DRG 272: does it provide adequate burn center reimbursement for the care of patients with Stevens-Johnson syndrome and toxic epidermal necrolysis?

Patients with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TENS) often are referred to burn centers for wound and intensive care management. Unless they undergo a surgical procedure, patients with this diagnosis are assigned to DRG 272 to determine hospital reimbursement. In 2002, this DRG had an average length of stay of 5.2 days and an average national Medicare reimbursement of $4,416. The purpose of this study was to compare demographics, resource utilization, and hospital charges and reimbursement for all patients assigned to this DRG and to evaluate the effect of the extent of surface area involvement on resource utilization, hospital costs, and reimbursement. We reviewed the records of all patients admitted to our burn centers who were assigned to DRG 272 from January 1998 through December 2002. Patients with dermatologic diagnoses assigned to this DRG were compared with patients with SJS and TENS from our institutions and the American Burn Association National Burn Repository for calendar years 2000 and 2001. Patients assigned to DRG 272 with TENS involving >or=20% TBSA had significantly greater mortality, ventilator days, intensive care unit days, and length of hospital stay than patients with dermatologic conditions or SJS who were assigned to this DRG. In addition, patients with TENS had significantly greater hospital charges and costs than patients with dermatologic diagnoses and SJS. This study supports the need for a reassessment of the adequacy of DRG 272 for the reimbursement of burn center hospitals caring for patients with TENS. This would likely require modification of the current ICD-9-CM diagnosis codes to better quantify the extent of cutaneous involvement and the frequently associated comorbid conditions that accompany the cutaneous manifestations.

Livedoid dermatitis and severe necrosis (Nicolau's syndrome) after intramuscular hydroxyzine injection.

Nicolau's syndrome, also called embolica cutis medicamentosa, is characterized by well- circumscribed livedoid dermatitis with aseptic necrosis after intramuscular injection. We report the case of a 45-year-old woman with severe necrosis of the thigh several days after a routine intramuscular injection of hydroxyzine who was transferred to and treated at our Regional Burn Center. Although there has been one case report and numerous voluntarily reported instances of intramuscular hydroxyzine-induced necrosis to the Food and Drug Administration Spontaneous Reporting System, this phenomenon is rare.

Effect of blood transfusion on outcome after major burn injury: a multicenter study.

OBJECTIVE: To delineate blood transfusion practices and outcomes in patients with major burn injury. CONTEXT: Patients with major burn injury frequently require multiple blood transfusions; however, the effect of blood transfusion after major burn injury has had limited study. DESIGN: Multicenter retrospective cohort analysis. SETTING: Regional burn centers throughout the United States and Canada. PATIENT POPULATION: Patients admitted to a participating burn center from January 1 through December 31, 2002, with acute burn injuries of >or=20% total body surface area. OUTCOMES MEASURED: Outcome measurements included mortality, number of infections, length of stay, units of blood transfused in and out of the operating room, number of operations, and anticoagulant use. RESULTS: A total of 21 burn centers contributed data on 666 patients; 79% of patients survived and received a mean of 14 units of packed red blood cells during their hospitalization. Mortality was related to patient age, total body surface area burn, inhalation injury, number of units of blood transfused outside the operating room, and total number of transfusions. The number of infections per patient increased with each unit of blood transfused (odds ratio, 1.13; p<.001). Patients on anticoagulation during hospitalization received more blood than patients not on anticoagulation (16.3+/-1.5 vs. 12.3+/-1.5, p<.001). CONCLUSIONS: The number of transfusions received was associated with mortality and infectious episodes in patients with major burns even after factoring for indices of burn severity. The utilization of blood products in the treatment of major burn injury should be reserved for patients with a demonstrated physiologic need.

Richard F. Edlich, MD, PhD: recipient of Distinguished Alumni Award from the University of Minnesota Medical Alumni Society.

On May 20, 2005, Dr. Richard F. Edlich, MD, PhD, was the recipient of the Distinguished Alumni Award from the University of Minnesota Medical Alumni Society. It is the purpose of this report to review his academic contributions, which have resulted in dramatic improvements in healthcare in our nation. Dr. Edlich began his general surgical training at the University of Minnesota under the guidance of his beloved mentor, Dr. Owen H. Wangensteen. During his 8-year surgical residency, Dr. Edlich spent 4 years in Dr. Wangensteen's multidisciplinary research laboratory. This unique research opportunity allowed him to initiate a wide variety of important clinical investigations involving the biology of wound repair and infection, the control of gastrointestinal hemorrhage, as well as the revascularization of the ischemic myocardium. After Dr. Edlich completed his 8-year surgical residency training, Dr. Wangensteen selected a 2-year plastic surgical residency at the University of Virginia Health Sciences Center for Dr. Edlich, which would allow him to complete his plastic surgical training. During his plastic surgical training and subsequent academic career at the University of Virginia, Dr. Edlich modeled his clinical and research training after that of Dr. Owen Wangensteen. Working with gifted scientists, Dr. Edlich championed the development of revolutionary advances in emergency medical care as well as burn care in our nation. He left the University of Virginia Health Sciences Center in 2001 to expand his research interest by participating in a unique multicenter evaluation of surgical products, to accept the special opportunity of being Editor-in-Chief of the Journal of Long-Term Effects of Medical Implants, and to assume a leadership position as Director of Trauma Research, Prevention and Education at Legacy Emanuel Hospital (Portland, Oregon). His academic journey that involves his beloved 2000 students is outlined in this report.

Burn specialty teams.

Natural disasters have always been a threat. human-caused disasters, especially terrorist acts, are increasing in frequency. Burn centers and providers have an important contribution to make in caring for those injured in these incidents. The most effective way to make a contribution is to act in cooperation with the Federal Disaster Response, which is organized by the Department of Homeland Security and the Federal Emergency Management Agency. It appears that this can be most effectively accomplished through participation in the Burn Specialty Team Program, which has been developed to rapidly augment emergency medical teams with burn expertise.

Telemedicine follow-up of burns: lessons learned from the first thousand visits.

Telemedicine is an evolving technology that is used for health education, health care administration, and health care distribution. The potential benefits of telemedicine include a decrease in travel expenses, improved continuity of care, and increased access to specialized consultants, thus meeting the needs of patients, practitioners, and communities. Telemedicine has many evolving applications, including improved access to health care in medically underserved and rural areas. Regions Burn Center assessed the efficacy and efficiency of burn visits via telemedicine and identified the barriers and benefits specific to burn care. Information regarding travel costs and financial data were evaluated from a total of 1000 burn follow-up visits with 294 patients via telemedicine during a 5-year interval. Our results indicate that telemedicine burn visits are a cost-effective clinical alternative for the patient. However, telemedicine can be a financial burden to health care systems and inefficient for health care providers.

Treatment of hydrofluoric acid burn to the face by carotid artery infusion of calcium gluconate.

Hydrofluoric acid (HF) is highly corrosive substance often used in industrial processes. HF burns to the skin cause local tissue injury. Systemic hypocalcemia may ensue, with the potential to produce life-threatening arrhythmias. Medical treatment consists of local application of topical calcium gels, subcutaneous injection of calcium gluconate, and intravenous or intra-arterial infusion of calcium gluconate. Calcium gluconate infusions have been used for HF burns on distal extremities and digits. We report a case of HF burn to the face that was treated by the use of calcium gluconate infusion via the external carotid artery.

Successful placement of an adult sternal intraosseous line through burned skin.

Obtaining vascular access can be difficult in the critical adult patient. This can be especially true in a severely burned patient, where the usual insertion site may be involved in the burn injury. We present a case in which a sternal intraosseous line was placed through a full-thickness injury, in a patient in full arrest, who subsequently underwent a successful cardiac resuscitation.

No ice, no butter.

Preview It is often difficult to determine the true extent of a burn, but most small thermal burns can be easily evaluated and managed by primary care physicians. In this article, the authors review the characteristics of different types of bums, describe those that require treatment in a bum center, and discuss appropriate measures to hasten healing and promote a satisfactory cosmetic outcome.