The BUrn Mortality Prediction (BUMP) Score - An improved mortality prediction score based on data of the German burn registry

Understanding Epidemiological Trends in Geriatric Burn Injuries: A National Multicenter Analysis from NEISS 2004-2022

Burn injuries pose a significant source of patient morbidity/mortality and reconstructive challenges for burn surgeons, especially in vulnerable populations such as geriatric patients. Our study aims to provide new insights into burn epidemiology by analyzing the largest national, multicenter sample of geriatric patients to date. Using the National Electronic Injury and Surveillance System (NEISS) database (2004-2022), individuals with a "burn" diagnosis were extracted and divided into 2 comparison age groups of 18-64 and 65+. Variables including sex, race, affected body part, incident location, burn etiology, and clinical outcomes were assessed between the 2 groups using 2 proportion z-tests. About 60,581 adult patients who sustained burns were identified from the NEISS database with 6630 of those patients categorized as geriatric (65+). Geriatric patients had a significantly greater frequency of scald burns (36.9% vs 35.4%; P < .01), and third-degree/full-thickness burns (10.4% vs 5.5%, P < .01) relative to nongeriatric adult patients with most of these burns occurring at home (75.9% vs 67.4%; P < .01). The top 5 burn sites for geriatric patients were the hand, face, foot, lower arm, and lower leg and the top 5 burn injury sources were hot water, cookware, oven/ranges, home fires, and gasoline. Geriatric patients had over 2 times greater risk of hospital admission (odds ratio [OR]: 2.32, 95% CI: 2.17-2.49, P < .01) and over 5 times greater risk of emergency department mortality (OR: 6.22, 95% CI: 4.00-9.66, P < .01) after incurring burn injuries. These results highlight the need for stronger awareness of preventative measures for geriatric burn injuries.

Comparative efficacy of tranexamic acid versus placebo on hemostatic outcomes after the surgical debridement of burn patients: A randomized controlled clinical trial

INTRODUCTION

Burns are traumatic events that can affect multiple systems beyond the skin. The rapid removal of the burn eschar is a key step in the effective treatment of severe burns, and surgical debridement is currently the standard of care for eschar removal in burn patients. However, surgical debridement is highly hemorrhagic. Tranexamic acid, an antifibrinolytic lysine analog, may reduce bleeding.

METHODS

A randomized control trial was conducted to examine the effects of preoperative tranexamic acid administration in the early surgical debridement of severe burns. The study was conducted from January to December 2022.

RESULTS

The general characteristics of patients and mechanism of injury were similar between the treated and control groups. The burned body surface area was 26.46 % ± 5.45 % in the study group and 27.10 % ± 4.45 % in the control group (p = 0.83). Intraoperative hemorrhage volume was larger in the control group (299.3 ± 88.9 ml) than in the study group (117 ± 51.7 ml) (p = 0.0001). The decreases in hemoglobin and hematocrit levels were larger in the control group (2.1 ± 1.4 g/dl and 5.7 % ± 4.6 %) than in the study group (0.85 ± 0.4 g/dl and 2.1 % ± 0.5 %) (p = 0.004 and 0.01, respectively). Six patients in the control group but no patients in the study group required blood transfusion (p = 0.002). No thromboembolic events were observed.

CONCLUSION

These findings suggest that tranexamic acid was effective at reducing intraoperative hemorrhage volume and the need for transfusion in burn surgery patients. It was shown to be safe for use in these patients.

[Optimising Processes in a Severe Burn Intensive Care Unit through the Implementation of a Digital Management System]

BACKGROUND

The treatment of severely burned patients is demanding and necessitates specialised centres capable of providing adequate therapy over several months. The establishment of digital management systems in intensive care units signifies a substantial advancement in modern healthcare. Introducing such a system in a specialised intensive care unit for severe burn patients presents opportunities for optimisation but also potential obstacles. This study aims to provide insights into the perception of change from the perspective of staff and discuss the implementation of digital systems in the field of intensive care medicine.

METHODS

After a selective sample was established, the impacts of the digital management system were examined across various categories. The data collected through a questionnaire and brief interviews were evaluated in terms of average values within each category, with interpretations taking into account characteristics such as professional group and work experience.

RESULTS

Overall, the digital management system is considered suitable for use in the intensive care unit for severe burn patients by both medical and nursing staff. The continuous monitoring of vital parameters and the reduction of errors in medication administration are highlighted as positive aspects. However, negative points include the inferior documentation of burn wounds and specialised documentation for burn patients.

CONCLUSION

In due consideration of various factors such as experience, team size, and patient clientele, which impact the usability of the program, some aspects in need of improvement were identified. In summary, however, it can be said that there was a positive and favourable consensus regarding the introduction of such a system in the intensive care unit. Additionally, it can be concluded that the system is described as significantly more effective for a general surgical intensive care unit than for a specialised intensive care unit, e. g. an intensive care unit for severe burn patients.

Cumulative sum (CUSUM) analysis: A 10 year experience of outcome monitoring in a regional burn centre

INTRODUCTION

Outcome monitoring can identify fluctuations in healthcare. Cumulative sum (CUSUM) analysis can detect when mortality deviates from expected, allowing early intervention through targeted audit. We present a 10-year experience of the prospective use of CUSUM methodology in a regional burn centre.

METHOD

Prospective outcome monitoring was conducted for all admissions to the intensive care unit between 2012 and 2022. The revised Baux score was used for mortality risk prediction. Risk-adjusted CUSUM charts tracked mortality against that predicted by the revised Baux score. Deviations from expected outcomes triggered detailed structured analysis. Learning outcomes were identified from internal and external governance groups.

RESULTS

CUSUM analysis was triggered on eight occasions: one paediatric (excess deaths), six adult (four excess survivors, two excess deaths) and one elderly (excess survivors). Detailed analysis identified areas for continuous improvement and positive themes from excess survivors.

CONCLUSION

The use of CUSUM as an early warning trigger stimulates assessment of practice and critical appraisal of factors contributing to unexpected mortality or survival. The revised Baux score at its foundation needs to be carefully considered but remains a valid model. One benefit is positive reinforcement of team cohesion and morale during periods of care excellence leading to excess survivors.

Global epidemiology of geriatric burns, capacities of care, and injury outcomes: Perspectives from the World Health Organization global burn registry

BACKGROUND

An increasing aging population alongside a potentially increasing injury risk emphasizes a critical need for evidence-based burn care regarding preventive and therapeutic strategies tailored to the unique needs of older adults. However, we note a critical gap in understanding geriatric burn trends on a global scale and the care capacity across settings. Thus, this study sought to ascertain the global trend of geriatric burns with a focus on patient demographics, injury characteristics, capacities of care, and injury outcomes.

METHODS

A retrospective design focusing on older adults aged ≥ 60 years with burns recorded in the World Health Organization Global Burn Registry as of 31st May 2023 was employed. Descriptive statistics were employed to analyze the data.

RESULTS

Of the 9277 records obtained from the Global Burn Registry, 849 participants (9.2%) were aged ≥ 60 years with the majority of these reported from the Eastern Mediterranean (EMRO) and Southeast Asia (SEARO) regions. More females than males were involved in burn injuries with the most common aetiological factor being flame. Most burns occurred in the home/ domestic setting with a seasonal variation (more injuries occurred in December and January). In terms of burn care capacity, the data suggest the availability of specialized services in most settings albeit the AFRO and SEARO regions still lacked the resources to offer specialized burn care. While most injured older adults were discharged home with no physical impairment (395, 46.5%), a substantial number died (250, 29.4%) during hospitalization, particularly in the African (AFRO) region and 111 (11.1%) left the facility against medical advice with the majority from the SEARO region (88).

CONCLUSION

Burn injuries in older adults remain a public health issue. On the preventive aspect, the results demonstrate a need to intensify safety in the home or domestic setting, and during festive seasons. Therapeutically, the findings underscore a need to consider the inclusion of more specialist geriatric and palliative care services in the burn management process. Additionally, we identified a need to strengthen burn care capacity in the AFRO and SEARO regions.

The Revised Baux Score as a Predictor of Burn Mortality: A Systematic Review and Meta-Analysis

Mortality following a severe burn is influenced by both patient- and injury-factors, and a number of predictive models have been developed or applied. As there is no consensus on the optimal formula to use, we aimed to investigate the predictive value of the revised Baux score in comparison to other models when determining mortality risk in patients with burn injuries. A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The review yielded 21 relevant studies. The Prediction model Risk Of Bias ASsessment Tool quality appraisal checklist was used with many studies classified as "high" quality. All studies assessed the utility of the revised Baux score in comparison to other scoring systems such as the original Baux, Belgian Outcome in Burn Injury, Abbreviated Burn Severity Index, Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, Boston Group/Ryan scores, the Fatality by Longevity, APACHE II score, Measured Extent of burn, and Sex model, and the Prognostic Burn Index. There was a range of 48 to 15975 participants per study, with a mean age range of 16 to 52 years old. The area under the curve (AUC) values of the rBaux score ranged from 0.682 to 0.99, with a summary AUC of 0.93 for all included studies (CI 0.91-0.95). This summary value demonstrates that the rBaux equation is a reliable predictor for mortality risk in heterogeneous populations. However, this study also identified that the rBaux equation has a diminished ability to predict mortality risk when applied to patients at both extremes of age, highlighting an important area for future research. Overall, the rBaux equation offers a relatively easy means to quickly assess the mortality risk from burn injury in a broad range of patient populations.

Improvement of Predictive Scores in Burn Medicine through Different Machine Learning Approaches

The mortality of severely burned patients can be predicted by multiple scores which have been created over the last decades. As the treatment of burn injuries and intensive care management have improved immensely over the last years, former prediction scores seem to be losing accuracy in predicting survival. Therefore, various modifications of existing scores have been established and innovative scores have been introduced. In this study, we used data from the German Burn Registry and analyzed them regarding patient mortality using different methods of machine learning. We used Classification and Regression Trees (CARTs), random forests, XGBoost, and logistic regression regarding predictive features for patient mortality. Analyzing the data of 1401 patients via machine learning, the factors of full-thickness burns, patient's age, and total burned surface area could be identified as the most important features regarding the prediction of patient mortality following burn trauma. Although the different methods identified similar aspects, application of machine learning shows that more data are necessary for a valid analysis. In the future, the usage of machine learning can contribute to the development of an innovative and precise predictive score in burn medicine and even to further interpretations of relevant data regarding different forms of outcome from the German Burn registry.

Impact of elevated body mass index on burn injury-associated mortality in a representative US sample

BACKGROUND

The impact of obesity on burn-related mortality is inconsistent and incongruent; despite being a risk factor for numerous comorbidities that would be expected to increase complications and worsen outcomes, there is evidence of a survival advantage for patients with high body mass index-the so-called obesity paradox. We used a national data set to explore further the relationship between body mass index and burn-related mortality.

METHODS

Deidentified data from patients with second and third-degree burns between 2014 and 2018 were obtained from the Cerner Health Facts Database. Univariate and multivariate regression models were created to identify potential factors related to burn-related mortality. A restricted cubic spline model was built to assess the nonlinear association between body mass index and burn-related mortality. All statistical analyses were conducted using R (R Foundation for Statistical Computing).

RESULTS

The study included 9,405 adult burn patients. Univariate and multivariate analyses revealed that age (odds ratio = 2.189 [1.771, 2.706], P < .001), total burn surface area (odds ratio = 1.824 [1.605, 2.074], P < .001), full-thickness burns (odds ratio = 1.992 [1.322, 3.001], P < .001), and comorbidities (odds ratio = 2.03 [1.367, 3.014], P < .001) were associated with increased mortality. Sensitivity analysis showed similar results. However, a restricted cubic spline indicated a U-shaped relation between body mass index and burn-related mortality. The nadir of body mass index was 28.92 kg/m², with the lowest mortality. This association persisted even after controlling for age, total burn surface area, full-thickness burns, and comorbidities, which all remained significant.

CONCLUSION

This study confirms a U-shaped association between body mass index and burn-related mortality along with age, total burn surface area, full-thickness burns, and comorbidities as risk factors.

The modified 5-item frailty index as a predictor of complications in burn patients

The modified 5-item frailty index (mFI-5), as a measure of frailty and biological age, has been shown to be a reliable predictor of complications and mortality in a variety of surgical specialties. However, its role in burn care remains to be fully elucidated. We, therefore, correlated frailty with in-hospital mortality and complications after burn injury. The medical charts of all burn patients admitted between 2007 and 2020 who had ≥ 10 % of their total body surface area affected were retrospectively reviewed. Data on clinical, demographic, and outcome parameters were collected and evaluated, and mFI-5 was calculated on the basis of the data obtained. Univariate and multivariate regression analyses were used to investigate the association between mFI-5 and medical complications and in-hospital mortality. A total of 617 burn patients were included in this study. Increasing mFI-5 scores were significantly associated with increased in-hospital mortality (p < 0.0001), myocardial infarction (p = 0.03), sepsis (p = 0.005), urinary tract infections (p = 0.006), and perioperative blood transfusions (p = 0.0004). They were also associated with an increase in the length of hospital stay and the number of surgical procedures, albeit without statistical significance. An mFI-5 score of ≥ 2 was a significant predictor of sepsis (odds ratio [OR] = 2.08; 95% confidence interval [CI]: 1.03 to 3.95; p = 0.04), urinary tract infection (OR = 2.82; 95% CI: 1.47 to 5.19; p = 0.002), and perioperative blood transfusions (OR = 2.61; 95% CI: 1.61 to 4.25; p = 0.0001). Multivariate logistic regression analysis revealed that an mFI-5 score of ≥ 2 was not an independent risk factor for in-hospital mortality (OR = 1.44; 95% CI: 0.61 to 3.37; p = 0.40). mFI-5 is a significant risk factor for only a few select complications in the burn population. It is not a reliable predictor of in-hospital mortality. Therefore, its utility as a risk stratification tool in the burn unit may be limited.

Comparative Analysis of Composite Mortality Prediction Scores in Intensive Care Burn Patients

Multiple outcome scoring models have been used in predicting mortality in burn patients. In this study, we compared the accuracy of five established models in predicting outcomes in burn patients admitted to the intensive care unit and assessed risk factors associated with mortality. Intensive care burn patients admitted between March 2007 and December 2020 with total body surface area (TBSA) affected ≥ 10% were analyzed. Multivariate analysis was conducted to examine variables associated with mortality. The ABSI, Ryan, BOBI, revised Baux and BUMP scores were analyzed by receiver operating characteristics. A total of 617 patients were included. Morality was 14.4%, with non-survivors being significantly older, male, and having experienced domestic burns. Multivariate analysis identified age, TBSA, full-thickness burns and renal insufficiency as independent mortality predictors. The BUMP score presented the highest mortality prognostication rate, followed by ABSI, revised Baux, BOBI and Ryan scores. BUMP, ABSI and revised Baux scores displayed AUC values exceeding 90%, indicating excellent prognostic capabilities. The BUMP score showed the highest accuracy of predicting mortality in intensive care burn patients and outperformed the most commonly used ABSI score in our cohort. The older models displayed adequate predictive performance and accuracy compared with the newest model.