TY - JOUR
AB - 1. Does a Patient's Weight Matter in Burn Resuscitation? J. Salinas, PhD, C. A. Fenrich, BS, M. L. Serio-Melvin, MS, RN, J. C. Graybill, MD, I. R. Driscoll, MD, L. C. Cancio, MD, FACS, K. K. Chung, MD, W. C. Peterson, MD U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX Introduction: Optimal fluid resuscitation of burn patients with burns greater than 20% total body surface area (TBSA) is critical to prevent burn shock during the initial 24 to 48 hours post burn. Currently, most resuscitation formulas and fluid prediction equations require a patient's weight to estimate amount of fluid required during this phase. However, it is unclear if actual or ideal body weight is appropriate for estimating fluid requirements accurately. The objective of this study was to determine the effects on resuscitation fluid requirements as patients deviate from their ideal body weight (IBW). Methods: We performed a retrospective review of patients admitted to our burn intensive care unit from December 2007 to April 2013 who were resuscitated using our electronic computer resuscitation decision support system. We classified patients into BMI categories of underweight (BMI: < 18.5), normal (BMI: 18.5 - 24.9), overweight (BMI: 25.0 - 29.9), or obese (BMI: > 30.0) and categories based on a patient's percent difference from their IBW (calculated using the Hamwi formula). We compared fluid volumes received for patient across all BMI and IBW categories during the initial 24 hours of resuscitation. Results: We analyzed a cohort of 194 patients that included resuscitation parameters as well as weight and height values. Mean TBSA was 40 ± 19% with a full thickness (FT) burn of 15 ± 22%. Mean age and weight were 46 ± 19 years and 84 ± 20 kg respectively. IBW for this cohort was 69 ± 11 kg with a BMI of 28 ± 6. Univariate analysis showed no significant difference in ml/kg/TBSA (range: 2.73 ± 1.33 ml/kg/TBSA to 3.09 ± 0.8 ml/kg/TBSA) or ml/kg (range: 98 ± 55 ml/kg to 127 ± 73 ml/kg) in the first 24 hours between any BMI categories (Figure). Analysis on IBW showed a significant difference in ml/kg requirements when patients deviated from IBW and actual weight (p<0.05), however, there was no difference when TBSA was included (ml/kg/TBSA). Conclusions: This analysis showed that overweight or obese patients with large burns may not require any additional fluids during their initial fluid resuscitation. In our case, there was no significant difference in fluid needs between atients with normal BMI and other BMI categories. In addition, there was no significant different in fluid needs as patients deviated from their expected IBW. Applicability of Research to Practice: Patient's weight may not be a factor when estimating the need for fluids during burn fluid resuscitation. View largeDownload slide View largeDownload slide 2. Acute Kidney Injury in Burn Victims: Progression to Dialysis I. Pronina, BSc(Hons), C. Malic, MD, FRCSC, N. Radulovic, BSc, J. Bian, BSc(Hons), M. A. Burnett, BSc(Hons), M. G. Jeschke, MD, FACS, FCCM Sunnybrook Health Sciences Centre, Toronto, ON, Canada Introduction: Acute kidney injury carries a high mortality in patients who sustain moderate to severe burn injuries. Renal replacement therapy may be required for more than 20% of patients developing AKI, yielding a higher mortality and irreversible renal changes. Previous studies have shown that age, gender and %TBSA were independently related to developing AKI. High levels of plasma creatinine 12 hours post injury indicates higher risk of developing AKI and increases mortality from burn shock. This study aims to review the outcomes of burn patients who were diagnosed with AKI and who required or not renal replacement therapy (RRT). Methods: This retrospective study over 9 years (2006–2014) at a single tertiary burn centre looked into patients with documented AKI and/or renal replacement therapy. The acute kidney injury was defined by AKIN criteria or RIFLE criteria. Two subgroups were analysed and compared further: patients who required renal replacement therapy and those who did not. Statistical analysis of demographic data, Mann Whitney test as well as multivariate logistic regression analysis were used. Results: Out of 1405 patients admitted, 53 patients were diagnosed with AKI (3.8%) with a mortality of 42%. The mean age was 53 with male predominance and a mean TBSA of 39.8%. The mean APACHE score was 11.8 (5–35), 27 patients were diagnosed with inhalational injury and 30 patients required escharotomies. The age (p=0.002) and inhalational injury (p=0/016) had a significant impact on outcome. Out of this group, 21 patients required RRT (39.6%) (33% mortality), and 32 patients did not (47% mortality). The two subgroups were comparable with no statistical differences in terms of age, inhalational injury on admission, %TBSA, APACHE Score, mean levels of plasma creatinine, time to AKI diagnosis, cardiac, renal morbidities and presence of diabetes (p>0.05). The AKIN Score was higher in the dialysis group (p<0.05). There was no relationship between AKIN score and outcome, the APACHE score in the dialysis group did not affect the mortality, although an earlier start of dialysis had a better outcome (p<0.05). Average creatinine did not affect time to dialysis or outcome. Time to diagnose AKI did not impact on the need of dialysis. The mean time to dialysis was 10.7 days (range 0–41 days), whereas the mean time in dialysis was 28 days (range 2–74 days). Conclusions: This is the largest cohort of burn patients reported who were diagnosed with AKI. Increased age and presence of inhalational injury in burn patients with AKI has a worse outcome despite extent of the burn injuries. Although the time to AKI diagnosis did not influence the final outcome, the earlier the dialysis is started, the better the outcome. Applicability of Research to Practice: Renal Replacement therapy has its role in AKI diagnosed in patients with significant burns with good outcomes. External Funding: CIHR #123336, CFI Leaders Opportunity Fund: Project #25407, NIH RO1GM087285-01. 3. Hold the Pendulum - Rates of Acute Kidney Injury are Increased in Patients Who Receive Resuscitation Volumes Less than Predicted by the Parkland Equation S. A. Mason, MD, A. B. Nathens, MD, PhD, C. C. Finnerty, PhD, R. L. Gamelli, MD, FACS, N. S. Gibran, MD, FACS, B. D. Arnoldo, MD, R. G. Tompkins, MD, ScD, FACS, D. N. Herndon, MD, FACS, M. G. Jeschke, MD, PhD Department of Surgery, Sunnybrook Health Sciences Centre and Division of General Surgery, University of Toronto, Toronto, ON, Canada; Shriners Hospitals for Children- Galveston and Department of Surgery, University of Texas Medical Branch, Galveston, TX; Department of Surgery, Loyola University Stritch School of Medicine, Maywood, IL; Department of Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, WA; Department of Surgery, University of Texas Southwestern Medical School, Dallas, TX; Department of Surgery, Massachusetts General Hospital, Shriners Hospital for Children, and Harvard Medical School, Boston, MA; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre and Division of Plastic Surgery, University of Toronto, Toronto, ON, Canada Introduction: Recent studies demonstrate that patients often receive volumes in excess of those predicted by the Parkland equation, with potentially fatal consequences. The consequences of under-resuscitation are not well-studied. We sought to identify the impact of administering less fluid than predicted by Parkland on three patient outcomes: acute kidney injury (AKI), burn wound infections (BWI), and nosocomial (non-burn wound) infections. Methods: Data were collected from a multicenter prospective cohort study of burn-injured patients. From this cohort, we identified adult patients with greater than 20% total burned surface area injury and two patterns of fluid resuscitation in the first 24 hours: volumes less than, or equal to/greater than those predicted by the Parkland equation. Multivariate regression analysis was employed to determine the effect of fluid group on AKI, BWI, and nosocomial infections. Results: Among 330 patients who met inclusion criteria, 33% received 24-hour fluid volumes less than predicted by Parkland, and 67% received volumes equal to or in excess of predicted. At baseline, the groups differed significantly in Apache score (16.4 vs 22.9, p<0.0001) but were similar in all other characteristics: age, sex, TBSA, % third degree burn, and ED base deficit. After adjusting for age, sex, TBSA, inhalation injury, and APACHE score, resuscitation with volumes less than Parkland was associated with a greater probability of AKI (OR 3.40, 95% CI 1.44–8.03), while there was no significant difference in the probability of nosocomial infections (OR 0.69, 95%CI 0.38–1.26). After adjusting for age, sex, TBSA, and inhalation injury, there was no significant difference in the probability of BWI (OR 0.84, 95%CI 0.51–1.38). Conclusions: The probability of AKI is increased in patients who receive 24-hour fluid resuscitation volumes less than predicted by the Parkland equation. There is no impact of resuscitation strategy on rates of infectious complications. Applicability of Research to Practice: While recent evidence has supported strategies to reduce fluid resuscitation, our data suggest that administration of fluid volumes less than Parkland increases the probability of AKI. Further research is warranted to identify the optimal resuscitation volume that best balances the negative effects of over and under-resuscitation. External Funding: This study was supported by a Large-Scale Collaborative Research Grant from the National Institute of General Medical Sciences (U54 GM62119) awarded to Ronald G. Tompkins at the Massachusetts General Hospital, Boston, MA and by research grants awarded to David N. Herndon at the University of Texas Medical Branch, Galveston, TX by the National Institute of General Medical Sciences (P50 GM060338, R01 GM056687, T32 GM0008256) and Shriners Hospitals for Children (71008, 84080) as well as to Marc G. Jeschke by the National Institute of General Medical Sciences (R01 GM087285), Canadian Institutes of Health Research (#123336), and CFI Leaders Opportunity Fund (Project #25407). CCF is an Institute for Translational Sciences Career Development Scholar supported, in part, by KL2RR029875 and UL1RR029876. This study was conducted with the support of the Institute for Translational Science at the University of Texas Medical Branch, supported in part by a Clinical and Translational Science Award (UL1TR000071) from the National Center for Advancing Translational Science, National Institutes of Health. Authors have no conflicts of interest to declare. 4. Drugs of Abuse during Burn Resuscitation: Bystanders or Bad Actors? P. O. Kwan, MD, FRCSC, J. Dhillon, Z. R. Godwin, BS, T. L. Palmieri, MD, FACS, FCCM, D. G. Greenhalgh, MD, FACS, S. Sen, MD, MS, FACS University of California - Davis Medical Center, Sacramento, CA Introduction: Amphetamines (AMP), cocaine (COC), and ethanol (ETOH) have been reported to complicate the burn patient resuscitation. Yet, burn outcome comparisons of the most commonly screened for drugs of abuse: AMP, COC, and ETOH, are limited. Methods: A retrospective chart review was conducted of all adult (age > 18 years) patients, admitted to a single burn center from 2006 to 2010 with burns ≥20% total body surface area (TBSA). Data collected include: demographics (age, gender), injury characteristics (inhalation injury, burn size, etiology), treatment (intravenous fluids, urine output, opioid analgesics and benzodiazepines), and admission screen results for AMP, COC, and ETOH. Statistical tests were student's t-test, analysis of variance, and multivariate linear regression. Values given as mean ± standard error. Statistical significance was set at p < 0.05. Results: There were 134 patients, 78% male and 22% female. Mean age was 43.0 ± 1.3 years, mean burn size was 36.4 ± 1.5% TBSA, mean hospitalization was 42.6 ± 2.7 days, 16% had inhalation injury, and mortality rate was 17%. Patients with positive drug screens for AMP (14.9%), COC (6.7%), or ETOH (14.2%) were similar to those with negative (NEG) drug screens (67.9%) in admission demographics, inhalation injury, burn size, and etiology. Patients positive for COC or ETOH required significantly more fluid, 2.25 ± 0.81 mL/kg/%TBSA and 1.62 ± 0.58 mL/kg/%TBSA more versus NEG patients, for resuscitation (p = 0.006), whereas AMP positive patients did not. Patients with AMP or ETOH required significantly more analgesics from 4 hours to 24 hours versus NEG patients (p < 0.03), but there were no significant differences in the quantity of benzodiazepines administered. Conclusions: When compared to NEG patients, those with positive screening for AMP, COC, or ETOH had more complex resuscitations. Patients using COC or ETOH had a higher fluid requirement over the first 24 hours, with ETOH positive patients requiring more fluid early, and COC positive patients requiring more fluid late in resuscitation. AMP positivity can reflect drugs besides methamphetamines, thus increasing variability in resuscitation. Burn resuscitation is further complicated by increased analgesic requirements in ETOH and AMP positive patients. Additional monitoring may be necessary for burn patients with associated extracurricular drug use. Applicability of Research to Practice: Patients screening positive for AMP, COC, or ETOH have more complex resuscitation requirements in terms of fluid and analgesia required. View largeDownload slide View largeDownload slide 5. Impact of Implementation of a Combined Spontaneous Awakening Trial and Spontaneous Breathing Trial in a Burn Intensive Care Unit Y. L. Lee, MD, S. Gulati, MD, J. S. Hodge, MD, J. D. Simmons, MD, M. A. Frotan, MD University of South Alabama, Mobile, AL Introduction: Paired spontaneous awakening (SAT) and spontaneous breathing trial (SBT) for sedation and ventilator weaning is considered safe and efficacious in the intensive care unit. To date there are few reports on the unique nature of burn patients utilizing this combined protocol. We implemented combiend SAT & SBT into our burn ICU on January 1, 2012. The purpose of this study was to evaluate the impact of a standardized SAT & SBT protocol on ventilator days and ventilator associated pneumonia in a burn ICU. Methods: We performed a retrospective review of our burn registry from Jan 1, 2010 to Jan 31, 2014. All patients admitted to the Burn ICU at the University of South Alabama Regional Burn Center and placed on mechanical ventilation were included in this IRB-approved study. After Jan 1, 2012, patients underwent daily SAT unless undergoing active resuscitation or requiring significant ventilator support. SAT consisted of decreasing narcotic dose by 50% and a complete sedation vacation, with success defined by the Richmond Agitation Sedation Scale, hemodynamic stability, and ability to spontaneously breathe and maintain oxygen saturation >90%. If successful, SBT was performed, with success defined as respiratory rate <40, heart rate <120% baseline, mean arterial pressure <120% baseline, oxygen saturation >90%, calmness, and Rapid Shallow Breathing Index <105. Recorded patient data include age, %Total Body Surface Area (TBSA) burn, %full thickness burn, and inhalation injury. Outcome measures included ventilator days, ICU and hospital length of stay (LOS), ventilator-associated pneumonia (VAP), tracheostomy, disposition, and mortality. Data were analyzed by Mann-Whitney Wilcoxon test and Fisher's exact test as appropriate. Results: There were 171 included admissions in the pre-SAT/SBT period, versus 136 after protocol implementation. Patients did not significantly differ with respect to age, %TBSA, or incidence of inhalation injury, though patients in the post-SAT/SBT period had greater %full thickness burns (7.691 ± 1.417 post-protocol vs. 6.070 ± 2.061 pre-protocol, p<0.05). Patients undergoing SAT/SBT had fewer ventilator days than those who did not (7.213 ± 1.734 vs. 11.63 ± 1.516, p<0.05). Incidence of VAP was also lower after implementation of SAT/SBT (3.06 vs. 8.05 per 1000 ventilator days, p<0.05). ICU and hospital LOS, need for tracheostomy, disposition, and mortality were not different. Conclusions: The number of ventilator days and incidence of VAP was significantly decreased in our burn ICU after the implementation of a combined spontaneous awakening and spontaneous breathing trial. Applicability of Research to Practice: The application of combined SAT and SBT is safe and should be routine practice in the burn intensive care unit. 6. Does Brochoscopic Evaluation of Inhalation Injury Severity Predict Outcome? S. Spano, BSc, S. Hanna, BSc, Z. Li, BSc, D. Wood, RRT, R. Cartotto, MD, FRCSC Ross Tilley Burn Centre, Toronto, ON, Canada Introduction: Although bronchoscopic evaluation of the tracheo-bronchial mucosa is essential to the diagnosis of smoke inhalation injury (INH), controversy still exists over whether or not the visualized severity of the mucosal injury predicts clinically meaningful outcomes. The purpose of this study was to assess whether the grade of mucosal injury severity was associated with various outcomes among adult burn patients. Methods: Retrospective review of all patients requiring > 48 hours of mechanical ventilation that were admitted between 1/1/07 and 6/1/13 to an adult regional ABA-verified burn center. Bronchoscopy was performed on all subjects at burn center admission and grading of severity was documented by one of the four attending burn surgeons, using the grade 1–4 levels described by Endorf and Gamelli1. Subjects with Grade 1 or 2 injury formed the Mild-Moderate Injury Group while those with Grade 3 or 4 Injury formed the Severe Injury Group. Acute Respiratory Distress Syndrome (ARDS) was defined using the Berlin Criteria. Values are shown as the median (Q1-Q3). A p value < 0.05 was considered statistically significant. Results: The study population consisted of 160 subjects [age 48 (35–60), %TBSA burn 28 (19–39.9), % full thickness(FT) burn 12.8 (0–30), with INH in 61%]. There were 62 subjects in NO INH, 78 subjects in Mild-Moderate INH (40 grade 1 and 38 grade 2), and 20 subjects in Severe INH (19 grade 3 and 1 grade 4). There were no significant differences in age, %TBSA burn, or %BSA full thickness burn between these three groups. Outcomes are shown in the table. Conclusions: Within this group of mechanically ventilated burn patients, increasing severity of inhalation injury from Mild-Moderate to Severe, as assessed by bronchoscopic evaluation, was not associated with significantly increased 24 or 48 hour fluid resuscitation volumes, significantly reduced oxygenation over the 1st three post burn days, significantly prolonged duration of ventilation, or significant reductions in ventilator-free days/1st 30 days. There were no significant differences in development of ARDS or survival between bronchoscopically-diagnosed mild-moderate inhalation injury and severe inhalation injury. Applicability of Research to Practice: This study suggests that the grading of the severity of mucosal injury as assessed by bronchoscopy may be of limited prognostic value. 1. Endorf FW and Gamelli RL. JBCR 2007;28:80–83. External Funding: Queen's University. View Large View Large 7. The Impact of Severe Burn Trauma with or without Sepsis on Skeletal Muscle Bioenergetics F. J. Bohanon, MD, C. Porter, PhD, D. N. Herndon, MD, FACS, P. T. Reidy, MS, B. B. Rasmussen, PhD, N. Bhattarai, BS, L. S. Sidossis, PhD University of Texas Medical Branch, Galveston, TX Introduction: Mitochondrial thermogenesis, i.e. respiration uncoupled from ATP production, contributes to hypermetabolism in burn victims. Sepsis, the leading cause of death in burn victims, exacerbates the hypermetabolic stress response to burn trauma. While burn trauma or sepsis alone are known to independently alter skeletal muscle bioenergetics, the impact of sepsis on skeletal muscle mitochondrial function in burn victims remains unknown. We hypothesize that sepsis worsens the mitochondrial respiratory capacity and coupling control in burn victims. Methods: Quadriceps muscle biopsies were taken from 7 non-septic burn and 12 septic adult burn patients with burns encompassing >40% of the total body surface area during the acute hospitalization period. Muscle biopsies from 16 healthy adults were collected as non-burned controls. Coupled and uncoupled mitochondrial respiration was determined in fresh, permeabilized muscle fiber bundles. Sepsis was determined by a retrospective review of patient records and classified according to the ABA Sepsis Criteria or physician determination of sepsis. Results: Maximum, coupled mitochondrial respiration was lower in non-septic and septic burn victims when compared to healthy controls (31 ± 5 vs. 24 ± 3 vs. 62 ± 5 pmols/mg/sec, respectively; P<0.001). Mitochondrial thermogenesis was significantly greater in non septic (65%) and septic (118%; P<0.001) burn patients when compared to healthy controls, evidenced by a reduction in oligomycin sensitivity. Conclusions: Non-septic and septic burn victims have impaired skeletal muscle mitochondrial respiratory capacity and function. While mitochondrial thermogenesis is elevated in skeletal muscle of all burn victims, this response is more significant in burn victims who are septic. As such, our data indicate that altered mitochondrial coupling control contributes to the more profound hypermetabolism seen in septic burn victims. Applicability of Research to Practice: Environmental and/or pharmacological strategies which blunt mitochondrial thermogenesis may be efficacious with regards to managing the hypermetabolic stress response to burn trauma and sepsis. External Funding: National Institutes of Health-P50, Project 9 (81754), R01 AR049877, P30 AG024832, T32-GM8256. ITS UL1TR000071. Shriners Hospitals for Children (84090, 71006, 85310). ADA 67666. NIDRR H133P110012. View largeDownload slide View largeDownload slide 8. Micafungin Concentrations in Plasma and Burn Eschares in Severe Burned Critically Ill Patients A. Agrifoglio, MD, PhD, M. J. Asensio, MD, PhD, M. Sánchez, MD, PhD, B. Galván, MD, PhD, E. Herrero, MD, PhD, L. Cachafeiro, MD, PhD, E. Perales, MD, PhD, S. Luque, PhD, A. Garcia de Lorenzo, MD, PhD Burn Unit/Intensive Care Medicine Service. University Hospital La Paz/IdiPAZ, Madrid, Spain; Pharmacy Department, Hospital-del-Mar, Barcelona, Spain Introduction: Fungal infections in burned patients are associated with high mortality rates. Micafungin (MCF) has a broad activity against Candida spp., which are the most common fungi isolated in burned patients. Due to the limited information about its pharmacokinetics (PK), we investigate MCF levels in plasma and burn eschar tissues in this population. Methods: Pharmacokinetic study of MCF at standard dosage (100 mg/day) in severely burned patients. Cmax (end of the infusion) and Cmin (before next dose) plasma levels of MCF were obtained after first dose and at steady state (days 4 and 5 of therapy); and on day 5 in eschares (1-3h after MCF infusion) and they were measured by HPLC. Spearman's rho test was used for bivariate correlations between MCF exposure and patient's clinical factors. Results: Ten patients (8 men;age: 18–77 years). Clinical and PK data are in table 1. MCF concentrations showed a high interindividual variability. Peak plasma concentrations after the first and repeated doses of MCF were inversely correlated with % burned TBSA (Spearman's rho=-0.695 and -0.750 (p<0.05)), respectively, but not with the time from burn injury. MCF concentrations in burn eschars were not correlated with % burned TBSA. One patient (10%) had candidemia and the crude mortality was 40%. Conclusions: This is the largest pharmacokinetic study of 100mg/daily of MCF in severely burned critically ill patients. The inverse correlation between MCF exposure and % burned TBSA suggests that patients with large burned TBSA may need higher doses of MCF. Nevertheless, MCF levels in plasma and burn eschar tissues after first and multiple doses were above the MIC90 against most clinically important Candida species. Applicability of Research to Practice: This study provides very valuable information about the PK of echinocandins in burned patients and will help to optimize the dosage regimens of antifungals in this special population. External Funding: This work was supported in part by a grant from Astellas Pharma S.A. (Madrid, Spain). View Large View Large 9. It Takes a Village: Multi-Disciplinary Team Key to Individualizing Burn Preceptorship H. L. Greeley, RN, C. Mitchell, RN, BSN, J. R. Robbins, MSN, RN, CCRN, E. J. Hayes, MSN, RN, S. A. Phillips, MSN, RN, CCRN, E. A. Mann-Salinas, RN, PhD USAISR, JBSA Ft Sam Houston, TX Introduction: Burn centers struggle to find ways to quickly develop competence in new staff, especially in the environment of constrained resources. Using an evidence-based (EB) Precepting Program (PP) that is dynamically adaptable to the individual is a fundamental component of achieving this goal. Our aim is to describe how the multi-disciplinary team (MDT) is useful in individualizing preceptorship experiences and in evaluating competence. Methods: At our regional burn unit, a MDT identified the best approach for a center-wide, comprehensive PP to transition new hires (NH) into the complex burn environment. Tools used to individualize each preceptee's experience included: learning style assessment; clinical knowledge tests; high-fidelity simulation; wound care coaching plans; and progression tracking forms. “Field trips” with MDT members were provided to capitalize on availability of subject matter experts (SMEs) and to allow skill evaluation from the perspective of other disciplines. Interviews of preceptors, staff and NH were conducted upon completion of PP. Results: From SEPT 2012 to AUG 2014, 45 NHs participated: 31 complete, 3 incomplete, 2 exceptions, and 8 currently enrolled. NHs (n=31) achieved passing test scores >70% of the time; individual remediation was provided for those failing to achieve unit benchmarks. NHs competency progressions were evaluated weekly on a 1–10 (best) scale, with 7 indicating safe independent practice; initial ratings 5.3 ± 2.2, final rating 9.1 ± 1.2 (p<0.0001; n=29). Field trips were provided with wound care, rehabilitation, respiratory therapy, infection control, nutrition, anesthesia and operating room. Interviews indicated graduates of the PP have a broader understanding of the burn mission and of the role of each member of the MDT. Conclusions: Since the implementation of the PP, orienting new staff has become streamlined and more efficient, with a universally understood and applied process that involves all MDT members. Nurses stated they felt confident in their abilities to provide good basic burn care and look forward to continuing the mentoring relationship with the MDT as they improve on the skills learned in their first 8 weeks. Applicability of Research to Practice: An individually-adaptable PP that involves all MDT members ensures new staff successfully achieve burn competence. Finding ways to leverage the assistance of the entire team in precepting new hires may help to eliminate the revolving door phenomenon seen in health care employment. Also, the more “eyes on,” the quicker strengths and weakness can be established and dealt with. External Funding: Tri-service Nursing Research Grant. 10. The Use of a Nasal Bridle Tube Retaining System to Secure Feeding Tubes in Burn Patients E. Rivera, RN, BSN, A. Li, BS, M. Schenone, RN, BSN, M. Mendiola, RN, BSN, Y. Karanas, MD Santa Clara Valley Medical Center, San Jose, CA; Stanford University School of Medicine, Stanford, CA Introduction: The importance of parenteral nutrition in critically burned patients is well documented. Placement of nasogastric or nasojejeunal feeding tubes is standard in every burn center, but is not without risks. The feeding tube must be secured to prevent inadvertent removal or dislodgement of the tube. Many methods of securing the tube have been described in the critical care literature. Burn patients represent a unique subgroup because standard methods of taping may be ineffective in the setting of a burned face. Also, the surrounding tissue may already be compromised predisposing the patient to ulceration and skin breakdown. A nasal bridle tube retaining system (bridle) is an alternative method for securing feeding tubes that has been used in ICU patients. Its safety and efficacy in burn patients has not been well described. Methods: We performed a retrospective review of all patients admitted to our burn unit between 2010 and 2013. All patients with a feeding tube were identified and included in the study. These patient's charts were reviewed to determine their age, TBSA burn, LOS, method of securing the feeding tube (bridle or tape/elastic netting), length of tube feeds, number of pullouts, time off of feeding, number of abdominal xrays required and complications. Patients with more than one method used to secure their feeding tube or incomplete records were excluded from the study. The data were reviewed to determine statistically significant differences between the group of bridle patients and non-bridle patients. Results: 74 patients met our study criteria. 33 had standard tape/elastic netting techniques used to secure their feeding tube and 41 patients were treated with the bridle. There were no statistically significant differences between the groups in any demographics, including age, gender, length of stay, length of feeding, TBSA, mechanism of burn, or intubation. There was a significant difference in the rate of accidental tube pullouts between the two groups: Tape 9.0/100 tube days v. bridle 2.1/100 tube days P=.005. This resulted in significantly fewer xrays to verify tube placement in the bridle group 1.48 v. 2.21 in the non- bridle group P=.003. One patient in the bridle group experienced self-limited epistaxis after pulling out her tube. One patient in the tape/elastic netting group had breakdown of the nasal skin that healed with conservative treatment. Conclusions: The nasal bridle tube retaining system is a safe and effective way to secure feeding tubes in burn patients. The rate of inadvertent removal or dislodgement is decreased so fewer abdominal xrays are required. Applicability of Research to Practice: This study supports the routine use of the nasal bridle retaining system in burn patients as a safe and more effective means of securing feeding tubes. 11. Improving Nutritional Support of Burn Service Patients by Increasing the Number of Days When 100% of Prescribed Enteral Formula is Given P. F. Conrad, BSN, RN, J. N. Liberio, MSN, RN, CCRN, R. F. Aleem, MS, RD, LD, M. M. Halerz, MBA, RN, M. J. Mosier, MD, FACS, FCCM, A. P. Sanford, MD, FACS, R. L. Gamelli, MD, FACS Loyola, Maywood, IL Introduction: The importance of adequate nutritional support in patients with burns and large wounds is well established. Providing the prescribed amount of enteral formula (EF) via tube feeding in this patient population is challenging due to feeds being interrupted for procedures. Observing that patients were receiving less EF than prescribed, we hypothesized that delivery of EF could be improved and a Nursing Quality Improvement Project was initiated. We hypothesized that implementing a feeding algorithm to replace volume of formula missed would improve nutritional delivery. Methods: A retrospective review of 42 patient admissions (Group 1) requiring EF was completed from 11/12/2013 to 4/30/2014. Analysis showed that patients received 100% of prescribed EF an average of 60% of the days. A policy was created using an algorithm to meet the goal of improving nutritional delivery, recognizing this deficit. The algorithm standardized patients into 3 age groups for initiation of feeding, standard maximum hourly rate for infusion and replacement of formula post-procedures. Volume was increased pre and post-op to replace deficits related to holds for surgery. The new policy was implemented on 5/1/2014 and a prospective review of 39 patient admissions (Group 2) requiring EF was completed from 5/1/2014 to 9/19/2014. No patients were excluded in either group. Amount of formula prescribed, amount infused, and amount discarded, and amount received and reasons for missing EF were documented daily. Data collection included admitting diagnosis, age, and sex, length of stay (LOS), mortality, ventilator days and infections. Staff education was completed via electronic, verbal and posted teaching resources. Work sheet tools were developed to implement the new policy. Results: In groups 1 and 2 there were no significant differences in age, sex or mortality. See Table 1. Conclusions: Implementation of a feeding algorithm improved delivery of EF. This was associated with a lower incidence of infection, ventilator days, and LOS in group 2, despite higher %TBSA burn. This is now standard of care in our burn unit. Applicability of Research to Practice: A nurse driven feeding algorithm can improve nutrition support in patients requiring enteral feedings. View Large View Large 12. Return on Investment of Advanced Practice Medical Degrees: Nurse Practitioners vs Physician Assistants C. K. Craig, PA-C, J. W. Williams, PA-C, J. E. Carter, MD, J. H. Holmes IV, MD, FACS Wake Forest Baptist Health, Winston Salem, NC Introduction: America is facing an ever-increasing physician shortage. Furthermore, there are a limited number of residents entering the sub-specialty of Burn Surgery. Nurse practitioners (NP) and physician assistants (PA) are expected to fill this developing void. Student loans and tuition costs have many carefully assessing differences in reimbursement among advanced practice providers. There are no return on investment (ROI) analyses comparing PA salaries to NP salaries to date. National salary data, federal income taxes, and student loans were integrated using standard business methodology. Methods: Salaries were abstracted from the 2012 Bureau of Labor Statistics database. The 5% net present value (NPV) was calculated incorporating salary (positive cash flow) minus federal income tax and student loans (negative cash flow). NPVs were calculated for salaries in the 10%, 25%, median, 75%, and 90% percentile. Loans were calculated at a 30-year / 6% fixed interest rate. NPVs were used to project ROI at retirement. A relative career value was calculated by the average NPV of all non-doctoral healthcare degrees divided by the NPV of the career in question. Results: The average cost of a PA's educational loan was $129,484. NP's had a similar average cost. The median PA salary was $90,930/yr, as compared to the median NP salary of $89,960/yr. The 5% NPV of PAs was $781,323; as compared to $764,348 for NPs. Of note, the 5% NPV of a 4-year nursing degree is $728,436. Conclusions: PAs have a higher ROI as compared to NPs. These findings may change as dynamic adjustments occur within training models. Currently, most PA programs allow matriculation after obtaining a bachelor's degree. NP schools often require at least one year, if not two, of experience prior to entering their program. There are, however, some accelerated NP programs allowing immediate post-baccalaureate entry. NPs are projected to have doctoral degrees, requiring increased training and tuition costs, and decreasing the number of years employed. If interest rates rise, it will become fiscally preferable to remain in a nursing position due to the increased cost of education. Although not required, a similar reduction in ROI could be seen in optional PA residencies. Applicability of Research to Practice: This research will hopefully help guide practitioners as they navigate career options and assist with the closure of a critical gap in burn-trained physicians with advanced practice providers. 13. Impact of Continuous Renal Replacement Therapy Documentation Variability among Burn Centers E. C. Coates, MSN, RN, CCRN, E. A. Mann-Salinas, PhD, K. K. Chung, MD US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX Introduction: The American Burn Association (ABA) is the sponsor of a prospective randomized clinical trial for evaluating high-volume hemofiltration continuous renal replacement therapy (CRRT) in burn patients with sepsis and acute renal failure. The management of these patients can be complex and accurate hourly documentation is crucial for monitoring interventions and patient response to treatment. The purpose of this project is to describe variability with CRRT hourly documentation among burn centers participating in the multi-center clinical trial (MCT) and potential impact on future observational and retrospective studies. Methods: Nine burn centers participate in the ongoing MCT based on the presence of a mature CRRT program within their burn unit. Data was collected during routine initial and monitor on-site visits by the Study Coordinator. CRRT therapy devices, therapy modes utilized, physician order sheets, terminology, and hourly CRRT documentation tools were evaluated. Results: The Prismaflex (Gambro, Lakewood, CO) (n=5) and NxStage (NxStage Medical, Lawrence, MA) (n=5) were the site-specific CRRT devices utilized; 1 site utilized both machines. CRRT modes were Continuous Venovenous Hemodiafiltration (n=5); Continuous Venovenous Hemodialysis (n=2); and Continuous Venovenous Hemofiltration (n=2). Discrepancy noted in CRRT documentation included: 1. Terminology differences (“fluid removal” (n=6) and “CRRT dialysis” (n=1) for “actual ultrafiltrate”); 2. Inconsistency in charting (“actual fluid replacement” (n=4), “effluent” (n=8) and “delivered dose” (n=9) were not charted hourly while “access pressures” (n=9) and “blood flow rate” (n=9) were); 3. Method of charting (paper charting (n= 1) versus electronic (n=5) or both (n=3) were used). Conclusions: Variability of CRRT documentation among burn centers participating in a MCT exists. Hourly CRRT delivered doses and effluent balances are not routinely documented as part of clinical care, only for prospective studies among these centers. These discrepancies may represent significant obstacles when conducting observational and retrospective studies. Applicability of Research to Practice: Standardizing CRRT terminology and hourly documentation in the burn community will help facilitate and improve the quality of future observational and retrospective studies. External Funding: Department of Defense, Combat Casualty Grant (W81XWH-09-2-0194) awarded to the ABA. 14. Nurse Staffing and Utility of Patient Classification Systems in United States Burn Centers P. Kardos, MSN, RN, CCRN, K. J. Richey, RN, BSN, M. A. Pressman, PhD, K. A. Grimm, RN, D. M. Caruso, MD, FACS, K. N. Foster, MD, MBA, FACS Arizona Burn Center, Phoenix, AZ Introduction: Appropriate nurse staffing is fundamental to safety, high-quality patient care, improved outcomes and staff satisfaction and retention. Staffing ratios are typically based on patient classification systems (PCS) and staff skill-mix. However, these measures often fail to account for unit-specific variables such as volume, patient turnover, mixed age populations, and experience of staff. Aggressive cost cutting in healthcare has led to increased attention regarding adequate staffing levels by both the public and professionals. The purpose of this study was to describe PCS and staffing strategies in burn centers across the United States. Methods: A 26-item survey regarding basic unit demographics, staff characteristics and PCS variables was distributed online to nurse managers and directors across the United States. Basic descriptive statistics were performed. Results: There were a total of 26 respondents, 6 directors (23%), 16 managers (62%) and 4 other (15%) and a return of 14 (54%) complete surveys. Nursing variables such as education, experience, and staff mix were accounted for in only 19% of PCS and unit variables in 25% of systems. The most common function of PCS was shift-to-shift staffing decisions (38%). Identified limitations included no accounting for time required to coordinate multidisciplinary care (75%) or census fluctuation throughout day (56%), validity and reliability (69%), and primary focus on tasks rather than cognitive work (56%). The average budgeted hours per patient day (HPPD) was 16.86 (SD 4.41), with a range of 11.79 to 28.2. The most common strategies to stay within budgeted staffing ratios included canceling staff prior to shift, sending staff home early, and floating staff to other areas; these were reported by 94% of respondents. On-call staff was utilized by 53% of respondents to accommodate admissions. Only 1 (6%) respondent used acuity data to examine relationships between acuity, staffing and outcomes. Conclusions: Nursing leadership identified numerous limitations with their current PCS and staffing tools. Rarely was the data linked to patient outcomes, despite wide acceptance that nurse staffing has a significant impact on patient outcomes and safety. The wide range in HPPD likely reflects the wide diversity of individual burn center service lines. A myriad of variables make research in this area difficult; however as healthcare dollars shrink an evidence-based methodology would support decisions in budgeting, hiring to avoid seasonal variations and can assist with avoiding nurse burnout, yet maintain quality patient care. Applicability of Research to Practice: Development of an evidence-based burn staffing methodology would be beneficial to improving safety, outcomes and staff retention and satisfaction. 15. A Comparison of Burn Patients Fears at Time of Hospital Admission and Discharge K. J. Richey, RN, BSN, M. Albrecht, RN, M. A. Pressman, PhD, P. Kardos, MSN, RN, CCRN, D. M. Caruso, MD, FACS, K. N. Foster, MD, MBA, FACS Arizona Burn Center, Phoenix, AZ Introduction: Patients requiring hospitalization often experience a heightened sense of vulnerability or fear. These feelings may be intensified with traumatic events such as a burn injury. In other research, infection, incompetence, death and cost have been identified as common fears of hospitalized patients. It was hypothesized that burn patients have fears that differ from other populations and that these fears change over time. The purpose of this study was to assess the fears and concerns of burn and evaluate the effectiveness of interventions. Methods: This was a prospective study of patients admitted to a regional burn center. Interviews were conducted within 48 hours of admission, within 3 days of discharge and at the first clinic visit. Patients were initially asked open-ended questions concerning their fears and then were asked about burn specific fears (i.e. scarring, pain management, etc). They rated the intensity of each fear on a 1–10 Likert scale. Descriptive statistics were done. Results: A total of 34 patients had admission interviews, 79% (n=27) were male, mean age was 39.4 years ± 14.6, 74% (n=25) were English speaking, mean total body surface area (TBSA) was 3.9% ±2.6. The most common admission fears identified by greater than 85% of participants and corresponding intensity score included length of stay (LOS) (7.24), cost (7.12), pain management (6.44), surgery (6.33), and scarring (4.61). The most common discharge fears reported were pain (82%, 3.68), scarring (82%, 3.20), cost (78%, 5.95), wound care (67%, 4.31), access to care (26%, 1.29), and missed work (15%, 6.75). Only three fears were common to admission and discharge; pain, scarring and cost. However, the degree of fear decreased at discharge for each of these items with a significant decrease for pain related fear (p=0.0001). Ninety-six % of respondents noted that both their admission and discharge fears had been adequately addressed. Conclusions: Burn patients enter the hospital in crisis and have significant fears that differ from those identified in other patient populations. Additionally their fears change over time. In similar research, an increase in satisfaction scores was noted when patients were asked directly about their fears. Proactively talking to patients about their fears and concerns can provide insight and an opportunity to intervene. Applicability of Research to Practice: Formal assessment and diagnosis of patient fears should be incorporated into the admission and discharge process so that interventions can be planned, implemented and evaluated for efficacy. 16. Evaluation of a Nursing Pain Assessment Tool for Burn Dressing Changes in a Pediatric Burn Center S. A. Giles, BSN, RN, K. Kurtovic, BS, J. Groner, MD, R. Humphrey, BSN, RN, R. Fabia, MD, G. Besner, MD, V. Von Sadovszky, RN, PhD Nationwide Children's Hospital, Columbus, OH Introduction: Reliable pain assessment is essential for proper analgesia during burn dressing changes. The Faces, Legs, Activity, Cry, and Consolability (FLACC) scale is a valid and reliable tool for assessing general pain in pediatric populations; however, it was not designed to specifically assess pain during medical procedures. The purpose of this quality improvement (QI) project was to examine the reliability of nurses in rating procedural pain using the FLACC scale in a sample of pediatric burn patients. Methods: After IRB approval, burn dressing changes were videotaped. An interdisciplinary panel experienced in burn care reviewed the videos for pain rating consensus. The panel selected 4 videos that demonstrated pain ratings which ranged from low pain to extremely high pain. Twenty-four nurses watched the four videos in random order three times and rated the children's procedural pain in each video using the FLACC scale. Data was analyzed for intra- and inter-rater reliability using percent agreement and Fleiss' Kappa. Results: Intra-rater reliability was poor with nurses agreeing with themselves only 41.7% of the time on average (SD = 28.2%), with a range of 0% to 100% agreement. Inter-rater reliability was variable. The nurses reached the highest agreement (75%) on the video depicting the lowest amount of pain. Agreement on videos depicting higher levels of pain ranged from 17% to 33%. The Fleiss' Kappa Statistic was 0.19. Conclusions: Use of the FLACC scale was not reliable for measuring pediatric burn patients' pain during dressing changes. A procedural pain assessment tool for children currently does not exist. Creation of such a tool would be beneficial to the care of the pediatric burn patient population. One of our future goals is to establish an assessment tool specifically designed to assess procedural pain in the pediatric patient. Applicability of Research to Practice: This study identifies the need for a reliable and valid procedural pain assessment tool for the pediatric population, which would provide the opportunity to improve care delivery. 17. Translation of Research into Clinical Practice: Modification of an Early Enteral Nutrition Support Algorithm Improves Safety in Pediatric Burn Patients C. Sunderman, MS, RD, CNSD, M. M. Gottschlich, PhD, RD, C. Allgeier, DTR, R. J. Kagan, MD Shriners Hospital for Children, Cincinnati, OH Introduction: Maintenance of structural and functional gut integrity can be supported by the administration of enteral nutrition soon after thermal injury. The timing of early enteral nutrition support and titration to goal rates represent important clinical decisions in light of the known alterations in gut perfusion and intestinal blood flow during burn shock. This may increase the risk for intestinal ischemia and bowel necrosis. The purpose of this study was to examine the effect of a change in practice on the incidence of bowel necrosis following burn shock resuscitation. Methods: From 1991–2001, children admitted to our burn center with burn injuries >20% TBSA underwent routine nasoduodenal tube placement at the bedside with early initiation of a specialized enteral formula and titration to the goal rate within 12 hours of admission. A safety study (n=72) previously reported 5 patients with a comorbidity of bowel necrosis an average of 10 days postburn. Four of the 5 patients were in the early enteral feeding study arm (n=36). These adverse events prompted changes in practice. The clinical protocol was modified so that early feedings were initiated with trophic feeds in patients with under- or delayed resuscitation and/or a requirement for vasoactive agents. In addition, glutamine 12g/L was added to the standard enteral formula to elicit its potential cytoprotective effect on the gastrointestinal tract. A modified early enteral nutrition support algorithm was developed to guide the clinician on how to safely achieve targeted enteral nutrition needs. Fisher's exact test was used to compare results between the 2 study periods. Results: Five hundred and sixty five patients from 2001- until present received tube feeding following the change in enteral nutrition practice without incidence of aspiration or bowel necrosis. In addition, there was an overall statistically significant decrease in bowel necrosis following implementation of the new feeding procedure. Conclusions: Modification to our protocol for the initiation of enteral feedings during burn shock resuscitation, with the addition of glutamine into the enteral formulation, has eliminated complications related to gut ischemia in children with extensive burn injuries. Applicability of Research to Practice: This study underscores the clinical significance and safety of infusing trophic enteral nutrition with glutamine during hemodynamic instability in pediatric burn patients. View Large View Large 18. Decreasing Enteric Feeding Stop Times to Achieve Burn Patients' Nutritional Goals K. Siemons, MSN, M. Berry, RN, B. Griffin, BSN, A. Kanne, MS, J. Pollack, MD, B. Porshinsky, MD, F. Sadaka, MD, J. Shuman, PA-C, M. Smock, MD, B. Westlake, BSN Mercy Saint Louis, Saint Louis, MO Introduction: Burn patients are in a catabolic state. Interruptions of continuous adequate caloric/protein intake compromise optimum nutritional support and should be avoided if possible. Common practice at our institution was to hold tube-feedings during patient care activities including, but not limited to; turning, repositioning, dressing changes, and physical and occupational therapy. Tube-feedings were also stopped at midnight the day of surgery regardless of the patient's scheduled Operation Room time. These activities were contributing factors to patients having suboptimal caloric intake. Methods: Through the collaborative efforts of the Burn Unit team, the following prospective study was designed: Patients selected would receive continuous Tube-feeding until the moment the patient was taken from the room to go to the OR, throughout Occupational and Physical Therapy, during repositioning and every two hour turns, and during burn dressing changes. Inclusion Criteria consisted of; stable patients with no vasopressor infusion or active hemorrhage, patients with a secure airway, patients receiving enteral feedings that have been well tolerated. Patients falling outside of protocol inclusion criteria shall have enteral feedings discontinued 6 hours prior to surgery. Data collection was performed by RNs on the night-shift. Data was collected from the tube-feeding pump including infused amount of tube-feeding in milliliters for that 24-hour period, amount recorded on patient's enteral feeding calendar, and then volume cleared on tube-feeding pump to start the data collection for the next 24 hours. Results: View largeDownload slide View largeDownload slide Conclusions: Reduction of tube-feeding stop times and hold times led to an increase in Burn patients' daily caloric intake. There were no complications noted from this protocol. Barriers still remain including; vasopressor use, ileus onset, NPO for the duration of surgical procedure, NPO for diagnostic purposes, and high narcotic dose requirements. These factors all have potential to hinder gastrointestinal motility and toleration of tube-feeds, thus preventing patients from reaching their daily caloric intake goal. Applicability of Research to Practice: No adverse effects were noted with this change in practice. Patients were closer to meeting their daily nutritional goals. With continuous tube-feeding infusions, patients are at lower risk for ileus and translocation of bacteria from the gut to the blood-stream. 19. Tolerance of Enteral Feeding in Young Children Following Burns: Age Makes a Difference K. Kerley, MHS, RPA-C, S. Shea, RD, CDN, CNSC, P. Q. Bessey, MD, FACS, MS, A. Rabbitts, MS, RN, R. W. Yurt, MD, FACS NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY Introduction: Appropriate nutritional support with increased protein and calories is necessary for optimal wound healing following burns. Young children, however, may not be able to process tube feeding formulas with increased protein content, especially casein based protein, due to immaturity of the GI tract. The purpose of this study was to characterize feeding intolerance as a function of age in young children following burns. Methods: All children, age 6 months to 5.0 years, admitted between January 2012 and December 2013 who received enteral nutrition for more than 24 hours were reviewed. Patients with milk protein allergy were excluded. All patients received continuous delivery of a high protein enteral formula via a nasogastric feeding tube. Indicators of feeding intolerance included emesis 2 or more times per day, abdominal distension, documentation of loose or liquid stools, and 3 or more stools per day. Results: There were 123 patients who received enteral feeding for more than 24 hours. Of these, 66 (54 ± 5 %, Mean ± SEM) were male, 104 had burns due to scald (85 ± 3 %) and 5 were due to flame (4 ± 2 %). There were 90 patients between the ages of 6 months and 2.0 years and 33 patients 2.1 - 5.0 years of age. The age of the younger group was 1.27 ± 0.04 years and the older group 2.80 ± 0.11 years. The mean admission weight in the two groups was 10.7 ± 0.2 and 14.2 ± 0.4 kg respectively (p=<0.0001). Total burn size was small in both groups, but it was larger in the older children (5.8 ± 0.6 vs 9.2 ± 1.4 % TBSA (p=0.03)). The younger group received a slightly larger daily volume per kg of formula than the older group (3.86 ± 0.07 vs 3.46 ± 0.09 ml/kg/hr, p=0.0007). The presence of one or more indicators of feeding intolerance was more frequent in the younger group than in the older group (66 patients, 73 ± 5 % vs 17 patients, 51 ± 5 %, p=0.02). The major difference was in the incidence of 3 or more stools per day, (54 ± 5 vs 30 ± 8 %, p=0.02). The categorization of ‘loose stool’ also tended to be more frequent in the younger group (63 ± 5 % vs 52 ± 9 %, p=0.07). In the two groups as a whole, feeding intolerance decreased by almost 50% with each year of life (Odds Ratio 0.54 ± 0.15, P=0.02) but was not affected by daily formula volume per kg. Conclusions: Clinical signs of intolerance to high protein enteral feeding were common in both groups of young children but more frequent in the very young. This observation is consistent with the hypothesis that age affects tolerance of high protein enteral feedings following burn injury in young children. Further study would be required to determine whether this was due to the type and/or the amount of the protein in the formula. Enteral nutritional support in young children following burns should be reassessed. 20. Preoperative NPO Status Is Not Required in Mechanically Ventilated Burn Patients with Enteral Feeding Access J. Collins, MD, FACS, M. Loning, RD EVMS, Norfolk, VA Introduction: The American Society of Anesthesiologists Task Force on preoperative fasting recommends nothing by mouth for six hours for light meals. However, many patients are made NPO at midnight and may not have their operation till much later in the day. For the severely burned patient this time may result in a significant loss of protein and calories which may adversely affect wound healing. We hypothesized the intubated burn patient with established feeding access may be safely fed until the time they go to the operating room. Methods: A retrospective chart review of all patients older than 17 years admitted with burns greater than 20% TBSA and mechanically ventilated since January 2008. Demographics such as age, gender, TBSA, length of stay, and mortality were collected. Data such as time of NPO before operation, location of feeding tube, number of operations and incidents of immediate (within 6 hours) post-operative emesis were obtained. Tube feeds were resumed immediately after operation. Results: Eighty patients were admitted with burns greater 20% TBSA since 2008. Patients who died in the first three days or who were not mechanically ventilated were excluded leaving 26 patients for the data base. All had small bore feeding tubes placed within 24 hours of admission. Sixty-nine operative burn procedures were done with 46 tubes post-pyloric and 23 tubes gastric. All patients received tube feeds until they were transported to the OR. There were no episodes of emesis intra-operatively or in the immediate post-operative period. There were no episodes of aspiration pneumonia noted either. Conclusions: Mechanically ventilated patients with major burns and established feeding access do not need to be NPO for any length of time preoperatively. Tube feeds may be safely continued until transport to the operating room to enhance nutritional needs while having no adverse events. Applicability of Research to Practice: Maintains nutritional supplementation in major burn patients on OR days. 21. Long-Term Skeletal Muscle Mitochondrial Dysfunction in Severely Burned Children C. Porter, PhD, D. N. Herndon, MD, FACS, E. Børsheim, PhD, N. Bhattarai, BSc, T. Chao, MSc, P. T. Reidy, MSc, B. B. Rasmussen, PhD, C. R. Andersen, MSc, O. E. Suman, PhD, L. S. Sidossis, PhD Shriners Hospitals for Children, Galveston, TX; University of Texas Medical Branch, Galveston, TX Introduction: We have recently shown that skeletal muscle mitochondrial respiratory capacity and function are severely perturbed in burn survivors acutely post-injury. However, the long-term impact of burn trauma on skeletal muscle bioenergetics remains unknown. Here, we determined respiratory capacity and function of skeletal muscle mitochondria in healthy individuals and in burn victims for up to two years post-injury. Methods: Biopsies were collected from the m. vastus lateralis of 16 young healthy men (26 ± 4 years) and 69 children (8 ± 5 years) with burns encompassing ≥30% of their total body surface area. In total, 79 biopsies were collected from burn victims at approximately 2 weeks (n=18), 6 months (n=18), 12 months (n=25) and 24 months (n=18) post-burn. Skeletal muscle mitochondrial respiration was determined in fresh permeabilized myofiber bundles. Outcomes were modeled by analysis of variance, with differences assessed by Tukey-adjusted contrasts. Results: Maximal coupled mitochondrial respiration (OXPHOS) was significantly lower at 2 weeks (17 ± 2 pmol/mg/sec, P<0.001), 6 months (41 ± 4 pmol/mg/sec, P<0.05) and 12 months (35 ± 3 pmol/mg/sec, P<0.001) post-burn compared to healthy controls (62 ± 5 pmol/mg/sec). No differences were seen at 24 months post burn vs. healthy controls. OXPHOS was significantly greater at 6, 12 and 24 months post-burn vs. 2 weeks post-burn (P<0.001 for all). Mitochondrial ADP sensitivity was significantly lower at all time points post-burn vs. control (P<0.01 for all), but was greater at 6, 12 and 24 months post burn vs. 2 weeks post burn (P<0.001 for all). Conclusions: Skeletal muscle respiratory capacity remains significantly lower in burn victims for at least one year post injury. Mitochondrial coupling control (i.e., ATP producing efficiency) is diminished for up to two years post-injury in burn victims. These quantitative and qualitative derangements in skeletal muscle bioenergetics likely contribute to the long-term pathology of burn trauma. Applicability of Research to Practice: Strategies which improve skeletal muscle mitochondrial capacity and function, such as exercise, should be instigated acutely post-burn and remain part of out-patient rehabilitation for at least one year post-injury. External Funding: NIH, NIDRR, ADA, Shirners of North America. 22. Morphological and Functional Changes in White Adipose Tissue after Severe Burn Injury M. K. Saraf, PhD, D. N. Herndon, MD, FACS, C. Porter, PhD,T. Chao, MS, M. Chondronikola, RD, N. Bhattarai, MS, L. K. Branski, MD, R. Radhakrishnan, MD, R. P. Mlcak, PhD, L. S. Sidossis, PhD Shriners Hospitals for Children, Galveston, TX; University of Texas Medical Branch, Galveston, TX Introduction: Severe burn trauma represents a unique model of adrenergic stress. Animal studies suggest that severe burn injury increases the expression of UCP1 (uncoupling protein 1, a mitochondrial thermogenic protein) in white adipose tissue (WAT). However, the effect of severe burn injury on UCP homologue expression in the WAT of humans is unknown. Here, we studied the impact of severe burn injury on UCP expression and mitochondrial thermogenesis in WAT from burned patients. Methods: WAT was collected from ten burned pediatric patients (11 ± 3 yrs; 59 ± 21% total body surface area burned; on two separate occasions (10 ± 8 (early) and 34 ± 24 (late) days post injury). Whole body metabolic rate and WAT thermogeneis were measured by indirect calorimetry (Sensor Medics, CA) and high-resolution respirometry, respectively. Histology and Immunohistochemistry were performed in formalin fixed adipose tissue. UCP gene expression was determined by taqman-quantitative PCR. Results: Resting energy expenditure (35 ± 5.9 vs 45 ± 7 Kcal/kg/day, p<0.01) and mitochondrial respiration (1.5 ± 0.3 vs. 0.56 + 0.1 pmol/sec/mg, p<0.05) significantly increased with time post injury in burn victims. WAT histology demonstrated multiple fat droplets, reduced cell size and positive UCP1 immunostaining in late burn samples. UCP1 mRNA expression significantly increased (140 ± 57 fold, p<0.01) in burn patients WAT from the early to late time-point, however, UCP2, UCP3 and UCP4 mRNA expression were not different. The levels of UCP1 protein were significantly higher in the late burn group compared to healthy controls (22.9 ± 4.5 vs 2.7 ± 0.3 ng/mg; P<0.001) and the early burn group (6.9 ± 1.4 vs. 2.7 ± 0.3 ng/mg; P<0.01). Conclusions: This study provides the first evidence of differential expression of UCPs in white adipose tissue following burn injury. It provides evidence of association of UCP1 protein abundance, WAT thermogenesis, and hypermetabolism in severely burned patients. Applicability of Research to Practice: A better understanding of morphological and functional changes in WAT will help discern the mechanisms underlying hypermetabolism in burned patients, which will provide the basis for improved treatment strategies. External Funding: National Institutes of Health-P50, Project 9 (81754), R01 AR049877, P30 AG024832, T32-GM8256, CTSA [UL1TR000071], Shriners Hospitals for Children (84090, 71006, 85310), American Diabetes Association (67666). CP: NIDDR-Training Grant (H133P110012). 23. Mitophagy Resistance in Skeletal Muscles after Burn Injury R. Ueki, MD, PhD, A. Kashiwagi, MD, PhD, M. Hirose, MD, PhD, Y. Yu, MD, PhD, J. Martyn, MD, FACS, FCCM, S. Yasuhara, MD, PhD Shriners Hospital for Children, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Hyogo College of Medicine, Hyogo, Japan Introduction: Accumulating evidence suggests that mitochondrial dysfunction in skeletal myocytes leads to muscle wasting which worsens the prognosis of burned subjects. In normal cells, disturbed mitochondria can be sequestered and degraded during mitophagy, or autophagic degradation of mitochondria. There has been limited knowledge about the relationship between mitophagy and burn injury. In the current study, we tested the hypothesis that mitophagy response is compromised in burned mice, leading to a state of ‘mitophagy resistance’ which is assoicated with impaired mitochondrial function. Methods: Studies were conducted in a burn (B) mice model with 30–35% full thickness burn and a sham burn (SB) served as control. Parameters for mitophagy were measured in a distant muscle (sternomastoid) by in vivo miscroscopy on post burn day (PBD 3). The rate of mitochondrial degradation was assessed by photoconvertible fluorescent reporter, mito-Kaede. After being transfected by electroporation into sternomastoid muscle, mito-Kaede was photoconverted with UV, and the rate of fluorescent decay was measured during the first 6 hours with or without mitochondrial uncoupler CCCP. Mitochondrial membrane potential and mitochondria-derived superoxide production were also measured respectively, by injections of DiOC6 and MitoSOX dyes on PBD 3. CellTracker was used as internal control for staining of DiOC6. Results: The rate of mitochondria degradation following CCCP-induced mitophagy was compromised in B mice as compared to SB (57.0% vs. 37.7%). Mitochondrial membrane potential in burn group was significantly lower in B than SB mice (38.0 vs. 73.4 n=5, P<0.05). In mice without uncoupler CCCP treatment, mitochondria-derived superoxide production was not increased in B or SB mice (B vs.SB, 7.8 vs. 7.6). The uncoupling stimulation with CCCP led to increased superoxide production in B mice compared to SB group (79.6 vs. 33.7, n=5 P<0.05). Conclusions: Our data for the first time documented quantitatively the existence of burn induced ‘mitophagy resistance’. Burn injury reduced mitophagy turnover in response to uncoupling stress, indicating a ‘mitophagy resistance’ state. The compromised clearance of damaged mitochondria leads to the loss of mitochondrial membrane potential and the uncoupling-induced superoxide production. Mitophagy resistance contributes to the increased risk of cell injury in response to various stresses after burn injury. Applicability of Research to Practice: Similar to insulin resistance widely observed in many critical-illness induced muscle wasting syndromes, mitophagy resistance may be a mechanism involved in organ dysfunctions in many diseases and can be a novel therapeutic target. External Funding: NIH, Shriners Hospital. 24. Amino Acid Infusion Stimulates Protein Accretion in Skeletal Muscle of Burn Victims by Blunting Muscle Proteolysis C. Porter, PhD, D. N. Herndon, MD, FACS, M. Cotter, MSc, O. E. Suman, PhD, L. S. Sidossis, PhD, E. Børsheim, PhD Shriners Hospitals for Children, Galveston, TX; University of Arkansas for Medical Sciences, Little Rock,AR Introduction: Persistent skeletal muscle catabolism is a hallmark of the pathophysiological stress response to burn trauma, resulting in muscle cachexia and long-term morbidity. The impact of protein provision on skeletal muscle amino acid (AA) kinetics in burn victims is poorly understood. Using a combination of stable isotope and arterial-venous sampling methodologies, we set out to characterize the impact of intravenous AA infusion on muscle protein synthesis (MPS) and breakdown (MPB) in severely burned children. Methods: A constant infusion of L-[ring-2H5] phenylalanine was utilized to trace quadricep muscle AA metabolism in the fasted state and during an intravenous AA infusion (10% Travasol). Seven pediatric patients (12 ± 3 years; mean±SD) with severe burns (59 ± 12% of total body surface area) were studied following discharge from their initial hospitalization (47 ± 23 days post burn). Results: MPS was not altered by AA infusion (634 ± 122 vs. 604 ± 52 nmol/min/100 ml leg volume; mean±SE). AA infusion reduced MPB by 24% (777 ± 199 vs. 589 ± 53 nmol/min/100mlg leg volume), although this failed to reach statistical significance. Leg muscle protein retention (MPR, MPS-MPB) significantly increased with AA infusion (-143 ± 86 vs. 15 ± 35 nmol/min/100 ml leg volume; P<0.05). Conclusions: These data show that AA provision promotes protein accretion in skeletal muscle of burn victims. Interestingly, AA infusion resulted in a significant improvement in MPR by blunting MPB, not by augmenting MPS. This suggests that MPB dictates skeletal muscle protein turnover in burn victims. Applicability of Research to Practice: Our current findings underscore the importance of dietary protein provision in promoting muscle accretion in burn victims. External Funding: NIH, NIDRR, Shirners of North America. 25. Urban Telemedicine: The Applicability of Teleburns in the Rehabilitative Phase S. P. Fagan, MD, FACS, Y. Liu, MD, A. Vardanian, MD, T. Bozkurt, MBA, J. C. Schneider, MD, J. Hefner, MD, J. Goverman, MD Massachusetts General Hospital, Boston, MA Introduction: Telemedicine has been successfully utilized in the evaluation and care of acute burns. It has been shown to be cost effective; however, the utility of telemedicine for the rehabilitative phase of burn care management has yet to be evaluated. We expanded our telemedicine program to link our burn center with a rehabilitation facility. The goal was to make the rehabilitative phase of burn care at both facilities more efficient while maintaining quality of care. Methods: An IRB-approved retrospective review was performed of all patients enrolled in this program between March 2013 and March 2014. Data collected included: total number of encounters, visits, type of visit, physician time, and readmissions. Transportation costs were based on local ambulance rates between the two facilities. The impact of telemedicine was evaluated with respect to the time saved for the physician, burn center, and burn clinic, as well as rehabilitative days saved. Additionally, a brief patient and physician satisfaction survey was administered. Results: A total of 29 patients participated in 73 virtual visits through the telemedicine project. Virtual visits included new consults, preoperative evaluations and post-operative follow-ups. 146 ambulance transports were averted during the study period, totaling $88,800. Visits were calculated to be the equivalent of saving 5.6 burn clinic days, or 73 clinic appointments of 30 minutes duration. There were 48 inpatient bed days saved at the burn hospital, 13 of which occurred when hospital was at 100% capacity. The rehabilitation hospital saved an average of 2–3 days per hospital admission secondary to unnecessary travel. Satisfaction surveys demonstrated both physicians and patients to be satisfied with the encounters, primarily related to time saved. The decrease in travel time for the patient from the rehabilitation hospital to outpatient burn clinic improved adherence to the rehabilitation care plan and resulted in increased throughput at the rehabilitation facility. Conclusions: Videoconferencing between a burn center and rehabilitation hospital streamlined patient care and reduced health care costs, while maintaining quality of care and patient satisfaction. This program has changed the paradigm of traditional inpatient burn rehabilitation by maximizing the time spent in therapy and avoiding unnecessary patient travel to offsite appointments. Applicability of Research to Practice: Telemedicine can be utilized to facilitate many aspects of rehabilitative burn care. 26. Use of a Burn Specific Patient Reported Outcome Measure (PROM) with Real-Time Feedback in a Clinical Setting: A Pilot Study using the iPad Administered Young Adult Burn Outcome Questionnaire (YABOQ) C. M. Ryan, MD, FACS, A. F. Lee, PhD, G. D. Shapiro, MPH, L. E. Kazis, ScD, J. C. Schneider, MD, J. Goverman, MD, J. Kim, BS, S. P. Fagan, MD, FACS, R. L. Sheridan, MD, R. G. Tompkins, MD, ScD, FACS Massachusetts General Hospital, Shriners Hospitals for Children-Boston, Harvard Medical School, Boston, MA; University of Montreal, Montreal, QC, Canada; Department of Health Policy and Management, Boston University School of Public Health, Boston, MA; Spaulding Rehabilitation Hospital, Lincoln Memorial University- DeBusk College of Osteopathic Medicine, Harrogate, TN Introduction: The Young Adult Burn Outcome Questionnaire (YABOQ) is a psychometrically valid and reliable instrument for the assessment of multidimensional outcomes following burn injury in young adults. There are no previous reports using real-time patient reported outcome measures (PROMs) such as the YABOQ in clinical situations to benchmark burn recovery in adults. Methods: The YABOQ was administered to adults (ages 19–30 years, 1–24 months from injury), via an ipad platform in the office prior to outpatient burn visits. A report including recovery curves benchmarked to an unburned age-matched population and patients with similar injuries was produced for the Domains of Physical Function and Social Function Limited by Appearance. A copy of the domain reports as well as a complete copy of the patient's responses was provided to the doctor and the patient for use during the clinical visit. Satisfaction surveys using 5-point Likert scales were completed by the patient and the doctor(s) at the conclusion of the visit. Results: 10 patients and 11 providers completed the study. 90% patients found it very easy to use. 80% patients agreed/strongly agreed that it helped them communicate their situation to their doctor. 80% patients agreed/strongly agreed that it helped them understand their course of recovery. 100% agreed/strongly agreed that they would recommend this to others. Qualitative comments included “it helped organize my thoughts on recovery”, “it opened lines of communication with the doctor”, “it showed me how far I have come, and how far I need to go”, and “it raised questions I wouldn't have thought of”. 4/11 (36%) providers agreed it helped understand a patient's condition, and in 2/11 (18%) visits the providers stated that it helped identify an issue. 2/11 (18%) providers stated that a treatment plan was discussed or recommended based on the survey results. Conclusions: Real-time feedback using the ipad YABOQ was well received by both patients and doctors. The information provided by the reports can potentially impact clinical decisions. Applicability of Research to Practice: This pilot data shows the potential utility of using real time PROM data to improve clinical care. External Funding: This work is partially funded by the Fraser Family Fund of the Massachusetts General Hospital and the National Institute of Disability and Rehabilitation Research H133A130023 and H133A120034. 27. Automated Appointment Reminder Systems: Do These Systems Effectively Improve Follow-up Rates and Minimize Lost Revenue in the Burn Outpatient Setting? N. C. Toscano, MD, D. E. Bell, MD University of Rochester Medical Center, Rochester, NY Introduction: The ambulatory care setting has become increasingly important in the management of burn patients. Institutions have seen an increase in the total number of burn patients evaluated in the outpatient setting and ultimately an increase in no-show or missed appointments. In an effort to reduce no-show rates, some institutions have sent reminders via automated phone calls or short message services (SMS). We aim to investigate how automated reminder systems are impacting no-show rates in the burn surgery outpatient clinic as well as calculate lost revenue from missed appointments. Methods: This study was a retrospective chart review of patients scheduled for follow-up at an outpatient burn clinic at a regional burn center from June 30th, 2009 to July 1, 2014. Patients were eligible for study inclusion if they failed to attend a scheduled appointment at the outpatient clinic and were designated by the outpatient scheduling system as “no-show.” Data was analyzed by fiscal year and compared before and after the institution of the automated reminder system on July 1st, 2011. Results: A total of 19,051 patients were included in the study. Over the five-year study period there was a 26% increase in the total number of burn patients evaluated in the outpatient setting. No-show appointments accounted for 13.3% (2,533/19,051) of all scheduled appointments. Prior to the institution of the automated reminder system on July 1st, 2011, 38% (971/2,533) of the “no-show” patients were scheduled to be evaluated, while 62% (1,562/2,533) were scheduled after this date. There was no statistically significant difference in the rate of no-shows annually before or after the institution of the automated reminder system (13.37% ± 1.17%, p = 0.5). Additionally, there was no statistically significant difference in the rate of patient directed cancellations annually (17.43% ± 0.24%, p = 0.5). Maintenance and operation of the automated reminder system is $1,200.00 annually. Assuming projected generated revenue of $640.00 per patient, lost revenue was estimated to be $1,621,120.00 over five years and $324,224.00 annually. Conclusions: The successful outpatient management of burn injuries requires patient attendance at all appointments. Our study suggests that automated telephone reminder systems fail to effectively reduce no-show rates in the burn outpatient population, resulting in a significant loss of potential revenue. It is imperative to ascertain why burn victims are failing to attend scheduled appointments to identify interventions that may promote appointment attendance. Applicability of Research to Practice: It is necessary to reduce no-show rates in the burn patient population to ensure patient care and proper allocation of resources. 28. Investigating the Referral Patterns of Burn Patients to a Level I Trauma Center: Coherent or Chaotic? R. Y. Williams, MD, J. Collins, MD Emory University/Grady Health System, Atlanta, GA; Eastern Virginia Medical School, Norfolk, VA Introduction: Few studies have been conducted to examine referral patterns of patients with burn injuries to a Level I trauma center. It has been estimated that approximately 40,000 patients with burn injuries require hospitalization at more than 5,000 institutions across the country annually. Therefore, evaluating referral patterns and patient outcomes is essential for optimizing the utilization of health care resources. This study investigated the referral patterns of burn patients to our Level I trauma center for inpatient care versus outpatient clinic follow up. Methods: We conducted a retrospective review of 269 patients with burn injuries transferred to our Level I trauma center from 2010–2013. Clinical and epidemiologic data concerning mechanism of injury, average TBSA, burn depth, age of patient, insurance status and operative interventions, discharge versus admission and outcomes were collected. Statistical significance was calculated using Chi Squared and Student's t tests. Results: Approximately 55% of transferred patients were referred to our outpatient clinic and 46% to our Level I trauma center ER for immediate evaluation. Of those patients referred to our outpatient clinic we found that 14% of these patients required operative intervention. Those patients who required operative intervention had grease, flame or contact burns with an average TBSA of 3.0 %, 7.9% and 4.0% respectively (p<.05). Of those patients referred to our ER 67% required operative intervention while 17% were discharged directly home from our ER. Patients who were discharged home directly from the ERhad an average TBSA of 2.7% (p<.05%). Of those patients, 42% had grease burns with an average TBSA of 1.6%. Conclusions: These results have led us to formulate guidelines and contraindications modeled after the American Burn Association referral criteria to assist providers in triaging patients to outpatient clinic treatment versus inpatient admission. We propose that patients with superficial partial thickness burns less then 10% TBSA, burns that involve the face, hands, feet, and minor joints in partial thickness depths in amounts less then 2% TBSA are eligible for direct referral to outpatient follow up. Applicability of Research to Practice: Understand regional demographics of patients with burn injuries referred to inpatient versus outpatient care. Identify patients that are appropriate for outpatient clinic management to allow for more efficient transfers. 29. The Costs and Benefits of Caring- A Robust Financial Analysis of Burn Care in America J. E. Carter, MD, J. H. Stewart, MD, MBA, FACS, J. H. Holmes IV, MD, FACS Wake Forest University, Winston Salem, NC Introduction: Healthcare paradigms have become vulnerable due to fiscal constraints and regulations. The current movement toward value-based healthcare is focused on achieving the best outcomes at the lowest costs. Although burn centers have long offered exceptional care, modern robust financial analysis of their impact on society is lacking. The goal of this study was to calculate the return on investment (ROI) of a burn center. Methods: A financial model was created with the average costs or negative cash flows (NCF) and the average benefits or positive cash flows (PCF) with data from the 2013 National Burn Repository, Medical Group Management Association, and Bureau of Labor Statistics. NCF included burn center salary and non-salaried staff in accordance with ABA verification criteria and hospital charges for all patient care at an average sized burn center caring for adult and pediatric patients. Positive cash flows included federal income tax at the average household income and deferred disability payments with a 40% rate of return to work from the average age of injury. A net present value calculation accounted for discounted future PCF and NCF allowing a 33 year perspective in today's dollars. Results: 21 ABA verified burn centers were polled to delineate staffing models. We found that an average size burn center will generate a return on investment using conservative financial models within 11 years of origination if 40% of patients treated avoid death or disability as a result of specialized burn care. After 11 years of existence a burn center offers a growing return on investment to the community as more patients previously injured accumulate while returning employment. Conclusions: The growing patient population and shrinking healthcare funds will necessitate a good ROI for healthcare expenditures. Burn prevention remains the most economical approach to reducing expenses. Caring for patients with burn injuries is resource intensive and lacks the support found in other specialized care. This study offers fiscal insight and substantial support that caring for patients with burn injuries is an exceptionally important component of public health and preservation of the workforce and supports investment in burn center infrastructure. Applicability of Research to Practice: Further research should compare the ROI offered by other areas of specialized care so that healthcare investments are equitably distributed with the demands of society. 30. Is Burn Mortality Decreasing in the 20th Century? An Analysis of the National Burn Repository T. L. Palmieri, MD, FACS, FCCM, S. Taylor, PhD, M. Lawless, RN, T. Curri, MS, S. Sen, MD, FACS, D. G. Greenhalgh, MD, FACS Shriners - Northern California and UC Davis, Sacramento, CA Introduction: Despite multiple new treatment options in burns, there is sparse objective data demonstrating an improvement in patient outcomes. The purpose of this study was to compare patient characteristics and outcomes in two time intervals: 2000–9 and 2010–13. Methods: We obtained release of the National Burn Repository (NBR) from both the 2014 call (years 2010–13) and the 2009 call (years 2000–9) and removed records missing burn information, gender, age, and survival status. We then dropped readmissions, transfers, non-burn injuries, and duplicate records. Mortality models were constructed for all ages and age-specific models in the 2000–9 NBR data set and applied to the 2010–13 data set for all patient first, then children (<18 years), adults (18–60 years), and seniors (>60 years). Main effect and two-way interactions were used to construct age-group specific mortality models. Results: The three year dataset from 2010–13 (NBR13) consisted of 71,763 evaluable records from 87 facilities, while the 10 year dataset from 2000–9 (NBR9) had 100,051 evaluable records from 80 facilities. Compared to NBR9, patients in the NBR13 were older (32.4 ± 23.5 vs. 30.6 ± 22.7 years), and had a higher incidence of inhalation injury (10.2 vs. 8.9%), but smaller burn size (7.4 ± 11.8 vs. 9.4 ± 13.7% TBSA). Overall mortality in the NBR13 decreased to 2.94% compared to 4.1% in the NBR9 data. Mortality was lower for all age groups in the NBR13. (Table 1) The models developed from NBR09 overestimated mortality in the NBR13: for children, 128 deaths predicted vs. 107 actual; for adults, 1,087 deaths predicted vs. 914 actual; for seniors 1,274 deaths predicted vs. 1,092 actual. On further modeling, the effects of age and TBSA were similar in the two data sets; inhalation injury had a larger effect on the NBR13 data. Conclusions: Mortality in the 2010–13 NBR release is slightly lower than in the 2000–9 release even among different age groups. The decrement in burn size in the time period may have contributed to the mortality decline. However, improvements in burn care may also have contributed to the improvement in mortality. Applicability of Research to Practice: Allow for better mortality prediction. External Funding: USAMRMC Award#W81XWH-09-1-0691, NIH#TR000002, #UL1RR024146. View Large View Large 31. Frailty as a Predictor of Mortality in Burn Injury Is Not Limited to Those over Age 65 K. S. Romanowski, MD, E. Curtis, MD, T. L. Palmieri, MD, FACS, FCCM, D. G. Greenhalgh, MD, FACS, S. Sen, MD, FACS University of California, Davis, Sacramento, CA Introduction: As the elderly population increases, the number of burn injuries among the elderly also has risen. Recent evidence indicates that more severe frailty scores on admission are associated with increased mortality in burn patients over the age of 65. However, pre-injury physical fitness and co-morbid illness are not restricted to those over the age of 65. We hypothesize that admission frailty would be predictive of outcomes in people with burns ≥ 50 years of age. Methods: We performed a five year (2008–2013) retrospective chart review of all admitted acute burn patients 50 years or older at our center. Data collected included: demographics (age, gender, insurance status), injury characteristics (burn size, inhalation injury), outcomes (hospital mortality, length of stay, ventilator days, surgical procedures), and discharge disposition. Frailty scores were assessed from admission data by 2 independent practitioners and calculated using the Canadian Study of Health and Aging clinical frailty scale. Values expressed as mean ± SD. Results: A total of 502 patients with a mean age of 63.5 ± 10.7 years, 357 men and 145 women, were analyzed. Mean total body surface area burn (TBSA) was 11.7 ± 14.1%, 10% had inhalation injury, and mean frailty score (FS) was 3.7 ± 1.2 (7 being worst, 1 best). The mean length of stay was 15.5 ± 20.6 days, and 47 patients (9.4%) died. Multivariate logistic regression adjusted for age, TBSA, gender, and inhalation demonstrated an independent association between mortality and frailty score ≥5 (OR 1.94, 95% CI 1.3–2.8). The group was then subdivided into 50–65 years old and greater than 65 years old. Patients who were greater than 65 years old had significantly higher frailty scores (4.2 ± 1.2 vs. 3.5 ± 1.1), more inhalation injury (27 vs. 23 patients) and more deaths (26 vs. 21 patients). Multivariate logistic regression adjusted for age, TBSA, gender, and inhalation revealed that increased admission frailty scores significantly increased the risk of mortality to a greater extent in the 50–65 year old group (age 50–65: OR 2.5, CI 1.4–4.6; ≥age 65: OR 1.63, CI 1.003–2.7). Conclusions: Frailty scores on admission allow for an improved assessment of pre-injury physiologic condition in burn patients 50 years and older. Poor pre-injury physiologic fitness, as assessed by frailty scores, increases the risk of mortality in burn patients 50 years and older. Prospective application of the Canadian Study of Health and Aging clinical frailty scale is needed to fully establish benchmark models for burn injury outcomes. Applicability of Research to Practice: Frailty is an important marker of patient outcome that can be used to direct care and as a tool for quality measures in burn outcomes. 32. Socioeconomic Status and Burn Injury Outcomes N. Doctor, BSc, S. Yang, PhD, S. Maerzacker, BSc, P. Watkins, MA, S. Dissanaike, MD TTUHSC School of Medicine, Lubbock, TX Introduction: Graft loss and readmission, especially unplanned readmission, are used as quality indices for burn centers. We explored the impact of socioeconomic status (SES) on these outcomes. Methods: Retrospective review of patients with TBSA > 15% between 2005 & 2012. Demographics, injury details & clinical course were recorded. SES was approximated using census data of % below poverty level at patient zip code, categorized into three groups: Upper SES (≤ 19% population below poverty level), Middle SES (19–27.7%), and Lower SES (≥ 27.7%). The zip codes were also used to calculate distance to the regional burn center. Readmissions were categorized as planned vs. unplanned based on indication. Statistical analysis was performed using SAS. Odds ratios and 95% confidence intervals were calculated using univariate analysis followed by multi-variable logistic regression models for factors significantly associated with graft loss and readmission. Results: Of 250 subjects who survived to discharge 33.5% were upper SES, 31.7% middle SES, and 34.8% lower SES. With regards to distance, 14% of patients lived ≤ 99 miles from the burn center, 59.5% were 100–249 miles away, and 26.5% were ≥ 240 miles away. Patients with larger TBSA also had a greater proportion of 3° burn, which correlated with more skin grafts. A total of 81 readmissions occurred among 15.6% of patients, of which 44.5% were unplanned. Patients who received at least one skin graft were 6.5 times more likely to be readmitted. Each percent increase in TBSA was associated with a 4.5% increase in likelihood of being readmitted. There was a correlation between insurance category and readmission. Over one-third of the readmission patients were covered under worker's compensation (36%), compared to Medicaid (13%), private insurance (10%), Medicare (5%), and no insurance (5%). Patients with worker's compensation were 4 times more likely to be readmitted compared with private insurance. When comparing unplanned to planned readmissions, only worker's compensation had a majority of unplanned readmissions (57.7%). The remaining categories had a majority of planned readmissions: private (57.1%), Medicaid (66.7%), self-payer (100%), other (56%), and Medicare (50%). Graft loss occurred in 11.8% of patients. Those who lived in areas with high poverty had 4 times the odds of having graft loss than those who live in low poverty areas. There was no correlation between graft loss and insurance status or distance. Conclusions: Findings indicate strong and statistically significant correlations between type of insurance and likelihood of readmission, and between graft loss and poverty. Applicability of Research to Practice: These results merit consideration during discharge planning in patients with a low SES, and highlight the impact of patient environment and resources on clinical burn outcomes. 33. MC1R Gene Polymorphisms are Associated with Burn Wound Infection and Acute Systemic Inflammatory Response after Burn Injury D. W. Carter, MD, R. F. Sood, MD, M. E. Seaton, MD, L. A. Muffley, BS, S. Honari, RN, BSN, A. M. Hocking, PhD, S. A. Arbabi, MD, MPH, N. S. Gibran, MD, FACS Harborview Medical Center, Seattle, WA Introduction: The Systemic Inflammatory Response Syndrome (SIRS) is known to be associated with organ failure and infectious complications after severe burn injury. Recent evidence has linked melanocortin signaling to anti-inflammatory and wound-repair functions, with mutations in the melanocortin 1 receptor (MC1R) gene leading to increased inflammatory responses. Our group has previously demonstrated that MC1R gene polymorphisms are associated with post-burn hypertrophic scarring. Thus, we hypothesized that certain MC1R gene polymorphisms would be associated with increased burn-induced SIRS and increased infectious complications. Methods: We enrolled adults (>18 years of age) who sustained >20% TBSA partial/full thickness burns between 2006–2013. We screened for five MC1R SNPs (V60L, V92M, R151C, R163Q, T314T) by PCR from genomic DNA isolated from blood samples. We performed a detailed review of each patient chart to identify age, sex, race, ethnicity, percent total-body-surface-area burned (%TBSA), burn wound infections (BWI), and 72hr intravenous fluid volume (IVF), the latter a surrogate for a dysfunctional inflammatory response to injury. To examine the association between each MC1R SNP and burn wound infection, we used multivariate Poisson regression with robust standard errors and included age, sex, %TBSA, ethnicity, and race (to control for confounding by population substructure) as adjustment variables. To examine the association between each SNP and 72h IVF, we used linear regression with robust standard errors. Results: Of 106 subjects enrolled, 82 had complete data for analysis. Of these, 64 (78%) were male, with a median age of 39 and median %TBSA of 30%. A total of 36 (44%) subjects developed burn wound infections. The median total IVF in first 72h was 24.6 L. By multivariate Poisson regression, the R151C polymorphism was a significant independent risk factor for burn wound infection (adjusted prevalence ratio 2.03; 95% CI: 1.21–3.39; p = 0.007). By multiple linear regression, the V60L polymorphism was independently associated with increased resuscitation fluid volume (p = 0.021). Conclusions: This is the first study to demonstrate a significant association between genetic polymorphisms and a burn-induced SIRS complication. Our findings suggest that MC1R polymorphisms are important factors leading to dysfunctional responses to burn injury that may predict infectious and inflammatory complications. Applicability of Research to Practice: Understanding the mechanisms linking these genetic polymorphisms to increased inflammation and infection may lead to the development of novel therapies to improve clinical outcomes after burn injury. External Funding: NIH R01GM089704 and NIH T32GM007037. 34. Active Thermographic Imaging is a Sensitive Method for Distinguishing Burn Conversion and Potentially Salvageable Tissue N. Prindeze, BS, H. Hoffman, BS, J. Ardanuy, B. Carney, BS, J. Zhang, BS, L. Moffatt, PhD, J. Shupp, MD MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Center, Washington, DC Introduction: Recent reports have described the difference in thermal conductance between healthy and burned tissue, allowing for these wounds to be characterized by heat-transfer analysis. Active thermography is a powerful method of analyzing heat transfer, which is capable of providing three-dimensional information about an objects' structure. In this study full-thickness burns and adjacent tissue were examined using full-field laser perfusion imaging (FLPI) and active thermographic imaging (ATI) as these regions underwent conversion from viable tissue to damaged and necrotic tissue. Methods: A heated comb was used to create 4 contact burns separated by 3 interspaces on bilateral flanks of 5 rats, resulting in 40 full-thickness burns and 30 interspaces. Wounds were imaged by FLPI and ATI pre- and post-injury, and at hours 2, 4, 6, 12, 24, 36, 48, 60 and 72, with biopsy collection. Thermographic data was collected from an IR camera, following a single pulse from a 300W halogen array. Code for data acquisition and analysis was written in Matlab. Biopsies were examined histologically using H&E, Masson's trichrome, and by IHC for HMGB1. Results: FLPI imaging showed no differences in signal intensity between burns and interspaces at any time post-injury, while ATI resulted in obvious differences at every time-point. This sensitivity was significantly higher for ATI compared to FLPI at 5 of 9 time-points post-injury (p<0.03). Wound conversion was indicated over the 72-hour time course by the degradation of collagen and by the de-colocalization of the protein HMGB1 from nuclei. Delocalization was greater in burned skin compared to interspaces (p< 0.02) and increased in interspaces over time. Conclusions: This study demonstrates that ATI is capable of distinguishing viable tissue from non-viable tissue around burn wounds, with much greater sensitivity than FLPI. Unlike perfusion metrics, ATI provides a direct analysis of sub-surface tissue structure. This study demonstrates the superiority of direct structural analysis in the examination of burn-wound conversion; and suggests its future utility in the examination of questionably viable tissue. Applicability of Research to Practice: Incorporation of active thermography into burn assessment may provide new information for the characterization of wound severity, estimation of depth, and has the potential to guide surgical excision and grafting. External Funding: This work was funded in part by the DC Firefighters Burn Foundation. 35. Restoration of Natural Skin Color by Transplantation of Cryopreserved Human Melanocytes in Engineered Skin Substitutes S. T. Boyce, PhD, C. M. Lloyd, BS, D. M. Supp, PhD University of Cincinnati, Cincinnati, OH; Shriners Hospitals for Children - Cincinnati, Cincinnati, OH Introduction: Autologous engineered skin substitutes (ESS) have been shown to close excised, full-thickness burns, but generate consistently hypopigmented skin due to depletion of melanocytes during the culture process. Hypothetically, addition of cultured autologous melanocytes (hM) may restore pigmentation, and cryopreservation of hM may allow banking of cells to accommodate scheduling of transplantation. Methods: Keratinocytes, melanocytes and fibroblasts were isolated from de-identified surgical discard skin, and cultured in selective media. All three cell types were cryopreserved, recovered into culture, expanded in number and inoculated sequentially onto collagen-chondroitin-sulfate scaffolds in permissive media for epidermal morphogenesis. After 14 days, ESS with 1X104/cm2 added melanocytes (ESS-P) were grafted to full-thickness wounds in athymic mice, and followed for 6 weeks (n= 3–7 per group). At 2, 3, 4, 5, and 6 weeks after surgery, ESS and ESS-P were photographed for pigmented area, and evaluated with a Mexameter MX18 to determine pigment density. At euthanasia, healed skin was removed, and subjected to en face immunostaining of the basal surface of the epidermis with the melanocyte-specific marker, Mel-5, to determine melanocyte distribution. Values for melanocyte distribution and pigment density were compared to the tissue biopsy from which the ESS-P was generated. Significance was accepted at the 95% confidence level. Results: ESS-P with unfrozen or cryopreserved hM generated fully-pigmented skin with pigment density that was not significantly different from the donor skin. Average percentage pigmentation approached 100% by 6 weeks after transplantation. Similarly, hM density and distribution was not significantly different in ESS-P after transplantation than in the donor skin. Pigment transfer from hM to keratinocytes was also normal in wounds grafted with ESS-P. Conclusions: These results suggest that natural pigmentation may be restored by transplantation of autologous melanocytes in ESS-P grafted to excised, full-thickness wounds, and that hM proliferate after transplantation to restore normal cell density and pigment transfer to keratinocytes. Applicability of Research to Practice: Translation of engineered skin with melanocytes to clinical practice may promote reduction of morbidity from hypopigmentation, and restore normal skin color in grafted burns. External Funding: Support was provided from the US Department of Defense through the Armed Forces Institute for Regenerative Medicine (Contract W81XWH-13-2-0052), and by Shriners Hospitals for Children (Grant #84050). 36. Vascularity and Perfusion Are Influenced by Compression Therapy in a Porcine Model of Hypertrophic Scar S. Tejiram, MD, T. Travis, MD, N. Prindeze, BS, B. Carney, BS, A. Alkhalil, PhD, L. Moffatt, PhD, L. Johnson, MD, J. Ramella-Roman, PhD, J. Shupp, MD MedStar Washington Hospital Center, Washington, DC; MedStar Health Research Institute, Washington, DC; Florida International University, Miami, FL Introduction: Angiogenesis plays a large role in wound healing, and may correlate with the degree of scar formation that follows. As a result, increased fibrinogenesis and vascularity are observed in scar tissue relative to normal skin. Compression therapy is thought to work in part by ameliorating vasculogenesis in scar. To test this, we developed a mountable device capable of delivering precise pressure therapy. This study aims to identify pressure induced vascular changes in scar using this device in a reproducible porcine hypertrophic scar model. Methods: Excisional wounds were created by dermatome on Duroc pigs and allowed to scar. Weekly assessment of wounds included gross visual inspection, laser doppler imaging (LDI) to assess perfusion, and biopsy procurement. A mountable device capable of delivering 30 mm Hg of constant pressure was used to treat scar. Scars were separated into pressure treatment (device mounting and pressure delivery), sham treatment (device mounting and no pressure delivery), and no treatment (no device mounting or pressure delivery) groups. Treatment lasted two weeks. Biopsies were sectioned for histologic analysis using hematoxylin and eosin staining and immunohistochemistry (IHC) for α-SMA. Results: Vancouver Scar assessment did not reveal observable differences in vascularity between all groups. Initiation of pressure more than doubled mean perfusion compared to sham and untreated scar (p<0.01). Sham and untreated scar groups both showed no significant increase in perfusion during this period. Histologic analysis identified an increased number of blood vessels per high-powered field in pressure treated scar compared to untreated (p<0.05). This increase was greatest at day 14 of treatment with a near doubling of vasculature in pressure treated scar. IHC for α-SMA confirmed this increased vascularity in pressure treated scars. Conclusions: Pressure treated scars had increased perfusion and vascularity compared to untreated scars. The long term impact of this increased perfusion is still unclear, but may point to the histologic reason for pressure therapy effects. These results underscore the applicability of this pressure delivery model in swine to future study in scar. Applicability of Research to Practice: This model can help identify changes in vascularization that may be important in fully understanding the pathophysiology of scar formation and treatment. External Funding: This work was funded by a grant, NIH/NIBIB 1R15EB01343901, and in part by the DC Firefighters Burn Foundation. 37. Involvement of TGF-β1-Mediated Epithelial-Mesenchymal Transition in Keloid Scarring D. M. Supp, PhD, J. M. Hahn, BS, S. T. Boyce, PhD, K. L. McFarland, MS Shriners Hospital for Children - Cincinnati, Cincinnati, OH; University of Cincinnati College of Medicine, Cincinnati, OH Introduction: Keloid scarring is an extreme and recalcitrant form of fibroproliferative scarring that can occur after burns. The molecular mechanisms that underlie keloid scarring are only partially understood, hindering development of more effective therapies. Previously, expression profiling of keloid cells revealed abnormal adhesion, migration, and differentiation in keloid keratinocytes, suggestive of epithelial-mesenchymal transition (EMT). The process of EMT is critical to embryonic development and tissue repair, and is also involved in fibrosis and cancer. In EMT, changes in epithelial cell gene expression promote loss of cell-cell adhesion and acquisition of mesenchymal properties. Transforming growth factor- β1 (TGF-β1), which has been implicated in abnormal extracellular matrix production in keloid fibroblasts, is a key inducer of EMT. The goal of this study was to determine whether TGF-β1-mediated EMT is involved in keloid pathogenesis. Methods: Histological sections were prepared and primary cell cultures were established from keloids and normal skin obtained with IRB approval. Immunohistochemistry (IHC) was used to localize proteins associated with EMT, including β-Catenin, Vimentin (VIM), and Junction Plakoglobin (JUP). Gene expression in normal and keloid keratinocytes (N=3 donors each), +/− TGF-β1 or the TGF-β1 signaling inhibitor SB-525334, respectively, was measured using quantitative PCR (qPCR). Genes previously implicated in EMT were analyzed, including VIM, WNT5A, Frizzled 7 (FZD7), Hyaluronan Synthase 2 (HAS2), Cadherin 11 (CDH11), Snail Family Zinc Finger 2 (SNAIL2), and ADAM Metallopeptidase Domain 19 (ADAM19). Results: IHC revealed that VIM, a mesenchymal marker, and the active form of β-Catenin were increased in keloid vs. normal epidermis. JUP, which is frequently decreased in cells undergoing EMT, was reduced in keloid epidermis. Expression analysis showed that markers of EMT, including CDH11, HAS2, VIM, WNT5A, ADAM19, and FZD7, were increased in keloid keratinocytes compared with normal keratinocytes. Treatment of keloid keratinocytes with SB-525334 reduced expression of these EMT-related genes, and TGF-β1 treatment of normal keratinocytes increased EMT-related gene expression. Conclusions: The results show that keloids exhibit multiple features of EMT, suggesting a role for EMT in keloid pathology. Further, the data indicate that TGF-β1, which was previously implicated in abnormalities of keloid fibroblasts, regulates EMT gene expression in keloid keratinocytes. Applicability of Research to Practice: Understanding the molecular basis for keloid pathology can lead to development of more effective therapies. Our results suggest that treatments targeting EMT in keloid keratinocytes may be effective agents for keloid suppression. External Funding: Shriners Hospitals for Children Medical Research Grant. 38. Pseudomonas Aeruginosa Gene Expression in Blood is Significantly Altered in Burn Patients C. Kruczek, PhD, R. Kottapalli, PhD, S. Dissanaike, MD, J. Griswold, MD, A. Hamood, PhD Texas Tech University Health Sciences Center, Lubbock, TX; Texas Tech University, Lubbock, TX Introduction: Pseudomonas aeruginosa is a gram negative opportunistic pathogen that is a recognized source of sepsis in burn patients. We hypothesized that differential expression of virulence genes by P. aeruginosa in the blood of burn patients compared to healthy volunteers is one reason for the heightened propensity for systemic sepsis in major burns. Methods: Whole blood was obtained from four patients with burns between 25–59% TBSA within three days of injury, who had not received any antibiotics. Comparison group were four healthy volunteers. Using a closed loop flow-through model in which blood flows through silicone tubes, the P. aeruginosa strain PA14 was grown in approximately 7 ml of blood. After eight hours of incubation at 37oC, we harvested bacterial cells and extracted their RNA. We then examined the expression of different genes through RNA-sequencing utilizing MiSeq (Illumina Inc.) instrumentation. Differential gene expression analysis was completed using the Qseq (DNAstar) software suite. Fold changes in gene expression between groups were calculated by comparing reads per kilobase of transcript per million reads mapped (RPKM) values. Statistical significance was determined using a cutoff p-value of ≤ 0.01. Results: In comparison with the growth in blood from healthy volunteers, the growth of PA14 in blood from each burn patient resulted in altered expression of over 2,000 genes. The expression of iron acquisition genes, motility genes, cell wall synthesis genes, and genes coding for the type-three secretion systems was significantly increased. In contrast, the expression of some carbohydrate utilization genes and heme uptake genes was significantly reduced. In addition, the expression of genes that code for multidrug efflux pumps was either increased or decreased. Chemical analysis of blood samples revealed that in some patients the levels of calcium and iron were reduced below critical levels. Conclusions: These results suggest that the environmental milieu of blood in severely burned patients increases P. aeruginosa virulence by altering the expression of multiple virulence or virulence-related genes. Applicability of Research to Practice: Development of a potential effective therapy for burn patients systemically infected with P. aeruginosa is aided by the identification of specific inducible P. aeruginosa virulence factors. External Funding: CH Foundation. 39. Role of Hind Limb Immobilization on Burn Induced Heterotopic Ossification S. Agarwal, MD, C. Brownley, BS, M. Abdul Sattar Khan, PhD, J. Martyn, MD, S. Loder, BS, J. Peterson, BS, S. Woo, MD, D. Fine, BA, P. Cederna, MD, B. Levi, MD University of Michigan, Ann Arbor, MI; Harvard University, Boston, MA; Massachusetts General Hospital, Boston, MA Introduction: Patients with large-surface area burns are at risk for the development of heterotopic ossification (HO). Aggressive mobilization is an important management strategy in burn patients to prevent wound contracture but the impact of mobilization on HO is controversial. Conflicting retrospective studies suggest that early mobilization may have variable effects on HO formation. We hypothesized that immobilization of the hind limb in our mouse burn/Achilles tenotomy HO model would alter HO formation. Methods: Male C57BL/6 mice (age 8 weeks) underwent Achilles' tenotomy and 30% total body-surface area partial-thickness dorsal burn with immediate hind limb immobilization or no immobilization. Immobilization was performed using two techniques: 1) continuous mechanical immobilization at the ankle and knee using a validated plastic splint or 2) sciatic nerve transection resulting in limb paralysis. Mice were analyzed by μCT and histology for HO formation at 5 weeks. Separately, adipose derived mesenchymal cells (MSCs) from burned mice were cultured in osteogenic differentiation medium on plates with axial strain, with subsequent osteogenic differentiation assessed by alkaline phosphatase. Results: Mice that underwent hind limb immobilization using a splint developed less heterotopic bone than mice without immobilization (0.75 v. 1.61 mm^3; p<0.05). While a majority of the HO formed in non-immobilized mice was at the calcaneus, immobilized mice failed to develop HO at the calcaneus (0 v. 0.97 mm^3, p<0.01). Immobilization secondary to sciatic nerve injury resulted in more HO formation especially in the region of the calcaneus (3.17 v. 2.24 mm^3; p<0.05). In vitro we noted significantly more alkaline phosphatase deposition when mechanical load was applied to MSCs. Conclusions: We demonstrate that immobilization plays a central role in HO formation. Interestingly, HO formation differs if immobilization is caused by splint placement or nerve injury. Future studies will assess mechanisms behind these differences as well as key time-points needed for immobilization to mitigate HO formation. Applicability of Research to Practice: Whether early range of motion in large burn patients is beneficial or detrimental with regards to HO formation is still unknown. This study demonstrates a central role of mobility and HO formation. We hope this study will guide future trials on immobilization and its role in HO formation in burn patients at high risk. External Funding: NIH NIGMS 1K08GM109105, Plastic Surgery Foundation National Endowment Award, University of Michigan Coller Society, HHMI. View largeDownload slide View largeDownload slide 40. Pulsed Dosing of Small Molecule BMP Receptor Inhibitors Decreases Heterotopic Ossification in a Trauma-Induced Mouse Model S. Agarwal, MD, S. Loder, BS, C. Brownley, BS, J. Peterson, BS, O. Eboda, BS, K. Ranganathan, MD, S. Li, PhD, A. Mohedas, PhD, P. Yu, MD, B. Levi, MD University of Michigan, Ann Arbor, MI; Brigham and Women's Hospital, Boston, MA Introduction: The development of heterotopic ossification (HO) or ectopic bone in soft tissue following burns leads to severe disability and impaired quality of life. We have previously demonstrated that long-term inhibition of the Bone Morphogenetic Protein (BMP) receptor, ALK2/3 signaling with kinase inhibitor LDN193189 significantly decreases HO in our mouse burn/tenotomy model. Long term use of these drugs, however, can have detrimental side effects. In this study, we demonstrate the anti-HO effect of pulse dosing of ALK2/3 inhibitors in vitro and in vivo in our mouse burn/tenotomy model. Methods: Male C57BL/6 (8–10 weeks old) received Achilles' tenotomy with a dorsal 30% total body surface area partial-thickness burn. Mice then received daily intraperitoneal injections of LDN212854 (Alk2 inhibitor) continuously or during weeks 0–2, weeks 2–4, or weeks 4–6 after injury. At 5 and 9 weeks post-injury, mice were analyzed by μCT and histology for HO formation. Additionally, adipose-derived mesenchymal stem cells (ASCs) derived from mice 2-hours after burn injury were cultured in vitro with osteogenic differentiation media (ODM) with either a) vehicle control, b) LDN-19 for days 1–3, or c) LDN-19 for days 4–6 after initiation of culture in ODM. Osteogenic differentiation was assessed by alizarin red at day 14. Results: At 9 weeks following trauma, we found that the mean HO volume in mice treated with vehicle control (2.1 mm^3) was higher than for mice treated from 2–4 weeks (1.07 mm^3) or 4–6 weeks (1.44 mm^3) (p<0.05). Between those treated weeks 2–4 and 4–6, there was no significant difference in HO formation. In vitro studies demonstrated that pulsed dosing of LDN-19 at days 1–3 or days 4–6 after initiation of ODM culture resulted in a significant decrease in alizarin red staining (p<0.01). Conclusions: We demonstrate that pulsed dosing of the BMP type 1 receptor inhibitor LDN212854 decreased HO volume when administered from weeks 2–4. This finding suggests that optimally timed administration, and not long-term inhibition, may be maximize HO inhibition and minimize secondary toxicity. In vitro studies confirmed the potential for pulse dose treatment. Applicability of Research to Practice: Heterotopic ossification remains a significant clinical problem for severe burn patients. Our findings will inform drug treatment strategies with respect to effectiveness and toxicity studies as we move forward developing inhibitors of the BMP pathway to prevent HO. External Funding: NIH NIGMS 1K08GM109105-01, Plastic Surgery Foundation National Endowment Award, University of Michigan Coller Society, HHMI. View largeDownload slide View largeDownload slide 41. Does Therapeutic Hypothermia Attenuate the Hyper-Inflammatory Response After Burns? J. J. Ray, MD, S. S. Satahoo, MD, P. B. Spalding, BS, K. Julien, BS, J. P. Meizoso, MD, C. J. Allen, MD, H. M. Bramlett, PhD, L. R. Pizano, MD, MBA, FACS, N. Namias, MD, MBA, FACS, C. I. Schulman, MD, PhD, MSPH Divisions of Trauma, Surgical Critical Care, and Burns; DeWitt Daughtry Family Department of Surgery; University of Miami Miller School of Medicine, Miami; Department of Neurological Surgery, University of Miami Miller School of Medicine. Miami, FL Introduction: Therapeutic hypothermia is known to provide benefit in spinal-cord and cardiac injury. Thermal injury leads to a harmful severe inflammatory cytokine response. We hypothesized that hypothermia would attenuate this response after burns. Methods: Sprague-Dawley rats were assigned to one of three groups: sham (S), burn only (B), burn+hypothermia (BH). S animals were immersed in 37oC water, while B and BH animals were immersed in 96-100oC water to create an approximately 40% TBSA 3rd-degree burn. After resuscitation, those undergoing hypothermia were cooled to 33oC for 2 hrs then re-warmed to 37oC within 30 min. Normothermic animals were warmed and maintained at 37oC for 2.5 hrs. Serum was analyzed by ELISA for various cytokines at 6, 12, or 24-hrs post-burn. Mean and standard deviation was calculated for each cytokine at each time point. Results: At 6-hrs, cytokine-induced neutrophil chemoattractant (CINC)-1 increased after thermal injury compared to sham rats (p=0.002), and levels in those exposed to hypothermia were decreased compared to burn only (p=NS). Although not reaching significance, a similar trend was observed in IL-1β, while IL-10, an anti-inflammatory cytokine, was lowest in the S group and highest in the BH group, as expected. At 12-hrs, IL-6 demonstrated the anticipated decreased inflammatory response when comparing B/BH with significance between the S/B animals (p<0.001). Decreased levels were noted in the BH group for IL-1β, monocyte chemotactic protein (MCP)-1, and CINC-3 at 12-hours (p=NS). An increasing trend in IL-10 in the BH group was also demonstrated at this time. At 24-hours, IL-1β exhibited a significant attenuating response between the S/B and also B/BH groups (p<0.001). IL-10 and MCP-1 showed trends as expected, although no significance was reached (Table). Conclusions: Hypothermia attenuates the hyper-inflammatory response after thermal injury. Hypothermia was associated with significantly decreased IL-1β between B and BH, while trends (likely due to small sample size) in reduced levels of other pro-inflammatory markers were also noted. Conversely, the anti-inflammatory cytokine, IL-10, trended up in BH animals. Further research to determine the effects on other inflammatory mediators, as well as differing periods of hypothermia, is warranted. Applicability of Research to Practice: The goal of this research is to ultimately determine if therapeutic hypothermia can reduce the hyper-inflammatory burn response and therefore modulate secondary causes of morbidity. View Large View Large 42. Variation in the Gut Microbiome Is Associated with Differential Immune Response in the Gut Following Severe Burn R. Huebinger, PhD, D. L. Carlson, PhD, J. Song, MD, Y. Zhang, PhD, M. Allen, PhD, R. Barber, PhD, S. E. Wolf, MD, FACS UT Southwestern Medical Center, Dallas, TX; UNT Health Science Center, Fort Worth, TX Introduction: The intestinal tract is an important organ in the recovery from burn injury having roles in digestion, metabolism, and inflammation. Recent evidence suggests that resident bacteria in the gut play a crucial role in regulating key inflammatory factors. Previously, we identified considerable variation in the gut microbiome of patients who had experienced a severe burn. In this study, we systematically altered the gut microbiome in an animal severe burn model and examined cytokine expression following injury.Previously, we identified significant differences in cytokine expression (TNF-a, IL-6, and IL-10) in serum and lung tissue lysates. In addition, previous analysis of the microbiome by sequencing the 16S rRNA region using the ION Torrent PGM revealed an expansion in the relative abundance of Enterobacteracae at 24 hours after burn. In an expansion of our previous work, we examined gut tissue lysates at 24 hours after burn for cytokine expression. Methods: Adult male Sprague-Dawley rats were divided into treatment groups (depleted, supplemented, untreated, sham). Rats in the depleted group were gavaged with antibiotics daily for one week prior to injury. The supplemented group was gavaged with 3xlO^9 cfu of Lactobacillus reuteri (ATCC 23272) daily for one week. After pre-treatment, rats were anesthetized with isoflurane and given a 40% TBSA injury and resuscitated with lactated Ringer's solution, then sacrificed at 24 hours.Sham animals were treated as burns, except that room temperature water was used in the burn procedure. Cytokines (TNF-a, IL-6, IL-10) were measured by ELISA. Formalin-fixed gut tissue was analyzed for levels of apoptosis by TUNEL staining. Results: The bacterial supplemented burn group had decreased levels of both pro and anti-inflammatory cytokines relative to the microbiome depleted and untreated burn groups. The microbiome depleted group exhibited the highest levels of pro-inflammatory cytokines relative to the remaining groups. Histological analysis of the gut by TUNEL assay demonstrated increased apoptosis among animals with an untreated microbiome, relative to the microbiome depleted and microbiome supplemented groups. Conclusions: These data show that the microbiome in the gut plays a role in regulating inflammation after severe injury. Applicability of Research to Practice: The gut microbiome may be an important clinical target for treatment. 43. Mechanistic Insights on Impaired Erythropoiesis in Burn Patients S. Hasan, PhD, P. F. Conrad, BSN, RN, M. M. Halerz, MBA, RN, M. J. Mosier, MD, FACS, R. L. Gamelli, MD, FACS, K. Muthumalaiappan, PhD Loyola University Chicago, Maywood, IL Introduction: Transfusion is the only viable option to treat anemia in burn patients. Despite the adverse consequences, lack of a reliable test platform to study the molecular mechanisms of impaired erythropoiesis in burn patients has been a limiting factor to consider alternate treatment strategies. We have recently documented that peripheral blood can be utilized to mock Epo (erythropoietin)-dependent erythropoiesis to study persistent anemia in burn patients, and that CFU-E (colony forming unit-erythroid) production begins to decrease within a week after burn and continues to decline for one month studied. Considering that Epo receptors begin to be expressed only from the CFU-E stage, and burn patients are resistant to rhEpo, it is likely that erythropoietic defects are initiated upstream of CFU-Es. Here we studied the mechanisms governing CFU-E reduction in burn patients with specific emphasis on the myeloid regulatory transcription factor MafB, which has been shown to be increased in monocytes of burn patients. Methods: Five male patients (B), 40 ± 6 years age and 32 ± 9%, TBSA burn were studied with consent and IRB approval. Blood samples were collected twice within 2 weeks after burn. Five healthy volunteers served as controls (C). Ficoll separated PBMCs were placed in a conducive growth factor cocktail to preserve and proliferate residing hematopoietic stem cells and differentiate into erythro-myeloid progenitors. On day 5, lineage negative (linneg) cells were enriched using magnetic beads, incubated with a combination of surface Abs and intracellular MafB, and analyzed by flow cytometry. Megakaryocyte erythrocyte progenitors (MEPs) were identified by negative expression of IL-3R α and CD45RA and given as percentage of linnegCD34+CD38+ cells. Percentage of MafB+ cells in the linnegCD34+CD38+ fractions was determined. Results: PBMC derived MEPs are significantly reduced in all burn patients studied (B=18.8%±3.5, C=100%, P<0.001) while the non-erythroid progenitors were proportionately increased indicating robust proliferation. Overall, MafB+ cells are significantly increased in burn patient PBMC derived cultures compared to controls. (B=85%±3.9, C=54%±6, P<0.001). As MafB is specifically expressed in myeloid progeny, it is likely that hematopoiesis is averted from erythroid commitment in burn patients. Conclusions: 1. MafB orchestrates the lineage bias restricting MEP production in burn patients limiting CFU-Es. 2. PBMCs are viable conduit to study bone marrow erythropoiesis serving as a useful tool to evaluate targeted therapies that would reduce the need for transfusions. Applicability of Research to Practice: Our study gives mechanistic insight on the erythropoietic defects in burn patients, which can be therapeutically targeted to find safe and cost effective alternatives to transfusion. External Funding: NIH; R01DK097760 - 01A1 to KM. 44. Dermal Burn Injury Alters Lung Epigenetic Modification Through Activation of Histone Deacetylase 1 (HDAC1) B. J. Curtis, PhD, J. A. Ippolito, BS, L. Ramirez, BA, E. J. Kovacs, PhD Loyola University Chicago, Maywood, IL Introduction: In the United States, approximately 450,000 individuals seek medical care and 40,000 are hospitalized for burn injuries annually. One third of those hospitalized have scald injuries. Respiratory failure is a leading cause of morbidity and mortality following severe burn, in part due to excessive and prolonged production of pro-inflammatory factors. Clinical and experimental data demonstrates histone deacetylases (HDACs) serve a key role in the pathogenesis of many inflammatory and autoimmune diseases. Our study objectives were to use a mouse model to explore the effects of cutaneous scald burn on lung HDAC activity, individual HDAC levels and activation, and to characterize histone lysine acetylation. Methods: Male mice (C57BL/6) were subjected to sham or 15% total body surface area scald burn. At 24 hours after injury, mice were euthanized and alveolar macrophages were harvested by bronchoalveolar lavage or whole lungs were collected. We measured HDAC specific activity in lung nuclear extracts, analyzed levels of HDAC 1, 2, 3, 4 and 10 in whole cell lysates and histone lysine acetylation in purified histones by performing western blots, examined HDAC1, phospho-HDAC1, and HDAC2 localization in sectioned tissue and characterized HDAC1 phosphorylation in alveolar macrophages by immunofluorescence. Results: Lungs from burned mice had 24% higher HDAC activity (p<0.05). HDAC1 levels were increased 1.9-fold (p<0.05) in whole cell lysates, while other HDACs were comparable between groups. HDAC1 was increased in bronchioles and alveoli; elevated HDAC2 was observed in bronchioles. Burn altered histone H3 and H4 acetylation. Lungs from burned mice had a 47% decrease in total histone H3 acetylation (Ac) (p<0.05) and H3 lysine (K)-9-Ac (H3K9-Ac) was reduced by 27% (p=0.06). H3K18-Ac, H3K27-Ac, and H3K56-Ac levels were unchanged. H4K5-Ac, H4K8-Ac, and H4K12-Ac levels were decreased 50%, 15%, and 59%, respectively (p<0.05). Conclusions: Overall, our analyses reveal a novel mechanism regulating pulmonary inflammatory responses to burn through alterations in HDAC1 activity, expression, and downstream histone acetylation. Applicability of Research to Practice: Future studies will explore the role of HDAC inhibitors in reversing inflammatory defects and may ultimately lead to new treatment interventions for burn patients. External Funding: NIH P30 AA19373 (EJK), R01 AA012034 (EJK), T32 AA013527 (EJK), F32 AA021636 (BJC), F31AA022566 (JAI) and the Falk Foundation (EJK). 45. Changes in the Composition of the Cardiac Inflammasome Following Thermal Injury as Related to Inflammation H. E. Wolf, S. E. Wolf, MD, FACS, D. L. Carlson, PhD University of Texas Southwestern, Dallas, TX Introduction: Severe inflammation following burn injury is a common physiologic complication of burn care. The inflammasome is described as a multi-protein complex comprising caspase-1, adaptor protein apoptosis-associated speck-like protein containing a caspase-activating recruitment domain protein (ASC), and the sensor NLR. Inflammasomes contain a specific NLR protein, NLRP1, NLRP2, NLRP3, NLRP6, NLRP7, NLRP12, or NLRC4. The aim of this study was to examine the response of the inflammasome to burn injury and the associated NLR factors in the heart. Methods: Adult male C57/BL6 mice were divided into groups. One was treated as a control and one received a 40% TBSA burn injury. All were sacrificed and serum and heart samples taken at 0, 30 min., 1, 2,4, and 8 hr post injury. Heart protein was prepared for immunoblot with antibodies for various NLR factors, ASC and both inactive and active caspase-1. Serum was used to correlate inflammation via ELISA monitoring activity of TNF-alpha, IL-1B, IL-6, and IL-10. Results: Immunoblot analysis revealed that in control animals there was no difference in the amount of expressed ASC or NLRP1 in the heart. In comparison, by 30 min post burn injury, ASC had doubled in the cardiac tissue, and the NLRP1 had decreased by 2.7%. In addition to NLRP1, following burn injury we began to detect NLRP3 in cardiac tissue as well as active caspase-1. The predominant NLR at 4 and 8 hr post injury was NLRP3, a complete switch from the NLRP1, which was predominant prior to injury. Serum was tested by ELISA to correlate inflammation with observed changes in the cardiac inflammasome. TNF peaked at 2 hrs post injury (75 ± 2.7pg/ml control vs 342 ± 5.8pg/ml burn). Similar increases in both IL-6 and IL-1B were also observed, with Il- 1B demonstrating the latest peak at 8 hrs (67 ± 4.2 pg/ml control vs 350 ± 8.2 pg/ml burn). Conclusions: In response to thermal injury in the heart, there was a shift in expression from the NLRP1 sensor to the NLRP3. This shift in expression correlated with an increase in active caspase-1 as well as an increase in markers of inflammation including TNF, IL-1b and IL-6. From these data we conclude that upon stimulation by injury there is a shift in the sensor protein in the inflammasome, triggering activity and the production of active cytokines. Applicability of Research to Practice: Changes in inflammasome composition may lead to new and intriguing drug targets to control inflammation. 46. The Warburg Effect-Like Metabolic Shift Is Associated With Burn-Induced Muscle Insulin Resistance in Mice: Role of Protein Farnesylation H. Nakazawa, MD, PhD, M. Yamada, PhD, T. Tanaka, MD, PhD, K. Ben, Y. Yu, MD, PhD, A. J. Fischman, MD, PhD, J. Martyn, MD, PhD, R. G. Tompkins, MD, ScD, FACS, M. Kaneki, MD, PhD Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA; Vassar College, Poughkeepsie, NY; Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Shriners Hospitals for Children, Boston, MA Introduction: Metabolic derangements are a major complication of burn injury and affect the clinical outcome of burn patients. These metabolic alterations include hypermetabolism, insulin resistance, hyperlactatemia and muscle wasting. We have shown in mice that burn increases protein farnesylation (a lipid modification of cysteine residues at the carboxyl terminus) and that farnesylation inhibitor (FTI-277) reverses burn-induced insulin resistance. Burn-induced hyperlactatemia paralleles the development of insulin resistance and the increase in farnesylation in mice, all of which culminated at 3 days post-burn. In contrast, plasma lactate did not significantly increase at 6 and 24 h post-burn. These findings raise the possibility that the Warburg effect-like metabolic shift, the predominant glycolytic ATP synthesis over mitochondrial oxidative phosphorylation, may contribute to the burn-induced hyperlactatemia over and above deficits in oxygen due to the impaired microcirculation. We, therefore, studied the effects of burn and FTI-277 on the metabolic shift in mice. Methods: Male C57BL/6 mice at 8 weeks of age received full-thickness third degree burn by immersing the trunk in 80°C hot water or sham-burn under anesthesia. The mice were treated with FTI-277 (5 mg/kg/day, IP) or saline for 3 days. Rectus abdominis muscle was excised under anesthesia for biochemical analyses. Results: Burn induced protein expression of hypoxia-inducible factor-1α (HIF-1α) and M2 isoform pyruvate kinase (PKM2) (the master regulators of the Warburg effect) in muscle in parallel with hyperlactatemia. At 3 days post-burn, burn increased both protein and mRNA expression of HIF-1α several-fold compared with sham-burn (p<0.01). Consistently, burn increased PKM2 protein expression, mRNA levels of Glut1 and pyruvate dehydrogenase kinase-1 (the target genes of HIF-1α), and ex vivo lactate production by muscle under the fully oxygenated condition. These burn-induced alterations were reversed by FTI-277. Conclusions: Our data demonstrate that: (1) burn increased HIF-1α and PKM2 expression, a feature of the Warburg effect, and lactate production by muscle, which paralleled muscle insulin resistance and hyperlactatemia; and (2) these alterations in burned mice were reversed by FTI-277. These findings indicate that increased farnesylation plays an important role in the burn-induced Warburg effect-like metabolic shift and insulin resistance in mice. Applicability of Research to Practice: Our study identifies protein farnesylation as a novel potential molecular target to reverse insulin resistance and metabolic aberration in burn patients. This study paves the road to help develop a clinical study of a farnesylation inhibitor in burn patients. External Funding: NIH(P50GM021700), Shriners Hospitals for Children (85800). 47. Local Burn Injury Alters Cholinergic Regulation in Distal Skin Used for Grafting C. J. Holmes, MD, T. Griffen, MS, J. Plichta, MD, R. L. Gamelli, MD, FACS, K. Radek, Ph.D., ABPP Loyola University Medical Center, Maywood, IL Introduction: In burned patients, grafts exhibit functional deficiencies, the mechanisms of which are largely unknown. Keratinocytes comprise a non-neuronal cholinergic system, capable of regulating inflammation and stimulating tissue repair via the α7 nicotinic acetylcholine receptor (nAChR). Secreted mammalian Ly-6/ urokinase-type plasminogen activator receptor-related proteins (SLURPs) are endogenous modulators capable of facilitating ACh-dependent functions to modulate epidermal healing and cytokines. Despite the role of nAChRs in epidermal inflammation, no studies have evaluated cholinergic dysregulation in burns margin or donor sites as a mechanism for graft failure. Methods: Skin samples were obtained from burn margins and donor grafts. Control skin was collected from elective surgical procedures. Gene expression and protein abundance were evaluated by qPCR, ELISA, IHC, fluorometric assay and Western Blot. An in-vitro model was employed to study the effects of burn injury on Normal Human Epidermal Keratinocytes, (NHEKs), and were evaluated with immunocytochemistry and qPCR. Results: The α7 nAChR, showed no changes at the gene level yet a significant decrease in protein was observed for margin and donor vs. control skin. We demonstrated an increase of ACh in donor and margin vs. control skin. Greater SLURP1 and IL-8 gene expression was observed in donor and margin skin which coincided with protein levels. High Mobility Group Box Protein 1 (HMGB1), showed no increase at the gene level however there was a significant increase at the protein level of donor and margin samples. IHC confirmed the decrease in α7 nAChR in the epidermis of the donor and margin specimens and confirmed an increase in HMGB1 and Cleaved Caspase 3 (CC3). When exposed to a concentration gradient of Burn Conditioned Media (BCM), NHEK expression of cholinergic signaling molecules and inflammatory mediators were altered depending on the concentration of the BCM. Also ICC confirmed changes in necrotic and apoptotic NHEK cells exposed to burn over a period of 6 and 24 hours. Conclusions: The increase in SLURP ligands suggests that activation of α7 nAChRs may be enhanced in donor skin, which may influence apoptosis and re-epithelialization of skin grafts. Defects in the keratinocyte cholinergic system also plays a role in pro-inflammatory cytokine production in donor skin. HMGB1 is passively secreted from necrotic cells and CC3 is only in apoptotic cells the increase in donor skin, suggests that burn injury is promoting tissue apoptosis and necrosis in presumably normal skin. Applicability of Research to Practice: The ability to topically treat potential donor graft sites to improve function would have a significant impact on the treatment of burn wounds External Funding: T32 GM008750-14 (RLG). 48. Elevation of Serum Leptin Following Burn Injury Is Diminished in The Presence of Ethanol Intoxication E. B. O'Halloran, MD, M. M. Chen, BS, L. Ramirez, BS, E. J. Kovacs, PhD Loyola University Medical Center, Maywood, IL Introduction: Nearly half of all burn victims each year are intoxicated when injured, leading to worsened clinical outcomes. Elevations in serum leptin have been observed in burn patients immediately after injury and recent animal studies have shown that leptin attenuates post-injury organ damage, but serum leptin levels have been shown to decrease immediately following acute ethanol intoxication. We aimed to study patterns of insulin resistance and inflammation following burn injury in the setting of ethanol intoxication. Methods: In our well-established model, C57/BL6 mice were given water as vehicle or ethanol (1.2g/kg) by oral gavage 30 min prior to injury. After anesthesia administration, animals received sham injury by immersion in room temperature water or 15% total body surface area scald burn by immersion into 92 degree C water. Animals received fluid resuscitation and were sacrificed 24 hours after injury. Serum concentrations of electrolytes and of 8 diabetes biomarkers were measured by multiplex array. Results: Serum levels of leptin were elevated in mice who sustained burn injury without preceding ethanol intoxication when compared to sham injured animals (p<0.05), but not in mice who received ethanol prior to injury. Similarly, serum resistin was significantly elevated in mice given burn vehicle as compared to sham vehicle (p<0.05), but was not elevated in those subjected to ethanol and burn. A four-fold increase in serum glucagon was seen in both burn groups when compared to the sham vehicle group; while the burn vehicle group responded with a two-fold increase in plasma insulin, the burn ethanol animals showed serum insulin levels similar to the sham vehicle group. Appropriately, mice given ethanol and burn exhibited a significant elevation in serum glucose concentration 24 hours after injury when compared to all other groups. Conclusions: Burn injury induces an elevation of circulating leptin that is reduced when acute ethanol intake precedes the injury, suggesting altered metabolism in these animals. Applicability of Research to Practice: Exogenous leptin may represent a novel therapy to modulate the inflammatory dysregulation observed in patients that were intoxicated at the time of burn injury. External Funding: NIH R01AA012034 (EJK), T32 AA013527 (EJK), F30 AA022856 (MMC) and the Dr. Ralph and Marian C. Falk Medical Research Trust (EJK). 49. An Analysis of Survey-Based Abstracts Accepted to the American Burn Association Annual Meeting, 2009–2014 V. C. Joe, MD, A. Martinez, MD, R. Cartotto, MD, J. C. Jeng, MD, S. E. Wolf, MD, FACS, M. A. Pressman, PhD UC Irvine Health Regional Burn Center, Orange, CA; The Arizona Burn Center, Phoenix, AZ; Ross Tilley Burn Centre at Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Past Chair, Organization and Delivery of Burn Care, Chair, Ad Hoc Disaster Committee, American Burn Association; University of Texas- Southwestern Medical Center, Dallas, TX Introduction: Survey-based research has become popular in medicine due to relative ease of performance, broad range of application and potential generalizability. This is particularly attractive in burn care due to its multi-disciplinary nature and the questions that exist regarding practice variability, best practices and optimal outcomes. As with other research methodologies, adherence to the principles of sound study design, transparency of reporting and dissemination of results in a peer-reviewed format are essential. Methods: A list of accepted abstracts with the search term “survey” for the American Burn Association (ABA) annual meetings from 2009–2014 was obtained from the ABA central office; these were reviewed to ensure surveys were conducted. A PubMed search was performed to find abstracts that were subsequently published as manuscripts. These were evaluated for five elements of quality survey-based research design: 1) Provision of the survey or core questions, 2) Reported validity or reliability of the survey, 3) Definition of the response rate, 4) Discussion regarding the representativeness of the sample and 5) Description of how missing data were handled. Criteria were assessed on a yes/no basis with majority reviewer rule. Results: The initial search returned 177 abstracts of which 162 were determined to be survey-based studies. Of these, 27 (16.7%) were subsequently published in peer-reviewed journals. See table for survey methodology results. Only 25/27 manuscripts were evaluated as the other two were recent epublications and inaccessible due to website issues. Conclusions: The vast majority of survey-based abstracts accepted for the annual ABA meeting do not progress toward publication, making it difficult to critically assess the methodologies of these studies. In those that were published in peer-reviewed journals, the validity and reliability of the instruments were rarely reported. While the majority discussed representativeness of the samples, the population selection frame was often an issue. How researchers dealt with missing data was not often discussed. Collectively, these factors risk selection bias and incorrect extrapolations. Applicability of Research to Practice: Surveys can provide useful observations on a broad range of topics. In order to draw definitive conclusions, there must be adherence to the tenets of sound survey methodology. The ABA Research Committee could potentially play a role in assisting the membership in such future endeavors. View Large View Large 50. The Effect of Burn Center Volume on Mortality in A Pediatric Population: An Analysis of The National Burn Repository E. I. Hodgman, MD, M. R. Saeman, MD, M. Subramanian, MD, S. E. Wolf, MD, FACS UT Southwestern, Dallas, TX Introduction: The effect of burn center volume on mortality has been evaluated in adults, but a similar investigation has never been undertaken for children. A recent publication found an overall improvement in mortality but no linear relationship between mortality and increasing patient volume. We sought to evaluate whether such a relationship existed in a pediatric population. Methods: The National Burn Repository (NBR), a voluntary national burn registry sponsored by the American Burn Association, was queried for data on all patients aged 0–18 years from 2002 through 2011. Facility average annual burn volume was calculated. Cluster analysis was performed yielding low, medium, and high volume center groups. Demographics and clinical characteristics were compared across groups using Chi-square and Kruskal-Wallis tests as appropriate. Backward stepwise logistic regression was performed to evaluate relationships with facility volume, patient characteristics, and mortality. Results: A total of 38,236 patients were admitted to 88 facilities. Mortality was quite low and did not vary between groups (Table 1). Differences were found between groups in nearly all patient characteristics examined, including patient age, gender, %TBSA burned, and inhalation injury (p<0.001). Scald remained the most common type of injury, but a greater proportion of flame burns were seen at low volume centers than at medium or high volume centers. We found significant differences in both ICU and hospital length between the groups (p<0.001). Regression identified TBSA burn, presence of inhalation injury, number of comorbidities, and burn etiology to be associated with higher risk of mortality. Higher hospital volume also had an impact on mortality rates in the regression analysis. Conclusions: Mortality among pediatric burn patients was related to patient characteristics, such as burn size, inhalation injury, and burn etiology. Average annual admission rate also had a small effect on mortality. Applicability of Research to Practice: This is a description of epidemiology and outcomes among a national pediatric burn population. External Funding: National Institutes of Health award number 5T32GM008593-19. View Large View Large 51. 50 Years of Pediatric Burn Care at a Single Center: Epidemiology and Outcomes N. C. Benjamin, BS, A. Rodriguez, BS, D. Benjamin, RN, MSN, P. Stevens, BS, D. N. Herndon, MD, FACS Shriners Hospitals for Children, Galveston, TX Introduction: In the past, burn centers appeared as the result of a major tragedy while pediatric burn centers became necessary as physicians realized the specialized care required to treat burned children. Our regional pediatric burn center has provided care to children with burn injuries for 50 years and is now evaluating the epidemiology of the patients that have been treated and their survival. Methods: A retrospective review was performed for all patients admitted for acute burn and wound injuries. A database was created to collect and analyze data. Variables included demographic information, burn characteristics, hospitalization and outcome data. Descriptive statistics were utilized to summarize data and display any trends over time in ten year increments. Results: As Table 1 illustrates, in 50 years, approximately 9000 pediatric patients were admitted for acute burn care. These patients were 64% male, about 6 years of age, and had an average of 24% of their body burned most commonly from a flame source. They were predominantly White, not Hispanic or Latino, and from America, though more patients from Mexico have been treated in recent years. It was shown that patients have been admitted to our hospital in fewer days from the time of burn, have a shorter length of stay (LOS), and has a LOS/% burn that has decreased from 2.6 to 0.5 days/% burn over time. Additionally, the percent mortality has decreased from 12% to 2%, although the percent of patients with an inhalation injury has increased from 5% to 14%. Conclusions: Our results indicate that a substantial improvement in burn care has occurred at our institution over time as the LOS, LOS/% burn, and percent mortality has decreased in lieu of increasing patient acuity from factors such as inhalation injury and a larger number of patients transferred from other countries. Identifying factors that may affect the observed trends, such as, changes in leadership, resuscitation, infections and treatments, modulation of the hypermetabolic response, and surgical and clinical care practices may provide further insight to the past and future direction of burn care. Applicability of Research to Practice: Maintaining epidemiologic databases are an important practice in health care as they provide information related to productivity and accomplishments that can be shared with the local community and compared to national standards. Additionally, they provide important trending information that can identify areas for quality improvements or areas for focused research efforts. External Funding: UTMB BP Remembering the 15, Burn Research Education: 565450; SHC Special Shared Facility for Clinical Research: 84080. View Large View Large 52. Development of a Fire Risk Model to Identify Areas of Increased Potential for Fire Occurrences C. Lehna, PhD, A. Speller, C. Hanchette, PhD, E. Fahey, BSN, RN, M. Coty, PhD University of Louisville, Louisville, KY Introduction: The primary purpose of this study was to use geographic information systems (GIS) to create a cartographic risk model to predict areas of increased potential for fire occurrences. A secondary purpose was to obtain actual fire incidence data to validate the model. Methods: Census variables for seven risk factors associated with burn injury, as identified in the literature (i.e., age over 65 years, non-white race, below high school education, low socioeconomic status, rented housing, year home built, and home value), and GIS methods were used to develop the model. Residential county fire dispatch data and statistical analysis were used to validate the model. Results: The geographic areas identified as high and severe risk were primarily located in the northwestern and central areas of the county. There was a strong correlation (r = .66) between risk model scores and actual fire incidence rates. There were significant differences in mean fire rates by risk category (F = 87.58 187,3, p < .0001), with the exception of the low and medium risk categories. Fire incidence rates among census tracts showed positive spatial autocorrelation (Moran's I = 0.542, p < .0001) and produced a map showing a significant cluster of high fire incidence in the northwestern region of the county. Conclusions: Geographical aspects of the community should be taken into account when developing fire and burn prevention programs. Further research involving use and validation of this model in addressing communities' fire safety risks is needed. Applicability of Research to Practice: The fire risk model has potential to lead to more targeted and effective fire prevention and education programs. Such models would allow fire departments and local governments to focus their limited resources of money, equipment, and manpower on the geographic areas that are at highest risk for fires. External Funding: Federal Emergency Management (FEMA) Fire Prevention & Safety Grant #EMW-2012-FP-01181; academic institution Summer Research Opportunity Program. View largeDownload slide View largeDownload slide 53. Mental and Physical Health Outcomes in Parents of Children with Burn Injuries as Compared to Matched Controls J. Enns, BSc, J. P. Gawaziuk, MSc, S. Khan, PhD, D. Chateau, PhD, J. M. Bolton, MD, J. Sareen, MD, J. Stone, BSc, M. Doupe, PhD, S. Logsetty, MD University of Manitoba, Winnipeg, MB, Canada Introduction: Pediatric burn-injuries are common and the stress of caring for them can affect caregiver's health. The objective of this study was to examine the rates of mental and physical disorders of parents of burn-injured children (Cases) compared to matched controls (Controls). While previous studies have reported on these outcomes, they have not compared them to a control population, nor have they pre-injury to post-injury rates. We present a population based epidemiologic study comparing the prevalence of common mental and physical disorders in a population based cohort of parents of pediatric burn survivors as compared to parents of controls from the general population matched on age, sex and geographical location. We also report the relative risk of post-injury disorders compared to pre-injury disorders in these two populations. This methodology is an important strength of this study as this allows for correction of changes in rates due to aging or other factors. Methods: This population-based study links a regional pediatric burn centre registry with health information at the regional administrative data repository. Pediatric burn cases were matched 1:5 with control children from the general population based on age, sex and geographical location. 1029 parental Cases and 4923 Controls were identified. ICD codes were used to identify diagnoses of common mental and physical disorders, comparing rates of disease 2 years prior to and 2 years following the date of burn. The changes in the relative rates of health outcomes (pre-injury to post-injury) were compared between the cases and the controls. Results: The prevalence of substance abuse disorder 2 years prior to burn date was 3.0% among cases rising to 10.4% postburn; in controls this change was from 2.1% to 6.0%. There was an absolute rate increase of 7.4% for cases compared to 3.9% for the controls (a relative risk of 1.2). Similarly there was an absolute increase of 8.2% versus 4.6%, a relative risk of 1.4 more fractures in the Cases. There were no significant differences found in other Axis 1 mental, or physical disorders. Conclusions: Although rates of substance abuse and fractures increased in both cases and controls, there was an significantly increased relative risk of substance use disorder and fractures in the parents of burn-injured children compared to the matched controls post-index date. Applicability of Research to Practice: Parents of a burn-injured child are at risk of substance use and fractures, thus necessitating screening in this vulnerable population. External Funding: BSc Med Award and Department of Surgery GFT Award, University of Manitoba; Manitoba Firefighters' Burn Fund. 54. Implementation of Identification Badge Cleaning Practices in a Burn Center N. W. Caldwell, BA, RN, C. H. Guymon, MA, J. K. Aden, PhD, K. S. Akers, MD, E. A. Mann-Salinas, RN, PhD USAISR, JBSA Fort Sam Houston, TX Introduction: A 2013 study done in our burn intensive care unit (BICU) found that 85% of computer access cards harbored bacteria. In the outpatient burn clinic, the rate was higher, with 40% of that cohort yielding pathogenic bacteria. It was also determined that, as a whole, hospital employee badges cleaned in the last week had significantly less culture growth; cleaning rate was 14% at that time. Burn patients face enormous risk for infection and therefore any potential fomite warrants mitigation. The purpose of this study was to determine the rate of bacterial contamination following implementation of a computer access and identification card hygiene education program. Methods: Clinical burn staff were in-serviced on previous computer/identification card research demonstrating high bacterial contamination rates and were instructed to begin cleaning all cards/badges at least once per week. Approximately 2–3 weeks post-education, bacterial swab specimens were collected from the computer access cards of 5 experimental BICU cohorts (nurses, respiratory therapists, physicians, rehabilitation, and ancillary staff) and all available outpatient clinic staff. Control samples (n=10) were collected from 2 ancillary staff, 5 times over 7 days following an observed cleaning. Information was collected describing if the card had been cleaned, how often the card was typically cleaned, and whether or not the card owner had been educated regarding card hygiene. Chi-Squared and Fisher's Exact tests were used to compare groups. Results: Fifty-seven experimental group cards were swabbed in the post-education period, with a reported cleaning rate of 37% (21/57). The overall contamination rate was 81% (46/57); no difference was detected based on card cleaning (p=0.6) or in-service training (p=0.1). Pathogenic bacteria were recovered from 14% (8/57) of experimental cards, with half of those isolates recovered from cleaned badges. The control group contamination rate was 80% (8/10) with non-growth samples coming from Day 0 (1/2) and Day 7 (1/2) cultures. Conclusions: Despite improvements in computer access card cleaning, no improvement in bacterial culture rates was observed. Computer access card contamination remains high; re-contamination appears to occur shortly after cleaning. Applicability of Research to Practice: Weekly cleaning appears inadequate to reduce bacterial contamination of identity cards. Strict hand hygiene continues to be the best protection against this established fomite. 55. The National Incidence and Resource Utilization of Burn Injuries Sustained While Smoking on Home Oxygen Therapy E. M. Assimacopoulos, BS, J. Heard, BS, J. Liao, PhD, K. Kluesner, RN, J. Wilson, MD, L. Wibbenmeyer, MD, FACS University of Iowa, Iowa City, IA Introduction: The use of home oxygen therapy (HOT) has been on the rise. There is substantial risk to those who continue to smoke while on HOT. The purpose of this study was to establish the national incidence of burns incurred while smoking on HOT and to determine the resource utilization and sequelae of these injuries. Methods: This was a retrospective review of the American Burn Association's (ABA) National Burn Repository (NBR) from 2002–2011. Nine hundred and fifty seven HOT injuries were identified from the 169,283 records by filtering the event description for cases involving “oxygen” or “O2” (n= 1,003) and then manual review of the free text. Univariate comparison was performed with chi square or Fisher's exact tests for categorical variables and student T test for continuous variables. A multivariate analysis provided odds ratios for mortality controlling for all significant variables. P <0.05 considered as statistically significant. Results: Burns sustained on HOT significantly increased over the 10 year period reviewed from 44 to 219 injuries (p3.5 times the incidence of respiratory failure, 5 times the need for mechanical ventilation, and >2 times the mortality(9% v 4%). Intubation increased the mortality 11 times compared to non-intubated HOT burn patients (23% v 2%). On multivariable analysis, female gender, black race, area burned (full and partial thickness), older age, comorbidities (alcoholism, CHF, renal disease) and inhalation injury all increased the odds of death. Conclusions: This study demonstrates a significant and increasing problem of burns sustained when smoking on HOT. Compared to non-HOT injuries, HOT injuries are accompanied by higher inhalation injury and mortality risk with those requiring intubation at greatest risk. Smoking cessation counseling and treatment should be mandatory in all patients prescribed HOT. Applicability of Research to Practice: This study demonstrates the magnitude of this injury and the need for multiple disciplines to work together to help curb future injuries from HOT. External Funding: University of Iowa College of Medicine Research Program. 56. Traumatic Fatalities in Firefighters: An Analysis of the U.S. Fire Administration Database K. S. Romanowski, MD,T. L. Palmieri, MD, FACS, FCCM, D. G. Greenhalgh, MD, FACS, S. Sen, MD, FACS University of California, Davis, Sacramento, CA Introduction: Trauma is the second leading cause of death among all firefighters. Using the U.S. Fire Administration Database, we sought to elucidate the factors surrounding these deaths. We hypothesize that traumatic fatalities occur more commonly in the less experienced firefighters (i.e. younger and volunteer) and that these incidents were more likely to occur at the scene or in transit. Methods: We analyzed the Firefighter Fatalities and Statistics data collected by the U.S. Fire Administration (http://apps.usfa.fema.gov/firefighter-fatalities/fatalityData/statistics) from January 2002 to December of 2012. Data were analyzed for associations between age, firefighter classification, duty-type, and cause of fatal traumatic injury. Results: A total of 1,153 firefighter fatalities occurred during the 10-year period reviewed. Of these 33.3% fatalities had associated trauma. Mean age was significantly lower in the group that died of traumatic injuries (39.6 ± 15.6 vs. 49.3 ± 12.5)*. Volunteer firefighters suffered significantly higher proportion of traumatic fatalities (49.7%)* followed by career firefighters (33.3%)*. The highest proportion of traumatic fatalities occurred on-the-scene (32.2%)* followed by those that occurred while responding (31.3%)*. Most fatalities occurred as a result of a vehicle collision (46.1%)*, followed by being struck by a car/object (27.3%)* and falls (12.5%)*. Adjusting for rank and firefighter classification, fall (O.R. 43.2, 95% CI 2.6–712) and vehicle collision (O.R. 59.7, 95% CI 3.7–949.7) were independent predictors of a firefighter traumatic fatality. (*p<0.0001 by multivariate logistic regression). Conclusions: Both career and volunteer firefighters who are young and therefore relatively inexperienced are at significantly higher risk of a fatal traumatic event. These fatalities occur in a significant proportion on-the-scene and while responding to the scene. Specifically, falls and vehicle collisions cause a significant number of fatalities. National efforts need to be directed at educating young firefighters on safe driving practices and in improving the safety practices on-scene. Applicability of Research to Practice: Education of firefighters to improve safety. 57. Stress at School - How Do Burn-Injured Youth Compare to the Uninjured Population? R. B. Rimmer, PhD, R. C. Bay, PhD, D. W. Chacon, BA, L. D. Hansen, BA, K. N. Foster, MD, MBA, FACS, D. M. Caruso, MD, FACS Arizona Burn Center, Phoenix, AZ; AT Still University, Mesa, AZ; Burns Recovered Support Group, St Louis, MO Introduction: The school environment can be stressful and if students feel their self-esteem, security, or safety is threatened, anxiety can result. Anxious youth often have behavior problems, poorer self-worth and peer acceptance and lower school achievement. This study sought to determine if burn-injured youth's school anxiety levels differed from normative scores and causes of school-related stress. Methods: Burn-injured youth completed the School Situation Survey, a 34 item measurement of school anxiety. Subscales gauging sources of stress include: Teacher Interactions, Academic Stress (anxiety about academic performance), Peer Interactions (perceptions of classmates feelings towards them), and Academic Self-Concept (feelings of self-worth related to perceived ability). Additionally, 3 subscales measure stress manifestation; Emotional (feelings such as fear, shyness and loneliness) Behavioral (striking out or being hurtful and disrespectful), and Physiological (physical reactions such as nausea, or rapid heartbeat). Reports by burn-injured youth were compared to published normative scores. Results: Participants included Burn Survivors (n=199) mean age of 14.0 years, with 92 males (46%) and 107 females (54%). Ethnicity was Caucasian (42%), Other (58%) with 72% reporting visible scarring and 18% with a TBS A ≥ 50%. Burn-injured females reported higher Academic Self-Concept (p=.005) and less Academic Stress (p< .001), but significantly more Behavioral Stress (p=.005), than gender/ age matched peers. Burned boys reported greater problems with Peer Interactions (p=.015), and significantly more stress manifesting from Emotional (p=.04) and Physiological Stress (p<.001). Conclusions: Results were surprising as they indicate that burn-injured girls are experiencing less school stress than the peer group, as past studies have revealed girls reporting elevated anxiety disorder symptoms. It was also unexpected that the burn girls were more likely to engage in disrespectful or striking out behaviors, which may be a learned defense mechanism. Boys reported feeling frequent stress and emotional discomfort and having more somatic complaints such as stomachaches. Information on strategies for making friends and increasing self-confidence should be discussed with male pediatric patients. Applicability of Research to Practice: Burn care professionals should consider talking to pediatric patients about school experiences. Such dialogue can allow them to voice school-related challenges. Staff can also share possible solutions, such as becoming involved in clubs or sports at school. Burn camps may consider offering sessions dealing with school related stress and provide information on effective stress reducing strategies for both genders. 58. The Impact of Facial Burns on Patient Reported Health Outcomes Following Burn Injuries in Young Adults: A Five Year Study C. M. Ryan, MD, FACS, A. F. Lee, PhD, L. E. Kazis, ScD, J. C. Schneider, MD, T. L. Palmieri, MD, FACS, FCCM, F. Pidcock, MD, D. A. Reilly, MD, W. J. Meyer III, MD, R. L. Sheridan, MD, R. G. Tompkins, MD, ScD, FACS Massachusetts General Hospital, Shriners Hospitals for Children-Boston, Boston, MA; Boston University School of Public Health, Boston, MA; Spaulding Rehabilitation Hospital/Harvard University, Boston, MA; Shriners Hospital for Children - Sacramento/University of California at Davis, Sacramento, CA; Kennedy Krieger Institute/Johns Hopkins University School of Medicine, Baltimore, MD; University of Nebraska, Boston, MA; Shriners Hospital for Children - Galveston/University of Texas Medical Branch, Galveston, TX Introduction: Burns of the face have great potential impact on socialization, yet empiric measurement of long-term functional outcomes in young adults with facial burns remain poorly studied. Methods: This five year (2003–8) prospective multi-center study included burned adults ages 19–30 years who completed the Young Adult Burn Outcome Questionnaire (YABOQ) from 0–36 months after initial questionnaire administration. Non-burned subjects of comparable ages served as a reference. The questionnaire was summarized to 15 domains (Physical Function, Fine Motor Function, Pain, Itch, Social Function Limited by Physical Function, Perceived Appearance, Social Function Limited by Appearance, Sexual Function, Emotion, Family Function, Family Concern, Satisfaction with Symptom Relief, Satisfaction with Role, Work Reintegration, and Religion) representing functional recovery over time. Domain scores were standardized to a mean of 50 and a standard deviation of 10 based on non-burned controls. The association between functional recovery and face burns was analyzed longitudinally using generalized linear models with the generalized estimation equation (GEE) technique. The dependent variable in the model is each of the 15 domain scores; independent variables are face burn (yes or no), log of time since burn, and their interaction. The model is further adjusted for burn size, age, gender, and race. Comparisons are made on domain scores between baseline values during the first 6 months and follow-up values at 2 years (±6 months) from injury. Results: Of 620 questionnaires, 153 subjects had burns and 112 were not burned. 31% of burns involved the face. Facial burns had a significant impact on recovery in 4/15 domains. Baseline and 24 month levels for Emotion were lower in face burns (p=0.0007 at baseline and p=0.05 at 24 months). The difference was more apparent for those with burn size <20% TBSA (p=0.049). There was no difference in Family Function or Satisfaction with Role levels between the groups at 6 and 24 months, but face burns recovered more slowly in both domains (Family Function p=0.05 and Satisfaction with Role p=0.004). For Satisfaction with Role, the slower recovery was mainly associated with smaller burns (p=0.0029). Survivors with face burns had higher Religion scores at 6 (p=0.02) and 24 (p=0.01) months. Conclusions: Emotional function (persistent anger and sadness) was associated with face burns. Family disruption and role satisfaction recovered at a slower rate for burn survivors with face burns than those without. Religiosity scores were higher in those with face burns. Applicability of Research to Practice: Long-term follow-up of patients with face burns should include clinical screening for additional needs related to mental health and family support. External Funding: This work is partially funded by the Fraser Family Fund of the Massachusetts General Hospital and the National Institute of Disability and Rehabilitation Research H133A130023 and H133A120034. 59. The Effect of Socioeconomic Status and Parental Demographics on Activation of Department of Child and Family Services in Pediatric Burn Injury Y. M. Wong, MD, B. N. Hasty, MD, K. A. McElligott, LCSW, M. J. Mosier, MD, FACS, FCCM Loyola University Medical Center, Maywood, IL Introduction: It is well known that child abuse and neglect are common mechanisms of injury in the burned child, causing significant morbidity and mortality. Children under 3 years of age, from a single-parent home, admitted with burn injuries are at highest risk for abuse and neglect. Moreover, 36% of parents of children with burn injuries have significant dysfunction measured by a history of substance abuse, involvement with the Department of Children and Family Services (DCFS), incarceration, or a mental health history. Given the high rate of dysfunction in these families, we analyzed our institution's pediatric burn population in order to determine our profile of a pediatric burn patient and the outcomes of DCFS involvement. Methods: Following IRB approval we performed a retrospective review of pediatric burn patients from 2011–2014 who had DCFS notified during their admission either by an outside hospital (OSH) or our institution, due to concern for abuse or neglect. Variables collected for analysis were age, race, insurance status, zip code, parent's marital and employment status, parent's age, burn type, percent total body surface area (%TBSA) burned, and disposition. Results: Eighty-eight pediatric burn patients with a mean age of 2.7 + 3.4 years, who had DCFS involvement, were identified. The mean %TBSA was 6.2 + 6.4% with scald burn being the major mechanism of injury (70%). The majority of these cases were reported by the OSH prior to transfer with only 12 cases (14%) reported by our institution. Forty-seven (53%) of the 88 patients were of African American descent. With regards to the patients' parents, the mean age was 27.5 + 7.5 years-old with 45 (51%) being single. Fifty-two (59%) of the patients had at least one parent who was employed. However, the majority of patients (86%) were on Medicaid or uninsured. Most patients (76%) were cleared by DCFS to be discharged home with parents and the remainder discharged to relatives, foster homes, or a pediatric rehab facility. Our zip code analysis revealed 64 (73%) of the 88 patients came from suburban towns with a majority in lower economic neighborhoods. Conclusions: Our study confirms previous findings that patients with scald burn under the age of 3, from a single family may be at a higher risk of abuse or neglect. Additionally, children from families of low socioeconomic status are more likely to have DCFS involvement during their hospitalization. A majority of cases were found without evidence of abuse, which may reflect an element of reporting bias based on socioeconomic status. Applicability of Research to Practice: An improved understanding of patients at greater risk for suspected abuse or neglect, as well as involvement of social work in educating OSH referrals may improve the care process. 60. Quantifying Risk Factors for Long Term Sleep Problems after Burn Injury in Young Adults A. F. Lee, PhD, C. M. Ryan, MD, FACS, J. C. Schneider, MD, L. E. Kazis, ScD, N. Li, MPH, C. Wang, MSc, R. L. Sheridan, MD, M. H. Liang, MD, MPH, M. Rose, PsyD, R. G.Tompkins, MD, ScD, FACS Massachusetts General Hospital/Research Center for Medical Statistics and Actuarial Science, Xi'An University of Finance and Economics, Boston, MA; Massachusetts General Hospital, Shriners Hospitals for Children-Boston, Boston, MA; Spaulding Rehabilitation Hospital/Harvard University, Boston, MA; Boston University School of Public Health, Boston, MA; Boston University Metropolitan College/Shriners Hospitals for Children-Boston, Boston, MA; Brigham and Woman's Hospital/Harvard Medical School, Boston, MA; Baylor College of Medicine, Houston, TX Introduction: Restorative sleep is an important component of quality of life. Disturbances in sleep following burn injury have been reported, but the incidence and the impact of long-term sleep problems in young adult burn survivors remains undefined. Methods: This five year (2003–8) prospective multi-center study included adults with burn injuries ages 19–30 years who completed the Young Adult Burn Outcome Questionnaire (YABOQ) from 0–36 months after injury. The items measured fifteen domains, including: Pain, Itch, Emotion (persistent anger and sadness) and Religion (religion as source of strength and comfort, spiritually oriented, feeling closeness to God). Domain scores were standardized to a mean of 50 and a standard deviation (SD) of 10 based on an age-matched non-burned reference group. Sleep quality was assessed using the item, “How satisfied are you now with your sleep”, rated by a 5-point Likert scale. Patients responding with very and somewhat dissatisfied were classified as having sleep problems, and the remaining as less or no problem. The associations between sleep problems (yes/no) and % Total Body Surface Area burned (TBSA), Pain, Itch, Emotion, and Religion were analyzed longitudinally using generalized linear models with the generalized estimating equation technique, adjusted for age, gender, race and the presence of sleep problems prior to the burn. Results: Among 153 subjects, mean age at burn injury was 24 ± 3.5 years; 110 (73%) were male; and mean burn size was 11 ± 14% TBSA. Ten subjects did not respond to the sleep item, and 61 of the remaining 143 (43%) survivors complained of sleep problems following the injury. For each 10% increase of burn size there was 50% increase in the odds of having sleep problem (OR=1.5, p=0.0073, 95% confidence limits 1.1–1.9). For each standard deviation of worsening in the Pain, Itch, and Emotion domains, the odds of having sleep problems was greater by 55% (OR=1.55, p<0.0001, 1.28–1.87), 46% (OR=1.46, p<0.0001, 1.25–1.71), and 57% (OR=1.57, p<0.0001, 1.35–1.82), respectively. Subjects with higher Religion scores improved their sleep over time (OR=0.86, p=0.025, 0.76–0.98). There was no association of sleep problems before and after the injury. Conclusions: Sleep problems following burns were associated, in a dose-dependent manner, with increasing burn size, pain, itch, and emotional responses. An increased perceived religiosity was associated with reductions in sleep problems over the 3-year course of recovery. Applicability of Research to Practice: Long-term sleep deprivation after burn injuries is associated with greater pain, itch, anger and sadness. Patient supports with some focus on religiosity might contribute to improvements in sleep in this population of young adults. External Funding: This research was supported in part by the Fraser Fund of the Massachusetts General Hospital and the National Institute of Disability and Rehabilitation Research H133A130023 and H133A120034. 61. Body Image Issues in Adolescent Burn Survivors - Do Gender, Ethnicity or TBSA Matter? R. B. Rimmer, PhD, D. K. Wise, BA, R. C. Bay, PhD, D. W. Chacon, BA, L. D. Hansen, BA, K. N. Foster, MD, MBA, FACS, D. M. Caruso, MD, FACS Arizona Burn Center, Phoenix, AZ; Biola University, La Mirada, CA; AT Still University, Mesa, AZ; Burns Recovered Support Group, St Louis, MO Introduction: Surviving a serious burn with resultant disfigurement can pose significant challenges to the human psyche. Therefore, determining psychosocial outcomes of survivors has become increasingly imperative in burn research. Body image is related to one's self-perception of appearance and how it compares to others. This study examined whether burn survivor body image satisfaction differed from established gender norms and if body image based on gender, % TBSA, or ethnicity varied within the study group. Methods: The Body Image Disturbance Questionnaire (22 items) with 5 subscales including; Appearance Evaluation (AE), Appearance Orientation (AO), Body Area Satisfaction (BAS), Overweight Preoccupation(OP) and Self-Classified Weight (S-CW), is utilized to assess appearance-related concerns and impairment. It was voluntarily completed by adolescent burn survivors attending several US young adult burn retreats. A higher score on the AE and AO subscales indicates a more positive body image. Results: Surveys were completed by 79 teen burn survivors, mean age of 17.7 years,; 44 females, and 35 males. The ethnic makeup consisted of 46 (58 %) minority and 33 (42%) Caucasian and 16% reported a TBSA≥50%. When compared to survey norms, burn- injured girls reported more problems with AE, p=.009 and AO, p=.013. Burn-injured males reported significantly fewer issues with AE (p=.002) and OP (p<.001) than the norm group. Compared to burn-injured males, females only reported significantly more issues with OP (p=.006). Those with ≤ 50% TBSA showed a lower mean for (OP) (p=.038). Minorities also reported paying less attention to their looks and having less anxiety over their weight with AO (p≥.001) and OP (p=.02) than Caucasians. Conclusions: Adolescent female survivors were significantly less satisfied with their appearance than non-burned women, but reported spending less time attending to and paying attention to their looks. This may be an unproductive coping strategy. Minority participants also reported paying less attention to their appearance and were less worried about their weight, which has also been found to be true in their unburned peers. Further investigation as to what coping skills males are using to better accept their disfigurement is warranted. Applicability of Research to Practice: Assisting female burn survivors in becoming more confident regarding their appearance, through targeted body image improvement classes, could aid in improving their self-perception and self-esteem. Having young men share their body image coping skills with adolescent girls may also help them to be more accepting of their appearance. 62. Patient Reported Longitudinal Outcomes for Adult Burn Survivors G. J. Carrougher, RN, MN, K. McMullen, MPH, S. P. Mandell, MD, MPH, J. A. Fauerbach, PhD, L. E. Kazis, MD, J. C. Schneider, MD, R. K. Holavanahalli, PhD, N. S. Gibran, MD, FACS University of Washington, Seattle, WA; Johns Hopkins University School of Medicine, Baltimore, MD; Boston University of Public Health, Boston, MA; Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA; UT Southwestern Medical Center, Dallas, TX Introduction: Several studies have assessed general health and compared outcomes of medical interventions in adult burn survivors. Small sample size, short follow-up and single institution experience limit these reports and make generalizations of long-term health following a burn injury difficult. The purpose of this study is to summarize the health status for a large, diverse group of adult burn survivors for 2 years post-injury using 3 well-established patient reported outcome (PRO) measures. Methods: The sample consisted of adults with major burn injury (n=3249) who were followed longitudinally in a multi-center study examining burn injury outcomes (1993–2014). Data included the Satisfaction With Appearance Scale (SWAP), the SF-12® Health Survey Physical (PCS) and Mental (MCS) component summaries, and 5 questions from the Community Integration Questionnaire (CIQ). PROs were administered at discharge (includes pre-burn baseline measure), 6, 12, and 24 mo after injury. Wilcoxon Mann Whitney and chi-square tests analyzed differences in demographic and injury variables, disposition, and employment status pre- and post-burn. Stepwise logistic regression analyses determined the impact of significant variables on 2 binary dependent variables: disposition and return to work. Results: Table 1 summarizes the study population; Table 2 outlines survey scores. Compared to men, women reported greater dissatisfaction with appearance and lower PCS and MCS scores, but no difference in CIQ-5 scores. Survivors with larger burns had significantly higher SWAP scores. Those employed pre-burn had significantly less body image dissatisfaction (SWAP), better social interaction (CIQ) and better physical and mental health (PCS, MCS). Working before the injury and younger age were significantly associated with both living independently at discharge and return to work. Conclusions: SF-12, CIQ-5, and SWAP data from a large group of adult burn survivors reinforce the association between pre-injury status, burn size, and post-injury adjustment. Applicability of Research to Practice: Clinicians and researchers can use these findings to compare outcomes and to test interventions that improve health-related quality of life and community integration. External Funding: National Institute on Disability and Rehabilitation Research, grant numbers H133A13004 and H133A120024. View Large View Large 63. Social Participation of Burn Survivors: A Conceptual Framework M. Marino, MPH, M. Soley Bori, MS, F. Amaya, MPH, M. Rossi, BA, M. Slavin, PT, PhD, C. M. Ryan, MD, J. C. Schneider, MD, A. Acton, RN, BSN, A. M. Jette, PT, PhD, L. E. Kazis, ScD Boston University, Boston, MA; Shriners Hospitals for Children-Boston, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Spaulding Rehabilitation Hospital; Phoenix Society for Burn Survivors, Grand Rapids, MI Introduction: The ability to objectively measure community reintegration following burn injury is critical to the design of therapies that optimize the recovery of burn survivors. This complex concept has no adequate metric for burn survivors. This project aims to develop and validate a conceptual framework for understanding the social impact of burn injuries in adults and develop an item bank for future use in a Computerized Adaptive Test to measure community reintegration in burn survivors. Methods: We performed a comprehensive literature review and consulted with clinical experts and burn survivors about social life areas impacted by burns and modified items from established generic, burn-specific, and other condition-specific measures. We added original items to enrich the item pool. Three investigators independently classified items by subdomain; the research team reviewed items to ensure appropriate classification, and reached consensus on inclusion, modification, removal and addition of new items. Focus groups with burn survivors and clinicians were conducted to validate the framework and revise and augment the item pool. Transcripts were coded using grounded theory. The research team revised and crafted new items based upon focus groups analysis. Cognitive interviews with burn survivors were conducted to assess clarity and consistent interpretation. Results: The World Health Organization's International Classification of Functioning, Disability and Health (ICF), was chosen to conceptually ground the emergent content model. The primary construct identified was social participation (referred to as social impact), which contains two major concepts_societal role and personal relationships_each with several subdomains. The seven subdomains chosen for item development were work/employment, recreation and leisure, relating to strangers, romantic, sexual, family and informal relationships. An initial pool contained 252 items that were tested for clarity and interpretation by burn survivors and reduced to a final pool of 192 items. Conclusions: Qualitative results strongly suggest that the conceptual model fits the constructs for societal role and personal relationships with the respective subdomains. A large scale calibration study is currently underway which will lead to using IRT methods to develop a CAT for monitoring the social impacts of burn injuries during recovery. Applicability of Research to Practice: This CAT measure will be the first to specifically identify the social aspects of burn survivor's life throughout the recovery process. The measure has the potential for integration into electronic health records, allowing for burn survivors and their care providers to measure the current social consequences of burn injuries, and track their trajectories throughout the recovery process. External Funding: Supported by NIDRR H133A130023 and H133A120034. 64. Long-Term Outcomes: Are There Age-Related Differences in Perceived Functional Adaptation? R. K. Holavanahalli, PhD, P. A. Helm, MD, K. J. Kowalske, MD UT Southwestern Medical Center, Dallas, TX Introduction: The objective of this study was to examine age-related differences in perceived functional adaptation among survivors of large burns (mean = 53% TBSA) at an average of 17 years post injury. Methods: This is a cross-sectional descriptive study of a onetime evaluation of adult burn survivors (n=98) who were ≥ 18 years of age, survived ≥ 30% TBSA, and were ≥ 3 years from the time of their injury. The data used in this study is part of a larger study on long-term outcomes that included a battery of study questionnaires and a comprehensive physical examination performed by a physician. Subjects reported on their level of functional adaptation (on a scale of “extreme difficulty” to “no difficulty at all”) using the abbreviated Burn Specific Health Scale (BSHS). Subjects were stratified into 3 age categories: 18–44 years (n=38), 45–54 years (n=38), and ≥ 55 years (n=22). A one-way analysis of variance (ANOVA) was used to evaluate the relationship between the 3 age categories and perceived level of functional adaptation in all 4 domains (Physical, Psychological, Social, and General), their respective sub-domains, and a Global domain. The Tukey Post Hoc Comparisons were used to evaluate pair-wise differences among the means. Results: The subject and burn injury demographics, and mean BSHS domain scores are shown in the Table. Results of the oneway ANOVA showed no significant differences across age groups on the physical, social, general, and global domains. However, there was a significant difference noted across age groups in the perceived level of functional adaptation in the psychological domain (F (2,95)=4.20, p = .018), with a small effect size (eta-squared = .08); and the body image, a psychological sub-domain (F (2,94)=4.42, p = .015), with a small effect size (eta-squared = .09). Using Tukey HSD, subjects aged 18–44 years differed significantly (p=.02) from those 55 years and older. Conclusions: Subjects aged 18–44 years perceived a higher level of adaptation difficulty in the psychological domain, especially in the body image sub-domain, when compared to subjects who were 45–54, and > 55 years of age. Applicability of Research to Practice: Findings from this study underscore the need for long-term follow-up and appropriate age-specific interventions to improve long term functional health and well-being in patients with large burns. External Funding: The contents of this abstract were developed under a grant from the Department of Education, NIDRR grant number H133A020104. View Large View Large 65. The Efficacy of a Trident Flap Technique to Release First Web Space Contracture in a Burned Hand T. Huang, MD, FACS, D. N. Herndon, MD, FACS UTMB-Shriners Burns Hospital Galveston, Galveston, TX Introduction: A surgical approach that combines two z-plasties with one Y-to-V plasty, alias a trident flap technique or a “jumping man” flap technique, is used most frequently to reconstruct a contracted first web space in a burned hand. The technique is based upon the principle that release is made more effectively by incorporating two z-plasties and one Y-to-V flap; a total of five skin flaps is included in the design of this technique. The exact extent of release achievable, on the other hand, has not been clearly established. Methods: (1) Surgical Technique - A line is drawn along the crest of the contracted web space extending from the thumb IP joint level to the MCP joint of the second digit. A z-plasty was drawn at each end; the central limb is made in the crest incision. A straight line is drawn in the dorsum of the first web space perpendicular to but at the midpoint of the crest line. An inverted “V” with its apex is set at the mid-point of the crest line is drawn in the palmar surface of the web to form a “Y”-flap marking. The triangular volar skin flap of an inverted “Y” skin marking is moved dorsally to form a “V” closure. Triangular skin flaps at each end of the web crest incision were interposed to provide the release. (2) Clinical Material and Method of Measurement - There were a total of 165 hands in 121 patients between 2003 and 2012. An arc line formed in the web space between the thumb at IP joint level and the index finger at its MCP joint level was traced with a piece of #22 gauge stainless steel wire before and after the web space release. Results: The changes in arc length were measured in 43 hands in 26 patients. Although the range of thumb abduction was noted to have improved in all hands, lengthening of the web arc line; i.e., the curved line distance measured between the thumb IP joint level and the index finger MCP joint level was found to vary between 2.8 cm and 4.3 cm before release, with a mean value of 3.74 cm. The release gained with surgery varied between 4.6 cm and 7.2 cm, with a mean value of 6.04 cm, a mean gain in arc line length of 2.3 cm. Problems such as infection and/or hemorrhaging were not encountered in this group of children. Conclusions: Two z-plasties and one Y-to-V plasty should have provided mathematically two and half folds increase in arc line length; it is by inference that an x2.5 increase in the range of thumb abduction should be possible with this technique. The actual gain, however, was limited to 61.5%. A trident flap technique, despite its mathematical limitations, is still an effective approach in releasing a contracted first web space. The morbidities associated with procedure were nil. 66. Free Anterolateral Thigh Flap with Single-Perforator and Continuous Sub-Flap Suction for Salvage of the Extremities Injured by High-Voltage Electricity Y. Jia-ao Sr., MD, PhD, J. Zhenghua, MD, PhD, W. Weiwei, MSN, Z. Xin, MD, G. Xinxin, MD, C. Xinxin, MD The First Hospital of Jilin University, Changchun, China Introduction: High-voltage(higher than 1,000 V) electrical injury usually causes extensive and devastating damages to the extremities. Preservation and protection of the viable tissue may be a main determinant of the salvage and the ultimate functional outcome of the involved extremities. There are two challenges in the salvage protocol: one is to choose the appropriate flap for the coverage of the large skin defect, the other one is the management of the delayed-necrotic tissue, for the reason that it can not only break down the viable tissue, but also affect the survival of the flap. Thus, the timing of surgical intervention and wound coverage is still controversial. To develop a optimum technique for better salvage of the extremities injured by high-voltage electricity, We use free anterolateral thigh flap (ALT) combined with sub-flap sunction to recovery the intractalbe wounds. Methods: From March to July of the year 2014, 6 male patients admitted to our department for high-voltage electrical injuries on extremities with extensive skin defect and exposure of the subcutaneous vital tissues were enrolled in our study. The mean age was 44.4 years old. Following the primary debridement, we performed seven free anterolateral thigh flaps to cover the skin defect (one of the patients had wounds on both of his upper extremities), meanwhile, a porous rubber tube was put under the flap. After the operation, we exert continuous negative pressure through the tube to drain the exudate and colliquative delayed-necrotic tissue until complete survival of the flap. Results: The mean time of the performance of the flap after injury was 5.8 days, the mean size of the flaps was 24.17cmxlO.83cm, and the mean duration time of the exerted negative pressure was 14.6 days. All the flaps belonged to the single-perforator pedicles, and the survival rate was 100%. No infection, hematoma were noted. Follow-up of all the patients were present from 3 to 7 months, with no donor site sequelae noted. Conclusions: In our experience,the free anterolateral thigh flap with the single-perforator pedicle can provide prompt and adequate coverage of the wounds; moreover, when combined with continuous sub-flap suction (negative pressure exerted under the flap) which can drain the exudate and colliquative delayed necrotic tissue out. Applicability of Research to Practice: The technique can preserve the viable tissue utmostly, shorten the healing time, and thus, is a new technique for the salvage of the extremities injured by high voltage electricity. 67. Urban Frostbite 2014: One University Burn Center's Experience D. S. Shenaq, MD, A. O'Connor, MSN, M. Teele, PT, M. Robinson, MS OTR/L, L. J. Gottlieb, MD, FACS, D. Musgrove, BA The University of Chicago, Chicago, IL Introduction: Under ideal circumstances, severely frostbitten extremities are rapidly warmed and treated with thrombolytic therapy within 6–24 hours. In an “inner city,” urban environment, most patients who suffer frostbite injuries present in a delayed fashion, sustain repeated cold injuries further complicated by psychological issues or intoxication, and are rarely ideal candidates for thrombolytic therapy within the prescribed timeframe. We describe our experience with the treatment of urban frostbite injuries during the extreme Winter of 2014. Methods: This study is a retrospective review of cold injuries sustained between November 2013 - March 2014 that were treated at an 8-bed burn unit in an urban setting. Results: Fifty-three patients were treated for frostbite during the Winter of 2014 (42 males, 11 females). Average age was 43 years (range 2–84 years). Ten patients were classified with deep frostbite. No patients met criteria for thrombolytic therapy due to multiple freeze-thaw cycles or presentation greater than 24 hours after rewarming. Of these ten patients, 9 underwent debridement, which resulted in partial limb amputations at levels guided by Tc-99m bone scans. Wound closure was then achieved by: free flap coverage (n=2), a combination of V-Y and reverse sural artery flaps (n=3), split thickness skin grafting (n=1) and secondary intention healing (n=3). Of the 337 digits/limbs affected, 51 digital amputations were performed in addition to 4 proximal amputations including: TMA (n=2), Lisfranc, and a partial hand. Overall amputation rate was 21%. Conclusions: While tPA has been successful in reducing the need for digital amputation following frostbite injuries, in our experience, this treatment modality is not applicable to the urban patient population who often present late and after cycles of re-injury. Therefore, our approach focused on salvaging limb length with flap coverage as the injuries were unable to be reversed. Applicability of Research to Practice: Reviewing our experience with frostbite injuries will help to optimize quality of care for future patients, in addition to facilitate improved clinical outcomes. 68. Axillary Burn Contractures Release with Two-Layer Dermal Regeneration Template: Experience with 20 Axillae A. Bussieres, MD, T. A. Evans, MD, D. Roggy, RN, R. Sood, MD, FACS Indiana University, Indianapolis, IN Introduction: Burn scar contractures to the axilla are devastating functionally, limiting burn survivors' ability to perform common everyday tasks and independence. They also represent a reconstructive challenge for surgeons. In burn patients, donor sites for full thickness skin graft or flap are rare and recurrence rate is higher with split thickness skin graft. Dermal substitutes have become an alternative for reconstructive procedures and should be considered for complex axillary burn scar contractures. Methods: A retrospective review of our institution's dermal substitute database was performed to identify patients who underwent axillary burn scar contracture release with two-layers dermal template. Information collected included: demographic information, grade of contracture according to Kurtzman, size of Integra placed in the excised wound, thickness of the graft, pre-operative active range of motion measurements (AROM) and post-operative AROM when therapy plateau was obtained. Results: Fourteen patients with twenty-one sites were found in our database. Thirteen patients with twenty axillae were included since one patient lacked documented pre-operative or post-operative therapy treatment measurements. According to the Kurtzman classification, five axillae were classified as type IA, five as type II and ten as type III. The size of the two-layer dermal regeneration template placed in the excised wounds range from 100cm2 to 450cm2, Kurtzman III contractures requiring a larger template. In our population, mean active shoulder flexion increased by 38% and mean active shoulder abduction increased by 36%. Eight patients with eleven sites attained normal AROM in flexion (>150°) and nine patients with eleven sites attained normal AROM in abduction (>150°). No complications were recorded. No patient required subsequent surgical axillary release related to re-contracture. Conclusions: The use of a dermal regeneration template is an effective technique for every type of axillary burn contracture surgical release with a low rate of complication. It is a good reconstructive alternative when the previous burn limits donor sites for skin graft or flap. Applicability of Research to Practice: Dermal regeneration templates are easily available and technically simple to utilize. This reconstructive option should be an integral part of the reconstructive ladder for all types of axillary burn contracture release. 69. Regulation of Skin Color with Cell-Contained Biocomposites Based on Pigmentation Formula Relative to Melanocyte Numbers and Melanin Amount in Vitro and In Vivo N. Dai, MD, PhD, Y. Wang, MS, L. Dai, MD, PhD, K. Fu, PhD, P. Hsieh, MS, N. Liou, MD, PhD, K. Ma, PhD, J. Liu, PhD, S. Chen, MD, T. Chen, MD Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan; Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan; Department of Biology and Anatomy, National Defense Medical Center, Taipei, Taiwan Introduction: Discoloration of skin is usually observed in patients with deep second degree burn injury after spontaneous wound healing. In this work, we try to investigate the parameters crucial for skin pigmentation in terms of “L” value determined by chromameter, melanocyte numbers, and melanin production, and find the relationships among them. Methods: For the in vitro study, the human melanocytes and keratinocytes were cultured and purified from human foreskin sample. All of these parameters were crucial for skin pigmentation, including the “L” value (L) determined by Color Reader, the ratio (R) of melanocytes to keratinocytes in epidermis, and the melanin production (M) per 10^6 melanocytes. For the in vivo study, male Yorkshire cross-bred pigs were used. Full-thickness skin defects with 2-cm diameter were created on the dorsal skin of swine, which were subjected to 5 different treatments: KML50, keratinocytes and melanocytes with high L value; KML30, keratinocytes and melanocytes with low L value; KML50/F-Gelatin/Collagen, gelatin/collagen/polycaprolactone (GCP)-based biocomposit containing cells with KML50 ratio at the upper side and fibroblasts at the lower side; KML30/F-Gelatin/Collagen, GCP-based biocomposit containing cells with KML30 ratio at the upper side and fibroblasts at the lower side; normal pig skin (white area) as control. Pigmentation was evaluated by the Color Reader 7 and 9 weeks post surgery. Sections of the regenerated skin were also observed. Results: A significant correlation (R = 0.85) was found on formula that was described as “L=κ - 9.5(R x M)” in vitro. For the in vivo study, L value for all groups was significantly lower than that for the control group. L value for KML50 group was significantly higher than that for KML30 after 7 weeks. At week 9, L values for KML50 and KML50/F-Gelatin/Collagen were significantly higher than KML30 and KML30/F-Gelatin/Collagen, respectively. The groups with cell-contained biocomposites had significantly lower L values than those with only cells in vivo. Histological results showed that the regenerated skin of all cell only groups was epithelialized with structure of the rete ridges rather than the cell-contained biocomposite groups. Conclusions: By altering the ratio of melanocytes implanted, we could regulate the skin color by pigmentation formula. Applicability of Research to Practice: The pigmentation formula developed could be applied for melanocytes transplantation therapy to correct hypopigmentation induced by deep burn injury. External Funding: National Science Council, R.O.C. (NSC 96-2314-B-016-037-MY2). 70. Contractures in the Burn Model System National Database: Risk Factors and Implications J. Goverman, MD, FACS, A. J. Vardanian, MD, K. Mathews, BA, J. C. Schneider, MD, N. S. Gibran, MD, FACS, P. C. Esselman, MD, D. N. Herndon, MD, FACS, O. E. Suman, PhD, K. J. Kowalske, MD, C. M. Ryan, MD MGH / Shriners Boston, Boston, MA; Spaulding Rehabilitation Hospital, Boston, MA; University of Washington, Seattle, WA; University of Texas / Shriners, Galveston, TX; University of Texas, Galveston, TX; University of Texas, Dallas, TX Introduction: Post-burn contractures represent a significant morbidity for burn survivors. The purpose of this study was to characterize adult burn patients with contractures and to identify risk factors in their development. Methods: Prospectively collected data from 1994–2003 using the National Institute on Disability and Rehabilitation Research (NIDRR) Burn Model System (BMS) database was analyzed. The presence of contracture was evaluated, along with basic demographic information, including etiology of injury, location of injury, total body surface area burned and grafted, length of ICU stay, length of hospital stay, and return to work/school. Univariate and multivariate analyses were performed on the collected data in order to identify risk factors for the development of contractures. Results: A total of 2524 patients were analyzed, with a mean age of 30.5 (20.7) years and a mean total body surface area (TBSA) burned of 22.6% (19.1%). At the time of hospital discharge, 1349 (53.4%) patients were identified with no contractures and 1175 (46.6%) had at least one contracture. Univariate analyses showed that age, length of hospital stay, length of time in ICU, number of days to return to work/school, number of inpatient rehabilitation days, presence of inhalation injury, location of burn injury, percent TBSA burned, percent TBSA grafted, number of days on ventilator, number of operations, and amputations due to burn were all significantly increased (p<0.05) in patients with contractures. After step-wise multivariate logistic regression, the presence of burn contractures was associated with fire/flame etiology of burn injury (odds ratio 1.21; 95% CI 1.01–1.46), percent TBSA burned (odds ratio 1.02; 95% CI 1.02–1.03), arm burn (odds ratio 1.70; 95% CI 1.36–2.13), hand burn (odds ratio 1.36; 95% CI 1.11–1.65), and number of operations (odds ratio 1.42; 95% CI 1.32–1.52). Conclusions: This is the largest study evaluating the epidemiology of post-burn contractures. This information provides insight into the high incidence of contractures at the time of discharge from major burn centers. Patients with fire/flame injuries, higher severity of burns (increased TBSA), increased number of operations, larger skin grafted area, as well as upper extremity injury to the arm and hand were associated with contractures. This information may allow clinicians to target high risk patients for contracture prevention. Further studies to assess severity of contractures and long-term outcomes are needed. Applicability of Research to Practice: The high incidence of post-burn contractures present at hospital discharge underscores the need for primary prevention and earlier intervention. External Funding: The contents of this abstract were partially developed under a grant from the Department of Education, NIDRR grant number H133A120034. 71. 10 Years of Experience in Managing Burn Neck Contracture in Children T. Huang, MD, FACS, D. N. Herndon, MD, FACS UTMB & Shriners Burns Hospital Galveston, Galveston, TX Introduction: Burn neck contracture occurs in 18% of all children who had sustained burns of the head and neck area. While a neck brace applied soon after the injuries is the regimen advocated, the efficacy is often curtailed because of poor patient compliancy due to pain and discomfort from wearing a brace. Over the past decade, skin grafting or skin flaps has been the primary approaches in managing neck contractures at our hospital. The experience gained from utilizing two techniques formed the basis of this report. Methods: Between 2003 and 2012, a total of 377 primary neck releasing procedures were performed in 300 children. The techniques used were either partial or full thickness skin grafting or local skin flap that included tissue expansion (TE), z-plasty and an interpositional skin flap. Tight scars around the anterior neck interfering with neck movements and subjective complaints of tightness noted in the anterior neck elicited with neck extension were the indications for surgical intervention. The incident of recurrent contracture or persistent tightness around the neck because of contracting scar bands were the criteria used to determine the efficacy of each regimen. Results: Of 300 children studied, there were 203 boys. The youngest was 2 years of age while the oldest was 20, with an average age of 12.79 years. The length of follow up in 180 children varied between 1 and 10 years. The mean length was 5.06 years. The magnitude of original injuries; i.e., total body surface area (TBSA) involvement varied between 13 and 97% with a mean TBSA involvement of 58%. Local flap techniques; i.e., TE, z-plasty and inter-positional skin/skin muscle flap were used in 340 times while skin graft was 37 times. Re-releasing of neck contracture was needed in 53; i.e., a rate of 15.58% for the flap group while 33 re-releases were needed in skin graft group; i.e. ∼90%. Conclusions: Although the conventional procedure of skin grafting may remain effective in reconstructing neck contracture, re-release is less often if local flap techniques were used. 72. Burned Ear Reconstruction Using Porous Polyethylene Implants D. N. Driscoll, MD, FACS, J. Fernandes, MD Shriner's Hospital, Boston, Boston, MA; Massachusetts General Hospital, Boston, MA Introduction: Reconstruction of the external ear after a burn is particularly challenging for the plastic surgeon. The nature of the injury poses many problems such as extensive scar tissue, poor blood supply and the lack of adequate and appropriate materials for a framework. Options include z-plasty, skin grafts, cartilage grafts, conchal transposition flaps, costochondral and porous polyethylene reconstruction. In severely burned skin, due to the thick scar, the use of costochondral grafts often leads to poor outcomes, which do not justify the morbidity of the procedure. Children under the age of 10 commonly have insufficient cartilage for a costochondral graft. Porous polyethylene offers minimal morbidity and a very effective result. In this series we describe our experience using porous polyethylene to reconstruct severely burned ears. Methods: A total of 17 patients underwent 19 reconstructions, with two patients receiving bilateral procedures. Patients ranged from three to twenty years of age. All patients received porous polyethylene ear implants. Twelve patients were tissue expanded for alopecia during the staged ear reconstruction for an average of 4 months. Eleven temporoparietal fascial flaps were performed. In the remaining patients, coverage of the implant was achieved by local advancemant flaps, tissue rearrangements and skin grafts. Results: Only two patients had complications with exposure of the porous polyethylene construct after several years. In these two cases the implants were removed. Our experience has shown porous polyethylene reconstruction to be very efficient, with low morbidity and good cosmetic outcomes. Conclusions: Porous polyethylene ear implant is an excellent option for the reconstruction of both fully and partially burned ears as you may implant only the helical rim, base or both pieces. Our best results were achieved after scalp tissue expansion and with a temporoparietal fascial flap for implant coverage. This has become our preferred method for reconstruction of the severely burned ear. Applicability of Research to Practice: The burned ear is a difficult problem for the reconstructive surgeon. Porous polyethylene provides an excellent option in reconstructing part or all of the external ear with minimal morbidity and an acceptable complication rate. 73. National Burn Therapist Competency Guidelines - Are We Using Them? I. S. Parry, MS, PT, S. Sen, MD, FACS, T. L. Palmieri, MD, FACS, FCCM, D. G. Greenhalgh, MD, FACS Shriners Hospital for Children, Northern California, Sacramento, CA Introduction: Prior to 2011, there were no national standard competencies for rehabilitation therapist working in burn care. That year, the ABA Rehabilitation Committee published the Burn Rehabilitation Therapist Competency Tool (BRTCT) developed through Delphi questionnaire and expert consensus. The purpose of the present study was to evaluate if burn centers in North America have incorporated the BRTCT guidelines into practice and if there is a difference between ABA verified (V) and non-verified (NV) centers. Methods: A purposive sample of V and NV burn centers in North America were surveyed regarding therapist competencies. Rehabilitation personnel at each center were sent an electronic link to the survey. Follow up interviews were conducted with willing respondents to obtain more detailed information. Results: A total of 139 burn centers in North America were surveyed (65=V, 74=NV) and 35% responded (32=V, 17=NV). Table 1 provides information regarding therapy staffing, acute burn admissions and outpatients comparing V to NV centers. Most V centers (88%) reported currently having burn therapist competencies in place compared to only 65% of NV centers. For both groups, the most common method of competency training was skill demonstration (V=69%, NV=47%). Most V centers reported assessing competence annually (46%) while most NV centers that assessed therapist competency, did so upon initial orientation only (67%). The number of respondents familiar with the BRTCT guidelines was greater in V centers (78%=V, 38%=NV). The BRTCT guidelines have been, or are currently being incorporated into existing competencies in 41% of V and 24% of NV centers. In follow up interviews, all but one respondent stated that they are lacking some domains in their existing competencies as compared to the BRTCT. Conversely, all of those centers reported the BRTCT was comprehensive of the domains in their local competency. Conclusions: The burn rehabilitation community has made moderate progress toward the implementation of national standards for burn therapist competencies. The BRTCT is used more readily in V burn centers compared to NV centers. However, further education is needed to help both V and NV centers align their competencies with national guidelines. Applicability of Research to Practice: Improve the standardization of burn rehabilitation throughout burn centers. View Large View Large 74. Impact of Early Inpatient Rehabilitation on Adult Burn Survivors' Functional Outcomes and Resource Utilization M. Gomez, MD, M. Tushinski, MD, M. G. Jeschke, MD, FACS University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada Introduction: On July 2012, a rehabilitation hospital with the only burn rehabilitation program in our region merged with a trauma center where the regional burn center is located. The purpose of this study was to determine the impact of having the inpatient rehabilitation and the burn center in the same hospital and earlier initiation of inpatient rehabilitation on burn survivors' functional outcomes and resource utilization. Methods: A retrospective review of electronic data of burn survivors' functional outcomes (Functional Independence Measure [FIM™] ratings on admission, at discharge, and percent change), and resource utilization (waiting time for rehab, burn center length of stay [LOS], rehab LOS, physiotherapy and occupational therapy rehabilitation workload [RehabWorkload], and discharge destination) was undertaken. Adult burn survivors who required inpatient rehabilitation and were transferred from the burn center to the inpatient rehabilitation service BEFORE the merger (July 2010-June 2012) were compared with those transferred AFTER the merger (July 2012-June 2014). Results: One hundred thirty eight burn survivors were transferred from the burn center to the inpatient rehabilitation service during the study period, 60 (43.5%) BEFORE and 78 (56.5%) AFTER the merger. There were 97 (70.3%) males and 41 (29.7%) females with a mean age of 47.9 ± 17.9 years, total body surface area burn (TBSA) of 24.2 ± 16.9%, and full thickness burn (FTB) of 13.1 ± 16.4%. The etiology of their burns were flame (72.5%), scald (19.6%), electrical (5.1%), chemical (2.2%) and contact (0.7%). Patients in both groups had similar age, inhalation injury, TBSA, FTB, FIM™ ratings, Rehab Workload, and burn etiology. Patients transferred BEFORE the merger had significantly more chemical burns (5% vs.0%, p=0.046), and more work-related burns (26.7% vs. 7.7%, p=0.004). Patients transferred AFTER the merger had significantly shorter burn center LOS (28.5 ± 20.9 days vs. 38.8 ± 34.2 days, p=0.043), and shorter waiting time for rehab (0.68 ± 1.1 days vs. 1.52 ± 2.3 days, p=0.010). Also, they were more likely to have shorter rehab LOS (29.7 ± 24.2 days vs. 32.4 ± 24.2, p=0.519), fewer discharges to acute care (1.3% vs. 6.7%, p=0.167), and more discharges to home (88.5% vs. 80.0%, p=0.232), than patients transferred BEFORE the merger. Conclusions: Early initiation of inpatient rehabilitation, after the burn center and the inpatient rehabilitation service were located in the same hospital, improved burn survivors' resource utilization. Applicability of Research to Practice: Early transfer of burn survivors to an inpatient rehabilitation service improves their resource utilization and frees burn center beds for new admissions requiring specialized burn care. 75. Structural and Functional Changes in Pediatric Burn Victims Two Years after Injury J. Carson, MD, M. G. Jeschke, MD, PhD, R. P. Mlcak, PhD, D. N. Herndon, MD, FACS, O. Suman, PhD Shriners Hospitals for Children - Galveston, Galveston, TX; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada Introduction: We have previously published that among patients with a TBSA% >30, burn size directly correlates with short-term outcomes, with a burn size of approximately 60% TBSA representing a crucial threshold for post-burn morbidity and mortality. With a marked increase in survival over the past 30 years, modern burn centers face a new challenge_optimizing the long-term functional outcome in the survivors of massive burns. While it is well established that the acute physiologic response to major burn injury can persist for months to years, little is known regarding the physiologic or functional outcomes of burn patients long-term. Lean Body Mass index (LBMi) and Muscle Strength (MStr) are three quantitative objective measurements reflecting critical dimensions of physiologic function. This study was designed to characterize long-term functional and physiologic outcomes in a large cohort of pediatric survivors of major burn injuries. Methods: This is a single center prospective cohort study of pediatric patients with burns involving 30% TBSA or more, admitted between 1998 and 2009. LBM was assessed by Dual X-ray Absorptiometry (DEXA), and MStr was measured by isokinetic dynamometry. LBM and DEXA assessments were performed early during outpatient status (between discharge 6-months post-burn) and at approximately two years post burn. LBMi was defined as the ratio of lean body mass to height-squared. Statistical analysis was performed using Student's t-test, χ2 test, logistic regression, as appropriate, with significance set at p<0.05. Results: Our study included 245 burned children. 189 (76%) patients were male. The mean age was 12years (range 5–18), and the mean %TBSA burn was 59% (40%-95). LBMi was 13.8 +/−3.2 kg/m2 at early assessment, and 15.3 +/− 3.1 kg/m2 2-years post-burn, reflecting an increase of 28.1% +/− 7.3% (p=0.002). LBMi for age-matched non-burned controls was 15.5 +/− 3.2, p =0.28. Mean MStr of burned patients was 97.9 +/− 35.4 Nm/kg at early assessment, and increased to 156.9 +/− 33.8 Nm/kg at 2-years post-burn for an increase in 82% +/−82% (p<0.001). At two years post-burn, patient MStrs were still significantly below the mean of 223.3 +/−48.5 Nm/kg found in non-burned controls (p<0.0001). Conclusions: Our findings indicate that in pediatric survivors of massive burns, the traumatic insult of a major burn is associated with marked physiologic changes which persist for years following injury. This raises questions as to a) what findings at initial discharge might correlate with the severity of these changes, and b) what interventions might prove effective in mitigating these physiologic changes. Applicability of Research to Practice: These findings highlight the long-term functional consequences of burn injury which may influence the course of and response to effective rehabilitation. External Funding: NIH: P50 GM060388 • R01 HD049471 • NIDRR: H133A120091 • SHC: 71006, 71008, 71009, 84080 • T32-GM008256. 76. Treating Neuropathic Pain in Burn Survivors: A Case Series V. Calva, BSc, OT, A. Chouinard, BSc, PT, M. A. Couture, MSOT, E. Godbout, MSOT, A. De Oliveira, BSc, L. LaSalle, MD, B. Nedelec, PhD Villa Medica Rehabilitation Hospital, Montreal, QC, Canada; McGill University, Montreal, QC, Canada Introduction: Neuropathic pain is an enormous rehabilitation challenge, which has a negative impact on patient function and quality of life. Somatosensory rehabilitation (SR) is a novel, non-pharmacological intervention described by Claude Spicher based on neuro-plasticity of the somatosensory system. According to SR, treating hypoesthesia will decrease neuropathic pain. Sometimes the hypoesthesia is masked by mechanical allodynia (MA), which must be treated before treating the underlying hyposensitive zone. This case series describes the outcome 17 burn survivors treated SR for their neuropathic pain. Methods: Prior to initiating SRthe McGill Pain Questionnaire-short form (MPQ) was completed with the patients. The total score (x/64) was converted to percentage. The tactile sensitivity of the skin was also assessed with Semmes Weinstein Monofilaments (SWM). Touch with the 15g SWM that was rated as painful on the VAS (3/10 or resting pain +1/10) was the criteria for MA. The severity of MA was determined using 7 predetermined SWM to identify the smallest that elicited pain. The treatment consisted of avoiding all touch in the allodynic zone while concurrently providing proximal vibrotactile counterstimulation. Once the MA was eliminated, the underlying hypoesthesia was treated. A 10 SWM range from 1 to 60g was used to evaluate hypoesthesia and the percent improvement from baseline was calculated. The treatment for hypoethesia consisted of touch discrimination, localization and graphesthesia as well as vibratory stimulation. Results: Seventeen patients (70.6/29.4% male/female, 20.8 ± 25.0% TBSA, 486 ± 595 days post-burn) were evaluated and treated. Of these 15 initially presented with MA. The SWM scores had improved by 27.3 ± 21.2% (n=14) and 29.2 ± 25.7% (n= 12) at 2 and 3 months post-treatment respectively. The MPQ scores had improved by 8.9 ± 14.1% (n=8) and 22.7 ± 22.8% (n=6) at 2 and 3 months post-treatment respectively. There were 2 patients who initially presented with hypoesthesia and 4 who had their hypoesthetic areas treated after the MA had resolved. For these 6 patients their ability to perceive light touch improved by 26.7 ± 19.7% (n=6) and 37.5 ± 31.0% (n=5) at 2 and 3 months post-sensory re-education. The MPQ improved by 9% and 50% for the 2 patients who initially presented with hypoesthesia. Conclusions: In this case series the majority of patients (13/17) showed substantial improvement after SR treatment. Most of those who did not respond were suffering from major depression that was resistant to medical treatment. This therapeutic approach should be evaluated in a controlled clinical trial. Applicability of Research to Practice: Somatosensory rehabilitation may provide an efficient treatment option to diminish neuropathic pain in burn survivors, but further research is required. 77. The Percentage of Body Surface Area Grafted Does Not Influence the Perception of Thermal Strain during Exercise in the Heat C. G. Crandall, PhD, Z. J. Schlader, PhD, M. S. Ganio, PhD, J. Pearson, PhD, R. A. Lucas, PhD, E. Rivas, MS, K. J. Kowalske, MD University of Texas Southwestern Medical Center, Dallas, TX; University of Buffalo, Buffalo, NY; University of Arkansas, Fayetteville, AR; University of Colorado at Colorado Springs, Colorado Springs, CO; Umea University, Umea, Sweden Introduction: Individuals with a large percentage of their body surface area (BSA) grafted are at an elevated risk for a heat-related injury during exercise because of impaired heat dissipation. We tested the hypothesis that burn survivors can appropriately perceive thermal strain while exercising in the heat. Methods: Individuals with well-healed skin grafts covering 17–40% BSA (N=19) and >40% BSA (N=15), as well as non-grafted control subjects (N=9), exercised at a moderate workload (oxygen consumption: 1.0 l/min) in a 40°C, 30% relative humidity environment for 90 min. Physiological thermal strain (range: 0–10 units) was quantified via a validated formula using intestinal (body core) temperature and heart rate from pre-to end-exercise. Perceptual thermal strain (range: 0–10 units) was likewise quantified via a validated formula from perceived exertion and thermal perception between pre- and end-exercise. Results: Primary responses are depicted in Table 1. Conclusions: Although physiological thermal strain was greater in the grafted groups, an equally elevated perceptual thermal strain in these subjects demonstrates that having a significant percentage of BSA grafted does not impair the capability to perceive a thermal strain during exercise in the heat. Applicability of Research to Practice: These data demonstrate that individuals with a significant percentage of their BSA grafted can appropriately perceive physiological thermal strain during exercise in the heat and thus are capable of recognizing the need to enact behavioral adaptations to reduce that thermal strain prior to a heat-related injury. External Funding: National Institutes of General Medical Sciences - GM068865. View Large View Large 78. Effects of Whole Body Vibration on Bone of Thermally Injured Children F. J. Bohanon, MD, J. Edionwe, BS, C. Hess, BS, D. N. Herndon, MD, FACS, R. P. Mlcak, PhD, O. E. Suman, PhD Shriners Hospital for Children, Galveston, TX; University of Texas Medical Branch, Galveston, TX Introduction: Thermal injury results in a significant reduction of bone mineral content (BMC) and bone mineral density (BMD). This reduction of bone mass results in an increased morbidity including sporadic fractures and impaired mobility. In burned children, exercise alone has not been shown to increase bone mass. However, whole body vibration (WBV) has been shown to increase BMD in post-menopausal women and in female athletes. Thus, we hypothesized that WBV would increase BMD and BMC in burned children. Methods: Nineteen pediatric patients with >30% total body surface area (TBSA) burn were randomized to a group who participated in a 6-week exercise program of resistance and aerobic exercise (EX) or to a group who participated in EX supplemented with whole body vibration exercises (EX+WBV). The EX and EX+WBV programs started at hospital discharge. Both groups received resistive exercise three days per week and aerobic exercise five days per week for 20–40 minutes. The EX+WBV group also received vibration exercises five days per week. Dual-energy X-ray absorptiometry (DXA) was performed at the start and the end of each intervention to assess BMC and BMD. Results are expressed at mean ± SD, paired and unpaired T-tests were made within group and between groups as applicable and significance was set at p<0.05. Results: Nineteen patients completed the six weeks of study. There were no significant differences in age, height, weight, and TBSA between the EX (n=10) and EX+WBV (n=9) groups. At baseline, both groups were similar in BMD and BMC. At the completion of the study there was no difference in BMD in the EX compared to the EX+WBV group (total leg: 0.86 ± 0.2 vs 0.91 ± 0.2 g/cm3, whole body; 0.86 ± 0.1 vs 0.90 ± 0.2 g/cm3, lumbar spine: 0.72 ± 0.2 vs 0.76 ± 0.1 g/cm3, respectively, P>0.05). No difference was found in BMC between the groups (total leg: 270.8 ± 132.4 vs 249.7 ± 113.3 g/cm2, whole body 1431.5 ± 604.5 vs 1359.9 ± 548.0 g/cm2, lumbar spine: 35.8 ± 16.8 vs 27.3 ± 14.1 g/cm2, respectively, P>0.05). Finally, there were no significant difference in the percent change from pretest to post-test within each group for both BMD and BMC. Conclusions: Alternative strategies to EX+WBV or EX are needed to increase BMC and BMD following a severe burn. Alternative strategies may include pharmacological interventions such as pamidronate, exercise of longer duration than six-weeks or exercises that involve more intense bone loading such as leg squats. Applicability of Research to Practice: This study suggests that to improve BMC and BMD, we should focus on alternative strategies such as pamidronate or specific bone loading exercises. External Funding: NIH: P50 GM060388, R01 HD049471, 5T32GM8256-24. NIDRR H133A120091. 79. Differential Assessment of Distal Interphalangeal Joint Flexion Limitation of Burned Fingers R. L. Richard, PT, MS, W. S. Dewey, PT, J. A. Jones, BS, W. R. Anyan III, MPT, I. H. Faraklas, RN, BSN U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX; Independent Contractor, Portland, OR; University of Utah, Salt Lake City, UT Introduction: The hand/fingers have many structures that can affect function. As such, it is important to accurately identify tissue contributing to joint limitations in motion (LOM). After a burn, LOM of finger distal interphalangeal (DIP) joint flexion can be caused by several structures. Isolated DIP flexion is commonly limited by the Oblique Retinacular Ligament (ORL). One function of the ORL is to act as a checkrein to protect against excessive DIP flexion when a finger is fully extended. The purpose of this study was to investigate the accuracy of DIP joint LOM assessment in burned fingers relative to the ORL. Methods: Adult subjects' passive DIP joint range of motion (ROM) measurements were recorded in a prospective, multi-center study investigating burn scar contracture LOM. Thirteen (13) verified burn centers contributed data to the study. DIP joint ROM was measured in three prescribed hand/finger positions of composite, combined (hook fist) and isolated flexion. Concurrently, rehab clinicians were asked to identify any source of LOM and select the cause from a menu of possible choices for the restriction. Standard goniometry DIP flexion measurements were compared to isolated DIP measurements for qualitative and quantitative differences. Descriptive statistics were used in the analyses. Results: A total of 127 subjects had 409 finger DIP joints compared between all three positions. The vast majority of subjects were right hand dominant (84%) with a mean age: 39 + 15.7 years. The median total body burn was 9.7% (IQR: 4.6 - 19.3%) with a median dorsal hand burn of 71% (IQR: 29 - 99%). Composite, combined, and isolated DIP joint flexion was: 81°+ 12°; 87°+7°; and 72°+16° respectively. Isolated DIP flexion >75° was measured in 193 fingers (47%) while 216 fingers (53%) measured <75° DIP flexion. A significant difference was found between combined and isolated measurements (p<0.0001). However, in both of the foregoing groups, the co-morbid contributing factor of LOM attributed to ‘other soft tissue’ inclusive of the ORL was identified in only 8% and 18% of the groups respectively (Graph). Conclusions: The ability to accurately assess soft tissue restriction with joint LOM of burned fingers is an important clinical feature. These results indicate that assessment of the ORL as a source of DIP joint LOM may be under appreciated. Applicability of Research to Practice: The ability to accurately assess soft tissue restriction of joint range of motion in burned finger is important to establishing a treatment plan. External Funding: USAMRAA Award#W81XWH-08-1-0683. View largeDownload slide View largeDownload slide 80. Temporal Activation of Neuroinflammation in the Brain Following Burn Injury A. El Ayadi, PhD, Y. Wang, BS, A. Prasai, MS, R. MifHin, PhD, D. N. Herndon, MD, FACS, C. C. Finnerty, PhD University of Texas Medical Branch, Galveston, TX Introduction: Burn injury is characterized by a dramatic increase in circulatory cytokines and systemic inflammation that leads to a hypermetabolic state. However, few studies have focused on neuroinflammation following burn injury. Neuroinflammation has been long associated with traumatic brain injury and subsequent psychiatric disorders such as Post Traumatic Stress Disorder (PTSD) and bipolar disorder. While the effects of burn injury on systemic inflammation are well studied, little is known regarding the levels of cytokines and neuroinflammation markers in specific brain areas. Previous studies have indicated structural, metabolic, and signaling abnormalities in the frontal cortex of bipolar disorder patients and TBI patients. We now investigated the effects of burn injury on neuroinflammation in the prefrontal cortex using our established rat scald burn model. Methods: Using qPCR, we analyzed the effects of burn injury on neuroinflammation markers in the prefrontal cortex of rats following a 60% TBSA scald burn. The whole brain was removed at different time points post burn, flash frozen, and stored at -80 until analysis. Results: Our results indicated statistically significant higher mRNA levels of Cox2, GMCSF, IL-b, IL-6, caspase-1, p53 and CDC25A at 24 hrs post burn that return to baseline by 7 days post burn. Cinc-1 was significantly increased by 7 days post burn. MCP-1, INF-y, TNF-a, IL-18, Cdk-1 and the microglial marker CD11b were down regulated 24 hrs post burn before increasing or going back to normal at 7 days post burn. Conclusions: These data show that following burn injury, neuroinflammation markers are differentially modulated to orchestrate a response that will preserve the homeostatic state of the brain in high stress levels conditions. This response may halt cytotoxicity and subsequent neuropathology. Applicability of Research to Practice: Dissecting the molecular pathways involved in this complex response may give us insights on the long term effects of neuroinflammation that could evolve into more severe neurodegenerative diseases and psychiatric disorders that can manifest in burn patients. 81. Results of a Prospective, Multicenter, Randomized Clinical Trial Comparing a Low-Adherent, Silver-Based Antimicrobial Dressing to 5% Mafenide Acetate in the Post-Operative Management of Split-Thickness Skin Grafts B. A. Cairns, MD, FACS, J. H. Holmes IV, MD, FACS, W. L. Hickerson, MD, FACS, D. W. Mozingo, MD, J. Hwang, MD, L. C. Cancio, MD, FACS North Carolina Jaycee Burn Center, Chapel Hill, NC; Wake Forest Baptist Medical Center Burn Center, Winston-Salem, NC; Firefighters Regional Burn Center, Memphis, TN; UF Health Burn Center, Gainesville, FL; Brooke Army Medical Center, Fort Sam Houston, TX Introduction: The standard of care for managing deep partial-and full-thickness burns is early excision and split-thickness autografting. One common post-operative dressing is 5% mafenide acetate soaked gauze. The frequent re-wetting required for mafenide acetate can be painful for the patient and costly in materials and clinician time. An FDA-approved, low-adherent, moisture management, silver-based antimicrobial dressing, referred to as P6, has recently been developed that does not require pre-wetting or re-wetting. In this study, we conducted a prospective, multicenter, randomized, clinical trial comparing P6 to 5% mafenide acetate in the post-operative management of split-thickness skin grafts. Methods: We enrolled 72 participants between the ages of 18 and 65, with TBSA < 50%, and with at least two comparable burn sites requiring autografting. The primary objective was to compare clinical outcomes as measured by percent graft take on post-operative day six. Secondary objectives involved evaluations of data related to infection, adverse events, pain, ease of use, and cost. Data were examined using the Wilcoxon Signed-Rank test for the primary objective and exact binomial tests for discordant pairs for the secondary objectives. Results: Average graft take was not statistically different for the two dressings: 97.7% ± 11.4% and 98.3% ± 10.7% for P6 and 5% mafenide acetate, respectively (p = .344). There was no regrafting due to infection, and there were no treatment-related adverse events for either dressing. P6 statistically outperformed 5% mafenide acetate with regard to pain (p = 0.001) and ease of use (p < 0.001), with material costs for P6 that were 2.8 times lower than costs for mafenide acetate. Conclusions: P6 is clinically comparable to 5% mafenide acetate for the management of split-thickness skin grafts and results in less pain, greater ease of use, and lower costs. Applicability of Research to Practice: The results demonstrate that P6 is a proven clinical alternative to 5% mafenide acetate for the management of skin grafts, with potential benefits for the patient and the clinician. Less patient pain may result in greater compliance with treatment regimens or the need for less pain medication. The improved ease of use may minimize time in the OR and reduce lengthy maintenance and dressing change procedures. External Funding: This project was conducted by Milliken Healthcare Products, LLC and funded by a research grant from the U.S. Army Med. Res. & Materiel Command (USAMRMC) and the Telemedicine & Adv. Tech. Research Ctr. (TATRC) under Contract Number: W81XWH-10-2-0159. External Funding: This project was conducted by Milliken Healthcare Products, LLC and funded by a research grant from the U.S. Army Med. Res. & Materiel Command (USAMRMC) and the Telemedicine & Adv. Tech. Research Ctr. (TATRC) under Contract Number: W81XWH-10-2-0159. 82. Outcomes in Adult Survivors of Childhood Burn Injuries as Compared to Matched Controls J. Stone, BSc, J. P. Gawaziuk, MSc, S. Khan, PhD, D. Chateau, PhD, J. M. Bolton, MD, J. Sareen, MD, J. Enns, BSc, M. Doupe, PhD, M. Brownell, PhD, S. Logsetty, MD University of Manitoba, Winnipeg, MB, Canada Introduction: Limited research exists examining long-term mental and physical health outcomes in adult survivors of pediatric burn injuries. We present a population based epidemiologic study on the post-injury lifetime prevalence of common DSM-IV mental and physical disorders in a population based, pediatric burn cohort as compared to matched controls from the general population. Methods: 748 survivors of childhood burns were identified from a regional pediatric burn centre registry (between April 1, 1988 and March 31, 2010 with Total Body Surface Area burns >1%). These individuals were matched 1:5 to children from the regional general population based on age, sex and geographic residence. Post-burn prevalence and Odds Ratio (OR) comparisons of common Axis 1 mental and physical disorders were done. The diagnoses were made through physician billings, hospital claims and clinical data housed at the regional administrative Data Repository. Results: The burn cohort was 5.43 ± 5.02 years old (mean ± SD) with a % TBSA of 11.94 ± 12.03 (mean ± SD). In burn survivors, anxiety was the most prevalent Axis 1 mental disorder (22.59%), followed by major depression (14.17%), substance abuse/dependence (3.21%) and suicide attempts (1.2%). Total respiratory morbidity was the most prevalent physical disorder in burn survivors (51.34%), followed by arthritis (36.50%), fractures (30.21%), diabetes (3.61%) and cancer (1.47%). Compared to controls, the burn cohort showed a significant increase in major depression (OR = 1.76; CI 1.39–2.22), anxiety (OR= 1.74; CI 1.44–2.12), substance abuse/dependence (OR=2.85; CI 1.71–4.73), suicide attempts (OR=5.68; CI 2.18–14.7), arthritis (OR=1.33; CI 1.13–1.56), cancer (OR=2.05; CI 1.01–4.16), diabetes (OR=1.71; CI 1.09–2.67), fractures (OR=1.73; CI 1.46–2.07) and total respiratory morbidity (OR= 1.57; CI 1.32–1.84). Conclusions: Adult survivors of childhood burn injury report significantly increased prevalence and odds of post-burn Axis 1 mental and physical disorders. Applicability of Research to Practice: Screening for these common mental and physical disorders in adult survivors of childhood burn injuries is essential when caring for this population. External Funding: BSc Med Award and Department of Surgery GFT Award, University of Manitoba; Manitoba Firefighters' Burn Fund. View Large View Large 83. Autologous Engineered Skin Substitutes Reduce Mortality and Harvesting of Skin Graft Donor Sites for Closure of Extensive, Full-Thickness Burns S. T. Boyce, PhD, P. S. Simpson, MSN, M. T. Rieman, BSN, P. Warner, MD, K. P. Yakuboff, MD, J. K. Bailey, MD, FACS, J. K. Nelson, RN, L. A. Fowler, BSN, R. J. Kagan, MD University of Cincinnati, Cincinnati, OH; Shriners Hospitals for Children - Cincinnati, Cincinnati, OH Introduction: Stable closure of full-thickness burn wounds with autologous skin remains a limiting factor to recovery from burns of greater than 50% of the total body surface area (TBSA). Hypothetically, engineered skin substitutes (ESS) consisting of autologous cultured keratinocytes and fibroblasts attached to collagen-based scaffolds may reduce requirements for donor skin, morbidity from autograft harvesting and widely-meshed skin grafts, and possibly mortality. Methods: Between 2007–2010, ESS were prepared from split-thickness skin biopsies collected after enrollment of 16 pediatric burn patients by Informed Consent into an investigative protocol approved by the local Institutional Review Board, and regulated by the US FDA. ESS and split-thickness skin autograft (AG) were applied in a matched-pair design to patients with full-thickness burns involving a mean of 76.9% of the total body surface area (TBSA). Data collection consisted of photographs, area measurements of donor skin and healed wounds after grafting, biopsies of healed skin, comparison of mortality with the National Burn Repository, correlation of percentage closed wounds with percentage full-thickness burn, frequencies of regrafting within 28 days, and immunoreactivity to the biopolymer scaffold. Results: One subject expired before ESS were prepared. Fifteen subjects received 2056 ESS grafts with a total area of 4.89 m2 which were applied in 60 operative procedures. Mortality for these subjects was 6.25% (1/16), and 30.3% (305/1008) for a population with similar demographics in the National Burn Repository (p<0.05). Engraftment at POD 14 was 83.5 ± 2.0% for ESS and 96.5 ± 0.9 for AG. Percentage TBSA closed at POD 28 was 29.9 ± 3.3% for ESS, and 47.0 ± 2.0 for AG. The ratio of closed to donor areas at POD 28 was 108.7 ± 9.7 for ESS compared with a maximum of 4.0 ± 0.0 for each harvest of AG. Each of these values was significantly different between the graft types. Correlation of % TBSA closed with ESS at POD 28 with % TBSA full-thickness burn generated an R-squared value of 0.65 (p<0.001). Conclusions: These results indicate that autologous ESS reduce mortality and requirements for donor skin harvesting, for grafting of full-thickness burns of greater than 50% TBSA. Applicability of Research to Practice: These results suggest that availability of autologous ESS for treatment of extensive, deep burns may reduce time to wound closure, long-term morbidity and mortality in this patient population. External Funding: Support for this study was provided by Shriners Hospitals for Children. 84. Reasons for Distress at 6, 12 and 24 Months Post Burn Injury S. Wiechman, Ph.D., ABPP, K. McMullen, MPH, G. J. Carrougher, RN, MN, K. Roaten, PhD, J. A. Fauerbach, PhD, D. N. Herndon, MD, FACS, C. M. Ryan, MD, N. S. Gibran, MD, FACS University of Washington/Harborview Medical Center, Seattle, WA; UT Southwestern, Dallas, TX; Johns Hopkins University School of Medicine, Baltimore, MD; Shriners Hospital Galveston, Galveston, TX; Massachusetts General Hospital, Boston, MA Introduction: The purposes of this study were to: i) identify factors of distress among burn survivors, ii) determine if these factors change at various points, and iii) examine the impact of distress on physical and mental health outcomes over time. Methods: Participants were asked to rate 12 reasons for distress using a 0–10 scale at discharge, 6-, 12- and 24-months following injury. The SF-12® (physical component subscale [PCS] and the mental component subscale [MCS]) was administered to assess health-related quality of life. The Satisfaction With Appearance Scale (SWAP) total score was used to understand the impact of distress on body image, and number of days to return to work was used to assess impact of distress on employment. All measures were given at each time point. Predictive models with continuous outcomes were analyzed using a mixed model analysis. Variables with binary outcomes were analyzed using multivariate logistic regression. Analyses were adjusted for age, burn size and time. Results: A total of 1009 adults participated in the study between 2006–2014. The mean age was 44 (s.d. 15.5), mean TBSA = 19.6% (s.d. 17.36) and 72% were male. When compared to discharge, distress from pain, decreased range of motion, sleep disturbance, decreased strength, and long recovery time significantly decreased at all 3 follow up time points. Distress from itching significantly decreased at 12 and 24 months, discomfort with scars decreased significantly at 6 months. Distress from pressure garments and financial concerns showed a significant decrease at 24 months. The table summarizes the impact of distress on the various outcome measures. Conclusions: The mean scores as a group are lower at 2 years, indicating lower levels of distress. The long recovery time and financial concerns remain top reasons for distress throughout the two-year period and need focused analysis and intervention. Pain and sleep disturbance appear to have the biggest impact on long term physical and psychosocial quality of life and ability to return to work. Applicability of Research to Practice: This information could identify reasons for distress with the greatest impact on quality of life so that the burn community can establish temporally appropriate treatment interventions. External Funding: National Institute on Disability and Rehabilitation Research Grant #H133A13004, H133A120024. View Large View Large 85. Small and Large Burns Alike Benefit from Lengthier Rehabilitation Time R. L. Richard, PT, MS, J. A. Jones, BS, W. S. Dewey, PT, W. R. Anyan III, MPT, I. H. Faraklas, RN, BSN U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX; Independent Contractor, Portland, OR; University of Utah, Salt Lake City, UT Introduction: Mitigating burn scar contracture (BSC) or joint loss of motion (LOM) in patients after burn injury is difficult for burn clinicians regardless of burn extent. Previous research has documented an overall beneficial effect of increased burn rehabilitation time (BRT) on patient outcomes. The purpose of this investigation was to determine if the amount of BRT patients received during their acute hospitalization had a similar effect on patient groups with differing extents of burn injury. Methods: The study was a prospective, multi-center investigation into the physical outcome of burn survivors. Thirteen verified burn centers contributed data to the investigation from 2010–13. Goniometric measurements of joint range of motion (ROM) prone to BSC/LOM were recorded from Cutaneous Functional Units (CFU) at the time of acute hospital discharge. Univariate analysis and Multiple Logistic Regression were used to compare the effect that amount of BRT had on BSC/LOM development in two groups of patients sequestered into small (<10%) and large (>10%) total body surface area burns. Subjects were divided into a No Contracture (NC) and Contracture Group (CG) based on the presence of BSC/LOM at the time of hospital discharge. Statistics were bassed on Odds Ratios (OR) and strength of the regression model was based on Receiver Operating Characteristics (ROC) curves. Results: A total of 307 male-dominant (71%) subjects were analyzed (177 <10% burn; 130 >10% burn - see Table). Of the 8069 ROM measured, NC = 5285 (66%) and CG = 2783 (34%). Multivariate Logistic Regression revealed BRT by CFU as the highest predictor of BSC/LOM for both groups: < 10% OR = 1.067 (95% CI:1.222; 1.123) and >10% OR = 1.367 (95% CI: 1.118; 1.744). Area under the ROC (AUC) curve for <10% burn was 0.65 indicating a fair fit while the AUC for burns >10% was 0.83 indicative of a good-excellent fit. Furthermore, a significant interaction effect (p=0.0014) of more time was seen as a bigger benefit for larger burns. Conclusions: More rehabilitation time provided to patients with both small and large burns leads to better outcomes in terms of less BSC/LOM. The highest predictor of preventing BSC/LOM for both groups was amount of BRT/CFU. This effect is especially applicable to patients with larger burns. Applicability of Research to Practice: These results strongly support previous research and underscore the point that providing patients, regardless of burn size, with more burn rehabilitation leads to better outcomes. External Funding: USAMRAA Award# W81XWH-08-1-0683. View Large View Large 86. Eliminating CA-UTIs in the Burn Unit: Is it Possible and What Does the Evidence Say? S. Taylor, MS, RN, ACNS-BC, C. Scipione, MPH, A. Krzak, PA-C, J. R. Cherry-Bukowiec, MD, S. C. Wang, MD, PhD University of Michigan, Ann Arbor, MI Introduction: Hospital acquired infections can occur in as many as 20% of patients admitted to the intensive care unit (Legras, et. al. 1998). The burn patient in particular, is at an increased risk of infection related to a reduction immune function as well as environmental factors (Weber & McManus, 2004). Early indwelling urinary catheter (IUC) removal can be a challenge with burn and wound patients; however, the Centers for Disease Control and Prevention recommend only certain criteria for indwelling urinary catheter placement. Evidence is mounting that recommend the use of a nurse directed IUC removal protocol to help with timely removal and appropriateness of IUC placement. Methods: The CA-UTI rate in the TBICU has been above the NHSN benchmark for many years. Multiple interventions were trialed, including a silver impregnated catheter to reduce our infection rate; however, the cost did not outweigh the benefits. A Root Cause Analysis was conducted via an online survey, in person interviews, and observations to determine why the guidelines were not being followed. Three areas of concern identified were: education, supply availability, and general attitudes towards in-dwelling urinary catheters. Utilizing the best evidence for CA-UTI prevention, change theory, and implementation science, Trauma Burn identified a CA-UTI prevention champion. This person took the lead to educate, research likely causes of infections, and help identify what “critically ill” truly meant for our patients. The Unit Based Committee also helped with this initiative to reinforce education to all staff. Our medical director took an active role in championing this initiative and reinforced the necessity of in-dwelling urinary catheter placement with medical staff. The necessity of an IUC was placed on the ICU Daily Goal Sheet and is discussed daily on rounds. Results: We have decreased our rate to below the NHSN benchmark for burn patients in 2014. We have had many months with 0 CA-UTIs and have sustained that resulting in over a 200% reduction of infections. In addition, our catheter utilization is decreased below the NHSN benchmark. Conclusions: The implementation of our nurse directed IUC removal protocol successfully reduced our CA-UTI rates below the benchmark. Applicability of Research to Practice: The implementation of a nurse directed IUC removal protocol modified to meet the needs of our burn patients can help to reduce the rate of catheter associated urinary tract infections. View largeDownload slide View largeDownload slide 87. A Survey of Acute Respiratory Distress Syndrome Practices across Burn Centers in the United States and Canada V. C. Joe, MD, K. K. Chung, MD, M. A. Pressman, PhD, J. B. Lundy, MD, R. Y. Rhie, RRT, R. Cartotto, MD, R. C. McDermid, MD, R. P. Mlcak, PhD, W. L. Hickerson, MD, FACS, J. C. Jeng, MD UC Irvine Health Regional Burn Center, Orange, CA; US Army Institute of Surgical Research, San Antonio, TX; Arizona Burn Center, Phoenix, AZ; Ross Tilley Burn Centre at Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; University of Alberta, Edmonton, AB, Canada; University of Texas Medical Branch, Galveston, TX; University of Tennessee Health Science Center/Firefighters' Regional Burn Center, Memphis, TN; Past Chair, Organization and Delivery of Burn Care, Chair, Ad Hoc Disaster Committee, American Burn Association Introduction: Since the publication of the ARDSNet study in 2000 and subsequent studies on the use of low tidal volumes (LTV) in acute respiratory distress syndrome (ARDS), a lung-protective strategy combining the use of LTV and positive end expiratory pressure (PEEP) has been considered best practice in many critical care units. Numerous non-ventilator adjuncts have been studied and their efficacy remains controversial. It is unclear to what extent these strategies have been adopted in burn units. Data from a recent online survey were evaluated in order to begin addressing this question. Methods: In the summer of 2014, an online survey was sent to the directors and nurse managers of 129 burn centers in the United States and Canada. It consisted of 24 questions relating to ventilator mode and management preferences. A survey was acceptable if >75% of the answers were completed. Duplicates from the same facility were excluded. Chi-squared tests and the Cochran-Mantel-Haenszel test were performed. Answers to questions specific to the management of ARDS were analyzed for this report. Results: Of 74 responses, 55 were considered acceptable. Of these, 9 were duplicate entries and excluded. Included were 46/129 complete questionnaires (36% response rate), of whom 72% were burn surgeons/burn center directors. Of the respondents, 9% treated only pediatric patients, 19% only adults, and 72% both. Most burn centers reported >100 annual admissions (95.6%) while 48% reported >300. The use of an ARDSNet-based protocol was reported in 78% (36/46). The first step in ventilator management for patients with mild ARDS was most often to measure and utilize optimal PEEP (15/44, 34%) and to begin an ALI/ARDS protocol based on ARDSNet (21/44, 48%). Practice patterns changed significantly when asked about the management of severe ARDS, with a change to Airway Pressure Release Ventilation (APRV) in 28% (12/43) being most common and significantly less reporting the use of ARDSNet (p=0.0048). The use of other ventilator modes and the utilization of non-ventilator adjuncts were variable (see table). Conclusions: Considerable variability exists in how burn units manage ARDS. Practice patterns change significantly when dealing with severe ARDS with many abandoning LTV. Applicability of Research to Practice: This underscores the need for the burn community to evaluate the current state of the science regarding the management of ARDS and develop areas of consensus as well as critical areas for bum-specific research. External Funding: This project was commissioned by the Organization and Delivery of Burn Care Committee and funded in part by the American Burn Association. 88. A Retrospective Review of Clinical Laboratory Interferences Caused by Frequently Administered Medications in Burn Patients Z. R. Godwin, BS, K. Lima, BS, N. Tran, PhD University of California Davis, Davis, CA Introduction: Patients with burns represent an extreme model of critical illness. Due to the multifactorial nature of burn injury, numerous medications are required for managing the acute care phase of their hospital stay. Although drug-to-drug interactions are routinely monitored by hospital pharmacy, these medications may also have unintended effects on laboratory tests and result in dangerous erroneous measurements. To this end, improved understanding of drug interference on laboratory testing is needed to avoid potentially inappropriate treatment decisions by burn care physicians. The goal of this study is to quantify the number of medications prescribed to burn patients and identify potential drug interferences. Methods: We reviewed the medical records of 12 adult (age ≥ 18 yrs) burn patients with ≥20% total body surface area (TBSA) burns from an existing database at our institution. Dose, interval, and route of medications administered starting at severe illness, indicated by initiation of intensive therapies, and extending to the discontinuation of those therapies was recorded. Interfering substances to the most common laboratory tests were identified based on established clinical chemistry reference documentation. Results: The retrospective cohort of adult burn patients exhibited a mean (SD) age of 37.9 (3.0) years. Mean TBSA burn was 51.3 (9.3)%. Disease severity determined by the mean multiple organ dysfunction score was 5.4 (0.2). The mean prescribed medications per day were, 42.14 (9.52) with a daily range of 0 to 65 across all patients. A total of 666 interferences caused by medications prescribed were analyzed during the timeframe. Of these interferences, 261 were unique interference effects (e.g., increased glucose). Multiple medications shared similar interferences-—accounting for 475 of the 666 interferences having an unknown cause or were caused by more than one administered medication. Conclusions: The clinical impact of interfering substances on medical testing is well documented in laboratory medicine. These interferences have been shown to lead to erroneous measurements and impact patient care. To our knowledge, we report the first investigation that describes the number of medications prescribed to a burn patient and highlighting potential laboratory test interferences. We recommend intelligent electronic support tools flagging drugs that may interfere with laboratory testing. Given the substantial number of medications prescribed in burn patients, clinicians should work with laboratory personnel to identify potential interferences and define appropriate countermeasures where appropriate. Applicability of Research to Practice: Burn clinicians will be more aware of potential laboratory testing interferences. 89. Discovering Mental Models Used by Burn ICU Clinicians for Making Decisions J. C. Pamplin, MD, S. Murray, MSN, M. L. Serio-Melvin, MSN, J. K. Aden, PhD, E. A. Mann-Salinas, RN, PhD, K. K. Chung, MD, T. Huzar, MD, S. E. Wolf, MD, FACS, C. Nemeth, PhD US Army Institute of Surgical Research, San Antonio, TX; Memorial Hermann Hospital Texas Medical Center, Houston, TX; University of Texas — Southwestern Medical Center, Dallas, TX; Applied Research Associates, Inc., Fairborn, OH Introduction: Differences in the perception that Burn ICU clinicians have about patient condition and treatment priorities impedes effective collaboration and can impact patient outcomes.Better understanding of clinician perception about patient condition and treatment priorities could improve care and communication. Card sorting is an efficient, inexpensive way to understand perception, by learning about tacit mental models. We hypothesized that card sorting might elicit clinician mental models about information and treatment priorities. Methods: This was a prospective, mixed methods study of clinicians in two academic, regional referral burn ICUs. We developed a card sort based on interviews with burn critical care experts. The final card set included 10 categories of “features” used to judge patient condition and 9 categories “treatments,” for a total of 97 cards: 67 features and 30 treatments. Clinicians were asked to identify a patient's condition on a scale from “could die today” to “could transfer today,” then to examine feature or treatment cards, select cards they considered important, and to arrange them by priority in a grid. If an element important to them was missing, they could create a card for it. Figure 1 is a representative card sort. Results: We performed card sorts with 133 burn ICU providers (60 at site I and 73 at site II) including 19 staff physicians, 54 nurses, 29 residents, and 31 clinicians in other roles. Average time to complete a card sort was 35 minutes. The way clinicians prioritized information in decision making varied depending on their institution, professional background, experience, and the patient's condition. Figure 2 shows two distinct word clouds_graphical depictions of term importance or frequency— depicting differences in the mental models burn ICU care providers use while caring for critically ill patients. Conclusions: Card sorting revealed differences between the mental models that burn ICU care providers use to assess patient condition and determine treatment priorities. The card sort method can successfully elicit mental models from clinicians during routine daily activity. Applicability of Research to Practice: Understanding clinicians' mental models can be used to develop ecologically-valid tools that can improve decisions and communication in the work domain they are intended to support, such as the two burn ICUs in this project. External Funding: US Army Medical Research and Materiel Command Telemedicine and Advanced Technology Research Center. View largeDownload slide View largeDownload slide 90. Alcohol and Drug Abuse in Burns S. Rehou, BSc(Hons), R. Pinto, PhD, M. G. Jeschke, MD, PhD Sunnybrook Health Sciences Centre, Toronto, ON, Canada Introduction: Drug and alcohol abuse have been suggested to be associated with poor outcomes after burns. However, there are few studies determining the effects of alcohol and drug abuse on burn outcomes. The purpose of this study was to examine the effects of substance abuse on clinical outcomes. Methods: We conducted a retrospective cohort study of patients (age ≥16) admitted within 7 days of an acute burn injury to our regional burn centre between 2006 and 2014. Alcohol and drug abuse was identified by documented comorbidities upon admission. Data expressed as mean ± SD, median (IQR), or number (%) as appropriate. To examine the effects of alcohol and drug abuse we used negative binomial regression for the primary outcome length of stay (LOS) and number of complications and logistic regression was used for dichotomous outcomes (complications), adjusting for TBSA, age, sex, and inhalation injury and testing for the interaction between alcohol and drug abuse. All tests were 2-tailed and a P value of <0.05 was considered statistically significant. Results: There were 1,648 patients were admitted during this time period and of these 1,144 met inclusion criteria. Table 1 summarizes patient demographics, injury, and outcomes among the four groups. Regression analysis revealed that alcohol abusers were associated with a longer LOS (rate ratio=1.29, p<0.001) and greater number of complications (rate ratio=1.35; p<0.01). Due to the significant interaction between alcohol and drug abuse on bacteremia (p=0.027) we looked at the effect of alcohol abuse among drug abusers and found a significant effect (odds ratio=3.75; CI=1.13–12.46; p=0.031) whereas alcohol abuse among non-drug abusers was not significant (odds ratio=0.73; CI=0.32–1.63; p=0.437). Alcohol abusers were more likely to have sepsis (odds ratio=1.91; CI=1.0–3.64; p=0.051). Conclusions: Results indicate that alcohol abusers had worse outcomes even after adjusting for injury severity. The effect of drug abuse on post-burn injury did not have a strong signal to be detrimental. Applicability of Research to Practice: Early recognition of alcohol abuse in burn patients would lead to improved patient care strategies. External Funding: Canadian Institutes of Health Research # 123336. CFI Leader's Opportunity Fund: Project # 25407. NIH RO1 GM087285-01. Physicians' Services Incorporated Foundation - Health Research Grant Program. View Large View Large 91. Metabolomic Profiling of Serum Following Severe Human Thermal Injury C. M. Wearn, BSc, MBBS, MRCS(Eng), P. Hampson, PhD, J. Hazeldine, PhD, A. L. Bamford, RN, J. M. Lord, PhD, S. P. Young, PhD, N. S. Moiemen, MBBCh, MSc, FRCS, FRCS(Plast) Healing Foundation Centre for Burns Research, Birmingham, United Kingdom; Centre for Translational Inflammation Research, University of Birmingham, Birmingham, United Kingdom Introduction: Severe thermal injury results in a hypermetabolic response, a catabolic state characterised by increases in resting energy expenditure (REE), proteolysis, lipolysis, disturbed glucose homeostasis and futile substrate cycling. The consequences include loss of lean body mass, increased risk of sepsis, multiple organ failure and mortality. Approaches to studying these processes have largely been limited to individual metabolites or metabolic pathways. Metabolomics is a systems biology technique, which enables global untargeted measurement of metabolites. We hypothesised that NMR metabolomics could be used to study metabolic changes after severe thermal injury and develop metabolite models predictive of outcome. Methods: Adults (16–64 years) sustaining ≥15% TBSA thermal injury were enrolled into a prospective observational study. Clinical data on burn injury details and outcomes were collected prospectively and multiple organ failure (MOF) was assessed using the Denver-2 score. Blood samples were collected within 24hrs of injury (‘D1’) and repeated at 72–96 hrs post-burn. Serum was separated and stored at -80°C. Samples were filtered with a 3-kDa cut-off and 1H-NMR spectra acquired with a Bruker 600 MHz Spectrometer (Bruker Biosciences Corporation, USA). Spectra were pre-processed, binned and groups compared using partial least squares discriminant analysis (PLS-DA). Results: NMR spectra were acquired for a total of 37 burn injured adults with a mean age of 36.0 +/−12.0 years and a mean TBSA of 39.0 +/−20.0 %. Serum from six healthy volunteers, matched to the study group for age, gender and BMI was also analysed. Within the study group, mortality was 24% (9/37) and 43% (16/37) of patients developed MOF. Metabolite models constructed from D1 samples were able to accurately discriminate between burn injured patients and healthy controls with 100% sensitivity and 100% specificity (R2X=0.83, Q2X=0.67). Metabolites highly weighted in the model included pyruvate, glycine, alanine, 3-hydroxybutyrate, glucose and lactate. PLS-DA produced metabolite models capable of discriminating between survivors and non-survivors (sensitivity 85%, specificity 88%) and patients developing MOF versus no MOF (sensitivity 86%, specificity 86%). Conclusions: We have demonstrated that serum NMR-metabolomics can be used to study global metabolic changes post-burn injury. This is the first study to use this approach to develop metabolite profiles to predict outcomes following thermal injury in humans. Applicability of Research to Practice: Metabolomics is another tool in the ‘omics’ toolbox to study burn injury responses globally, with the potential to identify novel biomarkers to improve prognostication and diagnosis of complications post-burn. External Funding: The Healing Foundation, UK and The Royal College of Surgeons of England, UK. 92. Bone Maturation and Growth Following Severe Burn Injury in a Pediatric Population H. Juarez, BS, A. Ali, MD, D. N. Herndon, MD, FACS, S. Ojeda, LPN, W. J. Meyer III, MD University of Texas Medical Branch, Galveston, TX Introduction: Following severe burn injury there is a heightened and prolonged metabolic response. Unlike other forms of trauma, this may persist for months to years after initial injury. These effects may cause growth retardation despite appropriate nutrient supplementation. We postulate the hypermetabolic and hypercatabolic state induced by burn injury slows the progression of growth for a period of 1–2 years, as measured by bone age and growth velocity. Therefore, ultimate adult height in children may be impacted. We sought to determine the relationship between bone age and growth rate in children with severe burn injury. Methods: Data was collected retrospectively from 111 children with burns covering ≥30% of the total body surface area. Bone age was determined using the Greulich and Pyle (1959) standard for bones of the hand and wrist. Subsequently, the Pyle and Hoerr (1969) standard for determination of knee bone age was used if the first method was not applicable. Bone ages and heights were measured at discharge, 1, and 2 years post burn. This study was restricted to males between 3.75–12.25 years of age, and females between 3.75–10 years of age to avoid confounds of puberty on growth. All patients received standard of care treatment at the home institution and were divided into those with normal height velocity (≥4 cm/year; n=68), and those with impaired height velocity (<4 cm/year; n=43). Results: Children with normal growth rates were younger than those with abnormal growth rates, although not significant (6 ± 3 vs. 7 ± 3 years; p=0.06). Extent of partial thickness burn injury was not different between groups. Conversely, children with abnormal growth had endured significantly larger full thickness burns compared to those with normal growth rates (60 ± 19 vs. 52 ± 16 % respectively; p=0.04). Although height velocities remained significantly different between groups for the first two years following burn injury (p<0.001), the ratio between bone age and chronological age remained similar between groups over the same duration of time. Conclusions: Extent of full thickness burn injury alters growth rate in children. Abnormal growth rate was not associated with decreased bone age. Whether or not ultimate adult height is decreased in these patients warrants further investigation. Applicability of Research to Practice: Early identification via radiographic imaging of children with growth retardation provides insight in regard to those that may benefit from pharmacological intervention with anabolic hormones. External Funding: NIDRR (H133A070026, H133A70019); NIH (R01-GM56687,T32-GM8256). 93. Reduced Neutrophil Function in Response to Burn Injury Is Associated with Mortality P. Hampson, PhD, C. M. Wearn, BSc, MBBS, MRCS(Eng), J. Hazeldine, PhD, A. L. Bamford, MSc, R. J. Dinsdale, MSc, P. Harrison, PhD, J. M. Lord, PhD, N. S. Moiemen, MBBS, FRCS, FRCS(Plast) Healing Foundation Centre for Burns Research, The University of Birmingham, Birmingham, United Kingdom; Healing Foundation Centre for Burns Research, Queen Elizabeth Hospital, Birmingham, United Kingdom Introduction: Neutrophils are a critical component of the innate immune system, forming the first line of defence against bacterial infections. Burn injury leads to a reduction in neutrophil function, which is proposed to underlie the increased incidence of sepsis in this patient group. The longitudinal response of neutrophils to burn injury has not been thoroughly examined, and no association between neutrophil function and mortality has been investigated. Methods: Fifty-six adults with a burn size ≥15% total body surface area (TBSA) and 19 healthy volunteers were recruited. Blood samples were taken at various intervals post injury (admission [day 1], day 3, day 7, day 14, day 21, day 28, month 2, month 3 and month 6). Neutrophil phagocytosis and oxidative burst capacity in response to E.coli were measured using commercially available assays. Immature neutrophils were measured by immunostaining and flow cytometry (low CD 16 expression). Results: Neutrophil functional analysis was performed on blood from 56 burn injured patients with a mean age of 41 years (range 16–88 years) and a mean TBSA of 37% (range 15–95%). In-hospital mortality for the cohort was 27%. Neutrophil phagocytosis and oxidative burst capacity were significantly reduced in response to burn injury (p<0.005 compared to healthy volunteers).This reduction was evident within hours of injury and persisted for up to 2 months. Compared to survivors, individuals who did not survive their injury had significantly reduced neutrophil phagocytic function at day 1 after injury (phagocytic index: p=0.005; amount of bacteria phagocytosed: p=0.004; %phagocytosing cells: p=0.094). In a subset of patients, reduced neutrophil function was followed by the release of immature neutrophils from the bone marrow, as evidenced by the presence of CD16dim neutrophils in the blood. These cells showed reduced functional capacity. Conclusions: Reduced neutrophil phagocytic function in response to burn injury was associated with increased risk of death, most likely due to the individual being at increased risk of nosocomial infections and the development of sepsis. In a subset of patients, burn injury also led to the release of immature neutrophils into the circulation, further compromising immunity as these cells showed reduced functionality. Previous studies have demonstrated their release in response to endotoxin challenge and traumatic injury. Applicability of Research to Practice: Reduced neutrophil function in the hours following burn injury may provide a biomarker for poor outcome. Understanding the mechanism that underlies reduced neutrophil function may provide molecular targets by which to boost neutrophil function and reduce the incidence of infection and sepsis. External Funding: This work was funded by The Healing Foundation. 94. Epidemiology of Multiple Episodes of Moderate to Severe Kidney Injury in Burn Patients J. K. Aden, PhD, I. J. Stewart, MD, J. A. Sosnov, MD, J. A. Waters, MD, M. F. Buehner, MD, K. K. Chung, MD US Army ISR, Ft Sam Houston, TX; BAMC, Ft Sam Houston, TX Introduction: While acute kidney injury (AKI) is an independent predictor of mortality in burn patients, there is a paucity of data on the time to event distributions of multiple episodes of AKI over the entire hospital course. We sought to examine the epidemiology of moderate to severe kidney injury in burn patients. Methods: We conducted a retrospective chart review of burn patients that required mechanical ventilation admitted to our institution from 1 January 2003 to 31 December 2011. Demographic, injury characteristics and creatinine values were collected for each subject. AKI was determined using creatinine per the AKI Network (AKIN) criteria. Baseline serum creatinine values were estimated by using the lowest serum creatinine within the first 7 hospital days. Episodes of AKIN stage ≥2 occurring at least 3 days apart were considered distinct episodes. Results: A total of 891 patients were included. At least one episode of AKIN ≥2 occurred in 33% (n=294), with median time to first episode of 3 days (IQR 1,13). Of those 294 patients, 21% (n=62), 8% (n=24), 5% (n=17) and 7% (n=20) had 2, 3, 4 or 5 episode(s) of AKIN ≥2, respectively. For those who experienced 2, 3,4 or 5 episodes, they had a median (IQR) occurrence of 19 (11,34), 33 (21,58), 42 (28,70), and 64 (41,91) days, respectively. Conclusions: To our knowledge, this is the first description of multiple episodes of moderate to severe kidney injury in a burn intensive care unit. There is a varied distribution of days to each episode of kidney injury. Further analysis is required to determine if multiple episodes have distinct risk factors or associations with subsequent mortality. Applicability of Research to Practice: There is a paucity of data on the effects of multiple episodes of kidney injury occurring during the hospital stay. Our study is the 1st step in describing how kidney injury affects burn patients over their entire hospital courses. View largeDownload slide View largeDownload slide 95. Liver Enzymes Elevation Due to Peri-Operative IV Acetaminophen Use in Burn Patients A. Bussieres, MD, T. Walroth, PharmD, D. Roggy, RN, T. Soleimani, MD, R. Sood, MD, FACS Indiana University, Indianapolis, IN; Eskenazi Health, Indianapolis, IN Introduction: In 2010, the US Food and Drug Administration approved intravenous acetaminophen (IV APAP) for treatment of moderate to severe pain. IV APAP has many proposed advantages including a better safety profile than opioids. Compared to other forms of APAP, IV APAP has a lower risk of hepatic injury by bypassing the first hepatic exposure via the portal circulation. Given peri-operatively, it provides good early post-operative analgesia and could be beneficial to the burn population. IV APAP must be used with caution in the following conditions: liver disease, alcohol use, malnutrition, underweight, hypovolemia and acute renal failure. Since these conditions are frequently encountered in burn patients, the aim of our study was to evaluate if the risk of liver enzymes (LFT) elevation with IV APAP in this population is more elevated than the 1.8% reported in the general population. Methods: Since 2011, peri-operative IV APAP has been sporadically used for pain management in our burn unit. During this time period, an anecdotal increase in LFT possibly associated with the use of IV APAP was noted in our patients. To explain that finding, we retrospectively reviewed charts of all 24 burn patients who received peri-operative IV APAP and 24 patients randomly selected from the operative patients who did not receive IV APAP. Information recorded included: age, TBSA, BMI, alcohol use, malnutrition, renal function, peri-operative fluid balance, oxandrolone status and the dose of APAP received. Results: Forty-eight adult patients were included in this study, 24 patients in the IV APAP group and 24 in the non-IV APAP group. Both groups were comparable in terms of demographics and clinical characteristics. Overall, 11 patients (22.9%) showed LFT elevation. LFT elevation rate was higher in the IV APAP group (29.2%) than in the non-IV APAP group (16.7%). This difference was not statistically significant (p = 0.30). However, the IV APAP group had a significantly higher overall APAP dose (IV + PO) on the day of surgery (p <0.01). The sample was then analyzed according to LFT elevation. The 11 patients with LFT rise were compared to the 37 patients without LFT rise. In the LFT elevation group, 63.6% received IV APAP (p=0.30). There was no significant difference in demographics or clinical indicators between the two groups. A higher APAP dose the day of surgery and during the peri-operative time significantly increased the rate of LFT elevation (p=0.01 and p=0.02, respectively). Conclusions: Peri-operative IV APAP may be associated with a higher overall dose of APAP the day of surgery and may lead to LFT elevation in adult burn patients. Applicability of Research to Practice: IV APAP should be used with caution in burn patients and the total dose of APAP received the day of surgery, including the IV APAP, should be carefully monitored. 96. Intravenous Acetaminophen: A Non-Narcotic Adjunct for Burn Wound Care S. C. Dobson, MS, N. Bernal, MD University of California, Irvine Medical Center, Orange, CA Introduction: Adequate pain control without sedation is a challenge in burn patients. Many studies have shown that burn pain management is inadequate even in the ideal setting of a burn center. Multiple studies have shown that intravenous acetaminophen (IV APAP) decreases the overall amount of narcotics administered as well as extending the time until drug rescue in post-surgical patients. The goal of this study was to determine if the incorporation of IV APAP into the multi-modal approach to control pain during wound care reduces the amount of narcotic medications administered. Methods: A retrospective chart review was conducted on all patients that were prescribed IV APAP prior to burn wound care between August 2011 and August 2013. We then examined the amount of narcotic medications given on days when IV APAP was administered as compared to days without it. We analyzed the differences in the amount of narcotics for burn wound care. We also looked at the effects of multiple doses of IV APAP in hepatic function. Results: Forty-one patients received IV APAP for wound care and had days without the medication to be the control. The overall average amount of narcotic units administered on days with administration of IV APAP was greater compared to days without administration of IV APAP, 2.1 vs 1.6 (p=0.002). After performing subgroup analyses, the addition of IV APAP reduced narcotic requirements in patients whose length of stay (LOS) was less than 7 days with IV APAP, 1.4 vs without IV APAP 1.7 (p=0.55). Specifically in patients with flash flame burn, IV APAP was more effective, 2.1 units with IV APAP and 2.5 units without IV APAP (p=0.55). There was no significant transaminitis developed in any of the study patients. The pain scores were not statistically different in both groups 3.182 with IV APAP compared to 3.197 without IV APAP. Conclusions: The study is the first to look at the use of IV APAP for burn wound care. To examine its effectiveness without altering currently practice, it was added to a combination of medications for wound care. When using patients as their own controls, the average amount of narcotics required to maintain pain scores less than 4 did not change. There did seem to be an advantage in smaller burns as shown by the data in patients with a shorter LOS and TBSA less than 15%. This is a small sample group, but has demonstrated that IV APAP can be used as a means to decrease narcotic pain requirements and improve pain control in select burn patients. We hope to use this study as the framework for prospective investigation on the effectiveness of intravenous acetaminophen controlling pain during burn wound care. Applicability of Research to Practice: This data can help support the development of pain control regimens with non-narcotic medications that provide adequate pain control, while decreasing the side effects associated with narcotics. 97. Auditory Interactivity Task Increases Effectiveness of Virtual Reality Pain Distraction (with and without Oculus Rift VR Goggles) H. G. Hoffman, PhD, W. J. Meyer III, MD, M. Gonzalez, BA, M. Ramirez, BA, R. Herrero, PhD, M. Navarro, PhD, B. Atzori, PhD, S. Sharar, MD, D. Patterson, PhD University of Texas Medical Branch, Galveston, TX; Jaume Universitat, Castellon, Spain; Meyer Childrens Hospital Burn Center, Florence, Italy; University of Washington, Seattle, WA Introduction: Children/adults with large severe burn wounds often endure uncontrolled pain during wound care. This study measured pain during Virtual Reality + auditory interactivity task compared to conventional Virtual Reality. Methods: 75 healthy volunteers received three 15-sec thermal pain stimulations (at a painful but tolerable temperature), during No VR, vs. VR vs. VR + interactive audio task. Results: VR + interactive audio task reduced pain more effectively than conventional virtual reality distraction, using a paired t-test for “worst pain”, t(74) = 9.10, p < .001, SD = 1.16, pain unpleasantness, t(74) = 7.27, p < .001, SD = 1.36, and for “Time spent thinking about pain”, t(74) = 10.04, p < .001, SD = 1.35. A second study has replicated these results using inexpensive wide field of view oculus rift VR goggles. Encouragingly, in a pilot study, several pediatric burn patients with large severe burns were willing and able to perform SnowWorld + interactive audio task during wound care, and also showed the predicted pattern. Conventional VR reduced pain during wound care, and VR + interactive audio task reduced pain more than conventional VR. Conclusions: Consistent with an attentional mechanism for how VR reduces pain, participants reported significantly larger reductions in pain during the VR+ auditory interactivity task (extra attention demanding) compared to conventional VR. Applicability of Research to Practice: Virtual Reality has potential as a powerful new non-pharmacologic psychological adjunct to help reduce suffering of severe burn patients during painful procedures. External Funding: Shriners Hospitals for Children Grant. 71011Gal; NIH grants R01 GM042725-17; R01AR054115-01A1. 98. Relationship Between Vitamin D and Post-Hospitalization Itch in Patients with Burn Injury M. Nordlund, MS, RD, T. N. Pham, MD, FACS, M. Rangel, BS, G. J. Carrougher, RN, MN, N. S. Gibran, MD, FACS Harborview Medical Center, Seattle, WA Introduction: Both itch and vitamin D deficiency are common in patients with burn injury. Vitamin D deficiency has been associated with itch and symptoms of itch have improved with treatment of vitamin D deficiency. However, there is no research to date that studies the link between pre-injury vitamin D levels and itch after burn injury. We hypothesize that vitamin D deficiency is correlated with increased numerical itch rating after burn injury. Methods: We performed a retrospective review of all adult critically ill patients from July 2011 to July 2014. By unit protocol, serum vitamin D 25 hydroxy levels (ng/dL) were drawn within the first week of admission and an enteral vitamin D supplement was started or multivitamin continued depending on levels. Numerical itch ratings (1–10 scale) were recorded at burn clinic follow-up appointments and compared to inpatient vitamin D levels. To improve our ability to detect an association between initial vitamin D levels and itch at discharge, we excluded patients with >30% TBSA burn due to longer hospitalizations, and patients without outpatient numerical itch ratings within 8 weeks of discharge. Injury and treatment characteristics between groups were analyzed with descriptive statistical techniques. Results: We identified 87 patients who met study criteria over the 3-year period. Average time to initial outpatient appointment was 12 days post-discharge (range 2–53). Mean total body surface area (TBSA) burn was 15% and mean hospital length of stay was 23 days. Most of the patients were Caucasian (80%). The other ethnicities represented were American Indian (6%), Hispanic (6%), Asian (6%) and Black (1%). Mean post-hospitalization itch level was moderate (3.9, SD 3.1). Whereas, most patients (61%) were taking medication for itch, only 17% of patients denied itch. Vitamin D deficiency did not correlate with a higher self-reported itch rating on post-hospitalization discharge visits (Table 1). Conclusions: In patients with burn injuries, self-reported itch is very common and moderately severe in the early post-hospitalization period. Vitamin D deficiency identified on hospital admission did not correlate with self-reported outpatient numerical itch ratings. Applicability of Research to Practice: Initial vitamin D deficiency is not a predictor of the severity of itch in patients with burn injuries. View Large View Large 99. Indwelling Peripheral Nerve Catheters are Effective and Safe Adjunctsto Improve Pain Management in Burn Patients K. Rustad, MD, A. Li, BS, E. Rivera, BSN, RN, B. Miller, MD, Y. Karanas, MD Santa Clara Valley Medical Center, San Jose, CA Introduction: The management of pain in burn patients is a challenging but crucial component of care in this patient population. Opioids continue to be used as the mainstay of analgesia; however the high doses that are often required and the significant associated side effects suggest a need to further explore other options for pain management. While single shot regional nerve blocks have been used in burn patients particularly to help with donor site pain, these blocks provide less than 24 hours of pain control. Indwelling catheters can be placed at the site of a nerve through which a local anesthetic can be continuously infused to provide a longer duration of directed analgesia without systemic side effects. They have been used with increasing frequency in orthopedic and trauma patients, yet there are only a few case reports of the use of peripheral nerve catheters in burn patients. Methods: We performed a retrospective chart review of all adult patients in our burn center who had regional nerve catheters placed to assist with pain management. Data were collected on patient age, gender, TBSA, mechanism of burn, co-morbidities, location of pain, type of regional anesthesia used, duration of nerve catheter, and catheter-related complications. The amount of narcotics used in the 48 hours preceding placement of a catheter and the 48 hours after catheter placement was recorded. An equianalgesic conversion chart was used to standardize the doses of all types of narcotics used to morphine equivalents. Results: Ten adult patients were identified who received indwelling nerve catheters. One patient did not have a functioning nerve catheter and was excluded from further analysis. Indwelling nerve catheters remained in place for an average of 5.1 days. There was a decrease in the amount of narcotics used in the 48 hours after catheter placement compared to the 48 hours preceding catheter placement equivalent to 15.96 mg morphine (p=0.03). There was a trend towards improved pain scores after nerve catheter placement compared to pre-catheter placement with an average decrease in pain score of-1.79 (p=0.08). One patient developed myoclonus, which resolved after administration of an IV benzodiazepine. There were no other complications. Conclusions: Placement of indwelling nerve catheters is a safe method to improve pain in burn patients and may be an effective means by which to decrease the amount of opioids needed to achieve adequate pain control. Further studies are needed to determine which patients will benefit most from indwelling nerve catheters. Applicability of Research to Practice: The study demonstrates that regional anesthesia can be used as a safe and effective means by which to decrease the amount of narcotic medications needed by burn patients while still providing adequate analgesia. 100. Pruritus in the Pediatric Population: A Five Year Retrospective Review J. Zuccaro, MSc, D. Budd, BSc, J. Wang, MSc, C. Kelly, RN (EC), MN, NP, K. Cross, MD, PhD, J. Fish, MD, MSc, FRCSC Hospital for Sick Children, Toronto, ON, Canada Introduction: Post-burn pruritus (itch) is highly problematic in the pediatric population as it negatively impacts quality of life during recovery from burn injury and can contribute to excessive scratching, graft loss, and infections. The complex nature of the condition and the lack of objective measures impact effective management of itch. Understanding the variables that contribute to post-burn itch will aid in the development of standardized assessment tools and treatment protocols. The purpose of this study was to evaluate the incidence and variables that may impact pruritus in a large pediatric sample size. Methods: This study is a retrospective chart review of 801 pediatric acute burn subjects presenting to our institution from 2009 to 2013. Data was collected regarding incidence of pruritus, demographics, burn history, and scar management. Pruritus-related data was also collected including healing time, surgery, infection, burn depth (partial v. full thickness) and TBSA. Statistical analysis was performed using SPSS v.22 (IBM, IL). Data was analyzed using chi-square and independent t-tests. Multivariate analysis (Cox-Regression) was used to determine which variables might be predictors of pruritus. Healing time was used as the dependent variable. Significance was achieved with a p-value <0.05. Results: Pruritus was documented in 30% of the patients enrolled in this study. The majority of injuries were due to scalds with an average TBSA of 3.6%. The majority of burns occurred to the face (22%), anterior torso (28%) and upper extremity (26%). Pruritus was treated with a combination of medication, pressure garments and massage. Multivariate analysis showed that TBSA >5% and partial thickness burns were more likely to experience pruritus with a relative risk ratio of 1.5 (95% CI, 1.2–2.0, p<0.005) and 1.6 (95% CI, 1.1–2.4, p<0.05). Subjects undergoing surgery were less likely to experience pruritus with a relative risk ratio of 0.5 (95% CI, 0.3–0.7 p<0.001). Conclusions: This is the largest study performed to date examining post-burn pruritus in an expansive pediatric population. The 30% incidence of pruritus in this study represents a more realistic outcome compared to the often published rates which suggest greater than 90% incidence. It is intuitive that pruritus is increased in larger burns as there is more surface area. The increased incidence of pruritus in partial thickness burns can be rationalized potentially by prolonged wound healing times. Pruritus-related factors should be identified in a pediatric population as these patients may be unable to communicate how pruritus affects their daily lives. Applicability of Research to Practice: Identifying pruritus-related variables can lead to a heightened clinical awareness and help identify high risk patients, potentially allowing for earlier treatment. 101. Continuous Ketamine Infusion for Pain Control in Pediatric Burns K. S. Romanowski, MD, T. L. Palmieri, MD, FACS, FCCM, D. G. Greenhalgh, MD, FACS, S. Sen, MD, FACS Shriners Hospital for Children Northern California, Sacramento, CA Introduction: Ketamine is a safe and effective means of procedural sedation in children. Ketamine enhances opioid-induced analgesia and prevents hyperalgesia. Given that postoperative pain control following tangential excision and split thickness skin grafting is a challenge, especially in children, we hypothesized that a continuous intravenous infusion of ketamine would safely to improve pain control in postoperative children with burns. Methods: We performed a matched cohort review of 22 patients admitted over a two year period. Patients receiving ketamine infusion were matched for age, burn size, and number of operations. Eleven patients received a continuous low dose infusion of ketamine at 2–3 mcg/kg/min in addition to standard post-operative pain control for the first 24 hours following their initial excision and grafting, while 11 patients only received standard post-operative pain control. Data collected included: demographics (age, gender), injury characteristics (burn size, inhalation injury), determinants of pain control (morphine equivalents given, mean RASS score, mean observational pain score), and outcomes (hospital mortality, length of stay, ICU days, ventilator days). Values are expressed as mean±SD. Results: The two groups were similar in age (4.7 ± 3.5 years in ketamine (K) vs. 4.8 ± 3.8 years in non-ketamine (NK)). There was no difference in % total body surface area (%TBSA) burned (16.9 ± 6.0 K vs. 17.6 ± 7.8% NK) Both groups had comparable outcomes for ventilator days (0.1 ± 0.3 K vs. 3.3 ± 7.9 days NK) and length of stay (21.3 ± 5.7 K vs. 26 ± 14.9 days NK). Groups had no significant difference in morphine equivalents (17.8 ± 14.3 vs. 16.0 ± 15.8), mean RASS score (-0.8 ± 0.5 vs. -0.9 ± 0.7), or mean observational pain scale (1.0 ± 0.9 vs. 1.1 ± 0.7). Individual mean observational pain scores differed: 8 out of the 11 patients receiving ketamine had a mean pain score <1 while only 4 out of 11 in the no ketamine group had mean pain score <1 (p=0.20, Fisher's exact test). There were no adverse effects related to ketamine in this study. Conclusions: This pilot study looking at the effects of ketamine infusions in children following tangential excision and skin grafting suggested that ketamine infusion could be safely administered postoperatively. While there were no significant differences between those who received ketamine and those who did not, there was a trend towards significance with respect to observational pain score. Ketamine infusion in postoperative period merits further investigation. Applicability of Research to Practice: Use of Ketamine infusion in post-operative burn patients is safe and well tolerated and may help enhance the activity of pain medications. 102. Post-Operative Pain Control for Burn Reconstructive Surgery in Ukraine: A Prospective Study G. Fuzaylov, MD, T. L. Kelly, MD, C. Bline, MD, A. Dunaev, MD, M. Dylewski, PhD, RD, D. N. Driscoll, MD Massachusetts General Hospital/Shriners Burn Institute, Boston, Boston, MA; Burn Center, Municipal Hospital #8, Lviv, Ukraine Introduction: Postoperative pain can significantly affect a patient's ability to heal following surgery. In Ukraine, it has been reported that opioid medications are used intra-operatively and in the intensive care units and are not available as intramuscular injections, intravascular injections, or even as oral medications on the ward or for ambulatory patients. In this study we introduced the concept of post-operative pain evaluation of burn patients as well as a technique for placement and use of subcutaneous catheters for continuous infusion of local anesthetic to provide analgesia during skin harvest by split thickness skin graft of the lateral thigh in a hospital in Ukraine. Methods: A total of 109 patients were enrolled in this study. The first 64 patients received the standard post-operative pain regimen of analgin/metamizole 1 g and/or ketorolac 3%- 30 mg at the discretion of the nursing staff. The following 45 patients received Pain Buster Post-Op Pain Relief System placed intra-operatively with continuous infusion of procaine 0.5% of 4-5ml/hr for 48 hours with the standard pain regimen available for breakthrough pain. All patients were assessed immediately post-operatively and in the peri- dressing change period by the nursing staff. Blood pressure, heart rate, and pain scores were documented based on the Wong-Baker Faces Pain Rating Scale. Results: Mean pain score immediately following surgery was 5.0 ± 1.7 in the control group, which was significantly greater (p= 0.0273) than 4.3 ± 1.7 for the patients receiving continuous infusion of procaine. However, there is no statistically significant difference in the change in pain score during the initial dressing change (p=0.5218, p=0.7336). Conclusions: The ability to share the concept of pain assessment and to share the simple technique of catheter placement with our Ukrainian colleagues may open doors for further pain interventions for post-operative pain control. Applicability of Research to Practice: The next step will be to train local physicians in advanced procedures, including the use of ultrasound to target specific peripheral nerves for increased and more reliable pain control. 103. Developments in Burn Care Surrounding World War II T. E. Travis, MD Medstar Washington Hospital Center, The Burn Center, Washington, DC Introduction: When searching for primary literature concerning the care of the burned patient, databases show a notable jump in the number of relevant manuscripts published surrounding the time period of the Second World War. In 1947, Cope, et al, suggested in the Annals of Surgery that the great threat to military manpower posed by burn injuries during World War II forced the reevaluation of the medical and surgical care offered to these casualties. This unique period of history lent itself to great advances in the care of the burned patient. Methods: Primary sources from the 1930s to 1950s were examined for information on the standards of burn care during this time period and the changes that occurred during and lowing World War II. Results: Research articles, textbooks, manuals, and other primary documents recorded advances in the organization and delivery of burn care, surgical techniques, first-aid, anesthetics, wound care, infection control, nutrition, reconstruction, and resuscitation. Conclusions: The period surrounding World War II was full of discoveries, advances, and improvements made by those involved in burn care for reasons of wartime survival, necessity, interest, and passion for the management of this unique injury. An in-depth look at those stepping stones in the history of burn care, made by centralizing the plethora of written accounts, recorded histories, and publications of the period, is a salute to wartime heroes, a nod to those burn providers who came before us, and a reminder of how far we have come. Applicability of Research to Practice: The appreciation of the history of burn care allows the current burn community to learn from the work of those who practiced many decades ago. External Funding: This project was funded by the Archives Committee's 2014 ABA History Manuscript Grant. 104. Home Fire Safety Education for Parents of Newborns C. Lehna, PhD, E. Fahey, BSN, RN, E. Janes, RN, S. Rengers, RN, J. Williams, BS, D. Scrivener, BS, J. Myers, PhD University of Louisville, Louisville, KY; Safe Kids Louisville, Kosair Children's Hospital; Children's Hospital Foundation Office of Child Advocacy at Kosair Children's Hospital, Louisville, KY; Louisville Fire Department, Louisville, KY Introduction: In children under one year of age the proportion of unintentional burn injuries increases with infant age and mobility. Treatment of acute burn injuries in children may be expensive in terms of dollars, physical, and emotional costs. The purpose of this study was to examine changes in home fire safety (HFS) knowledge and practices over time for parents of newborns. Methods: HFS knowledge of 103 parents was assessed at baseline, immediately after watching a DVD on HFS (recall measure), and at two-week follow-up (retention measure). In addition, the United States Fire Administration (USFA) Home Safety Checklist, which examines HFS practices in their homes, was administered. Results: Participants were 70% Caucasian, 65% were married, and 81% were first-time parents. Mean income was $58,297 ± 40,000. HFS knowledge significantly increased, when compared to baseline: baseline 45% correct responses, recall 87% correct responses, and retention 75% correct responses, p<0.001. For a sub-sample of parents who completed the USFA Checklist (n=22), the mean percentage of recommended HFS practices followed was 70.9% ± 10.8% (40%-88.9%). Conclusions: Findings from this study suggested using DVDs was an effective educational modality for increasing HFS knowledge. This addressed an important problem of decreasing burn injuries in infants through increasing parent knowledge and practice using an easy and inexpensive DVD. Applicability of Research to Practice: Educational HFS DVDs could be easily shown on televisions in obstetrician, pediatrician, and nurse practitioners' offices to effectively utilize parents' waiting time as an educational opportunity. External Funding: Federal Emergency Management (FEMA) Fire Prevention & Safety Grant #EMW-2012-FP-01181. 105. Homebound and Community Older Adults: A Comparison of Home Fire Safety Knowledge and Practices C. Lehna, PhD, M. Coty, PhD, E. Fahey, BSN, RN, J. Williams, BS, D. Scrivener, BS, G. Wishnia, PhD, J. Myers, PhD University of Louisville, Louisville, KY; Louisville Fire Department, Louisville, KY; Peaceful Families, PLLC, Louisville, KY Introduction: Older adults face significantly increased risks for mortality and morbidity from burn injuries. This study examined the home fire safety (HFS) knowledge and practices of 111 older adults; of these, 66 were in the community (CM) and 45 were homebound (HB) individuals. Methods: Participants' HFS knowledge was evaluated at baseline (T1), immediately after watching a DVD on HFS (recall measure; T2), and at two-week follow-up (retention measure; T3). In addition, the United States Fire Administration (USFA) Home Safety Checklist was administered, which examines HFS practices in their homes. Results: The majority of participants were Caucasian, accounting for 68.3% in the CM and 71.4% of the HB group. Both groups were predominately female, with male representation higher among HB older adults. The findings show statistically significant differences between CM and HB older adults' age, annual income, number of chronic illnesses, and checklist scores (See Table). Knowledge scores at T1 were significantly lower for the HB group (p=0.002), but T2 and T3 scores showed no difference. Knowledge scores increased significantly over time for both groups (p<0.0001). Conclusions: Older adults' knowledge about fire safety increased following participation in a HFS education program. At two week follow-up the participants' knowledge level remained the same [T2 to T3] suggesting that the HFS program was an effective strategy for increasing HFS knowledge and retention of knowledge among older adults. Based on known risk factors, differences in age, socioeconomic status, health status, checklist scores, and baseline knowledge scores indicate HB older adults are at higher risk for burn injury. Applicability of Research to Practice: There is a need for educational HFS intervention programs aimed at older adults. Socially active individuals are easily accessible through CM agency presentations. More isolated HB individuals can be reached through educational programs incorporated into social services such as meal delivery programs, church outreach groups, and home health agencies. External Funding: Federal Emergency Management (FEMA) Fire Prevention & Safety Grant #EMW-2012-FP-01181. View Large View Large 106. “It Happened in Seconds” Firefighter Burn Prevention Program: Evaluation of a “Train the Trainer” Course S. A. Kahn, MD, J. M. Held, MD, J. Woods, K. A. Hollowed, RN, J. H. Holmes IV, MD, FACS Vanderbilt University Medical Center, Nashville, TN; DC Firefighters Burn Foundation, Washington, DC; Medstar Washington Hospital Center, Washington, DC; Wake Forest University Baptist Medical Center, Winston Salem, NC Introduction: Each year, there are approximately 100 firefighter fatalities and tens of thousands of injuries in the United States. “It Happened In Seconds” is a firefighter burn injury awareness program offered to firefighters nationwide. The course focuses on situational awareness, PPE, and burn injury prevention. In order to create more instructors, a “Train the Trainer” instructor course was developed to prepare experienced firefighters and healthcare providers from around the US to teach firefighters in their respective communities. This study evaluates trainees' perception of the instructor course. Methods: Two instructor courses were held during 2013–2104. Trainees were asked to complete both pre/post-course assessments and provide demographics. In both surveys, trainees rated their confidence to instruct firefighters about burn prevention and their awareness about firefighter-specific burn issues using a 5-point Likert Scale (1=none,5=high). The post assessment asked if trainees thought the course should be mandatory for all firefighters. Pre and post-test scores were compared using a Wilcoxon signed-rank test. Results: A total of 90 experienced firefighters and healthcare professionals completed the Train the Trainer course; 83 completed both pre and post assessments. The average age was 41 ± 8 y, and 71 were male, 17 were female. Twenty-eight of the firefighters that took the course were in leadership positions. In addition, 33 lower-ranking firefighters took the course with 11 RNs, 3 MDs, 1 OT, and 2 PA-Cs. The average trainee had 15 ± 9 y experience in his/her respective job and 12 ± 11 y experience in burn care. Trainees reported a significant increase in their confidence to instruct firefighters about burn prevention (3.15/5 pre-course vs. 4.6/5 post-course, p<0.0001) and in their current awareness of firefighter-specific burn issues (3.40 pre-course vs. 4.6 post-course, p<0.0001). In the post-course assessment, all respondents agreed that the “It Happened in Seconds” course should be mandatory for all firefighters. The new instructors have trained over 1000 firefighters. Conclusions: This study showed that experienced firefighters and healthcare professionals thought that the course significantly improved their awareness level of issues specific to firefighter burn injury as well as their confidence in teaching these concepts to firefighters. Based on this positive evaluation, additional instructors will be trained to provide the course to all firefighters nationwide. Additional research must be conducted to evaluate whether the “It Happened In Seconds” course results in a decreased rate of firefighter burn injuries. Applicability of Research to Practice: An injury prevention course is available for firefighters across the US. External Funding: Jason Woods- FEMA AFG Grant supports the actual program. 107. The Effect of a Charge Nurse-Driven Referral Callback Process on Burn Center Patient Referral Volumes A. Bettencourt, MSN, RN, CCRN, R. Grady, RN, P. H. Chang, MD, FACS, R. L. Sheridan, MD, FACS Shriners Hospitals for Children-Boston, Boston, MA Introduction: Burn centers rely on receiving patient referrals from a large geographic area to maintain patient volume, staff competence, and financial stability. In today's healthcare environment referring hospitals face network and financial disincentives to send burn patients to verified burn centers even when the patients meet the ABA criteria for burn center referral. In combination with traditional marketing and outreach efforts, burn centers should develop peer-to-peer relationships with emergency departments that include timely feedback, opportunities to identify quality improvement issues, and networking for potential continuing education opportunities. While our center had an existing process for physician-to-physician referral follow up using letters and occasional phone calls, we noted that our referral partners felt disconnected from the patients they referred to us. To solve this problem, we designed and implemented a quality improvement process for real-time charge nurse-driven referral callbacks on all patients seen on the acute care burn unit. The charge nurse-driven referral callbacks are logged and details of the conversations are shared with hospital leadership. Methods: To measure the success of this intervention, a retrospective quality improvement study was performed to examine the rates of repeat referrals, grand rounds presentations requests, and ABLS course requests over the period of 10 months that charge nurse-driven referral callbacks have taken place. Hospitals with existing referral relationships were excluded from the study. Results: Of the 74 patient referral calls received, 58% requested education on burn care. In addition, 25% requested an ABLS course. This resulted in completing education in 53% of the hospitals requesting. Hospitals that received education were more likely to refer a patient again than those who did not. Finally, we were able to identify quality improvement issues in the management of 8.1% of our burn patients at the referring Emergency Department (ED), and have been able to coach our ED peers on best practices in real time. Conclusions: Establishing a process for real time peer-to-peer patient referral feedback is an excellent strategy for building relationships and partnerships with referring emergency departments, and provides opportunities for outreach education. Applicability of Research to Practice: Referral callbacks by burn charge nurses improve the quality and quantity of referrals to a burn center, build relationships, and ensure quality improvement feedback is shared with referring hospitals. 108. A Needs Assessment for Burn Surgery Education - Establishing Procedural Competencies for Burn Surgery A. D. Knox, MD, D. J. Courtemanche, MD, A. Papp, MD University of British Columbia, Vancouver, BC, Canada Introduction: Variations between training programs and on-going debate regarding the scope of Plastic Surgery have created challenges in standardization of training and assessment of residents. As accrediting and licensing bodies transition towards competency based training it will be crucial to identify and prioritize procedural competencies for burn surgery. Our objectives were to: establish consensus regarding which burn procedures are most important for training; determine the volume of burn surgery performed by residents; and determine if residents are performing these procedures independently prior to graduation. Methods: A multi-round item generation phase involving content experts (n=16) identified 288 plastic surgery procedures that residents are exposed to during training. Peer nominated expert panelists (n=37) were recruited to participate in a multi-round national consensus exercise using a modified Delphi method asking them to sort the procedures into 5 categories reflective of expectations of trainee ability. Consensus was defined a priori as &gt 80% agreement. Results from the consensus exercise were compared to a 10-year case log dataset from all plastic surgery residents at 9 institutions. Results: 2.8% of all plastic surgery procedures (8/288) were related to burn surgery, compared to 3.3% (4929/154036) of all case log entries. 100% of burn procedures reached consensus in the first round (final consensus range 88.9% - 100% agreement). 100% of burn related procedures were assigned to the “core-essential” category. The most common diagnosis was &lt 10% TBSA burn (34.1%). Small burns (&lt 20%TBSA) comprised 52.6% of all entries whereas large burns (&gt 20% TBSA) comprised 47.4%. The majority of burn surgery is performed in PGY3 (52.7%) followed by PGY4 (22.4%) and PGY5 (12.2%). Roles transitioned from mainly first assistant (most common role in PGY1,2,3) to surgeon or co-surgeon (most common in PGY4,5). Conclusions: Our results clearly demonstrate that burn surgery remains a core part of training in Plastic and Reconstructive surgery. Although the largest volume of burn surgery is performed as a first assistant in PGY3, residents are appropriately transitioning to perform these procedures independently in their 4th and 5th years. Applicability of Research to Practice: As we transition to a competency based model for residency training, identifying core procedural competencies for burn surgery will allow us to focus our efforts on instruction and assessment of procedures most likely to benefit graduates entering independent practice. External Funding: The Royal College Fellowship for Studies in Medical Education from the Royal College of Physicians and Surgeons of Canada. 109. Readability of Spanish Language Online Information for the Initial Treatment of Burn Injuries M. R. Metivier, BSN, RN, G. Rizzo, A. Bettencourt, BSN, RN, R. L. Sheridan, MD, FACS, P. H. Chang, MD, FACS Shriners Hospital for Children - Boston, Boston, MA Introduction: The Hispanic population of the United States has grown rapidly over the past decade. The 2014 National Burn Repository Annual Report states that 14% of the reported cases were patients of Hispanic origin. Many Spanish speaking patients are solely Spanish speaking or have limited English comprehension and thus dependent on Spanish language materials for information. When injured, patients frequently use online searches to find out the initial treatment for their condition. Medical associations uniformly reccomend that patient information be written at a 6th grade level so that a majority of the population can comprehend the material. In this study, the top 10 Spanish language websites for burn treatment on two major search engines were identified; their content was then analyzed as to the readability of the information. Methods: The phrase “tratamiento de quemaduras” was searched on Google and Bing on 9/15/2014, and the top 10 listed text-based results in Spanish were recorded. The text of a total of 23 articles was then analyzed using Readability Studio Professional Edition v 2012.1 (Oleander Software, Ltd., Vandalia OH). The software used 5 readability scoring tools appropriate for Spanish language analysis to generate a mean grade reading level. Results: Of the top 10 burn treatment Spanish language websites identified in Google and Bing searches, none were from either the ABA or any ABA verified burn centers. Only 3 websites (nih.nlm.gov, Salud.uncomo.com, and Oculus) were in both top 10 lists. The average grade reading level of all the examined websites ranged from 8.3 to 13.8 (standard diviation ranged from 1.5 to 3.1). Conclusions: None of the websites had the ideal 6th grade reading level, even withing 1 standard diviation.The ABA and ABA-verified burn centers have a responsibility to provide authoritative, reading-level appropriate information for the Spanish-speaking American public. Furthermore, both the ABA and its member burn centers should ensure that their websites appear at the top of any Internet searches. Applicability of Research to Practice: There is a need for online information on burn care and treatment in Spanish that meets the reading grade level necessary for a majority of this population to understand it. Burn professionals should make this authoritative, comprehensible information easily serachable online. Future research will analyze the accuracy of the information presented on these top 10 websites. View largeDownload slide View largeDownload slide 110. Attrition of Participants in a Large Database D. Amtmann, PhD, K. McMullen, MPH, R. K. Holavanahalli, PhD, G. J. Carrougher, RN, MN, L. Friedlander, MEd, N. S. Gibran, MD, FACS, D. N. Herndon, MD, FACS, J. A. Fauerbach, PhD, S. Wiechman, PhD, K. Johnson, PhD University of Washington, Seattle, WA; University of Texas Southwestern Medical Center, Dallas, TX; Partners Healthcare, Boston, MA; University of Texas Med Branch, Galveston, TX; Johns Hopkins University, Baltimore, MD Introduction: Loss to follow-up (LTF) in longitudinal research presents a threat to the validity and generalizability of results. Methods: Participants in a national study met ABA criteria for major burn injury, received care from 1 of 5 burn centers and agreed to participate in 2-year prospective data collection. A prior study examined adults ≥18 LTF between Oct 1993 and Sept 2002. This study provides an update by replicating previous analyses using data from Oct 2002- Feb 2014 and also includes data from parent proxies (for children ages 0–14) and from children ages 14–18 burned from 1993–2014. Analyses included step-wise logistic regression models to predict follow-up (F/U) at 6- (n=1528 adult, n=1985 child), 12- (n=1450 adult, n=1931 child), and 24-months (n=1329 adult, n=1876 child). Predictors of LTF in all models included age, gender, ethnicity, TBSA burned and grafted, etiology, length of hospital stay, circumstances of injury, pre-injury psychiatric care, physical and mental health at discharge, insurance at discharge, and history of F/U at 12 and 24 months. Other variables for adults included employment status, drug/alcohol abuse, and living situation after injury and for children included school status and history of CPS involvement. Bivariate analyses identified variables at discharge for which there was a difference between the groups who were LTF and not lost for at least one F/U, and for the adult sample, to compare F/U with the previous study. Results: F/U ranged from 72% (6 month)-55% (24 month). Younger adults were more likely LTF at 12 and 24 months and adults with flame or electrical injury were more likely to F/U. Both adults and children with history of F/U were more likely to F/U at subsequent points. Children with fewer surgeries were more likely LTF at 24 months and children with flame injuries were more likely to F/U at 6 months. Differences in the LTF group and the group that had at least 1 F/U are outlined in Table 1. The rates of adult F/U were significantly higher than reported in the previous study. Conclusions: People LTF are different from those who F/U. Researchers should be aware of the threat of selective attrition and examine the potential impact on results. Applicability of Research to Practice: Predictors of LTF can help target specialized retention strategies. The improvement in F/U since the previous study provides evidence of ongoing retention improvement strategies implemented by this research project. External Funding: This abstract was developed with a grant from Depart of Ed, NIDRR grant numbers H133A130004 and H133A120024. View Large View Large 111. Use of Midline Catheters in Burn Patients Decreases Central Line Use and Clabsi Rates S. A. Rotta, MD, J. Laird, RN, BSN, R. E. Crombie, MD, K. Connolly, PA-C, P. P. Possenti, PA-C, A. Savetamal, MD, FACS Bridgeport Hospital, Bridgeport, CT Introduction: Central line associated bloodstream infections (CLABSIs) have implications both for patient care and for reimbursement as mandated by the Centers for Medicare and Medicaid Services (CMMS). One alternative to the use of central lines is the midline catheter. This peripherally-inserted intravenous catheter can be left in place well beyond the three to five days allowed for a peripheral intravenous catheter. Unlike a peripherally-inserted central catheter (PICC), however, it is not considered a “central line”, and, with some exceptions, can be used for most purposes for which a central line would be placed. In July of 2012, midline catheters were introduced for use in our institution and quickly became a common feature in the burn unit. Review of our data revealed a significant decrease in both central line use and CLABSIs rate between 2012 and 2013. Methods: IRB approval was obtained to review burn unit data related to central line use for fiscal years 2012 and 2013, as well as overall data regarding the demographics of the burn unit's patients. Results: Total central line days decreased from 905 to 535 (40.7%) between fiscal years 2012 and 2013. The central line associated bloodstream infection (CLABSI) rate also dropped: the 12-month running rate decreased from 3.3 to 0.0 days per 1000 line days between FY 2012 and FY 2013. This improvement occurred despite an apparent increase in the number of inpatients treated during these two years. Our burn unit volume increased between 2012 and 2013 (172 to 251 inpatient admissions, 45.9%), as did the number of patients requiring ICU care (23 to 38, 65%). This dramatic volume change is due to the fact that during our 2012 renovation, many burn patients were housed outside of the burn unit and were not counted in our 2012 census. The subsequent decrease in line use noted after renovation and with a full census is therefore quite striking. Conclusions: Use of midline catheters, combined with a concerted effort at early removal of central lines, enabled our center to decrease our central line usage rate and, along with that, our CLABSI rate. Even with an increased census in the burn unit, including more critically ill patients, 41% fewer central lines were placed, and the incidence of CLABSI reduced to zero. Applicability of Research to Practice: Use of midline catheters will permit both delivery of appropriate care and significant decrease in the placement of and complications from central catheters. View largeDownload slide View largeDownload slide 112. Versijet Excision and Xenograft Placement Can Heal Partial Thickness Burns and Decrease Hospital Stays G. K. Lindberg, MD, PhD, A. Wiktor, MD Univ. of Colorado-Denver, Aurora, CO Introduction: Deep partial thickness burns are the hardest to evaluate for time to healing and need for autografting. This can lead to prolonged time in the hospital with painful daily dressing changes until an accurate assessment of the wound healing potential can be made. While there are laser doppler and ultrasound techniques to evaluate burn depth and healing potential, these devices are expensive and are not readily available. We have found a high pressure hydro-dissection tool valuable in determining wound depth and can help us decide whether a burn wound can be healed with xenograft placement or needs an autograft. Methods: Thirty patients, with an average burn size of 8%, were taken to the operating room and their burns excised with a high pressure hydro-dissection tool. Based on the tissue integrity after removing the eschar we placed the wound bed in xenograft or allograft/autograft. If, at the end of excising the burn eschar, we encountered healthy tissue with puncate bleeding and good tissue architecture with no exposed fat, we placed the wound in xenograft. If we encountered subcutaneous fat, we assumed the burn was full-thickness and proceeded with allograft or autograft. Patients were followed and the time to discharge, time to healing and narcotic use after surgery were recorded. Results: The thirty patients who received xenograft were compared to a similar population of patients admitted to the burn unit two yearts before. There was no difference in infection rates, but there was a marked decrease in narcotic usage and hospital length of stay, often with patients being weaned off intravenous narcotics and going home the next day after surgery. In addition, ninety percent of the patients treated with xenograft healed their burns, only 10% needed further autografting. Conclusions: High pressure hydro-dissection and xenografting can decrease the need for daily dressing changes and lead to earlier discharge from the hospital. In addition, this dissection technique can diagnose deep partial thickness burns from full thickness burns with a 90% accuracy. Applicability of Research to Practice: This technique leads to decreased hospital stays, decreased hospital costs and decreased narcotic use. 113. How Low Can We Go? Decreasing Central-Line Associated Bloodstream Infections K. Krout, RN, PhD, K. L. Huber, RN, MSN, R. Orosco, RN, BSN, C. Flores, RN, BSN, S. M. Milner, MD Johns Hopkins Burn Center, Johns Hopkins Bayview Medical Center, Baltimore, MD Introduction: Central line-associated bloodstream infections (CLABSI) are particularly a problem in burn patients who are critically ill. Our burn center has been involved in quality improvement related to CLABSIs since calendar year (CY) 2011. In CY2011, we had a CLABSI rate of 15.1 per 1000 central line days. This was above the baseline set by the National Healthcare Safety Network (NHSN) of 6.49. During that time multiple interventions were utilized to decrease our CLABSI rate. As a result our CLABSI rate dropped to a rate of 4.05 in CY2012, while our catheter utilization rate remained stable. In CY2013, our CLABSIs rate was 3.38, which was below the NHSN baseline, but still unacceptable to us. In CY2014, additional interventions were implemented to decrease the rate of CLABSI. Currently, our burn center has 0 infections for CY2014, even though our catheter utilization rate has remained stable. Methods: In CY2011 and 2012, our burn center embarked on a journey to decrease CLABSIs. Throughout these two years we implemented the following interventions: daily review of line necessity, use of an antimicrobial coated catheter, chlorhexidine antisepsis and full barrier precautions for central line insertion, scheduled line changes, and alcohol impregnated caps. Our rates decreased from a high of 15.1 per 1000 central line days in CY2011 to a rate of 4.05 in CY2012, even with catheter utilization remaining the same. In CY2013 we achieved a rate of 3.38 CLABSIs per 1000 central line days. We knew there was still room for improvement and additional interventions were introduced prior to CY2014 to reach a goal of achieving 0 CLABSIs for an entire calendar year. From a physician perspective, the main intervention that was implemented was the early excision and auto-grafting of the neck and clavicle area. We believed it was essential to heal this area as quickly as possible to ensure intact skin through which to place a catheter. From a nursing perspective, we began weekly audits of all central lines. Feedback was given from these audits in real time so the nurses could address the concern right away. Results: Currently in CY2014, our burn center has achieved and maintained 11 months of 0 CLABSIs. This was achieved while maintaining a constant catheter utilization rate of the past 4 years. Conclusions: It is possible to achieve 0 CLABSIs for an extended time period in a population such as burn patients through physician and nurse collaboration. Applicability of Research to Practice: Although burn patients are extremely susceptible to infection, it is possible to achieve a CLABSI rate below NHSN benchmarks through teamwork and multidisciplinary communication. Preventing a burn patient from sustaining a CLABSI can help to increase positive patient outcomes, decrease hospitalization, and decrease costs. 114. Setting Limits on Cardiopulmonary Resuscitation in Burns: Where Is the Line between Futility and Utility? P. O. Kwan, MD, FRCSC, S. Sen, MD, FACS, MS, D. G. Greenhalgh, MD, FACS, T. L. Palmieri, MD, FACS, FCCM University of California - Davis Medical Center, Sacramento, CA Introduction: Starting cardiopulmonary resuscitation (CPR) and do not resuscitate orders are crucial decisions for critically ill burn patients. In burn care, code status is reevaluated throughout hospitalization, yet little data exist on when code status changes occur and how these changes impact outcomes. The purpose of this study was to define the timing and outcomes of changes in code status and CPR after burn injury. Methods: A retrospective chart review was conducted of adult (age ≥18 years) patients who died, had CPR, or life threatening burns ≥20% total body surface area (TBSA), at a single burn center from 2008 to 2013. Study variables included: age, gender, inhalation injury, burn size, etiology, goals of care, cardiopulmonary resuscitation, and outcome. Burn admission survival was predicted using the Thermal Injury Mortality Model (based on age, burn size, and inhalation injury). Student's t test and Fisher's exact test were used, with values expressed as mean ± standard error, and p < 0.05 considered statistically significant. Results: Of the 94 deaths during the study period, 26 patients had “comfort care” initiated for nonsurvivable injuries, 5 patients were made “no CPR” based on advanced directives or comorbidities, and the remaining 52 patients were “full code”. Of the 52 patients with early “full code” status who died, 90% were made “no CPR” an average of 15.0 ± 2.0 days after admission and 6.8 ± 1.6 days before death. A family conference was held for 90% of these cases. Patients made “comfort care” had a significantly lower predicted survival (12.5 ± 3.3%) versus those dying after being admitted with “full code” status (55.1 ± 4.3%), and those surviving (81.7 ± 1.5%) (p < 0.001). There were no differences in predicted survival between patients who lived or died with a diagnosis of multi-organ failure (p = 0.86). Of the 27 patients receiving CPR 52% survived to discharge with good neurologic outcomes, significantly better than that reported in general hospital inpatients (27%) (p < 0.001). Of those receiving CPR, significantly more survived respiratory arrest (80%) than cardiac arrest (31%) (p = 0.021). Conclusions: The majority of deaths in burn patients are preceded by a change in resuscitation status to “no CPR” at 2 weeks as a result of multi-organ failure or poor prognosis, and died approximately 1 week later. Of those who receive CPR, more than half survive. Respiratory arrest is associated with a higher rate of survival to discharge than cardiac arrest, and survival in both groups is much higher than in general hospital inpatients. Applicability of Research to Practice: In appropriately selected burn patients CPR has improved survival to discharge and outcomes as compared to general hospital inpatients. 115. The Use of an Innovative Face Dressing to Reduce Unplanned Extubations in Pediatric Burn Patients A. Bettencourt, MSN, RN, CCRN, S. Vanasse, BSN, RN; R. Grady, RN, P. H. Chang, MD, FACS, R. L. Sheridan, MD, FACS Shriners Hospitals for Children Boston, Boston, MA Introduction: Securing endotracheal tubes in burn patients is challenging and often complicated by edema, exudate, and wound and graft care. Unplanned extubation is a potentially lethal complication in burn patients of all ages. Unplanned extubation rates are included in quality metrics for critical care units. Conventional methods, such as securing with tape, ties, dental apparatus, wires, or commercially available tube holders are often not feasible in pediatric burn patients. In addition, pediatric patients are particularly prone to accidental extubations due to their developmental stage and airway anatomy. In order to prevent unplanned extubations in pediatric burn patients, we developed a novel, cost effective face dressing technique that meets the need of safely securing the endotracheal (ET) tube in the pediatric burn patient. Methods: We performed a retrospective quality improvement study to examine the unplanned extubation rate for orally intubated children in whom this face dressing system was used. The sample included all intubated children hospitalized from 2003–2013 in an ABA-Verified pediatric burn center. We examined the relationship between having the novel face dressing and unplanned extubations. Our data set included 187 patients intubated for a total of 3089 days. Nurse/patient ratios, mean %TBSA, age, RASS scores, restraint usage, and burn etiology were also included in the analysis. We also reviewed the patient records for evidence of oral commissure breakdown. Results: Of the 187 patients over 10 years of practice in whom this ETT securing system was used, only one (0.5%) had an unplanned extubation. This resulted in an unplanned extubation rate of 0.009 per 100 ventilator days in patients with this dressing. This rate is lower than the generally reported rate for unplanned extubation in children (0.114 to 4.36 per 100 ventilator days), and lower than the rate reported in adult burn patients (2.7 per 100 ventilator days). In addition there were no instances of oral commissure breakdown (0%) associated with the dressing. Conclusions: The use of this face dressing technique is consistent with a very low rate of unplanned extubations in pediatric burn patients without any additional risks to the patient's oral commissures. Applicability of Research to Practice: This face dressing technique could be applied burn patients to help reduce unplanned extubation rates. The use of this dressing technique may improve hospital burn unit performance on quality metrics, and reduce the incidence of oral commissure breakdown. 116. BEAT (Burn Escharotomy Assessment Tool) Trial R. J. Ur, MD, J. E. Carter, MD, J. E. Johnson, PhD, J. A. Molnar, MD, PhD, J. H. Holmes IV, MD, FACS Wake Forest Baptist Medical Center, Winston-Salem, NC Introduction: Severe burn injuries can require an escharotomy incision (EI) which is an urgent, infrequent, and relatively high-risk procedure. Given the reduced exposure to burn care in general surgical residency and the absence of burn management in the Acute Care Surgery fellowship, there is a risk of inadequate practitioners capable of performing this procedure especially in the event of a large scale disaster. Our goal was to create a biomimetic synthetic human tissue simulator that allowed providers an opportunity to perform an EI with discrete points of failure (DPF) capable of discerning incompetent from competent providers at a reasonable cost. Methods: Our study included a careful needs assessment with ABLS national faculty, materials cost analysis by members of Human Analogue Applications (HAA), LLC and the Wake Forest Innovations Center for Applied Learning (CAL), and established goals to achieve face and content validity. Three DPF were defined: incomplete EI, inadvertent fasciotomy, and failure to evaluate distal pulse. Data included a participant pre- and post-procedure survey, escharotomy assessment by fellowship-trained burn surgeons, and statistical analysis using Fisher's exact test or t-test. Results: A circumferential upper extremity burn prototype was successfully constructed with the intent to produce high inter-and intra-rater reliability. Each procedure required a cartridge which averaged $50/learner and less than 2 minutes to prepare. HAA leveraged experience from nationally-acclaimed cinema effects artists to create a full-thickness burn of the upper extremity. 18 participants enrolled with clinical experience ranging from 0 to over 100 procedures previously performed. Participants with limited exposure (0–1 procedures) had increased DPF relative to more experienced participants (p=0.036). All participants noted increased comfort after performing the procedure on a 3 point scale (p=0.0028). Validity was further assessed with 100% of the participants answering that the model appeared realistic, benefited their training, and recommended future use of the model to other providers. Conclusions: The escharotomy trainer successfully differentiated unexperienced providers from more experienced providers. The escharotomy trainer demonstrated value in training and assessment of providers at a low relative expense when compared to other models. Applicability of Research to Practice: Further research is needed in assessing the translation of the acquired skills to clinical practice and patient outcomes. View largeDownload slide View largeDownload slide 117. Utility of Real-Time Feedback of Patient Reported Outcomes during Clinical Burn Encounters R. L. Sheridan, MD, FACS, C. Wang, BS, B. Weaver, BA, C. Chu, BA, C. M. Ryan, MD, R. G. Tompkins, MD, ScD, FACS, M. Lydon, RN, BSN, P. H. Chang, MD, FACS, A. F. Lee, PhD, L. E. Kazis, ScD Shriners Hospital for Children, Boston, MA; Massachusetts General Hospital, Boston, MA Introduction: Validated Patient Reported Outcomes (PROs) are recently available for children recovering from burns. PROs are not currently utilized in routine clinical burn encounters. We performed a pilot trial to determine the impact of burn-specific PROs provided to clinicians in real-time during routine clinical encounters. Methods: The validated SHC-ABA Burn Outcomes Questionnaire (BOQ) for children and adolescents 5–18 years of age was administered just prior to clinic visits of children recovering from burns in an IRB approved study. Children were eligible if they had suffered a burn of 20% or greater or if they had suffered full-thickness burns to the hands and/or face with a lesser burn size. The questionnaires were immediately scored and standardized to a mean of 50 and a standard deviation of 10, based upon results of a multi-center 5 year cohort of burned children. These results were presented to clinicians immediately prior to clinic encounters. Domains included were the 12 domains of the 5–18 BOQ (upper extremity function, physical function and sports, transfers and mobility, pain, itch, appearance, compliance with the instructions, satisfaction with current state, emotional health, family disruption, parental concern and school re-entry). The normed information was provided as a histogram. The clinicians' impression of the value of the added information was assessed following the clinic visit. Results: Of 18 children enrolled in the project, feedback was obtained from physicians for 15 clinical encounters. The 3 incomplete enrollments were due to an inability to complete scoring prior to the child being seen in the clinic (1 child) and mechanical problems with the scanning equipment (2 children). Five of the 15 children had burns under 20% with full-thickness face and/or hand injury. The remaining 8 children had an average burn size of 53.4% (range 20% to 88%). For the 15 clinical encounters, the clinicians report that in 93% of the visits the information conveyed by the metric scores was unexpected and of potential clinical importance; in 27% of the visits clinicians noted that the information impacted the treatment plan; and in 80% of the visits the information prompted some discussion with the family that would not otherwise have occurred. Additional narrative comments by the surgeons were generally favorable. Conclusions: Immediate feedback of granular multidimensional PROs is feasible from a technological and practical perspective. The results indicate that the metrics are potentially useful in routine clinical pediatric burn encounters. Further study is warranted and being planned. Applicability of Research to Practice: The addition of granular PROs may enhance the effectiveness of routine clinical encounters in children recovering from burns. 118. Universal Decolonization Protocol to Reduce MRSA Prevalence in a Burn Center C. Bell, MS, RN, M. A. Barron, MD, G. K. Lindberg, MD University of Colorado Hospital, Aurora, CO Introduction: Hospital acquired Methicillin Resistant Staphylococcus Aureus (MRSA) is a common complication in burn centers that is associated with negative consequences including wound infections, graft failure, central line blood stream infections (CLABSI), and increased lengths of stay. In 2013, our burn center experienced a disturbing increase in MRSA despite traditional contact precaution interventions. This prompted a quality improvement project in collaboration with the Burn and Infection Control Teams. Methods: After a comprehensive review of the literature, the interdisciplinary team chose to implement a Universal MRSA decolonization protocol for all patients admitted to the burn service. This protocol included MRSA screening on admission, administration of 2% intranasal Mupirocin ointment twice daily for five days, and daily 2% Chlorhexidine Gluconate (CHG) cloth bathing on all intact skin below the jawline. All nursing staff were trained on the protocol with focused teaching on screening swab collection technique, proper administration of intranasal Mupirocin and a standardized CHG bathing process. The protocol was implemented December 1, 2013 and MRSA cultures were trended by site pre and post protocol implementation. Results: From January 2013-November 2013 (Pre Universal MRSA Decolonization) 44 patients tested positive for MRSA. Four of the 44 patients tested positive for MRSA on admission. 40 tested positive for MRSA in the following sites: wound cultures (15), CLABSI (8), sputum cultures (7), surveillance cultures (6), non-CLABSI bacteremia (4). From December 2013-September 2014 (Post Universal MRSA Decolonization) only 1 MRSA was cultured (CLABSI). No adverse events were documented after implementing this protocol (allergy/skin reactions). Conclusions: Implementation of a Universal MRSA Decolonization Protocol proved to be an effective way to decrease the prevalence of MRSA. MRSA CLABSI was reduced from 8 to 1 in a consecutive 11 month time period and infection and colonization at other sites was reduced to zero. It was vital to involve the interdisciplinary team early in the process to ensure buy- in from the team and to provide appropriate education for the nurses and residents on this practice change. Applicability of Research to Practice: Complications associated with hospital acquired MRSA are a burden to patients and result in prolonged length of stay and additional expense. The reduction in MRSA colonization and infections helped prevent the potential transmission of MRSA within the unit. Implementing a decolonization protocol resulted in an estimated cost savings of $280,000 attributed to reduced CLABSI alone. The protocol was safe and well tolerated and may be another tool for preventing infections in burn patients. 119. Risk Factors for Burn Wound Infection: Data from the Inflammation & the Host Response to Injury Study C. M. Thompson, MD, G. E. O'Keefe, MD, N. S. Gibran, MD, FACS, B. D. Arnoldo, MD, R. L. Gamelli, MD, FACS, D. N. Herndon, MD, FACS, R. G. Tompkins, MD, ScD, FACS University of Washington, Seattle, WA; UT Southwestern Medical Center, Dallas, TX; Loyola University Chicago, Maywood, IL; University of Texas Medical Branch, Galveston, TX; Massachusetts General Hospital, Harvard University, Boston, MA Introduction: Burn wound infection is a serious complication following thermal injury that leads to significant morbidity, mortality & cost. Burn size is the main risk factor for burn wound infection. The Inflammation and the Host Response to Injury (“Glue Grant”) study is a multicenter research collaborative designed to advance our understanding of the host's response to severe injury. We sought to identify risk factors for burn wound infection in this cohort. Methods: We analyzed data from the burn injury subjects enrolled in the Glue Grant. Patient & injury characteristics were analyzed for association with burn wound infection using multivariate logistic regression analysis. We were specifically interested in factors including early blood transfusion & practice variations. Results: There were 573 subjects with a mean age of 26; 72% were male. In addition to total body surface area; transfusion in the first 48 hours after injury & transfer to a burn center ≥ 24 hours after injury were independently associated with burn wound infection. Early transfusion increased the risk of burn wound infection by three-fold while delayed transfer increased the risk of burn wound infection by over five-fold. Conclusions: Prevention & reduction of burn wound infection incidence begins with an understanding its risk factors. We have confirmed an association of early blood transfusion with this infectious complication, which indicates that limited use of blood transfusions early in the resuscitation may lead to a decrease in burn wound infections. We have also shown an association of burn wound infection with delayed transfer. Delayed transfer to definitive treatment may lead to increased burn wound infection because of the rapid bacterial colonization of the injured skin & delayed initiation of treatment indicating the importance of prompt transfer to definitive care. Applicability of Research to Practice: We have identified risk factors for burn wound infection in the immediate post-injury period. Future studies should focus on changes in practice patterns & their effect on the incidence of burn wound infection. View Large View Large 120. A Single Center, Open Label, Dose Escalation Trial to Evaluate the Safety of Application of Topical Lidocaine in Patient's Undergoing Negative Pressure Wound Therapy T. M. McSherry, CCRN, N. A. Kemalyan, MD, FACS Legacy Health Systems, Oregon Burn Center, Portland, OR Introduction: Burn and Wound patients undergoing dressing changes endure a significant amount of pain. Systemic medication is not always effective in controlling pain. It is common practice to utilize topical lidocaine for pain relief despite limited evidence to support the safety of this practice. The study was designed to determine a relationship between topical dosing of lidocaine and serum levels in patients undergoing negative pressure wound therapy (NWPT). Methods: Patients expected to undergo a minimum of four NPWT dressing changes were screened and enrolled. Initial dosing of topical lidocaine at 5mg/kg doubled at each subsequent dressing change to a maximum of 40 mg /kg. Lidocaine was infused into the wound 60 minutes prior to dressing removal. Serum levels of lidocaine were measured at 10, 60, 120, 180, and 240 minutes after infusion. Results: There were a total of 46 NPWT dressing changes in 15 patients with wound volumes up to 2500 cm3. No patient experienced a toxic (>4.5ug/ml) at any time during NPWT. At 5ug/ml dosing level (n=15 subjects), no detectable lidocaine level (<1.0 ug/ml) was measured using our standard laboratory assay. At the highest dosing level (n=10 subjects), or 8 times the initial dose, two patients demonstrated a nontoxic, measurable level. Conclusions: We cautiously interpret our limited data set using the most conservative cut off for toxicity of >4.5ug/ml, to suggest that the application of topical Lidocaine at 5mg/kg in open wounds for pain relief is a safe practice. Applicability of Research to Practice: There is no guidance to determine the safe dose range for the application of topical Lidocaine to open wounds. Use of a safe topical agent as a sole or adjunctive measure to manage pain is beneficial, as topical therapy is expected to have less adverse effects compared to systemic medications. This study contributes to a greater body of knowledge regarding use of topical lidocaine in open wounds. View Large View Large 121. Development and Implementation of a Wound Mapping Software: 5 Years in the Making M. L. Serio-Melvin, MSN, RN, C. A. Fenrich, BS, S. Shingleton, MS, RN, J. McCorcle, PA-C, L. C. Cancio, MD, FACS, J. Salinas, PhD USAISR,JBSA, FSH, TX Introduction: Ongoing wound assessment and tracking of wound healing are critical in care of patients with burns, soft tissue injuries and skin diseases. Most burn mapping procedures are paper-based, manually calculated, serve as a static representation of the burn wound and are unable to display patient photos. We developed a wound mapping software used for documenting the patient's initial injury, ongoing surgical treatments, and wound healing throughout the entire hospitalization. The software uses the same body segment percentages as the standard Lund and Browder chart to calculate the Total Body Surface Area (TBSA) of burns, grafts, donor sites and other wounds. The purpose of this project was to analyze data from our software to characterize the system's ability to map and track wound healing of the patients in our burn center. Methods: Beginning in August 2009, all patients admitted to our burn center were entered into the software by nurses or providers. Patient data was entered within 24 hours of admission, during every operation, or every 8 days, whichever came first. We extracted all patients mapped in the system from implementation until August 2014. Data was analyzed for frequency, wound type (TBSA, full thickness, partial thickness,) amount of time between sequential mappings, number of wound photos and bronchoscopies. Results: Since implementation, 2136 patients have been mapped for a total of 6057 mappings. Of the 2136 patients, a total of 1732 patients (81%) had a burn diagnosis and were mapped at an average TBSA of 10.82% (+/−15.05%), with a full thickness burn of 2.91% (+/− 10.38%) and partial thickness burn of 7.91% (+/− 10.53%). On average, patients were mapped every 4.67 (+/− 5.70) days and had an average length of stay of 12.88 days. There were 17,965 burn wound photos and 575 bronchoscopies uploaded into the system. Conclusions: Our wound mapping software has been adopted by the multi-disciplinary team and has been successfully incorporated into our daily practice. Further research is warranted to determine if the software enhances communication between multidisciplinary team members, results in earlier recognition of delayed wound healing and assists the team in developing an effective treatment plan. Applicability of Research to Practice: Our wound mapping software provides a database that can be the basis for future wound healing models and research protocols studying the complexities of wound healing. External Funding: Combat Casualty Care Research Program, Medical Research and Material Command, Ft. Dedrick, Maryland. 122. Effects of Cultured Substitutes on Outcome Measures in Massively Burned Children N. C. Benjamin, BS, F. Williams, MD, W. Norbury, MD, C. R. Andersen, BS, O. Suman, PhD, D. N. Herndon, MD, FACS Shiners Hospital for Children-Galveston, Galveston, TX; UNC-Chapel Hill, Chapel Hill, NC Introduction: The functionality and protective nature of skin is lost when it is burned thus, autografting is important to assure healing and prevent infection. Cultured epidermal autograft (CEA) is grown from a biopsy of the patient's healthy skin and is used to replace the epidermis of third degree burns. Cultured skin substitute (CSS) is also created from a biopsy of the patient's normal skin and is made into a dermal-epidermal matrix. Methods: Patients who were treated with CEA, CSS, or standard autografting techniques, at our institution between 2000 and 2008 and had a TBSA burn of ≥80% with ≥60% 3rd degree burned were included in this study. Patients who expired or had incomplete records were excluded from the analysis. Patient demographics, length of stay (LOS), LOS/% TBSA burned, number of surgeries, and scar quality using the Vancouver scar scale were assessed. Statistical analyses between CES, CSS, and autograft were performed using unpaired t tests, and significance accepted as p<0.05. Results: Patient demographics showed no significant differences between CEA, CSS, and standard autografting. Significant differences were observed in patients treated with CSS versus standard autograft, as patients treated with CSS had a greater LOS (p<0.01), LOS/% TBSA burned (p<0.02), total number of surgeries (p<0.001), number of acute surgeries (p<0.001), and number of reconstructive surgeries (p<0.03). Significant differences were observed in patients treated with CSS versus CEA in scar quality 18–24 months postburn, as the height was significantly greater in CSS patients (p<0.00001). Conclusions: Compared to standard autografting methods, CSS decreased patient mortality and increased LOS, LOS/% TBSA burned, number of total, acute, and reconstructive surgeries. Relative to CEA, CSS increased patient survival but decreased scar quality. Thus, the standard technique of autografting may be the best method available, although this luxury may not always be an option in patients with massive burns. Applicability of Research to Practice: Ultimately, no single method discussed is without faults when treating patients with massive burns. Therefore, understanding the effects of each kind of autografting method is important for improving patient care, decreasing morbidity and mortality, and improving long term outcomes. External Funding: UTMB BP Remembering the 15, Burn Research Education (565450), SHC Special Shared Facility for Clinical Research (84080), National Institutes of Health (P50-GM60338, R01-GM56687, and R01-HD049471), Shriners Hospitals for Children (71006, 71008, 71009). 123. Gram Stain Utility in Burn Wounds K. D. Capek, MD, M. L. Wyers, RN, BSN, C. Song, DO, P. Muthayya, MBBS, FRCS, FRCS(Plast), R. P. Mlcak, PhD, H. K. Hawkins, MD, PhD, J. O. Lee, MD, D. N. Herndon, MD, FACS Shriners Hospitals for Children-Galveston, Galveston, TX; Shriners Hospitals for Children/UTMB, Galveston, TX Introduction: The utility of Gram stain for burn wound samples has not been defined in the contemporary period of burn ICU care. The purpose of this study was to assess the diagnostic test characteristics of Gram stains from burn wound quantitative tissue culture and swab samples in pediatric burn patients. Methods: As part of a performance improvement project, the microbiological data for 20 recent and consecutive admissions to the pediatric acute burn unit were compiled. The gram stain, quantitative tissue culture, and wound swab culture findings were reviewed. These data were used to determine if there was a relationship between gram stain and both types of culture results. Quantitative tissue cultures were considered clinically significant if they showed 105 or more colony forming units (cfu) per gram of tissue for Gram positive organisms or 103 or more cfu/g for Gram negative organisms. Wound swabs were considered clinically significant when 3–4 growth was noted. Results: In these 20 patients, 263 skin wound biopsy specimens were submitted for Gram stain and quantitative culture, 49 were clinically significant positive quantitative cultures. Gram stain result performance compared to gold standard clinically significant tissue culture: Sensitivity 55%, Specificity 99%, Positive Predictive Value 96%, Negative Predictive Value 91%, Accuracy 91%, Likelihood Ratio Positive 55, Likelihood Ratio Negative 0.45. 132 specimens were submitted for gram stain and wound swab culture, 21 were clinically significant positive by swab culture. The data return the following comparison of swab Gram stain with swab culture 3–4+ growth: Sensitivity 52%, Specificity 99%, Positive Predictive Value 92%, Negative Predictive Value 92%, Accuracy 92%, Likelihood Ratio Positive 52, and Likelihood Ratio Negative 0.48. Conclusions: Gram stains provide rapid data regarding the presence of wound infection. The following interpretation of Gram stain results are suggested by our data: If the Gram stain is positive, a clinically significant infection is almost certainly present and treatment should not be delayed for culture results. Negative Gram stain results are more difficult to interpret, as some of these specimens ultimately have positive cultures. Nearly 10% of specimens with negative Gram stains returned clinically-significant positive culture results; therefore patient factors may appropriately determine the treatment course. It would seem reasonable to continue antimicrobial treatment of critically ill patients with negative Gram stains. In healthier patients with limited burns and plentiful donor sites, antibiotics could be curtailed more rapidly when Gram stain results are negative. Applicability of Research to Practice: This work delineates the role of Gram's stain as a rapid diagnostic test in evaluating burn wound infection. 124. Patient-Reported Outcomes of Patients Treated with Integra Dermal Regeneration Template™ S. Honari, RN, BSN, S. P. Mandell, MD, MPH, G. J. Carrougher, RN, MSN, K. McMullen, MPH, T. N. Pham, MD, FACS, N. S. Gibran, MD, FACS UWMedicine Regional Burn Center, Seattle, WA; UW Medicine, Seattle, WA Introduction: Patients with significant burn injury often require complex wound closure that may include use of skin substitutes. Whereas clinicians assume that these adjuncts improve outcomes, this has never been verified. The purpose of this study is to determine whether patients treated with Integra Dermal Regeneration Template™ have better patient reported outcomes than those treated with standard wound coverage. Methods: We followed a population of 265 adults with major burn injury longitudinally as part of a burn outcomes study (2008–13). Data included Satisfaction With Appearance Scale (SWAP), and SF-12® Physical and Mental Health Component Summary (PCS & MCS) scores administered at hospital discharge, 6, 12, and 24m after injury. We used Wilcoxon Mann Whitney and chi-square tests to analyze differences in demographic and injury variables. Linear regression analyses determined the impact of significant variables on PCS, MCS and SWAP scores. Results: Table 1 summarizes population characteristics; Table 2 outlines regression-modeling results. Whereas initial analysis shows that subjects treated with IntegraTM have reduced satisfaction with appearance at all time points, burn size, more operations and longer hospital stay suggest that worse injury may be a confounding variable. Regression analysis confirms that females and patients treated with Integra have decreased satisfaction with appearance 12 and 24m after injury. Conclusions: Our data indicate that IntegraTM wound coverage does not improve SF-12® scores, return to work status or satisfaction with appearance. This may, in part, be due to use of IntegraTM in larger, more severe burns. Applicability of Research to Practice: Our data suggest that it is possible to assess the effect of therapeutic interventions on patient-reported outcomes. Skin substitutes are costly interventions but their use may not translate into improved patient satisfaction. External Funding: National Institute on Disability and Rehabilitation Research, grant # H133A13004 & H133A120024. 125. Use of Fibrin Glue for Split Thickness Skin Graft Fixation Allows Early Mobilization without Graft Loss S. A. Rotta, MD, E. Labonte, PT, A. St. Clair, OT, J. Laird, RN, K. Connolly, PA-C, R. E. Crombie, MD, A. Savetamal, MD Bridgeport Hospital, Bridgeport, CT Introduction: Ambulation and mobilization of burned extremities early in the burn survivor's course is a key factor in preventing long term disability and avoiding the complications of prolonged bed rest. Though this is well established, concern for autograft loss due to shear forces or extremity edema have sometimes delayed the practice of early physical and occupational therapy after surgery. The development of fibrin glue products has allowed for improved autograft adherence. Using this product exclusively may help facilitate early mobilization without the adverse consequence of graft loss. Methods: A one year retrospective electronic medical record review of a single surgeon cohort of patients requiring extremity autografts was conducted. Patients had either lower extremity (29 cases) or upper extremity (34 cases) autografts affixed with fibrin glue only and were mobilized on post operative day zero or one. After applying exclusion criteria (critical illness, mobility restriction, multiple grafting procedures performed by several surgeons, lost to follow up), 15 lower extremity and 17 upper extremity cases were included. Graft location, size (cm2), graft take one month post-op, and patient co-morbidities were collected for analysis. Results: Lower extremity graft sites ranged from 12 to 800 cm2, average graft take was 92.3% with a standard deviation of 12.6; upper extremity graft sites ranged from 10 to 800 cm2, average graft take was 95.2% with a standard deviation of 8.0. For both groups combined average take was 93.8%. Of the four patients with partial failure (50–90% take), three had diabetes and one had a deep burn and morbid obesity. Conclusions: Extremity autografts adhered with fibrin glue and mobilized on post-operative day zero or one demonstrated an average of 93.8 % graft take. The majority of patients had greater than 90% graft take that did not require additional surgery. This indicates that early mobilization is possible with the use of fibrin glue with no significant graft loss. Applicability of Research to Practice: This provides support that autografts adhered with fibrin glue can withstand early patient mobilization; this can improve patient care and potentially long term recovery. 126. Clinical Outcomes in Burn Patients Treated with Cryopreserved Human NIKS Tissue B. L. Allen-Hoffmann, PhD, M. J. Schurr, MD, L. D. Faucher, MD, FACS, K. N. Foster, MD, MBA, FACS, S. E. Wolf, MD, FACS, B. T. King, MD, FACS, A. R. Comer, PhD, M. A. Lokuta, PhD, K. F. Barbeau, BA, J. H. Holmes IV, MD, FACS University of Wisconsin-Madison, Madison, WI; University of Colorado at Denver, Aurora CO and Mission Health Hospital Trauma Center, Asheville, NC; Arizona Burn Center, Phoenix, AZ; University of Texas Southwestern, Dallas, TX; US Army Institute of Surgical Research, San Antonio, TX; Stratatech Corporation, Madison, WI; Wake Forest Baptist Medical Center, Winston-Salem, NC Introduction: The need for a safe, readily-available skin substitute alternative to donor site harvest and autografting is critical, especially in difficult to treat patient populations such as children and the elderly. We have developed a cryopreserved universal human skin substitute (cryopreserved NIKS tissue) that can now be stored for greater than 1 year without loss of viability, barrier function, or tensile strength. NIKS tissue reproduces many of the structural and biological properties of normal human skin and is intended to provide immediate wound coverage, barrier function, and sustained expression of wound healing factors to promote the autologous regeneration and repair of the patient's skin without the need for donor site harvest. Here we report new clinical findings on the performance of cryopreserved NIKS tissue. Methods: A proof-of-concept, controlled, dose escalation clinical trial was conducted at six sites to examine the safety and efficacy of refrigerated and cryopreserved NIKS tissue in healing deep partial thickness (DPT) burns without autografting. Patients with 3–49% TBSA burns were enrolled in three cohorts, receiving up to 440 cm2 of refrigerated (cohorts 1 and 2) or cryopreserved NIKS tissue (cohort 3) as a single application following debridement. Each patient had two areas of DPT burn randomized to autograft or treatment with NIKS tissue. Primary clinical endpoints are percentage of human skin substitute-treated area requiring autografting by day 28 and wound closure at 3 months. Other assessments include safety, cosmesis, donor site pain, immunological responses, and presence of allogeneic DNA from NIKS tissue. Results: None of the DPT burns treated with cryopreserved NIKS tissue required autografting by day 28. All patients in cohort 3 who have reached the 3 month time point and whose wounds were treated per protocol have shown complete wound closure of both the NIKS tissue and autograft-treatment sites. There has been no safety signal related to use of either refrigerated or cryopreserved NIKS tissue. DNA from the NIKS tissue has not been detected after 3 months in patients of any cohort. Conclusions: Cryopreservation of NIKS tissue increased shelf-life >40-fold to over 1 year with no effect on clinical outcome. The clinical findings show that the cryopreserved NIKS tissue promotes repair and regeneration of autologous skin and thus prevented the need for donor site harvest. Applicability of Research to Practice: Cryopreserved NIKS skin substitute tissue has a substantially increased shelf-life making it a cost-effective, readily-available alternative to autografting of severe burns, reducing pain, scarring and other complications associated with donor site wounds. External Funding: Armed Forces Institute of Regenerative Medicine (AFIRM) grant, and Stratatech Corporation. 127. Do Standard Burn Mortality Formulae Work on a Population of Severely Burned Children and Adults? A. Tsurumi, PhD, Y. Que, MD, PhD, S. Yan, PhD, R. G. Tompkins, MD, ScD, FACS, L. G. Rahme, PhD, C. M. Ryan, MD, FACS Massachusetts General Hospital, Shriners Hospitals for Children-Boston/Harvard Medical School, Boston, MA; Lausanne University Hospital, Lausanne, Switzerland Introduction: Accurate prediction of burn mortality is useful to provide criteria for clinical treatment plans and resource allocation. Several common formulae for burn mortality prediction (Ryan NEJM score, ABSI Abbreviated Burn Severity Index (ABSI) and the classic and revised Baux scores, adult (R-Baux) and pediatric (P-Baux)) have not been externally validated in populations with severe burns. Such validation is necessary to reduce bias associated with under- or over-fitting. The performance of burn-specific mortality predictor models have not been compared with standard ICU mortality scores such as the Acute Physiology and Chronic Health Evaluation II (APACHEII) in severely burned patients. Validity of general and burn-specific formulae was tested using data from severely burned adults and children. Methods: The study database was the Inflammation and the Host Response to Injury Study (Glue Grant), a prospective, longitudinal study which enrolled patients with ≥20% total burn surface area (TBSA) at 6 centers (2003–2009). Patients (522) with early arrival, no missing data and at least one ICU day were included. Electrical burns were excluded. Patients were stratified by age (≥16y) vs (≤15y). Logistic regression analyses were performed comparing mortality risk of the current population using standard formulae. Calibration was assessed by Hosmer-Lemeshow Goodness-of-Fit Test and discrimination by total area under receiver operating characteristic curve (AUROC). Results: Burn-specific scores are more predictive for the severely burned patients compared to the general APACHEII score among adults (AUROC increase, p<0.001 for Baux, R-Baux and ABSI for adults; p>0.05 for Baux, P-Baux and ABSI for children). Risk factor number, as established in the Ryan NEJM study performed well, especially for the population most at risk (estimated mortality % [90%CI]: 0.3 [0.1–0.6] Ryan NEJM score versus 2.0 [1.0–4.2] current study for risk factor 0; 3 [2–5] versus 8.6 [6.1–12.1] for risk factor 1; 33 [26–41] versus 30.2 [24.3–36.9] for risk factor 2; 87 [78–93] versus 66.5 [51.3–78.9] for risk factor 3). The R-Baux score had excellent discrimination and calibration, while the P-Baux and ABSI scores, although appearing to have descent discrimination, overestimated the risk of death, indicating poor calibration. Conclusions: The Ryan NEJM and R-Baux models tested well for validity in critically burned patients outperforming APACHEII. P-Baux and ABSI are poorly calibrated for critically ill burn patients. We highlight challenges designing and employing scoring methods that are applicable to a wide range of study populations. Applicability of Research to Practice: The Ryan NEJM or the R-Baux are appropriate mortality models for severely burn injured populations. External Funding: U.S. Army Medical Research Acquisition Act of U.S. Department of Defense DM103014 (W81XWH-12-2-0007). 128. Foot Burns and Diabetes: More Than Double Trouble W. Zhang, MD, P. Q. Bessey, MD, FACS, MS, A. Rabbitts, MS, RN, R. W. Yurt, MD, FACS NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY Introduction: Diabetes (DM) complicates the course and treatment of burn injury, and lower extremity burns may be especially problematic. The purpose of this study was to characterize the influence of DM on the course of patients with burns of the feet, and to relate this to pre-morbid glucose control. Methods: Patients with foot burns and DM admitted between Jan 1, 2011 and June 30, 2014 were identified. Each patient was matched with a patient of similar age, gender, and burn size but without DM. Graft loss (GL), osteomyelitis, or delayed wound healing (DWH) (open wounds remaining at least 1 month after injury), as well as number of operations, length of stay (LOS) of the primary admission, and readmissions were compared between groups. Patients with foot burns and DM admitted during 2010 were added to the primary study group, in order to determine the influence of admission Hemoglobin A1c (HgbA1c) on outcome. Results: There were 51 patients with foot burns and DM admitted during the primary, 2 ½ year study period. One patient had an extremely long admission (200 days) and was excluded. An equal number of matching, control subjects without DM were identified, but this required also including patients from 2010. The age of the DM patients was 59.8 ± 1.9 years (Mean ± SEM) compared with 60.2 ± 2.0 years in the matched controls (P=0.9). There were 37 men in each group (74 ± 6 %), and 39 and 38 patients had scald burns. Total Burn size was similar (2.9 ± 0.5 vs 3.8 ± 0.8 % BSA, P=0.34). Admission glucose was almost twice as high in DM than in control (203 ± 14 vs 116 ± 5, P<0.01). More patients in DM than in controls required surgery (37 and 31, respectively, P=0.2). In those, there were almost twice as many operations per patient with DM (1.9 ± 0.4 vs 1.2 ± 0.1, P=0.05). There was only a slight trend toward longer LOS at the initial admission in DM (16.2 ± 1.4 vs 14.4 ± 1.7 days, P=0.4). The incidence of wound infection was similar (42 and 38 %), but DWH, GL, and Osteomyelitis were more frequent in DM (22 ± 6 vs 8 ± 4 %, P=0.03; 16 ± 5 vs 2 ± 2 %, P=0.01; 12 ± 5 vs 2 ± 2 %, P=0.05). There was a trend toward higher readmissions in DM (12 ± 5 vs 6 ± 3, P=0.16). Of the 67 patients in the larger group, 37 % had an established complication of DM and 43 % took insulin daily. The admission HgbA1c was 8.8 ± 0.3, and ranged from 4.8 to 15.7. DWH was more than twice as common in 24 patients with HgbA1c of 9 or more than in those with lower levels (38 ± 10 % vs 16 ± 1 %, P=0.04). HgbA1c was a significant predictor for DWH (Odds Ratio 1.27 ± 0.14, P=0.02). Conclusions: Burns of the feet are morbid injuries in all patients. In this review they were associated with more than twice the complication rate in patients with DM compared with non-diabetics. The risk of delayed wound healing in these patients may be further exacerbated by inconsistent glucose control prior to injury. 129. Comparing the Workload Perceptions of Determining Patient Condition and Priorities of Care Between Burn Providers in Three Burn ICUs S. Murray, MSN, RN, M. L. Serio-Melvin, MSN, RN, J. K. Aden, PhD, E. A. Mann-Salinas, RN, PhD, K. K. Chung, MD, T. Huzar, MD, S. E. Wolf, MD, FACS, C. Nemeth, PhD, J. C. Pamplin, MD USAISR, JBSA Fort Sam Houston, TX; Memorial Hermann Hospital Texas Medical Center, Houston, TX; University of Texas — Southwestern Medical Center, Dallas, TX; Applied Research Associates, Inc., Fairborn, OH Introduction: Multidisciplinary rounds (MDR) in the Burn Intensive Care Unit (BICU) serve as an efficient means to review patient status and plan care. To do that, clinicians must identify patient condition and determine care priorities. Both require cognitive work that clinicians often do not recognize. We sought to characterize clinician subjective sense of cognitive workload while completing these tasks, using the National Aeronautics and Space Administration Task Load Index survey (NASA-TLX). This survey assesses and summarizes the perception of workload on five 7-point scales (mental, physical, temporal, performance, effort and frustration). Methods: Research staff at 3 academic regional referral centers administered the NASA-TLX to clinicians during MDR. Surveys were administered immediately after MDR was completed for a single ICU patient. Clinicians assessed their workload associated with 1) “Identify[ing] if the patient is better, same, or worse than yesterday” and 2) “Identify[ing] the most important objectives of care for the patient today.” Data were collected on clinician type, years of experience, and hours of direct care of patient. Results: Surveys were administered to 154 total clinicians (Site 1: 64, Site 2: 62, and Site 3: 28). There were a total of 17 patient rounds assessed by 21 staff physicians (Site 1: 13, Site 2: 1, Site 3: 7), 27 nurses (Site 1: 11, Site 2: 6, Site 3: 10), 17 residents (Site 1: 8, Site 2: 3, Site 3: 6), 35 in other roles (Site 1: 8, Site 2: 11, Site 3: 16), and 13 students (Site 1: 13, Site 2: 0, Site 3: 0). Clinicians with less than 5 years of experience reported significantly more work for both tasks than those with more experience (p<.0001). Clinicians in the other group (respiratory therapists, dieticians, pharmacists, etc.) reported more work than all other groups for both tasks (p<.0001). Institution and hours of care did not influence the perception of workload for either task. Conclusions: The work of identifying patient condition and treatment priorities varies according to clinician type and experience level, but not by institution or the time spent caring for a patient. Applicability of Research to Practice: Identifying patient condition and treatment priorities may affect workflow, decision-making, communication, and teamwork. Understanding how various clinical roles perceive cognitive workload differently could improve clinician and team performance. External Funding: US Army Medical Research and Materiel Command Telemedicine and Advanced Technology Research Center (TATRC) (W81XWH-13-2-0011). 130. A Comparison of Diabetic and Non-Diabetic Burn Patients K. Ubesie, MD, M. J. Feldman, MD, A. Feghali, MD, S. Rekhtman, MPH Virginia Commonwealth University Medical Center, Richmond, VA; Institution Lincoln Medical and Mental Health Center, Bronx, NY Introduction: Diabetes mellitus (DM), known to be one of the major medical diseases in the world, is prevalent amongst patients that have suffered a burn injury. It is also known that uncontrolled DM may severely prolong wound healing and increase a patient's susceptibility for infection. The purpose of this study is to determine significant correlations between diabetes mellitus and clinical outcomes of burn patients as means to help manage these patients and provide a method for counseling diabetic burn patients about their expected course. Methods: We performed a retrospective review of 145 burn patients with diabetes, who were admitted over a five-year period. We collected demographic information including age, gender, race, hospital length of stay (LOS), number of days required for mechanical ventilation, mortality, co-morbidities, nicotine abuse, procedures, and presence of major clinical complications. This data was compared to 953 burn patients without diabetes who had similar age and TBSA. The control patients were treated at the same institution during the same period of time. Results: Out of a total of 1,098 burn patients with ages ranging from 18 to 35 years, 145 had diabetes (DM) and 953 did not have diabetes (non-DM). The range of total body surface area burned (TBSA) was from 0.1% to 93% with the average being 6.2%. Of the DM vs. non-DM patients: 49 (34%) vs. 312 (33%) were female, 96 (66%) vs. 641 (67%) were male, 65 (45%) vs. 344 (36%) were African American, 72 (50%) vs. 519 (54%) were Caucasian, and 8 (5%) vs. 89 (9%) were of other race. Mortality for DM vs. non-DM was 8 (5.5%) vs. 29 (3%). A logistic regression was used to analyze the compiled data for mortality (p_value 0.5560) and complications (p_value 0.0572). An ancova regression was used to analyze the compiled data for the ventilator days (p_value 0.0138) and hospital LOS (p_value <0.001). All above data was adjusted for significant co-factors: age, TBSA, gender, race, inhalation injury, smoker, hypertension, alcohol, and etiology of burn. Conclusions: When comparing compiled data for DM vs. non-DM burn patients after adjusting for significant co-actors, it is found that mortality, clinical complications, and ventilator days are not significant for diabetic burn patients when compared non-diabetic burn patients. However, the hospital LOS for diabetic burn patients is significantly longer than non-diabetic burn patients. Applicability of Research to Practice: Majority of the burn literature that involves diabetic mellitus focuses on wound management and/or infection risk. This is a large study in a controlled environment that focuses on major clinical outcomes in diabetic burn patients vs non-diabetic burn patients. The results of this study will contribute to the continuously evolving clinical management of burn patients in efforts to continue to achieve optimal outcomes. 131. Revised Baux Score Predicts Risk for Hospital-Acquired Infections after Burn Injury D. Van Duin, MD, PhD, S. W. Jones, MD, A. Fokar, MPH, A. M. Lachiewicz, MD, MPH, L. M. DiBiase, MS, C. S. Hultman, MD, S. Napravnik, PhD, D. J. Weber, MD, MPH, B. A. Cairns, MD, FACS University of North Carolina at Chapel Hill, Chapel Hill, NC Introduction: Hospital-acquired infections (HAI) remain an important source of morbidity and mortality in burn patients. Here, we describe the relationship between a revised Baux score (RBS) and HAI risk after burn injury. Methods: A retrospective single center cohort study was performed at an academic burn center. All patients admitted between 2004 and 2013 with a burn injury were included. Clinical data including burn characteristics were obtained from the local burn registry and the electronic medical record. HAIs were ascertained following Centers for Disease Control and Prevention criteria in real-time by infection preventionists. Time to HAI was compared between groups of patients with low (<60) vs. high (≥60) RBS using log rank test and for RBS components using Cox proportional modeling. Results: During the study period 6,222 patients were admitted with burn injuries. The median age was 31 years (interquartile range [IQR] 11–49), 4,266 (69%) were male, 3,046 (49%) were white. Overall all-cause hospital mortality was 214/6,222 (3.4%). The median percentage of total body surface area (%TBSA) was 4.5 (IQR 2–10), 425 (6.8%) patients had inhalational injury. The median RBS was 39 (IQR 19–58), corresponding to a median mortality risk of 0.3% (IQR 0.1%-1.3%). 368 (5.9%) of patients developed a HAI; 54 (0.1%) vascular infections, 105 (1.7%) respiratory tract infections, 68 (1.1%) urinary tract infections, 129 (2.1%) skin and soft tissue infections. Median time to first HAI was 6 days. RBS was associated with HAI risk; 113/4,676 (2.4%) patients with a low RBS vs. 255/1,546 (16.5%) patients with a high RBS developed any HAI (p<0.0001). RBS was also associated with time to first infection (p=<0.0001 by log-rank, Figure). In multivariable Cox proportional hazards analysis, all RBS components including age were independently associated with time to HAI. Burn size was most strongly associated with time to HAI; using <2% TBSA as the reference group, the hazard ratios (HR) for 2–4.5%, 4.6–10%, and >10% TBSA were 1.42 (95% CI 0.64–3.12, p=0.39), 3.83 (95% CI 2.05–7.14, p<0.0001), and 12.02 (95% CI 6.71–21.53, p<0.0001). The HR for inhalational injury was 1.73 (95% CI 1.36–2.19, p<0.0001). Conclusions: Patients with a revised Baux score ≥60 on admission are at high risk for hospital-acquired infection. Applicability of Research to Practice: These findings may guide directed strategies to decrease the number of infections in burn patients. External Funding: Supported by Award Number UL1RR025747 from the National Center for Research Resources. View largeDownload slide View largeDownload slide 132. Non-Invasive Stroke Volume Measurement During Acute Burn Fluid Resuscitation A. Bettencourt, MSN, RN, CCRN, W. J. Mohr, MD, FACS, L. Stuck, MS, A. Muhar, MS, D. H. Ahrenholz, MD, FACS Shriners Hospitals for Children Boston, Boston, MA; Regions Hospital Burn Center, St. Paul, MN Introduction: Effective fluid resuscitation is one of the cornerstones of modern burn care, but determining optimal resuscitation can be challenging. Traditional endpoints used have been urine output (UO) and mean blood pressure (MAP). Studies using cardiac output and index, oxygen delivery and consumption, and base deficit and lactate have resulted in increased IV fluid (IVF) administration without improvements in burn outcomes. Changes in Stroke Volume Index (SVI) and Stoke Volume Variation (SVV) in the hypovolemic individual (SVI < 33 and a SVV> 12%) have been shown to predict fluid responsiveness in some patient populations but has not yet been studied in burn patients. The purpose of this study was to determine if SVI and SVV, measured by a non-invasive cardiac output monitor (NICOM), correlates with traditional endpoints to predict the need for increased IVF during resuscitation. Methods: This was an IRB approved, prospective, blinded, observational study of patients ≥ 18 years old with >20% TBSA burns. The NICOM device was applied during the acute resuscitation and hemodynamic data were recorded every minute, stored on a memory device, and analyzed using standard Receiver Operating Curve (ROC) methods. Our standardized Nurse Driven Resuscitation Protocol, which titrates IVF based on hourly UO, MAP, and central venous pressure was used. Median SVI and SVV measurements in the hour prior to a patient recording of low UO were analyzed to determine their ability to predict such episodes. A ROC curve was plotted with confidence bounds, as well as the area under the curve (AUC) and its confidence interval. Potential thresholds for SVI and SVV were assessed for sensitivity and specificity. Results: This study included 20 patient resuscitations. In spite of chest wall burns, we were able to successfully obtain measurements from the skin sensors on all patients. SVI ROC analysis estimated an AUC of 67.6% (95% CI: 61.3%-73.8%), representing a moderate-low ability to predict an upcoming low UO. SVI values between 22.5 and 28.5 had both sensitivity and specificity >50%, with specificity reaching 75% for an SVI of 22. The SVV ROC analysis showed a low ability to predict low urine output (AUC=60.3% [53.7%-66.9%]. Conclusions: SVI below 33 does not predict need for increased IVF in the burn patient. A SVI < 22 would intervene early in half, while overtreating a quarter of the patients. Despite evidence in the literature to support the use of SVV in fluid resuscitation, SVV was not able to predict patients with low upcoming urine outputs as well as SVI in this patient population. Applicability of Research to Practice: SVI may provide useful data for burn resuscitation, but further research to determine better thresholds for intervention is warranted. 133. Boomtown: Analysis of Burn Injuries from the Bakken Oil Industry W. J. Mohr, MD, FACS, E. Null, BS, A. R. Morris, BS, M. B. Moseley, RN, S. S. Wewerka, MPH, J. G. Salzman, MA, F. W. Endorf, MD, D. H. Ahrenholz, MD, FACS Regions Hospital, St. Paul, MN Introduction: Increased oil production in the Bakken shale formation has resulted in a large number of serious work-related burn injuries. The purpose of this study is to compare patient demographics, burn characteristics, and outcomes of patients employed by the oil industry (OIL) to those not oil related (NO) admitted to a regional burn center. Methods: This is a retrospective observational study of patients admitted to our ABA verified Burn Center between July 2007 and October 2013. To accommodate the statistical analysis plan, we selected control patients (NO) in a 5:1 ratio for comparison. Patient demographics, treatment characteristics, and patient outcomes were abstracted. All variables were summarized and compared between groups using unadjusted Student t-tests for continuous variables, Chi-squared test, Fisher's Exact test, and Wilcoxon ranked-sum tests as appropriate for categorical variables. Results: A total of 184 patients (32 OIL, 148 NO) were included. OIL patients were significantly younger (38.0 ± 11.8 vs. 45.3 ± 18.4 years; p = 0.006), male (100% vs.75.4%; p < 0.001), burned due to an explosion (66% vs. 9%; p < 0.001), and had a higher median [IQR] %TBSA (22% [5%-24%] vs. 5% [3%-10%]; p = 0.006). A higher proportion of OIL patients underwent prehospital intubation (59% vs. 17%; p <0.001) and required continued burn center ventilation (41% vs. 18%; p = 0.004), but there was no difference in the median number of ventilator days (6 [2–11] vs. 2.5 [2–12]; p = 0.67). The OIL injured patients had a higher median [IQR] number of operations (1 [0–2] vs. 0 [0–1]; p = 0.02), and were more likely to experience at least one surgical complication (50% vs. 22%; p = 0.001) than the NO group. Both groups demonstrated a similar survival rate (OIL = 94%, NO = 97%; p = 0.61), but oil field patients had a much higher median hospital length of stay (13.5 [3–40] vs. 4 [1–13] days; p < 0.001). Conclusions: Injuries as the result of oil related activities have different demographic, treatment, and outcome characteristics compared to the general burn population. These patients are more severely burned, undergo more surgical procedures, require ventilatory support more often, use more intense in-hospital resources, and experience complications in greater numbers. Education and support for hospitals located near oil fields but hundreds of miles from definitive burn care is critical for initial resuscitation, and advanced planning to accommodate the small volume but resource intensive care required at regional burn centers should be considered. Applicability of Research to Practice: Detailing characteristics of this specific burn mechanism will allow for better prehospital stabilization and ultimate functional outcome for these patients. 134. Oil-Related Burns during Hydraulic Fracturing M. P. Rowan, PhD, J. F. Williams, PA-C, MPAS, J. B. Lundy, MD, B. T. King, MD, K. K. Chung, MD U.S. Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX Introduction: Growing population and energy demand have led to increased production of fossil fuels, most notably natural gas from shale reserves, which is predicted to replace coal as the primary fuel source for future electricity generation. The identification of rich supplies of shale and recent advancements in natural gas extraction, such as hydraulic fracturing, have fueled an increase in the production of natural gas. Workplace injuries resulting from hydraulic fracturing would be expected to accompany a larger workforce, but data are often limited or underestimated. Methods: Since 2011, we have seen a substantial increase in the number of thermal injuries secondary to hydraulic well fracturing at our regional burn center. Results: A total of 19 cases presented to our regional burn center over an approximate three year period. Patients were predominantly male and ranged from 20 to 68 years old, with a median age of 32. Injuries were sustained in a variety of manners, including burns from fire, scalds, chemical burns, and explosions. Extent of burn ranged from 1% to 67% TBSA, with a median of 14% TBSA and an average of 28% TBSA. Approximately half the patients required ICU stay, and those undergoing surgery required from 1 to 26 operations. The majority (90%) of patients survived to discharge. Conclusions: As demand for cleaner energy continues to fuel the production of natural gas, investigation and attention are needed into the types and prevalence of injuries sustained during hydraulic fracturing. This initial report characterizes a variety of injuries at our regional burn center, and highlights the need for collaborative efforts describing regional and statewide oil-related injuries. Applicability of Research to Practice: Identification of risk factors associated with the extraction and production of oil and natural gas may help to prevent future injuries in a rapidly growing industry. 135. ISBI Disaster Committee Report on Burn & Soft Tissue Trauma Mass Casualties: Steps in Preparedness L. Rosenberg II, MD ISBI Disaster Committee*, Chairman, ISBI, Israel Introduction: Disasters involve large numbers of burn/soft tissue trauma victims (cared for by the same personell and facilities) that is beyond the coping ability of local and sometimes national facilities. This presentation summarizes the ISBI Disaster Committee* discussions presented at the Disaster Symposium, Sydney 2014, aiming to develop a systematic approach for such mass casualty preparedness efforts. Methods: The anticipated flow, conditions and resources needed for the burn victims from the site of disaster through their complete recovery with potential bottlenecks were defined and potential solutions were reviewed. Drafts of this program have been presented and reviewed several times by the Committee members and attendees of the ISBI 2012, SIUST 2012, EBA 2013, IPRED III 2014 and ISBI 2014 congresses and modified accordingly. Results: The same personell and resources will be needed to treat burn and soft tissue injuries in most centers. Three response levels were recognized: Burn center level: individual patient care, Hospital level: support for the burn center, and Regional/national level: support for the hospital by providing/mobilizing manpower, resources, and supplies. The committee concentrated on the burn center/hospital levels and actual patient care. The 8 potential major bottlenecks in a disaster scenario were defined in the domains of: (1) highly trained personnel (surgeons, nurses, OR staff,), (2) surgical facilities (operating rooms, blood banks etc.), (3) space, beds & infrastructure (water, power, etc.) and, (4) supplies (dressings, medications etc.). Creative approaches for handling these bottlenecks are presented. The most challenging bottlenecks are dependencies on highly trained surgical teams and facilities that require years of preparation and massive investments in manpower and technology. None of these can be improvised in a disaster where similar resources are needed for simultaneous care of other trauma. Conclusions: Burn mass casualty disasters will require the same resources to simultaneously treat other soft tissue trauma. Preparedness should focus on solutions that relieve the principle patient care bottlenecks: from stock piling and space allocation to reducing dependency and replacing scarce resources such as highly trained surgical burn teams and surgical facilities. The authors appeal to continue and comment on any issue, submitting it to us to be merged into the final ISBI document. *Committee Members:Adam Singer(USA), Sidney Miller(USA), James Jeng(USA), Alessandro Masellis(MBC, WHO), Alan Kay (NATO-UK), Fiona Woods(Australia), Saidur Rahman Mashreky(Bangladesh), Richard E Nabuko(Nigeria) Applicability of Research to Practice: Development of burn disaster guidelines will help improve outcomes in mass casualties. 136. Effectiveness and Safety of Enoxaparin Prophylaxis Dosed by a Predictive Equation in Burn Patients S. S. Mudahar, PharmD, M. Miller, PharmD, S. Pollard, PharmD, A. O'Connor, MS, ANP, BC, L. J. Gottlieb, MD, FACS John H. Stroger, Jr. Hospital of Cook County, Chicago, IL; University of Chicago Medicine, Chicago, IL; University of Washington Medicine, Seattle, WA Introduction: Standard dosing of enoxaparin in acute burn patients has been shown to be inadequate in achieving prophylactic anti-factor Xa levels. Such findings led to the development of a predictive equation ({22.9 +[3.3 X (TBSA/10)] + [1.89 X (Weight/10)]} Q12H) to calculate an initial enoxaparin dose to reach a prophylactic anti-factor Xa level more effectively. Methods: This single-center, prospective, observational study evaluated the effectiveness of a predictive equation in calculating an appropriate initial prophylactic enoxaparin dose in adult acute burn patients admitted to a burn center between April 2013 and April 2014. Patients received an individualized dose of enoxaparin based on the predictive equation. An anti-factor Xa level was drawn after the third consecutive enoxaparin dose. If necessary, enoxaparin doses were adjusted by 20% increments to achieve goal prophylactic anti-factor Xa levels. The primary endpoint was the effectiveness of the predictive equation in achieving a prophylactic anti-factor Xa level of 0.2 - 0.4 IU/mL. Secondary outcomes included the incidence of venous thromboembolism (VTE) and adverse events. Results: Of the 329 patients screened, 34 patients met the inclusion criteria and received the protocolized dose of enoxaparin. Twenty-one patients (62%) achieved a goal anti-factor Xa level with the initial calculated enoxaparin dose and 26 patients (76%) achieved a goal anti-factor Xa level after one dose adjustment. The mean enoxaparin dose required was 40 mg SQ BID. One patient developed a VTE despite achieving a therapeutic anti-factor Xa level after one dose adjustment. There were no episodes of major bleeding. Conclusions: The enoxaparin predictive equation effectively achieves prophylactic anti-factor Xa levels in acute burn patients with no associated major bleeding events. Applicability of Research to Practice: Acute burn patients are at high risk for the development of deep vein thrombosis, and due to their unique pharmacokinetic and pharmacodynamics profiles, patients require significantly higher doses of enoxaparin to provide adequate DVT prophylaxis. 137. Use of Tranexamic Acid in Burn Excision and Grafting Procedures: A Case Series W. J. Mohr, MD, FACS, J. G. Salzman, MA, A. E. Zagar, BS, F. W. Endorf, MD, D. H. Ahrenholz, MD, FACS Regions Hospital / U of Minnesota, St. Paul, MN; Regions Hospital, St. Paul, MN Introduction: Blood loss associated with tangential excision (TE) is substantial, with estimates ranging between 0.5–1 mL for every 1 cm2 or 5–11% of the blood volume per 1% BSA of burn skin removed. This amount can be reduced by using tourniquets, but 26% to 50% (BMI > 40) of the body's surface is contained on the trunk and is out of reach of these devices. Tranexamic acid (TXA) is a lysine derivative that blocks the lysine site on plasminogen and inhibits fibrinolysis. This agent has been shown to decrease death from hemorrhage in trauma patients. We sought to determine if the use of TXA could decrease operative blood loss in the excision of truncal burns. Methods: This was a retrospective, observational case series of burn patients ≥ 18 years old treated at our ABA verified burn center who required excision of truncal burns as part of their staged reconstruction. A 1 gm dose of TXA was given over 10 minutes at the time of incision, and no continuous infusion was used. Patient demographic information and operative variables were abstracted and summarized. The estimated EBL was calculated using the Gross equation and compared to two EBL prediction formulas: Warden and Steadman. Results: From June 2013 - April 2014, there were 8 patients included in this pilot study, ages 18–59. Patients underwent TE with placement of a dermal replacement product between postburn day 1–5 (mean 3 days). The average TBSA burned was 32% (15–61%), with a mean excision of 2713 cm2 (1700–5250 cm2) or 13% BSA (8.5–26.1%). Patients received an average of 3,525 mL fluid intraoperatively (2200–5900 mL). Only 2 of 8 patients received transfusions within 24 hours of their operation, averaging 0.63 U per patient). The median post-operative hemoglobin drop was 5.7 g/dL to a value of 7 g/dL the following day. The calculated EBL was 1.1 mL/cm2 and 141 mL/%TE. This compares favorably with the Warden (110%) and Steadman (63%) estimates. There were no episodes of venous thromboembolism. Conclusions: Blood loss associated with burn excision of the trunk after TXA was similar to that described in the literature using tourniquets and subcutaneous infiltration with vasoactive agents. Perioperative transfusion was performed in only a quarter of these patients despite an average excision of 2713 cm2 (13% BSA). There were no episodes of VTE diagnosed during their hospitalization. A multi-center randomized trial would be necessary to determine a true benefit. Applicability of Research to Practice: This agent may be effective in reducing the blood loss during excision of areas not amenable to other adjuncts, such as tourniquets and clysis. 138. Surgeon-Performed Hemodynamic Transesophageal Echocardiography in the Burn ICU J. M. Held, MD, J. Litt, DO, J. Kennedy, MD, S. McGrane, MBChB, FRACS, O. L. Gunter, MD, L. Rae, MD, S. A. Kahn, MD Vanderbilt University Medical Center, Nashville, TN Introduction: Transesophageal echocardiography is usually performed by cardiac anesthesiologists or cardiologists and is not widely used in burn resuscitation. This study reports a novel series of surgeon-performed hemodynamic TEE (hTEE) using a less invasive 19-Fr probe and assesses the accuracy of the operators' interpretations. Methods: Records of patients treated in a regional burn ICU who underwent bedside hTEE (ClariTEE®, Imacor Inc, NY) between 10/12–5/14 were reviewed. Surgical critical care fellows performed hTEE on each of the patients to clarify volume status and R/L heart function when transthoracic windows were limited. The fellows' bedside interpretations were retrospectively verified for accuracy by a cardiac anesthesiologist who was blinded to initial read and clinical info. Results: Eleven patients were included with 29 series of images. Median age was 68.5 years (IQR:49.5–79.5) with 37%TBSA(IQR: 16.3–53%) burn. Four pts suffered inhalation injury. The operator's interpretation matched that of the cardiac anesthesiologist in 29/29 hTEEs. No complications were associated with probe placement. Hypovolemia was diagnosed in 3 patients, changes in volume status on hTEE preceded changes in urine output for two of these patients during acute resuscitation for burn shock. Fluid overload with adequate contractility was diagnosed with hTEE in a patient with grade 4 inhalation, requiring VV-ECMO. He was aggressively diuresed and ECMO was weaned. hTEE diagnosed cardiogenic shock in 7 older patients; 3 had LV dysfunction, 3 had RV failure, and 1 had biventricular dysfunction. hTEE was used to titrate fluids, pressors, inoptropes, and diuretics with at least transient improvement in cardiac function for 6/7 patients. Five patients died during hospitalization. Conclusions: hTEE is a useful adjunct to the difficult burn resuscitation when transthoracic echocardiogram windows are limited. Surgeons can accurately determine volume status, ventricular function, and use hTEE to guide treatment. The role of TEE in routine burn resuscitation need to be further studied. Applicability of Research to Practice: hTEE may help with burn resuscitation. 139. Blood Product Transfusion in Pediatric Burn Patients: What, Where, and Why Impact Mortality E. H. Teo, MD, S. Sen, MD, FACS, D. G. Greenhalgh, MD, FACS, T. L. Palmieri, MD, FACS, FCCM Shriners Hospital for Children Northern California and the University of California Davis, Sacramento, CA Introduction: Packed red blood cell transfusion (PRBC) has been linked to increased mortality and complications in critically ill patients, including children. However, outcomes related to other blood product components, such as fresh frozen plasma (FFP) and platelets (PLT), are less clear. Additionally the influence of the medical setting (ICU vs. operating room) for these transfusions is mostly unknown. We hypothesized that blood product component transfused as well as the medical setting would influence outcomes in burned children. The purpose of this study is to evaluate the impact of PRBC, FFP, and PLT administration as well as the setting of transfusion on mortality in burned children. Methods: Data were collected retrospectively from all pediatric burn patients admitted from 2006–14 with total body surface area (TBSA) burn ≥20% who received blood product transfusion. Data were collected on demographics, injury characteristics, and outcomes. Multivariate logistic regression for death was performed adjusting for age, TBSA, inhalational injury, number of operations, and ventilator days. Values are expressed as mean ± standard deviation. Results: A total of 383 patients were included in data analysis. Non-survivors (n=30) had larger burns than survivors (62.4 ± 17.5% vs 33.5 ± 19.1% TBSA, p<0.0001), higher incidence of inhalation injury (67% vs. 17%, p<0.0001), and received more units of all blood product components (PRBC 25.3 ± 26.7 vs. 8.9 ± 13.5 units, FFP 13.6 ± 16.2 vs. 2.6 ± 4.9 units, PLT 8.3 ± 11.6 vs. 0.37 ± 1.1 units, p<0.0001 for all components). Intraoperative transfusion of PRBC did not increase mortality. However, patients transfused with PRBC in the burn unit had a higher likelihood of death OR 1.21 (95% CI 1.05–1.4). Similarly, patients given FFP in the operating room had no difference in mortality but did have increased mortality when FFP was administered in the burn unit OR 1.15 (95% CI 1.01–1.31). PLT transfusion was associated with increased mortality in all hospital settings: OR 2.8 (95% CI 1.6–4.7) during total hospital admission, OR 4.4 (95% CI 1.9–10.2) during burn unit stay, and OR 2.35 (95% CI 1.3–4.3) with intraoperative transfusion. Conclusions: The amount of blood component transfused and setting of administration influences survival of burned children. Intraoperative transfusions are due to blood loss from burn excision and are well tolerated by patients. However, ongoing transfusion outside the operating room represents more complex changes in patient physiology, portending a worse prognosis. Applicability of Research to Practice: This study adds to the available evidence optimizing use of blood products to maximize patient outcomes. 140. A Preliminary Study of Transfusion Practices in Burn Patients in Ukraine: A Multihospital Experience G. Fuzaylov, MD, C. Homsy, MD, D. N. Driscoll, MD Massachusetts General Hospital/Shriners Burn Institute, Boston, MA; TUFTS Medical Center, Boston, MA Introduction: Burns are a major cause of injuries worldwide, and the 3rd leading cause of death in children in the developing world. In burn care, blood transfusion is a common practice. It is, however, associated with significant risks. The objective of this paper is to look at transfusion practice in burn patients and assess the associated risks by measuring clinical outcomes of wound infection, sepsis and mortality as an effort to improve burn care in Ukraine. Methods: A retrospective multicenter cohort analysis (2010–2013) of burn patients admitted to twenty hospitals including a burn center in one province in Ukraine was performed. Data was collected from hospital medical record and transfusion journal by burn surgeons in Lviv and audited by Chief of Burn Center in Lviv. The study included 1760 patients: 81 patients required transfusion and 1679 did not. The patient demographics and burn characteristics (type, total body surface area) were examined as well as three major complications (infection, sepsis and death). Statistical analyses with Student's T test, Fisher's exact test and Chi-square test were used for comparison. This work was approved by the Partners Human Research Committee (Protocol Number: 2012P000913) and by the Chief of the Burn Services in this province in Lviv, Ukraine. Results: Transfused patients had larger burns (22.9 ± 16.8 vs 2.6 ± 5.0, %TBSA). Also 23% of transfused patients were 5 years old and younger. Furthermore, 22% of the transfused had a TBSA <10%. Wound infection was more prevalent in the transfused group: 40% in the transfused vs 15% in the non-transfused, (p<0.001). Sepsis was noted in nine patients of the transfused group in comparison to 2 patients in the other group (p<0.001). Finally, mortality was significantly higher in the transfused group 14% vs 1% (p<0.001). Conclusions: This study points to areas of interest in blood transfusion in burns in Ukraine and the need to study indications and transfusion policies. Of particular interest is the surgical technique for patients with less than 10% TBSA burns requiring transfusion. Applicability of Research to Practice: This project is the foundation for further studies, to better understand transfusion practices and therefore develop new transfusion protocols in Ukrainian burn centers. We believe that standardization of transfusion indications will result in improved patient care and better understanding of burn management. View Large View Large 141. TRALI Following Fresh Frozen Plasma Resuscitation from Burn Shock N. G. Deluga, BS, R. A. Coffey, MSN, CNP, N. V. Brown, MS, P. S. Bhatti, L. M. Jones, MD, FACS The Ohio State University Medical Center, Columbus, OH Introduction: In 1992, Du et al. described resuscitation from burn shock using fresh frozen plasma (FFP). 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: With IRB approval, a retrospective chart review was conducted of patients admitted to our verified burn center between February 1, 2006 and June 30, 2013 and who received resuscitation with FFP. Data points included age, sex, TBSA, FFP administration (time and volume), presence and cause of acute lung injury (ALI) prior to FFP and laboratory and radiographic data. Patients with inhalation injury, left heart failure, ALI, aspiration, pulmonary contusion, and/or pneumonia, all prior to FFP, were excluded. The NHLBI Working Group Consensus definition of TRALI was used. Results: A total of 83 patients received resuscitation with FFP. Sixty-five met exclusion criteria. Of the 18 patients remaining for analysis only 2 (2.4%) demonstrated findings consistent with the definition of TRALI. Differences in the groups were for age (45.89 no TRALI, 57.89 TRALI), % 2nd degree burn (23.25 no TRALI, 44.25 TRALI) and % 3rd degree burn (32.5% no TRALI and 10% TRALI). Because of small sample size, reliable p values for these differences could not be calculated. No differences were noted in TBSA (55.16 no TRALI, 54.25 TRALI). Both patients with TRALI died. One patient developed TRALI after receiving 3006 cc of FFP, was extubated on post burn day 3 and died on post burn day 11 from sepsis. A second patient developed TRALI after receiving 3350 cc of FFP and died on post burn day 27 following an acute myocardial infarction. Conclusions: TRALI occurs in a small percentage of critically ill burned patients receiving FFP resuscitation, however the occurrence is so small that it should not deter clinicians from using FFP resuscitation. Applicability of Research to Practice: Supports interest in colloid resuscitation. 142. Cholecystitis and Percutaneous Cholecystostomy Tube Placement in Burn Patients at a Single Institution: Indications, Outcomes, and Trends in Placement. P. Diegidio, MD, S. Ortiz-Pujols, MD, H. Yu, MD, A. J. Isaacson, MD, B. A. Cairns, MD, FACS, C. S. Hultman, MD, MBA, FACS University of North Carolina, Chapel Hill, NC Introduction: Acalculous Cholecystitis is a potentially life threatening complication of critical illness. Burn Patients are susceptible to this disease process and it can be rapidly fatal if left untreated. To date there is little known about the efficacy of Percutaneous Cholecystostomy Tube (PCT) placement in this population. We reviewed our patient population to better define this disease process and its outcomes after placement. Methods: Patients who had a PCT placed by the Interventional Radiology (IR) department over the last 10 years were identified using the IR database, and were then cross referenced with the institutional ABA burn registry to define our cohort. A post-hoc review of these patients was performed to extrapolate data for analysis. Results: A PCT was placed in 21 patients being treated in the burn center for skin disorder. Fifteen patients had thermal injury, 4 patients had SJS/TEN, and 2 patient had traumatic injuries with some associated burns or degloving. Average age was 49, average length of stay was 102 days, average time in ICU was 97 days, with 90 average vent days, the average TBSA was 47.8; 80% of the burn patients had inhalation injury, average Baux score was 104.5, the mortality rate was 66.7%. The average length of drainage of the PCT was 70 days. All patients had some degree of dilatation, wall thickening, sludge, and or pericholecystic fluid. Five patients had incidental stones on ultrasound. Thirteen of the 21 patients had negative bile cultures, 7 of the 21 did not have a culture performed, and 1 SJS/TEN patient had Enterobacter and Pseudomonas. Two-thirds had burns or injury at or near placement site. Average number of transfusions prior to PCT placement was 18.5. The average time to defervescence was 29.6 hours in 6 patients, the remainder did not respond. Defervescence did not predict survival, as 4/6 of these patients eventually died. Twelve of the 21 patients were in septic shock with ongoing vasopressor requirements at time of placement. Two patients had an eventual cholecystectomy. Average follow up was 14 Months. Two-thirds of the drains were placed in the first half of the study period. Conclusions: Burn patients having PCT placed for suspected cholecystitis have a high mortality rate. Most patients in this study did not respond to decompression. Ultrasonographic findings listed above do not necessarily indicate acute biliary pathology. The gradual decline of PCT placement at our institution suggests faster diagnosis of the true source of sepsis negating the need for placement. Applicability of Research to Practice: Placement of a PCT can serve as a diagnostic adjunct to rule out the biliary tract as a source of sepsis; and as a marker for severe illness and high mortality in burn patients. 143. A Fifteen Years Retrospective Review of Acute Abdominal Compartment Syndrome in Burn Patients C. Malic, MD, FRCSC, N. Radulovic, BSc, M. A. Burnett, BSc(Hons), S. Shahrokhi, MD, FRCSC, M. G. Jeschke, MD, FACS, FCCM Sunnybrook Health Sciences Centre, Toronto, ON, Canada Introduction: Acute abdominal compartment syndrome (ACS) is a complication that may occur in patients with severe burns. The incidence of ACS in burn patients varies widely from 4.1 to 16.6%. Massive fluid resuscitation in the first 24 hours is the leading cause for ACS and yields a high mortality. There is no data about other co-founding factors that could potentially cause ACS. Methods: This is a retrospective study of burn patients who were diagnosed with ACS in the last 15 years (January 1999-December 2013). The aim of the study is to assess the incidence and the clinical outcome of burn patients who were diagnosed with ACS. Results: Over the 15-year period, 81 charts were reveiwed but only 28 patients fulfil the criteria for ACS as per WSACS definition (ACS incidence of 1.43%). The mean age was 45.4 and males were predominant (78.6%) with a mean admission weight of 82 kg. The mortality rate was 82%. The mean TBSA was 56.7% with the full thickness burn component of 41.8%. The mean arrival time to the Burn Centre was 9 hours and 25 minutes (range 1:45 to 92:30) from the time of injury. All patients were intubated, ventilated and diagnosed with inhalational injury on arrival. Upper extremities were escharotomised in 82% of the patients, followed by the chest (60.7%), whereas abdomen was found in 28.5%. The ACS was diagnosed within the 48 hours since injury, apart from 4 patients (14%) who were diagnosed after 72 hours. More than half of patients (16 patients) had laparotomy, 4 escharotomy of the abdomen and 8 of them had no surgical intervention. Three out of 5 survivors had laparotomy. Only 14 patients had albumin administration in the first 48 hours. The mean resuscitation volume for the first 24 hours in non-survivors was 9.1 ml/kg/TBSA, whereas in survivors group was 11.8 ml/kg/TBSA, with a mean urine output at 24 hours of 1.03 ml/kg/hr and at 48 hours of 0.94 ml/kg/hr. There were no statistically significant differences between the amount of sedation and opioid administered in the first 48 hours between patients from non survivors and survivors group. There was a significant difference of base excess between the two group (BE -0.53 in survivors vs -2.61 in non survivors group). Conclusions: The incidence of ACS here keeps in line with previous literature evidence and it is one of the largest cohort of patients after Van Niekerk et al study (45 patients) with a similar mortality. The resuscitation volumes were significantly in excess of the predicted volumes by Parkland formula in patients who had ACS. The urine output was on the upper end of the accepted range 0.5–1 ml/kg/hr, suggesting that over-resuscitation may have contributed to ACS development. Applicability of Research to Practice: The outcome of burn patients diagnosed with ACS, outcome after laparotomy and conservative treatment for ACS management. External Funding: Canadian Institutes of Health Research # 123336, CFI Leaders Opportunity Fund:Project #25407, NIH RO1 GM087285-01. 144. The 4T Score for Heparin Induced Thrombocytopenia in Burn Patients: Does Hitting the Target Help Select Patients for Testing? P. O. Kwan, MD, FRCSC, N. K. Tran, PhD, S. Sen, MD, FACS, MS, D. G. Greenhalgh, MD, FACS, T. L. Palmieri, MD, FACS, FCCM University of California - Davis Medical Center, Sacramento, CA Introduction: Due to the risk of venous thromboembolism (VTE), burn patients often receive heparin and low molecular weight heparin chemoprophylaxis, which can result in heparin induced thrombocytopenia (HIT). Burn patients also frequently have transient thrombocytopenia without HIT, making diagnosis problematic. In critically ill patients the 4T score (based on Thrombocytopenia, Timing, Thrombosis, and absence of other causes) predicts the pretest probability of HIT, and guides ordering of a HIT assay and concurrent changes in chemoprophylaxis. This study examined platelet dynamics following burn injury and the impact on utility of the 4T score in burn patients. Methods: A retrospective chart review was conducted for all adult (age ≥18 years) patients with burns admitted to a single burn center from 2009 to 2013. Study variables included: age, gender, inhalation injury, total body surface area (TBSA) burned, etiology, medications, platelet counts, and HIT diagnostic testing. The 4T pretest clinical scoring model of HIT was calculated based on the time course of platelet counts, with conservative intermediate scores for skin lesions and the possibility of alternate causes of thrombocytopenia used for burn patients. Student's t test was used, with values expressed as mean ± standard error, and p < 0.05 considered statistically significant. Results: There were 573 patients with ≥5 days of platelet data during admission. Using the 4T pretest 1.6% had low scores, 84.5% had intermediate scores, and 14.0% had high scores. Maximum 4T scores occurred on day 5.14 ± 0.08. Of those with a high 4T score, significantly more were on heparin (60%) than dalteparin (20%) (p < 0.001), 8% had diagnosis of HIT based on positive anti-PF4 antibody tests, and 89.1% had a return of platelets to admission levels 8.7 ± 0.3 days post nadir without a change in therapy. Admission platelet counts were similar between low, intermediate, and high 4T score groups, but those with high 4T scores had significantly larger TBSA burns than intermediate and low 4T scores (43.6 ± 2.8% versus 14.7 ± 0.6%) (p < 0.001), and a significantly higher incidence inhalation injuries than intermediate and low 4T scores (40.3 ± 5.8% versus 8.0 ± 1.3%) (p < 0.001). Conclusions: Platelet variability during the first several weeks following burn injury leads to intermediate and high 4T scores for most burn patients in the absence of HIT. Burn patients at high risk of VTE should be on chemoprophylaxis, but also have high 4T scores, limiting the utility of this tool in this subpopulation. Applicability of Research to Practice: This study suggests the 4T score should not be used as the sole guide to selecting burn patients for diagnostic HIT testing. 145. The Burn SIRS Response: How Long is Too Long? N. C. Toscano, MD, L. M. Gribelyuk, MD, MBA, D. E. Bell, MD University of Rochester Medical Center, Rochester, NY Introduction: Burn patients elicit a profound systemic inflammatory response syndrome (SIRS) after initial injury and as a result there is limitation in using this criteria to predict infection. SIRS is defined as two or more of the following: temperature (T) > 38°C or 90 beats per minute (bpm), respiratory rate (RR) > 20 breaths per minute or PaCO2 12,000/mm3 or < 4,000/mm3. We aim to determine factors that correlate with the duration of SIRS response in burn victims. Methods: This study was a retrospective chart review of adult burn patients, greater than 18 years of age, admitted to a regional burn center from 2010 -2014. Eligible patients sustained a burn, regardless of etiology, with a total body surface area (TBSA) greater than 10%, were admitted for more than 72 hours, and had a complete electronic medical record. Patients that died were excluded. The SIRS criteria including T > 38°C or 90bpm, RR > 20/min or PaCO2 12,000/mm3 or < 4,000/mm3 were evaluated for each patient. The daily average and the number of days it took each parameter to return to normal were calculated. Results: 69 patients were eligible for study inclusion between 2010 and 2014. Mean age was 41.5 and TBSA 19.1%. 23 out of 69 patients had burns over 20% TBSA. Six patients died and were excluded. The duration of meeting SIRS criteria for T, HR, RR, and WBC were 2.2, 8.8, 2.8 and 2.4 days, respectively. Paired t-tests revealed SIRS HR criteria was met for a significantly longer duration as compared with the remaining criteria (p < 0.005). These differences persisted even when patients with burns exceeding 20% TBSA were analyzed separately (p < 0.005). Analysis of variance revealed that TBSA and not age or inhalational injury, was significantly associated with meeting HR, T, and RR (p 0.05). The final linear regression analysis independent variable was paired to TBSA, which revealed the coefficients of correlation between TBSA and HR, T and RR rate were 0.65, 0.55, and 0.53, respectively. From the regressions, we derived separate formulas for predicting duration of meeting SIRS criteria for these three parameters. Overall, patients with burns exceeding 20% TBSA have an average SIRS response for HR, T, and RR lasting 16.5, 5.0 and 8.1 days. Conclusions: Our study demonstrates that TBSA positively correlates and is predictive of the duration of a SIRS response. We predict a model that will estimate the length of a SIRS response for a given TBSA. Although SIRS criteria may not be predictive of infection initially, the failure of SIRS criteria to resolve after a given time period as defined by our model should raise concern for an underlying infectious etiology. Applicability of Research to Practice: With the profound SIRS response burn patients elicit, it is imperative to define parameters that will reliably predict infection and aid in diagnosis. 146. Severely Burned Adults Express Profound Peripheral Insulin Resistance at Time of Discharge S. Rehou, BSc(Hons), M. A. Burnett, BSc, M. G. Jeschke, MD, PhD Sunnybrook Health Sciences Centre, Toronto, ON, Canada Introduction: A hallmark of severe burns is hypermetabolism associated with insulin resistance and hyperglycemia. Despite the well-documented alterations in glucose metabolism, few studies have examined the exact changes in glucose metabolism in severely burned adults. The aim of the present study was to determine specific glucose indices post-burn via calculations from standardized oral glucose tolerance tests. Methods: Adults (age 18 ≥) with a burn injury larger than 20 % TBSA, underwent a 2-hour 75 g oral glucose tolerance test (OGTT) when their wounds were 95% healed. To measure serum glucose and insulin levels, blood samples were collected in the fasted state and at 30, 90, and 120 minutes after ingestion of a glucose load. Plasma glucose and insulin levels and insulin sensitivity indices were compared with established normal values, Insulin indices included the homeostasis model assessment for insulin resistance (HOMA-2R), quantitative insulin sensitivity check index (QUICKI), whole body insulin sensitivity (WBIS), and the insulinogenic index (IGI) were compared with established normal values. Data expressed as mean ± SD or median (IQR) as appropriate. Results: Forty-two adults, aged 45 ± 17 years and 37 ± 15% TBSA burned had an OGTT. The average length of stay was 32 (22–60) days. Glucose kinetics indicated a hyperglycemic response with 2-hour glucose levels at 157 (114–184) mg/dL. Insulin indices showed increased insulin resistance including QUICKI, IGI, and decreased estimates of β-cell function using HOMA2 (Table 1) but no impairment in insulin production. Conclusions: Severely burned adults have alterations in glucose metabolism associated with increased insulin resistance. Applicability of Research to Practice: This finding demonstrates that severely burned adult patients experience a hyperinsulinemic hyperglycemic response that can be detected by an OGTT. External Funding: Canadian Institutes of Health Research # 123336. CFI Leader's Opportunity Fund: Project # 25407. NIH RO1 GM087285-01. Physicians' Services Incorporated Foundation - Health Research Grant Program. View Large View Large 147. Hyperkalemia in Electrical Burns - Breaking a Paradigm N. Navarrete-Aldana, MD Hospital Simon Bolivar, Bogota, Colombia Introduction: Classically, hyperkalemia has been regarded as a significant expectation in patients with electrical burns. Metabolic acidosis, extensive skin lesions, the destruction of red blood cells, severe muscle damage, rhabdomyolysis, and an increased risk of developing renal failure, has been used to explain this. Given the possible additive effect of hyperkalemia to arrhythmias in electrical injury from any other causes, our goal was to determine the incidence of hyperkalemia in patients within the first 24 hours of electrical burn injury and any relationship to TBSA or muscle damage Methods: A retrospective, cross-sectional study was conducted, based on review of medical records of adult patients hospitalized in the first 24 hours post electrical injury between January 1, 2007 to December 31, 2013 in the Burn ICU of a Burns reference hospital in a middle-income country. Potassium (K+) levels tested during the first 24 hours after injury were divided into low, normal and high groups with breakpoints at 3.5mEq/L and 5.0mEq/L. To assess potential differences according to the time elapsed since the injury to the sampling time, data were grouped as follows: t1: Taken in the first 6 hours post-injury; t2: 6–12 hours; t3: between 12–24 hours. The nonparametric Kruskal-Wallis test was used to evaluate possible association of the value of K+ with the extent of thermal injury (TBSA) and severity of muscle damage as measured by creatine phosphokinase (CPK). Results: 336 patients were studied. The average age was 34.5 years (± SD: 12.8). 95.2% of patients were men (p <0.001). Low values of K+ occurred in 13.7% and normal values in 85.1%. The prevalence of hyperkalemia was only 1.2%. According to decision time, t1 reported 164 patients (48.8%), t2: 84 patients (25%) and t3 88 patients (26.2%). There were significant differences in mean K + between t1 and t3 groups (p <0.01): 3.81 (± SD: 0.45) and 4.00 (SD ± 0.43), respectively. Elevated CPK of 10.000 U/L was found in 22.6%. No association was found between the value of potassium and TBSA or the highest value of CPK Conclusions: Despite the long held belief, patients with electrical injuries where skin lesions and muscle damage is more severe rarely show clinically significant hyperkalemia. Secondly, the presence of hyperkalemia is independent of the severity of rhabdomyolysis or the extent of the burn. This is the first study that breaks the old paradigm Applicability of Research to Practice: By protocol, many institutions manage patients with generous crystalloid use and, in patients with rhabdomyolysis, use diuretics or alkalinization of urine, both of which may cause decreased K+. This study shows no contraindication to the early administration of potassium in patients with normal values at admission. 148. Hypernatremia Occurring in Burned Patients Receiving Fresh Frozen Plasma Resuscitation L. M. Jones, MD, FACS, J. K. Bailey, MD, FACS, K. Urban, MD, P. S. Bhatti, N. V. Brown, MS, R. A. Coffey, MSN, CNP The Ohio State University Medical Center, Columbus, OH; Rush University Medical Center, Chicago, IL Introduction: Hypernatremia in burned patients has been described as a marker for sepsis and mortality. In previous reports, crystalloid fluids have been used for resuscitation. No series has reported the occurrence of hypernatremia following colloid resuscitation. At our verified burn center the resuscitation of critically ill burned patients employs fresh frozen plasma (FFP) as the primary resuscitation fluid. This report describes our experience with hypernatremia using FFP for resuscitation. Methods: With IRB approval, a retrospective chart review was conducted of patients admitted to our burn center between March 01, 2006 and July 31, 2012 and who received FFP resuscitation. Data points obtained included sex, age, TBSA, presence of inhalation injury, serum sodium values, complications (number and type) and survival to discharge. ABSI was calculated for all patients. Hypernatremia was defined as a serum sodium > 145 meq/dl. Statistical analysis was performed using SAS 9.3. Results: Fifty-four patients met inclusion criteria. Twenty-nine (53.7%) displayed hypernatremia during or after resuscitation with FFP. There was no difference between the two groups (hypernatremia and no hypernatremia) regarding age, TBSA, ABSI and presence of inhalation injury. Twenty of the hypernatremic patients died (68.9%) while 14 of 25 patients without hypernatremia (56%) died (p=0.3271; OR 1.746, 95% CL 0.573 - 5.323). Pneumonia was the most common complication (35.2% of all patients). Fifty patients (92.6%) presented with inhalation injury. Of those, 27 (54%) developed hypernatremia and 14 (51.9%) developed pneumonia. Of the 23 patients with inhalation injury who did not develop hypernatremia, only 4 (17%) developed pneumonia (RR 2.98; 95% CL 1.1393 - 7.8024). In a multivariable model, there was no demonstrated relationship between hypernatremia and sepsis (p= 1.000) and death (p=0.5076; OR 1.536, 95% CL 0.431–5.472). Conclusions: While hypernatremia occurs in critically ill burned patients receiving resuscitation with FFP, it does not appear to be a strong predictor of sepsis or mortality. There may be a relationship between the occurrence of hypernatremia and the development of pneumonia in these patients. Further study of these observations in this unique patient population is warranted. Applicability of Research to Practice: Supports increasing interest in the use of colloid for burn resuscitation. 149. Patterns of Propranolol Use in Severely Burned Adults M. E. Evans, BS, S. A. Finch, BS UT Southwestern Medical School, Dallas, TX Introduction: Severely burned patients are affected by hypermetabolism associated with a hypercatecholamine state. The use of beta blockade with propranolol has been previously employed in children, effectively decreasing adrenergic stimulation and improving energy expenditure. However, the effects of propranolol in adult burn patients has not been well explained and can be associated with episodes of mild hypotension not observed in children. It was our focus to describe the pattern of propranolol use in severely burned adults and evaluate the resulting effects on the cardiovascular system. Methods: We retrospectively reviewed the electronic medical records of burned adults admitted to the regional burn center ICU between January 2011 and February 2012. We included patients with a total burn surface area (TBSA) burn greater than 20% who received propranolol orally. We recorded the initial propranolol dose, any dose changes or holds, and patient hemodynamics. Statistical analysis was performed with Sigma Plot. Results: Thirty patients out of 344 met our criteria. The mean age was 39 years (± 3 SEM) and the median TBSA burn was 31% (27, 60 [IQR]). Hospital stay was a median of 24 days (20, 51 [IQR]) with 9 (4, 27 [IQR]) median ICU days. The median propranolol start day was on day 3 (2, 4 [IQR]). Propranolol was held at least once in 23 patients with a median of 4 holds (1, 7 [IQR]). One patient had a maximum of 18 holds. Medication holds due to hypotension were documented in 13%, the remaining holds were undocumented. The dose was changed a median of 1 time (0, 3 [IQR]) and up to 5 times in one patient. Starting doses ranged from 10 to 80mg with the majority of patients, 37%, starting at 20mg. Dose was increased in 32%, and 8% of patients had a decrease in dose. The final doses ranged from 10 to 120mg of propranolol with the majority, 27%, still at 20mg. There was a statistically significant decrease in mean heart rate from 120 (± 2 SEM) prior to propranolol use to 107 beats per minute (± 2 SEM) at 2 weeks after injury (p<0.001). No patients were prescribed propranolol at discharge. Conclusions: Propranolol in severely burned adults appears to be tolerated in this retrospective review. However, there were medication holds and we infer doses were lowered due to hypotension. Overall we found that propranolol did significantly decrease heart rate in severely burned adults. Further clinical trials are required to evaluate outcomes with propranolol use in adult burn. Applicability of Research to Practice: Use of propranolol in adult burn. External Funding: National Institutes of Health award number T32GM008593. 150. Propranolol Dosing Regimen to Attenuate the Hyperdynamic Cardiovascular Response to Severe Burn Injury in Children S. Ojeda, LPN, L. Robles, LPN, P. Stevens, BS, M. M. Celis, PA-C, A. Ali, MD, O. E. Suman, PhD, C. C. Finnerty, PhD, D. N. Herndon, MD, FACS, W. J. Meyer III, MD University of Texas Medical Branch, Galveston, TX; Shriners Hospital for Children-Galveston, Galveston, TX Introduction: Propranolol has been demonstrated to effectively control the hyperdyamic cardiovascular response in children who have suffered severe burn injury. This study was performed to determine the typical dosing regimen necessary to reduce systolic blood pressure (SBP) and resting heart rate (HR) with propranolol in children surviving burn injury. Additionally, the study attempted to define age-appropriate dosing in this population. Methods: Propranolol was administered shortly after burn injury for 1–2 years in 92 children with burns covering 30–92% of the total body surface area admitted between 2006 and 2012. Titration of propranolol to meet a 15–20% reduction in admission heart rate was recorded. Propranolol was administered either every 6 hours or once daily as an extended release tablet. The following guidelines were set for the respective age groups: ≤3 years- 70–80 mm Hg, HR ≥90; 4–10 years- SBP ≥80 mm Hg, HR ≥80; 11–18 years- SBP ≥90 mmHg, HR ≥65. Vital signs were monitored and recorded throughout drug administration. SBP and HR were documented prior to each dose: if unable to meet set parameters at the time of the next dose, then that dose was held and given at the next scheduled time. Data is described as means ± standard deviation unless otherwise noted. Results: Age ranged from 5 months to 18 years in this cohort and included 28 female and 64 male children. A mean dose of 4.7 ± 2.3 (range 1.1–8.5), 4.5 ± 2.2 (range 1.9–9.7), and 2.7 ± 1.4 (range 1.2–7.5) mg/kg/day of propranolol was administered to children less than 4, 4–10, and 11–18 years of age respectively. SBP and HR ranges were found to be 72–141, 89–135, 88–147 mm Hg and 96–166, 85-149 68-144 bpm for children less than 4, 4–10, and 11–18 years of age respectively. As time post burn increased, propranolol dosing decreased. It was necessary to stop propranolol in selected patients due to aberrations in vital signs but at no time did they complain of adverse effects. Neither burn size nor gender effected dosing regimen (p>0.05). Conclusions: An average dose of propranolol of 4.6 mg/kg/day was effective in controlling SBP and HR following burn injury in prepubertal children. Thereafter, children older than 10 years required a lower dose (2.7 mg/kg/day) to achieve the same effect. Propranolol seems to be effective and safe in the management of cardiovascular aberrations following severe burn injury in children. Applicability of Research to Practice: This dosage analysis can be used as a guide for propranolol dosing in children with hyperdynamic cardiovascular changes post burn injury. External Funding: NIDRR (H133A070026, H133A70019); NIH (R01-GM56687,T32-GM8256). 151. Survey of the Use of Propranolol in Burn Centers: Who, What, When, and Why? M. T. LeCompte, MD, L. Rae, MD, S. A. Kahn, MD Vanderbilt University Medical Center, Nashville, TN Introduction: Many burn centers utilize propranolol in both adult and pediatric burn patients to attenuate the hypermetabolic response, decrease muscle wasting, and improve wound healing despite the relative paucity of data in adults compared to children. The purpose of this study was to evaluate how many centers use propranolol, for which groups it is being used, the trigger for initiation, length of use, and the intended benefit. Methods: A 17 question survey regarding the use of propranolol was distributed to burn center directors with a link to provide anonymous responses. The survey responses were analyzed using descriptive statistics. Results: Of the 123 surveys distributed, 34 responses were obtained (28%response). Results demonstrated 55.9% use propranolol while 44.1% do not. “Lack of data supporting improved outcomes” was the primary reason given in 53% of centers not using propranolol. Use in both adult and pediatric patients was reported in 84% of centers using propranolol. Propranolol is used for > 20% TBSA burns in 68.4% and > 40% TBSA in 26.3%. Propranolol is started after initial resuscitation in 31.6% while 42% wait for hemodynamic changes prior to initiation. The drug is discontinued after improved hemodynamics in 21.4% and 23%, at hospital discharge in 35.7% and 52.9%, and at 6 months in 21.4% and 5.9% of pediatric and adult patients respectively. Propranolol dosing ranged from 10mg BID to 30mg QID in adults and 0.1mg/kg to 1mg/kg given BID to QID in pediatric patients. The dose was titrated to a reduced heart rate in 37.5% of adults and 42.8% of peds. Propranolol was felt to improve outcomes in 52.6% of responses while 5.3% felt that it did not and 42% were unsure. Conclusions: The use of propranolol varies widely among burn centers, with a slight majority of centers citing regular use. The majority of centers utilize it in adult and pediatric patients despite the lack of randomized controlled studies in adult populations. In addition, the wide variation of practice highlights the need for further study in regard to patient outcomes, duration of therapy, and dosing in adults. Previous studies suggest benefit in children when propranolol is continued for 6 months after injury and is dosed based on target heart rate reduction however, the majority of centers to not follow these practices. Applicability of Research to Practice: The efficacy of propranolol among adult burn patients needs further investigation. 152. Initiation of Insulin Protocol Improves Complications of Severely Burned Patients H. K. Gill, MD, S. Godard, BSc(Hons), J. Bian, BSc(Hons), M. A. Burnett, BSc(Hons), M. G. Jeschke, MD, FACS, FCCM Sunnybrook Health Sciences Centre, Toronto, ON, Canada Introduction: Patients who are severely burned experience a systemic response in which the body has increased metabolism, inflammation, associated hypoglycemia and hyperglycemia. A substantial percentage of patients with burn injuries have diabetes, or develop hypoglycemia/hyperglycemia from stress related after burn injury. It is very important to treat glucose imbalance in a patient, especially burn patients. The dangers of hypoglycemia/hyperglycemia in burn patient's increases morbidity and mortality, delays wound healing, and can lead to recurrent infections. Benefit of insulin therapy is substantial, however the literature on management of hyperglycemia with insulin therapy is limited. We are here to prove that after starting the insulin protocol in 2010 we have seen significant reduction in complications in burn patients. Our objective is to compare glucose levels, complications in patients pre- and post-protocol implementation to determine if insulin administration protocols can improve outcome in burn patients. We hypothesis the implementation of insulin protocol in 2010 has improved glucose control, improving complication rates. Methods: Retrospective chart review, data was collected from January 1998 to August 2014, a total of 512 patients who had more then 20% total body surface area (TBSA) burns. Data was collected through medical record charts and EMR database. The data was analyzed in Microsoft Excel. Results: From the database we have seen a decrease over time in glucose levels from 1998–2009 and 2010–2014, indicating better glucose control. Based on Fischer's exact test there has been a statistically significant decrease in the number of complications of pneumonia, bacteremia, ARDS, DVT, PE and thrombosis. Hypoglycemia and hyperglycemia incidents have decreased over time based on Fischer's extract test 1998–2009 to 2010–2014, which is statistically significant. Conclusions: There have been improvements in complications overtime. These outcomes may be attributable to the implementation of an insulin protocol 2010. Applicability of Research to Practice: Being a physician you have to know the clinical knowledge in order to provide patient care to best of your abilities. Including research to your practice is very helpful to provide better patient care. As you learn from practice the typical problems you encounter, its important to learn new strategies to overcome them. By doing research, conducting studies we can try new methods and new approaches and see how that may improve patient care. Thus the applicability of research to practice is very important. External Funding: CIHR#123336, CFI Leaders Opportunity Fund: Project #25407, NIH RO1GM087285-01. 153. Impact of Diabetes on the Clinical Outcomes of Burn Admissions J. Bian, BSc(Hons), W. Xiong, MSc, N. Radulovic, BSc, M. A. Burnett, BSc(Hons), M. G. Jeschke, MD, FACS, FCCM Sunnybrook Health Sciences Centre, Toronto, ON, Canada Introduction: Diabetes mellitus is one of the most common diseases in developed countries across the world. Previous studies have generated mixed results regarding the effects of diabetes on morbidities and mortalities of burn patients. No study has been designed to examine how different severities of diabetes can affect burn patients' complications and survival. We present the outcome differences between diabetic and non-diabetic burn patients,as well as differences between well-controlled and poorly-controlled diabetic burn patients. Methods: All burn admission data from 2006 to 2014 were extracted and reviewed. Admissions were divided into well-controlled, poorly-controlled and non-diabetic patient groups using 0.07 as the HbA1c value cutoff. Multivariate Poisson regression was utilized to analyze complication counts. Results: Out of the 136 diabetic patients, 25 patients were classified in the well-controlled diabetic group, 30 patients in the poorly-controlled group and the remaining 1065 were non-diabetic patients. Diabetic patients in general were much older (61.9 vs 45.1 yrs, p<0.0001) and showed significantly higher number of complications (1.3 vs 0.8, p=0.0074) and mortality rates (13.2% vs 6.4%, p=0.0037). Multivariate analysis after adjusting for age, TBSA and inhalation injury further confirmed that diabetic burn admissions presented with significantly more complications than non-diabetic admissions (RR=1.3, 95% CI=1.1–1.5, p=0.0031). 81 of the diabetics were excluded from the comparative analysis between well-controlled and poorly-controlled groups due to lack of HB A1C values. Based on current data with limited sample size (n=55), the results showed that poorly controlled diabetics overall had no significant differences in number of complications when compared against well controlled diabetics (RR=1.2, 95% CI=0.75–1.87, p=0.4597). Conclusions: After adjusting for TBSA percentage, age and inhalational injury rate between diabetics and non-diabetics, diabetic burn admissions still had a significantly higher complication rates. This suggested that high blood glucose condition pre-hospital admission affects the in-hospital recovery of burn patients. Well-controlled diabetics and poorly-controlled diabetics showed non-significant difference for complications. Applicability of Research to Practice: In practice, the care standard for diabetic burn admissions in general should be more stringent due to their worse outcomes compared to the non-diabetics. Therefore devising a comprehensive treatment plan specifically for diabetic patients will likely improve the post-burn outcome of these patients. The severities of diabetic conditions however should not affect the burn care standard. External Funding: Canadian Institutes of Health Research # 123336, CFI Leaders Opportunity Fund:Project #25407, NIH RO1 GM087285-01. 154. Woodsmoke Inhalation in a Murine Model Generates Acute Lung Injury that is Compounded by Cutaneous Burn J. Dunn, BS, L. Kartchner, BS, C. Jania, BS, S. Tilley, MD, R. Maile, PhD, B. A. Cairns, MD, FACS The University of North Carolina, Chapel Hill, NC Introduction: Smoke inhalation is a major risk factor for burn patients, causing loss of lung function, risk of pulmonary infection, and increased mortality. Previous studies by our group and others have identified prognostic indicators in patients; however, a robust animal model is needed to elucidate specific mechanisms of injury and to identify treatments. We hypothesize that burn injury amplifies pulmonary pathologies observed following smoke inhalation. Here, we demonstrate that inhalation of smoke generated by combustion of particle board leads to phenotypic indicators of acute lung injury (ALI) in mice that are aggravated by cutaneous burn. Methods: Female C57B/6 mice were anesthetized, shaved, and given subcutaneous morphine before undergoing a full-thickness 20% total body surface area contact burn. Mice were intubated prior to six minutes of exposure to smoke generated by smoldering of particle board. Cells and supernatants from broncho-alveolar lavage fluid (BALF) were analyzed by flow cytometry and enzyme linked immuno-sorbent assay (ELISA), respectively. Results: We have previously demonstrated that our model of a 20% TBSA burn does not lead to ALI, however our model of woodsmoke inhalation leads to an increase in total protein and cytokines in BALF, increased cellularity early after injury, and an increased percentage of neutrophils infiltrating the lung. Cumulatively, these results are consistent with ALI occurring due to woodsmoke inhalation, and preliminary findings indicate that these effects may be amplified by combined burn injury and woodsmoke inhalation. Conclusions: We observed that our model of woodsmoke inhalation induces characteristics of ALI that mimic pathological changes in humans following smoke inhalation. Early results indicate that this is a promising model for future studies of interventions that could decrease pathological inflammation and improve bacterial clearance. Applicability of Research to Practice: Previous reports suggest that inflammation in the lung after burn and smoke inhalation does not control pathogens. Using our model, we intend to identify immuno-modulatory drug targets that decrease initial pathological effects of ALI so that lung tissue more rapidly returns to homeostasis and pulmonary pathogens can be cleared. External Funding: National Institutes of Health. 155. Neutrophil Extracellular Trap (NET) Formation in Patients with Post-Burn Sepsis R. J. Dinsdale, MSc, P. Hampson, PhD, C. M. Wearn, BSc, MBBS, MRCS(Eng), J. Hazeldine, PhD, J. M. Lord, PhD, N. S. Moiemen, MBBCh, MSc, FRCS, FRCS(Plast), P. Harrison, PhD University of Birmingham, Birmingham, United Kingdom Introduction: Major thermal injury results in immune dysfunction increasing the risk of infection and sepsis. Neutrophils are the first line of defence of the innate immune system and play a key role in controlling and eradicating infections. NETs (Neutrophil Extracellular TRAPs) are an emerging concept in neutrophil biology and there is increasing evidence for their role in host defence. As NETosis is important both in infection and sepsis we hypothesized that NETs are likely to be involved in either the host immune response to burn injury and/or during the pathogenesis of sepsis. NETosis is commonly measured by analysing extracellular DNA levels; this method alone is limited and non-specific. However, we have measured a specific post translational marker of NETosis (Citrullinated Histone H3) alongside extracellular DNA levels to provide a more robust marker of NETosis. Methods: Patients were recruited onto a multi-centre observational cohort study. Blood samples were routinely collected from the day of injury up to 12 months. Plasma cell free DNA levels from 38 patients (Mean TBSA 27.36%) were analysed using a Sytox® Green fluorometric assay. Citrullinated Histone H3 (Cit H3) was analysed by SDS-PAGE and Western blotting in patient samples (n=8) using a specific polyclonal antibody (ab5103, Abcam). Episode of sepsis in patients were defined as an ABA score ≥3 with evidence of microbiological infection. The difference in change of cell free DNA levels between the groups was analysed using a t-test. Results: Cell Free DNA levels were surprisingly only modestly elevated post injury compared to normal control samples. However, maximal DNA levels were significantly elevated (p = 0.016) compared to the first baseline sample in patients who experienced at least one septic episode (n= 14, mean delta change in DNA 992 ng/ml from baseline) compared to patients who had no episodes of sepsis (n=24, mean delta change 196 ng/ml). Severity of injury causes a significant difference (p=0.007) in change of maximal DNA compared to baseline. Burns above 30% TBSA have significantly higher levels of cell free DNA compared to burns equal to or below 30% TBSA. Conversely, there is a poor correlation (R squared=0.023) between TBSA and DNA levels 24 hours following thermal injury. Importantly, Cit H3 was detectable as a 17kDa band in samples corresponding to the cell free DNA peak and septic episodes at significantly higher levels than the early time points. Conclusions: This study provides evidence that NETosis is occurring following human thermal injury and that elevated levels of extracellular cell free DNA are significantly associated with septic episodes. Applicability of Research to Practice: Extracellular DNA and Cit H3 represent both a diagnostic tool and/or therapeutic targets in the pathogenesis of sepsis. 156. Role of Stat3 Signaling in Diaphragm Atrophy and Dysfunction after Severe Burn Injury in Rats H. Duan, MD, D. N. Herndon, MD, FACS, X. Zhang, PhD, C. C. Finnerty, PhD Shriners Hospital for Children, Department of Surgery, University of Texas Medical Branch, Galveston, TX; Department of Burns and Plastic Surgery, First Affiliated Hospital of PLA General Hospital, Beijing, China Introduction: Severe burn injury, with or without inhalation injury, is always complicated by respiratory dysfunction. As the dynamic of external respiration, the diaphragm performs 60%∼80% of the inspiratory work. Respiratory muscle atrophy may induce weakened respiration, insufficient ventilation, coughing reflection suppression, pulmonary infection increase, difficulty in weaning off respirators, and even respiratory failure. Our previous study indicates there is diaphragm atrophy after severe burn injury. Accumulated evidences suggest activation of STAT3 signaling is an important contributor of diaphragm atrophy and dysfunction induced by mechanical ventilation and other pathological conditions. Therefore, we investigated whether severe burn injury induces diaphragm dysfunction, and whether activation of STAT3 signaling plays a role in this process. Methods: Male Wistar rats sustained a 60% body surface area full thickness thermal injury or sham injury (control). Blood and diaphragm muscles were harvested at 2h, 1d, 3d, 7d, and 14d after burn or sham injury. The contractile property of diaphragm muscle was determined using diaphragm strips incubated ex vivo. Serum cytokines were assessed by ELISA. Expression of STAT3 signals and related proteins was detected by Western blotting. Results: Thermal injury resulted in significant reductions of body weight and diaphragm muscle mass compared with those of time-matched controls. Diaphragm muscle contractile force increased with low frequency stimulation (60Hz) compared to control. IL-6, Angiopoitin 2, and IL-1β in serum increased significantly and peaked at 1st and 3rd day respectively after burn injury. Expression of both phospho STAT3 (Tyr 705 and Ser 727) increased significantly and peaked at 2 hours and 3 days post-injury, whereas total STAT3 did not change significantly. SOCS2 and SOCS3, inhibitors of STAT3, showed no significant change in expression after burn injury. Calpain activity increased at 1st and 3rd post-injury days even there were no significant change in its protein expression. Also, active caspase-3 expression increased significantly in diaphragm and peaked at 3rd post-injury day. Conclusions: These results indicate there are diaphragm atrophy and dysfunction induced by enhanced proteolysis after severe burn injury. Activation of STAT3 signaling possibly plays a role in this process. Applicability of Research to Practice: To elucidate the underlying mechanisms mediating the atrophic response is important in establishing potential therapeutic interventions that could prevent and/or reduce diaphragm muscle atrophy and preserve its physiological function after burn injury. External Funding: This work was supported by grants from Remembering the 15 Endowment, SHC 80500 and the National Natural Science Foundation of China. 157. Smivastain Inhibits Burn/Inhalation Induced Acute Lung Injury G. Zhao Sr., MD, PhD, Y. Yu, MD, PhD, R. G. Tompkins, MD, ScD, FACS, A. J. Fischman, MD, PhD Shriners Hospital for Children; Massacusetts General Hospital, Boston, MA Introduction: Smoke inhalation injury is closely related to the mortality of severely burned patients. Simvastatin is commonly used for the treatment of hypercholesterolemia. Recently, the anti-inflammatory property of simvastatin has attracted much attention. The present study aims at exploring the effects and mechanisms of simvastatin treatment on burn/smoke inhalation (B/SI) injury using genetically modified mouse models. Methods: Wild type, TNF-alpha knock out (TNF-α KO) and NF-κB KO mice were subjected to B/SI. The mice were then treated with Simvastatin, TNF inhibitors, or NF-κB inhibitor via nebulization. The lung tissue, bronchoalveolar lavage (BAL) and serum were collected; the bronchial epithelial cells were cultured with BAL to assess the injury to the lung, the therapeutic effects of Simvastatin and the related genetic signaling pathways. Results: During the first 24 hours, B/SI induced marked epithelial cell apoptosis (sham 3+/−1.5% vs. burn/smoke 16+/−3.7%, P<0.001), significant neutrophil in BAL (sham 0.2+/−0.013 X104 vs. 5.6+/−1.1 X 104, P<0.001), remarkable myeloperoxidase (MPO), TNF-α and NF-κB expressions in the lung tissue and serum (P<0.005). The TNF-α KO and NF-kB KO mice presented much mild epithelial apoptosis, less neutrophil in BAL, lower expression of MPO (P<0.005). Simvastatin, TNF-α and NF-κB inhibitor treatment decreased the apoptosis, MPO in lung (P<0.005), neutrophil in BAL (P<0.005), and the expressions of TNF-α and NF-κB in both lung and serum. Inhibitors and Simvastatin increased the survival rate of injured wild-type mice (P<0.05). BAL-treated bronchial epithelial cell demonstrated significant expression of TNF-α and NF-κB, and apoptosis which could be attenuated by Simvastatin treatment and TNF- α and NF-kB inhibitors. There were no additive effects of Simvastatin, TNF-α and NF-κB inhibitor on epithelial apoptosis, MPO expression, Neutrophil in BAL, and the survival rate. Conclusions: Simvastatin inhibited inhalation/burn induced acute lung injury via decreasing the expression of TNF-α and NF-κB. Applicability of Research to Practice: Results of the present study strongly suggest a potentially important therapeutic application of Simvastatin for treatment on burn/inhalation injured patients. External Funding: Shriners Hospitals for Children (Grant 87100) and National Institute of Health (P50 21700). 158. Cardiovascular Reactivity to Vasoactive Agents after Severe Burn Injury P. G. Vana, MD, R. H. Kennedy, PhD, R. L. Gamelli, MD, FACS, M. Majetschak, MD, PhD Loyola University Chicago, Maywood, IL Introduction: Adequate fluid resuscitation after burns is essential for patient outcomes. Current resuscitation strategies involve crystalloid fluids, colloids and vasoactive agents. Changes of the cardiovascular reactivity to vasoactive agents after burns, however, are not well understood. Thus, it was the aim of the present study to assess changes in the cardiovascular reactivity to arginine vasopressin (aVP) and phenylephrine, a selective α1-adrenergic receptor agonist, in a euvolemic rat burn model. Methods: Anesthetized Sprague-Dawley rats (300-325g) were subjected to sham procedure or 30–40% total body surface area dorsal scald burn, followed by crystalloid resuscitation according to the Parkland formula. Twenty-four hours after burn or sham procedures, rats were re-anesthetized and instrumented with a central venous catheter and an arterial catheter that was placed in the femoral artery. Each rat was then resuscitated with lactated Ringer's solution to a mean arterial blood pressure (MAP) ≥ 80mmHg. Subsequently, rats received 16 increasing doses of aVP (500 fg/kg - 50 ng/kg; Sham=6, Burn=8) or 10 increasing doses of phenylephrine (5 ng/kg - 10mg/kg; Sham=6, Burn=7) i.v. in 5 min intervals. MAP was monitored continuously, and the area under the MAP curve (AUC) for each dose was calculated and used to generate dose-response curves. Non-linear regression analyses were used to calculate maximum response and EC50 values (GraphPad Prism). Best fit values were compared with Extra sum-of-squares F test. Data are presented as mean (95% confidence interval). Results: The EC50 for aVP was 580 (366/920) pg/kg after sham procedure and 146 (93/226) pg/kg after burn injury (p=0.0007 vs. sham). Maximum response values for aVP were 219(198/240) after sham procedure and 258(237/280) after burn (p=0.02 vs. sham). EC50 and maximum response for phenylephrine were not significantly different between sham and burn animals. Conclusions: Burn injury results in a differential regulation of the cardiovascular responsiveness to vasopressin and α1-adrenergic receptor agonists. Burn injury sensitizes and enhances the cardiovascular response to aVP under euvolemic conditions. Applicability of Research to Practice: A better understanding of the cardiovascular consequences after burn injury may help to develop improved resuscitation strategies for severely burned patients. External Funding: Falk Foundation, DoD W81XWH-10-2-0172, NIHT32GM008750. 159. The Effects of Severe Burn Injury on Bone Structure and Strength in Mice R. Matthews, BS, V. Parker, BS, L. Koniaris, MD, T. Zimmers, PhD Indiana University School of Medicine, Indianapolis, IN Introduction: Severe burn injury has been shown to induce systemic bone loss by causing a systemic hypermetabolic and hyperinflammatory response. Patients with burn injury show decreased bone mineral content up to 3 years after injury. There is a need for robust models of burn-induced bone loss. Current literature describes short-term effects of burn on bone in rats (14 days) and in Balb/c and C3H/H3N mice (10 days). We sought to determine whether sustained bone loss was observed in a longer-term model in a mouse strain often used for genetic manipulations. Methods: Male 12–16 week old C57BL/6J mice were subjected to 20% BSA contact burn injury. Carcasses obtained at 1-, 7-, 14-, 30- and 50-days were examined by PIXImus, microCT, and three point bending tests to obtain data on bone density, microarchitecture and strength. Results: Mice displayed hyperphagia and lower weight versus sham controls for the duration of the experiment, suggesting hypermetabolism. Muscle mass was generally decreased and organ mass increased over the time of observation. No loss of bone mineral density (BMD) was observed 1 day post-burn injury and no differences were present in trabecular bone structure or overall femoral strength at 1 or 7 days. However, significant changes in BMD were present as early as 7 days after burn injury. At 14-days after burn injury, mice showed statistically significant losses of BMD both overall and in vertebrae and femur, with reduced trabecular bone and trend towards decreased bone strength. At 30-days after burn injury, mice showed significant loss in all areas of BMD testing and significant reduction of bone fraction, trabecular number and thickness, with increased trabecular spacing. By 50-days after burn injury, mice showed no significant difference in BMD, but maintained reduced trabecular bone structure. Conclusions: Burn injury in mice induced significant bone loss with decreased trabecular bone. Changes in microarchitecture at 50 days were less than at 30 days, suggesting healing. Overall this model recapitulates musculoskeletal features of human burn injury. Applicability of Research to Practice: The long-term persistence of pathophysiologic responses to burn injury may cause substantial changes in bone microarchitecture, thereby contributing to long-term clinical outcomes. Further research examining the effects of burn injury on skeletal morphology and the mechanisms behind the bone loss is needed. This mouse model of longer-term burn associated musculoskeletal changes appears to reflect the human condition sufficiently for use in mechanistic, genetic studies. External Funding: NIGMS R01-GM09275. 160. Pulmonary Chemokine and Cytokine Response to Combined Burn and Radiation Injury T. P. Plackett, DO, FACS, S. R. Carter, MD, C. R. Deburghgraeve, MD, J. L. Palmer, MS, R. L. Gamelli, MD, FACS, E. J. Kovacs, PhD Loyola University Medical Center, Maywood, IL Introduction: Although infrequent in occurrence, nuclear events carry a significant risk of concomitant thermal injury. Prior studies have shown that combined injury results in a pronounced neutrophil response in the first 48 hours after injury that is greater than either injury alone. The present study expands upon these findings to determine the time course of this response. Methods: C57BL/6 mice were subjected to either a sham procedure, 5 Gy of total body irradiation, 15% total body surface area scald burn, or a combination of the two (CRI). Animals were sacrificed at 1,2, 3, and 7 days after injury. Lungs were examined for chemokine, cytokine levels, and myeloperoxidase levels. At each time point, results were normalized against sham levels and are presented as fold increase above sham levels. Results: Myeloperoxidase was 4-fold higher after burn injury, but decreased after radiation alone. However, CRI results in an exaggerated response relative to burn alone, peaking at 2 days with a 7.5-fold elevation and dissipated by 7 days. This early neutrophil response was paralleled by a greater than 3-fold rise in KC and MIP-2 by 2 days after burn injury, however there was no difference between burn alone and CRI. Additionally, there was a late rise in KC at 7 days after injury (1.6-fold for burn alone & 1.3-fold for CRI), but not MIP-2. Radiation alone had minimal effect on either chemokine. Interleukin-6 also increased 12-23-fold during initial two days after burn injury. Levels of IL-6 were consistent lower in CRI compared to burn alone, but this difference was not statistically significant. Levels dropped back to basal by 3 days. In contrast, by 2 days after injury MCP-1 levels had risen 5-fold in response to burn alone and 12-fold after CRI, however they peaked with radiation alone they were already decreasing the following day, whereas they continued to remain significantly elevated in CRI for up to 7 days after injury. Conclusions: CRI results in a pulmonary immune response that parallels both the neutrophil and macrophage response of burn injury. While the neutrophil response and inflammatory cytokine production follows a similar time course and magnitude to burn alone, the macrophage response is of greater duration and magnitude. Applicability of Research to Practice: Targeted therapeutics should consider these temporal differences when designing future studies and consider use of these biomarkers to monitor injury progression. External Funding: This work was supported by the National Institutes of Health R33 AI080528 (EJK) & T32 GM00850 (RLG), Illinois Excellent in Academic Medicine Grant (EJK), and the Dr. Ralph and Marian C. Falk Research Trust (EJK). 161. Establishing a Porcine Model of Systemic Inflammatory Response Syndrome (SIRS) Due to Thermal Injury Alone D. M. Burmeister, PhD, S. Natesan, PhD, R. J. Christy, PhD US Army Institute of Surgical Research, Fort Sam Houston, TX Introduction: Excessive Systemic Inflammatory Response Syndrome (SIRS) following large total body surface area (TBSA) burns can lead to Multiple Organ Dysfunction Syndrome (MODS) which has potentially life-threatening side effects. While rodent models have provided some insight into the mechanistic basis of SIRS/MODS, large animal models of burn-induced SIRS are lacking. Although porcine skin is widely regarded as the closest surrogate for human skin in terms of structure and healing, SIRS in the pig due to burn alone has not been studied. Methods: Full thickness burns wounds were created using two brass blocks (9x15 and 5x5 cm) heated to 100°C and applied to create a 35%TBSA burn wound. Vitals were recorded and blood sampled on days 1,2,3,7, 10 and 14 post-burn. On day 14, organ biopsies were taken for histopathology and immunohistochemical staining for myeloperoxidase (MPO). Results: Burn depths were confirmed to be full thickness upon histological analysis. Classical SIRS markers were significantly elevated as heart rate, respiratory rate, body temperature, and white blood cells all increased from day 0 (86 ± 5.6 beats/min, 14 ± 1.0 breaths/min, 37.27 ± .37°C, and 16.3 ± 2.5 103cells/mL) to day 7 (131 ± 4.5 beats/min, 41 ± 9.6, breaths/min, 38.3 ± 0.5°C, and 32.4 ± 4.2 103cells/mL). While TNF-α levels were only elevated 2 hours post-burn, IL-6 levels remained elevated throughout the experiment, with circulating levels remaining at 138.5 pg/mL on day 14. Acute kidney injury was apparent with blood urea nitrogen levels reaching 15.68 mg/dL on day 1. Alanine aminotransferase (122.0 ± 11.37U/L) and aspartate aminotransferase (96.5 ± 29.3U/L) were also elevated on day 1 compared to baseline, indicative of liver damage. Histological analysis revealed lung damage in the form of atelectasis, thrombi, and thickened airways, along with a chronic population of MPO-positive neutrophils on day 14. Conclusions: Elevations in circulating cytokines (Il-6, TNF-α) post-burn created transient damage to the kidneys and liver, with chronic effects on the lungs. Thus, we have created a survivable burn injury in a pig severe enough to produce measurable outcomes of SIRS and MODS. Applicability of Research to Practice: This non-lethal porcine large TBSA model will allow characterization of cytokines/biomarkers associated with burn-induced SIRS which can be utilized for standardized preclinical evaluation of the immunomodulatory effects of cell therapies, small molecules, or other biologics treating SIRS/MODS in burn patients. In addition, polytrauma (eg. smoke inhalation, sepsis) may be added to further identify biomarkers specific for burns and/or associated comorbidities. External Funding: US Army Medical Research and Materiel Command. 162. Reducing CLABSI: A Focus on Nursing Care and Maintenance B. Baldwin-Rodriguez, MSN, RN, CCRN, M. Makamure, BSN, RN, V. C. Joe, MD UC Irvine Health, Orange, CA Introduction: The reduction of Central Line-Associated Blood Stream Infection (CLABSI) rates is a priority in healthcare. CLABSI rates in our burn ICU had been at or below the expected National Health and Safety Network (NHSN) rate from 2009 through 2nd quarter 2013. However, rates were above the expected NHSN benchmark in 3rd and 4th quarter, 2013. There is a gap in the literature related to compliance with nursing standards of care and maintenance. In our unit 85% of the CLABSI occurred more than 5 days post insertion, indicating that quality improvement should focus on the care and maintenance, rather than insertion practices. The purpose of this project is to review nursing adherence to standards of care in our unit. Methods: An initial survey to nurses revealed a large number of missed nursing care (errors of omission). A total of 17 of 28 RNs (60%) responded and it was noted there were between 6% and 88.2% of missed nursing care episodes, indicating that basic standards of care were not met. Surveys indicated poor practice habits were the cause of most missed nursing care with 118 ideas for improvement suggested. An educational video was created, best practice were shared during change of shift, “Days without CLABSI” were posted, and quality audits for dressing appearance and documentation (including photos) were completed. Results: As of September 30, 2014 our unit has been 265 days without a CLABSI. Rates of self-missed nursing care dropped from a high of 88.2% to 53.3%. The video was noted to be the most meaningful intervention, with 78.57% of nurses indicating that their personal practice has changed since the project started. Nurses strongly agreed, 57.14%, that the having a staff member lead the project had a significant impact on their ability to change practice. A model for sustainability is being developed. Conclusions: Basic care and maintenance of central lines, according to standardized procedures is essential for achieving quality of care for patients. Nurses must first evaluate actual practice against standards when evaluating care and prior to revising policies and procedures. Applicability of Research to Practice: Improvement efforts should focus barriers and facilitators of enhancing nursing adherence to standards of practice, with consideration of the unit culture and needs of nurses who provide direct care to patients. 163. Decreasing the Rate of Catheter-Associated Urinary Tract Infections through a Nurse-Driven Intervention L. C. Smith, RN, J. Peyton, RN, K. Krout, RN, PhD, C. A. Cox, RN, MS, K. L. Huber, RN, MSN Johns Hopkins Burn Center, Johns Hopkins Bayview Medical Center, Baltimore, MD Introduction: Catheter-associated urinary tract infections (CAUTIs) contribute to 40% of all healthcare acquired infections, and can extend hospitalization significantly costing the hospital upwards of $1400. The Centers for Disease Control (2014) estimates 14,000 annual deaths attributed to CAUTIs. According to the National Healthcare Safety Network (NHSN), the national benchmark for CAUTIs in burn centers throughout the country for calendar year (CY) 2013 was 4.7, in comparison to our Burn Intensive Care Unit (ICU), which had an infection rate of 15.85 per 1000 catheter days for CY2013. The frequency by which indwelling catheters are utilized must also be considered when attempting to reduce CAUTI rates. The national benchmark in burn centers for CY2013 was 0.5, in comparison to our Burn ICU rate of 0.63. Methods: In an effort to decrease the CAUTI rate in our Burn ICU, we are working on a performance improvement project. A pre-test was administered to nurses to ascertain their baseline knowledge on the insertion, maintenance, and removal of urinary catheters. A urinary catheter insertion gap analysis was conducted with Burn ICU nursing staff. Education modules for nursing staff were also developed. A nurse driven catheter removal protocol is also being utilized. CAUTI rates and catheter utilization rates will be obtained starting in September 2014 and collected for at least 12 months in hopes of showing a significant improvement. Results: Of the Burn ICU nursing staff, 54% of them showed variation among catheter insertion. All (100%) of the nurses included in the gap analysis performed the steps of catheter insertion in varying sequences. According to our pre-test, approximately 40% of the Burn ICU nursing staff was not aware of the nurse driven catheter removal protocol that exists within our hospital. Another 40% were unaware that the balloon no longer needs to be tested by inflation/deflation prior to insertion. Currently in CY2014, our rate of CAUTIs is 6.11 per 1000 catheter days, which is still above the NHSN benchmark. Conclusions: This is an on-going project in our Burn ICU. It is our hope through the results of the gap analysis and nursing education, we can improve our CAUTI rates in the Burn ICU for the remaining CY2014 and for CY2015, bringing us more in-line with the NHSN benchmarks for both rate and utilization. Applicability of Research to Practice: We anticipate being able to show that a decrease in CAUTIs in our Burn ICU will lead to a decrease in hospitalization length, a decrease in patient complications, and a decrease in cost for both the patient and the hospital. Once successful, we anticipate returning to the American Burn Association with a nurse driven protocol specific to the burn population that may be utilized by other burn centers. 164. Infection Control Practices in a Burn Unit to Reduce the Incidence of Hospital Acquired Infections B. A. Gill, BSN, RN, C. J. Yowler, MD, FACS, FCCM, A. Khandelwal, MD Metrohealth Medical Center, Cleveland, OH Introduction: Hospital acquired infections (HAI), such as ventilator associated pneumonia (VAP), central line associated blood stream infections (CLABSI) and catheter associated urinary tract infections (CAUTI), contribute significantly to health care costs, morbidity and mortality and length of stay. Pneumonias, urinary tract infections and septicemia/bacteremia remain some of the most prevalent complications reported by burn centers to the National Burn Repository. Our hospital has taken a multidisciplinary, proactive approach toward reducing these infections. We sought to review the impact implementation of various protocols had on the incidence of HAI in our burn center. The Infection Control Committee meets monthly to discuss and update infection control policies and review infection data from each patient care area. A subcommittee, formed in the Second Quarter of 2012, also meets monthly to review each VAP, CLABSI and CAUTI after a root cause analysis has been performed by the nurse manager. The nurse manager from the burn center was added as member of the subcommittee in the first quarter of 2013. These discussions have led to updated action plans, staff education and changes in policy when a problem is identified. Methods: Descriptive review of infection control practices and policies that have been effective in reducing the number of hospital acquired infections, particularly VAP, CLABSI and CAUTI. The policies and procedures newly developed or updated to include infection prevention bundles as a result of the Infection Control Committee and VAP/CLABSI/CAUTI subcommittee will be detailed, as well as the steps taken in the root cause analysis. Staff education in the form of in-services, annual competencies and mandatory policy review “read and sign” packets were also implemented. Results: After implementation of these updated protocols between 2012 and 2014, our burn center has not had a VAP since First Quarter of 2012, a CLABSI since Second Quarter of 2013 or a CAUTI since the Fourth Quarter of 2013. Conclusions: A comprehensive, multidisciplinary approach can be effective in reducing hospital acquired infections. Focusing correction on root causes with the goal of preventing the occurrence of hospital acquired infections can be effective in burn centers. Applicability of Research to Practice: Reducing hospital acquired infections will lower hospital costs, decrease morbidity and mortality, decrease length of stay and improve patient safety and outcomes. 165. Improving Burn Wound Care Documentation: A Multisystem Approach B. Do, BSN, M. Wallace, BSN, J. Hartford, BSN UCSD Health System, San Diego, CA Introduction: Since the transition to electronic medical records (EMR), the academic regional burn center has prioritized documentation as an area of ongoing improvement. After encountering several obstacles, the nurses returned to paper documentation for wound care. Staff satisfaction and charting compliance, however, remained below unit standards. After surveying the registered nurses, the consensus was to return to EMR wound care documentation once improvements permitted. Methods: A task force was formed with objectives to reform documentation that will meet the burn center needs. Baseline data was obtained from associate burn centers and a collaboration network was established, revealing many similarities in regards to the challenges of documenting the care of burn injuries. Monthly meetings with representatives from each facility were organized to share ideas and practice standards to better patient outcomes. Documentation concepts and terminology were developed from the multi-center discussions, establishing the stage for a collective, standardized EMR documentation. Using knowledge from the multi-hospital collaboration, documentation drafts were produced with a designated analyst. With each subsequent revision, the task force members would demonstrate progress to peers at the bedside and a formal demonstration was presented to the burn center staff during annual competencies. Feedback from the staff along with subsequent revisions produced remarkable progress from the initial product. Results: With implementation of the task force, audit data demonstrated staff documentation compliance with a mean greater than 80% (n= 1,250), a marked increase from a mean less than 60% as staff awareness grew with pending developments. Pre and post survey implementation will be utilized to gain feedback from the staff to continue incremental updates. The task force continues to gather data and examine short and long term trends in documentation once implemented. Conclusions: The original intent of the task force was to improve the efficiency in which the burn center's nurses can document wound care delivered to patients. While the objective nears implementation, communication will continue with the multi-burn center group in order to further improve not only wound care documentation, but patient-care overall. The task force will continue pursuing the advancements that have been set in motion in regards to burn wound care. Applicability of Research to Practice: Findings from this study may assist in advancing collaborations among burn centers as well as promoting future efforts to improve the practices of burn care beyond documentation. 166. Design and Application of Elastic Vests on Fixation of Dressing for Pediatric Patients with Scald Burns on the Trunk D. Cheng, BSN, RN, C. Li, BSN, RN, W. Wu, MA, RN First Hospital of Jilin University, Changchun, China Introduction: Scald burns on the trunk are very common among pediatric patients, while the fixation of the dressings is one of the challenges during wound management because of the the poor compliance of the children. A stable fixation of the dressings can lead to decreased time of the procedure, followed by less pain of the children and increased work efficiency of the doctors and caregivers. But, to the best of our knowledge, there have not been any methods that can meet all the criterias above. Methods: The vest which is made of cotton cloth combined with elastic bands and velcro fasteners was designed according to the height and weight of normal children, and customized according to different wounds and special demands for each child. Twenty children aged 1–5 years old were enrolled in the study. All the wounds are partial-thickness, with the size varied from 5% to 10% TBSA. Patients of the same age were randomized to two groups, while patients in both groups need to have the dressings changed everyday. The patients treated with bandages for dressing fixation were selected as control group, and those with bandages followed by the elastic vests the next day as the experimental group. Time needed for dressing changes, and the SAS scores for psychological anxiety during the procedure that was given by the family members who took care of the patients were i recorded and statistically analyzed for comparison between the two groups. Results: Time and the SAS scores of the experimental group is less than that of the control group (p<0.001), while the t value is 10.2865 and 3.9527 respectively. Conclusions: Our elastic vests can save the time of dressing changes, lighten the anxiety of the family members. Applicability of Research to Practice: The elastic vests can improve work efficiency of the doctors and caregivers, promote the satisfaction of both the hospital and the patients' family. Because of the above, the vests are worth clinical promotion. 167. Awareness of Nonverbal Communication in Pediatric Burn Nursing T. Skinner, RN, M. Hutson, RN, BSN, R. P. Mlcak, PhD, D. N. Herndon, MD, FACS Shriners Hospitals for Children-Galveston, Galveston, TX Introduction: General care of the pediatric burn patient places the nurse in a highly stressful and emotional environment. Most nurses are unaware of the nonverbal communication they are displaying in a fast-paced situation and how it effects the patient/caregiver. Burn patient outcomes correspond with effective nursing skills, communication, and interventions. Methods: For quality improvement, a survey was distributed to nurses within a pediatric burn facility in order to determine their knowledge and understanding of body language, and how stress can unknowingly effect nonverbal communication. The survey consisted of 11 questions regarding: the nurse's awareness and perception of body language; changes when stressed; instances when the hospital elicits a subdued versus energized atmosphere; effects on patient care; acknowledging a co-worker's display of negative nonverbal communication; and any related changes or need for improvement. Additional data was collected by a literature review on of body language and observation of nursing care. Press-Ganey survey results were also reviewed for the inpatient and ambulatory surgery nursing categories. Results: At least 80% of the nurses surveyed are aware of body language as well as changes in the display of nonverbal communication when stressed. Also, 100% of the nurses surveyed interpret nonverbal communication from their patient/caregiver. Only 81.8% of nurses feel comfortable in acknowledging a co-worker's body language. Instances when the hospital appears subdued include patient death, low patient census, upset coworkers; energized instances include eventful times of patient admission, high patient census, good workflow. Patient care was mostly affected by a sense of being rushed. Highly noted changes in nonverbal communication include facial expressions and dedicating more time to communication. Nurses felt that touch, hugs, and support help in effective communication. Our Press-Ganey score was an average of 93.3% for Quarter 1 & 2 in 2014. Conclusions: In review of all of the data collected, we identified a need for re-education of staff to improve nonverbal communication. There is also a need for education on stress relief and relaxation techniques to improve nursing performance under stressful situations. This will be an ongoing project, Press-Ganey scores will be monitored for improvement and nurses will be surveyed for effectiveness of education. Applicability of Research to Practice: Improved patient satisfaction and patient outcomes in the pediatric burn patient population. 168. Use of a Complex Patient Meeting in the Outpatient Burn Clinic B. Moats, RN, K. Gabehart, MSN, RN, D. Roggy, RN, R. Sood, MD, FACS Richard M Fairbanks Burn Center, Indianapolis, IN Introduction: Burn patients needs following discharge vary greatly from patient to patient. In order to address the needs of our complex patient needs, the Burn Outpatient Team developed criteria to identify these patients that may require more attention. A complex patient is a patient who may be at a rehabilitation facility, one with a significant burn injury that will impede function, or one with socio-economic or psychosocial issues. Our Outpatient Burn Clinic team consists of a nurse practitioner, a nurse, physical and occupational therapists, the clinic scheduler, and a medical assistant meets weekly to discuss the needs of complex patients and to coordinate treatment plans. Information discussed at these meetings range from patients' progress at rehabilitation facilities, progress in therapy, wound progression, the potential need for surgical intervention, and the socio-economic or psychosocial issues that may be impeding the patients' care. Methods: Each week, prior to the meeting, a list of patients is compiled by nursing staff and therapy that identifies patients with complex issues. The staff reviews the patient list, gives current plans of care for both nursing and therapy and identifies the needs of each patient. The scheduler is present to assist with identifying and coordinating return visits for these individuals who need visits with both nursing and therapy staff. Inpatient therapists attend the meeting to provide a discharge date for complex patients to outpatient and to present an overview of their inpatient treatment, current wound and physical status, and assist in creating the outpatient treatment plan. Results: This meeting allows for a larger team approach for the patient, as well as maintaining a consistent plan of care. The information shared provides insight for all team members and allows for the ability to continually update plans of care based off of current information. It is a multidisciplinary form of communication between staff members, and provides consistency identifying issues for the medical director's attention. Conclusions: By discussing these patients weekly, it allows the team to closely monitor at- risk patients. The Outpatient Team works in a collaborative manner that improves efficiency while being consistent with goals and expectations in outpatient treatment. This process allows the staff to proactively identify patient needs, develop treatments, and track any progression or regression that occurs. Applicability of Research to Practice: improved continuity of care from inpatient to outpatient 169. Comparison of Concerns of Burn Patients Treated in an Outpatient Setting E. Phelan-Rohrer, MSW, D. G. Greenhalgh, MD, FACS,T. L. Palmieri, MD, FACS, FCCM, S. Sen, MD UC Davis Medical Center/Shriners Hospital for Children Northern California, Sacramento, CA Introduction: The focus for most burn research has been on patients requiring hospitalization. However, most burn injuries are only treated in the outpatient setting. While the extent of burns for these patients may not warrant admission, these patients may have same hierarchy of concerns as patients requiring inpatients admission. We hypothesized that burn patients treated in only an outpatient setting would have a similar hierarchical concerns as hospitalized patients. Methods: A survey was performed of adult burn patients and their family members treated in either the burn clinic (CLIN) or in the burn unit (INP). Surveys were given to INP patients and their family members while they were admitted to the burn unit. OUT patients were only treated in the burn clinic. Survey questions addressed the following areas of concern: pain, emotional coping, financial, physical movement, housing, employment, legal, medical insurance, illicit drug use, appearance, transportation, wound care, and medical supplies. Participants rated each concern on a 1 to 4 scale (1-no concern, 2- somewhat concerned, 3- very concerned, 4- extremely concerned). All values are expressed as mean ± standard deviation. Results: A total of 113 surveys were completed (INP patients-19, INP families-12, CLIN patients-54, CLIN families-28). INP patients and families were most concerned about pain (3.2 ± 0.8, 3 ± 0.8), and physical function (3.1 ± 1, 2.9 ± 0.7). While CLIN patients and families were less concerned overall in these areas, pain (2.5 ± 0.8, 2.5 ± 1), and physical function (2.3 ± 0.9, 2.4 ± 0.9) remained the most common concerns. Conclusions: Burn patients treated in the outpatient setting have a similar hierarchy of concerns as burn patients admitted to the hospital. Addressing their needs of pain control and restoring physical function should be the initial goals for these patients. Further studies are warranted to determine if these goals are being met and what interventions are needed to improve the treatment of these concerns. Applicability of Research to Practice: Understanding the hierarchy of concerns of outpatient burn injured patients. 170. Development of a Pre and Post-Procedure Checklist and Implementation of a Standardized Handoff Process at a Regional Burn Center Caring for Pediatric Patients Undergoing Anesthesia Dressing Changes C. Manabat, RN, BSN, K. Jelincic, RN, BSN UCSD Health System, San Diego, CA Introduction: At our Burn Center, pediatric patients are frequently placed under anesthesia for dressing changes. It was noted by nurse feedback that handoff report between the primary and procedure nurse was ineffective and lacked detail essential to patient safety. The goal of this performance improvement project was to improve handoff processes prior to sedation procedures and upon recovery of the patient. Methods: A literature review regarding evidenced based practice of standardized handoff processes and tools was completed. A pre-survey was conducted to determine staff knowledge and current handoff practice. With interdisciplinary input, pre and post-procedure checklists were developed. Education regarding the new checklists and handoff process was given through one-on-one discussion as well as an in-service during a unit-wide skills day. Multiple revisions to the checklists were done based on staff suggestions. Results: Since implementation in May 2014, over 150 procedures have been completed using the checklists and new handoff process. Post-survey data reveal that primary nurse respondents now feel “moderately prepared” (50%) and “well prepared” (50%) to care for the patient post-procedure as compared to pre-survey data of “poorly prepared” (33.3%) and “moderately prepared” (66.7%). Procedure nurse respondents feel “moderately prepared” (36.4%) and “well prepared” (63.6%) to receive the patient pre-procedure as compared to “poorly prepared” (55.6%) and “moderately prepared” (38.9%). Conclusions: Nursing staff report that using a standardized process has increased confidence in safely caring for patients pre and post-sedation. Ongoing education will aide in continued compliance to this safe practice. This patient safety initiative driven by nursing and supported by burn interdisciplinary staff has ensured positive patient outcomes related to sedation recovery and safe handoff. Applicability of Research to Practice: As a result of this project, a Burn ICU hand-off checklist for post-op patients has been developed and accepted by the Department of Anesthesia as a standard for handoff communication. 171. HEAT: Nursing-Led Multidisciplinary Rounds G. Kim, RN, BSN, K. Yukon, RN, BSN, D. Boc, RN, A. Lozano, RN, BSN, L. J. Gottlieb, MD, FACS, A. O'Connor, MSN, ARNP University of Chicago Medicine, Chicago, IL Introduction: Although as burn nurses we provide twenty-four hour bedside care to our patients, we surprisingly did not participate in weekly multidisciplinary rounds prior to this initiative. We implemented weekly nurse-led rounding utilizing a standard, burn-focused report template called HEAT to ensure that all pertinent patient information was addressed. The acronym HEAT stands for History, Event/Etiology, Assessment, and Treatment plan and includes information from various disciplines including physical therapy, pharmacy, nutrition, spiritual care, and other patient care teams. This project challenged the use of resident physicians in depicting patient status during rounds as the primary source of information. We also addressed the barriers to communication between various patient care team members. The goals of this project aimed to increase effective communication, legitimize nursing expertise, and improve relationships between all team members. Methods: The outcomes of the effectiveness of HEAT were measured through survey data collection. A survey was conducted before the initiation of HEAT presentations to measure the views of the multidisciplinary team members about communication during rounds. After nurse-led rounding was established with continual use of the HEAT template, bimonthly surveys were conducted to measure the effectiveness of communication and evaluate staff responses to the project. Results: There was an improvement in communication between the disciplines on our team, as was demonstrated by evidence collected in the survey responses. We hoped that our nursing input would be integrated into the plan of care in order to improve patient outcomes. As a result, nursing-led rounds continue to foster better working relationships between the residents, staff nurses, and other team members. Conclusions: In order to give nursing a more prominent voice on our unit, we stepped up our role as coordinators of patient care by leading weekly rounds. In addition to improving communication, favorable staff survey responses affirm that this project enhances collaboration and offers suggestions for continued improvements. Applicability of Research to Practice: To our knowledge, other institutions do not currently use a burn specific acronym during rounds. We hope our model will influence practice change in other burn centers. Additionally, we expect this project to decrease patient complications, increase throughput, and enhance staff satisfaction. Future data collection will focus on measuring and tracking these variables as well as continuing to work toward providing the best possible collaborative care to our patients. 172. Serum Albumin Levels as a Novel Predictor for Prolonged Hospital Stay in Younger Burns Patients K. Amavizca, BS, S. Yang, PhD, S. Dissanaike, MD, FACS Texas Tech Health Sciences Center School of Medicine, Lubbock, TX Introduction: The capillary leak induced by burn injury causes a decrease in circulating plasma albumin levels which has been shown to increase probability for sepsis, morbidity, and mortality. The purpose of this study was to assess whether albumin levels could be used to predict hospital stay in burn patients. Methods: A retrospective review of burn patients from 2009 to 2014. Demographic and injury details, albumin levels within 72 hours of admission, and clinical outcomes were recorded. The Abbreviated Injury Severity Index (ABSI) was calculated for each patient. We defined hospital stay > 3 weeks as a “prolonged stay”. Since albumin at admission showed a significant interaction with age, patients were divided into two groups based on a median age of 40 years. Albumin, TBSA, and ABSI were each used as predictors, and the area under the curve (AUC) of a receiver operating characteristic (ROC) curve was calculated and compared. Results: 38 of 198 (19.2%) patients had a stay > 3weeks, of whom 99 (50%) were ≤ 40 years. The AUCs for albumin level, TBSA and ABSI alone were 0.97, 0.97, and 0.96, respectively (see graph) indicating very good prediction, with albumin shortly after admission being equal to TBSA. Among patients > 40 years the AUC values were substantially lower. Conclusions: Serum albumin shortly after admission was an effective predictor of prolonged hospital stay in patients ≤ 40 years. As patients aged, the association with serum albumin became more variable and predictive power lessened. Applicability of Research to Practice: Serum albumin levels shortly after admission is a novel predictor for prolonged hospital stay in burn patients ≤ 40 years old. View largeDownload slide View largeDownload slide 173. Time Course of Metabolic Derangement Following Severe Burn Injury in Adults M. Chondronikola, MS, RD, D. N. Herndon, MD, FACS, C. Porter, PhD, F. J. Bohanon, MD, T. Chao, MA, A. D. Delgadillo, BS, D. R. Abdelrahman, MS, M. K. Saraf, PhD, R. P. Mlcak, PhD, L. S. Sidossis, PhD University of Texas Medical Branch/Shriners Hospital for Children-Galveston, Galveston, TX; University of Texas Medical Branch/Shriners Hospital for Children-Galveston/Institute for Translational Sciences, Galveston, TX Introduction: Large burns cause a pronounced hypermetabolic response, which has been associated with increased morbidity and mortality.The time course of metabolic derangements in the acute phase of burn injury currently remains unknown. The purpose this study was to investigate acute the temporal metabolic perturbations in glucose and lipid homeostasis in adults with severe burn injuries. Methods: Twenty-six severely burned adults (burn size 55 ± 30%) and 5 healthy age and weight-matched subjects studied using stable isotope infusions and hyper-insulinemic euglycemic clamps. Burn patients were studied on two occasions; approximately one and three weeks post burn. Results: During the first week post-injury patients had elevated resting energy expenditure (89 ± 10% above predicted); adipose tissue lipolysis (4.0 ± 0.3 vs. 1.5 ± 0.2 µmol/kg/min); intracellular triglyceride-free fatty acid cycling (3.8 ± 0.5 vs. 1.0 ± 0.3 µmol/kg/min, p<0.05); and endogenous glucose production (23.1 ± 2.0 vs. 10.5 ± 0.3 µmol/kg/min) compared to healthy patients (p<0.05 for all) These values remained elevated to the third week post burn (p<0.05 for all). Compared to the healthy volunteers, burn patients also exhibited decreased whole-body insulin sensitivity (1st week: 0.8 ± 0.1, 3rd week: 1.3 ± 0.2 vs. 2.0 ± 0.3*10–3 dl/kg/min/(μU/ml), p<0.05 for both) and increased hepatic (1st week: 329.4 ± 70.0, 3rd week: 210 ± 66 vs. 57.3 ± 5.0 µmol/kg/min*(μU/ml), p<0.05 for both) and adipose tissue insulin resistance (1st week: 98.8 ± 14.1, 3rd week: 95.2 ± 24.6 vs. 10.8 ± 2.1 µmol/kg/min*(μU/ml), p<0.05 for both) at both time-point post-burn. Conclusions: Our results show marked derangements in lipid and glucose metabolism in burn victims during the acute hospitalization period, which are associated with diminished central and peripheral insulin sensitivity. Applicability of Research to Practice: Clinical interventions in burn victims aimed at normalizing fatty acid and glucose metabolism will likely improve the clinical outcomes. External Funding: National Institutes of Health-P50, Project 9 (81754), Shriners Hospitals for Children (84090, 71006, 85310), American Diabetes Association (67666), and Alexander Onassis Foundation. 174. Checklist and Decision Support in Nutritional Care for Burned Patients E. M. Bernal, MD, S. E. Wolf, MD, FACS, D. N. Herndon, MD, FACS, T. Huzar, MD, C. E. Wade, PhD, E. Ross, MD UTSW/Parkland, Dallas, TX; UTMB, Galveston, TX; UT Houston, Houston, TX Introduction: Higher nutritional needs are associated with severe burns, supporting immediate initiation of tube feedings. Evidence suggests 70–80% of recommended calories are given. The additive effect of interruptions contributes to the overall failure of reaching 100% of goals. Causes for delays in initiation include urgent or emergent procedures, and causes of interruptions include expeditions from the ICU or pauses peri-extubation. Efforts to compensate for these delays or interruptions are lacking. We set out to identify the causes of failure to reach calculated caloric goals in burned patients admitted to the ICU of three burn centers. Our aim is to construct a system checklist in which providers can adjust hourly tube feedings real-time to work toward achieving 100% of caloric goals. Methods: Chart review of 242 burned patients admitted to the BICU (2011–2013), initiated on tube feedings. Data collected for length of first ICU stay. Total hourly tube feedings delivered and expected were recorded. The percentage attained of expected tube feeding goal was calculated per patent and entire cohort. Delays in initiation and interruptions are described. Total tube feeding days and changes in weight were calculated. Results: Tube feedings were started on the day of admission in 43%, within one day in 78%, and more than 48 hours from admission in <12%. Delays in initiation were associated with urgent or emergent procedures. Duration of tube feedings was 18 days [10,30]; ICU days with tube feedings given was 91% [64,100] and hospital days 67% [44,91]. Interruptions attributed to operative intervention, trips to MRI, presumed sepsis, high residuals, and pauses peri-extubation. The median age was 41 [25,56], TBSA burned 37% [24,55], full thickness burn area 20% [8,43], and 31% had inhalation injury. Admission weights were 79kg [66,94] and discharge weights 70kg [63,81]. Average weight loss during the hospitalization was 7kg [-15,-2] and percentage loss from admission was 9% [-17,-3]. Conclusions: Severely burned patients have high caloric needs, and many fail to meet their nutritional goals. Expeditions from the ICU, pauses for extubation, and high residuals constitute interfering obstacles. Progress in nutritional support should improve overall outcomes. Collected data will supplant the construction of a system checklist that will enable providers to make more timely adjustments to hourly tube feedings with the overall aim of achieving 100% of expected daily and overall caloric goals. Applicability of Research to Practice: Improve outcomes in burn patients by improving nutritional support. 175. Vitamin D Biomarkers Associated with Abnormal Scar Formation M. M. Gottschlich, PhD, RD, S. A. Sethuraman, MS, C. Allgeier, DTR, T. Mayes, RD, CCRC, D. M. Supp, PhD, J. Khoury, PhD, R. J. Kagan, MD Shriners Hospitals for Children, Cincinnati, OH; University of Cincinnati College of Medicine, Cincinnati, OH; Childrens Hospital Medical Center, Cincinnati, OH Introduction: The mechanisms responsible for keloid and hypertrophic scarring (HTS) are poorly understood. The prevalence of hypovitaminosis D among burn patients is well documented; suboptimal vitamin D (Vit D) metabolism (relative to dietary intake, skin color, gene expression) may have possible role(s) in keloid and HTS. The relationship between Vit D status and scars has never been investigated following burns. Methods: This retrospective study used a cohort of patients (n=50; mean total body surface area (TBSA) of 55.7 + 2.5%; mean age 7.5 + 0.8 yrs) who received daily supplementation of Vit D2, D3 or placebo. Vit D biomarkers (serum D25, D1,25, parathyroid hormone (PTH) and calcitonin) were obtained at baseline, midpoint, discharge and 1-yr follow-up. Scars were classified as keloid or HTS based on physician documentation in medical record; diagnoses were subsequently confirmed by visual evaluation of patient photographs for distinguishing features (e.g. keloid growth beyond wound margin over time). Kruskal-Wallis was used to examine Vit D biomarker differences between groups due to sample size; median [25th and 75th percentiles] are reported. Chi-square or Fisher's exact test was used for differences in proportion. Results: Four (8%) and 29 (58%) subjects developed keloids and HTS, respectively. Age, race and gender were similar among groups (scar vs. normal healing and keloid vs. HTS). TBSA burn and % full thickness were slightly lower in the keloid group (unadjusted p-values 0.07 and 0.04 respectively). While the majority of patients in both scar and normal healing groups demonstrated suboptimal Vit D status over the course of treatment and follow-up, median serum Vit D25 at acute discharge for the keloid group (26.6 [24.0,28.8] ng/mL) was lower than for patients without scars (44.3 [29.8,51.5] ng/mL) (p<0.07). Furthermore, acute discharge serum Vit 25D3 concentrations were 24, 25.1 and 34.4 ng/mL, respectively in keloid, HTS and normal healing groups (p<0.03). No differences in PTH or calcitonin were discerned. Conclusions: This investigation provides further evidence that Vit D status is compromised in burned children. While it is speculated that Vit D deficiency may be associated with heightened scar risk, more research needs to be devoted to optimizing Vit D nutriture as well as elucidating the role of Vit D in scar formation. Applicability of Research to Practice: The data suggest that low serum Vit D25 may be related to the development of keloids. Clinicians should be aware of the importance of continued Vit D supplementation post discharge due to association of serum levels within normal range and quality of healing. 176. Evaluation of the Effect of Oxandrolone Dose Reduction on Efficacy and Safety Outcomes in Adult Burn Patients T. A. Walroth, PharmD, BCPS, K. M. Bussard, ACNP-C, A. Clore, RD, D. Roggy, RN, R. Sood, MD, FACS Eskenazi Health, Indianapolis, IN Introduction: Oxandrolone is a testosterone derivative used to attenuate the hypermetabolic response in burn patients. It is known to cause hepatotoxicity, although to an unknown extent. Despite standard dosing recommendations, no specific direction exists in patients with evidence of hepatotoxicity for dose reduction, frequency of monitoring, or long term follow-up. Our objective was to evaluate the effects of oxandrolone dose reduction on efficacy and safety in adult burn patients. Methods: This retrospective study included inpatients from 1/1/08-7/31/11 initiated on standard dose oxandrolone (10 mg PO q12hrs for patients with ≥20% TBSA). Patients who were <18 yrs, pregnant, incarcerated, initiated on an alternative dose, or did not have admission and discharge weights recorded were excluded. Patients were divided into two groups: those who did (intervention) vs. did not (control) require dose reduction due to LFT elevation. The primary outcome was length of stay (LOS). Secondary outcomes were overall weight change and peak vs. discharge ALT/AST. Percent of patients requiring dose reduction was compared between those who gained vs. lost weight in a post-hoc analysis. Results: Of 64 patients identified, 46 were included. The control (n = 8) vs. intervention (n = 38) groups were well matched. Patients with a dose reduction had a significantly longer median LOS compared to controls (p = 0.005). There was no significant difference in mean weight change (p = 0.953). Intervention patients experienced significantly higher median peak ALT/AST levels compared to controls (p = 0.018 and p = 0.022, respectively). Levels returned to normal in all groups upon discharge and did not significantly differ at that time. In a post-hoc analysis, twice as many patients were on a reduced dose in the group that lost weight (p = 0.439). Conclusions: Median LOS was significantly longer in patients who required oxandrolone dose reduction compared to those who did not. While there were significant increases in peak ALT/AST levels in the intervention group, both returned to within normal limits by discharge and did not differ significantly from controls. It can be hypothesized that oxandrolone dose reduction may actually result in an increased overall LOS. Applicability of Research to Practice: While increased hepatic transaminases justify dose reduction of oxandrolone, this may result in negative clinical outcomes, such as increased LOS. Risks and benefits should be considered until further data is available. View Large View Large 177. Retrospective Chart Review of Perioperative Enteral Nutrition and Incidence of Aspiration in Adult, Burn Patients A. Krzak, PA-C, S. Taylor, MS, RN, ACNS-BC, J. R. Cherry-Bukowiec, MD, S. C. Wang, MD, PhD University of Michigan Health System, Ann Arbor, MI Introduction: Adequate nutrition is critical in thermal injury patients. Estimated energy needs increase by 200 to 300% after burn injuries with protein needs of more than 2gm/kg/d. Enteral nutrition (EN) is often necessary to meet needs. Many obstacles impede delivery of EN including procedures, nursing care, intolerance, and loss of feeding access. EN in burn patients is often interrupted for wound debridement and skin grafting due to concern for aspiration regardless of feeding tube location. Recent studies found that EN interruptions result in a 52% daily caloric deficit and that 66% of interruptions are avoidable. Incidence of regurgitation and aspiration is decreased by changing the level of EN infusion from stomach to small bowel (SB). Underfeeding predisposes patients to infections, decubitus ulcers, poor wound healing, prolonged length of stay (LOS), and delays in rehabilitation. In order to limit cessation of EN, we investigated the incidence of aspiration in thermal injury patients receiving perioperative/intraoperative SB feeding. Methods: A retrospective chart review was performed for patients (≥ 18 years old) admitted to the burn unit in 2013 at a tertiary academic hospital/verified burn center. Patients with burn diagnosis who received SB EN and required operative intervention were included. Exclusion criteria were prone positioning, lack of EN initiation pre-operatively, or gastric feeding tube location. Each operative case was reviewed to evaluate incidence of perioperative aspiration as well as postoperative signs indicating aspiration pneumonia. Results: Table 1. Conclusions: Perioperative EN does not increase incidence of aspiration in patients positioned supine receiving SB EN. When applied appropriately, continuation of SB EN during the perioperative period is safe and reduces nutrition deficits. Applicability of Research to Practice: Given average procedure duration of 6 hours, patients who received intraoperative EN were provided an additional 800 kcal and 40 gm of protein (avg). Typically, EN is also held for a minimum of 6 hours prior to and several hours following the case during patient recovery. This results in withholding of EN for a minimum of 14 hours leading to a 58% nutrition deficit on operative days. In burn patients who require multiple trips to the OR, this deficit quickly leads to malnutrition. Limiting EN interruptions demonstrates many benefits including improved wound healing, decreased infections, shortened LOS and rehabilitation. View Large View Large 178. Wellness Program for Pediatric Burn Patients within Rehabilitative Phase J. Hall, MS, RD, M. K. Donovan, MS, RN, PNP-BC, K. Prelack, PhD, RD, P. H. Chang, MD, FACS, R. L. Sheridan, MD, FACS Shriners Hospital for Children, Boston, MA Introduction: Pediatric burn patients have a unique set of needs that cannot be met during an inpatient admission. Interdisciplinary interventions in all aspects of wellness such as nutrition, physical capabilities, and social well-being are needed to support the patient in transition from the hospital. We developed a Wellness Program to nurture this progression in the continuum of care. The program includes structured nutrition and physical fitness sessions, a Wellness Garden, and therapeutic dance. Major aims of the program are to minimize unplanned re-admissions and optimize gains during the patient's immediate rehabilitative care. The purpose of this study was to evaluate patient satisfaction and efficacy of the program. Methods: Retrospective review of patients enrolled into the Wellness Program for > 3 weeks was done from 2011–2014. Nutritional status, physical fitness level, and multidisciplinary goals were recorded weekly. Progress made was assessed using discipline specific tools such as Presidential Fitness testing (PF), weight change and emotional state. Patients who participated in Wellness Garden (WG) activities were given a 5 question Likert scale based survey on the experience. Results are reported using general descriptive statistics. Results: Thirteen patients, aged 11.9 ± 3.9 years, with an average burn size of 43.3 ± 22% met the criteria for review. Patients participated in the program for an average of 6.03 ± 4.1 weeks with the involvement of 5 disciplines. Only one patient was readmitted for wound care. The mean weight at program entry was 99 ± 1.2 % of admission weight (range: 0.75–1.2). Patients gained a mean of 2.2 ± 2.34 kg. Patients showed weekly improvements in rehabilitation therapy goals and demonstrated improved emotional state through a combination of child life, music and dance therapies. Five patients completed repeat measures for PF, with an average 55%, 223%, and 163% increase respectively in measured sit ups, pushups, and walking distance while enrolled. Ten patients visited the WG. Mean total Likert scores were 4.9 ± 0.3. All patients agreed (score >4) the garden was relaxing and educational, and wished to return. Conclusions: Patients were able to spend additional time working with needed disciplines while in the Wellness Program and were able to achieve goals such as weight gain and rehabilitative improvements. Patients and parents enjoyed the garden and supported its continuation. The Wellness Program assists patients in their transition from acute to rehabilitation phase of care prior to full integration back to community. Applicability of Research to Practice: The Wellness Program as a whole can improve patient progress and experience during rehabilitative care. 179. Safety and Efficacy of a Moderate Glycemic Control Insulin Therapy Protocol in the Pediatric Burn Unit K. Prelack, PhD, RD, M. Dylewski, PhD, RD, D. Hursey, PharmD, J. Hall, MS, RD, M. Lydon, RN, BS, J. Weber, RN, MSN, P. H. Chang, MD, FACS, R. L. Sheridan, MD, FACS Shriners Hospitals for Children -Boston, Boston, MA Introduction: Stress-induced hyperglycemia, a familiar aspect of the metabolic response to burn injury, was historically tolerated due to its transient nature. However, evidence linking poor glycemic control with adverse outcomes has prompted a more aggressive approach to glucose management in all ICU patients, including burned children. Despite the potential benefits of tighter glucose control, the inherent risk of hypoglycemia warrants safety measures to be implemented. In 2008, we developed a protocol for insulin management aimed at moderate glucose control (110–149 mg/dl) in burned children. The purpose of this review is to evaluate the efficacy and safety of this tool. Methods: An IRB approved retrospective review of patients with ≥ 30% total body surface area burn (TBSA) was performed over a 6 year period (2008–2014). Patients who were in the ICU for at least 28 days, and received insulin for glucose management by this protocol were determined. Briefly, the protocol was implemented when blood sugar levels (BS) were greater than 149 mg/dl for over 24 hours. The first line of measure was elimination of dextrose containing solutions and maintenance of glucose infusion rate in parenteral nutrition of no more than 5 mg/kg/min, followed by sliding scale insulin if necessary. Insulin drips were not initiated unless BS were greater than 149 mg/dl for greater than 48 hours. Data collection for this review included patient demographics, daily glucose values (minimum and maximum), incidence of hypoglycemia (BS <60 mg/dl) and overall clinical outcome (as defined by length of stay and mortality). Results: A total of 147 patients were reviewed, only 18 patients (12%) proceeded to insulin therapy. Their mean age and burn size was 10.1 ± 5.9 years and 47 ± 12.6% TBSA. From a total of 869 BS levels, the average minimum and maximum glucose levels were 128 ± 31 mg/dl and 151 ± 55 mg/dl respectively. During the 28 day period, 74.2% of BS levels were within our target range. Average insulin intake per patient was 4.4 ± 4.6 units, only 3 patients progressed to an insulin drip. There was no incidence of hypoglycemia. All patients survived, with a mean length of stay of 58.5 ± 24.4 days. Conclusions: Our protocol incorporating non-insulin measures to attain glucose levels in a range of 110-149mg/dl minimizes use of insulin with reasonable attainment of target levels while preventing complications of hypoglycemia. Clinical outcome for burned children who were managed with this protocol was good, as evidenced by length of stay and mortality. Applicability of Research to Practice: A formalized insulin therapy protocol that incorporates non-insulin measures is safe and can be useful in maintaining glucose target levels. 180. Characterization of Vitamin D Deficiency and Effects of Supplementation in Adult Burn Patients T. A. Walroth, PharmD, BCPS, M. E. Blair, PharmD, K. M. Bussard, ACNP-C, A. Clore, RD, D. R. Foster, PharmD, R. Sood, MD, FACS Eskenazi Health, Indianapolis, IN Introduction: In the critically ill, vitamin D deficiency is linked to increased morbidity and mortality. Little research has examined the effect of vitamin D status on outcomes in adult burn patients. Vitamin D deficiency is a widespread problem in the general population due to a decrease in dietary consumption and increases in sun protection and BMI. Burn patients are exposed to additional risk factors for continued deficiency: hypermetabolism, decreased sun exposure and impaired synthesis by the skin. Standard supplementation recommendations are not established for this population. Our objective was to characterize vitamin D status and supplementation in adult burn patients. Methods: This retrospective study included patients admitted from 4/1/11 to 3/31/13 with a documented baseline or initial serum 25(OH)D level. Baseline level was defined as one obtained within 2 days of admission and initial as one obtained within one month of admission. Patients 30 ng/dL), insufficient (21–29 ng/dL) or deficient (< 20 ng/dL). Secondary endpoints were percent achievement of normal serum 25(OH)D level, LOS, sepsis, mortality and adverse effects. Results: Of 660 patients admitted, 55 were identified for review and 33 met inclusion criteria. Median age was 40 yrs [IQR 31–66] and 82% were male. Median TBSA was 23% [IQR 13.5–37.5]. Baseline/initial serum 25(OH)D levels showed 15% of patients were normal (n=5), 21% were insufficient (n=7) and 64% were deficient (n=21). Median level was 18 ng/dL [IQR 13–24]. Vitamin D was supplemented in 23 patients, with 91% receiving ergocalciferol 50,000 IU/week. Nine patients, all on 50,000 IU/week, had a follow-up level and none were within normal range. Mean levels increased from 15.2 + 7.2 ng/dL to 19.2 + 6.1 ng/dL (p=0.209). Median LOS was 27 days [IQR 15–37]. The rate of sepsis was 30% (n= 10) and overall mortality was 12% (n=4). No adverse effects were reported. Conclusions: The majority of patients were insufficient/deficient in vitamin D when checked. The high prevalence of deficiency and potential impact on patient outcomes warrants screening on admission. When supplemented using a common regimen (50,000 IU/week), no patients achieved a normal level. More aggressive supplementation is likely needed for this patient group. A prospective study is underway to examine a dosing protocol and the clinical impact of obtaining normal levels. Future directions include readmission rates, chronic supplementation and long-term effects of vitamin D status. Applicability of Research to Practice: This study highlights the need for a standard approach to vitamin D monitoring and supplementation in adult burn patients. 181. Prolonged Elevated Skeletal Muscle Protein Turnover Following Severe Burn Injury T. Chao, MS, D. N. Herndon, MD, FACS, C. Porter, PhD, F. J. Bohanon, MD, N. Chaidemenou, BS, L. S. Sidossis, PhD University of Texas Medical Branch, Galveston, TX; Shriners Hospital for Children-Galveston, Galveston, TX; Harokopio University, Athens, Greece Introduction: Patients with severe burns exhibit altered muscle protein metabolism for up to 9 months post injury. However, the temporal relationship between skeletal muscle fractional synthesis and breakdown rates following burn trauma remains unclear. Here, we determined protein kinetics skeletal muscle fractional synthesis (FSR) and breakdown (FBR) rates in burned children for one year following injury. Methods: We studied 42 pediatric patients with severe burns (>30% total body surface area) from their acute hospitalization up to 12-months post burn injury. Protein kinetics were determined with bolus injections of 13C6 and 15N phenylalanine. Skeletal muscle biopsies were obtained from the m. vastus lateralis. Plasma, muscle intracellular and bound protein pool enrichments were determined by gas chromatography-mass spectrometry (GCMS). Results: Significant increases were seen from acute hospitalization to discharge in muscle FSR (0.11 ± 0.02% vs. 0.19 ± 0.03%, p<0.05) and FBR (0.18 ± 0.02% vs. 0.27 ± 0.03%, p<0.05). FBR significantly decreased from discharge to six month post injury (0.27 ± 0.03% vs. 0.18 ± 0.03%, p<0.05). Although there was a reduction in FSR from discharge to six months post injury, statistical significance was not found. No significant differences were found from six months to 12 months in protein turnover. FSR in all time points were significantly higher (2- to 3-fold) compared to healthy non-burned adults (p<0.05). Conclusions: Skeletal muscle protein turnover remains elevated for up to one year in burn victims. This appears to be mediated by concurrent elevations in both FBR and FSR. Applicability of Research to Practice: Elevated skeletal muscle protein turnover contributes to cachexia and hypermetabolism in burn victims. Our data calls for further investigation into agents which blunt muscle protein turnover in burn victims. External Funding: NIH-P50, Project 9 (81754), R01 AR049877, P30 AG024832, T32-GM8256, The ITS at UTMB (supported in part by a CTSA [UL1TR000071] from the NCATS,NIH).Shriners Hospitals for Children (84090, 71006, 85310), ADA (67666). NIDRR(H133P110012). 182. Nursing Practices and Perceptions towards Delirium in the Burn Intensive Care Unit D.J. Flores, BSN, RN, M. L. Leas, RN, C. Lopez, BSN, RN, J. R. Meisner, RN, J. C. Pamplin, MD, E.A. Mann-Salinas, RN, PhD USAISR, Fort Sam Houston, San Antonio, TX Introduction: Delirium is a multi-factorial disorder that can be exacerbated by routine interventions for severely burned patients. To improve practice in our burn intensive care unit (BICU) a Delirium Working Group (DWG) was established and staff surveys were performed to assess nurses' knowledge about delirium. The purpose of this project was to evaluate the effectiveness of the DWG educational interventions on identified deficits in nursing staff knowledge and practice regarding delirium. Methods: A comprehensive education program was developed to address an identified delirium knowledge gap. In 2014, a written survey was given to assess BICU staff knowledge about the following topics: staff perception regarding importance of delirium, assessment for delirium, triggers for delirium, delirium assessment tool Confusion Assessment Method in the ICU (CAM-ICU), and if the education provided changed their practice. Results: Survey participation was 60% (41/68). Responses included: 90% felt delirium education provided was helpful and relevant to practice; 98% identified delirium as important; 55% noticed an increase in the diagnosis of delirium; and 99% believed that sleep is helpful in reducing delirium. Comments provided in rank order included: 1) CAM-ICU was difficult to use in intubated patents (n= 10/24); 2) an inability to complete their assessments using the CAM-ICU (n=12/18); 3) physicians do not use nurses' assessments (n=8/13); and 4) a more subjective tool might be useful and easier (n=26/41). Staff identified nursing interventions that decreased delirium: implementation of a sleep protocol, limitation of benzodiazepines, family presence, transitioning patients from ICU sooner, reduced poly pharmacy, use of haloperidol, sleep aids, continuation of home medications. Conclusions: Education improved staff understanding of the clinical implications of patients with delirium and interventions. Recently, we evaluated the Intensive Care Delirium Screening Checklist (ICDSC), are developing a sedation/delirium protocol, and included delirium and sleep to multi-disciplinary care team daily rounds. Evidence-based literature on delirium best practices are provided to new and rotating staff and nurses can now request behavioral consults as indicated. Applicability of Research to Practice: A comprehensive, multi-disciplinary approach to delirium prevention, recognition and management is essential for our critically ill BICU population. 183. Quantification of Anesthetic Requirements in the Operating Room as Total Burn Surface Area Increases R. M. Singa, MD, MPH, R. D. Kale, BA, A. J. Iskander, MD, A. P. Houng, MD Saint Barnabas Medical Center, Livingston, NJ Introduction: Pathophysiological alterations in burn patients commonly necessitate greater doses of anesthetic medications. However, there is currently no quantification of these increased intraoperative drug requirements in the literature. We aim to correlate the intraoperative doses of medication used as total burn surface area increases. Methods: After obtaining approval from the Saint Barnabas Medical Center (SBMC) institutional review board (IRB), we obtained records of all SBMC burn procedures from August 2013 to January 2014. We collected demographics, total burn surface area (TBSA), dosages of drugs delivered, and duration of cases. We calculated the amount of drug delivered per kilogram per minute for fentanyl, propofol, and rocuronium, in each procedure. Correlations of each case TBSA and unit delivery of fentanyl, propofol, and rocuronium were calculated using statistical analysis. The units delivered were then distributed into TBSA stratifications of minimal (0–19%), moderate (20–39%), and severe (40–60%) burn (no burn patients had a TBSA greater than 60%). Results: We found 70 cases that had corresponding anesthesia intraoperative monitoring system (AIMS) data. The data demonstrated an average age of 46 years, TBSA of 23%, procedure duration of 160 minutes, and delivery of fentanyl 0.0267 mcg/kg/min, propofol 0.036 mg/kg/min, and rocuronium 0.007 mg/kg/min. Calculations demonstrated that increased TBSA percentages were positively correlated with increased delivery of fentanyl (correlation=0.09), propofol (correlation=0.53), and rocuronium (correlation=0.28). Distribution of drug delivery units into the burn severity stratification demonstrated increasing requirements of fentanyl, propofol, and rocuronium as a function of units/kg/min, as the percentage of TBSA increased: Fentanyl 0.0251 mcg/kg/min in 0–19%, 0.0275 mcg/kg.min in 20–39%, and 0.0290 mcg/kg/min in 40–60% burn; propofol 0.0158 mg/kg/min in 0–19%, 0.0331 mg/kg/min in 20–39%, and 0.0881 mg/kg/min in 40–60% burn; and rocuronium 0.00573 mg/kg/min in 0–19%, 0.00697 in 20–39%, 0.00814 in 40–60% burn. Conclusions: While we often utilize larger doses of drugs in burn patients, this increase in drug delivery has not been quantified. We demonstrated that increasing TBSA percentages were positively correlated with progressively increasing deliveries of fentanyl, propofol, and rocuronium. Future studies will evaluate larger numbers of burn procedures, as well as match burn and non-burn patients to further quantify increases in drugs delivered. Applicability of Research to Practice: Quantification of drug requirements for burn patients undergoing procedures can provide a safer anesthetic in a population that has increased morbidity and mortality as total burn surface area increases. 184. Effect Of Extracorporeal Shock Wave Therapy on Scar Pain in Burn Patients C. Seo, MD Hallym University, Seoul, Republic of Korea Introduction: Burn patients commonly experience scar pain after wound recovery. Extracorporeal shock wave therapy (ESWT) has been used to treat various musculoskeletal diseases and wounds. ESWT reduces pain and promotes tissue regeneration and wound healing. Therefore, we investigated the clinical utility and effects of ESWT on scar pain in burn patients. Methods: A total of 21 patients complaining of scar tenderness and pain underwent ESWT. Low-energy ESWT (0.05–0.12 mJ/mm2) was administered once weekly for 3 weeks. The numerical rating scale (NRS), Nirschl pain phase system, 70-point scoring system, and Roles and Maudsley scores were evaluated before ESWT and after the third ESWT. Results: NRS, total Nirschl pain phase system, and 70-point scoring system scales showed a significant decrease (p < 0.05) from values before ESWT initiation compared to those taken 1 week after three ESWT sessions. The Roles and Maudsley scores showed a significant increase in patient satisfaction with regard to pain relief after the third ESWT (p < 0.05). Conclusions: ESWT is a non-invasive, feasible, and effective treatment for scar pain relief in burn patients. Applicability of Research to Practice: This preliminary data shows that ESWT in the burn patient may be helpful for post-burn scar pain and itching control. External Funding: This study was supported, in part, by grants from Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education (NRF-2014R1A1A4A01007956 to CHS). 185. Pain Scores with Atypical Pain Regimens in Severe Burn E. E. Jang, BS, M. R. Saeman, MD, S. S. Banon, BA, A. Burris, RN, S. E. Wolf, MD, FACS University of Texas Southwestern Medical Center, Dallas, TX Introduction: Severely burned patients receive a variety of medications to alleviate their pain. We wondered if there are differences in pain scores and perceived acceptable levels of pain in patients who receive only opioids versus patients who receive atypical pain medications in addition to opioids. Methods: The regional burn center's database was queried for subjects with greater than 20% TBSA (total body surface area) burn admitted from January 2011 to March 2014. Subjects who received only opioid medications were categorized into the “opioid” group, and those who received any combination of atypical non-opioid pain medications in addition to opioids were in the “non-opioid” group. Non-opioid medications included haloperidol, olanzapine, benzodiazepines, SSRIs, tricyclics, trazodone, gabapentin, and NSAIDs. The non-opioid subjects were matched for TBSA burn, age, and gender with opioid subjects. Pain scores and reported acceptable levels of pain were collected from review of the electronic medical record. Scores were averaged from the first five days of hospitalization and compared to scores from the last five days of hospitalization to evaluate for differences. Statistical analysis was performed with SigmaPlot using t-test, Mann-Whitney, chi-square, and Wilcoxon signed rank test where appropriate. Results: Twenty-eight subjects were identified in each cohort. The median TBSA burn was 25% (21, 31[IQR]) in non-opioid subjects and 28% (24, 32 [IQR]) in opioid subjects. The median length of stay was 31 days and the mean age was 42 years for both groups. There was no statistical difference in TBSA burn, gender, age, or length of stay between groups. We found no differences in pain scores or acceptable pain levels between groups at either time points. Paired t-test demonstrated no statistical change in pain scores over hospitalization in the opioid group. However, those who received non-opioid pain medications had a statistical improvement (p = 0.018) in pain scores over their hospitalization from 2.5 (1.6, 3.9 [IQR]) to 1.8 (1.2, 2.5 [IQR]) at the end. There was no statistical difference in the acceptable level of pain over hospitalization in either group. Conclusions: Our results suggest improved pain scores with atypical pain regimens compared to opioid only treatments. Applicability of Research to Practice: Non-opioid pain medications should be considered in pain regimens after severe burn. External Funding: National Institutes of Health award number T32GM008593. 186. A Preliminary Study on qEEG in Burn Patients with Chronic Pruritis F. K. Miraval, MD, C. Santiago, BA, L. Morales-Quezada, MD, B. Fernandes, PT, PhD, D. Nadler, BA, V. L. Shie, BS, C. M. Ryan, MD, J. C. Schneider, MD, F. Fregni, MD, PhD, MSPH Spaulding Rehabilitation Hospital, Charlestown, MA; Massachusetts General Hospital, Boston, MA Introduction: Chronic pruritis is common after burn injury. Pruritis may be associated with plasticity changes in cortical neural circuits. Electroencephalography (EEG) can be a useful tool to investigate such changes. The objective of this study was thus to determine in an exploratory manner whether there are EEG changes in burn patients with chronic itching compared to healthy subjects. Methods: 8 subjects were recruited for this exploratory pilot study: 4 patients with pruritis after burn injury matched by gender and age with 4 healthy subjects. EEG recordings were analyzed for absolute alpha, low beta, high beta and theta power for both groups. Results: The mean age of the burn patients was 41.75 while the mean age for the matched healthy subjects was 41.5. All subjects were males. A decreased alpha activity was observed in the occipital channels (0.82 vs 1.4; p=0.01) and a decreased low beta activity in the frontal area (0.22 vs 0.4; p=0.049) in the eyes closed condition. An overall decreased theta trend was observed in both the eyes open and eyes closed conditions in burn patients compared to healthy individuals. Conclusions: This preliminary study presents initial evidence that chronic pruritis in burn subjects may be associated with brain plasticity changes at the cortical level characterized by an EEG pattern different from that of chronic pain. Applicability of Research to Practice: The results of this study may be useful in better understanding and developing effective treatments for chronic itch in the burn population. External Funding: The contents of this manuscript were developed under a grant from the Department of Education, NIDRR grant number H133A120034. 187. Association between Burn Characteristics and Pain Severity A. J. Singer, MD, L. Beto, BS, D. Singer, MS, J. Williams, BA, S. Sandoval, MD Stony Brook University, Stony Brook, NY Introduction: Sensitivity to pinprick and presence of pain have traditionally been used to determine burn depth, with the understanding that most third degree burns are painless due to destruction of underlying sensory nerves. We explored the association between patient and burn characteristics and pain severity in burn patients and determined whether 3rd degree burns were less painful than more superficial burns. Methods: We performed a structured retrospective review of medical records of all patients presenting to a regional burn center between 2010 and 2013. Data abstracted included baseline patient demographics and burn characteristics (etiology, size, location, depth). The primary endpoint was pain severity on patient arrival to the hospital using a verbal numeric score of 0 to 10 (from none to most). Univariate and multivariate analyses were used to explore the association between patient and burn characteristics and pain severity. Results: There were 507 patients between 2010–2013. Mean (SD) age was 29.9 (23.6); 38% were ages less than 18 and 68% were males. Main etiologies included scalds (44%), flame (22%), contact (13%), and chemical (8%) burns. Median (IQR) total body surface area (TBSA) was 4% (2–8%). The median (interquartile range [IQR]) pain score was 5 (2.8). Of all patients 7% had isolated 3rd degree burns. Median (IQR) pain scores in isolated 3rd degree burns were slightly lower than in more superficial burns; 4 (1–8) vs. 6 (2–8) respectively, P=0.09. 25% of patients with isolated 3rd degree burns had pain scores of 0 compared to 18% of all others (P=0.28). There was no correlation between TBSA and pain severity, however, the number of burns the patient sustained was associated with pain scores (P=0.007); pain scores increased with the number of burns. Older age (greater than 18 years) was associated with higher pain scores while isolated head/neck/facial burns were associated with lower pain scores. Conclusions: While pain severity may be slightly less with 3rd degree burns compared with more superficial burns, most patients with isolated 3rd degree burns have pain. Applicability of Research to Practice: Presence or absence of pain should not be used to determine burn depth. External Funding: Grant. Suffolk County Volunteer Firefighters Burn Center Fund Inc. 188. Pediatric Treadmill Burns Re-Visited: A Past Problem Requiring a Future Solution C. R. Bennett, RN, K. J. Richey, RN, BSN, M. A. Pressman, PhD, K. D. McCrory, K. N. Foster, MD, MBA, FACS, P. Kardos, MSN, RN, CCRN Arizona Burn Center, Phoenix, AZ Introduction: Treadmill burn injuries in the pediatric population are most common in young children due to their unique developmental traits. Several published articles cite the need for treadmill injury prevention, but few document actual injury prevention initiatives. At a regional burn center we sought to determine the current extent of this problem, and if prevention efforts are still required. Methods: Data were collected over a five year span using a retrospective chart review. Inclusion criteria were patients 0–18 years of age who sustained friction burns from treadmill use. Descriptive statistics were calculated for all variables including age, total body surface area (TBSA), length of stay (LOS), occupational therapy requirements, cost, and re-imbursement. Results: Fifteen pediatric patients received treatment for treadmill friction burns at a regional burn center between the years 2009 and 2013. Their ages ranged from 2- 12.9 years with a mean of 4.4 years. The average TBSA distribution between partial and full thickness burns were 2.1% and 2.2 % respectively. The overall TBSA measurements ranged between less than 1% and 10%. The hands and fingers were the most commonly affected sites. Hospitalization was required for 100% of the subjects (n=15), with a mean LOS of 2.6 days. All patients required occupational therapy services with an average of 6.1 visits per hospitalization. The average hospital charge was $69,076.70 per stay, with a mean reimbursement of $22,810.40. Approximately 43.75% (n=7) of the subjects had private insurance, and 50% (n=8) were insured through Medicaid. On a national scale, the US Consumer Product Safety Commission reported the incidence of treadmill burns in children during the years 2009 through 2013 ranged between 53 and 84 per year. Conclusions: Although a small percentage of the population is affected by these injuries, they may be associated with devastating outcomes. Friction burns associated with treadmill use in children carry a significant risk for morbidity, including motor function loss. According to our data children in the late toddler age group were the most vulnerable to friction burns from treadmill use. These preventable injuries also impose a significant financial burden on the healthcare system. Applicability of Research to Practice: Prevention efforts are necessary to avoid functional impairment from treadmill friction burns, especially in young children whose motor development is not yet complete. 189. Nonsuicidal High-Risk Fire Behaviors Leading to Self-Inflicted Burns in Social Media: Are Adolescents Burning to Be Cool? P. O. Kwan, MD, FRCSC, D. Neal, RN, BSN, K. Viega, S. Sen, MD, FACS, MS, D. G. Greenhalgh, MD, FACS, T. L. Palmieri, MD, FACS, FCCM University of California - Davis Medical Center; Shriners Hospitals for Children - Northern California, Sacramento, CA Introduction: Social media platforms are widely used to disseminate ideas and create an online presence. Displays of high-risk fire behavior may normalize these dangerous activities for others. We investigated nonsuicidal high-risk fire behaviors on YouTube.com to better understand this phenomenon and suggest opportunities for prevention campaigns. Methods: A search of YouTube.com was performed using the keywords “fire challenge”. The top 150 videos were manually curated for type of video, viewing restrictions, age and gender of participants, number of individual views, video duration, number of attempts, ignition source, accelerant use, location, fire suppression plans, and other related data. Three independent assessors judged the age of participants. Results: A total of 68,800 videos matched the search terms. Of the 150 videos reviewed, 18.7% showed participants actively igniting parts of their body on fire, with the top 5 videos having an average of 31,172 (range 20,869 to 500,024) individual viewers. Participants were predominantly male (86%) adolescents, age 16.4 ± 0.6 years (range 11 to 22 years). Videos were 1.91 ± 0.5 minutes in duration, and depicted an average of 2.35 fire ignitions. The majority of participants used a lighter as the ignition source (71%), and readily available household accelerants to promote flames (36% rubbing alcohol, 21% hand sanitizer). Only 19% of videos were restricted to viewing by those age ≥18 years, while the remaining 81% were visible without restriction, and only 13% of videos were accompanied by warnings or follow-up videos about the consequences of high-risk fire behavior and self-inflicted burns. Conclusions: Social media platforms, such as YouTube. com, display a large number of videos depicting high-risk fire behavior, which reach a large audience. Presumably the largely adolescent male participants engage in such visible behavior to boost their social media presence. Videos are widely available with few restrictions on the ages of those viewing them, and few participants discourage the behavior in others. Applicability of Research to Practice: Social media depictions of high-risk fire behavior are widely available to other adolescents without screening by age, and rarely depict adverse consequences. Prevention campaigns should target social media. 190. Glass Front Fireplaces: A Continued Hazard to Little Hands E. H. Teo, MD, S. Sen, MD, FACS, T. L. Palmieri, MD, FACS, FCCM, D. G. Greenhalgh, MD, FACS Shriners Hospital for Children Northern California and University of California Davis, Sacramento, CA Introduction: Contact burns due to glass-front fireplaces are a known common source of injury in children. Despite current prevention strategies, burns from these devices are an ongoing problem due to the lack of data. The purpose of this study is to better define the risk factors and outcomes for children sustaining these burns. Methods: Data were collected retrospectively from all children seen at our hospital sustaining hand contact burns from glass front fireplaces from 2006–11. Information collected include patient demographics, injury pattern, need for operative intervention, and number of follow-up clinic visits. Values are expressed as mean ± standard deviation unless otherwise noted. Results: A total of 88 patients were treated for 122 hand burns. The mean patient age was 15.7 ± 11.5 months (median age of 12 months, range 2 months-5 years). Total body surface area (TBSA) burned was 1.27 ± 0.98%. Bilateral palm burns were present in 34 patients (38.6%). Involvement of additional body areas occurred in 6 patients (6.8%), including 5 facial burns and 1 foot burn. Early toddlers were most at risk with 45.5% of patients falling in the 10–12 month old range and 26.1% of patients aged 13–24 months. Children were also more likely to be injured during cooler months (see chart). Thirteen patients (14.8%) required excision and full-thickness skin grafts. Patients requiring operative intervention tended to have larger burns (2.3 ± 0.01% TBSA vs. 1.2 ± 0.01% TBSA, p<0.0001) and were more likely to have bilateral hand injury (76.9% vs 32% bilateral involvement). Operative patients also required longer follow-up, 11.3 ± 4.1 clinic visits vs. 2.8 ± 1.7 clinic visits (p<0.0001). Conclusions: Glass front fireplaces continue to be a hazard to young toddlers. The rate of injury is highest during the cooler months. While these burns tend to be small, a notable subset of patients requires surgical intervention with prolonged outpatient follow-up. Despite efforts, glass front fireplaces continue to cause significant morbidity in children. Applicability of Research to Practice: This study provides evidence to support prevention, education, and advocacy efforts to improve safety of glass front fireplaces. View largeDownload slide View largeDownload slide 191. Need for Standardized Youth Firesetting Data Collection and Prevention Education: Initial Findings from Two National Pilot Studies K. S. Klas, RN, BSN, P. J. Tammaro, Fire Prevention Specialist, D. W. Porth, BS, M. M. King, BS, T. Flamm, EMT-P University of Michigan, Ann Arbor, MI; Billerica Fire Department and International Association of Fire Fighters Charitable Foundation, Billerica, MA; SOS FIRES: Youth Intervention Programs, Portland, OR; West Allis Fire Department, West Allis, WI; International Association of Fire Fighters Charitable Foundation, Washington, DC Introduction: Previous studies show youth firesetting (YFS) incidence is vastly under-reported, likely due to lack of standardized data capture in national burn (NBR) & fire incident (NFIRS) databases. There are also sparse data on YFS prevention & intervention (YFSPI) educational activities. To address these gaps, 2 national pilot surveys were conducted for baseline assessment of existing YFS databases & YFSPI prevalence in communities. Methods: Between 2012–2013, a 6-item survey (YFS1) was emailed to State Fire Marshals & regional YFSPI programs querying the presence of local/state YFS electronic databases, software, management, costs, & data elements collected. Simultaneously, a nationally distributed YFSPI toolkit requested personnel to complete a 19 multiple-choice question online survey (YFS2) on agency/staff demographics, burn/fire prevention education activities, target audiences, & YFSPI programs. Results: Of the 65 groups sent YFS1, 91% (n=59) responded. Overwhelming 70% majority of respondents (n=41) had no electronic database (i.e. used paper records), only used NFIRS, and/or used simple spreadsheets. Twenty-one (36%, n=21/59) provided details on data collected, with wide variability in number (mean 58, range 13–136) & type of data elements. Only 1 included data dictionary definitions for each field. YFS2 was completed by 448/19500 (2.3%) respondents & revealed: 92% are fire service; toolkits were used for YFSPI (72%), school education (56%), & community fire safety education (50%); primary target audiences were middle (87%) & high school (69%) students & parents (64%). Half (56%) of YFS2 reported having formal YFSPI programs, with wide variability in program maturity (mean 11.6 years, range 1–40) & number of firesetting youth served annually (mean 67, range 0-1530). Conclusions: Results demonstrate the need for a standardized electronic YFS database. Modeling the NBR/burn registry, it should be tier-leveled to capture a minimal set of de-identified national incident data, with expanded secure fields to meet local multidisciplinary YFS program case management needs. Moreover, initial pilot data show nearly half of YFS2 respondents are providing YFSPI education outside of formal programs. This has potential qualification & community risk reduction implications, indicating a need for readily-accessible professional training on best practices in YFSPI education. Future research is needed to evaluate feasibility of multiple disciplines using a standardized YFS database & effectiveness of a widely distributed YFSPI toolkit. Applicability of Research to Practice: Baseline assessment of existing YFS data sources & community prevention education identifies gaps & directs priorities in future training & research initiatives. External Funding: Funding provided through DHS/FEMA's Grant Program Directorate for Assistance to Firefighters Grant Program - Fire Prevention and Safety Grants. 192. The Fire Challenge: An Analysis of Viral Videos of Self Immolation R. Harris, BA, W. Lee, BSN, RN, K. Marren, BSN, RN, A. Bettencourt, MSN, RN, CCRN, R. L. Sheridan, MD, FACS, P. H. Chang, MD, FACS Shriners Hospital for Children-Boston, Boston, MA Introduction: The “Fire Challenge” (FC) is a social phenomenon in which participants pour a flammable substance on their bodies, ignite it, and post filmed footage on social media. In the summer of 2014, there seemed to be a spike in the number of postings and media coverage about the FC. This study was designed to analyze FC videos to better understand the FC participants. Methods: A search of FC videos posted to YouTube was performed by using the term “fire challenge.” All videos posted in the one month span of August 2, 2014 through September 2, 2014 related to the FC were viewed. Data about the participants and the act of immolation was collected; means and frequencies were calculated. Results: A total of 219 videos from users across North America were viewed. Of these, 45 (33%) contained FC footage and 174 (67%) contained anti-FC messages. The 45 videos showing individuals' FCs averaged 32 times as many likes as dislikes, and 8.9% were reposted. Friends/family watched in 84.4%, including mothers in 4.4%. Average time on fire and percent body surface area on fire (%BSA) were 4.5 sec and 9% respectively. The most common known accelerant and fire source were acetone/nail polish remover and lighters. Clothing involvement caused fires that burned 3 times as long on average. The most common method to extinguish was rubbing the area vigorously (33.3%), while Stop, Drop, and Roll (SD&R) was employed once (2.2%). Males comprised 89% of FC performers, and the 15–20 year age bracket was the most common to both perform and speak against the FC. African Americans (AAs) were the most common to both perform the FC and speak against it. However, Caucasians (CCs) averaged a slightly longer time on fire and a much higher %BSA than AAs. Conclusions: Males aged 15–20 were the most common group to perform the FC. While the current practice is to teach fire safety in elementary school, this data suggests fire education should be revisited in high school/college. Education must also extend to parents, evidenced by their presence during FCs and the fact that the most commonly used materials are common household items. Current programs teach to stop, drop, and roll and seek fire extinguishers. However, most FC participants vigorously rubbed their body to put out flames, and no one used a fire extinguisher. Education must be altered to be more effective. This study revealed YouTube as a popular vector through which dangerous activities can be perpetuated. Thus, it could be a tool to combat the FC trend, for example by purchasing fire safety ads to appear with certain search words. Applicability of Research to Practice: Targeted burn education could easily be added to high school/college orientation. In addition, burn providers could utilize social media for burn prevention, especially to target a younger, web-savvy population. 193. Prepackaged Noodle Soup in Styrofoam Microwavable Container Result in Increase in Number Scald Burns in School Age Children M. K. Donovan, MS, RN, PNP-BC, J. A. Fabbri, RN, CPNP, K. Prelack, PhD, RD, R. L. Sheridan, MD, FACS, P. H. Chang, MD, FACS Shriners Burn Hospital, Boston, MA Introduction: Over the last few years prepackaged noodle soups have been reported as a causative agent in soup scalds particularly in school age children. The ease in preparing prepackaged cup style noodle soup has gained in popularity and is resulting in an increased number of scalds in children seen in our outpatient clinic. As part of a burn prevention initiative, a retrospective review of scald burns related to prepackaged noodle soup was conducted to determine predictable pattern, heating mechanism, type of packaging, injury, and the circumstances surrounding the injury. Our findings will be developed into a teaching tool for provider and parents' regarding the potential risks with use of prepackaged soup and how to institute appropriate safety measures. Methods: Information on all patients greater than or equal to 18 years of age, treated for scald burns from prepackaged noddle soup during the years 2011 through 2014 was gathered from a data registry bank maintained by the outpatient department of a tertiary burn care facility. Data collection elements included: age, gender, preparation method (microwave, stove), packaging style (polystyrene cup vs. square package in bowl), burn site and total body surface percentage, and circumstances surrounding the injury(spilled, sitting at table or on a couch). General descriptive statistics were used to report results. Results: Forty children between the ages of 11 months to 18 years were seen at our facility. The majority of burns occurred in school aged children (42.5%). Distribution of the remaining children was as follows: 2 infant, 9 toddlers, 9 preschoolers, and 3 adolescents. Soup packaged in a polystyrene cup represented the highest incidence of these scalds (77.5%) vs. square noodle packs in bowl (20%). Microwave heating was the most common cooking method (85 %), while stove cooking was the least reported (15 %). The most frequent burn site was the anterior thighs and the perineum (60%). Burn injury most commonly occurred with the child reaching for the cup (60%), followed by burn during removal and transport (48%), and when seated on the couch (40%). Conclusions: The risk for soup scald injury is increased in school age children who prepare soup in microwave polystyrene cups. The mechanism of cause is multifaceted. Patterns of injuries sustained related to removal from microwave, transport or while eating the soup on the couch. An educational brochure was created to provide to providers and parents related to the risk and precaution associated with prepackaged noodle soups. Applicability of Research to Practice: This data was used in the development of a anticipatory teaching tool for parents and providers. This tool will provide safety measures in the use of prepackaged noodle soups. 194. The Fire Challenge: A Case Report and Review of Self-inflicted Flame Injury Posted on Social Media A. H. Avery, MD, L. Rae, MD, J. B. Summitt, MD, S. A. Kahn, MD Vanderbilt University Medical Center, Nashville, TN Introduction: With the advent of social media platforms such as Facebook and YouTube, online dissemination of exhibitionist videos has gained popularity. One recent trend is the “fire challenge” wherein a participant douses his or herself in a household accelerant such as isopropyl alcohol or acetone, sets him or herself ablaze, and attempts to extinguish the flames before serious burns are incurred. As expected, participants in the “fire challenge” often accidentally suffer serious burns. A 17 year old white male was recently treated at our burn center after participating in the “fire challenge.” He suffered 15% TBSA full and partial thickness burns requiring split thickness skin grafting to his abdomen. He reported lighting himself on fire because he had seen this stunt performed on the internet. Methods: A search for “fire challenge” and similar terms was conducted on YouTube (www.youtube.com). Gender and ethnicity of each participant were documented. Burn size, burn depth, and age of video participant were estimated by two attending burn surgeons evaluating YouTube videos. Results were reported with descriptive statistics. Results: The search yielded thousands of hits, mostly home videos, stunt compilations, and commentaries. After omitting duplicate and irrelevant videos, 50 videos were selected for the study. Of these, 13 videos included post-burn footage demonstrating burn wounds of various location, size, and severity. Of these burns, the median TBSA burned was 4% ± 2.7% with a maximum size of 10%. Superficial and partial thickness burns were sustained on the torso (10/13, 77%), face (4/13, 31%), and extremities (2/13, 15%). Full thickness burns were seen in 2/13 videos. Some burn wounds were obscured by dressings. Of the 50 videos reviewed, 45/50 participants (90%) were male and 32/50 (64%) were African American with 29/50 participants (58%) estimated to be under age 20. Conclusions: The “fire challenge” is a popular social media phenomenon, but it can result in severe injury as seen with the patient at our institution. The lure of a challenge and potential for a shocking video to “go viral” might entice people to mimic this risky behavior. The current study shows a disturbing trend, but undoubtedly only reflects a small portion of actual participants. A disproportionate number of videos featured young African American males, making this a target population for education and prevention efforts. Our patient's burn size exceeded the maximum found on YouTube, suggesting that less severe burns may be posted online while larger burns are not, diminishing perceived risk and encouraging this behavior. Applicability of Research to Practice: Understanding high-risk behavior is key to injury prevention. Identifying populations at risk helps focus educational and preventative efforts. 195. The Salt and Ice Challenge: A Case Series and an Internet Phenomenon L. O. Roussel, BA, S. A. Kahn, MD, D. E. Bell, MD University of Rochester, Rochester, NY; Vanderbilt University Medical Center, Nashville, TN Introduction: “Salt and Ice Challenge” (SIC) entails applying salt then ice to the skin and measuring how long a participant can withstand the pain of inducing a freezing burn. Limited reports in clinical publications have described single cases or small case series of frostbite injuries that resulted from participation in a SIC. Innumerable articles in the lay press have described participants' experience taking the challenge. No studies to date have described the patient population vulnerable to this mechanism of injury. This study sought to describe the profile and outcomes of those participating in the SIC in an online video repository. Methods: A search on popular video website, YouTube, was conducted. Search terms included “salt and ice challenge gone wrong,” “salt and ice challenge burn,” and “salt and ice challenge.” The first 50 relevant videos were selected for dual evaluation by two surgeons with specialized training in burns. Each physician made note of the approximate total body surface area of burn and estimated burn depth. Videos selected met the following criteria: 1) Video footage of when ice was first applied to skin with salt to the time when ice was ultimately removed, 2) Adequate visualization of the skin before and after SIC. Demographics, length of time ice in contact with salt and skin, depth of burn, approximate total body surface area of burn, and burn location were analyzed. Results: Fifty videos with 63 SIC participants were observed (32 females (50.8%) and 31 males (49.2%)). Age of participants was approximated, with participants in 7 videos appearing less than 10 years of age, participants in 35 videos appearing 10–20 years of age, and participants in 8 videos appearing to be greater than 20 years of age. Nine videos were censored or removed from YouTube due to violating the website's Community Guideline that prohibits posting content that encourages harmful and dangerous behavior. Surgeons estimated mean burn size to be 0.41% and 0.5% TBSA. Surgeons agreed that 12 participants suffered deep partial or full thickness burns and 44 had superficial partial thickness burns (Kappa=0.605, SE=0.112, CI=0.384–0.825). Most commonly burned areas included dorsal forearm (n=21), palm (n=15), and abdomen (n=4). Salt and ice were in contact with skin on average for 101.4 seconds. Conclusions: SIC is a popular social media-driven phenomenon. Teens are often driven by peer pressure, frequently utilize social media, and are at higher risk of injury. Increased public education and parent awareness are essential to address this public health concern. Applicability of Research to Practice: Primary care providers, emergency physicians and staff, burn surgeons, dermatologists, and other providers that participate in the care of the aforementioned population must be aware of this rampant and widespread self-injurious behavior. 196. An Initial Analysis of the Media Coverage of the Fire Challenge W. Lee, BSN, RN, K. Marren, BSN, RN, R. Harris, BA, A. Bettencourt, BSN, RN, R. L. Sheridan, MD, FACS, P. H. Chang, MD, FACS Shriners Hospital for Children-Boston, Boston, MA Introduction: Over the summer, the “Fire Challenge” viral video phenomenon gained attention in the mainstream media. Young people were pouring flammable substances on their bodies, igniting themselves, and posting the film of this self-immolation on social media. An analysis was made of online media reporting on “The Fire Challenge” to better understand this “contagious” practice. Methods: To assess the breadth and depth of online coverage, searches on Google News, Bing, and Yahoo using the term “fire challenge” were performed on 2 dates (9/18/2014 and 9/21/2014). The first 200 hits through each of the search engines were evaluated for relevance to the viral self-immolation and filming phenomenon. Twenty-six relevant stories were identified and then analyzed with regards to geographic location of the reporting organization, type of media source (television vs. newspaper vs. online blog), and content. Results: Of the twenty six stories identified as reporting on the “Fire Challenge”, 12 (46%) were videos from local television news stations, 8 (31%) were text articles from local area newspapers, and the remaining 6 (23%) were from online blogs. The geographic locations of the newspapers and television stations (20/26) were from 11 distinct states (AL, AR, AZ, GA, AR, NC, AZ, MO, KS, MI, FL) and 2 countries (US and New Zealand). A majority of these geographically identifiable stories were from the southeastern United States (12/20 or 60%). Regarding content, 10 (38%) of the stories reported on a participant who had been injured doing the fire challenge and the other 16 (62%) were about the viral phenomenon and a generalized warning to their audience about the dangers of this practice. Only one story referred to an ABA-verified burn center, and only one other story referred to the ABA's position statement regarding the “Fire Challenge.” Conclusions: Based on the media analysis, the midwest and the southeast U.S. were where the majority of the stories were reported from. Online blogs constitute another venue for the dissemination of these stories. Burn professionals should cultivate relationships with their local media so that they will be the experts of first reference when a burn story is being prepared. Applicability of Research to Practice: First, online monitoring of news stories has been used by epidemiologists to track the spread of contagious diseases. This methodology can also be used by the burn community to monitor for the spread of dangerous, fire-related behaviors inspired by online media. In addition to the traditional television and newspaper coverage, online blogs are another outlet through which burn professionals can communicate about safety and prevention. 197. Evaluation of the Impact of a Day Program on Social Comfort and Self-Concept of Children and Teens: A Pilot Study K. L. Badger, PhD, A. Clark, BS, D. Royse, PhD, S. Fisherkeller, MSW, P. Peterson, RN, BSN University of Kentucky, Lexington, KY; The Phoenix Society for Burn Survivors, Grand Rapids, MI Introduction: Burn-injured children and teens, their siblings, and children of burn survivors face psychosocial recovery. Participating in a 3-day structured group program building peer relationships based on shared-experiences, educating about physical and emotional healing from burns, and learning coping skills may assist in adjustment. This study examines the impact of such a program on participants' level of social comfort, self-concept, and informational needs. Methods: The pilot study used a pre and posttest design with a sample of 36 children and adolescent participants. Following IRB approval, study participants completed a pretest at the start and a posttest on the last day of their program, which included demographics, standardized measures for Social Comfort and Self Concept, and items about informational needs and the program's value. Results: Fifty-three percent of the participants were male and on average 13 years old (SD = 3.2). Nineteen (53%) were burn survivors with a TBSA of 48% (SD = 22) sustained 4 years prior (SD = 4). There were no significant demographic differences between the survivor and other group. The total group mean was 3.9 (SD = .89) on the Social Comfort Scale pretest; burn survivors scored 4.19 (n = 18, SD = .6) and the others scored 3.64 (n = 17, SD = 1.1) on the pretest (range 1–5 (high). Analysis found no significant differences on Social Comfort between pre and posttests for any group. Scores on the Self-concept Scale for Children [range 22–110 (high)] were statistically significantly different on pre (M = 91.4, SD = 13, n = 35) compared to posttests (M = 98, SD = 8.8, n = 28) for the overall sample (t (28) = -3.1, p = .004). Burn survivor group pre (M = 92.7, SD = 11.2) and posttest (M = 97, SD = 10.7) scores were also statistically significant (t (16) = -2.87, p = .011). Higher levels of Social Comfort were strongly associated with higher scores on the Self-Concept Scale (r = .69, p = .000, n = 35), even when controlling for pretest Social Comfort scores. Participants rated their informational needs about topics such as interacting with others, coping with negative responses, and feelings about themselves. These needs decreased following the program. Qualitative responses showed participants valued the peer support, spending time with others who shared/understood their experiences, meeting new people, and participating in the activities. Conclusions: Study findings suggest that this programming with its peer support and age-specific educational components contributes positively to participants' healing, specifically regarding self-concept and informational needs. Additional study is needed to further explore retention of the program's impact. Applicability of Research to Practice: This study evaluates the program's impact and identifies perceived benefits. 198. Adolescents Burn Survivors' Reported Anxiety Levels in Social and Dating Situations as Compared to Several Non-Burn Injured Peer Groups R. B. Rimmer, PhD, D. K. Wise, BA, R. C. Bay, PhD, D. W. Chacon, BA, L. D. Hansen, BA, K. N. Foster, MD, MBA, FACS, D. M. Caruso, MD, FACS Arizona Burn Center, Phoenix, AZ; AT Still University, Mesa, AZ; Biola University, La Mirada, CA; Burns Recovered Support Group, St Louis, MO Introduction: Adolescent peer group relationships play an important role in the successful development of social skills and self-perception, both important aspects of effective adult functioning. Friendships, peer interactions, and dating habits appear to be essential factors in assisting them to create personal identity and increase autonomy. It is important to identify barriers to interpersonal growth. This study sought to examine the social and dating anxiety levels of burn-injured adolescents as compared to two groups of non-burned young people. Methods: Three groups of adolescents, Burn Survivors, Lower SES High School Students and Middle to Upper Middle Class College Students were invited to complete the 22-item Social Anxiety Scale for Adolescents (SAS-A) with 3 subscales measuring fear of negative evaluation by others (FNE) social avoidance and distress in new situations (SAD - New) and the (SAD-General) which measures social anxiety and distress experienced among peers. The Dating Anxiety Scale (DAS-A) with 3 identical subscales was also completed in a classroom setting. Results: Participants included Burn Survivors (n=42) mean age±SD (18.8 ± 2.2), High School Students (n=44), mean age (16.4 ± 0.6) and College Freshman (n=56), mean age (19.4 ± 0.7). Burn scars were visible on 72% of survivors. On the DAS, Burn Survivors admitted to significantly more problems than the college students on the FNE (p=.03) and the SAD-New, (p=.004) subscales, but did not differ from the high school group. On the SAS, burn survivors also expressed more problems with FNE (p=.002), the (SAD-New), (p=.004) and the (SAD-General) (p=.001) than the college group, but not from the high school group. Conclusions: It is not surprising that the college students were significantly more confident in both dating and social situations than either the burn survivors or high school students. Although the burn-injured group was two years older than the high schoolers, it is encouraging that there were no differences between their reported dating or social anxiety levels. This particular burn survivor group, on average, had spent over 7 years attending burn camp with nearly 2 years of engagement in a youth burn retreat. These support programs may have contributed to the lack of differences. Applicability of Research to Practice: Burn-injured youth, like all children and adolescents, are in need of support and positive peer interactions for successful growth and development. Burn care professionals can help to support pediatric burn patients by discussing the psycho/social benefits of attendance at burn camp and young adult retreats with children, teens and parents. 199. Psychological Outcome of Pediatric Burn Patients Who Sustained Electrical Injury M. Rosenberg, PhD, N. Mehta, PA-C, L. Rosenberg, PhD, M. Ramirez, BS, D. N. Herndon, MD, FACS, C. R. Andersen, MS, W. J. Meyer III, MD, C. Thomas, MD Shriners Hospital for Children, Galveston, TX; The University of Texas Medical Branch, Galveston, TX Introduction: The adult literature identifies various physical, cognitive, and emotional consequences of electrical injuries including changes with memory, executive functioning skills, and personality changes. Few studies have examined the psychological outcome of electrical injury with children. The aim of the present study was to compare the nature of psychological difficulties experienced during the initial acute hospitalization and at the last follow up visit for children who sustained electrical injuries (EI) with children who did not (Non-EI). Methods: A chart review was done on admissions to this acute care facility from 1997- 2002. Results: The medical records of 67 patients with electrical injuries and 67 matched controls (TBSA, age, & time of injury) were reviewed. For the EI group, the mean age at injury was 12.6 ± 3.9 years, the mean age at follow up was 15.5 ± 4.6 years, and mean TBSA 32 ± 21%. Eighty-eight percent were Hispanic, 82% lived in Mexico and 87% were male. For the Non-EI group, the mean age at injury was 12.4 ± 3.9 years, the mean age at follow up was 14.5 ± 4.7 years, and mean TBSA 32 ± 21.5%. Sixty-one percent were Hispanic and 70% male. During the acute hospitalization, 34 (51%) of patient with EI had acute stress disorder/post-traumatic stress disorder, 15 (22%) neuropathic pain, 24 (36%) had one or more amputations, and 7 (10%) had amnesia about the incident of injury, which were statistically significant (Chi-square tests p < .04). No differences were found between the groups in the areas of general anxiety, depression, grief, and behavior problems. Follow up information from the last documented psychology/psychiatric visit (>6 months post-burn) was available for 42 patients with EI and 39 without EI and an equal number of patients experienced anxiety disorders, depression, grief, and behavioral problems. Four patients in the EI group reported long-term difficulty with memory and 2 with neuropathic pain, but this was not significant. Conclusions: While there were some differences between the two groups immediately post-injury with respect to anxiety, pain, and cognitive functioning, long term outcomes were similar. It is possible the early psychological and psychiatric interventions facilitated post-burn adjustment. Applicability of Research to Practice: Results of this study can help guide assessment and treatment for those with electrical injury. 200. Caregiver Dynamics Following Childhood Burn Injury A. Cochran, MD, FACS, FCCM, I. H. Faraklas, RN, BSN, G. Graves, A. Washburn, DPT University of Utah, Salt Lake City, UT Introduction: Providing care to a family member with a chronic condition is known to have both positive and negative impacts on caregivers. Although an extensive body of literature exists examining caregiver burden in other disease states, little is known about caregiver burden on parents of childhood burn survivors. Methods: The Caregiver Reaction Assessment (CRA), a validated instrument, was voluntarily administered to care providers of children who attended burn camps affiliated with our institution in 2013 and 2014. CRA questions partition into five different domains of caregiving: self-esteem, lack of family support, family concerns, disrupted schedule, and health problems. The study was declared exempt by the IRB. Results: At three burn camps per year, we obtained 93 Completed CRAs representing 74 unique burn injuries in 91 families. There were 13 repeat participants. The mean age of respondents was 38 years and 57 female respondents. Of the 91 families represented, only 13 had a change in caregiver marital status following the burn injury. Most respondents (92%) were the parents of the burned child. Median time from burn injury was four years. The self-esteem subscale, which represents a positive aspect of caregiving, had a mean score of 1.67 (SD ± 1.01), consistent with a strongly positive experience. Negative aspects of caregiving, specifically lack of family support and personal health problems, received moderate to low ratings as issues (3.55 SD ± 1.34 and 2.76 SD ± 1.67, respectively). Financial concerns were intermediate (3.55 SD ± 1.47), with many subjective comments addressing specific healthcare cost-related concerns. Disrupted schedule was also intermediate (3.88 SD ± 1.30), consistent with adults caring for children. Conclusions: Adult care providers generally view their care of childhood burn survivors as a positive experience, particular in regard to the self-esteem gained by the caregiver experience. Knowledge of available financial resources to assist in the care of these children would likely mitigate the most highly rated negative impact of providing care to these children. Applicability of Research to Practice: Providing care for a childhood burn survivor is a generally positive experience. Understanding financial resources that might be available to these caregivers might help bolster their experiences. External Funding: International Association of Fire Fighters Foundation. 201. Association of Family Functioning and Hope to Self-Concept in Pediatric Burn Survivors C. L. Duncan, PhD, J. Mentrikoski, MS, M. Szabo, MS, P. Enlow, BS, K. Ferris, MS, L. Castanon, MD, FACS, R. Kelly, MD, FACS, A. M. Aballay, MD, FACS West Virginia University, Morgantown, WV; Allegheny Health Network West Penn Burn Center, Pittsburgh, PA Introduction: Previous studies have found that greater family cohesion (e.g., emotional bonding or support among family members) is related to better psychological adjustment and quality of life in pediatric burn survivors. In addition, studies have suggested that greater hope was related to better self-concept (e.g., beliefs about one's popularity, intelligence, or social status) among youth with burn injuries. However, no studies to date have examined how child hope may mediate the relation between family functioning and self-concept. Thus, the current study investigates the extent to which youth hope explains the relation between family functioning and self-concept of youth with burn injuries. Methods: Thirty-eight youth (Mage = 12.6 years, range = 8 - 17; 63% male) and their primary caregivers were recruited from outpatient burn clinic visits at two sites, registration for an annual Summer Burn Camp, and by letter and telephone contact with patients in burn registry databases. Youth completed standardized questionnaires that measured hope and self-concept, while their primary caregivers completed a measure of family functioning. Data collection for this study is currently ongoing and thus, a larger sample size is expected by the time of presentation. Results: Mediation was examined using Baron and Kenny's (1986) approach of simultaneous regressions. Greater family cohesion (β = .50, p = .002) and lower youth hopelessness (β = - .50, p = .002) were significantly associated with greater youth self-concept. Youth-reported hopelessness (β = - .40, p = .013) was found to partially mediate the association between family cohesion (β = .35, p = .025) and youth self-concept, Adj. R2 = 0.35, F (2,31) = 9.96, p< 0.001. Conclusions: Results from this study suggest that family cohesion and youth hope significantly predicted the self-concept of pediatric burn survivors. Using a mediation model, results also indicated that the association between greater family cohesion and higher youth self-concept is partially explained by lower youth hopelessness. Applicability of Research to Practice: Our results suggest that targeting hope and family functioning in interventions might promote better self-concept or self-esteem in pediatric burn survivors. External Funding: West Penn Hospital Foundation; West Virginia University Department of Psychology Student Research Fund. 202. Management of Dog Bites in a Pediatric Burn Center M. M. Gottschlich, PhD, RD, C. Allgeier, DTR, T. Joyce, RN, BSN, L. E. James, MS, D. Billmire, MD, R. J. Kagan, MD Shriners Hospitals for Children, Cincinnati, OH Introduction: Dog bites (DB) are a significant cause of pediatric injury. Many practices that optimize conditions for wound repair and quality of life following burns can be applied to the management of bite wounds. The purpose of this study was to determine characteristics of children with DB injuries treated at our burn center and describe their management. Methods: This retrospective review used descriptive statistics to characterize the demographics of DB victims and of the dogs that caused these injuries. Outcomes (operative procedures, comorbidities, infection, commencement of care, psychosocial, sleep interventions) were assessed using Student's t-test, the Wilcoxon rank sum test and χ2 test. Comparisons were made between acute and deferred care patient groups. Additionally, statistics from the NBR and CDC are tabled for visual reference. Results: 28 children admitted to our burn center for acute and/or reconstructive management of DB wounds were studied. 57.1 % were male and 92.6% were white non-Hispanic. The injuries involved an average of 7.3 % TBSA and 29.6 % were inflicted by Pit Bulls. A disproportionate number of injuries in this study involved head and neck (89.2%). Our hospital found 94.1% (16/17) of patients with head and neck injuries in the 0–4 age group compared to 64.9% of children < 4 years of age in the 2001 CDC data (p < 0.001). Children treated during the acute phase began treatment within 8 + 4 days of injury, whereas children admitted later (1453 + 428 days) corresponds to delay of rehabilitative/reconstructive services (p = 0.0045). No difference in number of surgical procedures, comorbidity or infection was detected. Psychosocial issues (PTSD, anxiety, depression, night terrors, insomnia, bullying) were prevalent in both acute and later admission groups. 71% of children admitted for acute care received school re-entry, SOAR, pet therapy, outings and/or sleep interventions. Conclusions: This study provides preliminary evidence that children with DB injuries can be treated effectively in pediatric burn centers. While it is speculated that early, specialized services enhance outcomes, psychological issues remain. More research should be devoted to both prevention and management of DB injuries. Applicability of Research to Practice: DB injuries represent a potential referral base for burn hospitals. Continued surveillance of DB data including TRACS is needed if we are to better understand how to provide optimal care and reduce the incidence of DB injuries. View Large View Large 203. Camp Karma: Challenges and Results of India's First Pediatric Burn Camp A. Khandelwal, MD, N. Venkateshwaran, MBBS, MS, MCh, FRACS, V. Puri, MBBS, MS, MCh, FRACS MetroHealth Medical Center, Cleveland, OH; Jupiter Hospital, Mumbai, India; SGS Medical College and KEM Hospital, Mumbai, India Introduction: A valuable resource for the psychosocial rehabilitation of pediatric burn survivors is the the conduction of pediatric burn camps. India is a low-middle income country with a large pediatric burn population and is known for having a victim-based culture. We sought to launch India's first pediatric burn camp with the mission to create an environment unlike any other that fosters friendship, inclusivity and personal development. Methods: Burn surgeons in and around Mumbai, India's largest metropolitan were contacted, however, there was limited interest, citing lack of benefit and too much work as factors. Ultimately, two surgeons expressed interest, however due to no experience with recreational camps, they were sponsored to attend a burn camp in Israel. Challenges to establish the camp included difficulty in recruiting, administrative support, lack of infrastructure, distrust of parents and lack of knowledge amongst counselors. Surgeons from area hospitals were contacted to recruit children. In addition, brochures were given to municipal schools. Recruitment of administrative support was difficult, ultimately assigned to two plastic surgery residents and a therapist. A professional organization that conducts educational and team-building camps was contacted to assist with the design. Parents completed questionnaires and a mini-conference was held two months prior and one week prior to the camp. Counselors were coached and required to watch educational burn camp videos. A timeline and details of challenges with subsequent action plans are provided. Results: Camp Karma was conducted with 20 children and 20 volunteers over a three-day, two-night period. Demographics of the campers and volunteers are provided. Majority of children belonged to the upper lower class economics. None of the children had been to an event outside of home, hospital or school. Luxuries that were normally taken for granted by the staff were found to be new life events for the majority of children. Sporting, educational, team-building, and artistic events were organized. Positive feedback was received from all children. Conclusions: Establishing a burn camp for pediatric burn survivors in India proved to be challenging on various levels that are atypical of the burn camp model in the United States. However, a burn camp can be conducted successfully with appreciable results even in a lower-middle economic country that has not experienced such an event. Applicability of Research to Practice: This experience can serve to educate others about the challenges that one may face in developing burn camps in countries that do not currently offer them, especially in lower-middle economies. This descriptive review identifies a knowledge gap and fear about the psychosocial effect of burns and burn camps that should be addressed. 204. Combined Psychosocial-Opiate Interventions Reduce PTSD Symptoms in Pediatric Burn Patients F. J. Stoddard Jr., MD, L. Stone, PsyD, A. Kim, BS, A. Ceranoglu, MD, E. Sorrentino, MA, D. S. Chedekel, PhD, J. M. Murphy, PhD, R. L. Sheridan, MD, FACS, R. G. Tompkins, MD, ScD, FACS Massachusetts General Hospital, Boston, MA Introduction: This study examined the hypothesis that combined psychosocial and pharmacological interventions would decrease PTSD symptoms in burned children, more than medication alone. Previous research informed the development of this study, such as the finding that using higher doses of morphine for pain in young children may be associated with a decreasing number of PTSD symptoms (Stoddard, 2009). Improved psychosocial outcomes in children were measured by the reduction in PTSD symptomatology at 3–6 month follow-up. Methods: Data from a previous psychosocial intervention in young burned children was used in this study, and opioid administration was determined by retrospective chart review during the first week of a patient's hospitalization. 0–5 year old burned children admitted to Shiners Hospital for Children-Boston who spoke English or Spanish were eligible to receive the psychosocial and opioid interventions. The psychosocial interventions were either DEF-only (The Distress, Emotional Support, and Family Functioning protocol; nctsnet.org) or DEF+COPE (The Creating Opportunities for Parent Empowerment program; Melnyk et al. 2004). The DEF-only intervention provided support and referrals to parents while the DEF+COPE increased parent's knowledge of their child's injury and their role in their child's care. PTSD symptomatology was measured using the Posttraumatic Stress Disorder Semi-Structured Interview and Observational Record (PTSDSSI; Sheeringa et al., 1994; Sheeringa et al., 2003) at baseline and follow-up. 30 patients participated, 16 females and 14 males. The average age was 2.2 years old. Results: The overall model was significant (p=0.001), accounting for 39% of the variance in the follow-up PTSD score. Burned children receiving opioid medication and family psychosocial intervention had a mean follow-up PTSDSSI score significantly lower (p<0.05) than those receiving medication alone (psychosocial and medication M=3.62, medication alone M=1.55). Conclusions: These results support the hypothesis that combined psychosocial-opiate interventions are superior to medication alone in reducing PTSD symptoms of young burned children. Future research with larger samples is needed to optimize treatment for young children with severe trauma. Applicability of Research to Practice: Children other than pediatric burn patients may also benefit from these findings, including severely injured and traumatized children, and survivors of disasters. External Funding: Alden Trust, Shriners Hospital for Children. View largeDownload slide View largeDownload slide 205. Secure Attachment Associated with Less Pain in Burn Patients S. M. Escolas, PhD, C. A. Rauschendorfer, BSN, S. L. Walker, BS, J. K. Aden, PhD, J. E. Nyland, PhD, K. K. Chung, MD US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX Introduction: This study examines the relationship between attachment style and acute burn pain. Attachment is defined as an enduring emotional bond that connects one person to another. Infants have instinctive behaviors that are important for the formation of attachment to their caregiver. It has been suggested a person's response to pain could be considered an attachment-related behavior, in that pain triggers attachment-related cognitive, behavioral, and emotional mechanisms, which affect the experience and adjustment to pain. Burn pain is one of the most severe and prolonged types of pain. Therefore it is relevant to look at this population. Methods: Patients were included if they were initial burn admissions with 30% or less total body surface area (TBSA) burns; English speaking; and 18 years old and over. Patients completed a questionnaire to determine attachment and information related to pain level and narcotic administration was collected via chart review. Results: Of the129 subjects enrolled and data analyzed, 80% were males, 86% civilian, with an average age of 39 ± 17 and burns involving a mean of 8 ± 7% TBSA. Fifty percent reported at least some college education and a median annual income of $27,000. From our sample, 48% selected the secure attachment category with the remaining distributed across the insecure categories; fearful (19%), preoccupied (9%) and dismissing (24%). There was a significant difference between subjects self-classified as secure receiving less pain medications (33.8 ± 22.9 vs. 43.1 ± 27.7) average daily morphine equivalents, t(126)=2.07,p=0.04) and a trend towards secure reporting lower verbal pain scores (3.6 ± 1.4 vs. 4.1 ± 1.7, p=0.09) then those self-classified as insecure. Conclusions: As data collection continues (129 subjects to date), it appears that attachment may play a role in how pain is experienced and expressed. It is hypothesized that an understanding of burn pain and attachment style may improve strategies for pain management and may reduce the development of psychological issues. Updated numbers and statistics will be presented. Applicability of Research to Practice: Through better understanding of burn patients' pain and attachment style, we can improve on strategies for pain management and possibly prevent future psychological issues. 206. Important Aberrations in Burn Recovery Are Missed During Routine Clinical Encounters R. L. Sheridan, MD, FACS, B. Weaver, BS, C. Chu, BS, M. Lydon, RN, BS, C. M. Ryan, MD, FACS, P. H. Chang, MD, FACS, M. Dylewski, PhD, RD, J. C. Schneider, MD, A. F. Lee, PhD, L. E. Kazis, ScD Shriners Hospital for Children, Boston, MA; Spaulding Rehabilitation Hospital, Boston, MA Introduction: A variety of multi-dimensional Patient Reported Outcome Measures are available for children recovering from burns. The value of adding this information to routine clinical encounters is unknown. It is important to know if this granular information is already captured with current methods before expending time and money to add these measures to routine clinical encounters. Methods: The clinical records of 25 children who had been enrolled in a prospective burn outcome program for at least two years and who had one or more measures that were known to be at least one standard deviation below the norm were examined retrospectively in an IRB approved study. Metrics were the validated 12 domains of the 5–18 year-old ABA-SHC Burn Outcome Questionnaire, including upper extremity function, physical function and sports, transfers and mobility, pain, itch, appearance, compliance with the doctors instructions, satisfaction with current state, emotional health, family disruption, parental concern and school re-entry. Appearance in the clinical outpatient records of the issues described by the domains which were at least one standard deviation below the norm was examined. Results: Twenty-five patient records were examined. Four patients were excluded because follow-up information was not present in the available outpatient record. The 21 remaining children had an average burn size of 12.4 (±3.5) years when burned, and average burn size of 26 (±21) % of the body surface. In this select cohort, the average number of domain scores that were at least one standard deviation below the norm was 3.95 (±3.46) with a range of 1 to 10 and median of 3. Of the 252 domains scored (21 patients times 12 domains), 86 (34.1%) were deficient in this selected group of patients. Of these 86 deficient domains, 19 were specifically mentioned in the outpatient record. The remaining 67 (78%) problem domains did not seem to be directly addressed in the outpatient record. The potentially unaddressed issues included Pain (5), Itch (5), Physical Function and Sports (7), Appearance (7), Compliance (3), Satisfaction (9), Emotional Health (7), Family Disruption (6), Parental Concern (8), and School reentry (10). Conclusions: Adding granular outcome information to routine clinical encounters may enhance the value of these encounters by identifying issues emerging as problems before they manifest overtly, facilitating earlier intervention. Applicability of Research to Practice: The addition of granular outcome information may enhance the effectiveness of routine clinical encounters in children recovering from burns. External Funding: Shriners Hospitals for Children. 207. A Qualitative Analysis of Community-Based Support for Burn Injured Persons T. E. Abrams, PhD, R. Ogletree, PhD, D. Ratnapradipa, PhD, M. W. Neumeister, MD, FACS SIU School of Medicine, Springfield, IL; Southern Illinois University at Carbondale, Carbondale, IL Introduction: Social support is one of the most important predictive variables in burn recovery. Social networks provide linkages between people and environmental functions of social support, social capital, social influence and companionship. Types of available support vary depending on patients' home communities, impacting services that must be augmented through discharge plans. This prospective, qualitative analysis provides an opportunity to observe how environmentally-based factors such as population size influenced support received by participants following discharge from our burn center. Methods: Eight participants were interviewed one time for 45 to 60 minutes, using semi-structured interview scripts employing the seven dimensions of health as a framework. Three wives and one mother were interviewed for triangulation purposes. All twelve interview recordings were transcribed verbatim and checked for accuracy by participants. Transcripts were coded line by line, identifying dominant themes and analyzed for shared meaning among the sample. Qualitative data analysis sought to discover how participants perceive support in their home communities during recovery from major burns. Results: Participants are from a non-probability, purposive sample recruited from the 2012 Survivors' Recognition Dinner. All are Caucasian, with seven men and one woman. Participant burns were > 20% total body surface area (TBSA) including deep partial and full thickness burns to the face, hands, feet, or joints. Range of time since burn injuries occurred was 12 months to 23 years. Mean age at time of burn injuries was 42.38 and mean age at time of interviews was 54.38 years. Study results identified differences in structural characteristics of participants' home communities based on population size. Characteristics of reciprocity, complexity and geographic dispersion were most represented within communities with populations of < 5,000, while formality, intensity and homogeneity were most represented in communities with populations of > 5,000. The structural characteristic of directionality was not represented within data, which may be due to inherent vulnerabilities in burn recovery resulting in imbalances in social capital. Conclusions: Discharge from hospital to home is not a one-size-fits-all endeavor. When discharging patients from a burn center, it is critical to consider all types of resources patients will need as they recover. It is believed that health is reinforced when basic human needs of companionship, intimacy, sense of belonging and individual worth are sufficiently met. Applicability of Research to Practice: Understanding the unique nuances of supportive assets and deficits within patients' home communities will aid providers when organizing discharge plans with the greatest impact. 208. Resilience Theory in Psychosocial Burn Research: A Qualitative Analysis T. E. Abrams, PhD, R. Ogletree, PhD, D. Ratnapradipa, PhD, M. W. Neumeister, MD, FRCSC SIU School of Medicine, Springfield, IL; Southern Illinois University at Carbondale, Carbondale, IL Introduction: Resilience is a strength-based construct that has been referenced in burn care literature for over 25 years without a valid, reliable theoretical foundation to illucidate results. Resilience theory is a health-based framework that most closely represents the strengths shared by participants when interviewed about their burn-specific health. We present this qualitative resilience study with burn patients. Methods: Participants within this prospective study had burns > 20% total body surface area (TBSA) which included deep partial and full thickness burns to the face, hands, feet, or joints. Individual interviews were conducted one time for 45 to 60 minutes, using semi-structured interview scripts with focus on the seven dimensions of health. Three wives and one mother were interviewed for triangulation purposes. All twelve interview recordings were transcribed verbatim and transcripts were coded line by line. Dominant themes were identified then analyzed for shared meaning among the sample. Phenomenological data analysis sought to discover how resilent protective factors were experienced by participants during recovery from major burn injuries. Results: Eight participants are from a non-probability, purposive sample who were recruited at the 2012 Burn Survivors' Recognition Dinner. All are Caucasian, with seven males and one female. Mean interview age was 54.38 years and mean age at time of burn injuries was 42.38. Range of time since burn injuries occurred was 12 months to 23 years. Reductionist data analysis of all twelve verbatim transcripts, field notes, and reflexivity journal were performed, rendering three emergent themes: “Being Burned,” “The Constant Me” and “Growth through Burns.” Within each theme are shared sub-themes depicting resilient protective factors in burn adaption and recovery. Sub-themes within “Being Burned” are body image and social support. Within “The Constant Me” are sub-themes of self-efficacy & goal directedness, insight, optimism and humor. Within “Growth through Burns” are sub-themes of spirituality & attributions for prayer, empathy and gratitude. Conclusions: Qualitative research provides unique personal, subjective accounts of the condition of interest. Findings from this qualitative study validate the appropriateness of Resilience theory when investigating strengths that support recovery from major burn injuries. Utilization of predictive, standardized measures for resilience may be useful in future research and program development for the burn population. Applicability of Research to Practice: Acknowledging Resilience theory as an acceptable theoretical framework for use in burn care research provides additional objective measures that are currently used to investigate and support populations with other chronic health conditions. 209. Connections between Burn-Related Health and Mental Health in Individuals with Burn Injury H. LiBrandi, BS, M. E. Sutter, MS, P. B. Perrin, PhD, M. J. Feldman, MD, L. Parsa, K. Lyford Virginia Commonwealth University, Richmond, VA Introduction: Burn injuries commonly affect patients' satisfaction with life, body image, interpersonal relationships, and psychosocial functioning. This study examined specific associations between eight domains of burn-related health and anxiety, depression, and satisfaction with life. By identifying the aspects of patients' burn-related health that are most associated with their mental health, it is possible to provide more focused care and interventions that improve burn patients' overall quality of life after injury. Methods: Individuals with burn injury (N = 74; 70.1% male; average age = 41.16) completed measures of burn-related health (heat sensitivity, hand functioning, treatment regimens, work, sexuality, interpersonal relationships, simple abilities, and body image) and mental health (depression, anxiety, and satisfaction with life [SWL]). The majority of patients had 0–10% total burn surface area (61.0%). Results: In three simultaneous multiple regressions, indices of burn-related health were regressed onto the three patient mental health variables. Burn-related health was robustly associated with patient depression [F(8, 68) = 11.68, p < .001, R-squared = .58], anxiety [F(8, 68) = 8.62, p < .001, R-squared = .50], and SWL [F(8, 68) = 7.01, p < .001, R-squared = .45]. Individually, interference with work was uniquely associated with depression [β = -.25, p = .007], anxiety [β = -.38, p < .001], and SWL [β = .27, p = .009]. Heat sensitivity was uniquely associated with depression [β = -.24, p = .016] and anxiety [β = -.25, p = .020], and hand functioning was related to depression [β = -.22, p = .037]. Body image was uniquely associated with depression [β = -.27, p = .012] and SWL [β = .31, p = .011]. Finally, problems with interpersonal relationships were associated with SWL [β = 29, p = .019]. Conclusions: Burn-related health was robustly related to the mental health of individuals with burn injury, with burn-related health explaining between 45–58% of variance. Interference with work due to burn injury may exert a particularly strong influence on patient mental health. Physical functioning and social factors may especially affect depression and life satisfaction. Targeting these burn-related health domains may have positive implications for mental health. Applicability of Research to Practice: These findings can supplement evidence-based interventions for improving functioning of individuals with burn injury. Isolating the burn-related health domains that affect patients' mental health may help tailor interventions to reduce psychosocial problems and increase satisfaction with life. 210. Intervention to Reduce PTSD in 0–5 Year Olds with Burns F. J. Stoddard Jr., MD, A. Kim, BS, J. M. Murphy, PhD, D. S. Chedekel, PhD, G. White, BA, B. C. Williams, BS, G. N. Saxe, MD, J. K. Man, BS, K. Canenguez, PsyD, R. L. Sheridan, MD, FACS Massachusetts General Hospital, Boston, MA; Shriners Hospital for Children-Boston, Boston, MA; NYU Langone Medical Center, New York, NY Introduction: The objective of this study was to use two interventions to decrease PTSD and PTSD symptomatology in young burned children as measured by the Posttraumatic Stress Disorder Semi-Structured Interview and Observational Report, or PTSDSSI (Sheeringa et al., 1994; 2003). The PTSDSSI was an appropriate instrument for evaluating PTSD in young children because its use elsewhere informed the DSM 5 diagnostic subtype, “PTSD in Children 6 Years and Younger” (APA, 2013). The PTSDSSI also requires parent observation of symptoms appropriate for young children-such as children's posttraumatic play, distressing dreams, withdrawal and irritibility; with a maximal score of 38. The Intervention group in this study received either the DEF (Distress, Emotional Support, and Family Functioning protocol) or the DEF+COPE (Creating Opportunities for Parent Empowerment program). Outcomes of child stress were compared with a Non-Intervention, control group. Methods: Children aged 0–5 years old admitted for an acute burn or for reconstructive surgery and their families, who speak English or Spanish, were eligible. The DEF consists of an initial meeting with caregivers to identify distress or support from an interview and offer clinical referrals for the family, and can be found online on nctsnet.org. The COPE (Melnyk, 2004) provides a workbook to increase parents' knowledge of typical behaviors and emotions children display in hospital and advice on how to participate more directly in child's care. Parents completed the PTSDSSI after their child's admission and at 6 month follow-up, to measure child stress. The 6-month change scores of the PTSDSSI were analyzed for three symptom clusters: re-experiencing(B), numbing/avoidance(C), and hyperarousal(D). Results: Although results did not reach statistical significance in this small sample, there was a clear trend of larger decreases in PTSD symptoms for children in the intervention group as compared to children in the control group. Conclusions: Both forms of intervention appear to have aided in the reduction child stress as measured by the PTSDSSI. Future studies with larger samples should explore both types of intervention. Applicability of Research to Practice: The psychosocial interventions outlined have clear benefits that should be taken into consideration when providing care to children with burns. External Funding: Grant #8894, Shriners Hospitals for Children. View largeDownload slide View largeDownload slide 211. Psychological Support Strategies in Hospitalized Burn Patients: A Quality Performance Improvement Assessment M. J. Rothbauer, MSW, J. Rood, RN, D. H. Ahrenholz, MD, FACS, D. Dries, MD, W. J. Mohr, MD, FACS, F. W. Endorf, MD Regions Hospital Burn Center, St. Paul, MN Introduction: Psychological intervention and support is an integral part of a burn recovery. Working in a Level I trauma center which serves a five state area creates an additional set of challenges for the psychosocial team. Early and consistent interventions by social work/case management, child life and chaplaincy can create a safe and healing environment for patients and families which contribute to positive outcomes. Methods: Creating this community of support starts in the acute setting and is offered throughout the hospitalization and into the months and years post injury. Assessments upon admission reveal individual patient and family needs but the importance of frequent and consistent involvement for the duration of the hospitalization and during follow up care can significantly affect outcomes. Every burn patient is expected to have a consult to every discipline within the psychosocial team including social work/case management, chaplaincy, and child life (if applicable). These consults remain in the electronic medical record until the consult has been completed. During this consult the social worker assesses the appropriateness for any/all of our psychological programs offered at our burn center. These programs are offered during and after the inpatient admission. The implementation of these programs is discussed in our weekly provider care rounds and all team members are encouraged to provide input into what programs would be suitable for each patient/family. Results: A random retrospective quality performance assessment of 30 patients admitted to the burn center during 2014 was completed. The length of stay for these patients ranged from 1 to 126 days. One hundred percent of the 30 patients were seen by social work/case management. All five children had child life consults completed. In addition there was one adult patient who was also seen by child life. Chaplaincy saw 17 of the 30 patients. Conclusions: A consistent approach to psychosocial interventions facilitates optimal psychosocial support. Ongoing outreach, education, and communication with our referral sources are crucial to long term positive psychological outcomes for burn survivors and their families. Applicability of Research to Practice: Eliciting feedback and satisfaction surveys from patients and that specifically address their experiences of being hospitalized regionally could further support ongoing psychological programming. 212. Psychological Factors Associated with Pressure Garment Adherence in Pediatric Burn Patients C. L. Duncan, PhD, P. Enlow, BS, M. Szabo, MS, J. Mentrikoski, MS, R. Kelly, MD, FACS, L. Castanon, MD, FACS, A. M. Aballay, MD, FACS West Virginia University, Morgantown, WV; West Penn Allegheny Health System, Pittsburgh, PA Introduction: Adherence to treatment regimens is associated with positive health outcomes; unfortunately, many youth exhibit poor treatment adherence. Previous studies have found that various psychological variables (e.g., psychopathology, treatment satisfaction) are associated with adherence in pediatric chronic illness populations. Although past research suggests compliance is problematic in rehabilitative regimens, the relation of these variables to adherence in pediatric burn survivors has not been studied. Thus, there is a need to understand what factors are associated with adherence to pressure garment use in pediatric burn survivors. Methods: To date, 10 youth between the ages of 2 and 17 years and their caregivers have been recruited from a burn center in the eastern United States. Data collection is ongoing; a sample of at least 25 youth is anticipated for this presentation. During clinic appointments, participants completed questionnaires assessing demographics, treatment satisfaction, pressure garment adherence, and child psychopathology. Two independent medical team members also rated scar appearance, condition of the garment, and estimated adherence to pressure garment regimen. Results: Hyperactivity (r = .84, p < .01), attention problems (r = .71, p < .05), and overall behavior problems (r = .78, p < .01) were associated with worse parent-reported pressure garment adherence. In contrast, higher youth-reported locus of control was associated with better medical staff-rated pressure garment adherence (r = -.99, p < .05). Greater parent treatment satisfaction was correlated with less scar elevation (r = .71, p < .05), while presence of conduct problems was associated with worse treatment satisfaction (r = -.78, p < .05). Conclusions: These findings suggest that caregivers of youth with externalizing behavior problems may perceive more non-adherence and feel less satisfied with the pressure garments. Caregivers may also be more satisfied with pressure garments when scar appearance improves. However, medical staff may perceive greater adherence when youth have better locus of control. Applicability of Research to Practice: Results from this study can help improve treatment outcomes in pediatric burn survivors. Specifically, strategies to enhance patient sense of control over burn recovery as well as behavior plans to bolster treatment adherence and satisfaction in youth with known externalizing behavior problems could be key target areas. 213. Efficacy and Safety of Bupivacaine Liposome in Older Pediatric Reconstructive Surgical Burn Patients D. Hursey, PharmD, R. M. Seagren, PharmD, K. Prelack, PhD, RD, D. N. Driscoll, MD, FACS Shriners Hospitals for Children - Boston, Boston, MA Introduction: Contracture release and grafting procedures are painful for children requiring post-operative pain management. Use of alternative wound coverings, intraoperative use of local anesthetics, and post-operative opioids are standard approaches utilized. Despite their use, donor site pain can remain problematic leading to an increase in opioid use and side effects, increased length of stay, and decreased patient satisfaction. The introduction of bupivacaine liposome (BL) shows promise in managing post-operative pain due to its local duration of action of up to 72 hours. BL was approved at our institution with strict criteria for use in 2013 for patients at least 16 y/o with no known cardiac anomalies. The efficacy and safety of the drug is reported over a 12 month period. Methods: A retrospective chart review was conducted for patients receiving BL at our institution from 8/2013–8/2014. Each patient was matched to a similar procedure without the use of BL. Mean pain scores, total mg of morphine equivalent (ME) used in 72 hours, total opioid doses in 72 hours and inpatient days were used to compare BL efficacy to standard therapy. Local anesthetic systemic toxicity (LAST) and cardiac arrhythmias were recorded to assess safety of therapy. Comparisons were made by Student's t test. Results: Nine patients (5 female, 4 male) were identified for a total of 10 administrations of BL. Of the self-matched procedures, 7 received standard therapy of intra-operative bupivacaine with post-operative opioids and 3 received standard therapy plus local bupivacaine infiltration pump (LBIP). Table 1 shows their results. All endpoints were significantly lower with BL use. There was a trend toward improved efficacy endpoints with patients who received BL versus LBIP, although the sample size was too small to detect a difference. There were no reports of LAST or cardiac arrhythmias in either arm. Conclusions: Bupivacaine liposome use significantly improved mean pain scores, total opioid consumption and inpatient days compared to standard therapies over a 72 hour period in older pediatric reconstructive patients undergoing burn contracture release and grafting procedures with no reports of adverse effects. Further investigation is warranted to further define the role of BL in pediatric surgical patients. Applicability of Research to Practice: Use of bupivacaine liposome in the population reviewed shows promise for improved patient comfort and reduced length of stay. View Large View Large 214. Readmissions to a Regional Burn Center M. A. Pressman, PhD, G. Izraeli, MSW, D. M. Caruso, MD, FACS, K. N. Foster, MD, MBA, FACS Arizona Burn Center, Phoenix, AZ Introduction: Rates of readmission for patients being discharged from hospitals is becoming increasingly scrutinized by insurance companies and influencing reimbursement rates. This study evaluated the readmission rates for burn and wound care patients. Methods: A retrospective study was performed for all patients seen at a regional burn center over the course often years (2003–2013). Descriptive statistics were calculated for all variables. Student's t and Chi-square were used for comparisons, as appropriate. A p<0.05 was set as statistically significant for all variables. Results: A total of 6942 patients were admitted into the burn center during the ten year study period. A total of 695 (10%) of those patients were readmissions. Of these readmissions, 474 (68%) were planned readmissions and 221 (32%) were unplanned. Reasons for planned admissions included contracture releases, final grafting of wounds that were sent out in wound vacs, follow up care of wounds, Reasons for unplanned admissions included graft failure, infections, failure to thrive, poor pain control and lack of good wound care Of the IA patients, 5656 (90.5%) of them were burn injuries and 591 (9.5%) were non burn injuries and skin related diseases. Of the RA, 582 (83.7%) were burn patients, and 113 (16.3%) of the patients were non burn patients (p<0.0001). In the planned group 579 were burn patients and 78 were non-burned patients. In the unplanned group 24 were burn patients and 13 were non-burned patients. Average TBSA for IA was 8.2% and 16.2% for RA. Average age of IA was 44.15 and for RA 44.14. Males made up 70.8% of IA patients and 62.3% of the RA patients. The average LOS for IA was 12.2 (SD=16.9) days and for RA was 9.1 (SD=9.8) days. Of the 6247 IA patients, 5645 (90.4%) had insurance and 602 (9.6%) were uninsured/self-pay patients;.for the RA patients, 657 (95%) had insurance and 38 (5.5%) were uninsured (p=0.0005). In the planned RA patients, 36.8% were uninsured and in the unplanned group 63.2% were uninsured. Of note, 493 (71%) of the patients that were readmitted were originally sent home with no services and only family or friends supporting and assisting them with their wound care. Conclusions: Over 30% of the readmissions were unplanned. The majority (71%) of these patients were sent home without services. The data shows that more services need to be put in place to prevent readmissions. Applicability of Research to Practice: It is imperative that hospital staff and discharge planners put more services in place and better equip family and patients with wound care knowledge prior to discharge. 215. HAPU Reduction in the Burn Unit D. Ildefonso, BSN,RN UC Irvine Health, Orange, CA Introduction: Hospital acquired pressure ulcers (HAPU) are considered to be an indicator of the quality of nursing care patients receive. Changes in reimbursement for HAPU have mandated that new strategies be developed to maintain a heightened awareness of pressure ulcers while minimizing the overhead necessary to sustain such vigilance. Between July 1st, 2013 and December 31st, 2013 our burn unit had a total of 19 HAPU. Of the 19 HAPU in our unit, five were reported to the state department of health because they were category III, IV or unstageable. The purpose of this quality improvement project was to evaluate the risk factors for HAPU development in patients with burn and skin disorders in our burn unit, while implementing strategies for HAPU reduction. Methods: A survey of nurses in November 2013 identified the following barriers to HAPU prevention in our unit: lack of assistance to turn, difficulty in assessing pressure related tissue damage around burn injuries and uncertainty on how or when to remove dressings to assess pressure areas. A 32 point data collection tool was developed using literature found on HAPU prevention in rehabilitation, critical care and burn populations. Charge nurses received one on one training to collect data and perform a through skin inspection while mentoring staff. Patients with a Braden score of 15 or less received a two-person assisted skin inspection each shift. Results: From January 14th, 2014 to August 31, 2014, our unit had one reportable pressure ulcer. This change from our baseline of 26.3% to a current rate of 8.3%, represents a 17.9% overall reduction in our reportable HAPU rate. Additionally, our HAPU development shifted from pressure point related ulcers to mucosal and device related ulcers. Conclusions: Sustainability of performance improvement for the reduction of HAPU is essential. We believe that implementing a two-person head to toe assessment approach with particular attention to burn and areas that are covered with dressings was the essential key to reducing reportable HAPU. Mentoring is one strategy to offer continuing education, support, accountability and sustainability to reduce HAPU in the population of burns, trauma and skin disorders. Applicability of Research to Practice: Finding methods for sustaining excellence in practice is imperative for burn units to meet quality benchmarks and to ensure that avoidable hospital acquired conditions are prevented. 216. An Improved Simple Model for Practicing the Surgical Skills of Burn Excision and Grafting Y. Liu, MD, R. L. Sheridan, MD, P. H. Chang, MD, FACS Massachusetts General Hospital, Boston, MA; Shriners Hospital for Children, Boston, MA Introduction: With decreasing work hours for surgical residents and fellows, more emphasis has been placed on the role of simulation training in the acquisition of surgical skills. The core skills of a burn surgeon include tangential excision, skin graft harvest, and meshing. Animal models are expensive and require significant preparation. Previous literature described using cooked lasagna pasta draped over IV fluid bags to simulate the skin on an extremity. However, there is a tendency for IV fluid bags to be punctured with this system, leading to accidental spills. Furthermore, the IV fluid bags do not capture perfectly the firmness of human soft tissue. With this in mind, an improvement in the underlying support system for the pasta was proposed using silicone gel rolls for the scaffolding under the pasta. Methods: Generic brand standard egg lasagna was purchased from a local supermarket. The lasagna sheets were cooked in salted boiling water for approximately 10 minutes to obtain an al dente consistency. The sheets were then drenched in cold water and kept submerged until the simulation was set up. The cooked lasagna sheets were then dried completely and draped over silicone gel chest rolls. The surface of the lasagna was then lubricated and then either tangentially excised with a Weck blade or Watson knife or harvested using an electric dermatome. Operating room personnel of differing educational levels included: 1 burn surgeon, 1 pediatric surgeon, 2 fourth year medical students, 1 physician assistant student, and 8 experienced operating room nurses. They practiced tangential excision and harvesting on the lasagna-silicone gel model. Results: All staff who practiced on the lasagna-silicone gel model was able to obtain harvests from the lasagna without damaging the underlying silicone gel. The experienced surgeons agreed that the tactile experience was extremely close to the real-life experience. Conclusions: The lasagna-silicone gel model provides an inexpensive, easy to clean simulation to permit trainees to practice the surgical skills of burn surgery. Applicability of Research to Practice: This project will permit surgical trainees an excellent model to practice tangential excision and skin graft harvesting prior to utilizing these skills on patients. View largeDownload slide View largeDownload slide 217. Comparing Hospital Acquired Infections and Outcomes in Patients Admitted to a Burn Center in the Stevens-Johnson-Syndrome to Toxic Epidermal Necrolysis Spectrum to Non-Bullous Skin Disorders. P. Diegidio, MD, S. Ortiz-Pujols, MD, L. M. DiBiase, MPH, D. Weber, MD, MPH, D. Van Duin, MD, PhD, S. W. Jones, MD, FACS, B. A. Cairns, MD, FACS, C. S. Hultman, MD, MBA, FACS University of North Carolina, Chapel Hill, NC Introduction: Patients admitted to a burn center suffering from the Stevens-Johnson-Syndrome to Toxic Epidermal Necrosysis (SJS-TEN) spectrum are typically thought of as having high hospital morbidity and mortality. Little is known about patients admitted to a burn center suffering from non-SJS-TEN Skin Disorders (SD). This group includes severe rashes, non-healing wounds, erythema multiforme, and unknown skin lesions requiring hospitalization. At our institution we compared patients in the SJS-TEN group to SD in terms of healthcare-associated infections (HAIs), and mortality. Methods: A post-hoc analysis of prospectively collected data was performed on 445 patients who had a diagnosis of SD and were admitted our 36 bed ABA accredited burn center over the last 10 years. These charts, divided into SJS-TEN and SD, were cross referenced with the hospital wide infectious control database to identify patients who suffered from HAIs that met the Center for Disease Control National Healthcare Safety Network surveillance definitions. These two groups were then compared using a 2-tailed t-test, or chi-square, for nominal and categorical variables, respectively. Results: There were 316 patients in the SD group and 129 in the SJS-TEN. Our results are seen in table 1 expressed as mean (standard deviation).*CAUTI: Catheter Associated Urinary Tract Infection; BSI: Blood Stream Infection; UTI: Urinary Tract Infection. The most common pathogens in SD in descending order were P. aeruginosa, Candida, Acinetobacter, C. difficile, and MRSA compared to MRSA, P. aeruginosa, Candida, Stenotrophomonas, and Acinetobacter in SJS-TEN. Conclusions: A substantial mortality rate exists among patients admitted to burn centers for non-burn/SJS-TEN skin disorders that approaches the mortality rate of our SJS-TENs group. These patients were significantly more likely to be female, spend a longer amount of time in the ICU and on a ventilator, and were more likely to have a UTI compared to BSI or CAUTI in the SJS-TEN group. Applicability of Research to Practice: Clinicians taking care of non-SJS-TEN Skin Disorder patients in burn centers should be aware of a high mortality rate, susceptibility to HAIs especially UTIs, and the potential for a prolonged ICU stay and high number of ventilator days. View Large View Large 218. Digital Photography and Burn Center Clinician Workflow: Implications of a Pilot Experience N. E. Leahy, MPH, RN, B. Duchac, BSN, RN, J. Deal, BSN, RN, A. McDougall, BSN, RN, K. C. Eaton, BSN, RN, D. Bedell, BSN, RN, A. Greenway, MSN, RN, CCRN, M. Krugman, MPA, RN, R. W. Yurt, MD, FACS NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY Introduction: During spring 2014, this center introduced digital photography (DP) into patient care and team operations. Although data support DP use for patient care, findings on its impact on the clinical practice, team communication, and workflow are limited. To better learn how DP impacts these this center surveyed burn team end users, and anticipated that although operationalizing DP processes can be challenging, its benefits would support the provider experience. Methods: In absence of an institutional DP protocol, the burn team developed a basic process to enable clinical nursing leaders to obtain, label, upload, and document digital images in the electronic medical record (EMR). Hardware and procedures met institutional security, consent, and confidentiality requirements. After a 4-month pilot, an anonymous, 15 question e-survey was developed and distributed in 9/14 to 114 team members to elicit feedback on the above domains. Results: A 54% response (n=62) was achieved and included a range of disciplines (69% RN; 16% MD/PA; 15% other) and professional tenure (0-5yr (42%), 20+yrs (26%)); 100% were aware of the center's DP use; 91% have viewed images in the EMR; 91% use DP outside of work. Fewer have obtained (67%), uploaded (45%), or documented (45%) images in the EMR; 70% support expanding eligibility to perform these duties. Most common image uses are to augment patient handoff (82%), capture wound baseline/monitor progress (82%), support wound care planning if direct observation was not possible (75%). Least common is for triage of patient referrals (14%). Over 90% affirm DP helps to teach staff about wounds and operational processes don't impede workflow. A minority agrees that images help patients to understand injury severity (36%), treatment options (26%) and discharge teaching (17%). 28% favor obtaining daily images for each inpatient. Uploading and correcting inadvertent uploads were most often rated as challenging; tablet use for image acquisition was most often rated as simple. 59% agree image quality sufficiently supports clinical practice; 64% affirm images correlate well to in-person assessment. Many (58%) rate DP as very helpful in clinical practice; 77% report it improves the quality of wound EMR documentation. 94% are interested in applying new technology to clinical practice, especially to improve workflow efficiency (39%), team communication (39%), and patient education (31%). Conclusions: Pilot feedback strongly supports the expansion of DP in burn team operations and serves as a model and resource for hospital colleagues. Future steps will seek to refine DP logistics, expand staff/patient participation, and address impediments as to maximize its positive impact on clinical practice and outcomes. 219. Profile of Medication in the Outpatient Burn Clinic: What Drugs Are Being Prescribed and to Whom? R. B. Rimmer, PhD, M. A. Pressman, PhD, K. N. Foster, MD, MBA, FACS, D. M. Caruso, MD, FACS Arizona Burn Center, Phoenix, AZ Introduction: Effective pain, depression, and anxiety management of patients following an acute burn care hospitalization is fundamental to helping individuals achieve positive outcomes. The purpose of this study was to determine what percentage of discharged patients, with a significant burn injury, continued to require pain, and or anti-depressant and anti-anxiety medications in the outpatient setting. Although opioid abuse and accidental death from narcotics and other prescription drugs has increased dramatically in the US, there is a surprising paucity of research regarding burn patient's post-hospital drug usage. Methods: A prospective design was used to identify the percentage of discharged burn patients with a TBSA ≥15% being prescribed medication to treat on-going pain, anxiety, depression, and sleeplessness in the outpatient burn clinic setting. Data collected included; gender, ethnicity, number of hospital days, location and severity of burns, number of skin grafts, incidence of documented inpatient anxiety and PTSD and % of patients reporting pain at discharge. Results: A total of 224 adult patients with a 15% or greater TBSA were discharged from the burn center over a 2 year period. The patient population consisted of males (67%), female (33%), Caucasian (46%), Hispanic (36%), Native American (8%) and Other (10%). The upper extremities were the most common injury site (75%), followed by lower extremities (61%) and thorax (47%). A full 67% sustained third degree and 20% deep 2nd degree burns while 79% required skin grafts. Average number of ICU days was 13, OR visits 3.3, and length of stay 33 days. PTSD or Anxiety was diagnosed in 27% of the inpatients and 25% reported on-going pain at discharge. Opioids were prescribed to 88% of patients and non-opioid medications to 15%. Anti-anxiety or antidepressants were prescribed for 31%, neuropathic pain medication 32%, sleep medication to 21%, antipsychotics to 15% and antibiotics to 2%. Conclusions: Nearly all burn patients in this study continued to need narcotics for pain control discharge from the burn center. Nearly a third was also taking an anti-anxiety medication. Drug overdose is a public health concern and opioid drugs are the most frequent cause of drug-related death. Further investigation into length of time burn patients use such medications, as well as the percentage that become addicted, is recommended. Applicability of Research to Practice: Serious burns result in severe acute and often chronic pain issues. It is important to effectively address pain for positive patient outcomes. However, further investigation into length of time narcotics and anti-anxiety medications are being prescribed plus more information on the number of patients having narcotic withdrawal issues is warranted. 220. Using Burncase 3D to Document and Determine Graft Loss N. C. Benjamin, BS, D. Benjamin, RN, MSN, D. N. Herndon, MD, FACS Shiners Hospital for Children-Galveston, Galveston, TX Introduction: Traditionally, determining a specific and accurate surface area of a burn wound, debridement, and graft is uncommon and not easily attainable. With the use of a 3D computerized program, the user is able to trace from a reference picture overlain onto a computer diagram, and the resulting marked area is summed in square centimeters. With an accurate method of documenting the surface area grafted, graft loss can be easily determined. This project looks at using Burncase 3D as a way to document and calculate graft take versus graft loss. Methods: Digital pictures were collected during surgery and imported into Burncase 3D (RISC Software GmbH, Austria), a computerized diagram. The pictures were superimposed over the 3D diagram of a human matching the patient's description including, height, weight, gender, age, and overall build (normal or corpulent). The computerized diagram is divided into 40 body segments for analysis. Diagrams of the initial burn injury, debridement, and grafting were constructed from the photographs of the patient. Burncase 3D calculated the area, in cm2, of each marked surface. Results: Each type of diagnosis, treatment, surgical procedure, and dressing is assigned a different color and design. These distinguishable and different markings allow each type of event to be summed. For example, the surface area of the initial burn, debridement, grafting, donor sites, and areas healed can each be calculated separately. It follows that each calculation can be used in analyses to define the extent of third degree by determining the area that required debridement
TI - Abstracts
JF - Journal of Burn Care & Research
DO - 10.1097/BCR.0000000000000251
DA - 2015-07-01
UR - https://www.deepdyve.com/lp/oxford-university-press/abstracts-GqMeo1TzVB
SP - S66
EP - S281
VL - 36
IS - suppl_1
DP - DeepDyve
ER -