival at hospital, and those needing admission are found a nearby bed in a suitable unit through the National Burn Bed Bureau. The aim of this study was to investigate the effect on outcomes of service pressures due to shortages of beds. METHODS: We took an extract of the anonymised patient data from the specialised burn injury database, iBID, and created a new database based on matching that data with bed availability data provided by the national Burn Bed Bureau. Cox proportional hazard modelling was used for analysis to investigate if there is an impact of bed occupancy (a proxy measure of workload) on LOS. RESULTS: Cox proportional hazard modelling indicated that half of the services in England and Wales are less likely to discharge a patient if the bed availability is high. Two of the services have abnormally high bed availability and LOS, therefore a model without these two services indicates a general reluctance to discharge patients when beds are available. CONCLUSIONS: It is possible that the effect we observed is a result of gaming as service providers are paid by the number of admissions. In addition, providers many not all give the same level of accuracy of bed availability information to the NBBB: some may under report availability, for example at times of high pressure on staff. Furthermore, burn services may not empty beds to avoid being filled up by work from other specialties, thus making them unable to admit a burn when referred.

Developing a Pediatric Burn Treatment Program in a Community Hospital.

There are 120,000 pediatric burn injuries annually in the United States (Center for Research Injury and Policy [CRIP], 2010). Although many pediatric thermal injuries are not severe, referral to a burn unit for any burn regardless of depth, size, location, or severity is common. Many patients with smaller burns can be effectively managed in a community hospital, which allows children and their families to remain close to home, reducing costs and some stress associated with hospital stays. This article describes the process of creating a community pediatric burn care program at St. John Hospital in Detroit, Michigan, and initial outcomes of the program.

Rising to the challenge: transforming an adult ICU into an adult and pediatric ICU.

Published literature on natural disasters describes lessons learned in preparing for disasters, evacuating patients, and caring for patients in the immediate aftermath. Some disasters, however, require longer-term solutions to best meet the health needs of the community during the recovery from the disaster. This article presents an account of one academic medical center's experience in transforming an existing adult burn intensive care unit into an adult and pediatric burn intensive care unit to meet the needs of a community following a hurricane. The process of training 2 groups of specialty nurses and the success of expanding an adult unit are described.

Burn disaster preparedness and the southern region of the United States.

Disasters with significant numbers of burn-injured patients create incredible challenges for disaster planners. Although not unique to burn care, high-intensity areas of specialty such as burns, pediatrics, and trauma quickly become scarce resources in a disaster.All disasters are local, but regional support is critical in burn disaster planning. On a day-to-day basis, burn bed capacity can be problematic. A review of the literature and our experiences, including mathematical modeling and real events, reaffirm how rapidly we can overwhelm our resources.This review includes the Southern Burn Plan, created by the burn centers of the American Burn Association's Southern Region, should there be a need for additional hospital burn beds (capacity) and burn care (capability) in response to a disaster. This article also explores planning and preparedness developments and describes options to improve our efforts, including training and education.It is incumbent upon everyone in the healthcare profession to become comfortable managing burn-injured patients until the patients can be moved to a burn center. Understanding the regional capacity, capability, and when a surge of patients may require the practice of altered standards of care is essential for those involved in medical disaster preparedness.

Burn Unit Design-The Missing Link for Quality and Safety.

The relationship between infrastructure, technology, model of care, and human resources influences patient outcomes and safety, staff productivity and satisfaction, retention of personnel, and treatment and social costs. This concept underpins the need for evidence-based design and has been widely adopted to inform hospital infrastructure planning. The aim of this review is to establish evidence-based, universally applicable key features of a burn unit that support function in a comprehensive patient-centered model of care. A literature search in medical, architectural, and engineering databases was conducted. Burn associations' guidelines and relevant articles published in English, between 1990 and 2020, were included, and the available evidence is summarized in the review. Few studies have been published on burn unit design in the past 30 years. Most of them focus on the role of design in infection control and prevention and consist primarily of descriptive or observational reports, opportunistic historical cohort studies, and reviews. The evidence available in the literature is not sufficient to create a definitive infrastructure guideline to inform burn unit design, and there are considerable difficulties in creating evidence that will be widely applicable. In the absence of a strong evidence base, consensus guidelines on burn unit infrastructure should be developed, to help healthcare providers, architects, and engineers make informed decisions, when designing new or renovated facilities.

[Management strategy of burn and wound care ward during coronavirus disease 2019 pandemic].

The prevention and control of coronavirus disease 2019 (COVID-19) has already entered a key period. The patients treated in the burn and wound care ward are susceptible to viral infection because of disease, age and other factors, so it is very important to manage the burn and wound care ward during the prevention and control of COVID-19 pandemic. In this paper, combining with the key clinical problems of prevention and control in hospital during the epidemic period of COVID-19 infection, medical evidence, and clinical and management experience, the authors formulate prevention and control management strategy of the author's unit in order to provide reference for prevention and control of burn and wound care ward.

Toxic Epidermal Necrolysis and Steven-Johnson Syndrome: A Comprehensive Review.

Significance: Toxic epidermal necrolysis (TEN) and Steven-Johnson syndrome (SJS) are potentially fatal acute mucocutaneous vesiculobullous disorders. Evidence to date suggests that outcomes for patients with both TEN and SJS are largely dependent on stopping the causative agent, followed by supportive care and appropriate wound management in a specialized burns unit. These are life-threatening conditions characterized by widespread full-thickness cutaneous and mucosal necrosis. This article outlines the approach to holistic management of such patients, in a specialized unit, highlighting various practical aspects of wound care to prevent complications such as infection, mucosal and adhesions, and ocular scaring. Recent Advances: There is improved understanding of pain and morbidity with regard to the type and frequency of dressing changes. More modern dressings, such as nanocrystalline, are currently favored as they may be kept in situ for longer periods. The most recent evidence on systemic agents, such as corticosteroids and cyclosporine, and novel treatments, are also discussed. Critical Issues: Following cessation of the culprit trigger, management in a specialized burns unit is the most important management step. It is now understood that a multidisciplinary team is essential in the care of these patients. Following admission of such patients, dermatology, ear, nose, and throat surgery, ophthalmology, urology, colorectal surgery, and gynecology should all be consulted to prevent disease sequelae. Future Directions: Looking forward, research is aimed at achieving prospective data on the efficacy of systemic immunomodulating agents and dressing types. Tertiary centers with burns units should develop policies for such patients to ensure that the relevant teams are consulted promptly to avoid mucocutaneous complications.

[Practice and thinking about the establishment and management of burn intensive care unit].

The treatment of critically burned patients has benefited from the development of knowledge and technologies that we got in critical care medicine of our country in the past ten years. The close-ended management model of general intensive care unit (ICU) and the idea of general ICU doctors who treat the monitoring of organ function and alternative therapy of organs as their primary tasks would affect the treatments for special critical patients hospitalized in general ICU, especially for those patients who were severely burned. If the burn wounds of patients are not treated timely, properly or in effective manner, the final treatment outcome would be affected. Therefore, the establishment of burn ICU is necessary. The development and close-ended management of burn specialty ICU has significantly improved the success rates, reduced complications, shortened hospitalization time, and increased the quality of wound healing of severe burn patients in the past more than 10 years in our unit. With the reducing of burn, especially severe burn accidents, the construction of regional burn center and burn specialty ICU locating in burn center is necessary. It can not only reduce the waste of medical resource, but also ensure timely and professional treatments for the patients in sudden fire accidents. At present, there is no consensus on the establishment and management model of burn specialty ICU, and further discussion is needed in practice.

Combat burn life support: a military burn-education program.

The Advanced Burn Life Support Course has been used to train military physicians and nurses for more than 16 years. Although it useful for teaching the fundamentals of burn care, the course is designed for a civilian audience, covers only the first 24 hours of burn care, and presumes the availability of a burn center for patient transfer. In preparation for hostilities in Iraq, we developed several add-on modules to the standard Advanced Burn Life Support course to meet specific needs of military audiences. These modules cover the treatment of white phosphorus burns; the treatment of mustard gas exposure; the long-range aeromedical transfer of burn patients; the management of burn patients beyond the first 24 hours; and the delivery of burn care in austere environments. These add-on modules are termed Combat Burn Life Support. Between January 22, 2003, and May 12, 2003, Advanced Burn Life Support and/or Combat Burn Life Support courses were provided to a total of 1035 military health care providers in the United States, Germany, and the Middle East. Student feedback was largely positive and is being used for further course refinement. The Combat Burn Life Support Course is designed to augment, rather than replace, the Advanced Burn Life Support Course. Although intended for a military audience, the course material is equally applicable to civilian terrorist or mass casualty situations.

Managing a combined burn trauma disaster in the post-9/11 world: lessons learned from the 2003 West Pharmaceutical plant explosion.

At 1:37 pm on January 29, 2003, an explosion occurred at the West Pharmaceutical chemical plant in Kinston, North Carolina. The explosion killed three people at the scene and resulted in more than 30 admissions to area hospitals. The disaster resulted in 10 critically ill burn patients, who were all intubated with inhalation injuries, many with combined burn and trauma injuries. All 10 critically injured patients were admitted to a tertiary care facility 100 miles away with both a Level I trauma center and a verified burn center. Ultimately, 7 of 10 patients survived (a mortality rate of 30%), and none were transferred to another trauma or burn center. This article analyzes the unique challenges that combined burn and trauma patients present during a disaster, critically examines the response to this disaster, describes lessons learned, and presents recommendations that may improve the response to such disasters in the future.

Burn support for Operation Iraqi Freedom and related operations, 2003 to 2004.

Thermal injury historically constitutes approximately 5% to 20% of conventional warfare casualties. This article reviews medical planning for burn care during war in Iraq and experience with burns during the war at the US Army Burn Center; aboard the USNS Comfort hospital ship; and at Combat Support Hospitals in Iraq and in Afghanistan. Two burn surgeons were deployed to the military hospital in Landstuhl, Germany, and to the Gulf Region to assist with triage and patient care. During March 2003 to May 2004, 109 burn casualties from the war have been hospitalized at the US Army Burn Center in San Antonio, Texas, and US Army Burn Flight Teams have moved 51 critically ill burn casualties to the Burn Center. Ten Iraqi burn patients underwent surgery and were hospitalized for up to 1 month aboard the Comfort, including six with massive wounds. Eighty-six burn casualties were hospitalized at the 28th Combat Support Hospital for up to 53 days. This experience highlights the importance of anticipating the burn care needs of both combatants and the local civilian population during war.

Complete integration of inpatient and outpatient burn care: evolution of an outpatient burn clinic.

Burn centers are under continuing pressures to lower costs and maintain quality of care. One method of achieving this goal is to integrate inpatient and outpatient care in the burn unit. In 1991, our unit instituted an on-site outpatient clinic that was expanded significantly in 1996. The clinic is staffed by the inpatient personnel and allows for 24-hour availability and accommodation of all nurse and physician visits. The number of outpatient visits has increased from 1604 in 1992 to 4728 in 1996, despite a 33% reduction in registered nurse staffing during this time. From 1990 to 1996, the average length of inpatient stay for burns of 0% to 5% total burn surface area (TBSA), 6% to 10% TBSA, and 11% to 15% TBSA has decreased from 7.5 to 3.7 days, 10.3 to 7.7 days, and 16.6 to 11.8 days, respectively. Complete integration of inpatient and outpatient burn care can be achieved. An expanded on-site outpatient facility leads to optimal continuity of care, outpatient management of a larger percentage of burn injuries, and a shift in census from the inpatient to outpatient settings.

Home health care and burn care: an educational and economical program.

Changes in health care reimbursement have challenged providers of health care to work smarter instead of harder, with more efficient and effective use of resources. Patients with burn injuries remain hospitalized for dressing changes that could be completed in the home environment by health care professionals. An early discharge for a select group of patients from a resource-intensive hospital stay to a quality, cost-effective home care program was achieved. An educational program was developed to provide home care nurses the necessary knowledge and skill to care for the patient with burn injuries at home. This program combines didactic classroom lectures with a clinical orientation for home care registered nurses. The outcome for patients is a well-integrated continuity of care with a decreased length of hospital stay.

A knowledge-based information system for advice in the crisis management of the patient with burns.

A knowledge-based information system that has been designed to be used as an electronic advisor to guide in fluid resuscitation and in the management of the most frequently occurring complications during the first 48 hours after burn injury is described. The system was also developed for training physicians and nurses and may eventually be used for peer review of the management of patients in the burn unit. Ten data screens are used for entry of the administrative data, the clinical background, and the monitored data. The latter include tables for recording fluid therapy and laboratory results. The knowledge base consists of a series of heuristic decision rules that were formulated by a burn care expert and that express the Uppsala fluid resuscitation program to prevent burn shock. The data recorded for a patient are compared with the data in the knowledge base, and the appropriate conclusions are generated. The system's conclusions, the fluid and ventilation prescription, and other required patient management measures are then displayed as a report. The underlying reasoning for each case may be explored by means of the system's explanation facility. The system has been successfully validated by 125 hypothetic cases that represent typical situations of patients with severe burns.

Hospital and prehospital resources for optimal care of patients with burn injury: guidelines for development and operation of burn centers. American Burn Association.

Each year in the United States burn injuries result in more than 500,000 hospital emergency department visits and approximately 70,000 acute inpatient admissions. Most burn injuries are relatively minor, and patients are discharged following outpatient treatment at the medical facility where they are first seen. Of those patients with injuries serious enough to require hospitalization, about 20,000 are admitted directly or by referral to hospitals with special capabilities in the treatment of burn injury. Hospitals with these service capabilities are normally termed "burn centers." This document defines the system, organizational structure, personnel, program, and physical facilities involved in establishing the eligibility of hospitals with the capability of being identified as burn centers.

Mixing inpatient with outpatient care: establishing an outpatient clinic on a burn unit.

Outpatient care of patients with burns is an important aspect of a total health care plan. Changes in the health care system, which focuses on cost containment, force reevaluation of the methods used for delivery of high-tech care, particularly in areas such as burn care. Great advances that have taken place over the past decade in the field of burn care have enabled health care providers to treat more patients with burns as outpatients. Those who are specially trained in burn care continue to be the optimal caregivers. The appropriate facilities, spray tables, hydrotherapy, and dressing rooms in which patients with burns are treated are equally important and must be adapted to meet the needs of patients who are ambulatory. The goals of an outpatient burn clinic should be to provide daily wound care and patient education to prevent unnecessary admissions and to promote early discharge for hospitalized patients. Nurses trained in burn care are the optimal providers of ambulatory burn care; therefore the clinic location should be where the caregivers are available. Several obstacles needed to be overcome before an outpatient clinic could be established on the burn unit itself. Wound care is now provided by burn unit nurses, which leads to better results and more consistent follow-up. Patient satisfaction is increased, patient teaching is provided by experienced staff, unnecessary admissions are prevented, and patients are able to be discharged from the hospital earlier or to be followed as outpatients even if surgery is eventually required.

Burns in India.

The personal experiences and data collected during an extensive 3-month tour of India are reported. Twenty-eight hospitals in 14 cities were studied in depth, and data were collected with regard to admissions, burn capacity, practice characteristics, support services, and community efforts. Conclusions and recommendations based on this report are presented.

The occurrence of acquired immunodeficiency syndrome and unsuspected human immunodeficiency virus in burn patients.

Although the risk of nosocomial transmission of human immunodeficiency virus remains low, burn center personnel may be at greater risk. Approximately 10% of burn patients admitted to an urban center were found to be positive to the human immunodeficiency virus, consistent with other findings of increased prevalence in trauma patients. "Universal" precautions adequate for other health care settings may not be sufficient in the burn center. Knowledge of a patient's human immunodeficiency virus status has important treatment implications.

Outpatient management of the burn patient.

Data from the National Burn Repository 2002 report indicate that most burns are minor and that 80%, to 90% of burn injuries can be treated on an outpatient basis. This article discusses the assessment and outpatient management of burn injuries, the role of specialized burn centers, and the reimbursement for outpatient burn care.

Media dramatize need for center. Oregon friends rally for burn center remodeling cause.

A carefully orchestrated fund-raising and media relations campaign contributed to the opening earlier this year of the new Oregon Burn Center on Legacy Health System's Emanuel Hospital campus, Portland, Ore. The new $5 million center is the only facility of its kind between Sacramento, Calif., Salt Lake City and Seattle. It replaces the original 12-bed facility built in 1973. The expanded center has 16 beds in 16 private rooms, treatment areas designed for children and a host of other state-of-the-art improvements that make the Oregon Burn Center among the nation's finest. Between Legacy's investment of $3 million and contributions from Oregonians, more than $5 million was raised for the new center. Beyond that, annual giving, which amounted to $85,000 in fiscal 2001, is holding steady in 2002.