Impact of Chronic Alcohol Use on Fluid Resuscitation in Burn Patients.

Acute alcohol intoxication in burn patients has been associated with increased mortality, renal dysfunction, and difficulty with adequate fluid resuscitation. It is less clear how chronic alcohol use, regardless of intoxication status on admission, impacts patient outcomes. In this study, we examine varying levels of alcohol use in burn patients and its impact on both short- and long-term outcomes.

Higher Admission Frailty Scores Predict Increased Mortality, Morbidity, and Healthcare Utilization in the Elderly Burn Population.

The Rockwood Clinical Frailty Scale is a validated rapid assessment of frailty phenotype and predictor of mortality in the geriatric population. Using data from a large tertiary care burn center, we assessed the association between admission frailty in an elderly burn population and inpatient outcomes. This was a retrospective analysis of burn patients ≥65 years from 2015 to 2019. Patients were assigned to frailty subgroups based on comprehensive medical, social work, and therapy assessments. Cox proportional hazards regression was used to estimate associations between admission frailty and 30-day inpatient mortality. Our study included 644 patients (low frailty: 262, moderate frailty: 345, and high frailty: 37). Frailty was associated with higher median TBSA and age at admission. The 30-day cumulative incidence of mortality was 2.3%, 7.0%, and 24.3% among the low, moderate, and high frailty strata, respectively. After adjustment for age, TBSA, and inhalation injury, high frailty was associated with increased 30-day mortality, compared to low (hazard ratio 5.73; 95% confidence interval 1.86, 17.62). Moderate frailty also appeared to increase 30-day mortality, although estimates were imprecise (hazard ratio 2.19; 95% confidence interval 0.87-5.50). High frailty was associated with increased morbidity and healthcare utilization, including need for intensive care stay (68% vs 37% and 21%, P < .001) and rehab or care facility at discharge (41% vs 25% and 6%, P < .001), compared to moderate and low frailty subgroups. Our findings emphasize the need to consider preinjury physiological state and the increased risk of death and morbidity in the elderly burn population.

In Patients with Lower Extremity Burns and Osteomyelitis, Diabetes Mellitus Increases Amputation Rate.

In this retrospective analysis, we investigated the rate of radiologically confirmed osteomyelitis, extremity amputation and healthcare utilization in both the diabetic and non-diabetic lower extremity burn populations to determine the impact of diabetes mellitus on these outcomes. The burn registry was used to identify all patients admitted to our tertiary burn center from 2014 to 2018. Only patients with lower extremity burns (foot and/or ankle) were included. Statistical analysis was performed using Student's t test, chi-squared test, and Fischer's exact test. Of the 315 patients identified, 103 had a known diagnosis of diabetes mellitus and 212 did not. Seventeen patients were found to have osteomyelitis within three months of the burn injury. Fifteen of these patients had a history of diabetes. Notably, when non-diabetics were diagnosed with osteomyelitis, significant differences were observed in both length of stay and cost in comparison to their counterparts without osteomyelitis (36 vs 9 days; p=0.0003; $226,289 vs $48,818, p=0.0001). Eleven patients required an amputation and 10 (90.9%) of these patients had comorbid diabetes and documented diabetic neuropathy. Compared to non-diabetics, the diabetic cohort demonstrated both a higher average length of stay (13.7 vs 9.2 days, p-value=0.0016) and hospitalization cost ($72,883 vs $50,500, p-value=0.0058). Our findings highlight that diabetic patients with lower extremity burns are more likely to develop osteomyelitis than their non-diabetic counterparts and when osteomyelitis is present, diabetic patients have an increased amputation rate. Further study is required to develop protocols to treat this population, with the specific goal of minimizing patient morbidity and optimizing healthcare utilization.

Performance of ABCD-10 and SCORTEN mortality prediction models in a cohort of patients with Stevens-Johnson syndrome/toxic epidermal necrolysis.

BACKGROUND: Age, bicarbonate, cancer, dialysis, 10% body surface area risk model (ABCD-10) has recently been proposed as an alternative to the SCORe of toxic epidermal necrolysis (SCORTEN) model for predicting in-hospital mortality in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN). In contrast to SCORTEN, ABCD-10 incorporates prior dialysis and upweights the impact of cancer. OBJECTIVE: To determine the performance of ABCD-10 compared with that of SCORTEN in mortality prediction at a large, tertiary burn center. METHODS: A retrospective analysis of 192 patients with SJS/TEN admitted to the North Carolina Jaycee Burn Center from January 1, 2009, to December 31, 2019, was conducted. Data on these patients were collected using the burn registry and a manual chart review. The performance of both the mortality prediction models was assessed using univariate logistic regression and the Hosmer-Lemeshow test. RESULTS: The overall mortality was 22% (n = 43). Nine (5%) patients had cancer, and 7 (4%) had undergone prior dialysis; neither factor was associated with mortality (P = .11 and P = .62, respectively). SCORTEN was well calibrated to predict inpatient mortality (P = .82), whereas ABCD-10 appeared to have a poorer fit (P < .001) in these patients. Both the models showed good discrimination. LIMITATIONS: Small sample size. CONCLUSION: SCORTEN was a better predictor of inpatient mortality than ABCD-10 in a North American cohort of patients treated at the tertiary burn center.

Association Between Alcohol, Substance Use, and Inpatient Burn Outcomes.

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

Bias in alcohol and drug screening in adult burn patients.

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

COVID-19 related admissions to a regional burn center: The impact of shelter-in-place mandate.

The ramifications from the 2019 severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic caused by the novel corona virus will be felt globally for years to come. Mandates to shelter-in-place were called in nearly every state to limit viral exposure. The impact of the mandate on acute burn admissions was unknown. Our objective was to assess the impact of a shelter-in-place order on acute burn admissions at our burn center. All patients admitted to the burn center with burn injuries- including inhalation injury only- and desquamating skin disorders between March 10th to May 22nd, 2020 were eligible for inclusion. We compared all burn center admissions to a month-matched historical cohort from 2019, and summertime admissions for the last five years. Statistical significance was accepted as p < 0.05. There was a 9% increase in pediatric admissions after the shelter-in-place order. Compared to the 2019 cohort, there was a 28% increase in admissions of school aged children in 2020. This was not statistically significant. While the purpose of the "shelter-in-place" mandate was to reduce viral transmission of COVID-19, it consequently led to an increased percentage of admissions of school age children- comparable to our summertime numbers. More outreach and education are needed to provide safe resources for families during this pandemic.

Osteomyelitis Increases the Rate of Amputation in Patients With Type 2 Diabetes and Lower Extremity Burns.

In patients with diabetes mellitus (DM), amputation rates exceed 30% when lower extremity osteomyelitis is present. We sought to determine the rate of osteomyelitis and any subsequent amputation in our patients with DM and lower extremity burns. We performed a single-site, retrospective review at our burn center using the institutional burn center registry, linked to clinical and administrative data. Adults (≥18 years old) with DM admitted from January 1, 2014 to December 31, 2018 for isolated lower extremity burns were eligible for inclusion. We evaluated demographics, burn characteristics, comorbidities, presence of radiologically confirmed osteomyelitis, length of stay (LOS), inpatient hospitalization costs, and amputation rate at 3 months and 12 months after injury. We identified 103 patients with DM and isolated lower extremity burns. Of these, 88 patients did not have osteomyelitis, while 15 patients had radiologically confirmed osteomyelitis within 3 months of the burn injury. Compared to patients without osteomyelitis, patients with osteomyelitis had significantly increased LOS (average LOS 22.7 days vs 12.1 days, P = .0042), inpatient hospitalization costs (average $135,345 vs $62,237, P = .0008), amputation rate within 3 months (66.7% vs 5.70%, P < .00001), and amputation rate within 12 months (66.7% vs 9.1%, P < .0001). The two groups were otherwise similar in demographics, burn injury characteristics, access to healthcare, and preexisting comorbidities. Patients with DM and lower extremity burns incurred increased LOS, higher inpatient hospitalization costs, and increased amputation rates if radiologically confirmed osteomyelitis was present within 3 months of the burn injury.

Work-Related Burn Injuries in a Tertiary Care Burn Center, 2013 to 2018.

The features of work-related burn (WRB) injuries are not well defined in the literature and they vary depending on geographical location. We wanted to describe these characteristics among patients treated in the UNC Burn Center to evaluate the potential impact of commonly accepted prevention efforts. Adults of working age, admitted between January 1, 2013, and December 31, 2018, were identified using our Burn Center Registry. Demographic data, characteristics of injury, course of treatment, and patients' outcomes were described. Differences between work-related and non-work-related injuries were evaluated using the Chi-square test and Student t-test where appropriate. Three thousand five hundred and forty-five patients were included. WRB cases constituted 18% of the study population, and this proportion remained relatively stable during the study timeframe. Young white males were the majority of this group. When compared with non-WRB patients, they were characterized by fewer co-morbidities, decreased TBSA burns, decreased risk of inhalation injury, shorter time of intensive care treatment, shorter lengths of hospital stay, and lower treatment cost. In contrast to non-WRB, among which flame injuries were the main reason for admission, work-related patients most often suffered scald burns. They also had a dramatically increased proportion of chemical and electrical burns, making the latter the most common cause of death in that group. WRB are characterized by a characteristic patient profile, burn etiologies, and outcomes. Learning specific patterns at this group may contribute to optimize work safety regulations and medical interventions.

Acuity Is Seasonal in a Tertiary Care Burn Center.

Supply and demand dictate resource allocation in large academic institutions. Classic teaching is that burns is a seasonal specialty with winter being the "busiest" time of year. Resident allocation during the winter and summer months, however, is traditionally low due to the holidays and travel peaks. Our objective was to evaluate our acuity-defined as patient complexity-based on seasons, in order to petition for appropriate mid-level provider allocation. We performed a retrospective review of all admissions to an accredited, large academic burn center. All patients admitted between January 1, 2009 and December 31, 2018 were eligible for inclusion. Demographics, length of stay, injury characteristics, and mortality were evaluated. Thirteen thousand four hundred fifty-eight patients were admitted during this study period. Most patients were admitted during the summer. Patients admitted to the intensive care unit were more likely to be admitted in the winter, although this was not statistically significant. Winter admissions had the longest lengths of stay, and the highest incidence of inhalation injury. Female and elderly patients were more likely admitted during the winter. There was a significant difference in mortality between summer and winter seasons. Acuity is seasonal in our large academic burn center and resource allocation should align with the needs of the patients. This data may help large centers petition their institutions for more consistent experienced mid-level providers, specifically during critical seasons.

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

BACKGROUND: Psychiatric and substance use disorders are common among trauma and burn patients and are known risk factors for repeat episodes of trauma, known as trauma recidivism. The epidemiology of burn recidivism, specifically, has not been described. This study aimed to characterize cases of burn recidivism at a large US tertiary care burn center and compare burn recidivists (RCs) with non-recidivists (NRCs). METHODS: A 10-year retrospective descriptive cohort study of adult burn patients admitted to the North Carolina Jaycee Burn Center was conducted using data from an electronic burn registry and the medical record. Continuous variables were reported using medians and interquartile ranges (IQR). Chi-square and Wilcoxon-Mann-Whitney tests were used to compare demographic, burn, and hospitalization characteristics between NRCs and RCs. RESULTS: A total of 7134 burn patients were admitted, among which 51 (0.7%) were RCs and accounted for 129 (1.8%) admissions. Of the 51 RCs, 37 had two burn injuries each, totaling 74 admissions as a group, while the remaining 14 RCs had between three and eight burn injuries each, totaling 55 admissions as a group. Compared to NRCs, RCs were younger (median age 36 years vs. 42 years, p = 0.02) and more likely to be white (75% vs. 60%, p = 0.03), uninsured (45% vs. 30%, p = 0.02), have chemical burns (16% vs. 5%, p <  0.0001), and have burns that were ≤ 10% total body surface area (89% vs. 76%, p = 0.001). The mortality rate for RCs vs. NRCs did not differ (0% vs. 1.2%, p = 0.41). Psychiatric and substance use disorders were approximately five times greater among RCs compared to NRCs (75% vs. 15%, p <  0.001). Median total hospital charges per patient were nearly three times higher for RCs vs. NRCs ($85,736 vs. $32,023, p <  0.0001). CONCLUSIONS: Distinct from trauma recidivism, burn recidivism is not associated with more severe injury or increased mortality. Similar to trauma recidivists, but to a greater extent, burn RCs have high rates of comorbid psychiatric and medical conditions that contribute to increased health care utilization and costs. Studies involving larger samples from multiple centers can further clarify whether these findings are generalizable to national burn and trauma populations.

Evaluation of the New North Carolina Burn Registry.

High-quality burn registries can facilitate best practices in burn treatment, patient education, and research. A new burn registry was designed and implemented at the North Carolina Jaycee Burn Center in June 2013. The primary goals for the design of the new North Carolina (NC) burn registry were to improve reporting to the American Burn Association's National Burn Repository while maintaining current functionality and preserving previously collected data. The objective of this evaluation was to review the literature for best practices in designing a disease registry, benchmark the design of the NC burn registry with the best practices identified in the literature, and compare data quality before and after implementation of the new NC burn registry. The NC burn registry was evaluated using six measurable elements identified from essential indicators of the Agency for Healthcare Research and Quality user's guide for design, implementation, analysis, interpretation, and quality evaluation of registries. These elements were achieving objectives, using literature to inform the choice of data elements, improving completeness of information, employing consistency checks, providing clear, operational definitions of outcomes and other data elements, and minimizing active data collection. Five of the six chosen essential elements were found to have been met during the evaluation of the new NC burn registry. One essential element, improving completeness of information, had mixed results. The new NC burn registry improved reporting to the National Burn Repository while maintaining current functionality and preserving previously collected data.