Publications by authors named "Rebecca Coffey"

34 Publications

Clinical outcomes following burn injury across the continuum of chronic glycemic control.

Burns 2020 Nov 7. Epub 2020 Nov 7.

Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, OH, United States. Electronic address:

Diabetes has been associated with poor outcomes following burn injury. There is limited data related to prediabetes in burn injury, and no studies to date have compared clinical outcomes inpatients without diabetes, with prediabetes, and with diabetes. Therefore, this study aimed to compare clinical outcomes after burn injury across the continuum of pre-injury glucose control. A propensity score weighted cohort study of adult patients admitted for initial management of burn injury was performed. Patients were categorized as no diabetes, prediabetes or diabetes based on their admission hemoglobin A1c and past medical history. The primary outcome was length of stay per percent Total Body Surface Area (TBSA) burn. Secondary outcome measures included length of stay, all-cause hospital mortality, disposition at discharge, re-grafting of same site, and amputations. A total of 2450 patients were screened; 1137 patients were included for evaluation (236 diabetes, 191 prediabetes, 710 no diabetes). After inverse probability weighing to adjust for potentially confounding factors, patients in the diabetes group had longer length of stay/%TBSA burn than both the no diabetes group (ratio of geometric means (95% CI) = 1.65 (1.25, 2.18), p < 0.001) and the prediabetes group (ratio (95% CI) = 1.49 (1.10, 2.02), p = 0.01). No statistically significant differences in secondary outcomes were observed between groups other than a higher rate of amputations in the diabetes group (2.7%) compared to the no diabetes (0.7%, p = 0.047) and prediabetes (0%, p = 0.04) groups. Further studies are needed to delineate the differences across the continuum of pre-injury glucose control in order to identify mechanisms to optimize burn-related outcomes.
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http://dx.doi.org/10.1016/j.burns.2020.10.018DOI Listing
November 2020

Safety, feasibility, and acceptability of patient-controlled anxiolysis with dexmedetomidine for burn-care dressing changes: an open-label, single-arm, pilot study.

Int J Burns Trauma 2020 15;10(5):269-278. Epub 2020 Oct 15.

Department of Surgery, Division of Trauma, Critical Care and Burn, The Ohio University Wexner Medical Center Columbus, OH, USA.

Anxiety is common among patients with burn injury, occurring frequently surrounding wound care. Few pharmacologic interventions targeting anxiety in burn injury have been evaluated. This study aimed to evaluate patient-controlled anxiolysis using dexmedetomidine (PCA-DEX) in patients undergoing burn dressing changes. This was a prospective, open-label, single-arm pilot study to determine the feasibility, safety, and acceptability of PCA-DEX. PCA-DEX included a loading dose, continuous infusion, and patient-administered boluses during dressing changes for up to 5 days. Vital signs were monitored throughout PCA-DEX. Procedural pain and anxiety were evaluated before and after each dressing change. Nursing and patient satisfaction were evaluated after each dressing change. Twenty patients were included; 9 (45%) males and 11 females (55%) with a mean age of 45.1 ± 16.9 years and median total body surface area burn injury of 7 [IQR 4-9.5]%. Median heart rate and systolic blood pressure prior to PCA-DEX on day 1 were 82 [75-97] bpm and 147 [128-170] mmHg. Overall PCA-DEX was tolerated well with a median heart rate of 72 [66-82] bpm and systolic blood pressure 115 [99-141] mmHg after PCA-DEX. One patient was withdrawn due to severe bradycardia (heart rate < 45 bpm) not attributed to PCA-DEX; 4 patients experienced mild hypotension (systolic blood pressure 85-89/diastolic blood pressure 45-49 mmHg), all of which resolved without intervention. The majority of both nurses and patients were either satisfied or highly satisfied with PCA-DEX overall (78.1% for nursing, 86.5% for patients). PCA-DEX is a novel, safe and feasible method of anxiolysis during burn dressing changes with high patient and nurse satisfaction rates. A randomized, controlled trial is warranted to confirm the efficacy of PCA-DEX.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675207PMC
October 2020

Nurses Can Resuscitate.

J Burn Care Res 2021 Mar;42(2):167-170

Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio.

Fluid resuscitation in the first 48 hours postburn is crucial in the management of burn shock. The primary purpose of this study was to evaluate nurses' adherence to a nurse-driven fluid resuscitation protocol at one adult burn center. Their secondary goal was to establish that the use of a nursing-driven protocol did not result in over resuscitation. Following implementation of a nurse-driven burn resuscitation protocol, a 48-hour data resuscitation data collection tool was developed by the burn physicians and nurses. All resuscitations were reviewed in real-time and in burn leadership meeting to identify opportunities for improvement. Follow-up with nursing staff was done in real time by the clinical nurse specialist following each burn resuscitation. Twenty-two patients requiring formal fluid resuscitation were included in the review. Patients had a median age of 36.5(IQR: 38.74) years and were predominantly male. They found that in the first 24 hours that patients received 3.47 ml/kg/hr and then in the next 24 hours they received an average of 2.68 ml/kg/hr. All 22 patients' resuscitation was initiated using the Parkland formula in the emergency department, and nurses were successful in consistently adjusting fluid infusions consistent with the protocol. Using a multidisciplinary approach and preparatory and real-time education processes, burn nurses can successfully guide burn resuscitation. Providing education and follow-up in real time can improve the process.
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http://dx.doi.org/10.1093/jbcr/iraa153DOI Listing
March 2021

Direct comparison of reproducibility and reliability in quantitative assessments of burn scar properties.

Burns 2021 Mar 2;47(2):466-478. Epub 2020 Aug 2.

Department of Biomedical Engineering, The Ohio State University, Columbus, OH, United States; Department of Materials Science and Engineering, The Ohio State University, Columbus, OH, United States; Research Department, Shriners Hospitals for Children, Cincinnati, OH, United States. Electronic address:

Introduction: Determining the efficacy of anti-scar technologies can be difficult as qualitative, subjective assessments are often utilized instead of systematic, objective measures. Perceptions regarding the reliability of instruments for quantitative measurements along with their high cost and increased data collection time may discourage their use, leading to use of scar scales which are relatively quick and low-cost. To directly evaluate the reliability of instruments for quantitative measurements of scar properties, instruments and two qualitative scales were compared by assessing a variety of cutaneous scars.

Methods: Scar height and surface texture were evaluated using a 3D scanner and a mold/cast technique. Scar color was evaluated by using a spectroscopy-based tool, the Mexameter®, and digital photography with image analysis. Scar biomechanics were evaluated using the BTC-2000™, Dermal Torque Meter (DTM®), and ballistometer®. The Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) were used to qualitatively evaluate the same scar properties. Intraclass correlation coefficients (ICC) were used to determine inter- and intra-user reliability (poor, moderate, good, excellent) with all instruments and the kappa reliability statistic was used to asses inter-user reliability (poor, fair, moderate, good, very good) for VSS and POSAS. Time for measurement collection and after collection analysis was also recorded.

Results: The Mexameter® was the most reliable method for evaluating erythema and pigmentation compared to digital photography and image processing, POSAS and VSS. Digital photography and analysis was more reliable than POSAS and VSS. Assessment of scar height was significantly more reliable when using a 3D scanner versus VSS and POSAS. The 3D scanner and mold-cast techniques also offered an additional benefit of providing an absolute value of scar height relative to the surrounding tissue. Intra-user reliability for all mechanical tests was moderate to good. Inter-user reliability was greater when using the BTC-2000™ and ballistometer® versus the DTM®. All quantitative measurements took less than 90 s for collection, with the exception of the mold/cast technique.

Conclusion: Non-invasive instruments allow scar properties to be quantitatively assessed with high sensitivity and as a function of time and/or treatment without the need for biopsy collection. Overall, the reliability of scar assessments was significantly improved when quantitative instruments were utilized versus scar scales. Quantitative assessment of color and biomechanics were swift, requiring less than 90 s per measurement while assessments of texture and height required additional analysis time after collection. With proper training of clinical staff and well-defined protocols for measurement collection, reliable, quantitative assessments of scar properties can be collected with little disruption to the clinical workflow.
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http://dx.doi.org/10.1016/j.burns.2020.07.018DOI Listing
March 2021

Reply to Letter to the Editor on "The impact of serum zinc normalization on clinical outcomes in severe burn patients".

Burns 2020 08 29;46(5):1235-1236. Epub 2020 Apr 29.

Department of Pharmacy, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, OH 43210, USA. Electronic address:

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http://dx.doi.org/10.1016/j.burns.2020.04.007DOI Listing
August 2020

One center's experience developing a burn outpatient registry.

Burns 2020 06 23;46(4):836-841. Epub 2019 Nov 23.

Division of Trauma, Critical Care, and Burn, Department of Surgery, 395 W. 12(th) Avenue, 6th Floor, Columbus, OH 43210 United States. Electronic address:

Introduction: Recent advances in burn care have resulted in the transition of care from inpatient to outpatient. There is a growing appreciation that with improved survival, meaningful markers of quality need to include recovery of form, function, and reconstruction. Capture of the data describing care delivered in the outpatient setting is being missed.

Methods: Development of our outpatient database included providers, registrar, program manager, and outpatient nursing staff. Data points were included if they described the population, and epidemiology of our patients, were useful for programmatic changes and improvements as well as anticipated research focus areas.

Results: The database platform chosen was Midas+™ because it was in use by hospital quality and integrated with the electronic medical record. Fields were customized based on changing program needs and are updated for new programs or outcomes measures. Reports can be easily built and both outpatients and inpatients are included. This allows for longitudinal tracking of burn patients. Ongoing additions to original data points include variables to track outcomes related to laser therapy for scar management, time to custom garment donning, and to track functional outcomes. Epidemiologic data collected is used to target high-risk populations for prevention and outreach efforts. Outcome data is used for evaluation of programs and care.

Conclusions: High quality databases serve to measure effectiveness of care and offer insight for areas of improvement. There is a clear need for inclusion of outpatient activity in the National Burn Registry (NBR).
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http://dx.doi.org/10.1016/j.burns.2019.10.020DOI Listing
June 2020

The impact of serum zinc normalization on clinical outcomes in severe burn patients.

Burns 2020 05 21;46(3):589-595. Epub 2019 Sep 21.

Department of Pharmacy, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, OH 43210, USA. Electronic address:

Introduction: Patients with thermal burns become zinc deficient due to exudative losses, increased urinary excretion, and reduction of carrier proteins which results in impaired immunity, wound healing and glucose control. Previous trials have demonstrated improved wound healing utilizing fixed zinc supplementation, but none have assessed the potential benefits associated with normalizing serum zinc concentrations. The objective of this study was to compare the impact of zinc normalization on clinical outcomes in patients with severe thermal burns.

Methods: This retrospective, single-center study of patients with at least 10% total body surface area (TBSA) burn and three serum zinc concentrations compared the ratio of hospital length of stay (LOS) over TBSA burned (LOS/TBSA index) between those with normal (≥60 mcg/mL) and non-normal (<60 mcg/mL) serum zinc concentrations; delineated by the third measurement. Secondary outcomes were time to 90% epithelialization, infection incidence, and percentage of blood glucose values greater than 180 mg/dL. Data are reported as median [25-75% interquartile range] for continuous variables and frequency (percent) for categorical variables.

Results: A total of 56 patients were included for evaluation (11 normal and 45 non-normal). Burn size was 20.5% TBSA [11-29] for those with normal zinc and 27.3% [22-36] for non-normal; number of grafts for each group was 1 [0-1] vs 2 [1-3] respectively. LOS/TBSA index did not differ significantly between groups (1.10 normal vs. 1.21 non-normal, unadjusted p = 0.69; p = 0.75 adjusting for number of grafts). Time to 90% epithelialization was reduced in the normal group (27.5 vs. 57 days, p = 0.02), but this did not remain statistically significant after adjustment for %TBSA and number of grafts (p = 0.18). The groups did not differ significantly in incidence of infection or hyperglycemia in either unadjusted or adjusted analyses.

Conclusions: This was the first study, to our knowledge, to assess the clinical impact of normalizing serum zinc levels in patients with severe burns. Our results suggest the normalization of serum zinc levels through individualized zinc supplementation is not associated with improvement in clinical outcomes during hospitalization and therefore fixed-dose zinc supplementation without acquisition of serum zinc measurements should be considered.
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http://dx.doi.org/10.1016/j.burns.2019.08.012DOI Listing
May 2020

Pregabalin in the reduction of pain and opioid consumption after burn injuries: A preliminary, randomized, double-blind, placebo-controlled study.

Medicine (Baltimore) 2019 May;98(18):e15343

The Ohio State University Medical Center, Department of Anesthesiology.

Background: The primary objective of the study was to evaluate the efficacy of 300 milligrams (mg) and 600 mg of pregabalin compared to placebo in the reduction of pain in patients with noncritical partial and full thickness burn injuries.

Methods: A prospective, randomized, double-blinded, single center, placebo-controlled trial was conducted. Simple randomization method was used in this trial. After subjects met all the inclusion and none of the exclusion criteria, they were randomized and assigned to 1 of the 3 18-day treatments groups: Pregabalin 300 group, Pregabalin 600 group, or Placebo group. Demographics and clinical characteristics were recorded. The severity of pain was assessed by using the visual analog scale for pain intensity at baseline on day 3, day 9 ± 3, day 25 ± 7, day 90 ± 6, and day 180 ± 12.

Results: A total of 54 subjects were randomly assigned, and 51 were included in the data analysis. Demographics and clinical characteristics did not differ significantly between the 3 groups. There was a statistically significant difference in pain between the Pregabalin 300 and Pregabalin 600 groups (P-value = .0260). The Pregabalin 300 group had 17.93 units (95% confidence interval: 1.83-34.04) higher pain scores on average than the Pregabalin 600 group, regardless of time. The adjusted P-value comparing 0 to 300 was .1618, while the adjusted P-value for 0 versus 600 was .5304. There was an overall difference in pain across time regardless of study group (P-value = <.0001). An overall difference in opioid consumption (P-value = .0003) and BSHS (P-value = .0013) across time regardless of study group was noted.

Conclusions: Pregabalin could be part of a promising multimodal analgesic regimen in noncritical burn population. Future placebo-controlled studies assessing the use of pregabalin in burn victim patients may further endorse our findings.
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http://dx.doi.org/10.1097/MD.0000000000015343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6504294PMC
May 2019

Survey of national and local practice of compression therapy timing for burn patients in the United States.

Burns 2019 08 7;45(5):1215-1222. Epub 2019 Jan 7.

Division of Trauma, Critical Care, and Burn, Department of Surgery, College of Medicine, The Ohio State University, Columbus, Ohio, United States; Research Department, Shriners Hospitals for Children, Cincinnati, Ohio, United States. Electronic address:

Objective: Compression therapy (CT) has been an important, but debated, treatment for burn scars. To better understand one source of variation in observed outcomes after CT, an evaluation of CT timing of application is needed.

Materials And Methods: Following IRB approval, 126 burn centers were contacted to complete a 17-question survey regarding the center's practice pattern for compression garment therapy. Locally, study subjects were identified between March 1, 2014 and December 31, 2015 and medical records examined for timing of garment ordering, delivery and fitting.

Results: The majority believed that compression therapy is beneficial. Most centers reported using custom-fit and pre-fabricated garments, and a goal time of application between 2-4 weeks (42%) and 4-6 weeks (36%). After the garments are ordered, 61% of centers estimate that it takes 2-4 weeks for them to arrive. No significant differences in practices were found among centers treating pediatric patients only, adults only or both. Locally, the mean number of weeks between the date of original injury and garment order placement was 9.1 weeks with an additional 8.7 weeks between the date of order and date of delivery.

Conclusions: The current study identified that although the national reporting of time to garment application is estimated to be between 2-6 weeks at the majority of burn centers including our own, we found our center to be well in excess of 17 weeks. The findings offer an opportunity for local improvement, and raise the possibility of similar incongruity between goals and practice at other centers.
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http://dx.doi.org/10.1016/j.burns.2018.12.016DOI Listing
August 2019

Incidence of oxandrolone induced hepatic transaminitis in patients with burn injury.

Burns 2019 06 10;45(4):891-897. Epub 2018 Dec 10.

Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, United States. Electronic address:

The benefits of oxandrolone in burn patients has led to its accepted use in the burn care community, however details regarding the most common adverse effect, transaminitis, remains unclear. The purpose of this study was to determine the incidence of transaminitis in patients with burn injury and identify risk factors associated with the development of transaminitis. This single-center, retrospective risk factor analysis compared burn patients on oxandrolone with and without the development of transaminitis, defined as any aspartate aminotransferase or alanine aminotransferase value >100mg/dL. Patient demographics, past medical history, lab values, and burn characteristics were recorded. Overall 28 out of 66 (42%) patients developed transaminitis. The transaminitis group had a significantly higher proportion of other concomitant medications with a transaminitis risk (p=0.045). No significant difference in liver dysfunction or length of stay was observed between the two groups. Oxandrolone induced transaminitis is occurring in patients significantly more frequently than previously reported warranting further research to guide monitoring requirements, use of concomitant medications, and to determine if rechallenging after resolution should be considered.
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http://dx.doi.org/10.1016/j.burns.2018.10.024DOI Listing
June 2019

Incidence of Unplanned 30-Day Readmissions in Adult Burn Patients in the United States.

J Burn Care Res 2018 10;39(6):923-931

The Ohio State University College of Medicine, Columbus, Ohio.

This study characterizes adult burn readmissions in the United States using a nationally representative hospital inpatient sample. Readmission rates, diagnoses, and risk factors are discussed. We analyzed the 2013 and 2014 Nationwide Readmission Database for adult burn patients. The data were weighted to estimate national 30-day readmission rates. Principal readmission diagnoses were sorted into burn-specific or other readmission categories. We used multivariable logistic regression to assess the effects of patient and hospital stay risk factors on readmissions. An estimated 42,957 U.S. adult burn patients were discharged between January and November of 2013 and 2014. Of these patients, an estimated 3203 had unscheduled readmissions within 30 days (all-cause readmission rate: 7.5%, 95% CI: 6.7-8.2). An estimated 55.4 per cent of unplanned readmissions were for burn-specific principal readmission diagnoses. Burn-specific readmission was associated with burn severity and increased with both patient age and the number of comorbidities. Patients whose length of stay was less than 1 day per % total body surface area (%TBSA) burned had higher readmission risk (Adjusted odds ratio = 2.10, 95% CI = 1.48-2.99). The results of logistic regression models were similar for burn-specific readmissions and all-cause readmissions. In a nationally representative sample of adult burn patients, 4.1 per cent had unplanned 30-day readmissions for burn-specific reasons; 7.5 per cent were readmitted for any reason. Patient comorbidities and discharge before 1 day per %TBSA from the hospital impact readmission risk. Healthcare providers can use this information to identify at-risk patients, modify their treatment plans, and prevent readmissions.
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http://dx.doi.org/10.1093/jbcr/iry008DOI Listing
October 2018

The use of intravenous tPA for the treatment of severe frostbite.

Burns 2017 Aug 31;43(5):1088-1096. Epub 2017 Jan 31.

Department of Surgery, Division of Critical Care, Trauma and Burn, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH 43210, USA. Electronic address:

Objective: tPA and anticoagulation for treatment of severe frostbite have been reported suggesting differences in imaging techniques, route of tPA administration and management of patients after tPA infusion. This is a report of our results following a protocol of Tc-99m scanning, intravenous tPA administration, followed by either systemic anticoagulation or antiplatelet therapy.

Methods: Patients admitted to our burn center between February 13, 2015 and February 13, 2016 for frostbite who met inclusion criteria were treated with Tc-99m scan and intravenous tPA followed by systemic anticoagulation or antiplatelet therapy. Inclusion criteria included rewarming had not started more than 24h prior to the scan and no contraindications to the use of tPA.

Results: Fifteen patients met inclusion criteria and 12 were treated according to the protocol. Nine received scans with 2 showing normal perfusion. Seven displayed perfusion defects and received intravenous tPA. Five recovered fully after tPA. Two who showed improved but abnormal scans after tPA experienced bleeding complications necessitating stopping heparin/Coumadin. Those two went on to partial amputation of digits.

Conclusion: The use of intra-arterial or intravenous tPA along with angiography or Tc-99m scanning followed by systemic anticoagulation or antiplatelet therapy may be beneficial to patients suffering frostbite.
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http://dx.doi.org/10.1016/j.burns.2017.01.013DOI Listing
August 2017

TRALI following fresh frozen plasma resuscitation from burn shock.

Burns 2017 Mar 28;43(2):397-402. Epub 2016 Oct 28.

Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA. Electronic address:

Introduction: Resuscitation from burn shock using fresh frozen plasma (FFP) has been described. Critics of FFP resuscitation cite the development of transfusion related acute lung injury (TRALI) as a deterrent to its use. This study examines the occurrence of TRALI with FFP resuscitation of critically ill burned patients.

Methods: A retrospective chart review was conducted of severely burned patients who received FFP resuscitation. Data points included age, TBSA, TBSA full thickness, presence of alternate etiologies of acute lung injury, total FFP administered, and signs and symptoms of TRALI as defined per the Canadian Blood Services Consensus Conference.

Results: Eighty-three patients met the definition of severe burn and received FFP resuscitation. Of those, 65 met exclusion criteria. Eighteen patients were left for analysis with only one found to have signs and symptoms of TRALI. That patient suffered a 53.5% TBSA burn, received a total of 6228ml FFP, had no competing etiologies of ALI, and was diagnosed with TRALI within 6h of completing the FFP transfusion.

Conclusion: The possible occurrence of TRALI in burn patients receiving FFP resuscitation should be weighed against the reported benefits of such a resuscitation strategy.
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http://dx.doi.org/10.1016/j.burns.2016.08.016DOI Listing
March 2017

Low Vitamin D Level on Admission for Burn Injury Is Associated With Increased Length of Stay.

J Burn Care Res 2017 Jan/Feb;38(1):e8-e13

From the *The Ohio State University College of Pharmacy, Columbus; †Department of Clinical Nutrition, The Ohio State University Wexner Medical Center, Columbus; ‡Department of Surgery, Division of Trauma, Critical Care and Burn, The Ohio State University Wexner Medical Center, Columbus; and §Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus.

Currently, there have been few studies that have evaluated the incidence of vitamin D deficiency in adult burn patients or correlated vitamin D levels with burn-related outcomes. The primary objective of the study was to identify the incidence of vitamin D deficiency and insufficiency in an adult burn population. The secondary objective was to determine the impact of vitamin D deficiency and insufficiency on clinical outcomes in burn care. A single-center, retrospective, and observational cohort analysis of adult patients admitted for initial management of burn injury, who had a 25-hydroxyvitamin D (25D) level measured on admission, was performed. Patients were categorized as vitamin D deficient (25D <10 ng/ml), insufficient (10-29 ng/ml), or sufficient (30-100 ng/ml) based on admission measurements. Clinical outcomes including complications, intensive care unit (ICU) and hospital length of stay (LOS), and survival were compared between patients with vitamin D deficiency/insufficiency and patients with vitamin D sufficiency. Three-hundred and eighteen patients were eligible for evaluation. Admission 25D level correlated with deficiency in 46 patients (14.5%), insufficiency in 207 (65.1%), and normal in 65 (20.4%). Patients with vitamin D deficiency or insufficiency experienced higher rates of complications and longer ICU and hospital LOS compared with those with normal vitamin D levels. A large proportion of patients with burn injury presented with vitamin D insufficiency and deficiency which was associated with poor outcomes, including prolonged ICU and hospital LOS. Additional studies are needed to further describe the relationship between vitamin D status and clinical outcomes.
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http://dx.doi.org/10.1097/BCR.0000000000000445DOI Listing
February 2018

Survey of the Statewide Impact of Payer Source on Referral of Small Burns to Burn Centers.

J Burn Care Res 2017 Jul/Aug;38(4):e699-e703

From the Department of Surgery, Division of Trauma, Critical Care, and Burn, Wexner Medical Center, The Ohio State University, Columbus.

It is generally agreed that patients with large burns will be referred to organized burn centers, however, the referral of patients with smaller burns is less certain. A two-part survey was conducted to identify referral patterns for burn patients that meet American Burn Association referral criteria, and any effect insurance type might have on the referral patterns. The emergency departments of our state hospital association's member hospitals were contacted seeking a referral for a fictitious patient with a third-degree scald of the dominant hand. The referral sites were contacted twice, first stating that the patient had commercial insurance, next stating that the patient had Medicaid. Data collected included wait time for an appointment or reasons for denial of an appointment. Of 218 hospitals, 46 were excluded because they did not offer emergency care, and eight because they were listed as burn centers on the American Burn Association website. Of the remaining 164, 119 (73%) would refer to a burn center, 21 (13%) to a plastic surgeon, 10 (6%) to a hand surgeon, 7 (4%) to a wound center, 7 (4%) to another nonburn physician resource. There was no difference in wait time to the first available appointment with regards to insurance type (6.56 ± 4.68 vs 6.53 ± 5.05 days). Our state's referral pattern gives us insight into the regional referral pattern. This information will be used to guide a focused education and communication program to provide better service for the burn victims of our state.
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http://dx.doi.org/10.1097/BCR.0000000000000437DOI Listing
April 2018

Burn Center Barrier Protocols During Dressing Change: A National Survey.

J Burn Care Res 2015 Jul-Aug;36(4):e238-43

From the Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.

Infection control is a critical component of post-burn care with prevention of infection serving as a major cause of decreasing morbidity and mortality. One potential deterrent for infection is barrier protection during dressing changes; however, no evidence-based standard has been established among burn centers. The purpose of this study is to describe the current barrier techniques of American burn centers. A 24-question survey was sent to 121 burn center nurse managers within the United States. The survey was comprised of yes or no questions with comment sections available for further detail. Questions were constructed to gain insight into the variation and commonality that may exist between burn center barrier protocols. Forty-one out of 121 centers (34%) responded. Centers reported the use of head covers, masks, gowns, and gloves during admission of a new burn (71%, 82%, 95%, and 100% respectively); daily dressing changes (64%, 80%, 97%, and 100% respectively); postoperative dressing changes (64%, masks 80%, 97%, and 100% respectively); and dressing changes of a nonburn (66%, 82%, 97%, and 100% respectively). Burn centers reported their use of sterile gloves and gowns during typical burn dressing changes as occurring 20% and 10% of the time, respectively. Estimates for costs of these garments annually ranged from $0 to $250,000. A calculation performed for this study demonstrated that barrier garments used for dressing changes nationwide is approximately $2.43 million. We demonstrated the immense cost, to an institution and nationwide, of barrier garments used solely for dressing changes.
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http://dx.doi.org/10.1097/BCR.0000000000000136DOI Listing
April 2016

Comorbidity-polypharmacy score predicts in-hospital complications and the need for discharge to extended care facility in older burn patients.

J Burn Care Res 2015 Jan-Feb;36(1):193-6

From the Division of Trauma, Critical Care, and Burn, Department of Surgery, The Ohio State University College of Medicine, Columbus.

Advancing age is associated with increased mortality despite smaller burn size. Chronic conditions are common in the elderly with resulting polypharmacy. The Comorbidity-Polypharmacy Score (CPS) facilitates quantitative assessment of the severity of comorbid conditions, or physiologic age. Burn injury in older patients is associated with increasing morbidity and mortality and the CPS may be predictive of outcomes such as mortality, ICU and hospital LOS, complications, and final hospital disposition. Our goal was to evaluate the predictive value of CPS for outcomes in the elderly burn population. A retrospective study was undertaken of 920 burn patients with age ≥45 admitted with acute burn injuries (January 1, 2006 to December 31, 2012). CPS was calculated by adding preinjury comorbidities and medications. Subjects were stratified into three groups according to CPS severity. Data collected included demographics, total body surface area burned (TBSA), presence of inhalation injury, ICU/hospital length of stay, complications, discharge disposition, and mortality. Univariate and multivariate analyses were performed. The mean age was 55.7; 72.9% were males; the mean initial TBSA was 6.93%; and mean CPS was 8.01. The risk of in-hospital complications is independently associated with CPS (OR 1.35). CPS (OR 1.81) was an independent predictor of discharge to a facility CPS but not of mortality. While increasing CPS was associated with lower TBSA, mortality remained unchanged. CPS is an independent predictor of in-hospital complications and need for transfer to extended care facilities in older burn patients, which can be determined at the stage of admission to help direct patient management.
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http://dx.doi.org/10.1097/BCR.0000000000000094DOI Listing
October 2015

Evaluation of TCOM/HBOT practice guideline for the treatment of foot burns occurring in diabetic patients.

Burns 2015 May 16;41(3):536-41. Epub 2014 Oct 16.

The Ohio State University Wexner Medical Center, 10th Avenue, N748 Doan Hall, Columbus, OH 43210, United States.

Objectives: A multidisciplinary team developed an evidence-based guideline for the management of foot burns occurring in diabetic patients that included transcutaneous oxygen measurements (TCOM) and application of hyperbaric oxygen therapy (HBOT) to selected patients. This report represents an evaluation of preliminary TCOM/HBOT data.

Methods: This is a retrospective review of patients with diabetes mellitus (DM) who were admitted to a single American Burn Association (ABA) verified burn center for the treatment of foot burns. Patients were treated via the guideline if they were over the age of 16, admitted for the initial care of burns involving the feet between 4/01/2012 and 7/22/2013, and had a known or new diagnosis of DM.

Results: Eighteen patients were treated according to the guideline, 14 men and 4 women. Average age was 54 years+14.78. Average BMI was 30.63+6.34. Median burn size was 0.88% TBSA (median partial thickness of 1% and median full thickness of 0.5%). The average HbA1c was 9.08+2.42. Seven patients received pre-operative HBOT, two received post-operative HBOT and three patients healed their wounds with HBOT alone. Average hospital length of stay was 13.39 days+9.94 and was significantly longer for the group receiving HBOT. Admission HbA1c was not a predictor of the need for HBOT.

Conclusions: While TCOM/HBOT therapy has not been widely applied to the management of diabetic foot burns, the use of an evidence-based guideline incorporating TCOM/HBOT can provide a systematic way to evaluate the patients' microcirculation and ability to heal burns of the foot. The incorporation of TCOM determination and application of HBOT in selected patients with DM and burns of the feet warrant continued study.
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http://dx.doi.org/10.1016/j.burns.2014.08.001DOI Listing
May 2015

A clinician's guide to the treatment of foot burns occurring in diabetic patients.

Burns 2014 Dec 20;40(8):1696-701. Epub 2014 Mar 20.

Department of Endocrinology, Diabetes and Metabolism, The Ohio State University Wexner Medical Center, Columbus, OH, USA.

Introduction: Diabetes mellitus affects 25.8 million Americans and is predicted to almost double by 2050. The presence of diabetes complicates hospital courses because of the microvascular complications associated with disease progression. Patients with diabetes represent 18.3% of annual burn admissions to our unit and 27% have burns to the feet. The purpose of this project was to develop an evidence-based guideline for care of the patient with diabetes and foot burns

Methods: A multidisciplinary group was charged with developing an evidence-based guideline for the treatment of foot burns in patients with diabetes. Evidence was evaluated in the areas of diabetes, burn care, hyperbaric medicine, care of diabetic foot wounds and physical therapy. After guideline development and approval, key aspects were incorporated into order sets.

Results: Key aspects of this guideline are the ability to identify patients with undiagnosed diabetes, assess diabetic control, optimize glycemic and metabolic control, optimize burn wound management, treat microvascular disease, and provide education and a discharge plan. Evaluated outcomes are glycemic control, length of stay, complication rates, amputation rates, infection rates and the use of hyperbaric oxygen.

Conclusions: Best outcomes for this high risk population will be attainable with an evidence based guideline.
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http://dx.doi.org/10.1016/j.burns.2014.01.026DOI Listing
December 2014

The impact of prediabetes on glycemic control and clinical outcomes postburn injury.

J Burn Care Res 2014 Jan-Feb;35(1):5-10

From the *The Ohio State University College of Medicine, Columbus; and †Division of Trauma, Department of Surgery, and ‡Department of Pharmacy, Critical Care and Burn, The Ohio State University Wexner Medical Center, Columbus.

Poor glucose control and clinical outcomes have been observed in diabetic versus nondiabetic patients postburn injury. Prediabetes is a precursor to diabetes. The purpose of this study was to assess the effects of prediabetes on postinjury glucose control and clinical outcomes. A retrospective review was conducted comparing prediabetics and euglycemic controls. Patients who were admitted for burn care were 18 to 89 years of age and had a hemoglobin A1c (HbA1c) obtained on admission. Prediabetics were defined by an HbA1c of 5.7 to 6.4% and controls by HbA1c < 5.7%. Inpatient glucose levels were recorded, in addition to clinical outcomes. Two hundred eight patients were included: 54 prediabetics and 154 controls. The prediabetic population was older (50.7 vs 39 years; P < .001) with more hypertensives (44.4 vs 16.9%; P < .001), consisted of more African-Americans (20.4 vs 12%; P = .04), and had larger areas of full-thickness burns (4.5 vs 1.75%; P = .02). Median admission HbA1c was 5.9 (5.7-6.0)% among prediabetics and 5.3 (5-5.45)% among controls (P < .001). Prediabetics had significantly higher time-weighted glucose levels (127.7 [105.5-147.6] vs 108.0 [97.1-122.2] mg/dl; P < .001) and more had an average inpatient glucose >150 mg/dl (20.4 vs 9.1%; P = .028). There was no difference in rates of hypoglycemia (glucose <70 mg/dl) or glycemic variability. Prediabetics had lower survival rates (92.6 vs 98.7%; P = .041), but similar rates of unplanned readmission (1.9 vs 3.9%; P = .68), intensive care unit admission (29.6 vs 23.4%; P = .36), mechanical ventilation (24.1 vs 16.2%; P = .20), length of hospital stay (4 [2-8] vs 3 [2-11]; P = .71), and infection (11.1 vs 11.7%; P = .99). Prediabetic status has a significant impact on glucose control and mortality after burn injury.
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http://dx.doi.org/10.1097/BCR.0b013e3182a2adeaDOI Listing
September 2014

Of lust and lysol.

Authors:
Rebecca Coffey

Sci Am 2013 Apr;308(4):20

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http://dx.doi.org/10.1038/scientificamerican0413-20bDOI Listing
April 2013

Evaluation of the safety and efficacy of a nursing-driven midazolam protocol for the management of procedural pain associated with burn injuries.

J Burn Care Res 2013 Jan-Feb;34(1):176-82

Departments of Pharmacy, The Ohio State University Medical Center, Columbus OH 43210, USA.

Burn pain is one of the most excruciating types of pain and can be difficult to manage. Benzodiazepines may be effective in reducing pain by minimizing anxiety associated with dressing changes. This study aimed to evaluate the safety and efficacy of adjunctive midazolam during dressing changes in patients with uncontrolled pain using opioid monotherapy or significant anxiety associated with dressing changes. A retrospective cohort analysis comparing patients who received midazolam during dressing changes with control patients was performed. Each midazolam patient was matched with up to two control patients who did not receive midazolam on the basis of age, sex, TBSA burned, and grafting requirement. The primary endpoint was the oral morphine equivalents required during admission after initiation of midazolam. Thirty-six patients were included for evaluation (14 midazolam and 22 control patients). Baseline characteristics were similar between the two groups, although patients in the midazolam group had higher pain scores and oral morphine equivalent requirements at baseline. When adjusted for baseline pain, day postburn, age, sex, and grafting status, total oral morphine equivalents and mean pain scores during admission were similar between the groups. One midazolam patient experienced oxygen desaturation with midazolam, but did not require flumazenil for reversal. The use of midazolam during burn dressing changes in patients with poorly controlled pain and/or anxiety was not associated with reduced requirements for oral morphine equivalents or lower pain scores during admission. Further research into the role of benzodiazepines in burn pain management is warranted.
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http://dx.doi.org/10.1097/BCR.0b013e31826fc611DOI Listing
June 2013

The relationship between acute and chronic hyperglycemia and outcomes in burn injury.

J Burn Care Res 2013 Jan-Feb;34(1):109-14

Department of Pharmacy, Ohio State University Medical Center, Columbus, OH 43210, USA.

A significant proportion of patients with burn injury have diabetes. Although hyperglycemia during critical illness has been associated with poor outcomes, patients with chronic hyperglycemia based on elevated hemoglobin A1c (HbA1c) measurements at admission have been shown to tolerate higher glucose levels during hospitalization. This relationship has not been evaluated in the burn population. The objective of this study was to examine the impact of chronic glucose control on outcomes in the acute period after burn. This is a retrospective analysis comparing outcomes in patients with chronic hyperglycemia (HbA1c ≥ 6.5%) and euglycemia (HbA1c <6.5%). Patients aged 18 to 89 years, admitted for initial burn care between January 1, 2009, and June 30, 2010, with an HbA1c measurement at admission were included. The primary endpoint was unplanned readmissions, with secondary endpoints of length of stay and mortality. We included 258 patients (32 with chronic hyperglycemia and 226 with euglycemia). Burn severity was similar between the groups. Patients with chronic hyperglycemia were significantly older and were more likely to have diabetes, respiratory disease, and hypertension. Chronic hyperglycemia was associated with significantly higher time-weighted glucose and glucose variability. Survival rates were similar, but the chronic hyperglycemia group had a significantly longer length of stay (13 vs 9 days; P = .038) and a higher rate of unplanned readmission (18.8 vs 3.6%; P = .001). Chronic hyperglycemia before burn injury is associated with altered glycemic response after burn injury and worse outcomes. Further research is needed to identify whether chronic hyperglycemia necessitates a modified approach to burn care or glycemic management.
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http://dx.doi.org/10.1097/BCR.0b013e3182700025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809904PMC
June 2013

Impact of early methadone initiation in critically injured burn patients: a pilot study.

J Burn Care Res 2013 May-Jun;34(3):342-8

Department of Pharmacy, Methodist Healthcare, University of Tennessee Health Sciences Center, Memphis, USA.

Numerous studies have identified strategies to reduce mechanical ventilation duration by targeting appropriate sedation levels. However, applicability of these strategies to critically injured patients with burn injury has not been established. At our medical center, methadone is commonly used early in the care of burn patients to treat background pain and limit the development of opioid tolerance. The aim of this study is to evaluate the effect of early methadone initiation in critically injured burn patients requiring mechanical ventilation. This retrospective study compared patients who received early methadone with patients who did not while mechanically ventilated with the primary outcome of ventilator-free days in a 28-day period. Those who received methadone within 4 days of intubation and remained ventilated for 2 days after the first dose were included in the methadone group. Propensity scores were used to match up to three control patients to each methadone patient. Seventy patients (18 methadone and 52 matched control patients) were included in the final evaluation. Patients in the methadone group averaged 16.5 ventilator-free days compared with 11.5 in the control group (P = .03). There was no statistical difference in the duration of intensive care unit or hospital length of stay between groups. Our results suggest that early methadone initiation may have a significant effect on ventilator outcomes in critically injured patients with burn injury. However, further research is warranted.
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http://dx.doi.org/10.1097/BCR.0b013e3182642c27DOI Listing
October 2013

Effects of alcohol use and abuse on critically ill burn patients.

Crit Care Nurs Clin North Am 2012 Mar 20;24(1):1-7. Epub 2012 Jan 20.

Division of Critical Care Trauma and Burns, Department of Surgery, The Ohio State University, Columbus, OH 43210, USA.

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http://dx.doi.org/10.1016/j.ccell.2011.12.001DOI Listing
March 2012

End of life in the Burn/Trauma unit: A nursing perspective.

Int J Crit Illn Inj Sci 2011 Jul;1(2):129-31

The Ohio State University Medical Center, 410 W. 10 Avenue, N748 Doan Hall, Columbus, OH 43210, USA.

The issues related to end of life decisions and mortality in the intensive care unit are common occurrences for the nursing staff. For the Critical Care/Burn nurse, issues such as who should be resuscitated, what are the end points of treatment, and what will be the quality of life for the patient if he/she survives are major factors in end of life decisions. Furthermore, the close relationships that can develop between the nurse and the patient and/or the patient's family make end of life decisions emotionally difficult. Unlike the other members of the multidisciplinary team, the nurses spend more time with the dying patient and his/her family, answering questions, explaining the care and course of the illness, and assisting the patient and family in understanding what the doctors have said. Repeated explanations are needed because the family and patient are under tremendous stress. Nurses experience emotional distress and need to develop resilience to continue to care for and work with patients approaching the end stages of life. The purpose of this paper is to briefly review the literature and use a case scenario to illustrate the challenges the Critical Care/Burn nurse faces when caring for the dying patient.
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http://dx.doi.org/10.4103/2229-5151.84799DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3249845PMC
July 2011

Impact of the implementation of an alcohol withdrawal guideline on patients with burn injuries.

Clin Nurse Spec 2011 Nov-Dec;25(6):286-93

Burn Center, Ohio State University Health System, Columbus, OH 43210, USA.

Purpose: The purpose of this study was to determine the impact of implementation of evidence-based alcohol withdrawal syndrome (AWS) guideline using the Clinical Institute Withdrawal Assessment of Alcohol Scale--Revised scale on care and outcomes of burn patients with comorbid alcohol use and on physician and nurse documentation of alcohol screening, education, and referral.

Design: A retrospective medical record review of burn patients (n = 428) was completed. Data were collected on admissions 1 year before implementation of the alcohol withdrawal guideline and 1 year after implementation. Data collection included alcohol use, use of benzodiazepines, sitter use, restraint use, total body surface area, inhalation injury, previous alcohol withdrawal, length of stay, and physician and nurse documentation.

Setting: A Midwestern academic medical center with an American Burn Association and the American College of Surgeons verified burn center.

Methods: A multidisciplinary team developed evidence-based practice guidelines for the treatment of AWS. Treatment of AWS was evaluated before and after implementation of the new guidelines.

Results: Burn severity and inhalation injury were associated with patients at risk for alcohol abuse. There was no difference in the experience of alcohol withdrawal after guideline implementation. Documentation in the medical record of alcohol use, abuse, or previous withdrawal improved after implementation of the guideline.

Conclusion: Screening and treatment of alcohol abuse in the burn patient are still less than ideal.

Implications: Greater efforts should be directed at managing alcohol withdrawal. An advance practice nurse can make an important contribution.
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http://dx.doi.org/10.1097/NUR.0b013e318233ea75DOI Listing
February 2012

Early glycemic control in critically ill patients with burn injury.

J Burn Care Res 2011 Nov-Dec;32(6):583-90

Department of Pharmacy, The Ohio State University Medical Center, Columbus, OH 43210, USA.

Glucose management in patients with burn injury is often difficult because of their hypermetabolic state with associated hyperglycemia, hyperinsulinemia, and insulin resistance. Recent studies suggest that time to glycemic control is associated with improved outcomes. The authors sought to determine the influence of early glycemic control on the outcomes of critically ill patients with burn injury. A retrospective analysis was performed at the Ohio State University Medical Center. Patients hospitalized with burn injury were enrolled if they were admitted to the intensive care unit between March 1, 2006, and February 28, 2009. Early glycemic control was defined as the achievement of a mean daily blood glucose of ≤150 mg/dl for at least two consecutive days by postburn day 3. Forty-six patients made up the study cohort with 26 achieving early glycemic control and 20 who did not. The two groups were similar at baseline with regard to age, pre-existing diabetes, APACHE II score and burn size and depth. There were no differences in number of surgical interventions, infectious complications, or length of stay between patients who achieved or failed early glycemic control. Failure of early glycemic control was, however, associated with significantly higher mortality both by univariate (35.0 vs 7.7%, P = .03) and multivariate analyses (hazard ratio 6.754 [1.16-39.24], P = .03) adjusting for age, TBSA, and inhalation injury. Failure to achieve early glycemic control in patients with burn injury is associated with an increased risk of mortality. However, further prospective controlled trials are needed to establish causality of this association.
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http://dx.doi.org/10.1097/BCR.0b013e31822dc3daDOI Listing
March 2012

A web-based educational module increases burn prevention knowledge over time.

Burns 2011 Nov 2;37(7):1255-8. Epub 2011 Jul 2.

University of Louisville School of Nursing, Louisville, KY 40292, USA.

Unfortunately, burn prevention knowledge is low among nurses. Establishing efficient ways in which to increase burn prevention knowledge in nurses is warranted. The current multi-center study evaluated whether a web-based educational module was successful at increasing burn prevention immediately and whether the knowledge was retained over time. A valid, reliable burn prevention knowledge exam was administered to nurse at three time points (prior to receiving the educational module, immediately following receiving the educational module, and at least a minimum of two weeks after receiving the educational module). Generalized linear mixed effects modeling methods were used to evaluate whether scores on the burn prevention knowledge exam increased over time, while adjusting for traditional covariates (e.g., specialty area, years as a nurse, and years in current work area). Mean scores on the burn prevention knowledge exam increased over time (p=0.003); establishing that the educational module significantly improves scores over time. Mean score prior to receiving the educational module was 82.3%; the mean score was 83.8% immediately following receiving the educational module, and 86.1% two weeks after receiving the educational module. The educational module developed by the authors (www.burnpreventionstudy.org) is an efficient way in which to increase burn prevention knowledge and is available at their convenience. This education module could be used as a training module with nurses involved in burn prevention outreach, and with nurse practitioners, physicians, and emergency responders involved in primary care across the life span.
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http://dx.doi.org/10.1016/j.burns.2011.04.015DOI Listing
November 2011

Coral in love.

Authors:
Rebecca Coffey

Sci Am 2011 May;304(5):18

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http://dx.doi.org/10.1038/scientificamerican0511-18aDOI Listing
May 2011