Association Between Health Insurance and Outcomes After Traumatic Brain Injury: A National ACS-TQP-PUF Database Study.

INTRODUCTION: According to the US Census Bureau, roughly 8.6% of the population lacks health care coverage. Increasing evidence suggests that insurance status plays a role in outcomes after trauma. However, its role in the setting of traumatic brain injury (TBI) remains poorly understood. METHODS: The Trauma Quality Programs Participant Use Files were queried from 2017 to 2019. All patients with isolated TBI were identified. Isolated TBI was defined as: 1) Head Abbreviated Injury Scale (AIS) > 3 and 2) AIS <3 in all other anatomical regions. Patients dead on arrival, with Head AIS = 6, or missing key data were excluded. Demographic and clinical information was compared between those with and without insurance. Multivariate regressions were used to assess associations between insurance status and TBI outcomes (inhospital mortality, discharge to facility, total ventilator days, Intensive Care Unit length of stay (ICU LOS), and hospital LOS). RESULTS: In total, 199,556 patients met inclusion criteria; 18,957 (9.5%) were uninsured. Compared to the insured, uninsured TBI patients were younger with a greater proportion of males. Uninsured patients were less severely injured and less comorbid. Uninsured patients had shorter unadjusted LOS in the ICU and hospital. Yet, uninsured patients experienced greater unadjusted inhospital mortality (12.7% versus 8.4%, P < 0.001). When controlling for covariates, lack of insurance was significantly associated with increased likelihood of mortality (OR 1.62; P < 0.001). This effect was most noticeable in patients with Head AIS = 4 (OR 1.55; P < 0.001) and Head AIS = 5 (OR 1.80; P < 0.001). Lack of insurance was also significantly associated with decreased likelihood of discharge to facility (OR 0.38), decreased ICU LOS (Coeff. -0.61), and decreased hospital LOS (Coeff. -0.82; all P < 0.001). CONCLUSIONS: This study demonstrates that insurance status is independently associated with outcome disparities after isolated TBI. Despite the Affordable Care Act (ACA) reform, lack of insurance appears significantly associated with inhospital mortality, decreased likelihood of discharge to facility, and decreased time spent in the ICU and hospital.

Preliminary Exploration of Long-Term Patient Outcomes After Tracheostomy in Burns: A Burn Model System Study.

INTRODUCTION: Upper airway management is crucial to burn care. Endotracheal intubation is often performed in the setting of inhalation injury, burns of the face and neck, or large burns requiring significant resuscitation. Tracheostomy may be necessary in patients requiring prolonged ventilatory support. This study compares long-term, patient-reported outcomes in burn patients with and without tracheostomy. MATERIALS AND METHODS: Data from the Burn Model System Database, collected from 2013 to 2020, were analyzed. Demographic and clinical data were compared between those with and without tracheostomy. The following patient-reported outcomes, collected at 6-, 12-, and 24-mo follow-up, were analyzed: Veterans RAND 12-Item Health Survey (VR-12), Satisfaction with Life, Community Integration Questionnaire, Patient-Reported Outcomes Measurement Information System 29-Item Profile Measure, employment status, and days to return to work. Regression models and propensity-matched analyses were used to assess the associations between tracheostomy and each outcome. RESULTS: Of 714 patients included in this study, 5.5% received a tracheostomy. Mixed model regression analyses demonstrated that only VR-12 Physical Component Summary scores at 24-mo follow-up were significantly worse among those requiring tracheostomy. Tracheostomy was not associated with VR-12 Mental Component Summary, Satisfaction with Life, Community Integration Questionnaire, or Patient-Reported Outcomes Measurement Information System 29-Item Profile Measure scores. Likewise, tracheostomy was not found to be independently associated with employment status or days to return to work. CONCLUSIONS: This preliminary exploration suggests that physical and psychosocial recovery, as well as the ability to regain employment, are no worse in burn patients requiring tracheostomy. Future investigations of larger scale are still needed to assess center- and provider-level influences, as well as the influences of various hallmarks of injury severity. Nonetheless, this work should better inform goals of care discussions with patients and families regarding the use of tracheostomy in burn injury.

The effect of tobacco use on outcomes of laparoscopic and open ventral hernia repairs: a review of the NSQIP dataset.

INTRODUCTION: Tobacco smoking is a known risk factor for complications after major surgical procedures. The full effect of tobacco use on these complications has not been studied over large populations for ventral hernia repairs. This effect is more important as the preoperative conditioning, and optimization of patients is adopted. We sought to use the prospectively collected ACS-NSQIP dataset to evaluate respiratory and infectious complications for patients undergoing both laparoscopic and open ventral hernia repairs. METHODS: The ACS-NSQIP dataset was queried for patients who underwent open or laparoscopic ventral hernia repairs, by primary procedure CPT codes, between years 2009-2012. Smoking use was registered as defined by the ACS-NSQIP, as both a current smoker (within the prior 12 months) or as a history of smoking (having ever smoked). Univariate and multivariate analyses were used to investigate postoperative complications for 30-day morbidity and mortality by smoking status while adjusting for preoperative risk factors. RESULTS: The majority of cases were open, 82 %, compared to laparoscopic 18 %. Sex was evenly distributed with 58 % female and 42 % male; however, there was a difference in the distribution of current smokers (p = 0.03). On analysis there were significantly more respiratory complications (p = 0.0003) and infectious complications (p < 0.0001). When controlling for sex, age, and type of surgery, using logistic regression, there were associations between smoking in the prior 12 months and respiratory complications, including pneumonia (p < 0.0001), and re-intubation (p < 0.0001). Similar associations were seen on logistic regression if a patient ever smoked; including pneumonia (p < 0.0001), re-intubation (p < 0.0001), and failure to wean (p < 0.0001). CONCLUSION: Smoking tobacco, both current and historical use, leads to an increase in both respiratory and infectious complications. As more centers try to preoperatively condition patients for elective hernia repairs, it is important to note that patients may never return to the baseline outcomes of patients who never smoked.

The effect of tobacco use on outcomes of laparoscopic and open inguinal hernia repairs: a review of the NSQIP dataset.

BACKGROUND: As the effort to reduce postoperative morbidity and mortality continues, the search for modifiable patient risk factors to reduce complications is ongoing. Tobacco use is associated with impaired wound healing, but its effect on inguinal hernia repair has not been studied in a large population. An ACS-NSQIP dataset was used to evaluate the effect of tobacco use on outcomes of inguinal hernia repairs. METHODS: The ACS-NSQIP dataset was queried for patients who underwent open or laparoscopic inguinal hernia repairs, by primary procedure CPT codes, between years 2009-2012. Tobacco use was registered, as defined by the ACS-NSQIP, in two ways: current smoking (within the past 12 months), or history of smoking (having ever smoked). Univariate and multivariate analyses were used to investigate outcome variables for 30-day morbidity by type of smoking status, while adjusting for preoperative risk factors. RESULTS: During the study period, 90,162 patients underwent inguinal hernia repair. 76 % of the cases were open compared to 24 % laparoscopic. The population was overwhelmingly male, 91 %, compared to 9 % female. The average age of patients was 42.5 years. Of the available data (69 % of patients), 38.5 % had a history of smoking. 18 % had smoked within the 12 months prior to surgery (current smokers). Their average number of pack years was 27.2 (SD 24.0) compared to 4.5 pack years (SD 14.7) for those who had not smoked 12 months prior to surgery (historical smokers). Using Fisher's exact test, having ever smoked was found to be significantly associated with pneumonia (p = 0.0008) and return to the operating room (p = 0.010). This relationship held when preoperative variables were controlled for using logistic regression (pneumonia, p = 0.002; return to the operating room, p = 0.002). When preoperative variables were controlled for and logistic regression was performed for current smokers, there was also a significant association with pneumonia (p = 0.005) and return to the operating room (p = 0.01). CONCLUSION: Current smoking status is a modifiable risk of patients undergoing laparoscopic and open inguinal hernia repair. Failure to quit smoking prior to surgical repair is associated with complications like pneumonia and return to the operating room.

The utilization of laparoscopy in ventral hernia repair: an update of outcomes analysis using ACS-NSQIP data.

BACKGROUND: Numerous prospective studies and randomized controlled trials have demonstrated shorter length of stay, lower morbidity rates, and similar recurrence rates with laparoscopic ventral hernia repair (VHR) when compared to open VHR. Despite these promising results, previous data showed low utilization of laparoscopic VHR. The aim of our study was to evaluate the utilization of laparoscopic VHR using the most updated information from the American College of Surgeons-National Surgical Quality Improvement Project (NSQIP) dataset. The secondary aim was to evaluate the outcomes from NSQIP for patients undergoing open versus laparoscopic VHR for the outcome of 30-day mortality and the peri-operative morbidities listed in the NSQIP dataset. METHODS: We performed this study using 2009-2012 data from the ACS-NSQIP database. The study population included patients who had undergone an open or laparoscopic ventral hernia repair as their primary procedure based on CPT codes. Demographic characteristics, overall morbidity, and complications were compared using Chi-square tests for categorical variables and two-sided t tests for continuous variables. Secondary outcomes (mortality and any complications) were further analyzed using logistic regression. RESULTS: Utilization of laparoscopic VHR was 22%. While adjusted mortality was similar, overall morbidity was increased in the open VHR group (OR 1.63; CI 95% 1.38-1.92). The open group had a higher rate of return to the OR, pneumonia, re-intubation, ventilator requirement, renal failure/insufficiency, transfusion, DVT, sepsis, and superficial and deep incisional wound infections. CONCLUSIONS: The utilization of laparoscopic VHR remained low from 2009 to 2012 and continued to lag behind the use of laparoscopy in other complex surgical procedures. The mortality rate between laparoscopic and open VHR was similar, but laparoscopic repair was associated with lower overall complication rates.

Burn Injury Results in Myeloid Priming during Emergency Hematopoiesis.

INTRODUCTION: Hematopoiesis proceeds in a tiered pattern of differentiation, beginning with hematopoietic stem cells (HSC) and culminating in erythroid, myeloid, and lymphoid lineages. Pathologically altered lineage commitment can result in inadequate leukocyte production or dysfunctional cell lines. Drivers of emergency hematopoiesis after burn injury are inadequately defined. Burn injury induces a myeloid predominance associated with infection that worsens outcomes. This study aims to further profile bone marrow HSCs following burn injury in a murine model. METHODS: C57BL/6 mice received burn or sham injury with ~12% total body surface area (TBSA) scald burn on the dorsal surface with subsequent sacrifice at 1, 2, 3, 7 and 10 days post-injury. Bone marrow (BM) from hindlimbs were analyzed for HSC populations via flow cytometry and analyzed using FlowJo Software (version 10.6). Event counts and frequencies were analyzed with multiple unpaired t-tests and linear mixed-effect regression. RT-PCR performed on isolated lineage negative BM cell RNA targeted PU.1, GATA-1, and GATA-3 with subsequent analysis conducted with QuantStudio 3 software. Statistical analysis and representation were performed on GraphPad software (Prism). RESULTS: Flow cytometry revealed significantly elevated proportions of Long-Term HSCs at 3 days post-injury (p < .05) and Short-Term HSCs at days 2, 3, and 10 (all p < .05) in burn-injured mice. There was a sustained, but not significant, increase in proportions in the multi-potent progenitor (MPP) 2 and 3 subpopulations in the burn cohort compared to sham controls. The common myeloid progenitor (CMP) proportion was significantly higher on days 3 and 10 (both p < .01), while the granulocyte-macrophage progenitor (GMP) proportion increased on days 1, 2, and 10 (p < .05, p < .01, p < .01). Although the megakaryocyte-erythrocyte progenitor (MEP) proportion appeared consistently lower in the burn cohort, this did not reach significance. mRNA analysis resulted in a downregulation of PU.1 on day 1 (p = 0.0002) with an upregulation by day 7 (p < 0.01). GATA-1 downregulation occurred by day 7 (p < 0.05), and GATA3 showed downregulation on days 3 and 7 (p < 0.05). DISCUSSION: Full-thickness burn results in an emergency hematopoiesis via proportional increase of Long Term-HSC and Short Term-HSC/MPP1 subpopulations beginning in the early post-injury period. Subsequent lineage commitment displays a myeloid predominance with a shift toward myeloid progenitors with mRNA analysis corroborating this finding with associated upregulation of PU.1 and downregulation of GATA-1 and GATA-3. Further studies are needed to understand how burn-induced emergency hematopoiesis may predispose to infection by pathologic lineage selection.

A nationwide analysis of geriatric proximal humerus fractures: trends, outcomes, and cost.

Background: In the USA, proximal humerus fractures (PHF) are the third most common fracture among the elderly. Although most geriatric PHF are treated conservatively, surgical management remains an option. This retrospective study compares annual trends, patient outcomes, and hospital costs between operatively and non-operatively managed geriatric PHF. Methods: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample was queried from 2012 to 2015. Geriatric patients with PHF were identified and those who underwent operative or non-operative management were compared in trends, outcomes and costs. Results: In total, 137 810 patients met inclusion criteria, of which 51 795 (37.6%) underwent operative management. The operative cohort was younger (76.6 vs 80.9, p<0.001) with a greater proportion of females (81.8% vs 77.6%, p<0.001). The operative cohort demonstrated less frailty and lower Elixhauser Comorbidity Scores (both p<0.001). The operative cohort was also more likely to be discharged home (30.4% vs 13.9%, p<0.001). There was no significant linear trend in age-adjusted and sex-adjusted proportions of operative versus non-operative geriatric PHF (p=0.071), but a positive linear trend was statistically significant for total cost of operative geriatric PHF (p<0.001). Multivariable analyses demonstrated similar overall complication rates between cohorts (OR 0.95, 95% CI 0.89 to 1.00; p=0.06), although surgical intervention increased length of stay (LOS) by 0.15 days (95% CI 0.03 to 0.27; p<0.001) and median cost of hospitalization by US$10 684 (95% CI US$10 384 to US$10 984; p<0.001). Conclusions: This study identifies a positive linear trend in total cost of operatively managed geriatric PHF from 2012 to 2015. Operative management of geriatric PHF is associated with a similar overall complication rate and greater likelihood of being discharged home. Although non-operative management is associated with decreased LOS and hospital expenses, providers should consider surgical PHF treatment options when available and appropriate in the context of patient-focused outcomes, particularly long-term disposition after intervention. Level of Evidence: This level IV retrospective study identifies.

Inter-facility transfers for burn patients with concomitant traumatic injuries.

Burn patients with concomitant traumatic injuries suffer increased morbidity and mortality. Complex care coordination is necessary for these patients, and the prevalence of resulting inter-facility transfers has not yet been quantified by literature. This study examined the outcomes for traumatically injured burn patients to identify the occurrence of trauma system transfers in this group. The National Trauma Data Bank was reviewed from the years 2007-2016 for 6,565,577 patients with traumatic, burn, and concomitant burn & traumatic injuries. There were 5068 patients with both traumatic and burn injuries, 145,890 patients with burn injuries, and 6,414,619 patients with traumatic injuries. Trauma/burn patients were more often admitted to the ICU from the ED at a rate of 35.5% compared to 27.1% for burn and 19.4% for trauma (P < 0.001). For disposition when discharged from the hospital, trauma/burn patients required more inter-facility transfers at a rate of 2.5% compared to 1.7% for burn and 1.3% for trauma (P < 0.001). For level I trauma centers, 5.5% of trauma/burn, 7.1% of burn, and 0.5% of trauma patients required inter-facility transfers. For level II trauma centers, 29.1% of trauma/burn, 47.0% of burn, and 2.8% of trauma patients required inter-facility transfers. Among level I and level II trauma centers, patients with only burns and burn patients with concomitant traumatic injuries required more inter-facility transfers, and level II trauma centers required more inter-facility transfers for all patients. Quantifying these findings is the first step toward improving triage decisions and allocation of health care resources while expediting appropriate care.

American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation.

This Clinical Practice Guideline (CPG) addresses the topic of acute fluid resuscitation during the first 48 hours following a burn injury for adults with burns ≥20% of the total body surface area (%TBSA). The listed authors formed an investigation panel and developed clinically relevant PICO (Population, Intervention, Comparator, Outcome) questions. A systematic literature search returned 5978 titles related to this topic and after 3 levels of screening, 24 studies met criteria to address the PICO questions and were critically reviewed. We recommend that clinicians consider the use of human albumin solution, especially in patients with larger burns, to lower resuscitation volumes and improve urine output. We recommend initiating resuscitation based on providing 2 mL/kg/% TBSA burn in order to reduce resuscitation fluid volumes. We recommend selective monitoring of intra-abdominal and intraocular pressure during burn shock resuscitation. We make a weak recommendation for clinicians to consider the use of computer decision support software to guide fluid titration and lower resuscitation fluid volumes. We do not recommend the use of transpulmonary thermodilution-derived variables to guide burn shock resuscitation. We are unable to make any recommendations on the use of high-dose vitamin C (ascorbic acid), fresh frozen plasma (FFP), early continuous renal replacement therapy, or vasopressors as adjuncts during acute burn shock resuscitation. Mortality is an important outcome in burn shock resuscitation, but it was not formally included as a PICO outcome because the available scientific literature is missing studies of sufficient population size and quality to allow us to confidently make recommendations related to the outcome of survival at this time.

The Effect of Distance to Treatment Center on Long-Term Outcomes of Burn Patients.

Geospatial proximity to American Burn Association (ABA)-verified burn centers or self-designated burn care facilities varies across the country. This study evaluates the effect of distance to treatment center on long-term, patient-reported outcomes. Data from the Burn Model System (BMS) National Longitudinal Database were analyzed. Demographic and clinical data were compared between three cohorts stratified by distance to BMS center (<20, 20-49.9, ≥50 miles). Distance to BMS center was calculated as driving distance between discharge and BMS center ZIP code centroids. The following patient-reported outcomes, collected at 12-months follow-up, were examined: Veterans RAND 12-Item Health Survey (VR-12), Satisfaction with Life (SWL) scale, employment status, and days to return to work. Mixed model regression analyses were used to examine the associations between distance to BMS center and each outcome, controlling for demographic and clinical variables. Of 726 patients included in this study, 26.3% and 28.1% were <20 and between 20 and 49.9 miles to a BMS center, respectively; 46.6% were ≥50 miles to a BMS center. Greater distance was associated with white/non-Hispanic race/ethnicity, preinjury employment, flame injury, and larger burn size (P < .001). Regression analyses did not identify significant associations between distance to BMS center and any patient-reported outcomes. This study suggests that patients treated at BMS centers have similar long-term, patient-reported outcomes of physical and psychosocial function, as well as employment, despite centralization of burn care and rehabilitation services. Given a steady decline in the incidence of burn injury, continued concentration of key resources is logical and safe.

American Burn Association (ABA) Burn Care Quality Platform (BCQP) and Large Data Set Analysis Considerations: A Practical Guide to Investigating Clinical Questions in Burns via Large Data Sets.

The Burn Care Quality Platform (BCQP) consolidates data previously collected from the National Burn Repository and the Burn Quality Improvement Program into a single registry. Its data elements and their associated definitions are tailored to create consistency across other national trauma registries, namely the National Trauma Data Bank implemented by the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP). The BCQP now includes 103 participating burn centers and has captured data from 375,000 total patients as of 2021. With 12,000 patients entered under the current data dictionary, the BCQP represents the largest registry of its kind. On behalf of the American Burn Association Research Committee, the aim of this whitepaper is to provide a succinct overview of the BCQP, showcasing its unique features, strengths, limitations, and relevant statistical considerations. This whitepaper will highlight the resources available to the burn research community and offer insight on proper study design when preparing to conduct a large data set investigation for burn care. All recommendations herein were formulated through the consensus of a multidisciplinary committee and based on the available scientific evidence.

Surviving Sepsis After Burn Campaign.

INTRODUCTION: The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes. METHODS: The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported. RESULTS: The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis. CONCLUSION: Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.

Burn Shock and Resuscitation: Review and State of the Science.

Burn shock and acute fluid resuscitation continue to spark intense interest and debate among burn clinicians. Following a major burn injury, fluid resuscitation of burn shock is life-saving, but paradoxically can also be a source of increased morbidity and mortality because of the unintended consequence of systemic edema formation. Considerable research over the past two decades has been devoted to understanding the mechanisms of edema formation, and to develop strategies to curb resuscitation fluids and limit edema development. Recognition of burn endotheliopathy - injury to the endothelium's glycocalyx layer- is one of the most important recent developments in our understanding of burn shock pathophysiology. Newer monitoring approaches and resuscitation endpoints, along with alternative resuscitation strategies to crystalloids alone, such as administration of albumin, or plasma, or high dose ascorbic acid, have had mixed results in limiting fluid creep. Clear demonstration of improvements in outcomes with all of these approaches remains elusive. This comprehensive review article on burn shock and acute resuscitation accompanies the American Burn Association's State of the Science meeting held in New Orleans, LA on November 2-3, 2021 and the Proceedings of that conference published in this journal.

Age-Related Injuries From Escalators.

INTRODUCTION: Escalators and moving stairways are omnipresent in modern life. No study to date has examined nationwide incidence and outcomes associated with injuries directly related to escalator use. The aim of this study was to describe the injury patterns, incidence, and disposition as it pertains to youth compared to adults. METHODS: Descriptive and comparative analyses were performed using National Electronic Injury Surveillance System data. The frequencies of categorical variables were calculated across the two age groups. Chi-squared test was performed on all categorical variables. Significance was defined as two-tailed P < 0.05. Logistic regression was used on variables that were determined to be significant from the frequency tables, with additional variable selection being used to arrive on a final model for each outcome. RESULTS: From 2009 to 2019, there were 810 youth and 3669 adults injured in escalator-associated emergency department visits. Incidence in the youth population decreased over time. Disposition was similar between groups. Injury types were similar among groups. White female adults were more likely to sustain injuries related to escalator use. Adult patients were also significantly more likely to sustain head/neck/facial trauma. Last, adult patients were found to be more likely to suffer a fatal event in comparison to the youth population. DISCUSSION: Differences in the injury patterns between youth and adult patients related to the use of escalators illustrate a need for improved injury prevention. Improved education and safety guidelines, particularly in individuals in ages 18 and up, would likely lessen the discrepancies between age groups identified in this study.

Age-Related Differences in Injury Patterns and Outcome From Falls From Tree Stands.

From 2009 to 2019 there were 77 youth and 1046 adults injured in tree stand-related emergency department visits. There was no statistically significant different in sex or gender. Injury types were similar among groups and were categorized by body part. Despite the above-mentioned insignificant differences between the groups, we did identify several statistically significant findings. Adults that were not Caucasian or African-American were more likely to sustain injuries related to tree stands when compared to their youth counterparts (P-value 0.029). Adult patients were also more likely to sustain trauma to their torso (P-value 0.017). Lastly, adult patients were found to be more likely to require hospitalization in comparison to the youth population (P-value 0.018). Improved education and safety guidelines in the use of tree stands, particularly in individuals in ages 18 and up, would likely lessen the discrepancies between age groups identified in this study.

The impact of the Affordable Care Act's medicaid expansion on patients admitted for burns: An analysis of national data.

INTRODUCTION: The first states began implementing the Medicaid expansion provisions of the Patient Protection and Affordable Care Act (ACA) in 2014. Studies have yet to address its impact on burn patients. METHODS: Burn patients in geographic regions that expanded Medicaid coverage were compared to patients in regions that did not expand Medicaid before and after implementation of the ACA using bivariate statistics and a difference-in-differences model. A multivariable logistic regression was used to identify factors associated with having Medicaid insurance. The primary outcome of this study was the rate of Medicaid insurance. RESULTS: Of 25,331 discharges, we found greater increases in Medicaid coverage after the ACA in the Medicaid expander regions (23.4-40.2%) compared to the non-expander regions (18.5-20.1%). The difference-in-differences estimate between the expander and non-expander regions was 0.15 (95% CI: 0.11-0.18, p < 0.001). Patients admitted in expander regions were more likely to be insured by Medicaid (OR 1.57 [95%CI 1.21-2.05]), as were patients of Black race (OR 1.25 [95%CI 1.19-1.32), Hispanic ethnicity (OR 1.29 [95%CI 1.14-1.46]), and female sex (OR 1.59 [95%CI 1.11-2.27]). We also found a significant interaction between time period (pre-ACA/post-ACA) and expander region location (OR 2.10 [95%CI 1.67-2.62]). CONCLUSIONS: The Medicaid expansion provision of the ACA led to increased Medicaid coverage among burn patients which was significantly higher in areas with widespread implementation of the expansion.

Adoption of rescue colloid during burn resuscitation decreases fluid administered and restores end-organ perfusion.

INTRODUCTION: Traditionally, lactated Ringer's solution (LR) has been utilized for the resuscitation of thermally injured patients via the Parkland or Brooke formulas. Both of these formulas include colloid supplementation after 24 h of resuscitation. Recently, the addition of albumin within the initial resuscitation has been reported to decrease fluid creep and hourly fluids given. Our institution has previously advocated for a crystalloid-driven resuscitation. Given reports of improved outcomes with albumin, we pragmatically adjusted these practices and present our findings for doing so. METHODS: Our burn registry, consisting of prospectively collected patient data, was queried for those at least 18 years of age who, between July 2017 and December 2018, sustained a thermal injury and completed a formal resuscitation (24 h). At the attending physician's discretion, rescue colloid was administered using 25% albumin for those failing to respond to traditional resuscitation (patients with sustained urine output of <0.5 mL/kg over 2-3 h, or unstable vital signs and ongoing fluid administration). We compared the total volume of the crystalloid-only and rescue colloid resuscitation fluids given to patients. We also examined the in/out fluid balances during resuscitation. Statistical analysis was performed using Stata software. RESULTS: A total of 91 patients with thermal injuries were included: the median age was 40 (IQR 31-57), 73% were male, and 30 patients received rescue albumin. The percentage of total body surface area burned (%TBSA) was greater in those who received rescue albumin (40.3% vs. 34%; p = 0.047). Despite a higher %TBSA in the albumin group, the total LR given during resuscitation was not significantly different between groups (15,914.43 mL vs. 11,828.71 mL; p = 0.129) even when normalized for TBSA and weight (ml LR/kg/%TBSA: 4.31 vs. 3.66; p = 0.129. The average in/out fluid ratio for the rescue group was higher than for the crystalloid group (0.83 ± 0.05 vs. 0.59 ± 0.11; p = 0.06) and returned to normal after colloid administration. CONCLUSION: Rescue albumin administration decreases the amount of fluid administered per %TBSA during resuscitation, and also increases end organ function as evidenced by increased urinary output. These effects occurred in patients who sustained larger burns and failed to respond to traditional crystalloid resuscitation. Our findings led us to modify our current protocol and a related prospective study of clinical outcomes.

The end of the assembly line: Shifting patterns of automotive burns.

INTRODUCTION: As recently as 2006, carburetor flash burns comprised as much as 27% of admissions for car-related burns, despite the fact carburetors were last installed in pre-1990 automobiles. The prevalence of this injury pattern is related to the estimated 14 million cars on the road today that were manufactured prior to that year. The aim of this study was to investigate modern sources of automotive burns and describe any new trends in automotive burn-related epidemiology. MATERIALS AND METHODS: A retrospective review was conducted of all burn admissions from the years 2009-2013 to identify patients who suffered automotive-related burns. Pediatric patients (<18 years old) were excluded. Demographic information including age, gender, mechanism of injury, occupation, TBSA, number of operations, and length of hospital stay were recorded. RESULTS: From 2009-2013, the burn center saw 83 admissions for automotive-related burns. 14.5% of patients were mechanics. The most common injury pattern was from radiator burns (47%), followed by gasoline related burns (30%). There were only two carburetor burns (2.4%). 67.4% of patients were treated for less than two hospital days and there was one death (1.2% mortality). CONCLUSION: Despite the removal of carburetors from engines and a decrease in this specific mechanism, a significant morbidity remains with gasoline-inflicted burns. More public awareness is needed for the safe removal of radiator caps and handling of chemicals in overheating engines.

An Assessment of Research Priorities to Dampen the Pendulum Swing of Burn Resuscitation.

On June 17 to 18, 2019, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn resuscitation in Washington, DC. The goal of the meeting was to identify and discuss novel research and strategies to optimize the process of burn resuscitation. Patients who sustain a large thermal injury (involving >20% of the total body surface area [TBSA]) face a sequence of challenges, beginning with burn shock. Over the last century, research has helped elucidate much of the underlying pathophysiology of burn shock, which places multiple organ systems at risk of damage or dysfunction. These studies advanced the understanding of the need for fluids for resuscitation. The resultant practice of judicious and timely infusion of crystalloids has improved mortality after major thermal injury. However, much remains unclear about how to further improve and customize resuscitation practice to limit the morbidities associated with edema and volume overload. Herein, we review the history and pathophysiology of shock following thermal injury, and propose some of the priorities for resuscitation research. Recommendations include: studying the utility of alternative endpoints to resuscitation, reexamining plasma as a primary or adjunctive resuscitation fluid, and applying information about inflammation and endotheliopathy to target the underlying causes of burn shock. Undoubtedly, these future research efforts will require a concerted effort from the burn and research communities.

Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study.

BACKGROUND: Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS: An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS: The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION: Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication. LEVEL OF EVIDENCE: Prognostic, level III.