Higher energy delivery is associated with improved long-term survival among adults with major burn injury: A multicenter, multinational, observational study.

BACKGROUND: Numerous feeding strategies have been used to mitigate the catabolism of major burn injury. Whether higher energy and/or protein delivery results in better long-term outcomes is unknown. METHODS: We performed a secondary analysis of data from adults with major burn injuries enrolled in the Randomized Trial of Enteral Glutamine to Minimize the Effects of Burn Injury at 54 burn centers in 18 countries. The sample was restricted to those who were mechanically ventilated within 72 hours of injury and for ≥7 days. Our key exposure was adequacy of energy, and protein ([Deliveredi/Prescribedi] × 100) was categorized into three groups each: low, 0% to 50%; moderate, ≥50% to 79%; and high, ≥80%. We also analyzed adequacy using restricted cubic splines. Primary and secondary outcomes included 6-month mortality and functional outcomes (i.e., 36-Item Short-Form Health Survey, Katz Index of Independence in Activities of Daily Living, Lawton Activities of Daily Living scores), respectively. Regression models were adjusted for age, body mass index, Charlson Comorbidity Index, baseline Acute Physiology and Chronic Health Evaluation II and modified Sequential Organ Failure Assessment scores, burn size, energy/protein adequacy, and study site. RESULTS: A total of 493 participants met the cohort restriction criteria; 336 participants were alive at 6 months. 36-Item Short-Form Health Survey, Katz Index of Independence in Activities of Daily Living, and Lawton Instrumental Activities of Daily Living Scale were completed by 218, 216, and 215 participants, respectively. The mean ± SD age was 48 ± 17 years, and 74% were male. The mean ± SD burn size was 41% ± 18% total body surface area. Participants who received 25% of recommended calories had nearly four times the hazard of death during the 6-month follow-up period than participants who received 100% of prescribed calories (adjusted hazard ratio, 3.89; 95% confidence interval, 1.35-11.20) (p = 0.02). There was no significant association between protein and 6-month mortality or energy/protein delivery and 6-month functional outcomes. CONCLUSION: There was a positive association between higher doses of energy and 6-month survival. This relationship conflicts somewhat with several energy studies among critically ill and non-burn-injured patients. The lack of consistent evidence on optimal nutrition for critically injured patients, a fundamental component of burn care, suggests potential for a randomized trial of lower versus higher energy to improve long-term outcomes after burn injury. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Pediatric Patients with Post-Burn Amputations Report Worse Long-Term Physical Function but Not Self-Appearance: A Burn Model System Study.

Some severe burn injuries may warrant amputation; however, the physical and functional adjustments resulting from post-burn amputation can have long-term consequences. This study investigates longitudinal functional and psychosocial outcomes among pediatric burn amputees. Pediatric participants enrolled in the Burn Model System national longitudinal, multicenter database between 2015-2023 with post-burn amputations were included. Participants with amputations were matched using nearest-neighbor matching to those without amputations based on burn location, age, and % total burn surface area burn size. Primary outcomes were the PROMIS Pediatric-25 Profile v2.0 Physical Function and the Children Burn Outcomes Questionnaire: appearance sub-score, both measured at 6-, 12- and 24 months post-burn. In this study, 17 participants had amputations and 17 did not (matched participants). Pairwise analyses at each timepoint found those with amputations reported significantly lower physical function scores at 24 months post-burn (54.9 ±11.6 vs. 66 ±5, p=0.013). No significant differences were found in appearance scores. This study suggests that pediatric burn amputees may potentially face greater physical impairment long-term, highlighting an important area of research that deserves further attention.

Comparison of Demographics Across the Burn, Spinal Cord Injury, and Traumatic Brain Injury Model Systems.

OBJECTIVE: To analyze the demographic profiles of participants in the traumatic brain injury, burn injury, and spinal cord injury model systems databases. DESIGN: Data from the Burn Model System (BMS), Traumatic Brain Injury Model System (TBIMS), and Spinal Cord Injury Model System (SCIMS) National Databases were analyzed from 1994-2020. SETTING: Not applicable. PARTICIPANTS: The study included participants aged ≥16 years (N=42,407) with available data in selected variables, totaling 4807 burn injury, 19,127 TBI, and 18,473 SCI participants. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Variables including age, race, ethnicity, sex, education level, primary payor source, family income level, employment status at 1 year postinjury, etiology, and mortality at 1 year postinjury were analyzed across the database. RESULTS: Median ages at injury for BMS (40.4y), TBIMS (40y), and SCIMS (38y) National Database participants were comparable. Men constituted approximately 75% of participants in the BMS, TBIMS, and SCIMS datasets, with approximately 75% having a high-school education or less. The proportion of participants funded by Medicare during initial hospital care varied across the BMS (14%), TBIMS (15.6%), and SCIMS (10.2%). For family income (data available for BMS and SCIMS), approximately 30% of these participants reported a family income <$25,000. Etiology data indicated 49.0% of traumatic brain injury and 40.7% of spinal cord injury cases resulted from vehicular incidents. CONCLUSIONS: An overlapping at-risk population for these injuries appears to be middle-aged men with lower education levels and family incomes who have access to vehicles. This underscores the need for preventive initiatives tailored to this identified population to mitigate the risk of these injuries.

A Randomized Controlled Trial of Home-Based Virtual Rehabilitation to Improve Adherence to Prescribed Home Therapy after Burn Injury: A Northwest Regional Burn Model System Trial.

Daily rehabilitation after burn injury is vital for prevention of function-limiting contractures. However, adherence to prescribed therapy following acute burn hospitalization has historically been low and not well-studied. Studies involving virtual reality technology have demonstrated an association with improved functional outcomes in burn therapy. We conducted a five-year randomized controlled trial comparing 12 weeks of a home-based virtual rehabilitation (HBVR) system with standard burn therapy. Our primary outcome was adherence to prescribed home therapy, measured by e-diary self-report. Secondary outcomes included steps walked daily and patient-reported outcomes regarding stiffness, upper extremity function, and mobility. We enrolled 50 subjects, of which 48 provided data for analysis (23 HBVR, 25 control). Overall adherence to prescribed home therapy was low, 37.2% in the HBVR group and 60.0% in the control group. Reasons for non-adherence in the HBVR group included lack of time, engagement, and replacement of therapy with other physical activity. However, some subjects enjoyed HBVR and believed it aided their recovery. There was no difference in daily steps walked between the two groups. Daily walking gradually improved from 3,500 steps per day in the first week after baseline and plateaued at 6,000 steps per day at week five. There were no differences in stiffness, upper extremity function, and mobility between the two groups at baseline and 3-, 6-, and 12-month follow-up. Subjects demonstrated improved upper extremity function and mobility in the first year after discharge that coincided with increasing stiffness.

Geospatial analysis of injury severity on major roads in Ghana (2017-2020): implications for targeted injury prevention and control initiatives.

BACKGROUND: Road safety authorities in high-income countries use geospatial motor vehicle collision data for planning hazard reduction and intervention targeting. However, low-income and middle-income countries (LMICs) rarely conduct such geospatial analyses due to a lack of data. Since 1991, Ghana has maintained a database of all collisions and is uniquely positioned to lead data-informed road injury prevention and control initiatives. METHODS: We identified and mapped geospatial patterns of hotspots of collisions, injuries, severe injuries and deaths using a well-known injury severity index with geographic information systems statistical methods (Getis-Ord Gi*). RESULTS: We identified specific areas (4.66% of major roads in urban areas and 6.16% of major roads in rural areas) to target injury control. Key roads, including National Road 1 (from the border of Cote D'Ivoire to the border of Togo) and National Road 6 (from Accra to Kumasi), have a significant concentration of high-risk roads. CONCLUSIONS: A few key road sections are critical to target for injury prevention. We conduct a collaborative geospatial study to demonstrate the importance of addressing data and research gaps in LMICs and call for similar future research on targeting injury control and prevention efforts.

Severity of Inhalation Injury and Risk of Nosocomial Pneumonia: A Retrospective Cohort Study.

BACKGROUND: The impact of inhalation injury on risk of nosocomial pneumonia (NP), an important complication in patients with burns, is not well established. RESEARCH QUESTION: Is more severe inhalation injury associated with increased risk of NP? STUDY DESIGN AND METHODS: We performed a retrospective cohort study of patients with suspected inhalation injury admitted to a regional burn center from 2011 to 2022 who underwent diagnostic bronchoscopy within 48 h of admission. We estimated the association of high-grade inhalation injury (Abbreviated Injury Scale score 3 and 4) vs low-grade inhalation injury (Abbreviated Injury Scale score 1 and 2) with NP adjusted for age, burn size, and comorbid obstructive lung disease. Death and hospital discharge were considered competing risks. RESULTS: Of the 245 patients analyzed, 51 (21%) had high-grade injury, 180 (73%) had low-grade injury, and 14 (6%) had no inhalation injury. Among the 236 patients hospitalized for ≥ 48 h, NP occurred in 24 of 50 patients (48%) in the high-grade group, 54 of 172 patients (31%) in the low-grade group, and two of 14 patients (14%) in the no inhalation injury group. High-grade (vs low-grade) inhalation injury was associated with higher hazard of NP in both the proportional cause-specific hazard model (cause-specific hazard ratio, 2.04; 95% CI, 1.26-3.30; P = .004) and Fine-Gray subdistribution hazard model (subdistribution hazard ratio for NP, 2.24; 95% CI, 1.38-3.64; P = .001). INTERPRETATION: Among patients with inhalation injury, more severe injury was associated with higher hazard of NP in competing risk analysis. Additional research is needed to investigate mechanisms that may explain the relationship between inhalation injury and NP and to identify more effective risk reduction strategies.

Consumer focus group testing with stakeholders to generate an enteral resuscitation training flipbook for primary health center and first-level hospital providers in Nepal.

INTRODUCTION: Enteral resuscitation (EResus) is operationally advantageous to intravenous resuscitation for burn-injured patients in some low-resource settings. However, there is minimal guidance and no training materials for EResus tailored to non-burn care providers. We aimed to develop and consumer-test a training flipbook with doctors and nurses in Nepal to aid broader dissemination of this life-saving technique. MATERIALS AND METHODS: We used individual cognitive interviews with Nepali (n = 12) and international (n = 4) burn care experts to define key elements of EResus and specific concepts for its operationalization at primary health centers and first-level hospitals in Nepal. Content, prototype illustrations, and wireframe layouts were developed and revised with the burn care experts. Subsequently, eight consumer testing focus groups with Nepali stakeholders (5-10 people each) were facilitated. Prompts were generated using the Questionnaire Appraisal System (QAS) framework. The flipbook was iteratively revised and tested based on consumer feedback organized according to the domains of clarity, assumptions, knowledge/memory, and sensitivity/bias. RESULTS AND DISCUSSION: The flipbook elements were iterated until consumers made no additional requests for changes. Examples of consumer inputs included: clarity-minimize medical jargon, add shrunken organs and wilted plants to represent burn shock; assumptions-use locally representative figures, depict oral rehydration salts sachet instead of a graduated bottle; knowledge/memory-clarify complex topics, use Rule-of-9 s and depict approximately 20% total body surface area to indicate the threshold for resuscitation; sensitivity/bias-reduce anatomic illustration details (e.g. urinary catheter placement, body contours). CONCLUSION: Stakeholder engagement, consumer testing, and iterative revision can generate knowledge translation products that reflect contextually appropriate education materials for inexperienced burn providers. The EResus Training Flipbook can be used in Nepal and adapted to other contexts to facilitate the implementation of EResus globally.

Implementation of a geriatric care bundle for older adults with acute burns.

BACKGROUND: Frailty and comorbidities are important outcome determinants in older patients (age ≥65) with burns. A Geriatric Burn Bundle (Geri-B) was implemented in 2019 at a regional burn center to standardize care for older adults. Components included frailty screening and protocolized geriatric co-management, malnutrition screening with nutritional support, and geriatric-centered pain regimens. METHODS: This study aimed to qualitatively evaluate the implementation of Geri-B using the Proctor Framework. From June-August 2022, older burn-injured patients, burn nurses, and medical staff providers (attending physicians and advanced practice providers) were surveyed and interviewed. Transcribed interviews were coded and thematically analyzed. From May 2022 to August 2023, the number of inpatient visits aged 65 + with a documented frailty screening was monitored. RESULTS: The study included 23 participants (10 providers, 13 patients). Participants highly rated Geri-B in all implementation domains. Most providers rated geriatric care effectiveness as 'good' or 'excellent' after Geri-B implementation. Providers viewed it as a reminder to tailor geriatric care and a safeguard against substandard geriatric care. Staffing shortages, insufficient protocol training, and learning resources were reported as implementation barriers. Many providers advocated for better bundle integration into the hospital electronic health record (EHR) (e.g., frailty screening tool, automatic admission order sets). Most patients felt comfortable being asked about their functional status with strong patient support for therapy services. The average frailty screening completion rate from May 2022 to August 2023 was 86%. CONCLUSIONS: Geri-B was perceived as valuable for the care of older burn patients and may serve as a framework for other burn centers.

Physical and psychosocial outcomes among burn-injured people with heterotopic ossification: A burn model system study.

INTRODUCTION: Heterotopic ossification (HO), or ectopic bone formation in soft tissue, is a not so rare and poorly understood debilitating sequela of burn injury. Individuals developing HO following burn injuries to their hands often experience reductions in mobility, significant contractures, and joint pain. This study identifies demographic characteristics of individuals who develop HO and compares their physical and psychosocial outcomes to the general burn population. METHODS: Participant demographics, injury characteristics, and PROMIS-29 scores across three time points (discharge, six- and 12- months after injury) were extracted from the Burn Model System National Longitudinal Database representing participants from 2015-2022. Mixed-effects linear regression models were used to compare PROMIS scores across all three longitudinal measurements. Models were adjusted for age, sex, race/ethnicity, HO status, and burn size. RESULTS: Of the 861 participants with data concerning HO, 33 were diagnosed with HO (3.8% of participants). Most participants with HO were male (n = 24, 73%) and had an average age of 40 + /- 13 years. Participants with HO had significantly larger burn size (49 +/-23% Total Body Surface Area (TBSA)) than those without HO (16 +/-17%). Participants with HO reported significantly worse physical function, depression, pain interference and social integration scores than those without HO. After adjusting for covariables, participants with HO continued to report statistically significantly worse physical function than those without HO. Although physical functioning was consistently lower, the two populations did not differ significantly among psychosocial outcome measures. CONCLUSIONS: While HO can result in physical limitations, the translation to psychosocial impairments was not evident. Targeted treatment of HO with the goal of maximizing physical function should be a focus of their rehabilitation. LEVEL OF EVIDENCE: 2b TYPE OF STUDY: Symptom Prevalence Study.

Examining the association between military service history and outcomes after burn injury.

INTRODUCTION: The association between military service history and long-term outcomes after burn injury is unknown. This study uses data from the Burn Model System National Database to compare outcomes of individuals with and without self-reported military service history. METHODS: Outcome measures were assessed at 12 months after injury including the Veterans Rand-12 Item Health Survey/Short Form-12, Satisfaction With Life Scale, Patient Reported Outcomes Measure Information System 29, 4-D Itch scale, Post Traumatic Stress Disorder Check List - Civilian Version, self-reported Post Traumatic Stress Disorder, and employment status. This study included 675 people with burns of whom 108 reported a history of military service. RESULTS: The military service history group was more likely to be older, and male. Those with military service were most likely to be on Medicare insurance and those without military service history were most likely to be on Private Insurance/HMP/PPO. No significant differences were found between those with and without military service history in the outcome measures. CONCLUSIONS: Further research should examine differences in outcomes between civilians and those with military service history, including elements of resilience and post traumatic growth.

Predictors at 6 and 12 Months for Social Participation Outcome at 24 Months in the Adult Burn Injury Population: A Burn Model System National Database Study.

OBJECTIVE: To identify clinical factors (physical and psychological symptoms and post-traumatic growth) that predict social participation outcome at 24-month after burn injury. DESIGN: A prospective cohort study based on Burn Model System National Database. SETTING: Burn Model System centers. PARTICIPANTS: 181 adult participants less than 2 years after burn injury (N=181). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic and injury variables were collected at discharge. Predictor variables were assessed at 6 and 12 months: Post-Traumatic Growth Inventory Short Form (PTGI-SF), Post-Traumatic Stress Disorder Checklist Civilian Version (PCL-C), Patient-Reported Outcomes Measurement Information System (PROMIS-29) Depression, Anxiety, Sleep Disturbance, Fatigue, and Pain Interference short forms, and self-reported Heat Intolerance. Social participation was measured at 24 months using the Life Impact Burn Recovery Evaluation (LIBRE) Social Interactions and Social Activities short forms. RESULTS: Linear and multivariable regression models were used to examine predictor variables for social participation outcomes, controlling for demographic and injury variables. For LIBRE Social Interactions, significant predictors included the PCL-C total score at 6 months (ß=-0.27, P<.001) and 12 months (ß=-0.39, P<.001), and PROMIS-29 Pain Interference at 6 months (ß=-0.20, P<.01). For LIBRE Social Activities, significant predictors consisted of the PROMIS-29 Depression at 6 months (ß=-0.37, P<.001) and 12 months (ß=-0.37, P<.001), PROMIS-29 Pain Interference at 6 months (ß=-0.40, P<.001) and 12 months (ß=-0.37, P<.001), and Heat Intolerance at 12 months (ß=-4.55, P<.01). CONCLUSIONS: Post-traumatic stress and pain predicted social interactions outcomes, while depression, pain and heat intolerance predicted social activities outcomes in people with burn injury.

Implementation evaluation of tiered tele-triage pathways for burn center consultations and transfers.

BACKGROUND: Early transfer to specialized centers improves trauma and burn outcomes; however, overtriage can result in unnecessary burdens to patients, providers, and health systems. Our institution developed novel burn triage pathways in 2016 to improve resource allocation. We evaluated the implementation of these pathways, analyzing trends in adoption, resource optimization, and pathway reliability after implementation. METHODS: Triage pathways consist of transfer nurses (RNs) triaging calls based on review of burn images and clinical history: green pathway for direct outpatient referral, blue pathway for discussion with the on-call provider, red pathway for confirmation of transfer as requested by referring provider, and black pathway for the rapid transfer of severe burns. We used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to evaluate implementation. These pathways affected all acute burn referrals to our center from January 2017 to December 2019 (reach). Outcomes of interest were pathway assignment over time (adoption), changes to burn provider call volume (effectiveness), and the concordance of pathway assignment with final disposition (implementation reliability). RESULTS: Transfer RNs triaged 5,272 burn referrals between 2017 and 2019. By January 2018, >98% of referrals were assigned a pathway. In 2018-2019, green pathway calls triaged by RNs reduced calls to burn providers by a mean of 40 (SD, 11) per month. Patients in green/blue pathways were less likely to be transferred, with >85% receiving only outpatient follow-up ( p < 0.001). Use of the lower acuity pathways increased over time, with a concordant decrease in use of the higher acuity pathways. Younger adults, patients referred from Level III to Level V trauma centers and nontrauma hospitals, and patients referred by APPs were less likely to be triaged to higher acuity pathways. CONCLUSION: Implementation of highly adopted, reliable triage pathways can optimize existing clinical resources by task-shifting triage of lower acuity burns to nursing teams. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Experiences of Alaska Native people living with burn injury and opportunities for health system strengthening.

BACKGROUND: Injuries are a leading cause of death and disability for Alaska Native (AN) people. Alaska Native Tribal Health Consortium (ANTHC) is supporting the development of a burn care system that includes a partnership between Alaska Native Medical Center (ANMC) in Anchorage, AK and UW Medicine Regional Burn Center at Harborview Medical Center (HMC) in Seattle, WA. We aimed to better understand the experiences of AN people with burn injuries across the care continuum to aid development of culturally appropriate care regionalization. METHODS: We performed focus groups with twelve AN people with burn injury and their caregivers. A multidisciplinary team of burn care providers, qualitative research experts, AN care coordinator, and AN cultural liaison led focus groups to elicit experiences across the burn care continuum. Transcripts were analyzed using a phenomenological approach and inductive coding to understand how AN people and families navigated the medical and community systems for burn care and areas for improvement. RESULTS: Three themes were identified: 1-Challenges with local burn care in remote communities including limited first aid, triage, pain management, and wound care, as well as long-distance transport to definitive care; 2-Divergence between cultural values and medical practices that generated mistrust in the medical system, isolation from their support systems, and recovery goals that were not aligned with their needs; 3-Difficulty accessing emotional health support and a survivor community that could empower their resilience. CONCLUSION: Participants reported modifiable barriers to culturally competent treatment for burn injuries among AN people. The findings can inform initiatives that leverage existing resources, including expansion of the Extension for Community Healthcare Outcomes (ECHO) telementoring program, promulgation of the Phoenix Society Survivors Offering Assistance in Recovery (SOAR) to AK, coordination of regionalized care to reduce time away from AK and provide more comfortable community reintegration, and define rehabilitation goals in terms that align with personal goals and subsistence lifestyle skills. Long-distance transport times are non-modifiable, but better pre-hospital care could be achieved by harnessing existing telehealth services and adapting principles of prolonged field care to allow for triage, initial care, and resuscitation in remote environments.

Holistic Approach to Burn Reconstruction and Scar Rehabilitation.

More than 11 million burn injuries occur each year across the world. Many people with burn injuries, regardless of injury size, develop hypertrophic scar, contracture, unstable scar, heterotopic ossification, and disability resulting from these sequelae. Advances in trauma systems, critical care, safe surgery, and multidisciplinary burn care have markedly improved the survival of people who have experienced extensive burn injuries. Burn scar reconstruction aims to improve or restore physical function, confidence, and body image. Like acute burn care, burn scar reconstruction requires thoughtful, coordinated approaches along the continuum of burn injury, recovery, and rehabilitation.

Impact of Tele-Triage Pathways on Short-Stay Admission after Transfer to a Regional Burn Center for Acute Burn Injury.

BACKGROUND: Regionalized care for burn-injured patients requires accurate triage. In 2016, we implemented a tele-triage system for acute burn consultations. We evaluated resource utilization following implementation, hypothesizing that this system would reduce short-stay admissions and prioritize inpatient care for those with higher burn severity. STUDY DESIGN: We conducted a retrospective study of all transferred patients with acute burn injuries from January 1, 2010 to December 31, 2015, and January 1, 2017 to December 31, 2019. We evaluated the proportions of short-stay admissions (discharges less than 24 hours without operative intervention, ICU admission, or concern for nonaccidental trauma) among patients transferred before (2010 to 2015) and after (2017 to 2019) triage system implementation. Multivariable Poisson regression was used to evaluate factors associated with short-stay admissions. Interrupted time series analysis was used to evaluate the effect of the triage system. RESULTS: There were 4,688 burn transfers (3,244 preimplementation and 1,444 postimplementation) in the study periods. Mean age was higher postimplementation (32 vs 29 years, p < 0.001). Median hospital length of stay (LOS) and ICU LOS were both 1 day higher, more patients underwent operative intervention (19% vs 16%), and median time to first operation was 1 day lower postimplementation. Short-stay admissions decreased from 50% (n = 1,624) to 39% (n = 561), and patients were 17% less likely to have a short-stay admission after implementation (adjusted relative risk [aRR], 0.83; 95% CI, 0.8 to 0.9). Pediatric patients younger than 15 years old composed 43% of all short-stay admissions and were much more likely than adult patients to have a short-stay admission independent of transfer timing (aRR, 2.36; 95% CI, 1.84 to 3.03). CONCLUSIONS: Tele-triage burn transfer center protocols reduced short-stay admissions and prioritized inpatient care for patients with more severe injuries. Pediatric patients remain more likely to have short-stay admission after transfer.

Standardized trauma intake form with clinical decision support prompts improves care and reduces mortality for seriously injured patients in non-tertiary hospitals in Ghana: stepped-wedge cluster randomized trial.

BACKGROUND: The WHO Trauma Care Checklist improved key performance indicators (KPIs) of trauma care at tertiary hospitals. A standardized trauma intake form (TIF) with real-time clinical decision support prompts was developed by adapting the WHO Trauma Care Checklist for use in smaller low- and middle-income country hospitals, where care is delivered by non-specialized providers and without trauma teams. This study aimed to determine the effectiveness of the TIF for improving KPIs in initial trauma care and reducing mortality at non-tertiary hospitals in Ghana. METHODS: A stepped-wedge cluster randomized trial was conducted by stationing research assistants at emergency units of eight non-tertiary hospitals for 17.5 months to observe management of injured patients before and after introduction of the TIF. Differences in performance of KPIs in trauma care (primary outcomes) and mortality (secondary outcome) were estimated using generalized linear mixed regression models. RESULTS: Management of 4077 injured patients was observed (2067 before TIF introduction, 2010 after). There was improvement in 14 of 16 primary survey and initial care KPIs after TIF introduction. Airway assessment increased from 72.9 to 98.4 per cent (adjusted OR 25.27, 95 per cent c.i. 2.47 to 258.94; P = 0.006) and breathing assessment from 62.1 to 96.8 per cent (adjusted OR 38.38, 4.84 to 304.69; P = 0.001). Documentation of important clinical data improved from 52.4 to 76.7 per cent (adjusted OR 2.14, 1.17 to 3.89; P = 0.013). The mortality rate decreased from 17.7 to 12.1 per cent among 302 patients (186 before, 116 after) with impaired physiology on arrival (hypotension or decreased level of consciousness) (adjusted OR 0.10, 0.02 to 0.56; P = 0.009). CONCLUSION: The TIF improved overall initial trauma care and reduced mortality for more seriously injured patients. REGISTRATION NUMBER: NCT04547192 (http://www.clinicaltrials.gov).

Preliminary Exploration of Long-Term Patient Outcomes After Tracheostomy in Burns: A Burn Model System Study.

INTRODUCTION: Upper airway management is crucial to burn care. Endotracheal intubation is often performed in the setting of inhalation injury, burns of the face and neck, or large burns requiring significant resuscitation. Tracheostomy may be necessary in patients requiring prolonged ventilatory support. This study compares long-term, patient-reported outcomes in burn patients with and without tracheostomy. MATERIALS AND METHODS: Data from the Burn Model System Database, collected from 2013 to 2020, were analyzed. Demographic and clinical data were compared between those with and without tracheostomy. The following patient-reported outcomes, collected at 6-, 12-, and 24-mo follow-up, were analyzed: Veterans RAND 12-Item Health Survey (VR-12), Satisfaction with Life, Community Integration Questionnaire, Patient-Reported Outcomes Measurement Information System 29-Item Profile Measure, employment status, and days to return to work. Regression models and propensity-matched analyses were used to assess the associations between tracheostomy and each outcome. RESULTS: Of 714 patients included in this study, 5.5% received a tracheostomy. Mixed model regression analyses demonstrated that only VR-12 Physical Component Summary scores at 24-mo follow-up were significantly worse among those requiring tracheostomy. Tracheostomy was not associated with VR-12 Mental Component Summary, Satisfaction with Life, Community Integration Questionnaire, or Patient-Reported Outcomes Measurement Information System 29-Item Profile Measure scores. Likewise, tracheostomy was not found to be independently associated with employment status or days to return to work. CONCLUSIONS: This preliminary exploration suggests that physical and psychosocial recovery, as well as the ability to regain employment, are no worse in burn patients requiring tracheostomy. Future investigations of larger scale are still needed to assess center- and provider-level influences, as well as the influences of various hallmarks of injury severity. Nonetheless, this work should better inform goals of care discussions with patients and families regarding the use of tracheostomy in burn injury.

Systematic review of global hepatitis E outbreaks to inform response and coordination initiatives.

INTRODUCTION: Hepatitis E virus (HEV) is the most common cause of acute hepatitis. While symptoms are generally mild and resolve within weeks, some populations (e.g., pregnant women, immunocompromised adults) are at high-risk of severe HEV-related morbidity and mortality. There has not been a recent comprehensive review of contemporary HEV outbreaks, which limits the validity of current disease burden estimates. Therefore, we aimed to characterize global HEV outbreaks and describe data gaps to inform HEV outbreak prevention and response initiatives. METHODS: We performed a systematic review of peer-reviewed (PubMed, Embase) and gray literature (ProMED) to identify reports of outbreaks published between 2011 and 2022. We included (1) reports with ≥ 5 cases of HEV, and/or (2) reports with 1.5 times the baseline incidence of HEV in a specific population, and (3) all reports with suspected (e.g., clinical case definition) or confirmed (e.g., ELISA or PCR test) cases if they met criterium 1 and/or 2. We describe key outbreak epidemiological, prevention and response characteristics and major data gaps. RESULTS: We identified 907 records from PubMed, 468 from Embase, and 247 from ProMED. We screened 1,362 potentially relevant records after deduplication. Seventy-one reports were synthesized, representing 44 HEV outbreaks in 19 countries. The populations at risk, case fatalities, and outbreak durations were not reported in 66% of outbreak reports. No reports described using HEV vaccines. Reported intervention efforts included improving sanitation and hygiene, contact tracing/case surveillance, chlorinating boreholes, and advising residents to boil water. Commonly missing data elements included specific case definitions used, testing strategy and methods, seroprevalence, impacts of interventions, and outbreak response costs. Approximately 20% of HEV outbreaks we found were not published in the peer-reviewed literature. CONCLUSION: HEV represents a significant public health problem. Unfortunately, extensive data shortages and a lack of standardized reporting make it difficult to estimate the HEV disease burden accurately and to implement effective prevention and response activities. Our study has identified major gaps to guide future studies and outbreak reporting systems. Our results support the development of standardized reporting procedures/platforms for HEV outbreaks to ensure accurate and timely data distribution, including active and passive coordinated surveillance systems, particularly among high-risk populations.