Variations in access to specialty care for children with severe burns.


  • 影响因子:1.21
  • DOI:10.1016/j.ajem.2019.158401
  • 作者列表:"Ewbank C","Sheckter CC","Warstadt NM","Pirrotta EA","Curtin C","Newton C","Wang NE
  • 发表时间:2020-06-01

BACKGROUND:Pediatric burns account for 120,000 emergency department visits and 10,000 hospitalizations annually. The American Burn Association has guidelines regarding referrals to burn centers; however there is variation in burn center distribution. We hypothesized that disparity in access would be related to burn center access. METHODS:Using weighted discharge data from the Nationwide Inpatient Sample 2001-2011, we identified pediatric patients with International Classification of Diseases-9th Revision codes for burns that also met American Burn Association criteria. Key characteristics were compared between pediatric patients treated at burn centers and those that were not. RESULTS:Of 54,529 patients meeting criteria, 82.0% (n = 44,632) were treated at burn centers. Patients treated at burn centers were younger (5.6 versus 6.7 years old; p < 0.0001) and more likely to have burn injuries on multiple body regions (88% versus 12%; p < 0.0001). In urban areas, 84% of care was provided at burn centers versus 0% in rural areas (p < 0.0001), a difference attributable to the lack of burn centers in rural areas. Both length of stay and number of procedures were significantly higher for patients treated at burn centers (7.3 versus 4.4 days, p < 0.0001 and 2.3 versus 1.1 procedures, p < 0.0001; respectively). There were no significant differences in mortality (0.7% versus 0.8%, p = 0.692). CONCLUSION:The majority of children who met criteria were treated at burn centers. There was no significant difference between geographical regions. Of those who were treated at burn centers, more severe injury patterns were noted, but there was no significant mortality difference. Further study of optimal referral of pediatric burn patients is needed.


背景: 小儿烧伤每年有120,000急诊就诊和10,000次住院。美国烧伤协会有关于转诊到烧伤中心的指南; 然而烧伤中心分布存在差异。我们假设访问的差异将与烧伤中心访问有关。 方法: 使用2001-2011全国住院样本的加权出院数据,我们确定了符合美国烧伤协会标准的国际烧伤分类Diseases-9th修订代码的儿科患者。比较了在烧伤中心治疗的儿童患者和非烧伤中心治疗的儿童患者的主要特征。 结果: 在符合标准的54,529例患者中,有82.0% 例 (n = 44,632) 在烧伤中心接受治疗。在烧伤中心治疗的患者更年轻 (5.6对6.7岁; P <0.0001),更可能在多个身体区域发生烧伤 (88% 对12%; P <0.0001)。在城市地区,烧伤中心提供了84% 的护理,而农村地区为0% (p <0.0001),这一差异可归因于农村地区缺乏烧伤中心。在烧伤中心治疗的患者的住院时间和手术次数均显著增加 (分别为7.3天与4.4天,p <0.0001和2.3次与1.1次手术,p <0.0001)。死亡率无显著差异 (0.7% 对0.8%,p = 0.692)。 结论: 大多数符合标准的儿童在烧伤中心接受治疗。地理区域之间没有显著差异。在烧伤中心接受治疗的患者中,注意到更严重的损伤模式,但没有显著的死亡率差异。需要进一步研究小儿烧伤患者的最佳转诊。



作者列表:["Egro FM","Saliu OT","Zhu X","Corcos AC","Ziembicki JA"]

METHODS:BACKGROUND:Dermatome-induced lacerations are a known complication; however, there is a paucity of literature discussing the incidence and predisposing factors. The aim of this study was to determine the incidence and risk factors to develop a preventive algorithm. METHODS:An 18-question survey was sent to all US and Canadian burn unit directors. Surgeons were queried about type and location of their practices, average annual caseload of skin graft harvesting, and number of dermatome-induced lacerations. The survey also asked about donor site location, harvesting technique and equipment, laceration severity, and causative factors. An algorithm was developed based on the results. RESULTS:Fifty-six responses (42% response rate) were received from the burn unit directors. They reported an estimated 133 lacerations over the past 5 y. The overall incidence of dermatome-induced lacerations was approximately 0.1% per year (1.3 per 1000 cases). The most commonly attributed causes were excessive pressure (25.0%) and patient factors (18.4%). Most lacerations occurred when using air dermatomes (73.0%) with a 4-inch guard (63.5%), 0.010- to 0.015-inch thickness (78.4%), and 30°-45° angulation (47.3%); the most common brand was Zimmer (71.6%). The dermatome was typically set up by a scrub tech or nurse (48.6%), whereas the skin harvesting was performed by residents (39.2%) or attendings (35.1%). Lacerations typically extended to subcutaneous tissue (70.3%), with no neurovascular injury (86.5%). CONCLUSIONS:Our study showed that dermatome-induced lacerations are rare events and that certain factors predispose patients to injury. An algorithm was developed to provide guidance on risk factor identification and the set up and use of dermatomes.

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作者列表:["Karim AS","Shaum K","Gibson ALF"]

METHODS::In the management of indeterminate-depth burns (IDB), common challenges include the ability to predict time to healing and regenerative potential, risk of burn wound progression, and timing of excision. Several technologies exist to aid in determination of the depth of a burn injury, yet surgeons continue to rely on the naked eye-visual assessment-as the standard of care. Newer and improved imaging technologies are closing in on the goal of inexpensive, accurate, noninvasive modalities for depth determination. Likewise, management of IDB is becoming more sophisticated as newer wound healing technologies continue to be developed. By describing what is meant by "indeterminate" depth burns, and their associated challenges, we hope to stimulate interest in research to develop new therapies and management strategies. The ultimate goal is to treat IDB without the need for autografts.

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作者列表:["Griffin BR","Frear CC","Babl F","Oakley E","Kimble RM"]

METHODS:STUDY OBJECTIVE:First-aid guidelines recommend the administration of cool running water in the early management of thermal injury. Our objective is to analyze the associations between first aid and skin-grafting requirements in children with burns. METHODS:This cohort study used a prospectively collected registry of patients managed at a tertiary children's hospital. Multivariate logistic regression models were used to evaluate the relationship between first aid and the requirement for skin grafting. Secondary outcomes included time to re-epithelialization, wound depth, hospital admission and length of stay, and operating room interventions. Adequate first aid was defined as 20 minutes of cool running water within 3 hours of injury. RESULTS:In our cohort of 2,495 children, 2,259 (90.6%) received first aid involving running water, but only 1,780 (71.3%) were given the adequate duration. A total of 236 children (9.5%) required grafting. The odds of grafting were decreased in the adequate first aid group (odds ratio [OR] 0.6; 95% confidence interval [CI] 0.4 to 0.8). The provision of adequate running water was further associated with reductions in full-thickness depth (OR 0.4; 95% CI 0.2 to 0.6), hospital admission (OR 0.7; 95% CI 0.3 to 0.9), and operating room interventions (OR 0.7; 95% CI 0.5 to 0.9), but not hospital length of stay (hazard ratio=0.9; 95% CI 0.7 to 1.2; P=.48). CONCLUSION:Burn severity and clinical outcomes improved with the administration of cool running water. Adequate first aid must be prioritized by out-of-hospital and emergency medical services in the preliminary management of pediatric burns.

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