Christopher W. Lentz

National Burn Repository 2005: a ten-year review.

In the early 1990s, the American Burn Association (ABA) started its first burn registry development initiatives. The impetus for the registry development software originated from several directions, including the following: (1) the recognition that national registries were widespread and of proven benefit; (2) growing demands from accrediting institutions, payers, and patient advocacy groups for objective and verifiable data regarding patient costs, treatments, and outcomes; and (3) the shift toward “evidence-based” medicine and the ongoing analysis of treatment effectiveness. The ABA has issued three calls for burn registry data for its National Burn Repository (NBR): 1994, 2002, and 2005. In 1994, 28 burn centers contributed data for more than 6,400 patients treated from 1991 to 1993. The ABA announced its second call for data in 2001 and distributed the published results of more than 54,000 acute burn admissions treated from 1974 to 2002 at the Association’s 2002 Annual Meeting. The third ABA call for data was issued in the Fall of 2005. The results are detailed in this report, which provides a summary of more than a quarter million acute burn admissions from 1995 to 2005, representing 70 hospitals from 30 states plus the District of Columbia. Statistics are presented in chart and table format to illustrate such key factors as patient age, burn size group, types of injuries, mortality rates, and average hospital charges by etiology and length of hospital stay. The data presented herein should help stimulate quality improvement programs in burn care, as burn centers compare their performance with the national data and as research is expanded using the NBR. The NBR will be published annually and, with continued refinements to the registry software, should become of increasing importance to clinicians, payers, researchers, and the public.

National burn repository 2006: A ten-year review

This article presents findings from the National Burn Repository (NBR) 2006 Annual Report. Data reported herein cover a 10-year period from January 1, 1996, through June 30, 2006. This year’s report includes the first comparative presentations of data over time to show what appear to be trends in the dataset. The purpose of this report is to share information about the current state of care for burned patients in the United States. Some of the implications include epidemiology, burn-prevention efforts, research, education, acute care and quality improvement in burn programs, resource allocation, and reimbursement issues.

National Burn Repository 2007 Report: A Synopsis of the 2007 Call for Data

The complete National Burn Repository (NBR) 2007 report was distributed entirely electronically for the first time at the 2008 annual meeting of the American Burn Association (ABA) and represents countless hours spent by ABA staff and members of the NBR committee. The 2007 call for data resulted in the registry now containing data on over 300,000 burn patients treated by contributing hospitals. As in the past, this year’s report reflects a rolling 10-year average; 1998–2007; representing over 181,000 acute burn admissions. Although there are holes in the data and some fields are spottily populated, the NBR still represents the largest single collection of data on the care and management of burned patients available today. The goal of the committee is to improve and strengthen the validity of the data in every way possible. The ABA TRACS Users’ committee finalized the new data dictionary to accompany version five (v5) of the N-TRACS Burn Module. This will go a long way in refining the data in the NBR and lead to a fuller and more robust data set. The members of the NBR committee and ABA staff contributed time to meet regularly during the past year to support the activities of the committee including the ‘Glimmers,’ quality assurance of the NBR, and the annual report. Bart Phillips and Susan Browning of the American Burn Association have done yeoman’s service to the ABA by keeping the committee focused to produce this report in a timely fashion. The report presented herein should not be viewed as an in-depth statistical analysis of the data in the NBR but a presentation of summary data as submitted by the contributing hospitals. It is divided into five main for purposes here • Section 1—Analysis of Contributing Hospitals • Section 2—Analysis of All Records • Section 3—Analysis by Age Groups • Section 4—Analysis by Etiology • Section 5—Hospital Comparisons

Synopsis of the 2013 annual report of the national burn repository.

Most burn centers maintain some record or registry of the patients they treat. These registries typically include information on the clinical characteristics of the patients and their injuries, the care and treatment they received, and the clinical outcome. These records document the burn center’s work and experience. They can be used to estimate the resources—supplies, personnel, space—required to provide care. They can be reviewed by the clinicians working there to discern imperfections in their systems of providing care and to identify opportunities to improve the structure, processes, and outcomes of those systems. They may also, in part, describe the characteristics of burn injury in the community served by the burn center. More than 40 years ago, burn clinicians envisioned the creation of a larger database of burn-injured patients. Such a database would be composed of data from several individual facility registries. It could provide a much broader view of burn injury and burn care in a larger geopolitical region than a single community. It could serve as the basis for burn research, burn prevention, public health, health planning, and advocacy at a regional, state, and even national level. This database then would benefit victims of burn injury, providers of burn care, state and national policy makers, and the public. Such a database was started at the University of Michigan in the early 1970s. It included a handful of burn centers. Over the years, that database was transferred to other entities, and in 2001, the American Burn Association (ABA) assumed responsibility for it, almost three decades after it was begun. By then, it had become national in scope and was known as the National Burn Repository (NBR). An NBR Committee was formed by the ABA, and it began preparing annual summaries of the database in 2006. These reports summarized cases treated by contributing centers during a 10-year period. They were made available not only to members of the ABA but also to the public. Two of these reports were summarized for publication in this Journal,1,2 the most recent of which was a summary of the 2007 annual report published in 2008. As the result of efforts of both the NBR Committee and the Burn Registry Committee of the ABA to improve the quality of the data in the NBR in the intervening years, the annual NBR report prepared in 2013 was based on data that were of a much higher quality than those that existed before. The purpose of this current article is to summarize and review highlights from that 2013 NBR Report.

Burn Resuscitation Index: A Simple Method For Calculating Fluid Resuscitation in the Burn Patient

The Parkland formula is the standard for calculating the initial intravenous fluid rate for resuscutation after thermal injury. However, it is cumbersome when used by those with modest burn training. We propose an easier method to calculate fluid requirements that can be initiated by first-line providers. Burn size is estimated by using the Burn Size Score (BSS), which is then crossreferenced with the patients weight on a preprinted Burn Resuscitation Index (BRI), based on the Parkland formula, to determine initial hourly fluid rate. Seventy-two residents and faculty in the Departments of Surgery and Emergency Medicine were surveyed. Participants were shown a diagram of a burn patient and asked to calculate the initial fluid rate using the Parkland formula from memory. The study was repeated with a different diagram, and the participants were asked to calculate the initial fluid rate using the BRI (a preprinted card with written instruction pertaining to its use). Statistical analysis was performed with the McNemar test. Using the Parkland formula, 33% of surgeons and 17% of emergency medicine physicians were able to calculate the initial fluid rate. Using the BRI, 56% of surgeons and 77% of emergency medicine physicians were able to calculate the fluid rate correctly (P < .01 and P < .001, respectively). Fifty-four percent of physicians surveyed believed that the BRI was easier to use. The accuracy of determining initial fluid rate was low using the Parkland formula and “rule of nines” from memory. Accuracy increased when the BRI was used. The BRI serves as a visual aid and provides some instruction, allowing the user to calculate fluid resuscitation with greater accuracy than with rote memorization of a formula. The BRI might be a useful tool for providers with minimal burn training. However, further investigation is warranted.

Fictitious hyperglycemia: point-of-care glucose measurement is inaccurate during high-dose vitamin C infusion for burn shock resuscitation.

The use of high-dose vitamin C (hdVC, 66 mg/kg/hour × 18 hours) infusion is a useful adjunct to reducing fluid requirements during resuscitation of burn shock. Routine point-of-care glucose (POCG) analysis has been inaccurately high in observed patients undergoing hdVC. Inaccurate POCG could potentially lead to iatrogenic hypoglycemia if the fictitious hyperglycemia is treated with insulin. This study is a retrospective analysis of plasma glucose measurements from a central laboratory (LG) compared with POCG during and 24 hours after hdVC infusion. Records of adult patients receiving hdVC infusions during burn resuscitation over 1 year were reviewed. Charts selected for analysis included those with glucose measurements using POCG and LG that were taken simultaneously, during hdVC infusion, and 24 hours after completion. All specimens were drawn from arterial lines. POCG was measured with Accu-Chek Inform (Roche, Indianapolis, IN) and LG was measured by Siemens Dimension Vista 500 (Siemens, Deerfield, IL) using biochromic analysis. Nonparametric statistical analysis was performed using Wilcoxon’s matched pairs test and Spearman correlation with significance at P < .05. Of 18 adult patients undergoing burn resuscitation with hdVC infusion, 5 were chosen for analysis (%TBSA 40 ± 15; age 51 ± 18). All data were pooled with 11 comparisons both during and after hdVC. The mean POCG (225 ± 71) was significantly higher than mean LG (138 ± 41) on hdVC (P = .002). There was no difference between POCG (138 ± 30) and LG (128 ± 23) after hdVC was finished (P = .09). There was a negative correlation between POCG and LG on hdVC (−0.64, P = .04) and a positive correlation off hdVC (0.89, P = .0005). POCG analysis during hdVC infusion is significantly higher than laboratory glucose measurements. Once the hdVC infusion is complete, POCG and laboratory glucose measurements are not statistically different. Treating erroneously high glucose based on POC testing is potentially dangerous and could lead to hypoglycemia and seizures.

Prevention of Hypophosphatemia After Burn Injury With a Protocol for Continuous, Preemptive Repletion

Severe burn injury has been shown to result in hypophosphatemia. Hypophosphatemia can cause cardiac, hematologic, immunologic, and neuromuscular dysfunction. This study compares serum phosphate levels and outcomes in patients who were administered a continuous, preemptive phosphate repletion protocol vs those who only received phosphate supplementation after they developed hypophosphatemia. Records of patients with greater than 19% TBSA burn admitted to the intensive care unit from 2006 to 2010 were reviewed. Patients were divided into two groups: historical controls who received responsive repletion when serum phosphate levels were less than 2.5 mg/dl (2006–2008) and the experimental group that received 30 mmol intravenous every 6 hours starting at approximately 24 hours after injury as long as serum phosphate levels were less than 4 mg/dl (2008–2010). Patients with chronic kidney disease or acute kidney injury were excluded. Data collected included age, weight, burn size, age, all serum phosphate levels, and total amount of phosphate administered. Differences in groups were compared with Mann–Whitney U test and Fisher’s exact test. A total of 30 patients were included in the study, 20 in the responsive repletion group and 10 in the continuous repletion group. No significant difference was detected in age, sex, burn size, or full thickness burn size between groups. The continuous group had a statistically lower percentage of hypophosphatemic lab values compared with the responsive group, 13 ± 14% vs 45 ± 21% (P < .0001). No difference was found in percent of observations reflecting hyperphosphatemia (median of 2% in each group, P = .7). Four patients in the continuous group suffered cardiac and/or infectious complications compared with 16 in the responsive group (P = .04). Continuous, pre-emptive repletion of phosphate prevents hypophosphatemia after severe burn injury when compared with responsive repletion in historical controls. The protocol resulted in less hypophosphatemia without increasing the risk of hyperphosphatemia. This study also suggests that continuous repletion may result in fewer complications, but this needs to be confirmed in larger, prospective studies.