Pragmatic Approach to In Situ Simulation to Identify Latent Safety Threats Before Moving to a Newly Built ICU.

OBJECTIVES: Transitions to new care environments may have unexpected consequences that threaten patient safety. We undertook a quality improvement project using in situ simulation to learn the new patient care environment and expose latent safety threats before transitioning patients to a newly built adult ICU. DESIGN: Descriptive review of a patient safety initiative. SETTING: A newly built 24-bed neurocritical care unit at a tertiary care academic medical center. SUBJECTS: Care providers working in neurocritical care unit. INTERVENTIONS: We implemented a pragmatic three-stage in situ simulation program to learn a new patient care environment, transitioning patients from an open bay unit to a newly built private room-based ICU. The project tested the safety and efficiency of new workflows created by new patient- and family-centric features of the unit. We used standardized patients and high-fidelity mannequins to simulate patient scenarios, with "test" patients created through all electronic databases. Relevant personnel from clinical and nonclinical services participated in simulations and/or observed scenarios. We held a debriefing after each stage and scenario to identify safety threats and other concerns. Additional feedback was obtained via a written survey sent to all participants. We prospectively surveyed for missed latent safety threats for 2 years following the simulation and fixed issues as they arose. MEASUREMENTS AND MAIN RESULTS: We identified and addressed 70 latent safety threats, including issues concerning physical environment, infection prevention, patient workflow, and informatics before the move into the new unit. We also developed an orientation manual that highlighted new physical and functional features of the ICU and best practices gleaned from the simulations. All participants agreed or strongly agreed that simulations were beneficial. Two-year follow-up revealed only two missed latent safety threats. CONCLUSIONS: In situ simulation effectively identifies latent safety threats surrounding the transition to new ICUs and should be considered before moving into new units.

Outcomes for Hand Burns Treated With Autologous Skin Cell Suspension in 20% TBSA and Smaller Injuries.

In order to address the confounder of TBSA on burn outcomes, we sought to analyze our experience with the use of autologous skin cell suspensions (ASCS) in a cohort of subjects with hand burns whose TBSA totaled 20% or less. We hypothesized that the use of ASCS in conjunction with 2:1 meshed autograft for the treatment of hand burn injuries would provide comparable outcomes to hand burns treated with sheet or minimally meshed autograft alone. A retrospective review was conducted for all deep partial and full-thickness hand burns treated with split-thickness autograft (STAG) at our urban verified burn center between April 2018 and September 2020. The exclusion criterion was a TBSA greater than 20%. The cohorts were those subjects treated with ASCS in combination with STAG (ASCS(+)) vs those treated with STAG alone (ASCS(-)). All ASCS(+) subjects were treated with 2:1 meshed STAG and ASCS overspray while all ASCS(-) subjects had 1:1, piecrust, or unmeshed sheet graft alone. Outcomes measured included demographics, time to wound closure, proportion returning to work (RTW), and length of time to RTW. Mann-Whitney U test was used for comparisons of continuous variables and Fisher's exact test for categorical variables. Values are reported as medians and 25th and 75th interquartile ranges. Fifty-one subjects fit the study criteria (ASCS(+) n = 31, ASCS(-) n = 20). The ASCS(+) group was significantly older than the ASCS(-) cohort (44 [32-54] vs 32 years [27.5-37], P = .009) with larger %TBSA burns (15% [9.5-17] vs 2% [1-4], P < .0001) and larger size hand burns (190 [120-349.5] vs 126 cm2 [73.5-182], P = .015). Comparable results were seen between ASCS(+) and ASCS(-), respectively, for time to wound closure (9 [7-13] vs 11.5 days [6.75-14], P = .63), proportion RTW (61% vs 70%, P = .56), and days for RTW among those returning (35 [28.5-57] vs 33 [20.25-59], P = .52). The ASCS(+) group had two graft infections with no reoperations, while ASCS(-) had one infection with one reoperation. No subjects in either group had a dermal substitute placed. Despite being significantly older, having larger hand wounds, and larger overall wounds within the parameters of the study criteria, patients with 20% TBSA burns or smaller whose hand burns were treated with 2:1 mesh and ASCS overspray had comparable time to wound closure, proportion of RTW, and time to return to work as subjects treated with 1:1 or piecrust meshed STAG. Our group plans to follow this work with scar assessments for a more granular picture of pliability and reconstructive needs.

Referral patterns in pediatric burn patients.

Though multiple studies have demonstrated superior outcomes amongst adult burn patients at verified burn centers (VBCs) relative to nondedicated burn centers (NBCs), roughly half of such patients meeting American Burn Association (ABA) referral guidelines are not sent to these centers. We sought examine referral patterns amongst pediatric burn patients. Retrospective review of a statewide patient database identified pediatric burn patients from 2000 to 2007 using International Classification of Disease (ICD-9) discharge codes. These injuries were crossreferenced with ABA referral criteria to determine compliance with the ABA guidelines. 1831 children sustained burns requiring hospitalization during the study period, of which 1274 (70%) met ABA referral criteria. Of 557 treated at NBCs, 306 (55%) met criteria for transfer. Neither age, gender, nor payer status demonstrated significant association with treatment center. VBCs treated more severely injured patients, but there was no difference in survival or rate of discharge home from NBCs versus VBCs. Studies to evaluate differences in functional outcomes between pediatric burn patients treated at VBCs versus NBCs would be beneficial to ensure optimization of outcomes in this population.