Predictors of Mortality in Patients With Necrotizing Fasciitis: A Literature Review and Multivariate Analysis.

Background: Necrotizing fasciitis (NF) is a life-threatening infectious disease that can result in significant morbidity and mortality. Previously identified factors have not been verified in a large population. The objective of this study is to further examine the relationship of patient factors in NF mortality. Methods: This study is a retrospective review on patients ≥18 years old diagnosed with NF at the provincial referral centres from 2004 to 2016. The following data were examined: demographics, comorbidities, laboratory values, length of stay, and inhospital mortality. Results: Three hundred forty patients satisfied the inclusion criteria: 297 survived and were discharged, 43 died in hospital. In multivariate analysis, a prognostic model for NF mortality identified age >60 years, elevated creatinine, abnormal blood platelets, and group A ß-hemolytic Streptococcus (GABS) infection. Conclusions: Multiple factors were associated with mortality in NF. The strongest univariate association with mortality was age >60 years. In addition, a history of hypertension and/or dyslipidemia, renal disease, and the presence of GABS contributed to a predictive model for inhospital NF mortality.

Contexte: La fasciite nécrosante (FN) est une maladie infectieuse mettant la vie en danger et pouvant déboucher sur une morbidité et mortalité significatives. Les facteurs précédemment identifiés n'ont pas été vérifiés dans une large population. Cette étude avait pour objectif d'examiner plus en détail le rapport entre les facteurs liés au patient dans la mortalité de la FN. Méthodes: Il s'agit d'une étude rétrospective sur des patients âgés de ≥ 18 ans ayant eu un diagnostic de FN dans des centres de référence provinciaux de 2004 à 2016. Les données suivantes ont été examinées: Données démographiques, comorbidités, résultats des tests de laboratoire, durée du séjour à l'hôpital et mortalité à l'hôpital. Résultats: 340 patients ont satisfait les critères d'inclusion: 297 patients ont survécu et ont reçu leur congé; 43 patients sont décédés à l'hôpital. Un modèle pronostique pour la mortalité dans la FN a identifié dans une analyse multifactorielle un âge > 60 ans, une élévation de la créatinine, des plaquettes sanguines anormales et une infection par des streptocoques ß hémolytiques du groupe A (SGA). Conclusions: De nombreux facteurs sont associés à la mortalité dans la FN. L'association unifactorielle la plus forte avec la mortalité était un âge > 60 ans. De plus, des antécédents d'hypertension et/ou de dyslipidémie, une maladie rénale, et la présence de SGA ont contribué au modèle prédictif de la mortalité hospitalière liée à la FN.

Malnutrition in Burns: A Prospective, Single-Center Study.

The hypermetabolic response from a burn injury is the highest of the critically ill patient population. When coupled with the hypermetabolic response, preexisting malnutrition may increase the hospital resources used. The goal of this study was to evaluate the rate of malnutrition in burn patients and the associated hospital resource utilization. We collected prospective data on burn patients 18 years or older with a burn at least 10% TBSA admitted to a regional burn center. Demographics, %TBSA, comorbidities, length of stay (LOS), and standardized LOS (LOS/%TBSA) were evaluated on 49 patients. A multivariable regression model was constructed. Nutrition assessment was completed within 24 to 48 hours of admission including an SGA (Subjective Global Assessment) classification. SGA A (well-nourished) was compared to SGA B and C (malnourished). Fourteen patients (28.6%) in this study were malnourished. Malnourished patients were not statistically different with respect to median age (50 vs 39; P = .08) and body mass index (22.9 vs 26.5; P = .08) compared to the well-nourished group. However, malnourished patients had significantly longer median LOS (21.0 vs 11.0 days, P = .01) and LOS/%TBSA (1.69 vs 0.83, P = .001) than the well-nourished group. Being malnourished was a significant independent predictor of above-median LOS/%TBSA (P = .027) with an odds ratio of 5.61 (95% CI 1.215-25.890). The rate of malnutrition is important given the high metabolic demands of these patients. Malnutrition increased the resource requirements via higher standardized LOS. This underscores the importance of completing SGA on admission to identify malnutrition early on to optimize nutrition intervention during the patients' hospital stay.

Assessment of cleaning methods on bacterial burden of hospital privacy curtains: a pilot randomized controlled trial.

Healthcare-associated infections (HAIs) are an important global issue, leading to poor patient outcomes. A potential route of transmission of HAIs is through contact with hospital privacy curtains. The aim of this study is to evaluate cleaning on reduction of curtain bacterial burden. In this pilot cluster randomized controlled trial we compared the bacterial burden between three groups of 24 curtains on a regional burn/plastic surgery ward. A control group was not cleaned. Two groups were cleaned at 3-4 day intervals with either disinfectant spray or wipe. The primary outcome was the difference in mean CFU/cm2 between day 0 to day 21. The secondary outcome was the proportion of curtains contaminated with Methicillin-resistant Staphylococcus aureus (MRSA). By day 21, the control group was statistically higher (2.2 CFU/cm2) than spray (1.3 CFU/cm2) or wipe (1.5 CFU/cm2) (p < 0.05). After each cleaning at 3-4 day intervals, the bacterial burden on the curtains reduced to near day 0 levels; however, the level increased again over the intervening 3-4 days. By day 21, 64% of control curtains were contaminated with MRSA compared to 10% (spray) and 5% (wipe) (p < 0.05). This study show that curtains start clean and progressively become contaminated with bacteria. Regularly cleaning curtains with disinfectant spray or wipes reduces bacterial burden and MRSA contamination.

Narrative discourse of burn injury and recovery on peer support websites: A qualitative analysis.

Although advances have been made in burn care and recovery, less is known about the experience of living with severe burn injury. Like other patient groups, burn survivors are now turning to social media and shared web-based peer support resources during recovery and continuing long after discharge. Ongoing peer support is often part of the reclamation process after-burn injury. Peer support and event sharing helps foster hope, motivation and reassurance. OBJECTIVES: To: 1) Examine and further understand the narrative discourse of burn survivorship in peer support social media content, 2) establish commonalities in the sharing community and key themes related to recovery and adaptation. METHODS: This qualitative enquiry began with a comprehensive overview of burn narratives on survivor peer generated websites. We conducted a purposeful sampling of 21 biographies posted on burn survivor peer and patient support websites. Participants with greater than 30% burn injury were included that provided narrative and discourse regarding burn recovery and survivorship. Underlying story arcs, meaning behind sentences and shared language of the experience were investigated using thematic analysis. RESULTS: Four themes were identified: retelling of the traumatic event; social support; body image, the new normal; and rebirth and transformation. Accounts reflected the traumatic nature of the event with slowed downtime, attention to details and heightened recall. The value of peer and family support was a common theme. There was attention to the challenges related to changed body image and regaining confidence in body appearance. Most stories also documented transitioning and rebirth and other more positive aspects of trauma recovery. CONCLUSIONS: Accounting the burn experience and recovery is part of the reclamation process. Biographies document the trauma recovery process. Storying the event is an integral component of burn survivor community content. These online communities have become a mainstream resource and part of the reclamation process.

Interrupted Nutrition Support in Patients With Burn Injuries: A Single-Centre Observational Study.

BACKGROUND: Enteral nutrition (EN) is essential to meet the increased metabolic requirements of burn-injured patients. However, feeds are often suspended for care. This study examines the interruptions in EN (IEN). OBJECTIVE: To determine the frequency and duration of IEN and whether these interruptions are predictable or unpredictable. DESIGN: This retrospective chart review of 27 adult burn patients examined age, sex, body mass index, percentage of total body surface area, length of hospital stay, predicted energy requirements from equations and indirect calorimetry, EN start time, time EN reached goal rate, and interruptions to EN. RESULTS: Predictable interruptions accounted for 74.5% (frequency) and 81.6% (duration) of total interruptions. The most frequent and time-consuming interruptions were perioperative period, extubation, and tests/procedures (predictable) versus high gastric residual volume, emesis/nausea, and feeding tube displacement (unpredictable). CONCLUSIONS: Most IEN were due to predictable events. Based on these findings, compensating for predictable interruptions to meet nutritional requirements in burn patients is recommended.

HISTORIQUE: L'alimentation entérale (AE) est essentielle pour répondre aux besoins métaboliques accrus des patients brûlés. Cependant, elle est souvent suspendue pour procéder aux soins. La présente étude se penche sur les interruptions de l'AN (IAN). OBJECTIF: Déterminer la fréquence et la durée de l'IAN et établir si elles sont prévisibles ou non. MÉTHODOLOGIE: La présente analyse rétrospective des dossiers de 27 patients adultes brûlés a porté sur l'âge, le sexe, l'indice de masse corporelle (IMC), le pourcentage de la surface corporelle totale, la durée d'hospitalisation, les besoins énergétiques prévus à partir d'équations et de la calorimétrie indirecte, l'heure de début de l'AN, le temps pour parvenir au taux d'atteinte des objectifs d'AN et les interruptions à l'AN. RÉSULTATS: Les interruptions prévisibles représentaient 74,5 % (fréquence) et 81,6 % (durée) des interruptions totales. La période périopératoire, l'extubation et les tests et interventions (prévisibles) étaient les interventions les plus fréquentes et les plus chronophages, par rapport au volume gastrique résiduel élevé, aux nausées et aux vomissements, de même qu'au déplacement de la sonde gastrique (imprévisibles). CONCLUSIONS: La plupart des interruptions d'AN étaient attribuables à des événements prévisibles. D'après ces observations, il est recommandé de compenser les interruptions prévisibles pour répondre aux besoins nutritionnels des patients brûlés.

Pediatric frostbite: A 10-year single-center retrospective study.

OBJECTIVE: To describe frostbite (freezing cold injured tissue) in children and intrinsic (psychological and behavioral) and extrinsic (meteorological and safety hazard) factors related to the injury. METHODS: Retrospective chart review of children <18 years old referred to a regional pediatric hospital for frostbite, to determine the demographics, environment, and risk factors related to injuries. RESULTS: 47 patients met the inclusion criteria. Median age was 15 years (IQR 12-16). All injuries occurred between November and March. 49% were admitted to the hospital and frostbite was associated with use of alcohol (53%), cigarettes (34%), marijuana (23%), and symptoms of depression (with and without suicidal ideation) (32%). Frostbite injury treated with conservative wound management presented at <-6°C and injury that underwent surgical procedures occurred at temperatures ≤-23°C (p=0.001). Longer exposure duration also significantly increased the likelihood of a surgical procedure (p<0.001). Intoxication and lack of supervision were two common factors, with lack of supervision at time of injury most common among patients 0-12 years (64%), and intoxication most common among patients ages 13-17 (61%). CONCLUSION: Frostbite injuries in children begins at temperatures <-6°C; with risk of tissue loss increasing at temperatures below -23°C. Lack of supervision and intoxication are major risk factors for frostbite in children. Two-thirds of younger children were unsupervised, whereas intoxication was frequently related to frostbite in adolescents. Both of these factors can be addressed through an education-based prevention program.

The Relationship Between Income and Burn Incidence in Winnipeg, Manitoba, Canada: A Population Health Study.

Burns continue to be a common cause of morbidity around the world, and socioeconomic status has been linked to high-burn risk in developed and developing countries. The purpose of this study was to define in Winnipeg, Manitoba, Canada: 1) demographics of adult patients with severe burns; 2) the relationship between household income and burn incidence; and 3) specific geographic areas that may benefit from targeted burn prevention strategies. We conducted a retrospective study of adult (>18 years) patients in Winnipeg, with burns severe enough to require at least 1 day of hospitalization between 2006 and 2016. Area-level median household income data at two geographic levels were collected from 2011 Census based on patient postal codes. Of 207 patients that met study criteria, 156 (75.4%) were male. Mean age was 44.5 ± 16.9 years, and the most common cause of burns was fire/flame (52.2%). The analysis of income data revealed that lower area-level income groups had a higher incidence of burns, with the lowest income quintile group having 5.4 times higher incidence than highest income quintile group. Spatial analysis software was used to map the incidence rates, and clusters of high-risk burns were identified in and around the city center region. Overall, our study showed an inverse relationship between area-level income and burn injury incidence. The identification and mapping of high incidence hotspots will allow policy makers to target groups who will benefit most from burn prevention strategies.

Rate of contamination of hospital privacy curtains in a burns/plastic ward: A longitudinal study.

BACKGROUND: Since hospital patient privacy curtains can harbor bacteria, are high-touch surfaces, and are cleaned infrequently, they may be involved in pathogen transmission. The aim of this longitudinal prospective study was to understand curtain contamination to inform curtain hygiene protocols, thereby minimizing the role of curtains in pathogen transmission. METHODS: Over 21 days, cultures of 10 freshly laundered curtains (8 test curtains surrounding patient beds and 2 controls in an unoccupied staff room) were taken in the Regional Burns/Plastics Unit. Contact plates were used to sample the curtains near the edge hem where they are most frequently touched. Microbial contamination and the presence of methicillin-resistant Staphylococcus aureus (MRSA) were determined. RESULTS: By day 3, test curtains showed increased microbial contamination (mean colony-forming units [CFU]/cm2 = 1.17) compared to control curtains (mean CFU/cm2 = 0.19). Test curtains became increasingly contaminated over time, with mean CFU/cm2 for days 17 and 21 of 1.86 and 5.11, respectively. By day 10, 1/8 test curtains tested positive for MRSA, and 5/8 were positive by day 14. CONCLUSIONS: Patient privacy curtains became progressively contaminated with bacteria, including MRSA. Between days 10 and 14 after being hung, curtains showed increased MRSA positivity. This may represent an opportune time to intervene, either by cleaning or replacing the curtains.

In vitro measurements of burn dressing adherence and the effect of interventions on reducing adherence.

PURPOSE: There is a paucity of research on reducing dressing adherence. This is partly due to lack of an in vitro model, recreating the clinical variability of wounds. Previously we described an in vitro gelatin model to evaluate adherence in a standardized manner. We present evaluation of strategies to reduce adherence in six dressings. PROCEDURES: Dressing materials used were: PET (Control), fine mesh gauze coated in bismuth and petroleum jelly (BIS), nanocrystalline silver (NS), wide mesh polyester coated in polysporin ointment (WM), fine mesh cellulose acetate coated in polysporin ointment (FM), and soft silicone mesh (SIL). The dressing material was applied to gelatin and incubated for 24h. Adherence was tested using an Instron 5965 force-measurement device. Testing was repeated with various adherence reducing agents: water, surfactant, and mineral oil. RESULTS: Adherence from least to greatest was: SIL, NS, BIS, WM, FM, PET. Water reduced adherence in all dressings; the effect increasing with exposure time. Surfactant reduced adherence of NS. Mineral oil effectively decreased adherence of BIS, and WM. CONCLUSION: This model allows for reproducible measurement of dressing adherence. Different interventions affect various dressings. No single intervention optimally decreases adherence for all dressings.

Healthcare Resource Utilization Associated with Burns and Necrotizing Fasciitis: A Single-Center Comparative Analysis.

Necrotizing fasciitis (NF) patients are increasingly managed in burn units. Although treated similarly to burns, the healthcare resource utilization (HRU) in NF appears to be greater. Accurate knowledge of the HRU is important to better allocate resources and to compare outcomes between units. The goal of this study is to provide better understanding of the HRU for NF compared with burns. A retrospective chart review of patients ≥18 years admitted to two regional tertiary referral centers with either NF or burns requiring surgery. The authors examined age, sex, %TBSA, geographic region, anatomical location, length of stay (LOS) in hospital, LOS in intensive care unit, number of operative procedures, number of packed red blood cells transfused, amputation, death, and use of free tissue transfer or skin graft. There were 210 NF and 209 burn patients. The NF cohort had a smaller TBSA (3.3 vs 10.0%), longer LOS (20 vs 14 days), and consequently a longer LOS/%TBSA (6.0 vs 1.5 days). This difference persisted after adjusting for age. More of the NF cohort (44.8%) spent ≥1 day in the intensive care unit. The NF cohort also had more procedures (median 2 vs 1), required blood (46.2 vs 16.7%), died in hospital (13.3 vs 4.3%), had an amputation (12.4 vs 4.8%), or required free tissue transfer (7.6 vs 2.9%). This study shows that NF requires substantially more HRU compared with burns. This information is important in recognizing the impact of these patients on burn units and planning for allocation of appropriate resources.

Mental health outcomes of burn: A longitudinal population-based study of adults hospitalized for burns.

PURPOSE: This study investigates the increased risk of mental health outcomes and health care utilization associated with burn with two year of follow-up using a longitudinal population-based matched cohort design. METHODS: Adult burn survivors (n=157) were identified from a provincial burn registry and matched 1:5 with non-burn control subjects from the general population (matching variables age and gender). The prevalence of mental health outcomes and the rates of health care utilization between the groups were compared for the 2years pre and post index date using anonymously linked population-based administrative health care data. Rates were adjusted for age, gender and sociodemographic characteristics. RESULTS: While the burn cohort had an increased prevalence of mental health problems after burn compared to the control cohort, the burn group also had an increased prevalence of pre-burn depression (16.6% vs 7.8%; p=0.0005) and substance use disorders (8.9% vs 3.2%; p=0.001) when compared to controls. Once the pre-existing prevalence of mental illness was taken into account there was no significant change in the prevalence of mental health problems when comparing the burn group to controls over time. CONCLUSIONS: Although burns may not increase rates of mental health issues and health care utilization, burn survivors are a vulnerable group who already demonstrate increased rates of psychopathology and need for care. The present study highlights the importance of assessment and treatment of mental health outcomes in this population.

Mental and Physical Health Outcomes in Parents of Children with Burn Injuries as Compared with Matched Controls.

Pediatric burn injuries are common, and the stress of caring for them can affect caregivers' health. This study's objective was to examine the rates of common mental and physical disorders of parents of burn-injured children (cases) compared with matched controls (controls). This is a population-based study linking the Regional Pediatric burn registry with administrative health information. Pediatric burn cases were matched 1:5 with control children from the general population based on age, sex, and geographical location then parents identified. One thousand and twenty-six parental cases and 4858 controls were identified. International Classification of Disease codes were used to identify diagnoses of common mental and physical disorders. Using rates of disease 2 years before and 2 years after the date of burn, the changes in the relative rates of health outcomes were compared between the cases and the controls. The cases had higher rates of postinjury mental and physical illness compared with the matches. However, it was found that controls also had increased rates postindex date and additionally cases had increased rates of preinjury illnesses. There was no difference in the relative rates of illnesses between the groups from pre- to post-index date. The higher rate of illness in cases postinjury could be explained by preinjury illness, and similar rate increases in the control cohort. Evaluation of the effect of a child's burn injury on parents should take into context the preexisting health of the parent. Socioeconomic factors associated with increased risk of burns may also be associated with adverse health outcomes.

Outcomes in Adult Survivors of Childhood Burn Injuries as Compared with Matched Controls.

Limited research exists examining long-term mental and physical health outcomes in adult survivors of pediatric burns. The authors examine the postinjury lifetime prevalence of common mental and physical disorders in a large pediatric burn cohort and compare the results with matched controls. Seven hundred and forty five survivors of childhood burns identified in the Burn Registry (<18 years old and total BSA >1% between April 1, 1988 and March 31, 2010) were matched 1:5 to the general population based on age at time of injury (index date), sex, and geographic residence. Postinjury rate ratio (RR) was used to compare burn cases and control cohorts for common mental and physical illnesses through physician billings, and hospital claims. RR was adjusted for sex, rural residence, and income. Compared with matched controls, postburn cases had significantly higher RR of all mental disorders, which remained significant (P < .05) after adjustment (major depression RR = 1.5 [confidence limit {CL}: 1.2-1.8], anxiety disorder RR = 1.5 [CL: 1.3-1.8), substance abuse RR = 2.3 [CL: 1.7-3.2], suicide attempt RR = 4.3 [CL: 1.6-12.1], or any mental disorder RR = 1.5 [CL: 1.3-1.8]). The relative rate of some physical illnesses was also significantly increased in burn survivors: arthritis RR = 1.2 (CL: 1.1-1.4), fractures RR = 1.4 (CL: 1.2-1.6), total respiratory morbidity RR = 1.1 (CL: 1.02-1.3), and any physical illness RR = 1.2 (CL: 1.1-1.3). Adult survivors of childhood burn injury have significantly increased rates of postburn mental and physical illnesses. Screening and appropriate management of these illnesses is essential when caring for this population.

Zinc supplementation in burn patients.

Micronutrient supplementation is a common practice throughout many burn centers across North America; however, uncertainty pertaining to dose, duration, and side effects of such supplements persists. The authors prospectively collected data from 23 hospitalized patients with burn sizes ranging from 10 to 93% TBSA. Each patient received a daily multivitamin and mineral supplement, 50 mg zinc (Zn) daily, and 500 mg vitamin C twice daily. Supplements were administered orally or enterally. Albumin, prealbumin, C-reactive protein, serum Zn, and serum copper were measured weekly during hospital admission until levels were within normal reference range. Our study concluded that 50 mg daily dose of Zn resulted in normal serum levels in 19 of 23 patients at discharge; 50 mg Zn supplementation did not interfere with serum copper levels; and Zn supplements, regardless of administration route, did not result in gastrointestinal side effects.