Sidney F. Miller

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.

Identification of Cutaneous Functional Units Related to Burn Scar Contracture Development

The development of burn scar contractures is due in part to the replacement of naturally pliable skin with an inadequate quantity and quality of extensible scar tissue. Predilected skin surface areas associated with limb range of motion (ROM) have a tendency to develop burn scar contractures that prevent full joint ROM leading to deformity, impairment, and disability. Previous study has documented forearm skin movement associated with wrist extension. The purpose of this study was to expand the identification of skin movement associated with ROM to all joint surface areas that have a tendency to develop burn scar contractures. Twenty male subjects without burns had anthropometric measurements recorded and skin marks placed on their torsos and dominant extremities. Each subject performed ranges of motion of nine common burn scar contracture sites with the markers photographed at the beginning and end of motion. The area of skin movement associated with joint ROM was recorded, normalized, and quantified as a percentage of total area. On average, subjects recruited 83% of available skin from a prescribed area to complete movement across all joints of interest (range, 18–100%). Recruitment of skin during wrist flexion demonstrated the greatest amount of variability between subjects, whereas recruitment of skin during knee extension demonstrated the most consistency. No association of skin movement was found related to percent body fat or body mass index. Skin recruitment was positively correlated with joint ROM. Fields of skin associated with normal ROM were identified and subsequently labeled as cutaneous functional units. The amount of skin involved in joint movement extended far beyond the immediate proximity of the joint skin creases themselves. This information may impact the design of rehabilitation programs for patients with severe burns.

Early glycemic control in critically ill patients with burn injury.

Glucose management in patients with burn injury is often difficult because of their hypermetabolic state with associated hyperglycemia, hyperinsulinemia, and insulin resistance. Recent studies suggest that time to glycemic control is associated with improved outcomes. The authors sought to determine the influence of early glycemic control on the outcomes of critically ill patients with burn injury. A retrospective analysis was performed at the Ohio State University Medical Center. Patients hospitalized with burn injury were enrolled if they were admitted to the intensive care unit between March 1, 2006, and February 28, 2009. Early glycemic control was defined as the achievement of a mean daily blood glucose of ≤150 mg/dl for at least two consecutive days by postburn day 3. Forty-six patients made up the study cohort with 26 achieving early glycemic control and 20 who did not. The two groups were similar at baseline with regard to age, pre-existing diabetes, APACHE II score and burn size and depth. There were no differences in number of surgical interventions, infectious complications, or length of stay between patients who achieved or failed early glycemic control. Failure of early glycemic control was, however, associated with significantly higher mortality both by univariate (35.0 vs 7.7%, P = .03) and multivariate analyses (hazard ratio 6.754 [1.16–39.24], P = .03) adjusting for age, TBSA, and inhalation injury. Failure to achieve early glycemic control in patients with burn injury is associated with an increased risk of mortality. However, further prospective controlled trials are needed to establish causality of this association.

Comorbidity-polypharmacy score: A novel adjunct in post–emergency department trauma triage

OBJECTIVEnPost-emergency department triage of older trauma patients continues to be challenging, as morbidity and mortality for any given level of injury severity tend to increase with age. The comorbidity-polypharmacy score (CPS) combines the number of pre-injury medications with the number of comorbidities to estimate the severity of comorbid conditions. This retrospective study examines the relationship between CPS and triage accuracy for older (≥45y) patients admitted for traumatic injury.nnnMETHODSnPatients aged 45y and older presenting to level 1 trauma center from 2005 to 2008 were included. Basic data included patient demographics, injury severity score, morbidity and mortality, and functional outcome measures. CPS was calculated by adding total numbers of comorbid conditions and pre-injury medications. Patients were divided into three triage groups: undertriage (UT), appropriate triage (AT), and overtriage (OT). UT criteria included initial admission to the floor or step-down unit followed by an unplanned transfer to intensive care unit (ICU) within 24h of admission. OT was defined as initial ICU admission for <1d without stated need for ICU level of care (i.e., lack of evidence for tracheal intubation or mechanical ventilation, injury-related hemorrhage, or other traditional ICU indications, such as intracranial bleeding). All other patients were presumed to be correctly triaged. The three triage groups were then analyzed looking for contributors to mistriage.nnnRESULTSnCharts for 711 patients were evaluated (mean age, 63.5y; 55.7% male; mean ISS, 9.02). Of those, 11 (1.55%) met criteria for UT and 14 (1.97%) for OT. The remaining 686 patients had no evidence of mistriage. The three groups were similar in terms of injury severity and GCS. The groups were significantly different with respect to CPS, with UT CPSs (14.9±6.80) being nearly three times higher than OT CPSs (5.14±3.48). There were more similarities between AT and OT groups, with the UT group being characterized by greater number of complications and lower functional outcomes at discharge (all, P<0.05). The UT group had significantly higher mortality (27%) than the AT and OT groups (6% and 0%, respectively).nnnCONCLUSIONSnIn the era of medication reconciliation, CPS is easy to obtain and calculate in patients who are not critically injured. This study suggests that CPS may be a promising adjunct in identifying older trauma patients who are more likely to be undertriaged. The significance of our findings is especially important when considering that injury severity in the UT group was similar to that in the other groups. Further evaluation of CPS as a triage tool in acute trauma is warranted.

Admissions Across State Lines: Harnessing the Insight of the National Burn Repository for the Healthcare Accessibility, Fiscal, and Legislative Concerns Facing the American Burn Association

One of the most significant data collection efforts undertaken by the American Burn Association, the National Burn Repository (NBR) now encompasses more than 180,000 admissions. The Government Affairs Committee designated the prevalence of across-state-line burn admissions as one of its initial major inquiries to be made of the NBR. This line of inquiry could have bearings on healthcare access, legislative advocacy, and burn center solvency. The NBR Advisory Committee provided a specifically abstracted report after the 2005 call for data. Because of patient confidentiality concerns the file only contained admission frequencies by state-of-injury:state-of-care pairs. Nevertheless we were able to produce suggestive summary statistics and national maps for interpretations. This abstracted data encompasses records between 1995 and 2005, during which 8157 cross-state border admissions occurred, 6714 of which were to non-Shriner’s hospitals. The rate of border crossing ranged from 0 to 202 patients annually. The highest rates were from the northernmost western states, northernmost New England states, and several southern states. Utah, West coast, and Great Lakes states sent relatively few admissions to other states. Twenty-seven states received no out-of-state admissions whereas several states had very high hosting rates. Although mapping cross-state burn admissions is an elementary exercise it demonstrated the value of the NBR for the Committees on Organization and Delivery, Government Affairs, and other facets of the American Burn Association. Anticipated access to ZIP Code data will permit: 1) granular identification of underserved areas, 2) documentation and prediction of reimbursement challenges, 3) mapping of de facto burn center referral markets, 4) mass disaster capacity planning, and 5) community-level burn risk factor analyses.

Presidential Address: Looking Back in Order to Look Ahead

I would like to personally welcome all of you to the opening session of the 43rd annual meeting of the American Burn Association (ABA). This has been an exciting year of challenges, opportunities, and advancements. During the past year we have • rewritten our Association’s by-laws, • established the opportunity for long-term funding of our Department of Defense/ABA research by adding a line item to the Defense Appropriations budget for burn research, • reached out to the American College of Surgeons Committee on Trauma (COT) with the establishment within the COT of a burn section, • reopened meaningful discussions with Homeland Security on the needs of burn disaster planning and our joint concerns for true disaster planning, and • expanded outreach partnerships through the International Relations Committee with a first effort of working with Operation Smile to add burn resources and Advanced Burn Life Support courses to their overseas trips. Last fall I had the opportunity to visit the five regional burn meetings—the Eastern Great Lakes Regional Burn Meeting in Cincinnati, the Western Regional Burn Meeting in San Francisco, the Midwest Regional Burn Meeting in Madison, the Northeast Regional Meeting in Providence, and the Southern Regional Burn Conference in Memphis. Each has its own unique flavor and approach to providing an opportunity for scientific discussion and collegial networking. All allowed time for intellectual and social interaction which only a small meeting can accomplish. Most of these meetings lasted a day and a half to two days, and many were within driving distance of the represented burn centers. Eight hundred sixty-one individuals attended these sessions (Figure 1). Forty-two percent were nurses, 19% were physicians, and 39% were other members of the burn team (Figure 2). For many people, this was their first opportunity to present before an audience outside their own institution. For others, it was their first time to attend a burn meeting. For some, it was an opportunity to present a paper in anticipation of having it accepted at the annual meeting of the ABA. I’m sure that the input of the attendees at the regional meetings was quite valuable to the authors. All sessions allowed ample opportunity for discussion of the papers presented. The regional meetings held closer to home and for a shorter period of time than the annual meeting of the ABA allow for more members of the burn teams to attend a burn-specific continuing education conference and time to network with other burn centers. These regional meetings have taken on more importance during these hard financial times and have the full support of the Board of Trustees and the Central Office. Although they will never replace the annual meeting of the ABA for breadth and depth of offerings, in these days of tight budget restraints, regional meetings offer an opportunity to many who cannot or would not be able to afford 4 or 5 days off work with the accompanying travel and lodging expenses. I would strongly encourage those of you who do not live in areas serviced by these five regional meetings to consider either joining one of them or starting your own. The ABA staff and Board of Trustees support these regional meetings and stand ready to help in any way possible in expanding this educational opportunity to more of our membership. One of the themes I have touched on at the regional meetings is the obligation of membership. A first step is the recognition of those new members and first-time attendees of this ABA annual meeting. For this opening session, the first several rows of the auditorium are reserved for members of the Board of From the Department of Surgery, Ohio State University Medical Center, Columbus. Presented at the 43rd Annual Meeting of the American Burn Association, Chicago, Illinois, March 30, 2011. Address correspondence to Sidney F. Miller, MD, FACS, Burn Center Director, Ohio State University Medical Center, Department of Surgery, 410 W 10th Ave., Columbus, OH 43210-1228. Copyright

Impact of Early Methadone Initiation in Critically Injured Burn Patients: A Pilot Study

Numerous studies have identified strategies to reduce mechanical ventilation duration by targeting appropriate sedation levels. However, applicability of these strategies to critically injured patients with burn injury has not been established. At our medical center, methadone is commonly used early in the care of burn patients to treat background pain and limit the development of opioid tolerance. The aim of this study is to evaluate the effect of early methadone initiation in critically injured burn patients requiring mechanical ventilation. This retrospective study compared patients who received early methadone with patients who did not while mechanically ventilated with the primary outcome of ventilator-free days in a 28-day period. Those who received methadone within 4 days of intubation and remained ventilated for 2 days after the first dose were included in the methadone group. Propensity scores were used to match up to three control patients to each methadone patient. Seventy patients (18 methadone and 52 matched control patients) were included in the final evaluation. Patients in the methadone group averaged 16.5 ventilator-free days compared with 11.5 in the control group (P = .03). There was no statistical difference in the duration of intensive care unit or hospital length of stay between groups. Our results suggest that early methadone initiation may have a significant effect on ventilator outcomes in critically injured patients with burn injury. However, further research is warranted.