Joel S. Fish

An Outbreak Due to Multiresistant Acinetobacter baumannii in a Burn Unit: Risk Factors for Acquisition and Management

OBJECTIVESnTo describe the investigation and management of an outbreak due to multiresistant Acinetobacter baumannii and to determine risk factors for acquisition of the organism.nnnSETTINGnA 14-bed regional burn unit in a Canadian tertiary-care teaching hospital.nnnDESIGNnCase-control study with multivariate analysis of potential risk factors using logistic regression analysis. Surveillance cultures were obtained from the hospital environment, from noninfected patients, and from healthcare providers.nnnRESULTSnA total of 31 (13%) of 247 patients with acute burn injuries acquired multiresistant A. baumannii between December 1998 and March 2000; 18 (58%) of the patients were infected. The organism was recovered from the hospital environment and the hands of healthcare providers. Significant risk factors for acquisition of multiresistant A. baumannii were receipt of blood products (odds ratio [OR], 10.8; 95% confidence interval [CI95], 3.4 to 34.4; P < .001); procedures performed in the hydrotherapy room (OR, 4.1; CI95, 1.3 to 13.1; P = .02); and increased duration of mechanical ventilation (OR, 1.1 per day; CI95, 1.0 to 1.1; P= .02).nnnINTERVENTIONSnImproved compliance with hand hygiene, strict patient isolation, meticulous environmental cleaning, and temporary closure of the unit to new admissions.nnnCONCLUSIONSnAcquisition of multiresistant A. baumannii was likely multifactorial, related to environmental contamination and contact with transiently colonized healthcare providers. Control measures addressing these potential sources of multiresistant A. baumannii were successful in terminating the outbreak. Ongoing surveillance and continued attention to hand hygiene and adequate environmental cleaning are essential to prevent recurrent outbreaks due to antibiotic-resistant bacteria in burn units.

The use of silver coated dressings on donor site wounds : a prospective, controlled matched pair study

Acticoat, a new silver-coated dressing, produces a moist healing environment along with the sustained release of ionic silver for improved microbial control. These properties suggest that Acticoat might be a useful donor site dressing. However, there are no human studies which assess Acticoat for this use. The purpose of this study was to compare the healing of human skin graft donor sites dressed with Acticoat, to the healing of those dressed with Allevyn, an occlusive moist-healing environment material, which is our standard donor site dressing. In burn patients who had undergone burn excision and grafting, identical side-by-side split thickness donor site wound pairs were dressed with Allevyn and Acticoat. Re-epithelialization was directly assessed daily by a single observer from post-operative day 6 onward, and by four independent observers who rated the extent of re-epithelialization by viewing standardized digital images of the wounds that had been obtained on post-operative days 6, 8, 10,and 12. Donor sites were swabbed for bacterial culture on days 3, 6, and 9. Subsequently, each study donor site scar was rated by a blinded observer using the Vancouver Scar Scale at 1, 2, and 3 months. Sixteen paired sites in 15 patients (3 female, 12 male) were studied. Donor sites dressed with Allevyn were >90% re-epithelialized at a mean of 9.1+/-1.6 days while donor sites dressed with Acticoat required a mean of 14.5+/-6.7 days to achieve >90% re-epithelialization (P=0.004). The Allevyn sites had significantly greater estimated re-epithelialization at days 6, 8, 10 and 12 than the Acticoat sites based on the observations of the digital images. There were no significant differences in the incidence of positive bacterial cultures with either dressing at days 3, 6, and 9. Donor sites dressed with Acticoat had significantly worse scars at 1 and 2 months but this difference resolved by 3 months. Our findings do not support the use of Acticoat as a skin graft donor site dressing.

Near infrared spectroscopic assessment of hemodynamic changes in the early post-burn period

Near infrared reflectance spectroscopy and imaging was used to assess non-invasively the hemodynamic changes that occur in the early post-burn period in cutaneous burn injuries of varying depth. An acute porcine model was used to demonstrate the potential of near infrared spectroscopy and imaging to accurately determine the change in tissue oxygenation, blood volume and tissue water content following a thermal injury. Near infrared spectroscopy was used to monitor tissue at discrete locations, while spectroscopic imaging was able to survey large areas of tissue. Both methods were rapid and non-invasive. Tissue hemoglobin oxygen saturation, total hemoglobin and tissue water content were all affected by thermal injury and changed significantly over a 3 h post-burn monitoring period. Burns that ranged in severity between superficial and full thickness displayed a significantly different hemodynamic response. When the early post-burn profiles (1-3 h) of tissue hemoglobin oxygen saturation, total hemoglobin and tissue water content were considered jointly, injuries leading to superficial, intermediate partial thickness, deep partial thickness and full thickness burns could all be differentiated at high statistical significance. These results suggest that non-invasive hemodynamic monitoring in the early post-burn period using near infrared spectroscopy may be of value in the early assessment of burn injury.

Evaluation of the Extent of Under-Reporting of Serious Adverse Drug Reactions The Case of Toxic Epidermal Necrolysis

AbstractIntroduction: Toxic epidermal necrolysis (TEN) is a life-threatening adverse drug reaction (ADR) that is primarily the result of drug exposure (incidence 0.4–1.3 per million person-years). Life-threatening ADRs such as TEN should be reported to ADR monitoring programmes, which collect reports for suspected ADRs and alert the public and medical practitioners to new drug hazards. In Canada, reports are made to the Canadian Adverse Drug Reaction Monitoring Program (CADRMP).n Objective: To examine the extent of under-reporting for TEN in Canada.n Design: A retrospective case series design was used to collect all TEN cases for the period January 1995 to December 2000.n Methods: The CADRMP and 22 burn centres across Canada were contacted for all TEN patients treated during the specified time period.n Patient Groups Studied: The study population consisted of patients admitted to burn treatment sites across Canada, patient cases reported to the CADRMP and patient cases recorded by the Canadian Institute for Health Information (CIHI) hospital discharge summaries as the International Classification of Diseases Version 9 Clinical Modification (ICD-9-CM) code 695.1.n Results: Twenty-five TEN cases (six fatal) were reported to CADRMP from January 1995 to December 2000. During this period, 14 (63.6%) burn treatment sites reported admission of 250 TEN cases. Hospital discharge summaries using the ICD-9-CM code 695.1 indicated that 4349 cases were admitted to hospital during this time period and it was estimated that 15.5% (n = 674) of these cases were TEN. Using the burn facility data as the denominator, 10% (25 of 250) of TEN cases were reported to CADRMP. Using CIHI data as a denominator, only 4% (25 of 674) of TEN cases were reported to CADRMP.n Conclusions: There is serious under-reporting of TEN. Lack of reporting of life-threatening ADRs can compromise population safety. There is a need to increase awareness of ADR reporting programmes.

Clinical utilization of near-infrared spectroscopy devices for burn depth assessment.

The diagnosis of burn depth is based on a visual assessment and can be subjective. Near‐infrared (NIR) spectroscopic devices were used preclinically with positive results. The purpose of this study was to test the devices in a clinical setting using easily identifiable burn wounds. Adult patients with acute superficial and full‐thickness burns were enrolled. NIR point spectroscopy and imaging devices were used to collect hemodynamic data from the burn site and an adjacent unburned control site. Oxy‐hemoglobin and deoxy‐hemoglobin concentrations were extracted from spectroscopic data and reported as oxygen saturation and total hemoglobin. Sixteen patients (n=16) were included in the study with equal numbers in both burn wound groups. Point spectroscopy data showed an increase in oxygen saturation (p<0.0095) and total hemoglobin (<0.0001) in comparison with the respective control areas for superficial burn wounds. The opposite was true for full‐thickness burns, which showed a decrease in oxygenation (p<0.0001) and total hemoglobin (p<0.0147) in comparison with control areas. NIR imaging technology provides an estimate of hemodynamic parameters and could easily distinguish superficial and full‐thickness burn wounds. These results confirm that NIR devices can successfully distinguish superficial and full‐thickness burn injuries.

Classification of burn injuries using near-infrared spectroscopy

Early surgical management of those burn injuries that will not heal spontaneously is critical. The decision to excise and graft is based on a visual assessment that is often inaccurate but yet continues to be the primary means of grading the injury. Superficial and intermediate partial-thickness injuries generally heal with appropriate wound care while deep partial- and full-thickness injuries generally require surgery. This study explores the possibility of using near-infrared spectroscopy to provide an objective and accurate means of distinguishing shallow injuries from deeper burns that require surgery. Twenty burn injuries are studied in five animals, with burns covering <1% of the total body surface area. Carefully controlled superficial, intermediate, and deep partial-thickness injuries as well as full-thickness injuries could be studied with this model. Near-infrared reflectance spectroscopy was used to evaluate these injuries 1 to 3 hours after the insult. A probabilistic model employing partial least-squares logistic regression was used to determine the degree of injury, shallow (superficial or intermediate partial) from deep (deep partial and full thickness), based on the reflectance spectrum of the wound. A leave-animal-out cross-validation strategy was used to test the predictive ability of a 2-latent variable, partial least-squares logistic regression model to distinguish deep burn injuries from shallow injuries. The model displayed reasonable ranking quality as summarized by the area under the receiver operator characteristics curve, AUC = 0.879. Fixing the threshold for the class boundaries at 0.5 probability, the model sensitivity (true positive fraction) to separate deep from shallow burns was 0.90, while model specificity (true negative fraction) was 0.83. Using an acute porcine model of thermal burn injuries, the potential of near-infrared spectroscopy to distinguish between shallow healing burns and deeper burn injuries was demonstrated. While these results should be considered as preliminary and require clinical validation, a probabilistic model capable of differentiating these classes of burns would be a significant aid to the burn specialist.

Cost of medications in patients admitted to a burn center.

AbstractBackground: Few studies have examined the cost associated with burn patients, and those which have been conducted have generally focused on overall hospitalization costs associated with these patients. No studies to date have examined the overall drug utilization and costs of medications used in the treatment of burn patients.n Objective: To describe the pattern of drug utilization and associated costs for the treatment of patients admitted to the Ross Tilley Burn Centre at Sunnybrook and Women’s College Health Sciences Centre, Toronto, Ontario, Canada.n Methods: A retrospective chart review was conducted based on the medical records of 30 adult patients (>18 years old) consecutively admitted to the burn center between 1 August 1999 and 30 September 1999. Charts were examined to determine drugs administered, doses and duration of use. Medications administered in the operating room were excluded from the analysis. Drug costs were calculated using hospital acquisition costs (1999 Canadian dollars [

Near infrared hyperspectral imaging: the road traveled to a clinical burn application

Can]) and medications were categorized by pharmacological class according to the American Hospital Formulary Service. Demographic information for the patients was extracted from the burn center’s database. The economic analysis was performed from the perspective of the hospital burn center. A descriptive statistical analysis was completed for all variables; the Pearson correlation coefficient was used to examine the relationship between certain variables. A sensitivity analysis was conducted to examine the impact of patient subgroups on certain variablesn Results: Of the 28 patients included in the analysis, 19 were admitted with acute burn injuries, two with toxic epidermal necrolysis and seven for post-burn reconstructive surgery. Patients admitted for acute burns or toxic epidermal necrolysis had the highest associated drug costs. On average, patients received 13 different drugs representing four different pharmacological categories. The mean daily drug cost per patient was

The utility of the functional independence measure (FIM) in discharge planning for burn patients

Can18.39 and the mean expenditure per admission was

Emergency department management of minor burn injuries in Ontario, Canada

Can792.97. Opioid analgesics and sedatives accounted for the largest expenditure (50.9%), followed by anti-infective agents (23.4%). For patients admitted with acute burns, there was a good correlation between daily drug costs and mortality risk (r = 0.82, p < 0.001). The findings from this study group were used to extrapolate annual expenses for medications in the burn center and these were estimated to exceed