Accuracy of remote burn scar evaluation via live video-conferencing technology

OBJECTIVE

Telemedicine in outpatient burn care, particularly in burn scar management, may provide cost-effective care and comes highly rated by patients. However, an effective scar scale using both video and photographic elements has not been validated. The purpose of this study is to test the reliability of the Patient and Observer Scar Assessment Scale (POSAS) using live video-conferencing.

METHODS

A prospective study was conducted with individuals with healed burn scars in Kathmandu, Nepal. Three independent observers assessed 85 burn scars from 17 subjects, using the Observer portion to evaluate vascularity, pigmentation, thickness, relief, pliability, surface area, and overall opinion. The on-site observer was physically present with the subjects and used a live videoconferencing application to show the scars to two remote observers in the United States. Subjects used the Patient portion to evaluate the scar that they believed appeared the worst appearance and had the greatest impact on function.

RESULTS

The single-rater reliability of the Observer scale was acceptable (ICC>0.70) in overall opinion, thickness, pliability, and surface area. The average-rater reliability for three observers was acceptable (ICC>0.70) for all parameters except for vascularity. When comparing Patients' and Observers' overall opinion scores, patients consistently reported worse opinion.

CONCLUSIONS

Evaluation of burn scars using the Patient and Observer Scar Assessment Scale can be accurately performed via live videoconferencing and presents an opportunity to expand access to burn care to rural communities, particularly in low- and middle-income countries, where patients face significant access barriers to appropriate follow-up care.

An Executive Summary of the National Trauma Research Action Plan (NTRAP)

ABSTRACT

The National Trauma Research Action Plan (NTRAP) project successfully engaged multidisciplinary experts to define opportunities to advance trauma research and has fulfilled the recommendations related to trauma research from the National Academies of Sciences, Engineering and Medicine (NASEM) report. These panels identified more than 4,800 gaps in our knowledge regarding injury prevention and the optimal care of injured patients and laid out a priority framework and tools to support researchers to advance this field. Trauma research funding agencies and researchers can use this executive summary and supporting manuscripts to strategically address and close the highest priority research gaps. Given that this is the most significant public health threat facing our children, young adults, and military service personnel, we must do better in prioritizing these research projects for funding and providing grant support to advance this work. Through the Coalition for National Trauma Research (CNTR), the trauma community is committed to a coordinated, collaborative approach to address these critical knowledge gaps and ultimately reduce the burden of morbidity and mortality faced by our patients.

Experiences of Alaska Native people living with burn injury and opportunities for health system strengthening

BACKGROUND

Injuries are a leading cause of death and disability for Alaska Native (AN) people. Alaska Native Tribal Health Consortium (ANTHC) is supporting the development of a burn care system that includes a partnership between Alaska Native Medical Center (ANMC) in Anchorage, AK and UW Medicine Regional Burn Center at Harborview Medical Center (HMC) in Seattle, WA. We aimed to better understand the experiences of AN people with burn injuries across the care continuum to aid development of culturally appropriate care regionalization.

METHODS

We performed focus groups with twelve AN people with burn injury and their caregivers. A multidisciplinary team of burn care providers, qualitative research experts, AN care coordinator, and AN cultural liaison led focus groups to elicit experiences across the burn care continuum. Transcripts were analyzed using a phenomenological approach and inductive coding to understand how AN people and families navigated the medical and community systems for burn care and areas for improvement.

RESULTS

Three themes were identified: 1-Challenges with local burn care in remote communities including limited first aid, triage, pain management, and wound care, as well as long-distance transport to definitive care; 2-Divergence between cultural values and medical practices that generated mistrust in the medical system, isolation from their support systems, and recovery goals that were not aligned with their needs; 3-Difficulty accessing emotional health support and a survivor community that could empower their resilience.

CONCLUSION

Participants reported modifiable barriers to culturally competent treatment for burn injuries among AN people. The findings can inform initiatives that leverage existing resources, including expansion of the Extension for Community Healthcare Outcomes (ECHO) telementoring program, promulgation of the Phoenix Society Survivors Offering Assistance in Recovery (SOAR) to AK, coordination of regionalized care to reduce time away from AK and provide more comfortable community reintegration, and define rehabilitation goals in terms that align with personal goals and subsistence lifestyle skills. Long-distance transport times are non-modifiable, but better pre-hospital care could be achieved by harnessing existing telehealth services and adapting principles of prolonged field care to allow for triage, initial care, and resuscitation in remote environments.

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.

Trajectories of physical health-related quality of life among adults living with burn injuries: A burn model system national database investigation to improve early intervention and rehabilitation service delivery

INTRODUCTION

Understanding trajectories of recovery in key domains can be used to guide patients, families, and caregivers. The purpose of this study was to describe common trajectories of physical health over time and to examine predictors of these trajectories.

METHOD

Adults with burn injuries completed self-reported assessments of their health-related quality of life (HRQOL) as measured by the SF-12® Physical Component Summary (PCS) score at distinct time points (preinjury via recall, index hospital discharge, and at 6-, 12-, and 24 months after injury). Growth mixture modeling (GMM) was used to model PCS scores over time. Covariables included burn size, participant characteristics, and scores from the Community Integration Questionnaire (CIQ)/Social Integration portion, Satisfaction With Life Scale (SWLS), and Satisfaction With Appearance Scale (SWAP).

RESULTS

Data from 939 participants were used for complete-case analysis. Participants were 72% male, 64% non-Hispanic White, with an average age of 44 years and an average burn size of 20% of total body surface area (TBSA). The best fitting model suggested three distinct trajectories (Class 1 through 3) for HRQOL. We titled each Class according to the characteristics of their trajectory. Class 1 (recovering; n = 632), Class 2 (static; n = 77), and Class 3 (weakened; n = 205) reported near average HRQOL preinjury, then reported lower scores at discharge, with Class 1 subsequently improving to preinjury levels and Class 3 improving but not reaching their preinjury quality of life. Class 3 experienced the largest decrease in HRQOL. Class 2 reported the lowest preinjury HRQOL and remained low for the next 2 years, showing minimal change in their HRQOL.

CONCLUSIONS

These findings emphasize the importance of early universal screening and sustained intervention for those most at risk for low HRQOL following injury. For Class 2 (static), lower than average HRQOL before their injury is a warning. For Class 3 (weakened), if the scores at 6 months show a large decline, then the person is at risk for not regaining their HRQOL by 24 months and thus needs all available interventions to optimize their outcomes. Results of this study provide guidance for how to identify people with burn injury who would benefit from more intensive rehabilitation to help them achieve or regain better HRQOL. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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.

Defining numerical cut points for mild, moderate, and severe pain in adult burn survivors: A northwest regional burn model system investigation

INTRODUCTION

Pain is a common and often debilitating sequela of burn injury. Burn pain develops following damage to peripheral sensory nerves and the release of inflammatory mediators from injury. Burn pain is complex and can include background and procedural pain that result from the injury itself, wound care, stretching, and surgery. Clinicians and researchers need valid and reliable pain measures to guide screening, treatment, and research protocols. Unlike other conditions, visual analog, or numeric pain rating scale (VAS/NRS) scores that represent mild, moderate, and severe pain among people with burn injury have not been established. The aim of this study was to identify the most suitable average pain intensity rating scores for mild, moderate, and severe pain in adult burn survivors using a PROMIS Pain Interference (PROMIS-PI) short form.

METHODS

An average pain intensity VAS/NRS score (0-10) and customized PROMIS-PI short form were administered to adults with burn injury treated at a regional burn center at hospital discharge (baseline) and at 6, 12, and 24-months after injury. To identify pain intensity scores that represent mild, moderate, and severe pain, we computed F values and Bayesian Information Criterion (BIC) statistics associated with multiple ANOVA comparisons for mean pain interference scores by various pain intensity cut points. Six possible cut points (CP) were compared: CP 3,6; 3,7; 4,6; 4,7; 2,5; and 3,5. Optimal cut points were considered those with the highest ANOVA F statistics. Models with similar F statistics were also compared with BIC.

RESULTS

Data from a sample of 253 participants (83% white, 66% male, mean age 47 years) with VAS/NRS pain intensity and PROMIS-PI scores at one or more timepoints were analyzed. The optimal classification for mild, moderate, and severe pain was CP 2,5 at baseline and 12-months. Although CP 3,6 had the highest F value at 6-months, there was not strong evidence to support CP 3,6 over CP 2,5 (BIC difference: 2.9); similarly, CP 3,7 had the highest value at 24-months, but the BIC difference over CP 2,5 was only 2.2.

CONCLUSIONS

VAS/NRS scores for pain among adults with burn injury can be categorized as mild (0-2), moderate (3-5), and severe (6-10). These findings advance our understanding regarding the meaning of pain intensity ratings after burn injury, and provide an objective definition for clinical management, quality improvement, and pain research.

Posttraumatic Stress Disorder Symptom Clusters as Predictors of Pain Interference in Burn Survivors: A Burn Model System National Database Study

Individuals who experience burns are at higher risk of developing posttraumatic stress disorder and chronic pain. A synergistic relationship exists between posttraumatic stress disorder and chronic pain. We sought to evaluate the role of individual posttraumatic stress disorder symptom clusters as predictors of pain interference. We hypothesized that the hyperarousal and emotional numbing symptom clusters would be predictive of pain interference, even when accounting for the other two posttraumatic stress disorder symptom clusters, pain intensity, and other covariates. Multivariate linear regression analyses were completed using data from the Burn Model System National Database. A total of 439 adult participants had complete responses on self-report measures assessing posttraumatic stress disorder symptoms, pain intensity, and pain interference at 6-month after discharge and were included in analyses. Results indicate hyperarousal (B = .10, p = .03) and emotional numbing (B = .13, p = .01) posttraumatic stress disorder symptom clusters were each significantly associated with pain interference, even when accounting for pain intensity (B = .64, p < .001). Results highlight the importance of the emotional numbing and hyperarousal posttraumatic stress disorder symptom clusters in explaining pain interference. Findings suggest that when posttraumatic stress disorder symptoms or chronic pain are present, screening for and treating either condition may be warranted to reduce pain interference. Further, psychological interventions that target emotional numbing and hyperarousal posttraumatic stress disorder symptoms may be fruitful for promoting better coping with chronic pain and reducing pain interference.

Burn Wound Bed Management

Critical to the success of modern burn care is the management of the burn wound. Timely and complete removal of nonviable tissue is complicated by the irreplaceable nature of the tissue lost either through the burn injury or as "collateral damage" as part of the treatment. Challenges in distinguishing between viable and nonviable tissue and "replacing the irreplaceable" are discussed alongside potential disruptive technologies which could fundamentally change how burn care is delivered. Advances in burn wound bed management forms the foundation on which the goal of zero preventable death and disability after burn injury can be achieved.

Developing a National Trauma Research Action Plan: Results from the long-term outcomes research gap Delphi survey

BACKGROUND

In the National Academies of Sciences, Engineering, and Medicine 2016 report on trauma care, the establishment of a National Trauma Research Action Plan to strengthen and guide future trauma research was recommended. To address this recommendation, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. We describe the gap analysis and high-priority research questions generated from the National Trauma Research Action Plan panel on long-term outcomes.

METHODS

Experts in long-term outcomes were recruited to identify current gaps in long-term trauma outcomes research, generate research questions, and establish the priority for these questions using a consensus-driven, Delphi survey approach from February 2021 to August 2021. Panelists were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability including both military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population, Intervention, Compare/Control, and Outcome model. On subsequent surveys, panelists were asked to prioritize each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category.

RESULTS

Thirty-two subject matter experts generated 482 questions in 17 long-term outcome topic areas. By Round 3 of the Delphi, 359 questions (75%) reached consensus, of which 107 (30%) were determined to be high priority, 252 (70%) medium priority, and 0 (0%) low priority. Substance abuse and pain was the topic area with the highest number of questions. Health services (not including mental health or rehabilitation) (64%), mental health (46%), and geriatric population (43%) were the topic areas with the highest proportion of high-priority questions.

CONCLUSION

This Delphi gap analysis of long-term trauma outcomes research identified 107 high-priority research questions that will help guide investigators in future long-term outcomes research.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level IV.

122 PTSD Symptom Clusters as Predictors of Pain Interference in Burn Survivors

Introduction

Individuals who experience burns are at higher risk of developing post-traumatic stress disorder (PTSD) and chronic pain. There exists a synergistic relationship between PTSD and chronic pain in burn survivors. Theories exist about how aspects of each condition may perpetuate one another, or share underlying mechanisms. Both of these conditions are of relevance to pain-related disability. We sought to examine the role of individual PTSD symptom clusters as predictors of pain interference. We hypothesized that the hyperarousal and emotional numbing symptom clusters would be predictive of pain interference, even when accounting for the other two PTSD symptom clusters, pain intensity, and other covariates (burn size, hospital length of stay, age and gender).

Methods

Data were analyzed from the Burn Model System National Database. Inclusion criteria required participants to have a moderate to severe burn injury that required surgery for wound closure. Patient-reported outcome data: PTSD Checklist - Civilian, PROMIS-Pain Interference Short Form 4a, and a 0-10 average Pain Intensity item were analyzed at 6-months after injury. Hierarchical linear regression models were fit to examine the impact of PTSD symptom clusters on pain interference over and above that of pain intensity, and standardized betas were calculated (B).

Results

A total of 439 adult participants had complete responses on the measures of interest (e.g. PTSD symptoms, PROMIS-Pain Interference, and Pain Intensity) and were included in the analysis. Mean age, percent total body surface area burned, and hospital length of stay were 47 years, 18%, and 27 days, respectively. 69% were male and 82% were Caucasian. Results of a linear regression found that hyperarousal (B = .10, p = .03) and emotional numbing (B = .13, p = .01) PTSD symptom clusters were each significant predictors of pain-related disability, even when accounting for pain intensity (B = .64, p < .001). The covariates age, gender, days until discharge, and TBSA were all nonsignificant. The model accounted for 61% of the variance associated with pain-related disability.

Conclusions

Results highlight the importance of the emotional numbing and hyperarousal PTSD symptom clusters in explaining pain interference. Future evaluations parsing out the longitudinal relationships (i.e., beyond 6-months postburn) between PTSD symptom clusters, pain intensity, and pain interference, as well as evaluating other underlying mechanisms, are warranted.

73 Associations Between Pre-burn Occupation Type and Employment Outcomes at One Year

Introduction

Reintegration into the workforce after burn injury is an important issue for survivors. In a 2012 systematic review, 28% of burn survivors never returned to any form of employment. Although pre-burn employment status is strongly associated with post-burn employment, there are little data on the role of pre-injury occupation type on workplace reintegration. The aim of this project was to assess the impact of occupation type on employment outcomes after burn injury.

Methods

Data from the National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System National Longitudinal Database from 2015 to 2021 were used to investigate the association between occupation type and employment outcomes. Occupation type was classified into two groups, Labor and Non-labor, using the U.S. Bureau of Labor Statistics Standard Occupational Classification System. Demographic and clinical data were compared between groups. Mixed regression analyses examined associations between pre-burn occupation type and post-burn employment outcomes (employment at 1 year, days to return to work), controlling for age, gender, race, ethnicity, pre-injury employment, and burn size.

Results

Of the 600 patients who were employed pre-injury, 247 (41%) identified with a non-labor occupation and 353 (59%) with labor occupations. The Labor group was more male (82% vs. 61%) and Hispanic (23% vs. 6%), younger (mean age 42.1 vs. 48.3 years), less educated (high school or less, 25% vs. 11%) and more likely to have been injured at work (28% vs. 14%) compared to the Non-labor group (p< 0.001 for all comparisons). Changes in occupation were seen from pre-injury to post-injury; 16% of working survivors changed from Non-labor to Labor and 13% from Labor to Non-labor occupation types. For those who did return to work after injury, the average time to return to work was greater for Labor compared to the Non-labor group (150 vs 100 days; p=0.003). Additionally, those in the pre-injury Labor group were less likely to be employed at 12 months compared to the Non-labor group (odds ratio = 0.41; p=0.009).

Conclusions

Pre-injury occupation type is associated with employment outcomes after injury. Therefore, occupation type can be used to inform vocational reintegration resources, such as vocational rehabilitation programs, to optimize survivor outcomes.

10 The Impact of Insurance Disparities on Long-term Burn Outcomes: A Burn Model System Investigation

Introduction

Access to healthcare and insurance coverage are associated with quality of life, morbidity, and mortality outcomes. However, most studies have only focused on same-admission and short-term outcomes due to the lack of national longitudinal data and there is limited data on this topic in the burn literature. Our aim was to determine the effect of insurance status on long-term outcomes in a national sample of burn patients.

Methods

This is a retrospective study using the longitudinal Burn Model System National Database from January 2015 to April 2021. The inclusion criteria were all adult patients admitted for burn injury from participating sites. Main outcomes were the physical (PCS) and mental (MCS) health component summary scores of the Veterans RAND 12 (VR-12) score at 6, 12, and 24 months after injury. Multivariable regression was used to examine the association between insurance status and the outcomes, adjusting for demographics (i.e., age, gender, race/ethnicity) and burn injury severity.

Results

A total of 3,698 burn patients were included. Mean age was 43.39 (SD 15.84) years, 72% were male and 76% were white. Most patients had private/commercial insurance (56.37%), followed by Medicare (14.42%) and Medicaid (13.18%). The remaining 16% were uninsured patients (self-pay or philanthropy). Mean PCS scores were 43.64 (SD 10.87), 45.31 (SD 11.04) and 46.45 (SD 10.65) and Mean MCS scores were 47.80 (SD 12.35), 48.18 (SD 12.30) and 48.44 (SD 12.18) at 6, 12 and 24 months, respectively. In adjusted analyses, Medicaid insurance was associated with worse MCS at 6 months (Coefficient -3.90, p=0.001), and worse PCS at 12 and 24 months (Coefficient -3.09, p=0.004 and Coefficient -4.18, p< 0.001, respectively), compared to uninsured status. Medicare insurance was associated with worse PCS scores at 24 months (Coefficient -3.07, p=0.013).

Conclusions

Having Medicaid and Medicare insurance was significantly associated with a lower health-related quality of life at long-term follow up, even after adjusting for demographics and burn injury severity. Further studies need to focus on analyzing the reasons for these disparities and developing strategies to improve the quality of life of this subpopulation.

109 The Impact of Distance to Treatment Center on Long-term Outcomes of Burn Patients

Introduction

Geospatial access to American Burn Association (ABA)-verified burn centers or self-designated burn care facilities varies across the country. It is often necessary to transport patients hundreds of miles to provide definitive burn care and rehabilitation services. This study evaluates the impact of distance to treatment center on long-term outcomes of burn patients.

Methods

Data from the National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System (BMS) National Database, collected from 2015 to 2019, were analyzed to investigate the impact of distance to BMS center on long-term, patient-reported outcomes. Distance was calculated as driving distance between home zip code centroid and BMS center. Demographic and clinical data were compared between groups by distance from BMS center (< 20, 20-49.9, >50 miles). The following patient-reported outcome measures, collected 12 months after injury, were examined: Veterans Rand 12 Physical Component Summary Score (VR-12 PCS), Veterans Rand 12 Mental Component Summary Score (VR-12 MCS), Satisfaction with Life (SWL), employment status, and days to return to work. Mixed regression model analyses were used to examine the associations between distance to BMS center and each outcome measure, controlling for demographic and clinical variables.

Results

Of the 726 participants included in this study, 191 (26.3%) and 204 (28.1%) were < 20 and between 20-49.9 miles from a BMS center, respectively; 331 (46.6%) were >50 miles from a BMS center. Greater distance to BMS center was associated with white race/ethnicity (p< 0.001) and employment at time of injury (p=0.001). Greater distance to BMS center was also associated with flame injury (p< 0.001) and larger burn size (p< 0.001). There were no significant differences in length of stay or number of operations between groups. Regression analyses did not identify significant associations between distance to BMS center and VR-12 PCS, VR-12 MCS, SWL, employment at 12 months, or days to return to work.

Conclusions

After burn injury, patient-reported outcome measures of physical and psychosocial function, as well as employment, do not differ based on distance to BMS center.

114 Long Term Impact of Hospital Acquired Multi-drug Resistant Organisms on Health-related Quality of Life

Introduction

MDROs colonize wounds and cause infections for hospitalized burn patients, which may lead to increased infection risk, wound complications, longer (LOS) and more cost. Little is known about the long-term impacts of MDRO colonization and infection on burn survivors. We aimed to describe the impacts of colonization on long-term health-related quality of life (HRQoL), itch, and pain.

Methods

Data from adult participants in a multicenter longitudinal outcome study were used. Data was described and χ ² and Kruskal-Wallis testing was applied to determine differences between the two groups. Outcomes included Veterans RAND 12 (VR-12) physical component summary score (PCS), and PROMIS 29 domains for pain intensity, fatigue, pain interference, physical function, and sleep disturbance. Pruritus was assessed using the 4-D Itch scale for total itch. Multilevel, multiple linear regressions were used for outcome measures at 6 m post-injury. Random effects regression with robust standard errors (SE) were used to evaluate the impacts over time.

Results

The study included 704 individuals and 92 were MDRO colonized (13%). Colonized patients had larger burns (25% TBSA, IQR 9-45 vs. 8% TBSA, IQR 3–20; p < .001), more operations (4, IQR 2-7 vs. 1, IQR 1-3; p < .001), more grafting (17% TBSA, IQR 3-46 vs. 3% TBSA, IQR 1- 9; p < .001), more ventilator days (2, IQR 0–8 vs. 0 IQR 0-0; p < .001), and longer LOS (34 days, IQR 17 – 64 vs. 16, IQR 9 - 27; p < .001). Adjusting for confounding covariables, such as demographics, colonization was associated with a lower PCS score (OR -0.33, 95% CI -0.68, -0.06; p=.018); a higher fatigue score (OR 0.46, 95% CI 0.13, 0.79; p = .007) and worse itch (OR 0.4, 95% CI -0.01, 0.75; p = .036). There was no association with pain intensity, pain interference, or sleep disturbance. Random effects regression indicated that colonization was associated with lower PCS (OR -5.0, 95% CI -8.60, -1.39; p = .007).

Conclusions

Impact of colonization extends beyond the immediate hospitalization and likely has long-term effects on HRQoL. Given our observation of lower physical function after MDRO, more granular research on taxa-specific effects, timing of colonization, and interventions are indicated to elucidate the impact on HRQoL.

68 The Association Between Body Mass Index and Physical Function in Adult Burn Survivors

Introduction

An area of rehabilitation research in burns is the impact of co-morbidities. Obesity is one of these, is an increasing public health concern, and its role remains controversial regarding burn injury and physical recovery. Our aim was to evaluate associations between body mass index (BMI) as a measure of obesity, at discharge and self-reported physical function (PF) during recovery of adult burn survivors.

Methods

This study included data that was collected by four American Burn Association-verified burn centers, which contribute to the Burn Model System National Database project. The data included BMI obtained at hospital discharge and self-reported Patient-Reported Outcomes Measurement Information System (PROMIS)-29 PF-mobility and upper extremity scores assessed at 6-, 12-, and 24-months after burn. Mixed linear models for repeated measures and regression models were used to assess associations between BMI and PROMIS-29 PF scores over time. Values are expressed as means ± SD. Significance was set at p&lt; 0.05.

Results

A total of 502 adult patients aged 47 ± 16 years were included, with mean total body surface area burned (TBSA) of 17 ± 18 % (range; 1.0-88%) and mean BMI of 23.1 ± 5.4 kg*m-2 (range; 14.0-64.7 kg*m-2). We found no significant effect at 6 months (beta=-0.045, p= 0.54) nor at 12 months after injury (beta=-0.063, p= 0.44) when adjusted for age, burn size, and sex, however, BMI at discharge had a significant negative effect on self-reported mobility scores 24 months after injury (beta=0.218, p=&lt; 0.05).

Conclusions

Increased weight (i.e. BMI) at discharge was negatively associated with PF during recovery. Benefiting from a large sample size, our analysis suggests that long term recovery and restoration of PF in adult burn survivors is compromized by excess body weight.

78 Classification and Regression Tree Model for Predicting Satisfaction with Life Scale Scores After Burn Injury

Introduction

Current early burn care prognostication models predict in-hospital mortality (e.g., revised Baux Score). However, patients, families and clinicians need more holistic tools in the hours and days after injury to identify specific factors that might affect their quality of life and indicate a need for more intensive services. This project aims to predict Satisfaction with Life (SWL) in survivors of burn injury using patient, injury, and care factors available within 24 hours of admission.

Methods

Two hundred and fourteen participants were identified from a multicenter national longitudinal database and merged with clinical data from a single institution's trauma registry. Patients were randomized into a training dataset (80%) and a testing dataset (20%). A CART algorithm was used to examine the relative contributions of individual predictor variables in classifying low SWL at six-month follow up (SWL ≤ 20). Seventeen covariables obtained within 24 hours of index hospital admission were analyzed from five domains: demographics, comorbidities, injury, care, and host response to injury. Lab values were those closest to but not greater than 24 hours after index hospital admission.

Results

Multiple covariables contributed to the SWL score. CART analysis selected a pre-injury SWL score < 31 as the first node and strongest indicator of low SWL. CART then selected the following subgroups at risk for SWL ≤ 20 at 6 months: (1) hematocrit >55%; (2) lactate >4 mmol/L, age > 59; (3) total body surface area (TBSA) burned >30%, presence of a hand, neck, and/or face burn. The cross-validated predictive accuracy of the CART model was 69.4% with a cross-validated relative error of 0.379. In the validation data set, sensitivity and specificity were 62.5% and 72.0%, respectively.

Conclusions

The findings demonstrate the potential feasibility of creating a model that can predict a clinically meaningful quality of life outcome using covariables gathered within hours of hospital admission after burn injury. Predictive measures suggest that while some of the included covariables may be associated with SWL, they are not consistently and reliably predictive of low SWL alone. With more data and additional refined inputs, a similar model could be used to identify those in need of more intensive services earlier on in the hospitalization.

83 The Impact of Tracheostomy on Long-term Patient Outcomes: A Burn Model System National Database Study

Introduction

Management of the upper airway is crucial to burn care, especially in the setting of inhalation injury or burns to the face or neck. Endotracheal intubation is often performed to secure the airway; however, tracheostomy may be necessary in patients requiring prolonged ventilatory support. This study compares long-term outcomes of burn patients with and without tracheostomy.

Methods

Data from the Burn Model System National Database, collected from 2013 to 2020, were analyzed. Demographic and clinical data were compared between those with and without tracheostomy. The following patient-reported outcome measures, collected at 6-, 12-, and 24-months, were analyzed: Veterans Rand 12 Physical Component Summary Score (VR-12 PCS), Veterans Rand 12 Mental Component Summary Score (VR-12 MCS), Satisfaction with Life (SWL), Community Integration Questionnaire (CIQ), Patient-Reported Outcomes Measurement Information System (PROMIS-29), employment status, and number of days to return to work. Regression models were used to assess the impact of tracheostomy status on long-term outcome measures, controlling for demographic and clinical variables.

Results

Of the 714 patients included in this study, 39 (5.46%) received a tracheostomy and 675 (94.54%) did not. The two groups were similar across all demographic data collected. Tracheostomy patients were more likely to have flame injury, inhalation injury, larger burn size, more trips to the operating room, longer hospital stay, and greater number of days on a ventilator (p< 0.001). Regression model analyses demonstrated that tracheostomy was associated with worse VR-12 PCS scores at 6-, 12-, and 24-months (6.6 [95% CI 1.5, 11.8], p=0.012; 11.5 [6.2, 16.8], p< 0.001; 10.8 [4.2, 17.5], p=0.001). Tracheostomy was also associated with worse scores in two PROMIS-29 domains, physical function and pain interference. For physical function, the association was seen at 6-, 12-, and 24-months (7.4 [3.0, 11.8], p=0.001; 9.6 [5.2, 14.0], p< 0.001; 11.3 [5.8, 16.9], p< 0.001). For pain interference, the association was only seen at 12-months (-5.3 [-10.0, -0.55], p=0.029).

Conclusions

After burn injury, patient-reported outcome measures of physical function and pain interference were significantly worse with tracheostomy.

The relation between satisfaction with appearance and race and ethnicity: A National Institute on Disability, Independent Living, and Rehabilitation Research burn model system study

Research supports that people of color in the U.S. have poorer outcomes after burn injury compared to White individuals. The current study sought to explore burn health disparities by testing the relationship between racial and ethnic minority status, a proxy for systemic discrimination due to race and ethnicity, with two key constructs linked to functional outcomes, satisfaction with appearance and social community integration. Participants included 1318 burn survivors from the Burn Model System National Database (mean age = 40.2, SD = 12.7). Participants completed measures of satisfaction with appearance and social community integration at baseline, 6-, 12-, and 24-months after burn injury. Linear regressions revealed that racial and ethnic minority status significantly related to lower satisfaction with appearance and social community integration compared to White individuals at all time points. In addition, satisfaction with appearance continued to significantly relate to greater social community integration even while accounting for race and ethnicity, age, sex, burn size, and physical disability at 6-, 12-, and 24-month time points. Overall, the study supports that racial and ethnic minority burn survivors report greater dissatisfaction with their appearance and lower social community reintegration after burn injury.

Adolescents with and without head and neck burns: comparison of long-term outcomes in the burn model system national database

INTRODUCTION

Facial burns account for persistent differences in psychosocial functioning in adult burn survivors. Although adolescent burn survivors experience myriad chronic sequelae, little is known about the effect of facial injuries. This study examines differences in long-term outcomes with and without head and neck involvement.

METHODS

Data collected for 392 burn survivors between 14-17.9 years of age from the Burn Model System National Database (2006-2015) were analyzed. Comparisons were made between two groups based on presence of a head and neck burn (H&N) using the following patient reported outcome measures: Satisfaction with Appearance Scale, Satisfaction with Life Scale, Community Integration Questionnaire, and Short Form-12 Health Survey at 6, 12, and 24 months after injury. Regression analyses were used to assess association between outcome measures and H&N group at 12-months.

RESULTS

The H&N group had more extensive burns, had longer hospital stays, were more likely to be burned by fire/flame and were more likely to be Hispanic compared to the non-H&N group. Regression analysis found that H&N burn status was associated with worse SWAP scores. No significant associations were found between H&N burn status and other outcome measures.

CONCLUSIONS

Adolescents with H&N burn status showed significantly worse satisfaction with appearance at 12-months after injury. Future research should examine interventions to help improve body image and coping for adolescent burn survivors with head and neck burns.

Developing a national trauma research action plan: Results from the Burn Research Gap Delphi Survey

BACKGROUND

The 2016 National Academies of Science, Engineering and Medicine call for a national integrated, military-civilian trauma action plan to achieve zero preventable deaths and disability after injury included a proposal to establish a National Trauma Research Action Plan to "strengthen trauma research and ensure that the resources available for this research are commensurate with the importance of injury and the potential for improvement in patient outcomes." The Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma/burn care from prehospital to rehabilitation. The Burn/Reconstructive Surgery group represents one focus area for this research agenda development.

METHODS

Experts in burn and reconstructive surgery research identified gaps in knowledge, generated research questions and prioritized questions using a consensus driven Delphi survey approach. Participants were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability with military and civilian representatives. Literature reviews informed the panel. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population; Intervention; Compare/Control; Outcome. Participants ranked the priority of each question on a nine-point Likert scale, which was categorized to represent low, medium, and high priority items. Consensus was defined based on ≥60% panelist agreement.

RESULTS

Subject matter experts generated 949 research questions in 29 Burn & 26 Reconstruction topics. Five hundred ninety-seven questions reached consensus. Of these, 338 (57%) were high-priority, 180 (30%), medium-priority, and 78 (13%) low-priority questions.

CONCLUSION

Many high-priority questions translate to complex wound management and outcomes. Panel recognition that significant gaps in knowledge exist in understanding functional outcomes after injury underscores the importance of long-term recovery metrics even when studying acute injury or interventions such as resuscitation or inhalation injury. Funding agencies and burn/reconstructive surgery researchers should consider these gaps when they prioritize future research.

LEVEL OF EVIDENCE

Expert consensus, Level IV.

Temperature sensitivity after burn injury: A Burn Model System National Database Hot Topic

BACKGROUND

People living with burn injury often report temperature sensitivity. However, its epidemiology and associations with health-related quality of life (HRQOL) are unknown. We aimed to characterize temperature sensitivity and determine its impact on HRQOL to inform patient education after recovery from burn injury.

METHODS

We used the multicenter, longitudinal Burn Model System National Database to assess temperature sensitivity at 6, 12 and 24 months after burn injury. Chi-square and Kruskal-Wallis tests determined differences in patient and injury characteristics. Multivariable, multi-level generalized linear regression models determined the association of temperature sensitivity with Satisfaction with Life Scale (SWL) scores and Veterans RAND 12 (VR-12) physical (PCS) and mental health summary (MCS) component scores.

RESULTS

The cohort comprised 637 participants. Two thirds (66%) experienced temperature sensitivity. They had larger burns (12% TBSA, IQR 4-30 vs 5% TBSA, IQR 2-15; p<0.0001), required more grafting (5% TBSA, IQR 1-19 vs 2% TBSA, IQR 0-6; p<0.0001), and had higher intensity of pruritus at discharge (11% severe vs 5% severe; p=0.002). After adjusting for confounding variables, temperature sensitivity was strongly associated with lower SWL (OR -3.2, 95% CI -5.2, -1.1) and MCS (OR -4.0, 95% CI -6.9, -1.2) at 6-months. Temperature sensitivity decreased over time (43% at discharge, 4% at 24-months) and was not associated with poorer HRQOL at 12 and 24 months.

CONCLUSION

Temperature sensitivity is common after burn injury and associated with worse SWL and MCS during the first year after injury. However, temperature sensitivity seems to improve and be less intrusive over time.

Physical and Psychological Recovery Following Toxic Epidermal Necrolysis: A Patient Survey

Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are acute, life-threatening diseases that cause sloughing of the skin and mucous membranes. Despite improved survival rates, few studies focus on long-term outcomes. We conducted a single-center review of all patients with SJS/TEN admitted from January 2008-2014. SJS/TEN survivors were invited to participate in the validated Veterans RAND 12 Item Health Survey (VR-12) to assess health related quality of life using a mental health composite score (MCS) and physical health component score (PCS). The sample was compared to US norms using one sample two tailed t-tests. A second questionnaire addressed potential long-term medical complications related to SJS/TEN. Of 81 treated subjects, 24 (30%) long-term survivors responded. Participants identified cutaneous sequelae most frequently (79%), followed by nail problems (70%), oral (62%) and ocular (58%) sequalae. Thirty-eight percent rated their quality of life to be "unchanged" to "much better" since their episode of SJS/TEN. The average PCS score was lower than US population norms (mean: 36 vs. 50, p=0.006), indicating persistent physical sequelae from SJS/TEN. These results suggest that SJS/TEN survivors continue to suffer from long-term complications that impair their quality of life and warrant ongoing follow-up by a multidisciplinary care team.

Contracture Severity at Hospital Discharge in Children: A Burn Model System Database Study

Contractures can complicate burn recovery. There are limited studies examining the prevalence of contractures following burns in pediatrics. This study investigates contracture outcomes by location, injury, severity, length of stay, and developmental stage. Data were obtained from the Burn Model System between 1994 and 2003. All patients younger than the age of 18 with at least one joint contracture at hospital discharge were included. Sixteen areas of impaired movement from the shoulder, elbow, wrist, hand, hip, knee, and ankle joints were examined. Analysis of variance was used to assess the association between contracture severity, burn size, and length of stay. Age groupings were evaluated for developmental patterns. A P value of less than .05 was considered statistically significant. Data from 225 patients yielded 1597 contractures (758 in the hand) with a mean of 7.1 contractures (median 4) per patient. Mean contracture severity ranged from 17% (elbow extension) to 41% (ankle plantarflexion) loss of movement. Statistically significant associations were found between active range of motion loss and burn size, length of stay, and age groupings. The data illustrate quantitative assessment of burn contractures in pediatric patients at discharge in a multicenter database. Size of injury correlates with range of motion loss for many joint motions, reflecting the anticipated morbidity of contracture for pediatric burn survivors. These results serve as a potential reference for range of motion outcomes in the pediatric burn population, which could serve as a comparison for local practices, quality improvement measures, and future research.

"Living Well" After Burn Injury: Using Case Reports to Illustrate Significant Contributions From the Burn Model System Research Program

The Burn Model System (BMS) program of research has been funded since 1993 by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). The overarching aim of this program is to improve outcomes and quality of life for people with burns in the areas of health and function, employment, and community living and participation. This review reports on BMS contributions that have affected the lives of individuals with a significant burn injury using case reports to associate BMS contributions with recovery. In January 2020, current BMS grantee researchers assessed peer-reviewed BMS publications from 1994 to 2020. Using case report methodology, contributions were linked to three individuals treated at one of the four Burn Model System institutions. With over 25 years of NIDILRR funding, unique BMS contributions to patient recovery were identified and categorized into one of several domains: treatment, assessment measures, sequelae, peer support, employment, and long-term functional outcomes. A second review for significant results of BMS research that add to the understanding of burn injury, pathophysiology, and recovery research was identified and categorized as injury recovery research. The case study participants featured in this review identified select NIDILRR research contributions as having direct, personal benefit to their recovery. The knowledge generation and clinical innovation that this research program has contributed to our collective understanding of recovery after burn injury is considerable. Using case study methodology with three adult burn survivors, we highlight the impact and individual significance of program findings and reinforce the recognition that the value of any clinical research must have relevance to the lives of the study population.

Burn model system national longitudinal database representativeness by race, ethnicity, gender, and age

INTRODUCTION

Representativeness of research populations impacts the ability to extrapolate findings. The Burn Model System (BMS) National Database is one of the largest prospective, longitudinal, multi-center research repositories collecting patient-reported outcomes after burn injury.

OBJECTIVE

To assess if the BMS Database is representative of the population that is eligible to participate.

DESIGN

Data on adult burn survivors who were eligible for the BMS Database from 2015 to 2019 were analyzed.

SETTING

Not applicable.

PARTICIPANTS

Burn survivors treated at BMS centers meeting eligibility criteria for the BMS Database. Eligibility for the database is based on burn size and receipt of autografting surgery.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Race, ethnicity, gender, and age were compared between individuals who did and did not enroll. Regression analysis examined the correlation between demographic characteristics and study enrollment. Additional regression analysis examined the association between enrollment and the intersection of race, ethnicity, and gender.

RESULTS

A total of 982 adult burn survivors were eligible for the BMS database during the study period. Of those who were eligible, 72.1% Enrolled and 27.9% were Not Enrolled. The Enrolled group included more female and more younger survivors compared to the Not Enrolled group. In regression analyses, Black/African American burn survivors were less likely and individuals identifying as female were more likely to enroll in the BMS Database. Furthermore, White men and women were more likely to enroll compared to Black/African American men and women, and non-Hispanic/Latino men were more likely to enroll compared to Hispanic/Latino men.

CONCLUSIONS

This study found differences in BMS Database enrollment by race, ethnicity, and gender. Further research is warranted to investigate causes for the disparities found in this study. In addition, strategies are needed to improve enrollment to ensure future representativeness.

44 Examining the Impact of the COVID-19 Pandemic on Participants in a Longitudinal Study of Burn Outcomes

Introduction

The COVID-19 pandemic has had widespread effects on healthcare and society at large. There are limited data on the impact of the pandemic on the long-term recovery of the burn survivor. This study aims to compare physical and psychosocial outcomes of the burn survivor population before and during the COVID-19 pandemic.

Methods

Data from the Burn Model System National Database (2015-present) were analyzed. Data were divided into pre- and during-pandemic groups (before and after March 1st, 2020). Outcomes were compared at four cross-sectional time points: 6, 12, 24, and 60 months after burn injury. The following patient reported outcome measures were examined: SF-12 Health Survey, PROMIS-29, Post-Traumatic Growth Indicator, Community Integration Questionnaire, Patient Civilian Checklist, Satisfaction with Life Scale, Burn Specific Health Scale, NeuroQOL Stigma, 4-D Itch, and CAGE Questionnaire (drug/alcohol misuse). Given the cross-sectional design, potential differences in clinical and demographic characteristics were examined for each group at each time point. Adjusted mean outcome scores at each time point were compared between groups using a two stage multi-variable regression model with propensity score matching. For each time point, subjects from each group were matched. The propensity score was calculated using the following matching variables: gender, age, race, ethnicity, etiology, length of stay, and burn size. The mean score difference of outcomes within each matched sample was examined.

Results

Sample sizes varied by time point with a range from 420 at 6 months to 94 at 60 months. The during-COVID group comprised 10% of the total sample size. There were no significant differences in demographic and clinical characteristics between the groups at any time point. There were no significant differences between the groups in adjusted mean outcome scores across the different time points.

Conclusions

This preliminary examination showed no differences in myriad long-term outcomes at multiple time points after injury among burn survivors before and during the start of the COVID-19 pandemic. The results may suggest an element of resilience, however given the sample size and cross-sectional limitations further investigation is required to better understand the impact of COVID-19 on the burn population.

T5 The Impact of Burn Survivor Pre-injury Income and Payer on Health-Related Quality of Life Outcomes

Introduction

The critical care, surgery, and rehabilitation required to recover patients with serious burn injuries are associated with high financial costs. In the US, these costs are often borne by patients. However, the relationship between pre-injury finances (personal income and payer) and health-related quality of life (HRQL) of burn survivors has not been reported. We hypothesized that lower income and public payers would be independent predictors of poorer HRQL.

Methods

Burn survivors with complete data for pre-injury personal income and payer were extracted from the NIDILRR Burn Model System National Database. HRQL outcomes included VA-Rand 12 (VR-12) scores at 6-, 12-, and 24-months post-injury. VR-12 scores were evaluated using generalized linear models and adjusted for potential confounders (age, gender, self-identified race, measures of burn injury severity). Model performance was assessed with Akaike Information Coefficient.

Results

453 burn survivors had complete data for income and payer status. 36.4% earned less than $25k/year, 24% earned $25k-49k/year, 23% earned $50k-99k/year, 10% earned $100k-149k/year, 3% earned $150k-199k/year, and 3% earned ≥$200k/year. Mental component summary (MCS) and physical component summary (PCS) scores were highest for those who earned $150-199k/year (55.8, 55.8), and lowest for those who earned &lt; $25k/year (49.0, 46.4). There was a negative relationship between income &lt; $25k/year and MCS scores at 6-, 12-, and 24-months post-injury (p&lt; 0.05). This relationship was not observed with PCS scores. After adjusting for demographics, payer, and burn severity, 24-month PCS scores were negatively associated with Medicare payer (p=0.025), black race (p=0.008) and number of operations during index admission (p=0.026). There were no significant associations with MCS scores.

Conclusions

HRQL was highest for burn survivors earning between $150-199k/year. Participants who earned &lt; $25k/year had the lowest VR-12 scores and particularly MCS scores. On multivariable analysis, most of the differences in HRQL associated with pre-injury income were explained by differences in demographic, payer and burn severity factors.

Development of Proxy and Self-report Burn Model System Pediatric Itch Interference Scales: A National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System Study

Pruritus is a commonly reported symptom after burn injury. Valid and reliable scales to measure itch in pediatric burn survivors are important for treatment and epidemiological studies. This study sought to develop psychometrically sound, publicly available self- and proxy-report measures of itch for use in pediatric burn survivors suitable for use in research and clinical practice. A panel of burn experts developed a definition of itch interference and a set of parallel self- and proxy-report candidate items that covered important activities affected by itch. Candidate items were evaluated in cognitive interviews with pediatric burn survivors (n = 4) and proxies (n = 2). Items were translated to Spanish and administered in both English and Spanish to a sample (N = 264) of pediatric burn survivors and/or their proxy enrolled in the Burn Model System (BMS) longitudinal database. The mean age of the pediatric sample was 13 years and average time since burn 5 years. The final itch interference measures each included 5 parallel items calibrated using a one-parameter graded response item response theory model, with a mean of 50 representing the average itch interference of the sample. Reliability of the scores is excellent between the mean and two standard deviations above. Initial analyses provide support for validity of the score. Concordance between the self- and proxy-report scores was moderate (ICC = 0.68). The results support the reliability and validity of the itch scale in children and youth with burn injury. The new BMS Pediatric Itch Interference scales are freely and publicly available at https://burndata.washington.edu/itch.

Inpatient and post-discharge outcomes following inhalation injury among critically injured burn patients

Inhalation injury is associated with high inpatient mortality, but the impact of inhalation injury after discharge and on non-mortality outcomes are poorly characterized. To address this gap, we evaluated the effect of inhalation injury on post-discharge morbidity, mortality and hospital readmissions among patients who sustained burn injury, as well as on in-hospital outcomes for context.This was a retrospective cohort study of patients with cutaneous fire/flame burns admitted to a burn center intensive care unit from 1/1/2009-12/31/2015, with or without inhalation injury. Records were linked to statewide hospital admission and vital statistics databases to assess post-discharge outcomes. Mixed-effects Poisson regression was used to assess mortality, complications, and readmissions. The overall cohort included 830 patients with cutaneous burns; of these, 201 patients had inhalation injury. In-hospital mortality was 31% among inhalation injury patients versus 6% in patients without inhalation injury (adjusted OR 2.35; 95% CI 1.66-3.31). Inhalation injury was also associated with an increased risk of in-hospital pneumonia and tracheostomy (p<0.05 for all). Inhalation injury was not associated with greater post-discharge mortality, all-cause readmission, readmission for pulmonary diagnosis, or readmission requiring intubation. Among the subset of patients with bronchoscopy-confirmed inhalation injury (n=124; 62% of inhalation injuries), higher injury grade was not associated with greater inpatient or post-discharge mortality. Inhalation injury was associated with increased early morbidity and mortality, but did not contribute to post-discharge mortality or readmission. These findings have implications for shared decision-making with patients and families, and for estimating healthcare utilization after initial hospitalization.

Impact of the affordable care act's medicaid expansion on burn outcomes and disposition

BACKGROUND

We aimed to analyze the impact of the Affordable Care Act's Medicaid Expansion on clinical outcomes and patient disposition after burn injury. We hypothesized that increased insurance coverage results in improved outcomes and higher rates of discharge to inpatient rehabilitation.

METHODS

We reviewed the University of Washington Regional Burn Center registry data for patients admitted from 2011 to 2018. Patients were grouped into two categories: before (2011-2013) and after (2015-2018) Medicaid expansion; we excluded 2014 data to serve as a washout period. Outcomes assessed included length of hospital stay, patient disposition, and mortality. Multivariable logistic and linear regression models with covariates for sex, age, burn size, ethnicity ethnicity, distance from burn center, etiology of burn, and presence of inhalation injury were used to determine the impact of Medicaid expansion on outcomes.

RESULTS

Rates of uninsured patients decreased while Medicaid coverage increased. Despite increased median burn size after Medicaid expansion, inpatient mortality rates did not change, but average acute care length of stay increased. More patients were discharged to rehabilitation centers.

CONCLUSIONS

Our study corroborates prior findings of increased insurance coverage since Medicaid expansion. Increased insurance coverage is associated with higher rates of discharge to inpatient rehabilitation programs after burn injury.

Nursing Understanding and Perceptions of Delirium: Assessing Current Knowledge, Attitudes, and Beliefs in a Burn ICU

The number of delirium days in hospitalized patients directly correlates with mortality and long-term cognitive dysfunction. Burn patients are at greater risk for delirium due to prolonged mechanical ventilation, high sedative and analgesic medication requirements, and the common need for multiple operations. Limited research exists on nurses' understanding and comfort using delirium screening tools and preventive interventions. A process improvement project was developed in a single, regional burn intensive care unit (BICU) with the goal of increasing RN staff awareness of delirium, delirium assessment, and preventive interventions. A 10-question survey was developed and administered to the BICU RN staff before and after the educational intervention. Both quantitative and qualitative data analyses were performed. Twenty-seven (38%) anonymous surveys were returned. In pre- and postintervention surveys, respondents agreed that nursing interventions were important in preventing delirium. Despite educational intervention, 26% of the respondents reported that a tool is not needed to identify delirium. Survey analysis indicated strong support for nonpharmacologic nursing interventions in preventing delirium as well as reducing pharmacologic interventions, especially benzodiazepines. Mechanical ventilation was perceived as a barrier to performing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in both pre- and postsurveys. Staff compliance with documenting CAM-ICU assessments increased and CAM-positive days decreased over the project timeline. Overall, BICU nurses' awareness and general knowledge about delirium increased and specific knowledge deficits were discovered. Continued education about the CAM-ICU tool is still needed; additionally addressing barriers within the structure of the unit to provide nurses more resources to properly assess and prevent delirium.

Burn survivors' perception of recovery after injury: A Northwest Regional Burn Model System investigation

INTRODUCTION

Previous reports suggest that many factors impact recovery from burn injury. To improve our understanding of these factors, we queried adult burn survivors using a mixed method design during the first year after injury.

METHODS

An anonymous, 2-page survey was developed and administered to adult burn survivors during routine outpatient clinic follow-up visits at a regional burn center. Participants rated issues of concern and their impacts on return to pre-burn activity levels. Both quantitative and qualitative data were obtained. Descriptive statistics were used to analyze quantitative data and thematic analysis was used to identify, analyze and report patterns from open-ended responses.

RESULTS

Over seven months in 2016, 187 patients completed the anonymous survey. Study participants were predominantly male, white, and non-Hispanic. Participants who had not yet returned to pre-burn function reported worse outcomes for all issues queried compared to those who had. Burn survivors from racial and ethnic minority groups reported greater difficulty with accessing medical care and information about their injury as well as higher levels of self-identified posttraumatic stress, issues related to appearance and concerns for loss of strength. Several themes and sub-themes were identified that had both negative and positive impact on early recovery. Such themes included: healing process, psychological recovery and emotional health, and community reintegration/employment.

CONCLUSIONS

Several themes from responses provided insight into challenges as well as key support systems during the first year of recovery after injury. Collectively, these findings can be used to direct clinical outpatient care, patient education and psychosocial support services.

Mortality prognostication scores do not predict long-term, health-related quality of life after burn: A burn model system national database study

OBJECTIVE

Despite improved mortality rates after burn injury, many patients face significant long-term physical and psychosocial disabilities. We aimed to determine whether commonly used mortality prognostication scores predict long-term, health-related quality of life after burn injury. By doing so, we might add evidence to support goals of care discussions and facilitate shared decision-making efforts in the hours and days after a life-changing injury.

METHODS

We used the multicenter National Institute of Disability, Independent Living and Rehabilitation Research Burn Model System database (1994-2019) to analyze SF-12 physical (PCS) and mental component (MCS) scores among survivors one year after major burn injury. Ninety percent of the observations were randomly assigned to a model development dataset. Multilevel, mixed-effects, linear regression models determined the relationship between revised Baux and Ryan Scores and SF-12 measures. Additionally, we tested a model with disaggregated independent and other covariates easily obtained around the time of index admission: age, sex, race, burn size, inhalation injury. Residuals from the remaining 10% of observations in the validation dataset were examined.

RESULTS

The analysis included 1606 respondents (median age 42 years, IQR 28-53 years; 70% male). Median burn size was 16% TBSA (IQR 6-30) and 13% of respondents sustained inhalation injury. Higher revised Baux and Ryan Scores and age, burn size, and inhalation injury were significantly correlated with lower PCS, but were not correlated with MCS. Female sex, black race, burn size, and inhalation injury correlated with lower MCS. All models poorly explained the variance in SF-12 scores (adjusted r² 0.01-0.12).

CONCLUSION

Higher revised Baux and Ryan Scores negatively correlated with long-term physical health, but not mental health, after burn injury. Regardless, the models poorly explained the variance in SF-12 scores one year after injury. More accurate models are needed to predict long-term, health-related quality of life and support shared decision-making during acute burn care.

Pain across traumatic injury groups: A National Institute on Disability, Independent Living, and Rehabilitation Research model systems study

BACKGROUND

Pain is a common problem after traumatic injury. We describe pain intensity and interference at baseline and 1 year postinjury in burn, traumatic brain injury (TBI), and spinal cord injury (SCI) survivors and compare them with the general population (GP). We tested a custom Patient Reported Outcomes Measurement Information System (PROMIS) pain interference short form developed for use in trauma populations.

METHODS

We administered a pain intensity numerical rating scale and custom PROMIS pain interference short forms at baseline and/or 1 year postinjury from participants (≥18 years) at three Model System projects (burn, TBI, and SCI). Scores were compared across injury groups and pain intensity levels, and to the GP. Reliability and floor and ceiling effects of the custom PROMIS pain measures were calculated.

RESULTS

Participants (burn, 161; TBI, 232; SCI, 134) responded to the pain intensity and/or pain interference measures at baseline (n = 432), 1 year (n = 288), or both (n = 193). At baseline, pain interference and intensity were both significantly higher in all three groups than in the GP (all p < 0.01). At 1 year, average pain intensity in SCI and burn (p < 0.01) participants was higher than the GP, but only SCI participants reported higher pain interference (p < 0.01) than the GP. Half of all participants reported clinically significant pain interference (55 or higher) at baseline and one third at 1 year. Reliability of the custom pain interference measure was excellent (>0.9) between T-scores of 48 and 79.

CONCLUSION

The custom pain interference short forms functioned well and demonstrated the utility of the custom PROMIS pain interference short forms in traumatic injury. Results indicate that, for many people with burn, TBI and SCI, pain remains an ongoing concern long after the acute injury phase is over. This suggests a need to continue to assess pain months or years after injury to provide better pain management for those with traumatic injuries.

LEVEL OF EVIDENCE

Epidemiologic/Therapeutic study, level IV.

Inhalation injury is associated with long-term employment outcomes in the burn population: Findings from a cross-sectional examination of the Burn Model System National Database

Introduction

Inhalation injuries carry significant acute care burden including prolonged ventilator days and length of stay. However, few studies have examined post-acute outcomes of inhalation injury survivors. This study compares the long-term outcomes of burn survivors with and without inhalation injury.

Methods

Data collected by the Burn Model System National Database from 1993 to 2019 were analyzed. Demographic and clinical characteristics for adult burn survivors with and without inhalation injury were examined. Outcomes included employment status, Short Form-12/Veterans Rand-12 Physical Composite Score (SF-12/VR-12 PCS), Short Form-12/Veterans Rand-12 Mental Composite Score (SF-12/VR-12 MCS), and Satisfaction With Life Scale (SWLS) at 24 months post-injury. Regression models were used to assess the impacts of sociodemographic and clinical covariates on long-term outcome measures. All models controlled for demographic and clinical characteristics.

Results

Data from 1,871 individuals were analyzed (208 with inhalation injury; 1,663 without inhalation injury). The inhalation injury population had a median age of 40.1 years, 68.8% were male, and 69% were White, non-Hispanic. Individuals that sustained an inhalation injury had larger burn size, more operations, and longer lengths of hospital stay (p<0.001). Individuals with inhalation injury were less likely to be employed at 24 months post-injury compared to survivors without inhalation injury (OR = 0.63, p = 0.028). There were no significant differences in PCS, MCS, or SWLS scores between groups in adjusted regression analyses.

Conclusions

Burn survivors with inhalation injury were significantly less likely to be employed at 24 months post-injury compared to survivors without inhalation injury. However, other health-related quality of life outcomes were similar between groups. This study suggests distinct long-term outcomes in adult burn survivors with inhalation injury which may inform future resource allocation and treatment paradigms.

A Comparison of Contracture Severity at Acute Discharge in Patients With and Without Heterotopic Ossification: A Burn Model System National Database Study

This study assesses the association between heterotopic ossification and upper extremity contracture by comparing goniometric measured active range of motion outcomes of patients with and without heterotopic ossification. Data were obtained from the Burn Model System National Database between 1994 and 2003 for patients more than 18 years with elbow contracture at acute discharge. Absolute losses in elbow range of motion were compared for those with and without radiologic evidence of heterotopic ossification (location undefined) and were further examined by burn size subgroups using Wilcoxon rank-sum test. Differences in elbow range of motion were estimated using regression models, adjusted for demographic and clinical variables. Loss of range of motion of shoulder, wrist, forearm, and hand were also compared. From 407 instances of elbow contracture, the subjects with heterotopic ossification were found to have greater median absolute loss of elbow flexion among all survivors (median 50° [IQR 45°] vs 20° [30°], P < .0001), for the 20 to 40% total body surface area burn subgroup (70° [20°] vs 20° [30°], P = .0008) and for the >40% subgroup (50° [45°] vs 30° [32°], P = .03). The adjusted estimate of the mean difference in the absolute loss of elbow flexion between groups was 23.5° (SE ±7.2°, P = .0013). This study adds to our understanding of the potential effect of heterotopic ossification on upper extremity joint range of motion, demonstrating a significant association between the presence of heterotopic ossification and elbow flexion contracture severity. Further study is needed to determine the functional implications of heterotopic ossification and develop treatment protocols.

The Impact of Comorbid Conditions on Long-Term Patient-Reported Outcomes From Burn Survivors

Preburn comorbidities increase the risk of death in the acute phase, and negatively impact quality of life among survivors. Investigations to date have only evaluated comorbidities as indices, limiting the ability to target conditions and develop strategies for risk reduction. Therefore, we aimed to evaluate the differential effects of specific conditions on long-term, patient-reported outcomes after burn injury. A prospectively maintained trauma registry was merged with a longitudinal database of patient-reported outcomes from a regional burn center from 2007 to 2018. Demographic data, injury-specific information, and the prevalence of 20 comorbidities were systematically documented. The impact of comorbidities on responses to Short Form-12/Veterans RAND 12 (SF/VR-12) health surveys at 6, 12, and 24 months postinjury was evaluated with generalized linear models. The merged dataset included 493 adult participants. Median age was 46 years (interquartile range, IQR 32-57 years), and 72% were male. Median burn size was 14% TBSA (IQR 5-28%). Seventy percent of participants had ≥1 comorbidity (median 1 comorbidity/participant; IQR 0-2 comorbidities). SF/VR-12 mental component summary scores at 6 and 12 months postinjury were negatively associated with mental illness (P < .001, P = .013). SF/VR-12 physical component summary (PCS) scores were negatively associated with smoking (P = .019), diabetes (P = .001), and alcohol use disorder (P = .001) at 6-month follow-up. Twelve-month SF/VR-12 PCS scores were negatively associated with prior trauma admission (P = .001) and diabetes (P = .042). Twenty-four-month SF/VR-12 PCS scores were negatively associated with mental illness (P = .003). Smoking, alcohol use disorder, and diabetes were associated with lower PCS scores 6 months after injury; diabetes persisted as a negatively associated covariate at 12 months. Mental component summary scores were negatively associated with mental illness 6 and 12 months postinjury. Integrated models of postdischarge comorbidity management need to be tested in burn patients.

25 Social Integration in the First 2 Years After Moderate to Severe Burn Injury: A Burn Model System National Database Study

Introduction

Feeling a part of community and participating in social life are important aspects of overall quality of life. Burn survivors consider community reintegration one of the most important issues affecting their recovery. Integration, including social integration, has been studied in this population, but longitudinal analyses to examine factors associated with successful integration are lacking. The current study aims to assess variables associated with social integration during the first two years post-burn.

Methods

Adult (18+ years) burn survivors enrolled in the Burn Model System national longitudinal database responded to questionnaires at hospital discharge and 6-, 12-, and 24-months postburn. Social integration was assessed at all follow-up timepoints using the Community Integration Questionnaire Social Integration Component Scale, which has a possible range of scores from 0 (no community integration) to 12 (excellent community integration). To examine variables associated with social integration over time, linear mixed effect models utilizing generalized least squares with maximum likelihood and robust standard errors were used. Independent variables in the model included age, sex, % total body surface area (TBSA) burned, race/ethnicity, living status at time of injury, facial burn, history of psychiatric treatment preburn, employment at follow-up assessment, and SF-12 or VR-12 mental health component scores at the time of each follow-up assessment.

Results

Data from 1,848 adult burn survivors were included in the analyses. Average age of the survivors was 42.9 years, 74.0% were male, 77.7% were white, 47.0% were married or living common-law with a partner, and mean total body surface area burned was 18.2%. Factors associated with better social integration over time included younger age, female sex, lower TBSA (&lt; 40%) burn size, white/non-Hispanic race, no preburn psychiatric treatment, postburn employment, and better mental health. Time was not a significant predictor, indicating that social integration scores remain relatively stable over the 24-month follow-up period.

Conclusions

We identified several factors that contribute to greater social integration including age, gender, burn size, race/ethnicity, employment, and mental health, with the association between age, gender, and employment status and community integration a novel finding in this population.

Applicability of Research to Practice

This study suggests that while most factors associated with social integration are not modifiable, interventions aimed at improving mental health and helping burn survivors return to work could also improve self-reported social integration.

The impact of discharge contracture on return to work after burn injury: A Burn Model System investigation

INTRODUCTION

Despite many advances in burn care, the development of extremity contracture remains a common and vexing problem. Extremity contractures have been documented in up to one third of severely burned patients at discharge. However, little is known about the long-term impact of these contractures. The purpose of this study was to examine the association of extremity contractures with employment after burn injury.

METHODS

We obtained data from the Burn Model System database from 1994 to 2003. We included in the study cohort all adult patients who were working prior to injury and identified those discharged with and without a contracture in one of the major extremity joints (shoulder, elbow, wrist, hip, knee and ankle). We classified contracture severity according to mild, moderate and severe categories. We performed descriptive analyses and predictive modeling to identify injury and patient factors associated with return to work (RTW) at 6, 12, and 24 months.

RESULTS

A total of 1,203 participant records met criteria for study inclusion. Of these, 415 (35%) had developed a contracture at discharge; 9% mild, 12% moderate, and 14% severe. Among 801 (67%) participants who had complete data at 6 months after discharge, 70% of patients without contracture had returned to work compared to 45% of patients with contractures (p < 0.001). RTW increased at each subsequent follow-up time point for the contracture group, however, it remained significantly lower than in no-contracture group (both p < 0.01). In multivariable analyses, female sex, non-Caucasian ethnicity, larger burn size, alcohol abuse, number of in-hospital operations, amputation, and in-hospital complications were associated with a lower likelihood of employment. In adjusted analyses, discharge contracture was associated with a lower probability of RTW at all 3 time points, although its impact significantly diminished at 24 months.

CONCLUSIONS

This study indicates an association between discharge contracture and reduced employment 6, 12 and 24 months after burn injury. Among many other identified patient, injury, and hospitalization related factors that are barriers to RTW, the presence of a contracture at discharge adds a significant reintegration burden for working-age burn patients.

Burn injury

Burn injuries are under-appreciated injuries that are associated with substantial morbidity and mortality. Burn injuries, particularly severe burns, are accompanied by an immune and inflammatory response, metabolic changes and distributive shock that can be challenging to manage and can lead to multiple organ failure. Of great importance is that the injury affects not only the physical health, but also the mental health and quality of life of the patient. Accordingly, patients with burn injury cannot be considered recovered when the wounds have healed; instead, burn injury leads to long-term profound alterations that must be addressed to optimize quality of life. Burn care providers are, therefore, faced with a plethora of challenges including acute and critical care management, long-term care and rehabilitation. The aim of this Primer is not only to give an overview and update about burn care, but also to raise awareness of the ongoing challenges and stigmata associated with burn injuries.

Exploring the Burn Model System National Database: Burn injuries, substance misuse, and the CAGE questionnaire

Burn survivors who misuse alcohol and/other substances have been associated with poorer long-term outcomes and clinical complications following injury. The self-reported CAGE questionnaire (Cut down, Annoyed, Guilty, and Eye-opener) is an outcomes assessment tool used to screen for potential substance misuse. Understanding the persistence and emergence of potential substance misuse through examination of CAGE scores may provide important information about this population. Using data collected from the Burn Model System National Database, demographic and clinical characteristics of individuals who reported positive CAGE scores (total score of ≥2) and those who reported negative CAGE scores (total score of 0 or 1) for either alcohol or other drugs were compared.

Early patient deaths after transfer to a regional burn center

INTRODUCTION

Patients who sustain burn injuries are frequently transferred to regional burn centers. Severely injured patients, unlikely to survive, may be transported far from home and family to die shortly after arrival. An examination of early deaths, those that happen within a week of transfer, may offer an opportunity to revise the way we think about critical burns and consider the best way to provide regional care.

METHODS

This is a focused review of burn patients who survived ≤1 week after transfer to a regional center from 2013-2017. Originating location data such as city, state, population at origin were obtained. Transfer data, including mode of transport and distance traveled, as well as patient characteristics, Total Body Surface Area (TBSA) burned, inhalation injury, medical history with calculation of revised-Baux (r-Baux) score were analyzed.

RESULTS

25 patients (1.2%) met inclusion criteria. Patients were transferred from a wide geographic area with population ranges of 1000 to 279,000. 21 patients met criteria for burn resuscitation by TBSA; 4 (19%) were placed on comfort care upon arrival, 7 (33%) were placed on comfort care after discussion with the patient's family, and 10 (48%) received full resuscitation efforts. Of these 10 patients, 2 died as "full code", 8 were transitioned to comfort care after failed resuscitation or other events. Code status was not always addressed prior to the decision to transfer. Two patients were transferred after cardiac arrest in the field both of which had significant medical comorbidities in addition to their burn.

CONCLUSIONS

Regional burn centers support a variety of populations. Transferring patients for which care is futile may have a profound impact on resource utilization from a variety of perspectives including transferring centers, receiving centers, regional Emergency Medical Services and families. Referring providers need to be supported in identifying these severely injured, potentially expectant patients. Transfer of patients may negatively impact families as a loved one may die far from home, before family can arrive. With our increasing ability to utilize telemedicine, transfer may not always provide the best support we can offer for providers, patients, and families.

APPLICABILITY OF RESEARCH TO PRACTICE

Early deaths after transfer to a regional burn center, especially those that do not undergo a full resuscitation, should be critically examined to determine the appropriateness of transfer in a palliative, patient and family centered approach.

Prospective observational study comparing burn surgeons' estimations of wound healing after skin grafting to photo-assisted methods

INTRODUCTION

Appropriate graft healing after split-thickness skin graft and early recognition of complications (graft loss) are critical to burn patient management. Larger mesh ratio expansions and Meek micrografting may pose a greater challenge in estimating the percentage of wound healing. This study looks at the reliability of photograph assessments and the concordance of bedside evaluation to photograph assessments of wound healing after skin grafting.

METHODS

Three assessment methods for percentage of wound healing after skin Grafting were assessed: (1) clinicians' bedside rating, (2) clinician assessment of high-definition photographs, and (3) digital image analysis through color subtraction using Adobe Photoshop. We compared each method using a mixed-effects model on absolute agreement using intra-class correlation (ICC) and Bland Altman (BA) plots.

RESULTS

Fourteen burn patients were enrolled with 38 grafted wounds (100 sites). Bedside assessments had a mean ICC of 0.64 (compared to digital image analysis) and 0.69 (compared to photo assessment), with a wide range on BA-plots. Inter-rater reliability of photo assessment was excellent (0.96) among six clinicians. Repeated photo-assisted assessments had good intra-rater reliability (ICC: photo assessment: 0.88; digital analysis: 0.97).

CONCLUSIONS

Bedside wound healing assessments show variability; photograph documentation of sequential wound progression could supplement active clinical management or studies for more reliable assessments.

Outpatient opioid use of burn patients: A retrospective review

INTRODUCTION

Opioid overuse is a growing patient safety issue but continue to be integral to burn pain management. This study aims to characterize opioid use in discharged patients and factors for predictive of long term use.

METHODS

Participants with burns admitted to a single center from 2006 to 2015 were included. Total outpatient morphine equivalent dose (MED) was recorded at discharge and each clinic visit. Burn size, percent grafted, age, sex, and preadmission drug use were collected. For each time point, multivariate logistic regression was performed to examine the relationship of discharge MED and long-term opioid use, adjusting for age, sex, burn size, and percent grafted. MED was divided into low (0-150 mg per day), medium (151-300 mg per day), and high (greater than 301 mg) groups on day of discharge.

RESULTS

At discharge, 366 (90%) patients received opioids. At day 14, both the medium MED (OR 2.72; CI 1.18-6.23) and high MED (OR 2.74; CI 1.02-7.37) groups had an increased risk for continued opioid use. On day 60, only the high MED group (OR 6.06; CI 1.60-22.97) had an increased risk. History of drug use was significant at 60 days (OR 7.67; 1.67-35.26) and alcohol use was significant at 14 days (OR 3.14; CI 1.25-7.93) and 30 days (OR 5.92; CI 1.81-19.36).

CONCLUSIONS

Whereas opioids are widely prescribed upon discharge, most patients no longer use them 30 days later. Higher opiate utilization at discharge increases risk of long term use, as does pre-injury drug and alcohol use, but only temporarily.