Benefits of an outreach education coordinator: a burn center's experience.

Education of first responders and referring medical professionals is considered vital to high-quality burn care. Prior to 1999, the community education program at The Burn Center of MedStar Washington Hospital Center (MWHC) was staffed by ICU nurses who volunteered their time. As the program became more popular in the mid-1990s, the requests for lectures exceeded the capacity of a volunteer program. A request to hospital administration for a full-time education coordinator position was rejected in the climate of budget cut-backs and declining reimbursement. A business-oriented proposal, ultimately accepted, promised an increase in admissions, an improved payor mix, and an annual review of data to demonstrate the cost/benefit advantage. To advertise the creation of the coordinator position and education programs, letters were mailed to local fire departments, nursing schools and emergency departments. The response was positive, and, with a full-time coordinator, the requests were accommodated in a timely manner. Community education programs increased almost four-fold. Average annual admissions increased initially from 292 to 374 and have continued to increase, rising to 812 in fiscal year 2008. As expected, the average percent total body surface area burns decreased (from 10.8% to 6.9%), reflecting increased referral of smaller burns and, inferentially and per analysis, an improved payor mix. Most impressive was the increase in charitable donations, from an annual average of $27,500 before the position was created to an average of $183,000 annually thereafter. From this experience as well as the experience discovered by a national survey, there are desirable side effects of a full-time community burn education program coordinator, and the cost for The Burn Center at MWHC has been more than balanced by the benefits.

La formation des premiers appelés et des professionnels référents est considérée comme fondamentale pour la qualité des soins aux brûlés. Avant 1999, le programme de formation de la société du CTB de l'hôpital MedStar de Washington DC (MWHC) était géré par des infirmières de réanimation volontaires. Dans le milieu des années 1990 ce programme, rencontrant un auditoire de plus en plus large, le volontariat n'était plus matériellement possible. Une demande de création de poste de coordinateur de formation plein-temps a été refusée par l'administration, dans un contexte de restrictions budgétaires. La promesse d'une augmentation des hospitalisations, d'une meilleure valorisation des séjours et d'une évaluation annuelle de l'amélioration du rapport coût/service rendu a finalement emporté la conviction. Les pompiers, écoles d'infirmières et services d'urgence ont été avertis par voie postale de la mise en place de ce coordinateur. Ces formations, dès lors réalisées sur rendez-vous, ont quadruplé. Le nombre d'admissions est passé de 292 au préalable à 812 en 2008 et la surface moyenne brûlée a baissé de 10.8 à 6.9%, témoignant d'une augmentation des hospitalisations pour brûlure peu étendues. Il a, comme prévu, été observé une meilleure valorisation. De manière plus inattendue, les dons sont passés de 27 500$ à 183 000$ annuels avant/après. Notre expérience, ainsi que les résultats d'une étude nationale montre l'intérêt de la mise en place d'un coordinateur de la formation en matière de brûlures, qui a montré son intérêt médico-économique dans le CTB du MWHC.

Intraoperative assessment of colonic perfusion using scanning laser Doppler flowmetry during colonic resection.

BACKGROUND: Ischemia occurring on mobilization and mesenteric division is thought to be a major factor in the etiology of anastomotic dehiscence after colorectal resection. This study assessed the ability of the new technique of scanning laser Doppler flowmetry to measure changes in human colonic perfusion during mobilization at and adjacent to the anastomotic site. STUDY DESIGN: Colonic perfusion was measured in 10 patients undergoing large-bowel resection by making laser Doppler scans of the proximal bowel before mobilization, after mobilization and mesenteric division, and after resection of the specimen. Mean perfusion was calculated within 1-cm2 regions of interest, each of which contained 1,750 individual measurements of perfusion. These regions represented the anastomosis site and adjacent areas 1 cm and 2 cm proximal and distal to this. The results were expressed as mean perfusion units (PUs). RESULTS: After mobilization, there were significant decreases in perfusion in all the subjects between each time point and in all areas of the colon scanned. Median perfusion at the anastomosis site was 491 PUs before mobilization, and this fell to 212 PUs after mobilization, representing a decrease of 57%; the median within-person decrease was also 57% (p < 0.01). There was a gradient of reduced perfusion between the area 2 cm proximal to the mesenteric division (median within-person fall 25%; p < 0.05) and the area 2 cm distal to the mesenteric division (median within-person fall 84%; p < 0.01). After resection of the specimen, perfusion increased slightly at the anastomosis site to a median of 240 PUs (median within-person fall 41%; p < 0.01), but 2 cm proximal to this, median perfusion remained depressed at 330 PUs. CONCLUSIONS: This new technique can be used intraoperatively and appears to overcome the limitations of single-point laser Doppler flowmetry. In this small preliminary study, it measured large decreases in colonic perfusion during mobilization, and it may have widespread clinical applications.

Late pulmonary sequela following burns: persistence of hyperprocalcitonemia using a 1-57 amino acid N-terminal flanking peptide assay.

Seven patients were evaluated at a mean duration of 8.4 yr after sustaining inhalational injury associated with burns. At the time of re-examination, the patients were asymptomatic and had normal chest X-rays, and arterial blood gases. Three of the seven patients had abnormally elevated serum calcitonin levels. The spirometry (FEV1) measurements showed an inverse trend to that of the serum calcitonin levels. The elevated calcitonin levels had an abnormal predominance of the procalcitonin component as assessed by several region specific antisera. The serum calcitonin also showed a significant correlation with the hormone level which had been obtained at the time of prior discharge from the hospital (r = 0.91). Although there appears to be no or minimal chronic pulmonary sequela to inhalational injury in burns by pulmonary testing, we speculate that the hyperprocalcitonemia in some of the patients may reflect a long-term hyperplastic response of the bronchio-epithelial pulmonary neuroendocrine cells. The potential significance of this and other lung-associated endocrine markers is discussed.

Ambulatory surgery for pilonidal disease.

In conclusion, pilonidal cysts, sinuses, and abscesses appear to be acquired lesions, perhaps enhanced by the developmental presence of deep intergluteal clefts, dimples, or sinuses. The pahtophysiology depends upon physical invasion of hair, lint, and other foreign material into the subcutaneum and the formation of a foreign body reaction. Appropriate treatment is drainage of the infected cavity and removal of foreign material. Adherence to basic principles of treating surgical infection is necessary for a good result. Prevention of treatment failure demands a conscious attention by the patient to personal hygiene to avoid accumulation of debris and repeat occurrence of the pathophysiologic process. Adequate surgical management can be performed on ambulatory outpatients with tolerable discomfort. This method features a minimal loss of man-days and an acceptable recurrence rate. A major advantage is cost-effectiveness.

Laser Doppler imaging determines need for excision and grafting in advance of clinical judgment: a prospective blinded trial.

INTRODUCTION: Clinicians' judgment as to which burns require excision and grafting remains one aspect of burn care without objective measurements. This study presents a prospective, blinded trial to assess decision to operate by laser Doppler imaging (numerical criteria) versus the clinical judgment of an experienced burn surgeon. METHODS: A number of 23 patients were enrolled in this prospective trial and 41 representative wounds of indeterminate depth were selected for observation. Daily determination of need to operate (burn depth) was made by a single burn surgeon. Laser Doppler imager (LDI) scans of the same wounds were simultaneously obtained, and not revealed to the clinician. Data analysis compared quickness of decision to operate by LDI to the clinician's judgment. Concurrence of decisions by either method was compared. RESULTS: A total of 23 patients and 41 wounds were analyzed. LDI and the surgeon agreed in determination of wound depth 56% of the time (23/41, P=0.031). Biopsy confirmation was obtained for 21 wounds. The surgeon's determination of burn depth was accurate in 71.4% of wounds biopsied (15/21). When the LDI scan median flux indicated need for excision, it was 100% accurate (7/7). When both the surgeon and the LDI were correct in assessing wound depth, LDI would have saved median number of 2 days (minimum=0, maximum=4). CONCLUSION: LDI allowed for earlier, objective determination of need to operate. Concurrence with clinical judgment in this blinded study was excellent. LDI should be seen as an effective aid to clinical judgment when contemplating excision of burns with indeterminate depth.

Patient tolerance study of topical chlorhexidine diphosphanilate: a new topical agent for burns.

Effective topical antimicrobial agents decrease infection and mortality in burn patients. Chlorhexidine phosphanilate (CHP), a new broad-spectrum antimicrobial agent, has been evaluated as a topical burn wound dressing in cream form, but preliminary clinical trials reported that it was painful upon application. This study compared various concentrations of CHP to determine if a tolerable concentration could be identified with retention of antimicrobial efficacy. Twenty-nine burn patients, each with two similar burns which could be separately treated, were given pairs of treatments at successive 12-h intervals over a 3-day period. One burn site was treated with each of four different CHP concentrations, from 0.25 per cent to 2 per cent, their vehicle, and 1 per cent silver sulphadiazine (AgSD) cream, an antimicrobial agent frequently used for topical treatment of burn wounds. The other site was always treated with AgSD cream. There was a direct relationship between CHP concentration and patients' ratings of pain on an analogue scale. The 0.25 per cent CHP cream was closest to AgSD in pain tolerance; however, none of the treatments differed statistically from AgSD or from each other. In addition, ease of application of CHP creams was less satisfactory than that of AgSD. It was concluded that formulations at or below 0.5 per cent CHP may prove acceptable for wound care, but the vehicle system needs pharmaceutical improvement to render it more tolerable and easier to use.

Burned-and-battered adults.

The existence of a previously unrecognized group of patients, burned-and-battered adults, has been recognized. This retrospective review identifies some of the characteristics of the 41 burned-and-battered adults admitted to a burn center during a two-year period. The typical scenario was a domestic quarrel that included a male victim, a female assailant, and a scald injury involving the victims anterior trunk and upper extremity. The average burn size was 14% of the total body surface area. Four victims died as a result of their injuries. Although these victims represented only 10% of all patients admitted to the burn center, there may be many more undetected burned-and-battered adults. Only when the seriousness and magnitude of the problem are recognized can appropriate medical, legal, and social interventions be made to meet the needs of these burned patients.

Burn patient registries in the United States: a survey.

The Committee on Organization and Delivery of Burn Care of the American Burn Association conducted a survey among burn care facilities to determine the extent of interest in development and maintenance of computerized patient registries. Initial questionnaires were mailed to 178 burn care facilities. Responses were obtained from 112 (62.9%). Eighty-seven (77%) of the responders indicated that they have some form of registry. Thirty-five of these registries were in the form of handwritten logbooks, while 43 were personal computers with a wide variety of hardware and software. Uses of these registries include patient census and reports (64% of responders), clinical research (62%), patient care (61%), and, less common, quality assurance and education. Twenty-five facilities stated that they do not maintain a registry, but 22 (88%) of them indicated interest in developing one. It seems unlikely that a single system could be designed to fill the needs of all facilities, nor is it likely that existing registries can be "networked" successfully. This is due not only to the diversity of data in the existing registries, but also to the important differences in the way basic terminology is used in different facilities. For burn care facilities interested in developing their own registry, a selected list of successful representative registries is provided.

Arterial occlusion and progressive gangrene caused by mucormycosis in a patient with burns.

Ischemic necrosis of the upper extremities caused by invasive mucormycosis developed in a patient with soil contamination of severe burn wounds. An arteriogram of the arm showed complete obstruction of blood flow in the forearm. Histologic specimens showed nonseptate branching hyphae obliterating the arterial lumens. Cutaneous mucormycosis affects patients who are immunocompromised, including victims of multiple trauma and burns. This case represents a previously undescribed clinical presentation in a patient with major burns. Because of its lethal nature, mucormycosis in a patient with burns must be treated with aggressive surgical debridement, including amputation, and with parentral amphotericin B at the earliest sign of cutaneous presence.

The revised burn diagram and its effect on diagnosis-related group coding.

Diagnosis-related group (DRG) codes for burn injuries are defined by thresholds of the percentage of total body surface area and depth of burns, and by whether surgery, debridement, or grafting or both occurred. This prospective study was designed to determine whether periodic revisions of the burn diagram resulted in more accurate assignment of the International Classification of Diseases and DRG codes. The admission burn diagrams were revised after admission and after each surgical procedure. All areas grafted (deep second-and third-degree burns) were diagrammed as "third-degree," after the current convention that both are biologically the same and require grafting. The multiple diagrams from 82 charts were analyzed to determine the disparities in the percentage of total body surface area burn and the percentage of body surface area third-degree burn. The revised diagrams differed from the admission diagrams in 96.5% of the cases. In 77% of the cases, the revised diagram correctly depicted the percentage of body surface area third-degree burn as confirmed intraoperatively. In 7.3% of the cases, diagram revision changed the DRG code. Documenting wound evolution in this manner allows more accurate assignment of the International Classification of Diseases and DRG codes, assuring optimal reimbursement under the prospective payment system.

Serum lactate and base deficit suggest inadequate resuscitation of patients with burn injuries: application of a point-of-care laboratory instrument.

Urinary output of 30 to 50 ml/hr and mean arterial pressure of more than 70 mm Hg continue to be the yardsticks by which patients with burn injuries are resuscitated. We designed this prospective, descriptive study to compare these parameters with serial base deficit and serum lactate values, which have been found to be sensitive indicators of adequate fluid resuscitation in trauma patients. The sample group consisted of 53 patients, consecutively admitted to the burn intensive care unit, who had 15% or more total body surface area burns. No changes in resuscitation protocol were implemented. Within the 48-hour period after admission, 2 ml heparinized venous blood samples were collected and analyzed every 2 to 4 hours, and vital signs, urinary output, fluid type, and volume administered were documented each hour. Urinary output and mean arterial pressure were maintained at more than 30 ml/hr and more than 70 mm Hg, respectively. Partial correlations between the traditional resuscitation variables and serum lactate and base deficit were low. On average, serum lactate and base deficit remained abnormally high during the study period. These new parameters may be used to improve the fidelity with which burn shock resuscitation is undertaken. Further studies of these parameters and how they may be used as endpoints in fluid resuscitation are needed.

Cooking-related burn injuries in the elderly preventing the "granny gown" burn.

Cooking-related burn injuries accounted for 27% of the elderly female admissions at one burn center. The primary mode of injury was found to be ignition of clothing while reaching across a stove. To develop a prevention program for this problem, biologic and environmental hazards were identified. From this information, a two-phase prevention program was designed. Phase one, education, entailed the development, publication, and distribution of a pamphlet to a variety of local agencies. Phase two, an environment evaluation, consisted of contacting consumer relation departments of major stove manufacturers suggesting a product safety review. The community response to this program has been favorable. Its design should provide the foundation for preventing increased incidence of cooking-related burn injuries.

Treatment of toxic epidermal necrolysis by burn units: another market or another threat?

A survey of burn care facilities in the United States has provided information regarding the treatment of toxic epidermal necrolysis and related diseases in burn units. The survey suggests that a disproportionate share (12% to 15%) of the projected number of cases of toxic epidermal necrolysis that occur annually are being transferred to the 2% of United States hospitals that have burn units. Because of the potential for a complex hospital course and extended length of stay, treatment of these patients in a prospective payment system poses a significant fiscal threat to hospitals with burn units.

Pontine myelinolysis after correction of hyponatremia during burn resuscitation.

Central pontine myelinolysis is a neurologic disease produced by the rapid correction of hyponatremia. This report describes the occurrence of central pontine myelinolysis in a patient with burns. The natural history of this paralyzing condition and suggestions for its prevention are discussed. Severely burned and hyponatremic patients are at risk for this disorder because a large amount of sodium ion is typically required for the treatment of burn shock. Awareness of this phenomenon and avoidance of rapid correction of hyponatremia are essential to its prevention.

A pressure prevention device for burned ears.

Full-thickness burns to the external ear can produce loss of skin and cartilage and can result in severe cosmetic deformity. Even partial-thickness burns render the ear vulnerable to tissue loss if the helix is subjected to pressure from pillows, dressings, or straps that are used to secure endotracheal tubes. Because of the incidence of burned ear deformities and the difficulty in reconstructing the external ear, an ear protection device has been designed. The bilateral ear protection device, referred to as "headgear", is fitted to all patients in the burn center who require intubation for an inhalation injury; it is worn continuously until extubation. During a 15-month period 39 consecutive critically burned patients were fitted with the headgear because of the need for ventilator support and/or for protection of the burned ear(s). Pressure necrosis of ear tissue was prevented in all 33 survivors.

Intraoperative blood salvage in excisional burn surgery: an analysis of yield, bacteriology, and inflammatory mediators.

The diminution of intraoperative hemorrhage remains a fundamental goal of the burn surgeon. We hypothesized that intraoperative blood salvage during burn excisions would be feasible if predicated on yield, bacteriology, and concentration of inflammatory mediators in the washed product. Reinfusion of culture-positive blood has a clear precedent in the trauma literature. Eight operations with immediate and complete collection of shed blood into a cell-saver device were prospectively studied. A median salvage rate of 43% of total shed red blood cells was estimated to have been recovered. Actual volumetric measurement of intraoperative blood loss was achieved. Bacterial contamination was consonant with the abdominal trauma experience. The levels of C3a, C5a, TNF alpha, and IL-1 beta in the final cell-saver product were all found to be at clinically insignificant levels.

The 2003 Carl A Moyer Award: real-time metabolic monitors, ischemia-reperfusion, titration endpoints, and ultraprecise burn resuscitation.

Real-time metabolic monitoring of varied vascular beds provides the raw data necessary to conduct ultraprecise burn shock resuscitation based on second-by-second assessment of regional tissue perfusion. It also illustrates shortcomings of current clinical practices. Arterial base deficit was continuously monitored during 11 clinical resuscitations of patients suffering burn shock using a Paratrend monitor. Separately, in a 30% TBSA rat burn model (N = 70), three Paratrend monitors simultaneously recorded arterial blood gas and tissue pCO2 of the burn wound and colonic mucosa during resuscitation at 0, 2, 4, 6, and 8 ml/kg/%TBSA. Paratrend data were analyzed in conjunction with previously reported laser Doppler images of actual burn wound capillary perfusion. With current clinical therapy, continuous monitoring of arterial base deficit revealed repetitive cycles of resolution/worsening/resolution during burn shock resuscitation. In the rat model, tissue pCO2 in both burn wounds and splanchnic circulation differed depending on the rate of fluid resuscitation (P <.01 between sham and 0 ml/kg/%TBSA and between 2 ml/kg/%TBSA and 4 ml/kg/%TBSA). Burn wound pCO2 values correlated well with laser Doppler determination of actual capillary perfusion (rho = -.48, P <.01). The following conclusions were reached: 1). Gratuitous and repetitive ischemia-reperfusion-ischemia cycles plague current clinical therapy as demonstrated by numerous "false starts" in the resolution of arterial base deficit; 2). in a rat model, real-time monitoring of burn wound and splanchnic pCO2 demonstrate a dose-response relationship with rate of fluid administration; and 3). burn wound and splanchnic pCO2 are highly correlated with direct measurement of burn wound capillary perfusion by laser Doppler imager. Either technique can serve as a resuscitation endpoint for real-time feedback-controlled ultraprecise resuscitation.

Digital photography: enhancing communication between burn therapists and nurses.

Burn rehabilitation therapists rely on nursing staff to follow through with the positioning and splinting programs. To communicate more effectively, a communication tool that consisted of digital photos and written instructions was created. Microsoft Word and Nikon View software were used to design the communication tool. The purpose of the study was to assess the perceived effectiveness of a communication tool between burn therapists and burn nurses for splinting and positioning. Thirty-two surveys were distributed to burn nursing staff to assess their perception of the communication tool (digital photographs with written instructions) compared with previous methods of instructions (without digital photographs). Seventy-three percent of nurses felt the communication tool with verbal instructions were the best methods of communicating splinting and positioning needs. All respondents felt that the rehabilitation staff should continue to use the communication tool.

Serum calcitonin may be a marker for inhalation injury in burns.

One of the principal causes of death from burns is inhalation injury. The pulmonary neuroendocrine cell contains and secretes immunoreactive calcitonin (iCT), and, under the influence of various irritative stimuli, can be induced to secrete iCT in excess. A prospective study of serum iCT levels in 41 patients with burns was undertaken. Mean serum iCT levels were four times normal values at the time of admission and reached 31 times normal values by 24 hours after injury. These levels did not correlate specifically with burn size. However, serum iCT had a very strong positive correlation with mortality, and in addition, was highest in patients who died early after injury compared with those who died late after injury. Patients who were clinically suspected to have pulmonary injury and who died had markedly higher levels of iCT than those who survived. In addition, serum iCT correlated positively with the need for mechanical ventilation and the amount of pulmonary shunting. Although other factors may also play a role in hypercalcitoninemia, serum iCT may be an important marker for the presence of inhalation injury, as well as a prognostic indicator.

Microvascular assessment of burn depth conversion during varying resuscitation conditions.

Conversion of partial- to full-thickness injuries, even after the burning has stopped, remains a significant clinical problem. We developed a rat model with a wide range of burn depths to study this phenomenon by microvascular assessment. Fifty-four male Sprague-Dawley rats weighing 460 g on average were studied. Real-time tissue monitoring of pH, paCO2, and paO2 was achieved by placement of a continuous blood gas monitor transducer in the aorta. Ten, 2-cm x 2-cm burns were created on each animal with milled aluminum templates (100 degrees C) with varying contact times. Conversion of burn depth in these wounds was documented by serial laser Doppler imager scanning over a 5-hour period. Animals received Ringer's lactate resuscitation at 0, 2, 4, 6, and 8 ml/kg/%burn. Serial laser Doppler scanning directly demonstrated progressive loss of perfusion to partial-thickness burns dependent upon the amount of fluid resuscitation. Conversion of partial- to full-thickness burns in this rat model (documented by laser Doppler microvascular assessment) was dependent upon how the animals were resuscitated.