Efficacy of aerosolized hydrogen peroxide (Deprox) cleaning compared to physical cleaning in a Burns Unit.

BACKGROUND: The performance of Deprox aerosolized hydrogen peroxide (aHP) has not been extensively studied in real-world clinical settings. A comparative study of aHP terminal disinfection was conducted in a Burns Unit and its performance compared to physical cleaning alone. METHODS: Environmental surfaces were sampled pre-cleaning, post-cleaning and post-aHP disinfection. Samples were cultured for MRSA, VRE, Gram-negative multi-resistant organisms and other Gram-negative bacilli. RESULTS: 310 sites were sampled. There was a reduction in the rates of contaminated surfaces post-aHP, though pathogens were still recoverable in most cases, except for VRE. There was a marked reduction in MRSA contamination of soft surfaces (12% post-clean vs 6% post-aHP), and patient room surfaces (8.3% post-clean vs 2.8% post-aHP). It does not work as well for MRSA in bathrooms: 7% of surfaces were positive post-clean, and 9% post-aHP. There was a reduction in multiresistant Gram-negative bacteria (7%-3%), mostly due to drains (33%-13%). CONCLUSION: aHP is a useful method of environmental disinfection, especially for Gram-negative pathogens in drains and MRSA on hard and soft surfaces. Where ongoing acquisition of MRSA is a problem, an adjunctive method of terminal disinfection in bathrooms could be considered.

Using a clinical judgement model to understand the impact of validated pain assessment tools for burn clinicians and adult patients in the ICU: A multi-methods study.

BACKGROUND: Intensive care (ICU) patients' burn pain is difficult to assess, communicate and address, risking chronic pain syndromes and psychological morbidity. AIMS: To understand how the introduction of validated pain tools (Critical Care Pain Observation Tool [CPOT], Numerical Rating Scale [NRS], Pain Assessment in Advanced Dementia [PAINAD]) affected clinical judgement processes, analgesia/sedation administration and the experience of burn-injured patients. METHODS: Consecutive chart review compared type and amount of analgesia/sedation administered, ventilation time and length of ICU/hospital stay between consecutive burn patients pre- and 6-months post-intervention (n=70). Analysis of 36 qualitative interviews with ICU clinicians (n=12) and burn-injured adults (n=12) pre- and post-intervention was guided by Tanner's (2006) Clinical Judgement Model. RESULTS: Overall, there was a significant increase in morphine (P=0.04) and propofol (P=0.04) use and a trend towards increased paracetamol (P=0.06) use post-intervention. There was a trend towards greater Midazolam use for TBSA<20% (P=0.06), and significantly increased propofol use for TBSA≥20% (P=0.03). Ventilation time and ICU/hospital length of stay were unchanged. Qualitative analysis revealed complex clinical judgement dependent on the context of the patient's situation, unit culture, background beliefs of clinicians and in knowing the patient. Whilst the CPOT and NRS enhanced analytic reasoning and pain advocacy, the PAINAD appeared redundant. CONCLUSIONS: Effective pain assessment, management and advocacy are assisted by evidence-based assessment practices.

Donor white blood cell survival and cytokine profiles following red blood cell transfusion in Australian major trauma patients.

BACKGROUND: The potential for the co-existence of genetically disparate cells (microchimerism) and associated cytokine profiles following red blood cell (RBC) transfusion in trauma patients has not been well characterized to date. This study investigated the incidence of surviving donor white blood cells (known as transfused-associated microchimerism (TAM)) and cytokine changes following blood transfusion in trauma patients. STUDY DESIGN AND METHODS: Trauma patients with an injury severity score (ISS) >12 who had been transfused between 2012-2016 with at least 5 units of RBC units over a 4 h period were recruited. Trauma patients with ISS > 12 who did not require blood transfusion were recruited as controls. The incidence of TAM was determined using a panel of insertion/deletion (InDel) bi-allelic polymorphisms. Selected pro- and anti-inflammatory cytokine profiles were analyzed using cytometric bead array. RESULTS: The transfused cohort (n = 40) had median ISS of 28 [12-66], received a median of 11 RBC units [4-114] and had median hospital length of stay of 35 days [1-152]. Only 11 (27.5%) patients returned for follow-up blood sampling after discharge. Of these, one patient showed an InDel pattern indicating the presence of TAM. No patients in the control cohort (n = 49) showed TAM. Cytokines IL-10 and IL-6 were found to be elevated in the transfused trauma patients. CONCLUSION: In this cohort, TAM was found to occur in one patient of the 11 who received a blood transfusion. Elevated IL-6 and IL-10 cytokines were detected in those patients who were transfused. However, the incidence of TAM could not be correlated with the elevated cytokine profiles for this cohort.

A phenomenological construct of caring among spouses following acute coronary syndrome.

The aim of this study was interpret the existential construct of family caring following Acute Coronary Syndrome. Family support is known to have a positive impact on recovery and adjustment after cardiac events. Few studies provide philosophically-based, interpretative explorations of carer experience following a spouse's ischaemic event. As carer experiences, behaviours and meaning-making may impact on the quality of the support they provide to patients, further understanding could improve both patient outcomes and family experience. Fourteen spouses of people experiencing Acute Coronary Syndrome in Sydney, Australia were engaged in a single, semi-structured interview. Interviews were audio-recorded and transcribed verbatim. Data were analysed using hermeneutic interpretation within a Heideggerian phenomenological framework. Acute Coronary Syndrome disrupts lived temporality, and the projected potential for carers' being-alongside. Carers experienced an existential uncertainty that arose from difficulty in diagnosis, and situated fear as an attuned, being-towards-death. They constructed protective strategies to insulate their partner and themselves from further stress and risk, however, unclear boundaries for protection heightened carer anxiety. The existential structure of care included one of two possible Heideggerian modes: leaping-in care was a dominating mode that required a high level of carer vigilance; leaping-ahead care was a metaphorical walking alongside, as carers gave back control, freeing opportunities for the person to 'own' care. Supporting carers through the intensive phase of leaping-in care, and equipping them for informed leaping-ahead care should be a focus in both the acute and post-discharge care phases.

Emerging from the trauma bubble: Redefining 'normal' after burn injury.

BACKGROUND: Emotional trauma is recognised as a common feature in the experience of patients and families following burn injury and incidence may be unrelated to burn size and severity. AIM: The aim of this study was to interpret the lived experience of hospitalisation and recovery following burn injury in Australia. This paper explores the early stages of emotional recovery, how people begin to redefine normality and the needs and supports they describe as integral to this process. METHOD: We used Heideggerian phenomenology, framed by Merleau-Ponty's philosophy of the body. In-depth, semi-structured interviews with 18 patient and family participants were collected 1-3 weeks after hospital discharge. Median %TBSA was 25.3 (range 3-68%). RESULTS: From a point of being vulnerable, redefining normal was supported for all participants by family being close and involved, for family members by developing routines, and for patients by challenging physical otherness, rethinking work, finding empowerment through self-care, acknowledging a shared recovery and recognising a gradual return of 'good days'. CONCLUSION: Emotional trauma is highly prevalent among patients and families in the early burn recuperation period where both distress and recovery may co-occur. Despite an initial sense of vulnerability, normality is gradually redefined through practices that keep family close, engage patients in early self-care and allow time, space and support for return to work. Patients, initially confronted by their own physical otherness, share their recovery with fellow burns survivors and seek affirmation from family to negotiate a 'different' normal, integrated into a new self-concept. Early rehabilitation may be strengthened by promoting carer involvement, patient self-efficacy and peer support.

Predictors of moderate to severe fatigue 12 months following admission to hospital for burn: Results from the Burns Registry of Australia and New Zealand (BRANZ) Long Term Outcomes project.

INTRODUCTION: Fatigue has been identified as an outcome of concern following burn but is rarely captured in outcomes studies. We aimed to: (i) describe the prevalence, and predictors, of moderate to severe fatigue in the first 12 months following burn, and (ii) establish the association between fatigue and health-related quality of life and work outcomes. METHODS: Adult burns patients, admitted >24h, were recruited from five BRANZ sites. Participants were followed-up at 1-, 6-, and 12-months after injury using the Brief Fatigue Inventory (BFI), 36-item Short Form Health Survey (SF-36) and the Sickness Impact Profile (SIP)-work scale. Moderate to severe fatigue was defined as a global BFI score of 4-10. Multivariable mixed effects regression modelling was used to identify demographic, socioeconomic, burn size and severity predictors of moderate/severe fatigue at follow-up. RESULTS: The mean±SD age of the 328 participants was 42.1±16.7years, 70% were male, 47% were flame burns, and the mean±SD %TBSA was 8.7±11.2. The prevalence of moderate/severe fatigue decreased from 37% at 1-month, to 32% at 6-months and 26% at 12-months. The adjusted odds of moderate/severe fatigue were 2.62 (95% CI: 1.27, 5.42) times higher for women compared to men, and 2.64 (95% CI: 1.03, 6.79) times higher in patients with a %TBSA≥20. Compared to patients in major cities, the adjusted odds of reporting moderate/severe fatigue were 2.48 fold higher (95% CI: 1.17, 5.24) for patients residing in inner regional areas, and 3.60 fold (95% CI: 1.43, 9.05) higher for patients living in remote/very remote areas. At each time point, the physical and mental health summary scores, and each sub-scale score, of the SF-36 were significantly lower in patients reporting moderate/severe fatigue. Patients experiencing moderate to severe fatigue reported higher work-related disability on the SIP work scale at each time point after injury. DISCUSSION AND CONCLUSION: More than a quarter of participants reported moderate to severe fatigue on the BFI at 12-months and fatigue was strongly associated with poorer health-related quality of life and greater work-related disability.

Long term outcomes data for the Burns Registry of Australia and New Zealand: Is it feasible?

BACKGROUND: Incorporating routine and standardised collection of long term outcomes following burn into burn registries would improve the capacity to quantify burn burden and evaluate care. AIMS: To evaluate methods for collecting the long term functional and quality of life outcomes of burns patients and establish the feasibility of implementing these outcomes into a multi-centre burns registry. METHODS: Five Burns Registry of Australia and New Zealand (BRANZ) centres participated in this prospective, longitudinal study. Patients admitted to the centres between November 2009 and November 2010 were followed-up at 1, 6, 12 and 24-months after injury using measures of burn specific health, health status, fatigue, itch and return to work. Participants in the study were compared to BRANZ registered patients at the centres over the study timeframe to identify participation bias, predictors of successful follow-up were established using a Generalised Estimating Equation model, and the completion rates by mode of administration were assessed. RESULTS: 463 patients participated in the study, representing 24% of all BRANZ admissions in the same timeframe. Compared to all BRANZ patients in the same timeframe, the median %TBSA and hospital length of stay was greater in the study participants. The follow-up rates were 63% at 1-month, 47% at 6-months; 40% at 12-months, and 21% at 24-months after injury, and there was marked variation in follow-up rates between the centres. Increasing age, greater %TBSA and opt-in centres were associated with greater follow-up. Centres which predominantly used one mode of administration experienced better follow-up rates. CONCLUSIONS: The low participation rates, high loss to follow-up and responder bias observed indicate that greater consideration needs to be given to alternative models for follow-up, including tailoring the follow-up protocol to burn severity or type.

The trauma bubble: patient and family experience of serious burn injury.

The aim of this study was to understand the lived experience of burn injury for Australian patients and families. Of specific interest was the period covering emergency and inhospital care and early experiences of transition into the community. Eighteen participants including patients with serious burn injury and close family members engaged in indepth, semistructured interviews. Data were analysed using Heideggerian phenomenology and were interpreted within the framework of Merleau-Ponty's philosophy of the body. Participants experienced substantial emotional trauma that was unrelated to burn size or severity. Emotional distress was highest amongst people with facial burns. Strong recollections of the accident and poorly managed pain seemed to exacerbate the experience of trauma. Patients described physical otherness, memories of consuming, embodied pain, and recycling of the initial catastrophe. Family members expressed vicarious suffering and were confronted by the physical otherness of their loved one. Participants were isolated in their "bubble of trauma" as they tried to contain grief and loss, and protect loved ones from their distress. Emotional trauma persisted after discharge challenging family functioning and adjustment. These findings support a systematic approach to identifying and responding to the emotional needs of patients and family, including early information about possible emotional reactions to traumatic events and proactive engagement with psychology services. Best practice approaches for early pain management should be a focus for both clinical care and further research.