BackgroundBurns are time-sensitive injuries associated with significant morbidity and mortality. Delays in treatment can lead to prolonged hospital stays, unnecessary transfers, increased mortality, and added costs. In 2019, an effort to improve statewide burn care led by the Louisiana burn centers' medical directors collaborating with emergency physicians and the Louisiana Emergency Response Network (LERN), established statewide out-of-hospital care guidelines as well as routing guidelines based on criteria from the American Burn Association Burn (ABA). Burn-injured patient transfers were tracked in the subsequent years to assess the effectiveness of burn injury routing algorithms.Study ObjectivesTo determine the statewide impact of the new LERN routing algorithm on the transfer rates of burn patients and quantify potentially associated cost savings.Study MethodsOur study is a statewide review of central coordination center records for burn-injured patients between 01/2021 and 12/2021. Secondary transfers were defined as patients who required transfer from one hospital to another with burn capabilities. A chi-squared statistical analysis was performed. The associated transfer costs were also analyzed using available estimates for ground and air ambulances and length of stay data was queried from a statewide administrative database for years before and after routing.ResultsLERN directed 207 burn patients to facilities for further treatment during the study period, with 177 of the 207 going through the LERN call center in the out-of-hospital setting. Of those 177, only 5% of secondary transfers occurred when LERN's routing recommendation was followed, versus a 35% transfer rate when the ambulance or patient did not follow LERN's direction (p<.001). The estimated cost of a ground ambulance transfer in Louisiana includes a base fee of $2,700 with a transportation fee of $33/mile. Additionally, most burn injuries occur within 98 miles of a burn center in Louisiana. In 2020, the average base cost of a rotary- wing air ambulance was $30,446 thus savings ranged from $5,934-$30,446/patient. The median length of stay decreased 11.8 to 8.8 days when comparing all pre-routing and post-routing burn admissions in Louisiana.ConclusionToday, only 2% of hospitals have a burn center which creates a challenge for emergency medicine and out-of-hospital providers. LERN-facilitated routing using the ABA criteria resulted in decreased secondary transfers and savings from both a transfer and admitted length of stay perspective. Decreasing the need for secondary transfers reduces delays in burn care, thus enabling burn-injured patients to receive specialized urgent care while also reducing unnecessary secondary EMS transfers and ED visits. Our study is the first to demonstrate the impact of a statewide initiative to improve burn outcomes through out-of-hospital routing. Additional research should incorporate ABA Burn Care Quality Program (BCQP) outcomes data to better distinguish patterns and potential opportunities for improvement.No, authors do not have interests to disclose BackgroundBurns are time-sensitive injuries associated with significant morbidity and mortality. Delays in treatment can lead to prolonged hospital stays, unnecessary transfers, increased mortality, and added costs. In 2019, an effort to improve statewide burn care led by the Louisiana burn centers' medical directors collaborating with emergency physicians and the Louisiana Emergency Response Network (LERN), established statewide out-of-hospital care guidelines as well as routing guidelines based on criteria from the American Burn Association Burn (ABA). Burn-injured patient transfers were tracked in the subsequent years to assess the effectiveness of burn injury routing algorithms. Burns are time-sensitive injuries associated with significant morbidity and mortality. Delays in treatment can lead to prolonged hospital stays, unnecessary transfers, increased mortality, and added costs. In 2019, an effort to improve statewide burn care led by the Louisiana burn centers' medical directors collaborating with emergency physicians and the Louisiana Emergency Response Network (LERN), established statewide out-of-hospital care guidelines as well as routing guidelines based on criteria from the American Burn Association Burn (ABA). Burn-injured patient transfers were tracked in the subsequent years to assess the effectiveness of burn injury routing algorithms. Study ObjectivesTo determine the statewide impact of the new LERN routing algorithm on the transfer rates of burn patients and quantify potentially associated cost savings. To determine the statewide impact of the new LERN routing algorithm on the transfer rates of burn patients and quantify potentially associated cost savings. Study MethodsOur study is a statewide review of central coordination center records for burn-injured patients between 01/2021 and 12/2021. Secondary transfers were defined as patients who required transfer from one hospital to another with burn capabilities. A chi-squared statistical analysis was performed. The associated transfer costs were also analyzed using available estimates for ground and air ambulances and length of stay data was queried from a statewide administrative database for years before and after routing. Our study is a statewide review of central coordination center records for burn-injured patients between 01/2021 and 12/2021. Secondary transfers were defined as patients who required transfer from one hospital to another with burn capabilities. A chi-squared statistical analysis was performed. The associated transfer costs were also analyzed using available estimates for ground and air ambulances and length of stay data was queried from a statewide administrative database for years before and after routing. ResultsLERN directed 207 burn patients to facilities for further treatment during the study period, with 177 of the 207 going through the LERN call center in the out-of-hospital setting. Of those 177, only 5% of secondary transfers occurred when LERN's routing recommendation was followed, versus a 35% transfer rate when the ambulance or patient did not follow LERN's direction (p<.001). The estimated cost of a ground ambulance transfer in Louisiana includes a base fee of $2,700 with a transportation fee of $33/mile. Additionally, most burn injuries occur within 98 miles of a burn center in Louisiana. In 2020, the average base cost of a rotary- wing air ambulance was $30,446 thus savings ranged from $5,934-$30,446/patient. The median length of stay decreased 11.8 to 8.8 days when comparing all pre-routing and post-routing burn admissions in Louisiana. LERN directed 207 burn patients to facilities for further treatment during the study period, with 177 of the 207 going through the LERN call center in the out-of-hospital setting. Of those 177, only 5% of secondary transfers occurred when LERN's routing recommendation was followed, versus a 35% transfer rate when the ambulance or patient did not follow LERN's direction (p<.001). The estimated cost of a ground ambulance transfer in Louisiana includes a base fee of $2,700 with a transportation fee of $33/mile. Additionally, most burn injuries occur within 98 miles of a burn center in Louisiana. In 2020, the average base cost of a rotary- wing air ambulance was $30,446 thus savings ranged from $5,934-$30,446/patient. The median length of stay decreased 11.8 to 8.8 days when comparing all pre-routing and post-routing burn admissions in Louisiana. ConclusionToday, only 2% of hospitals have a burn center which creates a challenge for emergency medicine and out-of-hospital providers. LERN-facilitated routing using the ABA criteria resulted in decreased secondary transfers and savings from both a transfer and admitted length of stay perspective. Decreasing the need for secondary transfers reduces delays in burn care, thus enabling burn-injured patients to receive specialized urgent care while also reducing unnecessary secondary EMS transfers and ED visits. Our study is the first to demonstrate the impact of a statewide initiative to improve burn outcomes through out-of-hospital routing. Additional research should incorporate ABA Burn Care Quality Program (BCQP) outcomes data to better distinguish patterns and potential opportunities for improvement.No, authors do not have interests to disclose Today, only 2% of hospitals have a burn center which creates a challenge for emergency medicine and out-of-hospital providers. LERN-facilitated routing using the ABA criteria resulted in decreased secondary transfers and savings from both a transfer and admitted length of stay perspective. Decreasing the need for secondary transfers reduces delays in burn care, thus enabling burn-injured patients to receive specialized urgent care while also reducing unnecessary secondary EMS transfers and ED visits. Our study is the first to demonstrate the impact of a statewide initiative to improve burn outcomes through out-of-hospital routing. Additional research should incorporate ABA Burn Care Quality Program (BCQP) outcomes data to better distinguish patterns and potential opportunities for improvement.

BackgroundOver 1 million burn injuries occur each year in the U.S. seeking evaluation in emergent or urgent care settings. A major component of the initial evaluation includes burn wound assessment (BWA). Unfortunately, historical studies have demonstrated that providers incorrectly assess the depth of burn wounds (BW) in 25- 30% of injuries, in part because BW evaluation has no adjunctive labs or imaging tools to aid in the determination of healing versus non-healing BW.Study ObjectivesThe goal of our investigation was to study a diverse group of emergency medicine (EM) providers' assessments of BW to better discern baseline accuracy and practice patterns.MethodsIRB-approved, prospective study designed to collect data from emergency department providers. Using a tablet- based data entry device, EM participants enrolling in the study completed a brief questionnaire followed by a series of five scenarios of thermal BW each with images from ABA-verified burn centers. 21-day follow-up photos of the BW were used to determine healing and non-healing regions by a consensus panel of fellowship-trained burn surgeons. EM participants were asked to mark the non-healing portions of the wound using a stylus. Results from the EM participants were compared to the 21-day healed/non-healed consensus panel to determine accuracy on a pixel-for-pixel basis. Statistical analysis of the non-healing portions of the wounds was performed by Chi square. Non-healing BW were defined as thermal burns of severity 3rd degree and deep 2nd degree. Healing burn were defined as thermal burns of severity 1st degree and superficial 2nd degree. Sensitivity was the percentage of "non-healing burn" areas that were marked. Specificity was the percentage of the "healing burn + uninjured skin" areas that were not marked. Accuracy was the percentage of area in a participant's image correctly marked by the participant.Results77 participants enrolled in the study. 5 participants did not complete BWA drawings and were excluded. 360 images were reviewed in total for healing/non-healing BW. In the final cohort, 80% of the participants identified as emergency physicians in-practice (20% residents) with a median of 4 years in practice primarily at facilities not adjoined to a burn center (73%). For non-healing wounds, EM participants selected no surgery needed or local wound care only in 82% of the images. For healing wounds, participants correctly identified the wound as needing local wound care only in 34% of the images. Pixel-based mapping demonstrated a mean accuracy of 74%, sensitivity of 38%, and specificity of 77%.ConclusionsThis is the largest study to date examining emergency medicine providers ability to assess BW. This is important because in the event of a disaster, large numbers of burn casualties could overwhelm an already strained health care system and EM providers would be called upon to perform large volumes of BWA. Improvements in determining BW healing are essential to aid emergency department providers in the appropriate treatment of burn-injured patients.FundingFunding and technical support is provided by the Biomedical Advanced Research and Development Authority (BARDA), under the Assistant Secretary for Preparedness and Response (ASPR), within the U.S. Department of Health and Human Services (HHS), under ongoing USG Contract No. 75A50119C00033.Yes, authors have interests to discloseDisclosureAvita Medica, PolyNovo, Spectral MD, Access Pro Medical- in lieu of compensation all proceeds are donated to charities supporting burn outreach, education, survivor programs, and research.Consultant/AdvisorAvita Medica, PolyNovo, Spectral MD, Access Pro Medical- in lieu of compensation all proceeds are donated to charities supporting burn outreach, education, survivor programs, and research.DisclosureServes as the medical monitor for the Spectral MD DeepView Training StudyConsultant/AdvisorServes as the medical monitor for the Spectral MD DeepView Training Study DisclosureSpectral MD IncEmployee Spectral MD Inc BackgroundOver 1 million burn injuries occur each year in the U.S. seeking evaluation in emergent or urgent care settings. A major component of the initial evaluation includes burn wound assessment (BWA). Unfortunately, historical studies have demonstrated that providers incorrectly assess the depth of burn wounds (BW) in 25- 30% of injuries, in part because BW evaluation has no adjunctive labs or imaging tools to aid in the determination of healing versus non-healing BW. Over 1 million burn injuries occur each year in the U.S. seeking evaluation in emergent or urgent care settings. A major component of the initial evaluation includes burn wound assessment (BWA). Unfortunately, historical studies have demonstrated that providers incorrectly assess the depth of burn wounds (BW) in 25- 30% of injuries, in part because BW evaluation has no adjunctive labs or imaging tools to aid in the determination of healing versus non-healing BW. Study ObjectivesThe goal of our investigation was to study a diverse group of emergency medicine (EM) providers' assessments of BW to better discern baseline accuracy and practice patterns. The goal of our investigation was to study a diverse group of emergency medicine (EM) providers' assessments of BW to better discern baseline accuracy and practice patterns. MethodsIRB-approved, prospective study designed to collect data from emergency department providers. Using a tablet- based data entry device, EM participants enrolling in the study completed a brief questionnaire followed by a series of five scenarios of thermal BW each with images from ABA-verified burn centers. 21-day follow-up photos of the BW were used to determine healing and non-healing regions by a consensus panel of fellowship-trained burn surgeons. EM participants were asked to mark the non-healing portions of the wound using a stylus. Results from the EM participants were compared to the 21-day healed/non-healed consensus panel to determine accuracy on a pixel-for-pixel basis. Statistical analysis of the non-healing portions of the wounds was performed by Chi square. Non-healing BW were defined as thermal burns of severity 3rd degree and deep 2nd degree. Healing burn were defined as thermal burns of severity 1st degree and superficial 2nd degree. Sensitivity was the percentage of "non-healing burn" areas that were marked. Specificity was the percentage of the "healing burn + uninjured skin" areas that were not marked. Accuracy was the percentage of area in a participant's image correctly marked by the participant. IRB-approved, prospective study designed to collect data from emergency department providers. Using a tablet- based data entry device, EM participants enrolling in the study completed a brief questionnaire followed by a series of five scenarios of thermal BW each with images from ABA-verified burn centers. 21-day follow-up photos of the BW were used to determine healing and non-healing regions by a consensus panel of fellowship-trained burn surgeons. EM participants were asked to mark the non-healing portions of the wound using a stylus. Results from the EM participants were compared to the 21-day healed/non-healed consensus panel to determine accuracy on a pixel-for-pixel basis. Statistical analysis of the non-healing portions of the wounds was performed by Chi square. Non-healing BW were defined as thermal burns of severity 3rd degree and deep 2nd degree. Healing burn were defined as thermal burns of severity 1st degree and superficial 2nd degree. Sensitivity was the percentage of "non-healing burn" areas that were marked. Specificity was the percentage of the "healing burn + uninjured skin" areas that were not marked. Accuracy was the percentage of area in a participant's image correctly marked by the participant. Results77 participants enrolled in the study. 5 participants did not complete BWA drawings and were excluded. 360 images were reviewed in total for healing/non-healing BW. In the final cohort, 80% of the participants identified as emergency physicians in-practice (20% residents) with a median of 4 years in practice primarily at facilities not adjoined to a burn center (73%). For non-healing wounds, EM participants selected no surgery needed or local wound care only in 82% of the images. For healing wounds, participants correctly identified the wound as needing local wound care only in 34% of the images. Pixel-based mapping demonstrated a mean accuracy of 74%, sensitivity of 38%, and specificity of 77%. 77 participants enrolled in the study. 5 participants did not complete BWA drawings and were excluded. 360 images were reviewed in total for healing/non-healing BW. In the final cohort, 80% of the participants identified as emergency physicians in-practice (20% residents) with a median of 4 years in practice primarily at facilities not adjoined to a burn center (73%). For non-healing wounds, EM participants selected no surgery needed or local wound care only in 82% of the images. For healing wounds, participants correctly identified the wound as needing local wound care only in 34% of the images. Pixel-based mapping demonstrated a mean accuracy of 74%, sensitivity of 38%, and specificity of 77%. ConclusionsThis is the largest study to date examining emergency medicine providers ability to assess BW. This is important because in the event of a disaster, large numbers of burn casualties could overwhelm an already strained health care system and EM providers would be called upon to perform large volumes of BWA. Improvements in determining BW healing are essential to aid emergency department providers in the appropriate treatment of burn-injured patients. This is the largest study to date examining emergency medicine providers ability to assess BW. This is important because in the event of a disaster, large numbers of burn casualties could overwhelm an already strained health care system and EM providers would be called upon to perform large volumes of BWA. Improvements in determining BW healing are essential to aid emergency department providers in the appropriate treatment of burn-injured patients.

Journal Article 502 Treatment of Erythromelalgia and Frostbite: A Case Report Get access J Carter, MD, J Carter, MD Louisiana State University, New Orleans, LA; University Medical Center, New Orleans, LA Search for other works by this author on: Oxford Academic Google Scholar D Miller, RN, D Miller, RN Louisiana State University, New Orleans, LA; University Medical Center, New Orleans, LA Search for other works by this author on: Oxford Academic Google Scholar K Paulk, MD, K Paulk, MD Louisiana State University, New Orleans, LA; University Medical Center, New Orleans, LA Search for other works by this author on: Oxford Academic Google Scholar E Grieshaber, MD, E Grieshaber, MD Louisiana State University, New Orleans, LA; University Medical Center, New Orleans, LA Search for other works by this author on: Oxford Academic Google Scholar F Lau, MD F Lau, MD Louisiana State University, New Orleans, LA; University Medical Center, New Orleans, LA Search for other works by this author on: Oxford Academic Google Scholar Journal of Burn Care & Research, Volume 40, Issue Supplement_1, April 2019, Page S227, https://doi.org/10.1093/jbcr/irz013.394 Published: 08 March 2019

Proper treatment of hand burns is critical, as the function and aesthetic appearance play an important role in the patient’s ability to work and return to normal life. Hand burns are often treated with non-meshed autografts to achieve the best results possible. However, in larger TBSA injuries, there are limitations with availability of donor skin, and often wide mesh grafting is required to achieve definitive closure. In a recent pivotal randomized controlled trial (RCT), it was demonstrated that autologous skin cell suspension (ASCS) in combination with widely meshed split-thickness skin graft (STSG) achieved comparable healing and long-term outcomes to a less widely meshed STSG, however this study excluded the evaluation of hands and the safety and effectiveness has not been established. Through continued access of the pivotal RCT as well as through compassionate use of ASCS, hand burns were treated with ASCS across 5 US Burn Centers. The purpose of this study is to present the clinical results obtained using this treatment strategy. Patients were included in the study as part of IDE 13053 and IDE 15945 and had mixed-depth or full-thickness burns to the hands treated with ASCS in combination with meshed STSG. Adult and pediatric patients were included in the series and consented for education and research photographs in compliance with institutional standard of care and protocol requirements. Outcomes analysis included percent re-epithelialization, subjective cosmetic parameters, and adverse events including surgical intervention for graft failure or contracture release. Thirty patients were treated for hand burn injuries, totaling 50 hands treated. The average age was 36.7±21.0 and average TBSA was 47.8±23.7%. The majority of hands were treated with ASCS+3:1 meshed graft (60%). For evaluable wounds, 7 days following treatment, 51% (19/37) had ≥95% re-epithelialization and at 4 weeks 86% (38/44) had ≥95% re-epithelialization. At one year, the majority of all evaluable hands were matched or mildly matched in color (23/29), pigment (21/29) and texture (15/29) when compared to uninjured surrounding skin. Surgical intervention was required for regrafting (14%) and contracture release (16%) of hands treated. Non-cultured, ASCS can be used in the treatment of mixed depth hand burns to achieve definitive closure of hand burns. ASCS is a novel autograft-sparing technology that should be considered for use as part of a surgeon’s treatment algorithm for treating highly visible and functional areas.

Healthcare facility design to improve patient experience, safety, and quality faces many challenges when caring for those with burn injuries, from increased temperature and infectious considerations to unique rooms that accommodate procedures and therapies specific to burn care. New burn center (BC) design is rare due to the paucity of new BC undergo construction or renovation. Our study shares the results of a multi-specialty that designed and built a new comprehensive BC and the patient experience survey results. The healthcare system in collaboration with the state’s largest academic healthcare partner and the department of health performed a regional needs assessment to determine the need of a BC. A user-led work group included a healthcare architectural firm, hospital-based architect, nurses, physicians, therapists, engineers, infection control experts, and a burn survivor. The American Burn Association’s (ABA) verification requirements were incorporated into the design of a comprehensive BC which would house outpatient and inpatient care components. The work group met every week for 9 months and was led by a burn surgeon. A 27,000 ft2 BC was constructed which included: computer-controlled ventilation system with variable air ventilation heat exchangers to maintain humidity and temperature up to 95 degrees, 20 private inpatient rooms at 290 ft2 that were ICU-capable, handicap-accessible with walk-in showers, positive/negative ventilation, patient lift system, original artwork, natural light, 705 ft2 hydrotherapy room with general anesthesia capability, 290 ft2 balcony, family room/multipurpose room with kitchenette, and a 4,060 ft2 comprehensive acute rehabilitation gym with occupational, speech, and physical therapy services. Disaster/outpatient multidisciplinary clinic was designed adjacent to the inpatient unit along with teleconference room, classroom room, office space, and storage space. Sound dampening was facilitated through room/hall design. Infectious considerations were addressed in a multitude of ways including patient flow, paint, counter/surface materials, and ventilation design. Initial patient surveys demonstrated 100% overall patient satisfaction from anonymous surveys performed by the National Research Corporation of discharged patients. Patients additionally rated their satisfaction with cleanliness and quietness as 100%. Comprehensive BC are uncommon jewels in hospitals with only 130 of over 5,900 hospitals featuring a dedicated BC. Our results demonstrate that BC design can lead to valuable patient experiences. Our research in BC design for the patient experience may serve to help other BC undergoing renovation or construction.

Burn care and medical education has undergone dramatic change with clinical innovations, medical simulation, and curriculum design. Trauma has over 7 courses while burns has one, Advanced Burn Life Support. Our goal was to develop a course with an evidenced-based curriculum and novel simulators to meet the needs of healthcare professionals that require more advanced training. Following IRB approval, a 360-degree REDCap™ survey was distributed using a 5-point Likert scale with free text to: physicians, nurses, therapists, administrators, and survivors. A 360-survey was selected due to the multi-disciplinary aspect of burn injury management and the recognized expertise of non-physicians. The survey assessed participants’ perceived proficiency of providers managing adult and pediatric patients and was evaluated by a multi-institutional panel of recognized professionals in medical education and burn care. Procedure simulators were developed following the survey and subsequently validated and published. Course design incorporated adult learning theory with discussion-based sessions separated by hands-on skills labs. An after-course survey of participants was distributed with a 5-point Likert scale and free text. A total of 109 individuals participated with a 58% response rate and a diverse response pool: 34.5% physicians/advanced practice providers (APP), 33% nurses, 23% burn therapists, and 10% burn survivors, administrators, or social workers. Survey results by burn physicians/APP demonstrated the lowest self-rated proficiency scores at managing large pediatric burn injuries and frostbite while non-physicians reported developing wound treatment algorithms, performing an escharotomy, and aftercare/reintegration. The first course had 18 participants and incorporated a biomimetic escharotomy simulator. The after-course survey of participants noted a 100% agreed the course improved their understanding of managing burn injuries, improved their ability to troubleshoot, improved confidence to manage a patient up to 96 hours, and would recommend the course to a peer. 0% of the participants identified excessive industry bias. Providing burn care beyond the initial assessment and stabilization requires additional skills and knowledge. Providers that are challenged to provide this care may benefit from additional training. Further work is being invested to develop disaster management skills, assessment components, and determine course validity. This research may serve to broadly impact burn education and on-boarding of providers.

Current treatment for burn injuries is the use of split-thickness skin grafts (STSG), however this treatment is often limited by donor site availability and requires reharvesting of donor sites to obtain definitive closure. In uncompromised patients it can take 7-14 days to heal, and for patients with severe injuries, this time can be delayed. The RECELL® System is a point-of-care device that allows for the preparation and application of non-cultured, autologous skin cells; however the safety and effectiveness has not been established for use in the treatment of donor sites. This study presents the use of autologous skin cell suspension (ASCS), prepared using the RECELL® System for the treatment of donor sites in patients enrolled in a prospective uncontrolled observational study (IDE 15945—NCT02992249) with life-threatening burn injuries. Following harvesting of STSGs, ASCS was applied to the donor site. Clinical outcomes were evaluated up to one year including percentage of re-epithelialization, long-term cosmetic outcomes, and adverse events. Seventy-three patients from 15 burn centers had their donor sites treated with ASCS as part of their treatment regimen. The average subject age was 29 and the average TBSA injury was 54.1 ±16.5%. The mean Baux score was 84.3 with 32% of subjects having a score greater than 100. Collectively, 430 donor sites were individually treated. In this compromised patient population 45.5% were ≥95% re-epithelialized by week 1 (n=345), and by week 2, 91% of the donor sites were ≥95% re-epithelialized (n=277), regardless of times harvested. Approximately 20% of the donor sites treated with ACSC were reharvested multiple times following initial healing (3.5% three times, and two donor sites were harvested four times) and retreated. Of donor sites harvested more than once, 51.6% (n=62), 84.6% (n=66), and 96.4% (n=55) of sites were ≥ 95% re-epithelialized by week 1, 2 and 4, respectively. One-year data was available for 300 donor sites and the majority had matched or mildly mismatched color, pigment, and texture. Adverse events included one site with a hematoma and one patient with donor sites that had fragile skin loss secondary to traumatic friction. There were no other instances of infection or delayed healing. ASCS has been successfully used to achieve closure of donor site wounds without infection or delayed healing in patients with extensive burn injuries. Application of ASCS for donor site healing may be particularly applicable for patients requiring subsequent reharvesting to achieve definitive closure.

The Burn Referral Criteria of the American Burn Association were developed by consensus over 20 years ago to guide referring institutions in triage of burn patients and improve patient care. In the existing version, “referral” was not strictly defined, and has often been interpreted as “transfer.” Coupled with frequent errors in estimation of burn size and depth by non-burn centers, interpretation of the criteria as prescriptive has produced challenges in patient triage. Recognizing digital communication proliferation and the cost to patients and institutions of both under and over triage, we reasoned that the current criteria needed to be revisited. In the absence of compelling clinical trial data dictating burn triage, we convened a panel of experts in an iterative eDelphi consensus process to facilitate revision of the criteria. After IRB exemption, a panel of (n=61) burn experts including burn surgeons, intensivists, nurses, internists, advanced practice providers, emergency physicians and therapists from all ABA regions were invited to participate. Each participant received a 121 question survey. Consensus for any statement on the survey was defined as a % agreement of >70% among experts. Survey completion data were recorded anonymously in RedCap, and statistically analyzed using Stata IC v.15. After the initial survey, a second survey was distributed with those items not achieving the consensus (n=26) in round 1. Finally, a small and focused subgroup of the panel was enlisted to address the 16 statements that failed to achieve consensus in round 2. The eDelphi Round 1 response rate was 90% and Round 2 was 100%. All of the new guideline recommendations reflect >70% agreement. Broadly, consensus is that the next iteration should be a guideline for referrals, consultations and transfers. Statements address triage of patients with various injury types (depth, size of burn, inhalation injury), recommendations for children and the elderly, and triage of non-burn diagnoses such as toxic epidermal necrolysis. Expert consensus also recommends expanding the role of telemedicine in the referral, consultation, and transfer process. This process led to a robust, methodologically sound guideline for consultation and transfer of burn patients to burn centers. Expert consensus recommends burn center involvement in triage/ care decisions for most burn patients, with recognition that telemedicine greatly extends the reach and availability of burn center expertise. These overarching themes are present in the upcoming revision of the ABA Burn Center Referral Criteria. This study directly addresses guidelines for burn care consultation and referral.

Lack of available donor skin in patients with extensive burn injuries is often the central problem impeding operations for permanent closure. A recent pivotal randomized controlled trial (RCT) demonstrated the use of autologous skin cell suspension (ASCS) prepared using an ASCS device in the treatment of acute thermal full-thickness burn wounds (TBSA ≤50%) achieved comparable healing outcomes to conventional skin grafting, using significantly less donor skin (32% reduction). In the US, the safety and effectiveness of ASCS in acute thermal burn injuries in patients with >50% TBSA has not been established. The purpose of this study is to present preliminary data on the outcomes for adult patients with life threatening, >50% TBSA, burn injuries treated with the combination of meshed STSGs and ASCS. A prospective uncontrolled observational study was conducted under an Investigational Device Exemption (IDE 15945—NCT029992249) to evaluate healing outcomes and adverse events (AEs) following ASCS treatment in an adult population with life threatening burn injuries (compassionate use). Patients with a minimum of 8-week follow-up were included in the analyses. Twenty-two patients ≥18 years with >50% TBSA from 9 centers were treated with ASCS in combination with meshed STSG, totaling 150 wounds. Mean TBSA was 61.2% (range 52%-91%) and mean Baux score was 103.1±19.3. Thirty-five percent of wounds were treated with widely meshed autografts (4:1 or greater) and ASCS, and 53% of wounds were treated with a dermal substitute prior to meshed epidermal autograft and ASCS.At 8 weeks, 96% of wounds achieved healing (≥95% re-epithelialization) compared to 87.2% of wounds in the pivotal RCT (wherein healing was defined as 100% re-epithelialization confirmed at consecutive visits). Surgical intervention was required for graft failure in 8% (12/150) of wounds and for contracture release in 3.3% (5/150). No AEs were reported as related to the ASCS treatment.Subjective assessment of wound appearance by the physician at 1 year was available for 21 patients and color, pigment, and texture was reported as matched or mildly mismatched to uninjured skin for the majority of wounds, 83%, 78%, and 70%, respectively. ASCS and meshed STSGs achieves definitive closure for patients with extensive burn injuries, with preliminary results suggesting comparable outcomes to subjects with less severe injuries. ASCS is a novel autograft-sparing technology allowing immediate point-of-care treatment and should be considered for use as part of a surgeon’s algorithm for acute thermal burn injuries.

Early recognition of the need for escharotomy and other decompressive therapies is imperative for experienced burn providers. With deep burns, the eschar that develops is largely non-compliant resulting in burn-induced compartment syndrome. Due to burn care becoming less common in traditional surgical training the number of providers experienced in performing escharotomy or decompressive therapies is falling. An updated review of the available literature to guide assessment, management, and education of decompressive therapy is needed to guide care. Our goal was to conduct a systematic review of the literature for managing compartment syndrome in burn injuries. Studies investigating burn injury, decompression, escharotomy, and compartment syndrome were critically appraised and qualified from 2006–2016. Indications for escharotomy, technique for decompression, education methods, and complications were reviewed. Data from qualifying studies was classified according to the Oxford Centre for Evidence-based Medicine. A summary of the data was then used to develop new guidelines with grades of recommendation. After excluding case presentations, 14 manuscripts were identified and included in the review. The literatures had grown to include the prehospital setting, non-surgical methods of decompression, and biomimetic simulators for education. Indications and complications were largely unchanged. Data class varied from 2c to 5. Grade recommendations varied from B to C. Decompressive therapy for burn injuries remains an area of care that demands urgent attention and treatment. New techniques incorporating simulation may serve as a valuable method for educating and assessing providers. Enzymatic debridement may serve as a viable option for decompression. Additional research in early assessment and long term outcomes remains a challenge. Informing burn care providers of escharotomy assessment and techniques is essential for developing clear guidelines of care.

Proper assessment and management of a burn patients with >20% TBSA is a skill that must be completed appropriately by the entire multidisciplinary team to ensure the patient receives proper fluid resuscitation, necessary wound care and adequate monitoring and follow-up once admitted to the Burn Unit. This process is multi-faceted and can be overwhelming. Simulation training is a proven way to improve knowledge and skills with a high level of retention amongst participants. Multidisciplinary burn care simulation was successfully implemented and has shown to be a valid educational modality to improve patient care through team-based, contextually relevant, experimental learning exercises based upon endemic data followed by constructive debriefing. Live simulation exercises were executed to ensure all Burn Unit staff were able to participate. The simulation running time was a total of 55–60 minutes per simulation. This included a 5-min pre-brief, a 15–20 min simulation, a 30-min debrief and a 5-min post-simulation survey. The number of group members varied from 3–4, with a minimum of 2 staff nurses and 1 MD or PA-C per group. Each group also had an MD or PA-C, a charge nurse, and other staff nurses that were observing that provided feedback to the group as part of the debriefing. Post simulation surveys showed improved confidence and an anticipated improvement in providing the appropriate care to a burn patient. Our data suggests that the most improvement in all areas is seen in nurses with <3 years of experience in burn care. Our results are similar to other research exploring the use of simulation in improving patient outcomes and the reduction of errors in medical and non-medical disciplines. Experiential exercises are effective at providing a learning environment for all disciplines of the burn team. The simulations allowed for the performance of normal and expected job functions, identification of critical patient care concerns and the appropriate response in a realistic environment. Further research is needed to investigate long term outcomes from this style of burn unit education. Simulation exercises can be an inexpensive/effective way to provide education to a multidisciplinary team, with higher levels of knowledge retention than other educational modalities. A competent and comfortable staff inherently leads to improved patient outcomes.

Accuracy of burn depth assessment depends on expertise and can be as low as 64%, even for skilled practitioners. Imaging devices to classify burn depth, including laser Doppler imaging, multispectral imaging (MSI), and thermography, have been studied to address this issue. The objective of this study was to determine if a MSI device, previously developed in an animal burn model, could translate to clinical burns. We present current results of this ongoing proof-of-concept (POC) clinical study, including study design and initial burn detection accuracy. In an IRB-approved study, data were collected from subjects with 1 , superficial 2, deep 2 , and 3 thermal burns. Subjects were imaged following consent and daily for up to 7 days post injury. At imaging timepoints, the MSI device was used to collect images across the visible and near-IR spectrum. True severity of burn injuries, or ground truth, was determined using 21 day healing assessments or pathology for burns that required excision. Using MSI data and ground truth, we trained two deep learning algorithms to identify pixels in the image that represened non-healing burn tissue. A a fully connected convolutional neural network (CNN) and a fully convolutional neural network (SegNet) were trained to segment non-healing burn pixels from other pixels in the MSI images. Accuracy, sensitivity, and specificity of these algorithms ability to identify non-healing burns on the current study subjects were calculated using cross-validation (CV). Average accuracy was 75 ± 0.3% (fig. 1), and this accuracy increased as we collect more images. Additionally, classified output images could be processed in less than one second using the SegNet algorithm. Results from two deep learning algorithms on initial POC study subjects obtained using leave-one-out CV. Obtaining MSI images with the described clinical study design was feasible. The MSI images contained sufficient information to classify non-healing burn tissue as accurately as a skilled practitioner, and could provide these results rapidly. These preliminary results are promising, and future work will be aimed toward collecting more data to identify sources of variability and to increase algorithm accuracy. This study shows results from an ongoing POC study for developing an MSI device to aid in burn depth assessments. Eventually, the device could assist in EDs that lack specialized burn care and as an aid to burn surgery.

Copyright © 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Manure can provide valuable nutrients, especially N, for grass forage, but N availability is limited because of high NH 3 volatilization losses from standard surface‐broadcast application. Field experiments were conducted for 2 yr at two sites in Vermont to evaluate effects of broadcast or banded liquid dairy manure and broadcast N fertilizer on grass yield and N utilization. Treatments were applied to orchardgrass ( Dactylis glomerata L.) on a well‐drained silt loam and to reed canarygrass ( Phalaris arundinacea L.) on a somewhat poorly drained clay soil. Manure was applied three or four times per year at rates of 25 or 50 m 3 ha −1 either by broadcasting or by trailing‐foot spreading in narrow bands. Fertilizer N was broadcast at 0, 28, 56, and 84 kg N ha −1 on separate plots at the same time as each manure application. Fertilizer N increased yields significantly to the medium rate (224 kg ha −1 yr −1 ) on orchardgrass and the high rate (252 kg ha −1 yr −1 ) on the reed canarygrass site. The high rate of banded manure produced 80 to 110% of the yields from the high N fertilizer rate. Yields from the trailing‐foot, banded manure application were 6 to 14% higher than those from broadcast manure in the two site‐years where method had a significant effect. Fertilizer N equivalence of manure averaged 44% with banded and 34% with broadcast application. We conclude that surface‐banding manure with a trailing‐foot applicator has the potential to provide benefits over conventional broadcast application by improving N utilization and increasing yield.