Tap water scalds among seniors and the elderly: socio-economics and implications for prevention.

INTRODUCTION: Tap water scalds among those >or=60 years old are often attributed to physical impairments with aging. This study assesses socio-economics associated with tap water scalds among seniors and the elderly. METHODS: Charts of patients admitted to an urban Burn Center between 7/00 and 6/04 for treatment of tap water scalds were reviewed. Demographics, injury details, co-morbidities, surgical interventions/critical care requirements, length of stay (LOS), disposition and related economics were reviewed. RESULTS: During the study period, 68 patients >or=60 years were hospitalized for treatment of these scalds. Mean age and burn size were 78+/-1 years and 7+/-0.9% TBSA. Over 98% of patients were admitted with pre-existing co-morbidities; 60% required ICU care for 40+/-5 days; 22% required mechanical ventilation and 71% required surgery. LOS was 34+/-4 days. Most patients received government assistance income. Pre-injury, 32% resided alone. Post-injury, 10% of patients returned home alone; mortality was 22%. Per patient hospital costs approximated $113,000. CONCLUSION: These findings report that tap water scalds result in significant morbidity, mortality and health care costs for local seniors and the elderly. Socio-economic factors play a significant role in these injuries and must be assessed when planning prevention efforts.

The vulnerabilities of age: burns in children and older adults.

BACKGROUND: Both children and older adults are thought to sustain burns serious enough to warrant hospitalization disproportionately more often than other age groups, but the incidence, injury characteristics, and outcome have not been precisely defined. METHODS: Patients hospitalized with a burn diagnosis were identified from hospital discharge data from California, Florida, New Jersey, and New York for the 5-year period 2000-2004. RESULTS: In those states, 60,024 residents were hospitalized with a diagnosis of burn and/or inhalation injury according to the International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes. Using population data from the United States Census 2000, we found that the average annual incidence of hospitalization with a burn diagnosis in these 4 states was 155 per million (per M) (95% confidence interval,153-158). There were 13,453 children under 15 years of age: incidence, 163 per M (range, 157-169). Of these 9508 (70%) were under 5 years of age: incidence, 363 per M (range, 347-379). In contrast, there were 10,686 patients 65 years of age or older: incidence, 214 per M (range, 205-224), of whom 2091 were at least 85 years old: incidence, 347 per M (range, 314-380). The incidence of hospitalization with a burn diagnosis for patients 15 to 64 years of age was 141 per M (range, 138-145). Compared with children younger than 15 years, patients aged 65 years and older more often had flame burns (odds ratio [OR], 2.12), burns of 20% or more of body surface area (OR, 2.41), inhalation injury (OR, 2.88), respiratory failure (OR, 4.48), and death (OR, 16.53), all P < .0001. CONCLUSIONS: Older individuals are the most vulnerable to the morbidity and mortality of burn injury. Prevention strategies targeted to those older than 65 years should be developed.

A Pilot Study to Validate the Burn Center Pediatric Early Warning Score Tool in Clinical Practice.

The pediatric early warning score (PEWS) tool helps providers to detect subtle clinical deterioration in non-intensive care unit pediatric patients and intervene early to prevent significant adverse outcomes. Although widely used in general pediatrics, limited studies report on its validation; none report on use with burn-injured patients. New York-Presbyterian/Weill Cornell Medical Center modified a general PEWS system to a burn-specific PEWS and integrated its use into standard practice. This study investigated the external validity of the PEWS process in clinical practice. Fifty cases of patients aged 0 to 15.9 years admitted between January 2012 and June 2013, whose length of stay (LOS) more than 3 days were selected for review from this cohort of n equal to 187. Demographics, total PEWS and score changes, and compliance with PEWS documentation and with resultant interventions were reviewed. Continuous variables are presented as mean ± SD, P less than 0.05. Mean age, burn size, and LOS were 3.2 ± 3.3 years, 4.8 ± 5.7%, and 9.8 ± 7.0 days; 26% required grafting, and 50% were male. No mortalities occurred. One thousand six hundred and twelve PEWS from 1745 opportunities were documented (92.4%). For all PEWS (n = 1612) and PEWS greater than 0 (n = 912), means were 0.9 ± 1.2 and 1.6 ± 1.2, respectively. Among the 162 PEWS increase events, intake (54.1%) and output (4.5%) parameters increased most commonly. Of these, 129 PEWS increases (79.6%) were followed by an intervention that most commonly included text notation of score increase (93.7%), physician/physician assistant notification (70.5%), and feeding-tube insertion (25.6%). Patients with PEWS greater than 0 had similar age, LOS, and larger burn size (5.2% vs 1.4%, P < 0.05) than those with PEWS equal to 0. Compliance with PEWS performance and resultant actions based on score increases are high. Data support that even small changes in burn-injury specific PEWS stimulate provider discussion and intervention and support its validation; further studies on its effect on practice are warranted.

Burn injury in patients with dementia: an impetus for prevention.

Current literature has reported an increase in the rates of morbidity and mortality in elderly dementia patients who have suffered from illnesses such as pneumonia or traumatic injuries such as falls, motor vehicle collisions, and other insults. The role of dementia in elderly burn patients has not been studied in depth. To assess the extent of this problem, a retrospective, case-control study of patients with dementia who were admitted to a large urban burn center was performed. The demographics, circumstance and severity of injury, critical care use, and discharge disposition of those patients admitted with dementia were reviewed and compared with the findings of age/burn size-matched controls. The results support the premise that burn injuries in this patient population can be severe. Although not statistically significant, 22.2% of the study group patients required ventilatory support, and 75% required monitoring in the intensive care unit compared with the 15.3% and 61.6% of control patients who required ventilatory support and monitoring in the intensive care unit, respectively. Also, although not statistically significant, the mortality rate of the study group was 25%, almost double that of the control group (13.8%). No other significant differences were observed. These findings support the need for assistance and supervision with daily activity and burn prevention education for this population. As our population ages and we are faced with caring for those with dementia, further burn prevention is warranted.

Outpatient firefighter burn injuries: a 3-year review.

Previously, our Burn Center at the New-York Presbyterian/Weill Cornell Medical Center reported a decline during a 10-year period in the number of firefighters requiring hospitalization for burn injuries, from 53 patients per year to 15 patients per year. Because the incidence of structural fires continued at a constant rate of 26,240 to 30,841 per year during this time, it was postulated that an improvement in protective gear accounted for the decrease in injuries. However, it also was possible that more firefighters were being treated on an outpatient basis. Therefore, our Burn Center's outpatient treatment of firefighter burn injuries was reviewed to determine the epidemiology of firefighter burn injuries. On the basis of this study, the overall incidence of burn injuries in firefighters has continued at a constant level. These findings, however, demonstrate that the extent of injury has decreased in this population and suggest that the protective gear used by firefighters has contributed to these findings. These injuries, although minor to moderate, preclude the use of personal protective equipment until the burns are completely healed and contribute to a delayed return to full-duty status. These findings are consistent with nationally reported findings.

A regional burn center's response to a disaster: September 11, 2001, and the days beyond.

This report reviews the response of a regional burn center to the disaster that occurred in New York City at the World Trade Center on September 11, 2001. In addition, it assesses that response in the context of other medical institutions in the region. There were facilities in the region that had 120 burn care beds; only two-thirds of the burn-injured patients who required hospital admission were admitted to designated burn centers, and only 28% of burn-injured victims initially were triaged to regional burn centers. The care rendered at this center was made possible by a "disaster-ready" facility and supplementation of personnel from the resources provided by The National Disaster Medical System. The patient outcomes at this center exceeded that as predicted by logistic regression analysis.

Simulation of Tangential Excision: A Test for Construct Validity.

A foundational skill in burn surgery is tangential excision (TE). The purpose of this study was to develop a simulation model for TE, hypothesizing that simulation could be used in surgical training. TE simulation was created using the TE knife, foam, mineral oil, and base. Subjects, surgeons, or surgeons in training, were given a pre- and post-task questionnaire about experience with TE. Subjects were divided into three TE experience groups: novice--none, intermediate--some, and expert--TE in current or past practice. The task was to excise pre-marked rectangles, generating four excisional products (EPs). Evaluators blindly assessed performance by EP analysis using a novel scoring tool and reviewed videos using a modified objective structured assessment of technical skill (OSATS) rubric. Inter-rater reliabilities and P values were obtained, comparing Novice and Intermediate with Expert scores. Forty subjects completed the study: 16 were identified as TE novices, 17 as intermediates, and seven as experts. All EPs and videos were reviewed blindly by two evaluators using the EP scoring tool and OSATS methodology, respectively. Intraclass correlation coefficients were calculated to measure inter-rater reliabilities, which were acceptable (ICC => 0.42) for OSATS, time, and EP analysis: border and texture. Statistical differences between Novice and Expert scores were found (P < .0100, P < .0200, P < .0025, and P < .0005, respectively). Statistical differences between Intermediate and Expert scores were also found (P < .0100, P < .0200, P < .0100, and P < .0025, respectively). Post-simulation survey results showed experts 86% of the time agreeing or strongly agreeing that the simulation was similar to the clinical skin and 100% felt it would be a useful for training before clinical performance. Simulation for TE was successfully created to blindly discern level of TE experience. Participants agreed that simulation could play an essential role in burn surgical training.

Car radiator burns: a prevention issue.

Scald burns continue to be the major cause of injury to patients admitted to the burn center. Scald burns occurring from car radiator fluid comprise a significant subgroup. Although manufacturer warning labels have been placed on car radiators, these burns continue to occur. This retrospective review looks at all patients admitted to our burn center who suffered scald burns from car radiator fluid to assess the extent of this problem. During the study period, 86 patients were identified as having suffered scald burns as a result of contact with car radiator fluid. Seventy-one percent of the burn injuries occurred in the summer months. The areas most commonly burned were the head and upper extremities. Burn prevention efforts have improved greatly over the years; however, this study demonstrates that scald burns from car radiator fluid continue to cause physical, emotional, and financial devastation. The current radiator warning labels alone are not effective. The National Highway Traffic Safety Administration has proposed a new federal motor vehicle safety standard to aid in decreasing the number of scald burns from car radiators. The results of this study were submitted to the United States Department of Transportation for inclusion in a docket for federal legislation supporting these safety measures.

Diabetes and burns: retrospective cohort study.

Burn injuries are often associated with multisystemic complications, even in otherwise healthy individuals. It is therefore intuitive that for the diabetic patient, the underlying pathophysiologic alterations in vascular supply, peripheral neuropathy, and immune function could have a profoundly devastating impact on patient outcome. The effects of diabetes on morbidity and mortality of the burn-injured patient have not been examined in great detail. The purpose of this retrospective study was to compare clinical outcomes between diabetic and nondiabetic burn patients. We reviewed the charts of 181 diabetic (DM) and 190 nondiabetic (nDM) patients admitted with burns between January 1996 and May 2000, matched by sex and date of admission. Burn cause and size, time to presentation, clinical course, and outcomes were evaluated. Because age was a factor, the analysis was done by three age groups: younger than 18 years, 18 to 65 years, and older than 65 years. Of patients 18 to 65 years, 51% (98/191) were diabetic, whereas 84% (81/96) of those older than 65 and only 4% (3/85) of patients younger than 18 were diabetic. Because of the disproportion in numbers of diabetics compared with nondiabetics in the younger than 18 and older than 65 years-old groups, these patients will not be discussed. Diabetics were more likely to incur scald injury from tub or shower water rather than hot fluid spills (33% DM vs 15% nDM; P < or = 0.01), and have a delayed presentation (45 vs 23%; P = 0.00001). There was no difference in total burn size in all groups. Diabetics in the 18 to 65 years group had a higher rate of full-thickness burns (51 vs 31%; P = 0.025), skin grafts (50 vs 28%; P = 0.01) and burn-related procedures (57 vs 32%; P = 0.001), infections (65 vs 51%; P = 0.05), and longer lengths of stay (23 vs 12 days; P = 0.0001). Although there was no statistically significant difference in incidence of specific infections, the rates of cellulitis, wound infection, urinary tract infection, line infection, and osteomyelitis, were consistently higher in the diabetic population. Partial graft slough was 6% in diabetics 18 to 65 years with a 3% regraft rate, whereas nondiabetics had a 1% regraft rate. Comparing diabetics with controlled vs uncontrolled glucose levels, diabetics with uncontrolled glucose had higher rates of infection (72 vs 55%; P < or = 0.025), all burn-related procedures (68 vs 45%; P < or = 0.025), and longer ICU stays (24 vs 10 days; P = 0.048). Mortality rate was 2% for diabetics and for nondiabetics. In summary, presence of diabetes in the burn patient was associated with a worse outcome. A predilection for burn injuries in the diabetic was noted in the older adult population. Deeper burns, delayed presentation, higher rates of infection, graft failure and operations, and longer lengths of stay translate into an increased cost to society both economically and in lives. This data would suggest a need for better burn education for diabetics and health care professionals, recognizing the elderly population as a "high-risk" group. We believe that targeted prevention measures and treatment strategies, emphasizing earlier and more aggressive intervention for this population, may have a favorable effect on morbidity and mortality.

Cholesterol and interleukin-6 concentrations relate to outcomes in burn-injured patients.

The goal of this study was to determine the relationship among lipid concentrations, cytokine concentrations, and clinical outcomes of burn patients. Twenty-eight patients admitted within 24 hours of burn injury, segregated based on burn size, had blood samples drawn 24 and 48 hours after burn injury and then weekly for 3 weeks. Measurements included total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglyceride, interleukin (IL)-6, soluble IL-2 receptor, and soluble necrosis factor p55 and p75 receptors. Infection, length of stay (LOS), and survival were monitored. Cholesterol and lipoprotein concentrations decreased by at least 40% in patients with burns >20% total body surface area and inversely correlated with IL-6. Lower cholesterol and higher IL-6 values correlated with higher infection rates and longer LOS. IL-6 was the strongest predictor for LOS. In conclusion, outcomes after burn injury are related to low cholesterol and elevated IL-6 levels.

Firefighter burn injuries: a 10-year longitudinal study.

Our metropolitan area employs approximately 11,000 firefighters who respond to more than 435,000 fire-related incidents per year. It is inevitable that some of these firefighters will suffer burn injuries. This 10-year retrospective review describes the epidemiology of firefighters with burn injuries who were treated at our burn center. From 1992 to 2002, 987 firefighters were treated at our burn center. The total number of firefighters treated for burn injuries and the number of firefighters who were treated for burn injuries to the lower extremities occurred in a bimodal distribution. Injury prevention efforts will continue to further reduce the incidence of burn injuries in the firefighters of our community.

Pediatric sink-bathing: a risk for scald burns.

Our burn center previously reported a significant incidence of scald burns from tap water among patients treated at the center. However, mechanism of these scalds was not investigated in detail. A recent series of pediatric patients who sustained scalds while bathing in the sink was noted. To evaluate the extent of these injuries and create an effective prevention program for this population, a retrospective study of bathing-related sink burns among pediatric patients was performed. Patients between the ages of 0 and 5.0 years who sustained scald burns while being bathed in the sink were included in this study. Sex, race, age, burn size, length of stay, and surgical procedures were reviewed. During the study period of January 2003 through August 2008, 56 patients who were scalded in the sink were admitted, accounting for 54% of all bathing-related scalds. Among these, 56% were boys and 45% were Hispanic. Mean age was 0.8 ± 0.1 years. Burn size and hospital length of stay averaged 5 ± 0.7% and 11 ± 1 days, respectively. Of this group, 10.7% required skin grafting. The overwhelming majority (94% of patients) were discharged home. The remaining patients were discharged to inpatient rehabilitation, foster care, and others. Pediatric scald burns sustained while bathing in a sink continue to be prevalent at our burn center. Because of limited space and the child's proximity to faucet handles and water flow, sinks are an unsafe location to bathe a child. While such practice may be necessary for some families, comprehensive burn prevention education must address this hazard.

New management strategy for fluid resuscitation: quantifying volume in the first 48 hours after burn injury.

This study evaluated a 24-hour resuscitation protocol, established a formula to quantify resuscitation volume for the second 24 hours, described the relationship between the first and second 24 hours, and identified which patients required high volumes. A protocol for patients with burn >15% TBSA was implemented in 2009. Initial fluid was based on the Parkland calculation and adjusted to meet a goal urine output. Protocol compliance was defined as appropriate fluid titration to maintain urine output. Resuscitation ratio in the second 24 hours was tabulated as total fluid /(evaporative loss + maintenance fluid + estimated colloid). Data were collected prospectively from 2009 to 2011. A Wilcoxon rank test compared differences between groups. Regression analyses analyzed volume administered. P < .05 was statistically significant. Forty patients with burn >15% TBSA met criteria for inclusion. Mean age, burn size, and resuscitation volumes in the first and second 24 hours (mean + SD) were 47+ 20.7 years, 29.9 + 14.6% TBSA, 7.4 + 3.7 ml/kg/% TBSA, and a ratio of 1.9 times expected volume (SD, 1.3), respectively. Protocol compliance was 34%. Intubation, older age, and increased narcotic administration correlated with higher resuscitation volumes. A higher resuscitation volume in the first 24 hours significantly correlated with a higher resuscitation volume in the second 24 hours (P < .001). In conclusion, there is a significant relationship between fluid administration in the first and second 24 hours of resuscitation; intubation, older age, and narcotics correlate with higher volumes. A formula for observed/expected volumes in the second 24 hours is total fluid/(evaporative loss + maintenance fluid +estimated colloid).

The Potential of Gaming in Rehabilitation of the Burn-Injured Patient.

The use of videogames for non-entertainment purposes has interested educational and behavioral researchers for decades. Recent technology advances have increased the interactivity of games while maintaining reasonable costs, leading rehabilitation therapists to investigate gaming consoles as an adjunct to traditional techniques. Obstacles to large-scale trials exist, but the transformative potential of gaming consoles should motivate developers and healthcare professionals to find solutions.

Use of Nintendo(®) Wii(™) in Physical Therapy of an Adult with Lower Extremity Burns.

OBJECTIVE: The purpose of this exploratory case study is to describe differences in rehabilitation outcomes for a 47-year-old male with bilateral lower extremity burns when using conventional therapy techniques alone versus such techniques in combination with Nintendo(®) Wii™ (Nintendo of America, Inc., Redmond, WA) videogames. MATERIALS AND METHODS: The patient received three series of rehabilitation therapy over 2 weeks. During the second series, the Wii was introduced for a portion of the otherwise conventional therapy. Under standardized conditions and upon completion of each series, the Limits of Stability test with a SMART Balance Master(®) (NeuroCom(®), Clackamas, OR) was used to measure reaction time (RT), maximum excursion (MXE), endpoint excursion (EPE), movement velocity, and directional control. The Timed Up and Go (TUG) test for functional mobility and a questionnaire assessing level of motivation and interest were administered at the end of each day; these results formed mean scores for each series. RESULTS: The patient performed better on RT and MXE during the series that combined conventional therapy with the Wii than during the two series using conventional therapy alone. Improvement on EPE was greater for combined therapy than for conventional therapy alone and continued to improve after combined therapy. The patient completed the TUG test faster during the combined Wii series. Additionally, the patient reported increased motivation and interest levels for the series using combined therapy. CONCLUSIONS: The Wii may be a feasible and valuable adjunct to traditional therapy. Improvements during the series with Wii were demonstrated for areas of balance and functional mobility. Trends toward improvement in motivation and interest with the Wii suggest its use may elicit increased patient engagement during burn rehabilitation.

The utilization of Nintendo® Wii™ during burn rehabilitation: a pilot study.

The purpose of this study was to demonstrate feasibility and measure outcomes on pain, anxiety, active range of motion (AROM), function, enjoyment, and presence with the adjunctive use of Nintendo® Wii™ (Nintendo of America Inc., Redmond, WA) during acute burn rehabilitation. Participants were alternated and stratified based on the location of burn into Wii or control treatment groups. Joints of interest with limited AROM were the shoulder, elbow, wrist, hip, knee, and ankle. All participants received three consecutive sessions of passive range of motion and predetermined joint-specific exercises. This was followed by either designated Wii games or therapist-chosen interventions (control). The outcomes were compared between groups using t-tests (P < .05) and Cohen's d statistic. Data from 23 participants aged 20 to 78 years were analyzed. The difference in mean slopes suggested that the Wii group experienced less pain (x = -0.97, P = .07) than the control group over time. Overall, trends with anxiety (x = -0.1l, P = .77), AROM (x = 0.55, P = .81), function (x = -0.38, P = .43), and enjoyment (x = 0.09, P = .73) seemed to favor the Wii group. Presence minimally changed between successive treatment sessions for those in the Wii group. Although statistical significance was not reached in any category, feasibility was supported and the overall pattern for outcomes was positive for the Wii group, the most favorable being for pain reduction. Future research with larger sample sizes is warranted to explore best practice with video game technology throughout the continuum of burn rehabilitation with appropriate prescriptions.

Engaging older adults in burn prevention education: results of a community-based urban initiative.

The objective of the study is to educate New York City seniors aged 60 years and older about fire safety and burn prevention through the use of a community-based, culturally sensitive delivery platform. The ultimate goal is to reduce burn injury morbidity and mortality among this at-risk population. Programming was developed and provided to older adults attending community-based senior centers. Topics included etiology of injury, factors contributing to burn injuries, methods of prevention, emergency preparedness, and home safety. Attendees completed a postpresentation survey. Of the 234 senior centers invited to participate in the program, 64 (27%) centers requested presentations, and all received the educational programming, reaching 2196 seniors. An additional 2590 seniors received education during community-based health fairs. A majority reported learning new information, found the presentation helpful, and intended to apply this knowledge to daily routines. Data confirm that many opportunities exist to deliver culturally sensitive burn prevention programming to the older adult population of this large metropolitan area in settings that are part of their daily lives. A majority of respondents welcomed the information, perceived it as helpful, and reported that they were likely to integrate the information into their lives.

Burn survivors' perceptions of rehabilitation.

BACKGROUND: The perspectives of burn survivors offer a powerful tool in assessing the efficacy of burn therapy interventions and methods. Despite this potential wealth of data, comprehensive analysis of burn survivor feedback remains largely uninvestigated and underdocumented. The aim of this study was to evaluate specific burn therapy interventions based on the opinions of a sample of the burn community. METHODS: The survey was distributed to a convenience sample drawn from burn survivors attending the Phoenix Society's 21st Annual World Burn Congress in New York City, New York. Items of inquiry focused on therapeutic intervention and reintegration. The 164 surveys (a 44% response rate) returned included burn survivors from a variety of demographic segments and with burn injuries of disparate size, location, and severity. Interventions of interest included splinting and positioning, pressure garments, therapeutic exercise, group therapy, and nontraditional therapy. Respondents also rated the contribution of acute burn rehabilitation toward reintegration into familial, societal, and professional roles. RESULTS: The vast majority of respondents felt that the rehabilitative interventions they experienced positively affected their long-term physical and psychosocial outcomes. In the areas of improving movement and scarring and expediting reintegration and usefulness, the majority of applicable interventions generated "strongly agree" or "agree" as the most popular responses. CONCLUSIONS: These findings support the efficacy of many practices employed by burn rehabilitation specialists and offer a glimpse into the inherent benefits found in assessment of burn survivors' perspectives.

Burn disaster response planning in New York City: updated recommendations for best practices.

Since its inception in 2006, the New York City (NYC) Task Force for Patients with Burns has continued to develop a city-wide and regional response plan that addressed the triage, treatment, transportation of 50/million (400) adult and pediatric victims for 3 to 5 days after a large-scale burn disaster within NYC until such time that a burn center bed and transportation could be secured. The following presents updated recommendations on these planning efforts. Previously published literature, project deliverables, and meeting documents for the period of 2009-2010 were reviewed. A numerical simulation was designed to evaluate the triage algorithm developed for this plan. A new, secondary triage scoring algorithm, based on co-morbidities and predicted outcomes, was created to prioritize multiple patients within a given acuity and predicted survivability cohort. Recommendations for a centralized patient and resource tracking database, plan operations, activation thresholds, mass triage, communications, data flow, staffing, resource utilization, provider indemnification, and stakeholder roles and responsibilities were specified. Educational modules for prehospital providers and nonburn center nurses and physicians who would provide interim care to burn injured disaster victims were created and pilot tested. These updated best practice recommendations provide a strong foundation for further planning efforts, and as of February 2011, serve as the frame work for the NYC Burn Surge Response Plan that has been incorporated into the New York State Burn Plan.

Impact of diabetes on burn injury: preliminary results from prospective study.

Reducing diabetes mellitus complications has been a major focus for Healthy People 2010. A prior retrospective cohort of our burn center's admissions revealed worse outcomes among diabetic patients, that is, increased infection rates, grafting and graft complications, and increased length of hospital stay. Therefore, a prospective study has been designed to carefully assess wound repair and recovery of diabetic and nondiabetic burn patients. Our long-term aim is to determine the characteristics of the wound milieu along with global responses to injury that may predict poor outcome among diabetic patients. This is an initial phase of a larger observational study of in-hospital diabetic (types 1 and 2) and nondiabetic patients, prospectively matched for age (18-70 and >70 years) and burn size (<5, 5-15, and 16-25%). Time (days) to complete index wound closure, documented through serial photography, is the main outcome measure. Secondary measures compare delays in presentation, prevalence of infections, graft rates, wound and graft complications, adverse events, and length of hospital stay. Detailed history, physical, and baseline hemoglobin A1C are elicited from all subjects who are assessed daily over the initial 72 hours poststudy entry, then weekly until complete index wound closure, and finally monthly through 3 months. Forty subjects are presented herein, 24 diabetic and 16 nondiabetic patients. Time to index wound closure was significantly prolonged in diabetic patients, despite increased grafting. These findings suggest that excision and grafting in diabetic patients may not alone be sufficient to ensure rapid closure, as graft complications may contribute to protracted closure. Evaluating graft need may be more complex among diabetic patients, suggesting the need for alternative management strategies. The current prospective study confirms our previous retrospective analysis, notably manifested by significant delays in index wound closure. Our efforts continue in identifying the most important predictors of outcome, especially modifiable factors that would create a basis of intervention to improve care.