Choosing wisely in burn care.

BACKGROUND: The Choosing Wisely Campaign was launched in 2012 and has been applied to a broad spectrum of disciplines in almost thirty countries, with the objective of reducing unnecessary or potentially harmful investigations and procedures, thus limiting costs and improving outcomes. In Canada, patients with burn injuries are usually initially assessed by primary care and emergency providers, while plastic or general surgeons provide ongoing management. We sought to develop a series of Choosing Wisely statements for burn care to guide these practitioners and inform suitable, cost-effective investigations and treatment choices. METHODS: The Choosing Wisely Canada list for Burns was developed by members of the Canadian Special Interest Group of the American Burn Association. Eleven recommendations were generated from an initial list of 29 statements using a modified Delphi process and SurveyMonkey™. RESULTS: Recommendations included statements on avoidance of prophylactic antibiotics, restriction of blood products, use of adjunctive analgesic medications, monitoring and titration of opioid analgesics, and minimizing 'routine' bloodwork, microbiology or radiological investigations. CONCLUSIONS: The Choosing Wisely recommendations aim to encourage greater discussion between those involved in burn care, other health care professionals, and their patients, with a view to reduce the cost and adverse effects associated with unnecessary therapeutic and diagnostic procedures, while still maintaining high standards of evidence-based burn care.

Properties of an ideal burn dressing: A survey of burn survivors and front-line burn healthcare providers.

OBJECTIVES: The objective of this study is to identify what burn survivors and front-line staff indicate would improve satisfaction with burn dressings, and the ranking of importance of different burn dressing characteristics. These findings will guide the development of future dressings to meet these needs. METHODS: Burn survivors (including the person injured and their family) and front-line burn healthcare providers completed a questionnaire on the importance given to different burn dressing characteristics (non-stick, absorbent, able to wear for a long time, flexible, easy to put on, easy to take off, antimicrobial, and non-bulky), and about the adequacy of pain management during dressing changes. RESULTS: A total of 99 individuals filled out the questionnaire (31 caregivers/survivors and 68 front-line burn healthcare providers). The most important dressing characteristics by both groups were "non-stick" and "fights infection". There was a significant difference between burn survivors and front-line burn healthcare providers pertaining to adequacy of pain management during dressing change. Adequate pain management was reported by 59% of burn survivors, which was significantly higher than that reported by the 25% front-line burn healthcare providers (p=0.002). CONCLUSIONS: Our study suggests that burn survivors and front-line burn providers have similar views on what constitutes an ideal dressing. A significantly proportion of caregiver/survivors felt that pain associated with dressing changes is being adequately managed despite healthcare providers' perception.

Factors predicting health-related quality of life following necrotizing fasciitis.

BACKGROUND: Necrotizing fasciitis (NF) is a debilitating soft tissue infection that results in disfiguring scars and often amputations. While mortality rates have improved, long-term outcomes in survivors of NF are poorly understood. OBJECTIVES: The objective of this study is to analyze the impact of NF on survivors' health-related quality of life (HRQoL) influenced by age, sex, comorbidities, %TBSA, and confidence with appearance. METHODS: We surveyed 56 adult patients with NF treated at either of two regional referral centers in Manitoba, Canada, between January 1, 2004, and December 31, 2014. Necrotizing soft tissue infections involving the fascial planes were identified during surgical debridement. HRQoL was measured by the Medical Outcomes Short Form-36. Derriford Appearance Scale-24, age, sex, comorbidities, and %TBSA were recorded, and group comparisons and stepwise regression models were developed for the mental and physical component scores separately. RESULTS: Mean Mental Component Score (MCS) was 44.5 ± 14.3 and mean Physical Component Score (PCS) was 36.5 ± 11.5; both means were lower than the Canadian population norm of 50. Although stepwise linear regression analyses with block entry indicated influence from age, sex, and comorbid conditions for the MCS and PCS, the only factors that were statistically significant in the final models were confidence with appearance for the MCS and %TBSA for the PCS. CONCLUSIONS: NF has long-term impact on mental and physical health-related quality of life. Distress regarding confidence with appearance affects mental quality of life, whereas the size of the injured area impacted physical quality of life. These findings can help guide targeted interventions that could potentially improve recovery from NF.

Early ambulation after-grafting of lower extremity burns.

OBJECTIVE: Early ambulation of lower extremity burns that undergo a skin graft may help to avoid some of the complications associated with immobilization. Despite recent evidence supporting early ambulation, post-operative immobilization following lower extremity skin grafting is still a common practice. The purpose of this study was to retrospectively assess the outcomes of lower extremity skin graft cases dressed with a multi-layer compression bandage who were ambulated in the immediate post-operative period. METHODS: This single centre observational study examined patients with a lower extremity burn that received a compressive dressing (Profore™) application immediately after surgical grafting and were ambulated no later than 1day post-operatively. RESULTS: Forty-two burn patients (47 limbs) met inclusion criteria for this study. Of these 42 patients, 25 were operated on as an inpatient. The remaining 17 patients were done on an outpatient basis and discharged the same day of surgery. Mean patient age was 48.2 years and 34 (81.0%) of patients were male. Mean TBSA affected was 5.3% (792cm2). Mean number of procedures was 1 and mean graft take was 98.9%. Nearly all patients were ambulated within 1day of surgery. The graft take rate across all cases was 98.9±2.3%. No patients failed early ambulation with their compressive dressings, were readmitted or underwent repeated skin grafting. CONCLUSIONS: This study demonstrates the excellent graft take rates that can be achieved with immediate ambulation following lower extremity skin grafting and challenges the conventional teaching of post-operative bed rest following lower extremity skin grafting procedures.

Evaluation of a multidisciplinary burn care journal club: Lessons learned.

BACKGROUND: Journal clubs allow discussion of the quality and findings of recent publications. However, journal clubs have not historically been multidisciplinary. Burn care is recognized as a true collaborative care model, including regular multidisciplinary rounds. Since 2011 we have offered a multidisciplinary burn journal club at our institution. We present an evaluation of the factors that have made the sessions successful to facilitate others to commence their own club. METHODS: At the end of each journal club session participants anonymously completed a structured evaluation. Five-point scales were used to evaluate understanding, meeting objectives, presentation and appropriateness of information. Qualitative questions were asked to identify beneficial factors, suggestions for improvements, ideas for future sessions and feedback for the facilitator. RESULTS: Attendance grew from six to a maximum of 19. Members included physicians, nurses, dieticians, physiotherapists, occupational therapists, social workers, basic scientists and students. Presentations were undertaken by all of these disciplines. Ratings improved steadily over time. Understanding increased from a score of 4.5 to 4.8; meeting objectives from 4 to 4.9; satisfaction with method of presentation from 4.3 to 4.9 and with level of information from 3 to 4.9. CONCLUSIONS: Over time, the journal club has evolved to better meet the needs of our team. Successful multidisciplinary journal club implementation requires identification of champions and ongoing evaluation. APPLICABILITY OF RESEARCH TO PRACTICE: The success of the journal club has been possible through the engagement of the entire burn team. Champions within each discipline, facilitated discussion and evaluation tools have helped nurture a nonthreatening team based learning environment.

Rate of contamination of hospital privacy curtains on a burns and plastic surgery ward: a cross-sectional study.

BACKGROUND: Surfaces in the patient environment may play a role in microbial transmission if they become colonized by bacteria. Patient privacy curtains are one such surface that may pose a high risk for transmission because they are high-contact surfaces, are infrequently cleaned, and healthcare workers are less likely to wash their hands after contacting inanimate objects such as curtains. AIM: To determine the amount and type of bacterial colonization of patient privacy curtains at a regional burns/plastic surgery unit. METHODS: Privacy curtain contamination on the burns/plastic surgery ward was determined for two separate occasions six months apart: 23 curtains on August 2015 and 26 curtains on January 2016. Dey-Engley neutralizing agar (DENA) replicate organism detection and counting (RODAC) contact plates were used daily to sample curtains near the edge hem where they are most frequently touched. Microbial contamination was reported as cfu/cm2 and the presence of meticillin-resistant Staphylococcus aureus (MRSA) was determined. Swabs were also taken of any open wounds and from tracheostomy sites on the ward. FINDINGS: Curtain contamination in August 2015 was 0.7-4.7 cfu/cm2 with 22% testing positive for MRSA, whereas contamination on January 2016 was 0.6-13.3 cfu/cm2 with 31% of curtains testing positive for MRSA. CONCLUSION: Curtains on the burns/plastic surgery ward become colonized with significant quantities of bacteria. Future studies will need to address the rate of colonization and the clinical impact of this colonization to better inform cleaning protocols.

Evidence that a novel quaternary compound and its organic N-chloramine derivative do not select for resistant mutants of Pseudomonas aeruginosa.

BACKGROUND: Pseudomonas aeruginosa is well known for causing hospital-acquired infections that are often difficult to treat because of its high intrinsic and acquired resistance to antibiotics. Resistance-nodulation-division (RND) efflux pumps are the major contributors to the intrinsic multidrug resistance (MDR) in this organism. Various biocides used in hospital settings have been shown to select for RND-pump-overexpressing mutants of P. aeruginosa that show cross-resistance to clinically relevant antibiotics. Therefore, finding biocides that do not select for multidrug-resistant mutants is important in controlling the spread of bacteria such as P. aeruginosa. AIM: To evaluate the potential of a novel quaternary ammonium compound and its N-chloramine derivative in selecting for MDR mutants of P. aeruginosa. METHODS: P. aeruginosa PA01 was cultured in the presence of increasing concentrations of the quaternary ammonium compound and its N-chloramine derivative respectively, and one mutant each selected. Susceptibility of the mutants to both compounds as well as antibiotics was tested. Susceptibility of P. aeruginosa strains with deletions in RND pumps was also tested for both compounds to determine whether they are a substrate of these pumps. Expression of mexB, mexD, and mexY genes in the mutants was analysed using quantitative reverse transcriptase-polymerase chain reaction to determine whether the compounds can select for pump-overexpressing mutants. FINDINGS: We show that whereas both compounds can be pumped by the MexCD-OprJ pump, they neither select for mutants that overexpress RND pumps nor for mutants that display cross-resistance to antibiotics. CONCLUSION: These compounds are promising candidates to be used as disinfectants in hospital settings.

Intermediate-level disinfection with accelerated hydrogen peroxide prevents accumulation of bacteria in Versajet™ tubing during repeated daily debridement using simulated-use testing with an inoculated pork hock.

OBJECTIVE: This study assesses the feasibility of using the Versajet™ system (VJS) on an inoculated pork hock (PH) skin surface sequentially for 8 days with daily cleaning and intermediate-level disinfection (ILD). METHODS: Daily, PHs were inoculated with bacteria suspended in artificial test soil (ATS). An ILD protocol with accelerated hydrogen peroxide (AHP, OxivirTB(®)) was employed to clean and disinfect the VJS between debridements. RESULTS: PH skin contains 6.1-6.8×10(6)cfu/cm(2) bacteria. Bacterial counts in the handpiece and discharge hoses immediately after debridement of the PHs, and before cleaning, increased throughout the study period (5.19-6.43log10cfu/mL). Cleaning with the ILD protocol was reduced bacterial counts on the VJS by 6-log. Protein, a surrogate marker of organic contamination, was also reduced post-cleaning and ILD. Compared to a maximum post-debridement level of protein (57.9 µg/mL) obtained before ILD, VJS protein levels dropped to 9.8 (handpiece) and 13.8 µg/mL (discharge hose). CONCLUSIONS: Disinfection of the handpiece and discharge hose after debridement with AHP resulted in a 6-log reduction in bacterial count and 4.2 fold reduction in protein. An ILD protocol with an AHP may be a feasible method for serial skin surface debridements with the VJS for up to eight days.

Reduced blood loss during burn surgery.

The purpose of this study was to investigate the use of subcutaneous injection of burn wounds and skin graft donor sites with an adrenaline-saline solution to reduce blood loss during burn surgery. This retrospective study reviewed the requirements of blood products in 30 randomly selected adult patients with more than 10% body area burned, who had at least one burn operation at a university regional burn center, between January 1991 and June 1997. Patients were matched by age and percent body area burned and stratified according to the surgical technique in two groups. In Group 1, 15 patients received the modified tumescent surgical technique: subcutaneous injection of adrenaline (1 part/million in warm saline solution) into the subcutaneous tissue of the donor sites for autologous skin graft and areas of burn eschar to be excised, combined with pneumatic tourniquets in extremities and saline-adrenaline soaked nonadherent pads. In Group 2, 15 patients received the traditional surgical technique: soaked gauze compresses with an adrenaline-thrombin solution (1 ml of 1:1,000 adrenaline, thrombin 10,000 units, and 1 L of normal saline). Outcome measures, transfusion of blood products, operating time and complications between the two patient groups were analyzed using the Wilcoxon 2-sample test. The two patient groups were not different by age (40.4 +/- 19.4 vs 38.9 +/- 17.9), percent total body area burned (27.6 +/- 15.4 vs 32.8 +/- 13.4), or percent full thickness burn (7.0 +/- 8.5 vs 11.5 +/- 8.5). The modified tumescent surgical technique significantly reduced mean total blood units transfused per patient (7.9 +/- 11.5 vs 15.7 +/- 12.9 units; P = .031), and the mean blood units transfused intraoperatively per patient (4.7 +/- 7.8 vs 8.9 +/- 8.0 units; P = .026). The modified tumescent surgical technique significantly reduced the intraoperative and total blood transfusion requirements in our thermally injured patients.

Modern techniques for wound coverage of the thermally injured upper extremity.

The use of flaps; synthetic, dermal analogues; cultured skin substitutes; or a combination of these may one day help return severely burned arms to normal function and appearance. The complexity and expense of these alternatives limits their use in commonplace burns. As the techniques are refined with increased experience, so also will the roles for each of these options. Fortunately, an excellent result is still possible in most situations using simple autograft. The availability of these numerous choices to acutely cover the thermally injured upper extremity should not distract us from the gold standard of split-thickness skin graft (Fig. 7).

Functional limitations and recovery in children with severe trauma: a one-year follow-up.

To examine functional limitations, recovery rates, and association with Injury Severity Scores (ISSs), we followed 92 children with severe trauma and 59 control subjects with appendicitis at 6 months and 1 year after discharge. Physical health status was assessed by the Rand Health Insurance Study instrument. Overall, 73% and 55% of trauma patients had one or more functional limitations at 6 months and 1 year, respectively, in contrast to 14% and 9% of the controls. Overall functional status of the trauma patients improved by 22% in the first 6 months and 24% in the second. Much higher recovery rates (73% and 46%) were noted for self care. Although ISS did not correlate with overall functional status, higher ISSs were related to impairment in patients whose principal injury was to the head or the face-chest-abdomen but not in those whose principal injury was to an extremity. This study shows that many children with severe trauma are left with disabilities. Recovery rates are not uniform but depend on type of limitation. Functional impairment and recovery are related more to the body parts involved than to ISS.