TY - JOUR
AB - 1. The Association Between Prehospital Intubation and Pneumonia Risk in Burn Patients J. Webb, BS, C. Ellis, MD, D. Younan, MD, R. Griffin, PhD, T. Swain, BS, J. Kerby, MD, PhD University of Alabama School of Medicine, Birmingham, AL; University of Alabama at Birmingham, Birmingham, AL Introduction: Pulmonary Infection, particularly pneumonia, is the most common complication in intubated burn patients and is a significant cause of morbidity and mortality. An increased risk of ventilator-associated pneumonia in trauma patients has been associated with urgent non-ICU setting intubations (i.e. prehospital and emergency departments). Very few studies have investigated this association in the burn patients, despite the common use of this intervention in the burn population. Methods: Data was collected on burn patients admitted to a Level-I, academic burn center between January 2011 and December 2014 who stayed at least one day in the ICU. Demographic, injury, and clinical characteristics were compared among intubation groups (i.e. prehospital vs. hospital) using analysis of variance and chi-square tests for continuous and categorical variables, respectively. A conditional Cox proportional hazards regression using sandwich variance estimates was used to estimate hazard ratios (HRs) and associated 95% confidence intervals (CIs) for the association between time to first positive BAL and intubation group. Models were adjusted for gender and TBSA. In a secondary analysis, models were stratified by inhalation injury to determine possible effect modification. Results: Overall, there was no difference in the hazard of ventilator-associated pneumonia between intubation groups (HR 1.28, 95% CI 0.85-1.92), an association that remained after adjusting for sex and TBSA (HR 1.37, 95% CI 0.91-2.05). Among those with an inhalation injury, the hazard of ventilator-associated pneumonia was 80% higher for those intubated in the field compared to those intubated in the hospital (HR 1.92, 95% CI 1.07-3.46). This association became stronger after adjusting for sex and TBSA (HR 2.12, 95% CI 1.02-4.44). Field intubation was also associated with a near three-fold increase in hazard of ventilator-associated pneumonia for those with a TBSA below 15% (HR 2.85, 95% CI 1.03-7.86). Conclusions: In patients with minor burns and inhalation injury, our findings suggest that prehospital intubation is associated with an increased risk of ventilator-associated pneumonia. Further study is warranted to confirm the association between prehospital intubation of burn patients and increased risk pneumonia. Applicability of Research to Practice: Prehospital endotracheal intubation is a common intervention in the initial management of burn patients. While potentially life-saving in certain patients, the liberal application of this intervention can have important adverse outcomes. 2. Bacteremia After Combat-Related Burn Injury: A Higher Lethality with Gram-Negative Pathogens T. D. Le, MD, M. S. Clemens, MD, K. S. Akers, MD, J. C. Janak, PhD, J. A. Rizzo, MD, J. C. Graybill, MD, K. K. Chung, MD U.S. Army Institute of Surgical Research, Fort Sam Houston, TX; Brooke Army Medical Center, JBSA Fort Sam Houston, TX Introduction: Infectious complications such as bacteremia are common after severe burns and associated with mortality. Risk factors and lethality of gram-negative bacteremia are poorly characterized. We hypothesized that gram-negative bacteremia would be more lethal than gram-positive bacteremia or both among severely burned combat casualties. Methods: We evaluated consecutive military burn patients wounded during combat operations in Iraq and Afghanistan from 2003 to 2013 admitted to the US Army Burn Center. Demographic and outcome variables included presence of bacteremia, time to bacteremia, species of microorganisms, and other clinical outcomes including death. Chi-square or Fisher exact test, t-test or Wilcoxon-Mann-Whitney test, Cox proportional-hazards and logistic regression models, and Kaplan-Meier plots were used where appropriate. Results: A total of 902 combat related burn patients were included. Most were males (97%) with a median age of 23 (IQR: 21-28) and a median TBSA of 7.9% (3.3-20.8). Bacteremia was observed in 20% (n=178). Among bacteremic patients, 47% grew gram-negative, 20% grew gram-positive pathogens, and 33% grew both. Sixty-four patients (36%) had ≥2 recurrences of bacteremia. Overall, mortality was higher in bacteremic patients compared to those who did not develop bacteremia (22.5% vs 1.5%, P<0.0001). Mortality from gram-negative bacteremia was higher than gram-positive bacteremia or both (29% vs 9% vs 20%, P=0.04). The most lethal bacteria were Pseudomonas aeruginosa (50%), Acinetobacter spp. (47.5%), and Klebsiella pneumoniae (40.0%). On multivariate analysis, gram-negative bacteremia independently increased the risk of death (HR: 5.37; 95%CI: 2.06-14.05) while gram-positive bacteremia did not (HR: 4.14; 95%CI: 0.95-18.0). Kaplan-Meier survival analysis demonstrated that patients with gram-negative bacteremia died sooner than patients with gram-positive bacteremia or both. Conclusions: Among combat-related burns, gram-negative bacteremia is associated with a higher and earlier likelihood of death. Applicability of Research to Practice: Given the lethal magnitude of gram-negative bacteremia in burn patients, identification of risk factors for bacteremia may influence prophylactic practices to reduce burn mortality. Figure. View largeDownload slide Figure. View largeDownload slide 3. Clinical Outcomes Following Transfusion Protocol Changes K. J. Watson, BS, F. J. Bohanon, MD, C. D. Voigt, MD, C. R. Andersen, MS, L. C. Woodson, MD, PhD, J. O. Lee, MD, FACS, L. K. Branski, MD, C. J. Jimenez, MD, W B. Norbury, MD, MBBS, M. Silva III, BA, P. Stevens, BA, C. C. Finnerty, PhD, D. N. Herndon, MD, FACS University of Texas Medical Branch, Galveston, TX; Shriners Hospitals for Children, Galveston, TX Introduction: Recent reports show that a restrictive transfusion protocol is associated with fewer adverse events. Our group previously reported a relationship between reduced transfusion of blood products and improved outcomes in burn patients on our pediatric intensive care unit (PICU). In 2007, our institution implemented a restrictive transfusion protocol, lowering the hemoglobin (Hgb) threshold from 10 to 7 mg/dL. Our goals were to investigate compliance with the protocol change and determine whether patient outcomes improved. Methods: Patients admitted to the PICU from 2003 to 2012 with ≥ 40% of total body surface area (TBSA) burned were included in this analysis. Patients were assigned to the pre-protocol (pre; n=128) or post-protocol (post; n=154) group based on admission date. Demographics, injury characteristics, positive wound, blood, and respiratory cultures, creatinine levels, transfusions, total area grafted, and Hgb levels pre and post transfusion were collected. Rates per unit area were found by dividing total packed red blood cells (PRBC) given by total area grafted during acute admission. The relationship was modeled by a generalized additive model, adjusting for age and TBSA. Acute kidney injury (AKI) was classified using pediatric Risk, Injury, Failure, Loss, and End-stage (pRIFLE) scores based on creatinine clearance estimated by the original Schwartz model. Incidence of infection and AKI were modeled by regression with relation to age, TBSA, inhalation injury, and admission year. Survival analysis was performed using a Cox proportional hazard model. Results: Between 2007 and 2012, PRBC rates declined by 0.20 and estimated blood loss by 0.29 mL/cm2 grafted (p<0.001 in both cases). Hgb threshold for transfusion decreased from 9.3 ± 0.7 to 8.4 ± 0.8mg/dL (p<0.0001). Mortality and pRIFLE scores did not change significantly (p=0.94, p=0.7), however, the number of infections declined by 9% with each subsequent year of admission (p=.004). Conclusions: Since the transfusion protocol change, the amount of PRBC transfused per area grafted decreased significantly and infection rates have improved. Although we have reduced the transfusion threshold significantly, our institutional goal was not met. Applicability of Research to Practice: A restrictive transfusion protocol is associated with decreased morbidity. A comprehensive program to institute the protocol should be implemented to increase compliance and improve patient outcomes. The decreased use of blood products will be cost effective and conserve resources. External Funding: NIH P50-GM60338, R01-GM56687, R01-GM112936, UL1TR000071, and T32-GM8256, NIDILRR 90 DP00430100. Shriners Hospitals for Children (84080, 71008, 71009). 4. Clinical Value of Probiotic Treatment for Burn Patients Y. Jiang, BS, K. Opoku, BS, E. Larumbe-Zabala, PhD, J. E. Kesey, APRN, FNP, J. A. Griswold, MD, FACS, S. Dissanaike, MD, FACS Texas Tech University Health Sciences Center, Lubbock, TX Introduction: Probiotics are often prescribed to help restore alterations in gut microflora from antibiotic usage in critical illnesses such as burns. While many studies exist on the efficacy of probiotics in gastrointestinal diseases such as Clostridium difficile (C. diff) infections, there are very few studies on the efficacy of probiotics in burn patients. Methods: A retrospective cohort study in adult burn patients given >1 million CFU/ day of Lactobacillus acidophilus and Lactobacillus rhamnosus as routine supplementation. Subjects were divided into three groups: patients receiving >5 days of probiotics starting in the first week (n=35), those receiving ≥ 5 days of probiotics starting later than the first week (n=16) and a control group receiving ≤5 days of probiotics during their entire stay (n=57). Data was collected on outcome variables: diarrhea, number of daily bowel movements, emesis, gastric residuals, C. difficile infection, sepsis, serum CRP & prealbumin values, length of stay and mortality. Confounding variables were laxative use and antimicrobial use. Multivariate analysis was performed with adjustment for TBSA and age using STATA. Results: Demographics and injury characteristics were similar between groups, with mean TBSA 23.2 (14.3) percent and age 46.7 (16.8) years. There was no significant difference in clinical outcomes of C. difficile infection, sepsis, emesis, gastric residuals, length of stay or mortality. However diarrhea occurred more frequently in subjects who received early probiotics (p=0.001), who had an average of 9.5 daily bowel movements vs. 4.7 in controls (p=0.001) in the first week, which increased to 17.4 vs. 11.3 (p=0.002) in the second week. Serum CRP was found to be higher for those who received probiotics, 12.45pg/mL vs. 9.42pg/mL (p=0.015), while prealbumin was lower 13.52pg/mL vs. 17.59pg/mL (p=0.015). Conclusions: Probiotic administration was associated with increased diarrhea and worse serum protein markers in adult burn patients, without perceptible clinical benefit. Applicability of Research to Practice: Potential for harm demonstrated by these results suggest further study should be performed prior to routine administration of probiotics in burn patients. Table. No title available. View Large Table. No title available. View Large 5. Inconsistencies in Burn Fluid Resuscitation Practices During En Route Care N. W. Caldwell, RN, M. L. Serio-Melvin, MS, RN, J. Salinas, PhD, L. C. Cancio, MD, FACS, E. A. Mann-Salinas, RN, PhD U.S. Army Institute of Surgical Research, Fort Sam Houston, TX Introduction: Following a large burn injury, fluid balance is fundamental to avoiding complications associated with over or under-resuscitation. In 2006, a burn care clinical practice guideline (CPG) was developed at our institution to aid non-burn experts in the management of burn patients while en route to definitive care. The Burn Flow Sheet (BFS), a component of this guideline, was used to track hourly fluid resuscitation information during the first 72-hrs post-burn for patients with burns ≥20% total body surface area (TBSA). The goal of this analysis was to evaluate en route fluid management under this CPG. Methods: All available hardcopy BFSs from 2007-2012 were reviewed. Accuracy of TBSA estimation, used to calculate starting and 24-hr volume estimates, was evaluated by comparing the TBSA recorded on the BFS against the expert calculations recorded in the Burn Center registry at time of admission. Expected (Brooke formula) and actual administered 24-hr fluid volumes were compared as well as differences between burn patients and those with concomitant trauma. Finally, each BFS was evaluated for the presence of urine output-targeted fluid titration in the first 24-hrs. Results: From 2007-2012, 68 burn patients were transported to the Burn Center with a BFS listing TBSA. Mean burn size was 4l±21 (4-95)% TBSA, an average expert difference of 7 ± 7 (0-32)% TBSA. Overall, burn size was overestimated for 43% (n=29) and underestimated 31% (n=21) of patients. Eighteen BFSs (26%) documented accurate TBSAs, and 10 patients (15%) had errors of at least 15% TBSA. The mean 24-hr fluid administration estimate for patients with ≥20% TBSA was 96 ± 38(40-184)ml/kg based on estimated TBSA, 92 ± 38 (40-190)ml/kg based on true TBSA; 209 ± 85(79-44l)ml/kg was actually administered. Of 57patients with burns ≥20% with injuries recorded in the burn registry, 22 (38%) suffered concomitant trauma. Average fluid for burn injury only was 199 ± 83ml/kg, as opposed 226 ± 89ml/kg for burn and trauma. Fluid rates were titrated hourly to a target urine output (UO) of 30-50ml/hr on 5 (8%) BFSs; 22 (34%) were randomly titrated; and 36 (55%) had no titration based on UO. UO was non-responsive to high fluid volume for 2 (3%) additional patients; titration was not noted. Conclusions: Burn size is difficult to estimate by non-burn experts, however, it does not appear to have a great impact on total fluid administration. However, failure to titrate fluid to target urine output can have profound implications for both burn and trauma patients. Actual fluid administered was over two times greater than estimated amounts regardless of TBSA calculation. Applicability of Research to Practice: Education, improved guidelines, and automated decision support technologies may assist non-burn providers in appropriate fluid titration during burn shock. 6. Sepsis Worsens Central Insulin Sensitivity and Peripheral Muscle Catabolism in Severely Burned Adults F. J. Bohanon, MD, D. N. Herndon, MD, FACS, C. Porter, PhD, M. Chondronikola, PhD, RD, E. A. Tran, BS, N. Bhattarai, BS, A. D. Delgadillo, BS, R. P. Mlcak, PhD, R. S. Radhakrishnan, MD, FACS, L. S. Sidossis, PhD University of Texas Medical Branch, Galveston, TX; Shriners Hospitals for Children, Galveston, TX Introduction: Hypermetabolism, insulin resistance, and muscle catabolism are hallmarks of the stress response to severe burn trauma. Sepsis is the leading cause of mortality in burns; however, the impact of sepsis on metabolic regulation in burn victims remains unknown. Here, we determined the impact of sepsis on whole body and skeletal muscle metabolic function in adults with severe burns. Methods: Twenty-four patients with >30% total body surface area burn (TBSA) were prospectively studied. Sepsis was determined by a retrospective chart review using the ABA Sepsis Criteria. Glucose and lipid metabolism were measured using isotopically labeled glucose, glycerol, and palmitate infusions and hyper-insulinemic euglycemic clamps. Muscle fractional synthesis (FSR) and breakdown (FBR) rates were determined with bolus injections of 13C6 and 15N phenylalanine. Blood samples and muscle biopsies from the m. vastus lateralis were obtained to determine isotope enrichment by gas chromatography mass spectrometry. Results: We studied thirteen septic and eleven non-septic patients with similar age and TBSA. The rate of appearance (Ra) of glucose was significantly elevated in the septic group (25 ± 3 vs. 18 ± 1 μMol/Kg/min; p=0.04), indicating greater central (hepatic) insulin resistance. No significant differences were found in Ra of palmitate and glycerol, or insulin stimulated peripheral glucose disposal. Muscle FSR was similar between groups (0.08 ± 0.02 vs 0.05 ± 0.02 %/hr; p=0.3), while FBR was significantly greater in septic patients (0.40 ± 0.10 vs 0.08 ± 0.02 %/hr; p=0.03). This resulted in a significantly greater rate of protein loss in the septic compared to non-septic group (0.50 vs. 0.07 %/hr, P<0.05). Conclusions: Sepsis worsens the stress response to severe burn. Our data suggest that elevated hepatic glucose production and skeletal muscle proteolysis contribute to the hyperglycemia and muscle wasting seen in septic burn victims. Applicability of Research to Practice: Recognition that sepsis worsens the stress response to burns should prompt the burn care team to monitor closely and institute timely treatments following severe burn trauma. External Funding: NIH P50-GM60338, R01-GM56687, T32-GM8256, and UL1TR000071. NIDILRR 90DP0043-01-00. Shriners Hospitals for Children (84080 and 84090). 7. Bronchoscopic Grading of Burn Inhalation Injury Predicts 24-Hour Fluid Resuscitation and Ventilator Days D. R. Bharadia, MD, MPH, A. L. Madenci, MD, MPH, S. Fitzgerald, PA-C, L. Kingston, BA, N. Faoro, RN, R. K. Chan, MD, I. Sinha, MD Brigham and Women's Hospital, Boston, MA; U.S. Army Institute of Surgical Research, Fort Sam Houston, TX Introduction: Burn inhalation injury is a significant source of morbidity and mortality. Unfortunately, severity of inhalation injury is difficult to quantify. In this study, we graded severity of inhalation injury based on the Abbreviated Injury Severity (AIS) grading system for flexible fiberoptic bronchoscopic (FFB) findings. We hypothesized that patients with high-grade inhalation injury on FFB have higher 24-hour fluid requirement and spend more days on ventilator support than those with low-grade injury. Methods: We performed a retrospective chart review of all burn inhalation injury patients admitted to an American Burn Association-verified center between 2008 and 2014. We reviewed mechanism of injury, initial carbon monoxide (CO) level, FFB findings, and initial 24-hour fluid resuscitation requirements. The primary outcome was in-hospital mortality. Secondary outcomes included ventilator days, incidence of tracheostomy and pneumonia, ICU days, and length of hospital stay. We defined patients with high-grade inhalational injury as those with AIS grades greater than or equal to 2 (range 0-4). Results: A total of 121 patients were identified as our study population. Six patients, who were pronounced dead on arrival or had goals of care changed to comfort measures only within 24 hours of admission, were excluded. There were 32 (27.8%) female patients, and median age of all patients was 47 years. Median age, total body surface area (TBSA) and initial carbon monoxide (CO) level were not significantly different among patients with high-grade versus low-grade injury. Patients with high-grade inhalation injury had more frequent intubations (88% versus 74%, p=0.03), more number of days on ventilator (3 days versus 1 day, p=0.01) and higher 24-hour fluid resuscitation (6.9L versus 5.1L, p=0.01) compared to those with low-grade injuries. Patients with low-grade inhalation injury had non-significant trends toward shorter median ICU days (1.5 days versus 4 days, p=0.07), shorter median length of stay (3 days versus 7 days, p=0.06), and decreased in-hospital mortality (8% versus 23%, p=0.09), compared to patients with high-grade injuries. In the multivariable model, age and TBSA were strongest predictors of mortality in our patient population. Conclusions: Patients with high-grade burn inhalation injury based on bronchoscopic findings have significantly higher 24-hour fluid resuscitation requirement and number of days on mechanical ventilator. Applicability of Research to Practice: Standardized gradation of inhalation injury severity can help provide greater insight into patient management. The next step would be a prospective multicenter study validating the link between the AIS bronchoscopic grading system and outcomes in patients with burn inhalation injury. 8. Propranolol Kinetics in Severely Burned Pediatric Patients with or Without Oxandrolone Co-Administration A. N. Guillory, PhD, D. N. Herndon, MD, FACS, M. B. Silva III, BA, C. R. Andersen, MS, O. E. Suman, PhD, C. C. Finnerty, PhD University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX Introduction: The systemic impact of a severe burn injury affects many organs beyond the skin resulting in a variety of disorders which require therapeutic intervention. Propranolol, a non-selective (β1, (β2- adrenergic receptor antagonist, mitigates the effect of burn-induced elevated catecholamine levels and reduces resting heart rate and cardiac work. Oxandrolone, a testosterone mimetic, promotes protein synthesis and anabolism to counter the muscle wasting that often occurs after a severe burn injury. Co-administration of these drugs is expected to synergistically improve patient outcomes. This study was performed to determine whether the co-administration of oxandrolone altered plasma propranolol concentrations. Methods: A total of 108 patients < 18 yrs old with burns ≥30% of total body surface area were included in this IRB approved study. Demographic data was collected prospectively. Patients were randomized to receive propranolol or oxandrolone+propranolol. Propranolol was administered throughout the majority of the acute hospital stay. The concentration of propranolol in plasma was determined for two dosing strategies: q6 (liquid formulation; n=86) and q24 (extended release tablet; n=22). Samples were drawn at regular intervals immediately prior to drug administration, and then throughout the next 2 dosing periods (12 or 48 hours, respectively). Heart rate and blood pressure was recorded throughout the study periods. Results: The q6 drug dosing frequency had a propranolol decay of λ=0.21, corresponding to a half-life of 3.3 hours (p<.0001) and a 19% reduction in concentration per hour. The q24 drug dosing frequency had a decay rate of λ = 0.06, corresponding to a half-life of 11.2 hours (p<.0001) and a 6% reduction in concentration per hour. Percent predicted heart rate declined by 2.8% for each doubling of q6 propranolol concentration (p<0.0001). Percent predicted heart rate declined by 2.5% for each doubling of q24 propranolol concentration (p<0.0001). The addition of oxandrolone did not affect any of the measured parameters. Conclusions: Oxandrolone co-administration did not alter propranolol's plasma concentration, half-life, or effect on heart rate. Additionally, these data show that propranolol kinetics in severely burned pediatric patients is similar to what has been reported for healthy young adults. Applicability of Research to Practice: These data provide necessary information that can be used to determine the safety of oxandrolone and propranolol co-administration. External Funding: SHC - 84291, 79141NIH - T32 GM008256, P50 GM060338, W81XWH-11-1-0835 9. Decreasing the Rate of Catheter-Associated Urinary Tract Infections in a Regional Burn Center C. A. Cox, RN, MS, L. Smith, RN, BSN, K. Huber, RN, MS, K. Krout, RN, PhD Johns Hopkins Burn Center, Baltimore, MD Introduction: According to the Centers for Disease Control (CDC), catheter associated urinary tract infections (CAUTIs) are tied with pneumonia as the second most common type of healthcare-associated infection, and account for more than 15% of infections reported by acute care hospitals. Possible complications associated with CAUTI are prolonged hospital stay, potential pain and discomfort to the patient, increased cost, and increased mortality. Annually, it is estimated that more than 13,000 deaths are associated with CAUTIs. According to the National Healthcare Safety Network (Dudeck, et al., 2013), CAUTI rates are measured by the number of infections per 1000 urinary catheter days. The national benchmark for CAUTIs 2013 through current remains 4.7, in comparison to our Burn Intensive Care Unit (BICU) infection rate of 12.885 for fiscal year (FY) 2013. In addition our BICU had a Standardized Infection Ratio SIR of 2.93, well above the expected benchmark of 1.0. Methods: In July of 2014 we began working on a quality improvement project which provided educational opportunities for the staff in an effort to decrease the CAUTI rate in the BICU. Education focused on the insertion, maintenance, and removal of indwelling urinary catheters. The primary methods of education were through online learning modules, and an educational board was also posted in the staff break room. Education was assigned not only to the nursing staff, but also to the rehabilitation staff since they manipulate the urinary catheter when working with each patient. Finally, a pre and post-test were administered to the nursing staff testing their knowledge prior to the education, as well as post-education. Results: The BICU was able to decrease the number of actual CAUTIs from 28 in FY 2013 to 12 in FY 2014, and to only 4 in FY2015. Our CAUTI rate dropped from 12.885 in FY2013 to 9.397 in FY 2014, and to only 3.336 in FY 2015, which is below the national recommended benchmark of 4.7 set by the National Healthcare Safety Network (NHSN). The SIR decreased from 2.93 in FY2013 to 2.14 in FY2014, and finally to 0.76 in FY 2015, which is also below the benchmark of 1.0 set by the NHSN. This is a 74% decrease in our CAUTIs in the BICU over a 2 year period. Conclusions: Our burn center has been able to document that it is possible to significantly reduce CAUTIs in this vulnerable population. While the educational project has been completed and we have positive results with a significant decrease in our CAUTIs, we hope to maintain a rate and SIR that are in-line with the national benchmarks put forth by the NHSN. We will continue to monitor our CAUTI rates and SIR annually. Applicability of Research to Practice: It is our hope to develop and publish a nurse driven urinary catheter protocol specific to the burn population that may be utilized by burn centers throughout the country. 10. Development of a Program to Improve Evaluation of Burn Nursing Competencies K. K. Valdez-Delgado, BSN,RN, M. G. Barba, BSN,RN, A. L. Kuylen, BSN,RN, D. J. Flores, MPA, RN, P. B. Colston, MSN, RN, J. J. Melvin, MSN, RN, E. A. Mann-Salinas, RN, PhD U.S. Army Institute of Surgical Research, Fort Sam Houston, TX Introduction: Provision of appropriate burn nursing care requires technical skills and a comprehensive understanding of physiology in the context of clinical relevance. In our institution, newly hired staff possess extensive nursing experience. It is presumed that minimal additional training is required for a seasoned nurse to successfully acclimate to the burn environment; however, this has not been our experience in ensuring competency of the novice burn nurse. Our objective was to share our experience of improving our current competency-based orientation (CBO) tools for nurses transitioning to the burn specialty by incorporation of a method to ensure standardization of knowledge, progression tracking and competency documentation. Methods: A working group was created consisting of 4 Senior Nurse Preceptors, 4 Clinical Nurse Specialists, 1 Burn Educator, 3 Wound Care Specialist, 3 Nurse Scientists, 2 Nurse Managers, and a Program Coordinator. Weekly meetings were held to discuss implementing an improved transitioning process and included the revision of the existing competency form. The evidence-based Vermont Nurses in Partnership competency framework served as the basis of the project. Results: Over 32 meetings were held Aug 2012-Sept 2015. Legacy CBO tools (n=4) comprised 37 pages and consisted of 683 validation objectives requiring preceptor sign-off before the new nurse could complete the 10 week orientation process. Despite the extensive documentation, several important areas were not addressed, primarily the evidence of competency and critical thinking skills. The adopted tools included: a preceptor development course, a weekly periodic evaluation tool (PET), clinical coaching plans (CCP) and a concept-based CBO. The revised CBO (8 pages) identified 81 key skills prior to completion of orientation, and a total of 164 skills within 6 months of hire; a total of 164 preceptor initials were required. Burn specific CCPs to support the CBO were developed (critical care =12 and step-down =11). The PET was identified as a key tool to assess weekly progression in areas such as critical thinking, communication, organization allowing for evidence-based customization of orientation duration. Conclusions: A dedicated working group of nursing experts were able to successfully adopt and tailor evidence-based development tools to track transition-to-specialty-practice of a burn nurse. The program now has the means to reduce the administrative burden of the preceptor while vastly improving the ability to measure and document clinical competency and individualize the orientation process. Applicability of Research to Practice: A concept-based CBO combined with the PET can provide a more comprehensive method to objectively assess a new burn nurse's transition to practice. External Funding: HT9404-12-1-TS08 (N12-P04) 11. Challenges Associated with Managing a Multicenter Clinical Trial among Burn Centers: A Primary Research Nurse's Perspective E. C. Coates, MSN, RN, CCRN U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX Introduction: Managing a multicenter clinical trial (MCT) can be demanding and complex. The American Burn Association (ABA) is the sponsor of a group of MCTs to improve burn care. The purpose of this project is to share knowledge gained from expected and unexpected challenges coordinating a prospective, randomized MCT, and to provide some potential strategies for future prospective MCTs. Methods: Upon awarding of a grant next steps include: development and Institutional Review Board (IRB) approval (local and "second-level") for the Core and each Site-specific protocol; recruitment of participating sites; contracting for center reimbursement, equipment/supplies, and support staff; hiring and training of personnel; establishment of a data coordinating center and recurring participant meetings. Coordination required: initial routine site eligibility assessment; routine bi-monthly teleconferences; initial and monitor on-site visits, and on-site training by the Primary Research Nurse; and documenting all regulatory, contracting, and data management actions. Results: The grant proposal was submitted MAY 2009 and funds awarded to ABA SEPT 2009. The core protocol was finalized and submitted for approval APR 2010; approval received OCT 2010. Of the 13 sites recruited, 3 sites were replaced and 1 site opted out, resulting in 9 participating sites. The first subject was enrolled in APR 2012. See table for all time related variables. Conclusions: Conclusion: Expected and unexpected delays occur when coordinating MCTs. Some delays include: varying IRB requirements, contract/budget/training constraints, staff turnover, and multiple amendments. Maintaining strategic plans for study compliance through teleconferences, in-person investigator meetings, and continuous telephone or e-mail contact with all participating sites throughout trial can improve the quality and timely completion of a MCT. Applicability of Research to Practice: Time management challenges with managing a MCT can make it difficult for implementing these complicated studies. Improving the quality of future ABA MCT's can be facilitated by optimizing the initial pre-trial phase with concrete plans for recruitment, contracting, and budget planning. Management of expectations coupled with maintaining continuous correspondence with all relevant research parties during the duration of the MCT will contribute to success. External Funding: External Funding: Department of Defense, Combat Casualty Grant (W81XWH-09-2-0194) awarded to the ABA. Table. No title available. View Large Table. No title available. View Large 12. Formosa Fun Coast Color Play Disaster, Taipei, Taiwan: Experiences of a Burn Disaster Relief Group T. A. Lynch, RN, L. C. Ware, OT, D. M. Lough, MD, PhD, K. B. Gerold, DO, JD, S. M. Milner, MBBS, BDS Johns Hopkins Bayview Medical Center, Baltimore, MD Introduction: On June 28, 2015, more than 500 young people suffered devastating burn injuries at a water park in Taiwan. Colored powder used as a prop during a concert was ignited by a faulty speaker wire. A drained swimming pool/dance floor became an inferno, injuring hundreds of people. A mass causality incident of this magnitude affected the entire medical system and immediately eclipsed the number of designated burn beds, as well as the number of burn professionals. Consequently, there was an immediate need for burn training for all disciplines: nursing, rehabilitation, physicians, social workers, speech therapists, and psychologists. The incredibly low mortality rate (2.4%) speaks to the superb handling of the incident from beginning to end. After discussions with the Taiwanese embassy, a multi-disciplinary Burn Center group was assembled and travelled to Taiwan to offer assistance, advice and education in the treatment and rehabilitation of extensive burn injuries. Methods: The burn team visited 11 hospitals, 5 medical societies and 2 government ministries. The team participated in bedside rounding, lectures, hands-on training, demonstration of surgical techniques, and a splinting workshop. Lecture and training focused on: wound care, surgical management, fluid resuscitation, pain control, airway management, allocation and use of resources, rehabilitation and psychosocial needs of patients and family members. Results: Representatives from more than 20 institutions were present for each lecture. A report detailing observations and opportunities to improve practice was presented to Chiang Been-huang, Ph.D., Minister of Health, and Ma Ying-jeou, President of Taiwan. Collaborations of research and education are ongoing. Members of the group will return to Taipei in January, 2016 to conduct a burn rehabilitation conference. As a result of this humanitarian effort, lasting partnerships have been formed. Conclusions: After this mass casualty incident, the burden of care was placed upon many workers with little to no burn experience. The medical and disaster response communities of Taiwan deserve high praise for their efforts. Differences in medical and surgical management due to cultural considerations will be highlighted. Applicability of Research to Practice: This event allowed the Burn Team to share surgical techniques that help to address the unique problem of lack of donor sites. Future visits are currently being planned to continue to assist the medical professionals of Taiwan with the reconstruction and rehabilitation of hundreds of burn patients. 13. Burn Specialty Orientation for Nurses Working In and Out of the Burn Center H. Macklay, MA, RN, CCRN, A. Greenway, MSN, RN, CCRN, K. A. Sessler, MPH, RN, CCRN, A. Rabbitts, MS, RN, R. Dembicki, MS, RN NewYork Presbyterian/Weill Cornell Medical Center, New York, NY Introduction: A large urban academic medical center includes a burn nursing specialty orientation (BSO) curriculum for all new hires. This burn center has a > 5 year, new hire retention rate of 39 %. The BSO curriculum was revised in November 2008 and expanded to include Emergency Department (ED) and Pediatric (peds) nurse hires. In 2014, the burn center downsized from 40 to 20 beds while yearly admissions have remained constant. To continue high reliability care for burn patients admitted off-unit and those treated and discharged from the emergency department, the specialty curriculum has been further expanded to include the Surgical /Trauma (SICU) and Critical Care float nurses. The BSO has recently been approved for Continuing Education credits. The purpose of this study is to relate the BSO program to the requirements of the served burn population admitted and treated in the hospital, outside the Burn Center. Methods: The BSO is delivered during staged departmental specialty training sessions. The revised BSO curriculum consists of content that includes patient care during the emergent phase of burn injury; burn wound assessment / treatments, and burn specific standards of care (SOC). Evaluations were collected at the end of the program. Results: Between 1/2010 and 6/ 2015, 7-9 yearly BSOs were held. A total of 326 RNs attended these sessions and were separated into groups by area of hire: Burn: 26% (N=80), Peds: 38.8% (N=126), ED hires: 32.1% (N=105), Float critical care nurses (FN) 2.15% (N=7), SICU 2.45% (n=8). Evaluations of the program showed that 98 % of respondents rated the faculty as superior, 100% found the presentation applicable to their practice, 100 % indicated that the education program was either good or excellent in meeting their professional needs and that the relationship of the objectives related to the program. A nursing resource effort was undertaken that demonstrated in a 3-month period of 2015, there were a total of 777 burn nurse off- unit patient visits: Med-surg units 463 (59.5%); ED 189 (24.5%); Peds 125 (16 %) with a total documented burn nursing time of 24,060 minutes. Bedside RN's outside the burn center are expected to facilitate the seamless, consistent delivery and plans of care for these patients. Conclusions: BSO has been integrated into the orientation program for all burn center, ED, Peds, SICU and FN RN hires to the hospital. This highly rated educational offering is integral in the present model of care delivery as the burn team partners with colleagues in units throughout the hospital to ensure optimal care with fewer in-patient beds and an evolving staff. Applicability of Research to Practice: Directly Applicable. 14. Healthy Work Environment in the Burn Center: A PI Project D. J. Flores, MPA, RN, P. Colston, MSN, RN, S. Barbosa, MSN, RN, L. Thonpson, BSN, S. Phillips, MS, RN, ACNS-BC, J. Rodriguez, BSN, J. Melvin, MSN, RN, S. Murray, MSN, E. Mann-Salinas, RN, PhD U.S. Army Institute of Surgical Research, Falls City, TX; U.S. Army Institute of Surgical Research, FSJ, TX; U.S. Army Institute of Surgical Research, Fort Sam Houston, TX Introduction: Burn nurses take care of highly complex patients and in an environment that is challenging and unpredictable. Anecdotal reports of low staff morale and high turnover prompted nursing leaders to investigate the current situation. A key component to The Patient Caring Touch System (PCTS), the model of nursing care in our burn center, is a healthy work environment (HWE). Methods: As part of a performance improvement project lead by the education department, we used the AACN's HWE assessment tool to establish baseline data. The tool measures HWE across 6 standards: skilled communication (SC), true collaboration (TC), effective decision making (DM), appropriate staffing (AS), meaningful recognition (MR), and authentic leadership (AL). Results: We surveyed 123 nurses (39% completed, n=48) using the AACN HWE survey. Aggregate scores evaluated as "good" (mean=3.22; range 1-5) indicating 47% agreement/ strong agreement with scale items reflecting a HWE (29% neutral; 24% disagree/strongly disagree). The mean scores for each standard were: SC=3.18, TC=3.13, DM=3.39, AS=3.42, MR=2.90 and AL=3.31. The MR score was the only score that indicated "needs improvement." Conclusions: The MR scores were the lowest indicating that improvements are needed to meet that standard. The AACN reports that a deficit in this area can negatively impact job satisfaction, retention and patient outcome. Focusing PI attention on MR may increase the overall health of our unit. Applicability of Research to Practice: Assessing HWE may improve nurse retention, job satisfaction and patient safety. The AACN HWE tool is evidenced based which has not yet been utilized in a burn environment. Use of the AACN HWE survey tool will assist in the identification and can help units determine the specific standards that are not being met for the development of interventions to maintain an ongoing HWE. 15. Wound Care Team Effectiveness on Patient Care Efficiency and Quality S. K. Shingleton, MS, RN, R. D. Salinas, LPN, J. K. Aden, PhD, P A. Berry, LPN, C. R. Palmer, LPN, C. S. Russe, LPN, R. M. Trichel, LPN, J. J. Melvin, MSN, RN, B. T. King, MD U.S. Army Institute of Surgical Research, Fort Sam Houston, TX Introduction: High quality and consistent wound care is vital to the care of patients in the Burn Intensive Care Unit. Variability in wound care quality was a common perception among staff and attributed to varying staff experience levels and a lack of continuity in patient assignments. A staffing model change occurred in OCT2014 and a wound care team (WCT) was established and staffed with Licensed Vocational Nurses experienced in burn care. We evaluated the effectiveness of the WCT on wound care efficiency, quality of documentation, and rehab participation. Methods: The 5 member WCT is led by a Wound Care Certified LVN and is supervised by a Clinical Nurse Specialist. The WCT coordinates with the bedside nurse to establish a wound care plan. Patients with complex wound care and/or increased severity of illness have priority for WCT services. A retrospective review was conducted and PostWCT was divided into 2 groups: wound care by the WCT and by the rimary nurse (PN). Retrospective data was obtained for a baseline (PreWCT) comparison. A point-based audit tool based on burn center policy was developed and wound notes were randomly chosen for review. Descriptive statistics and student's t-test were performed. Results: PreWCT (APR2014-SEP2014) 506 wound cares occurred; TBSA was 22 ± 18%; mean wound care time was 92 ± 64 min 1(8 ± 79 min/TBSA); mean rehab time was 95 ± 67 min. PostWCT (DEC2014-JUL2015) 908 wound cares occurred (WCT n=492; PN n=4l 6); TBSA was 31 ± 23% (WCT 33 ± 21%; PN 26 ± 23%; p=<.001); mean wound care time was 98 ± 46 min for WCT and 72 ± 79 min for PN (p<.001); mean rehab time was 99 ± 76 min, however when controlled for TBSA, burns <20% improved from 71 to 91 min (p<0.0001); WCT note quality (n=17) was 96% compared 74% in the PN group (n=23, p<.005). WCT notes compared to PN notes reflected higher wound complexity (p<0.05). Conclusions: Overall wound care times decreased but were higher in the WCT vs PN group suggesting an improved efficiency regardless if wound care was performed by the WCT or PN; however, the WCT performed more complex wound care on larger wounds. Overall rehab times improved but smaller burns had a highly significant 20 min improvement. Overall note quality did not change post implementation but was significantly higher in the WCT group which supports the expertise of the WCT but suggests a need for ongoing education for the entire staff. Applicability of Research to Practice: Wound care teams may increase wound care efficiency and rehab participation while providing expertise and continuity of care at the bedside. Daily collaboration with the bedside and charge nurses has been a challenge but is vital to successful implementation of a significant operational change. Further evaluation is ongoing to include assessment of effects on patient alertness and delivery of sedation medications. 16. Addressing the Complexity of Burn Wound Care in an Effort to Develop a Patient Acuity Assessment Tool C. Steen, RN, J. Slater, MD, A. Quan, MPH, I. Snyder, RN, R. Shoemaker, BSN, K. Krout, RN, PhD, J. Caffrey, DO Johns Hopkins Bayview Burn Center, Baltimore, MD Introduction: Patient acuity assessment tools (PAATs) were developed to assist with staffing ICUs according to patient needs. To date, there are no available PAATs specific to the burn population. The development of such a tool for the burn unit must address several unique aspects involved in the care of these patients. While current PAATs do accommodate for complex wound care taking up to 30 minutes, the wound care for a burn patient can exceed 4 hours. Working with the templates provided by current PAATs and incorporating the complex wound care needs of the burn population will allow for the creation of a PAAT specific to the burn unit. Methods: Since wound care is more extensive for the burn population, The Burn Wound Dressing Log (BWDL) was developed to track the time spent by the nurse during wound care. The tool records the type of dressing, body area of the burn wound, TBSA% of the burn injury, and total time for wound care, including the presence of trainees or physicians, initial debridement, escharotomies or fasciotomies, post-op dressing takedown, and staple removal. The tool was completed by the nurse performing the wound care. Results: Data was entered into the BWDL for a 1 year timeframe. There were 48 patients treated with 160 dressing changes during this time. Ten different nurses completed the BWDL. The overall time for wound care ranged from 30 to 450 minutes. The three wound locations that required the most average time in minutes were the perineum (146), chest or abdomen (128), and face, head, or neck (122). Patients required from 1 to 5 different dressings and the average time for dressing changes went from 83 minutes for 1 dressing to 180 minutes for 5 dressing types. The average time in minutes for wound care according to the nurse's experience was 102 for two to five years, 97 for five to ten years, and 102 for greater than ten years. Average time in minutes for patients with TBSA less than 20% was 76, with TBSA 20% or greater being 133. Conclusions: Wound care for burn patients is often time consuming and must be considered when determining the number of nurses to safely staff a unit. When creating a PAAT for burn units, the presence of patients with perineal or torso wounds, wounds greater than 20% TBSA, or multiple different dressings should be differentiated as more complex patients. Applicability of Research to Practice: Since there are well established ICU assessment tools, but no nationally accepted burn patient acuity assessment tool, it is clear that the need for this type of tool exists. The information gathered with the BWDL can be utilized to establish a burn PAAT to help ensure patient safety, proper nurse-patient staffing ratios, and promote positive patient outcomes. 17. A National Study of the Additive Effect of Race on Burn Outcomes H. A. Bedri, MD, K. S. Romanowski, MD, J. Liao, PhD, G. Z. Al-Ramahi, MD, J. P. Heard, BS, T. Granchi, MD, FACS, L. Wibbenmeyer, MD, FACS University of Iowa Hospitals and Clinics, Iowa City, IA Introduction: Age, burn size and inhalation injury are the major contributing variables related to burn mortality. While the female gender has been linked to higher mortality, the relative roles of gender, race and socioeconomic status have not been well-documented. We sought to clarify the relative roles in outcomes of these factors in a national sample of burn patients. Methods: A retrospective review of 172,640 patient records of the National Burn Repository (NBR, version 8, 2002-2011) database was conducted. Of those, 36,960 (21.4%) patient records were excluded for duplicate entries, follow up visits, readmissions, non-burn injuries and skin diseases or incomplete entries (missing date of admission, date of discharge, race or TBSA). Univariate and multivariate analysis were performed to compare outcomes by race (black, white, Asian and other). In multivariate analysis, the confounding variables: age, gender, burn size and depth, insurance status, inhalation injury and burn type were controlled. Results: The study group included 135,680 patients and was predominately white (59.0% white, 19.0% black, 15.1% Asian and 3.5% other). The black race was associated with more operations, greater number of females, longer LOS, more ventilator days, more septicemia (all p<0.001) and more urinary tract infections UTI (p <0.01). The white race was more likely to be older, intubated and have longer ICU stays and higher mortality (all p<0.001). The Asian race had the largest burn sizes, most uninsured and lowest mortality (p<0.001). On multivariate analysis, the black race were 37% more likely to die (p <0.001), 50 % more likely to have complications (p< 0.001), 30% more likely to have UTIs (p 0.002) and 41% more likely to get septicemia (p< 0.001). Racial minority groups other than black had more acute respiratory distress syndrome, more pneumonias, more septicemia, more UTIs, longer hospital LOS and higher hospital charges when compared to white patients. Conclusions: Race appears to play a significant role in burn injury outcomes. Minority groups especially the black race, have a higher risk of mortality and morbidity compared to white burn patients. Future studies should focus on delineating the reasons for this disparity. Applicability of Research to Practice: The findings of this study should encourage further research on the difference in the pathophysiologic and immunogenetic reactions to burn injury between the different races and to help guide future burn treatment strategy planning and resources to focus more on populations that are at higher risks for post-burn mortality and morbidity. 18. The Impact of Gender on Long-Term Community Reintegration Following Burn Injury: A Life Impact Burn Recovery Evaluation (LIBRE) Study B. Levi, MD, G. D. Shapiro, PhD, J. Jeng, MD, FACS, A. F. Lee, PhD, P. Chang, MD, FACS, A. Acton, RN, BSN, M. E. Merino, MPH, A. Jette, PhD, J. C. Schneider, MD, L. E. Kazis, ScD, C. M. Ryan, MD, FACS Department of Surgery, University of Michigan, Ann Arbor, MI; McGill University, Montreal, QC, Canada; Mount Sinai Health Care System, New York, NY; Bentley University Department of Mathematical Sciences, Waltham, MA; Massachusetts General Hospital, Harvard Medical School, Shriners Hospitals for Children, Boston, MA; Phoenix Society for Burn Survivors, Grand Rapids, MI; Center for the Assessment of Pharmaceutical Practices (CAPP), Department of Health Policy and Management, Boston University School of Public Health, Boston, MA; Center for the Assessment of Pharmaceutical Practices (CAPP) Department of Health Policy and Management, Boston University School of Public Health, Boston, MA; Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA; Massachusetts General Hospital, and Shriners Hospitals for Children, Boston, MA Introduction: Burn injury leads to psychosocial challenges that continue well beyond the initial burn. Given the known differences in response to burn injury based on gender, we hypothesized that the social response to burn injury would also vary by gender. Methods: The LIBRE-192 was administered to 402 adult burn survivors with ≥5% TBSA burned or critical area burns. Items were answered on a 5-point Likert scale; higher scores denoted better outcome. Factor analysis was used to identify the key domains underlying the eight conceptual factors previously postulated based on the WHO International Classification of Function. Demographic and clinical characteristics of the study population were explored using descriptive statistics. Men and women were compared based on demographic and clinical characteristics using Pearson chi-square tests. Unweighted mean scores of all items in each domain as well as factor scores were compared between men and women using AN OVA. For domains and factors that differed significantly by gender, linear regression models were constructed with adjustment for relevant demographic and clinical variables. Results: Of 400 participants with data on gender, there were 199 women and 201 men. Women had a higher level of education than men (p<.01). There were no other significant differences in the demographic or burn characteristics between men and women in the study population. Mean scores in 4/8 domains (Recreation and Leisure p<0.1, Work and Employment p=.02, Relating with Strangers p<.01 and Sexual Relationships p<.01) were significantly lower for women than for men after adjusting for education level and burn size. No significant differences in the overall mean scores were observed for the remaining 4 domains (Sense of Purpose, Family Roles, Informal Relationships, and Romantic Relationships). However, at the more detailed factor level, women fared worse in certain selected factors for 7/8 domains, and reported better outcomes in two factors: Understanding from family and Interest and engagement from partner (Table). Conclusions: There are significant clinically relevant differences in social reintegration outcomes as assessed by the LIBRE-192 based on gender. Applicability of Research to Practice: Gender is an important determinant of long-term community reintegration following burns. Future studies are needed to further understand the cause of these differences and strategies are needed to improve these scores for both men and women. External Funding: The contents of this abstract were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research, NIDILRR grant number 90DP0055.NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS)..The contents of this abstract do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. NIH NIGMS 1K08GM109105.DODW81XWH-1 1-2-0073. 19. The Influence of Insurance Status on Transfer of Pediatric Burn Patients: An Analysis of 1870 Patients from the National Trauma Data Bank E. C. Hamilton, MD, M. T. Austin, MD, MPH, B. Cotton, MD, MPH, T. F. Huzar, MD, FACS University of Texas Health Science Center Houston, Houston, TX Introduction: The decision to transfer pediatric burn patients often is based on the ability of the hospital to offer specialized burn care. However non-medical factors may influence the decision to transfer. The purpose of this study is to investigate the association of insurance status and race/ethnicity with the probability of transfer after evaluation in the emergency department of level III/IV/non-designated trauma centers. Methods: We conducted a retrospective review of all pediatric burn patients (age < 16 years) registered in the National Trauma Data Bank between 2007-2012. ICD9 codes 940-947 were used to define burn injury. Regression techniques controlling for clustering at the hospital level were used to determine the impact of insurance and race/ethnicity on the probability of transfer versus admission from lower level centers to level I/II trauma centers. Subgroup analysis was performed for patients with total body surface area burn <20% Results: Of 1,870 patients evaluated at level III/IV, 1,452 (77%) were transferred from lower level centers to level 1/ II trauma centers. After adjusting for ISS, GCS, age, gender, race, and insurance status, university teaching status was the strongest predictor for non-transfer (OR 0.04, CI 0.003-0.47). Patients with public insurance were also less likely to be transferred than patients with private insurance (OR 0.53, CI 0.31-0.92). There was no difference in transfer rates between uninsured and privately insured patients or in transfer rates between whites and non-whites. Other indicators for transfer included ISS>15 (OR 5.5, CI 1.16-26). Among patients with reported total body surface area burn <20%, ISS<15, teaching/ university status, and public insurance remained predictive of non-transfer. Conclusions: Pediatric burn patients initially treated at lower level trauma centers were less likely to be transferred if publicly insured or if they were initially managed at a teaching/university hospital. There were no differences in transfer rates based on race or ethnicity. Applicability of Research to Practice: The understanding of current pediatric burn patient transfer patterns may lead to establishment of new recommendations for pediatric burn patient transfer plans. 20. Increased Mortality in Women: Sex Differences in Burn Outcomes S. Dissanaike, MD, FACS, I. Faraklas, BSN, B. Walker, BA, D. Ha, BSc, Y. Zhai, MPH, G. Graves, G. M. Lewis, MD, FACS Texas Tech University Health Sciences Center, Lubbock, TX; University of Utah, Salt Lake City, UT Introduction: Several studies show worse survival in burned women compared to men; however the etiology is not well understood. Body fat distribution between sexes is a potential explanation for survival differences. We evaluated sex differences in burn outcomes in a multi-center cohort of severely burned patients, and assessed the impact of obesity. Methods: Burn-injured adults admitted to two verified burn centers January 2008 to December 2014 with >20% TBSA burn injury were retrospectively reviewed. Data on demographics, hospital course, and outcomes was collected. Obesity was estimated using both body-mass index (BMI) and body surface area (BSA). TBSA and age-adjusted outcomes including mortality were compared between sexes. Statistical analysis included Rank-sum for continuous variables and chi-squared or Fisher's exact for categorical or nominal variables. Results: The median age of 334 subjects was 43 years (IQR 30-55) with 274 (82%) men and 60 (18%) women, and median TBSA of 34%(25-50). Patients were predominantly white (82%) with 26% of Latino origin. Comorbidities were similar except that women were less likely to suffer alcoholism 5% vs. 16% (p=0.024). Regarding obesity, median BMI was 28.2 (24 - 32) and did not differ between sexes, however BSA was significantly lower in women 1.86 (1.68 - 2) vs. 2.09 (1.92 - 2.27) (p<0.001). Women had significantly higher mortality 45% (27/60) vs. 29% (80/274) (p=0.01) despite similar TBSA 53% (IQR 36-69.5) v. 59% (35-82) (p=0.662), proportion of full-thickness burn (p=0.710) and age [63 (IQR: 45-73) v. 53 (39-66)] among non-survivors. Women who died were less likely to be of Latino origin than men 16% (3/19) vs. 45% (28/62)(p=0.021). BSA and BMI did not differ among survivors vs. non-survivors in either sex. Women trended toward earlier deaths on day 4 (IQR 2-17) vs. 10 (2-24) (p=0.281)(Fig 1) although this was not statistically significant. Women were more likely to suffer homograft failure (6/8)75% vs. (17 /54) 31%(p=0.043) and urinary tract infection 18% vs. 9% (p=0.04); men showed no increase in complications compared to women. Conclusions: Women are less likely to survive burn injuries than men. Body size does not appear to modulate this effect. Applicability of Research to Practice: Burn centers should be aware of the higher mortality and morbidity risk in female patients with large burns. Figure. View largeDownload slide Figure. View largeDownload slide 21. Factors Implicated in Safety-Related Firefighter Fatalities S. A. Kahn, MD, T. L. Palmieri, MD, FACS, FCCM, S. Sen, MD, FACS, J. Woods, O. L. Gunter, MD, FACS, MS University of South Alabama Medical Center, Mobile, AL; University of California Davis and Shriners Hospitals for Children, Sacramento, CA; DC Firefighter's Burn Foundation, Washington, DC; Vanderbilt University Medical Center, Nashville, TN Introduction: Firefighting is wrought with risk, as 80-100 firefighters (FFs) die on the job on each year in the USA. Many of the fatalities have been analyzed by the National Institute of Occupational Safety and Health (NIOSH) to determine contributing factors. The purpose of this study is to determine variables that put FFs at risk for potentially preventable workplace mortality such as use of personal protective equipment (PPE), seatbelts, and appropriate training/fitness/ clearance for duty. Methods: The NIOSH FF Fatality Database reports from 2009-14 were analyzed. Data including age, gender, years on the job, weather, other calls on the same shift, and department type were compared between FFs who employed protective equipment, seatbelts, or wellness/fitness and those who did not. A second group of firefighters was determined by NIOSH to have inexperience, lack of training, or inappropriate clearance for duty implicated in their fatalities. Comparisons for the second group were between those whose departments utilized training and safety related standard operating protocols (SOPs) and those who did not. Results: In 84/176 deaths, PPE/seatbelts/wellness were implicated in the fatality. Lack of PPE was more likely on clear days (p=0.03) but less likely on cloudy and windy days (p<0.001). These FFs dying with lack of PPE had more time on the job in a single department, 12.5 vs 20 years (p=0.03),and more time in a volunteer department, 5.5 vs 12 years (p<0.01). Being deployed on another call during the same shift was associated with lack of PPE- 65.9% vs 41.6% of those who had not been on another call (p=0.005). Firefighters who worked in departments that lacked SOPs for respirator fit testing, PPE, fitness testing, rapid intervention, medical clearance, or incident command were statistically more likely to have lack of experience/training/clearance implicated in the fatality. Percentage of deaths from these causes increased from 20% to 80% over a 4 year period. Conclusions: Good weather during a call and more years on the job, particularly in a volunteer department, are associated with FF mortality related to unsafe practices. These factors might create an air of complacency that puts FFs at risk for safety related omissions. Having been on a recent call may create distraction or fatigue that puts FF at risk during subsequent calls. Lack of safety related protocols appears to put FFs at risk of mortality, and the risk may be increasing over time. Further study and prevention efforts from multidisciplinary groups are needed to better understand and combat this problem. Applicability of Research to Practice: Identifying risk factors associated with preventable mortality will allow focused education, awareness, and prevention efforts in high risk groups of firefighters. 22. Description of Burn Patients with Diabetes Using the NBR Data Set 2002-2011 R. Coffey, RN, MSN, CNP, P. J. Salsberry, PhD, RN, FAAN The Ohio State University Wexner Medical Center, Columbus, OH Introduction: Diabetes is a growing problem in this country and because of the micro and macro vascular changes that occur as a result of the progression of the disease, persons with diabetes are at greater risk for experiencing burns. This risk in conjunction with an increasing aging population in the United States suggests that there may be an increase in the number of burn patients with the comorbid condition of diabetes in the future. If this occurs the impact on patients as well as the health care system is potentially great. We have limited knowledge about the characteristics of the burn patient with diabetes, including demographics, behaviors, burn severity and type, and outcomes. This study will begin to fill in these gaps by examining the characteristics of the burn patient with diabetes to better understand the epidemiology and outcomes in this high risk population. Methods: The National Burn Repository (NBR) was used to examine adults with diabetes in the United States. Records were included if they were 18 years of age or older, were first admissions for burn injury, and had comorbidity data in the NBR. Records were excluded if they had no cutaneous burn injury. Comparisons were made between those with and those without diabetes and across two age groups, the full sample and a sample limited to those over 65 years of age. Baseline characteristics, health behaviors, mortality, length of stay, ICU length of stay, charges and mortality were compared among these two age groups using χ 2 or student t test. Results: A total of 172,640 records were included in the 2002 to 2011 data base, of which 58,705 (34%) met inclusion criteria. In this sample 52,337 (89.15%) had no diabetes and 6,370 (10.85) of the patients had diabetes. Using student's t test patients with diabetes were significantly (p <.0001) older, had significantly higher percent of full thickness burns (p<.0001), had longer lengths of ICU stays (p<.0001), more ventilator days (p = 0.0475), longer hospital lengths of stay (p<.0001) and higher hospital charges (p<.0001). There were no significant differences in TBSA (p=0.1395) or the percent of partial thickness area between the two groups (p=0.8980). Patients with diabetes had significantly higher mortality rates (χ2 p<.0001) and higher inhalation injuries (p<.0001). Conclusions: This analysis demonstrates that the comorbid condition of diabetes can impact resource utilization and outcomes in burn patients. This focuses the need for further studies to prevent injuries in patients with diabetes and to better identify this group of high risk patients in practice. Applicability of Research to Practice: The NBR is a rich data source for epidemiologic studies and for outcomes research. 23. A Child's Eyes: Epidemiology of Sight-Threatening Problems in a Pediatric Burn Unit K. D. Capek, MD, S. C. Stout, BSc, D. Marsh, BSc, C. Jimenez, MD, T. T. Huang, MD, FACS, K. H. Merkley, MD, MBA, D. N. Herndon, MD, FACS Shriners Hospitals for Children, Galveston, TX Introduction: Sight is important in treatment, rehabilitation, development, and ultimate quality of life post-burn. Vision-threatening problems are not infrequent occurrences in our pediatric burn unit. We sought to better define the contemporary epidemiological scope of the problem. Methods: To better care for sight-threatening problems, starting in August 2013, we implemented a protocol for scheduled eye evaluation and topical care. Clinical diagnoses were made via patient exam and images, with final assignment by the lead author. When early eye findings were noted (punctate keratopathy, exposure, epithelial defects) medical treatment began. Microbiological cultures (swab or scraping) were obtained if indicated. Early surgical release and eyelid closure was performed in patients with full-thickness eyelid burns or marked corneal exposure. All new patients with burns (N=837) and skin-sloughing disorders (N=13) were included. Results: Of all pediatric burned patients (N=837), we noted abnormal eye findings in 167 (20%). Eyelid burns of any type (N=162) were associated with corneal ulceration (N=17) via odds ratio c. 80 and p<0.0001. Apparent 3rd degree eyelid burns (N=45) were also associated with corneal ulceration via odds ratio 32 (11-89, p<0.0001). Exposure keratopathy occurred in 145 patients (17%). Corneal epithelial defects (N=35) were noted in a subset of these patients. Exposure keratopathy was associated with the development of corneal epithelial defects with odds ratio c. 200, as well as corneal ulceration (odds ratio c. 90, p<0.0001 for both). Corneal ulcer microbial cultures showed viral (N=3), fungal (N=l), and bacterial (N=5) etiologies. The majority of corneal ulcers were sterile (N=8). Corneal scar was noted in 13 patients, and perforation developed in 2 patients with full-thickness eyelid burns and sterile corneal ulcers. Singed eyelashes were present in 72 patients; 9 of these patients had foreign bodies. Two of these were intraocular and required surgical removal. There were 4 with corneal burns; 3 thermal and one acid. Eye problems accompanied skin-sloughing disorders (N=13); membranous conjunctivitis (N=8), epithelial defects (N=8), sterile corneal ulcer (N=4), entropion (N=6), and corneal scar (N=2) were noted. All these occurred only in toxic epidermal necrolysis (TEN) patients. Conclusions: Eyelid burns and superficial (exposure) keratopathy are early findings, and strongly predict corneal deterioration. Eye problems and risk of visual loss frequently accompany pediatric burns and TEN. Applicability of Research to Practice: This analysis of 850 consecutive patients provides a mark for future measurable improvements in sight preservation at the pediatric burn ICU. External Funding: National Institutes of Health (P50 GM060338, R01 GM056687, and T32 GM008256) and Shriners Hospitals for Children (84080, 84090, 71006, and 85310) grants. 24. One Year Later: A Population-Based Analysis of Urgent Readmissions After Major Burn Injury S. A. Mason, MD, A. Gonzalez, MSc, A. B. Nathens, MD, PhD, M. G. Jeschke, MD, PhD Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada Introduction: Little is known about the trajectory that burn patients follow after their acute care hospitalization. We aimed to determine the rate and reasons for unplanned admission in the year after discharge. Methods: We conducted a retrospective, population-based cohort study of all patients >16 years who sustained major burn injury between 2003 and 2013, using administrative databases capturing all emergency department visits and admissions within a geographic region comprised of a population of >13 million. Major burn included any injury with >10% total burned surface area (TBSA), third degree burn to hands, face, or feet, or any burn with inhalation injury. Patients were excluded if they sustained concurrent trauma or were readmitted within 72 hours of discharge. Minimum follow-up was 1 year. Unplanned readmissions were categorized based on ICD-10 diagnosis codes. Results: Between 2003 and 2013, 2088 adults were discharged from hospital following an acute burn. Six hundred, thirty nine unplanned readmissions were identified among 372 patients within one year of discharge. The cumulative incidence of readmission at 1 year was 18%, and 134 (36%) patients had >1 readmission, with a range of 1-20 readmissions. Median time from discharge to readmission was 133 days (IQR 45-237). Compared to patients without a readmission, readmitted patients were older (median age 52 vs 45, p<0.001) and had a longer stay during the acute hospitalization (median 24 vs 14 days, p=0.001). Burn size and rates of inhalation injury were no different among patients who were re-admitted compared to those who were not. Overall, 69% (n=442) of all readmissions were due to diagnoses unrelated to the burn wound, the most frequent of which were mental health conditions (18%, n=113) (see table). Of the readmissions related to the burn wound (31%, n=197), postoperative complications were most frequent (9% of all re-admissions). Conclusions: Unplanned readmission is common in the first year after discharge for major burn injury. While many visits are due to burn sequelae, the single most common reason for readmission is related to mental health conditions. Readmission reasons differed by age strata, while few differences were observed between patients with greater or less than 20% TBSA injury. Applicability of Research to Practice: Burn-injured patients are at high risk for readmission, particularly due to mental health. Future work should characterize at risk patients to inform interventions aimed at preventing unplanned readmissions. Table. No title available. View Large Table. No title available. View Large 25. Length of Stay (LOS) Outliers: What Do We Know? K. A. Sessler, MPH, RN, CCRN, A. Greenway, MSN, RN, CCRN, A. Rabbitts, MS, RN, J. J. Gallagher, MD, FACS New York Presbyterian/Weill Cornell Medical Center, New York, NY Introduction: Burn patients generally experience prolonged LOS and its accurate prediction has strong implications for service delivery, resource management, and financial reimbursement. Despite widespread interdisciplinary efforts to streamline care and decrease LOS, this burn center has noticed a population subset that continues to fail to respond to such efforts and remain in hospital longer than those with illness of equal severity. It was hypothesized that these patients were largely impacted by social circumstances. Methods: An e-medical records review of all patients admitted to this center from 2012-2014 was done and LOS variance (VAR) was calculated (Estimated LOS (ELOS) - Actual LOS (ALOS) = VAR). LOS outliers were defined as any ALOS value that falls > the 98th percentile for its specific DRG and severity of illness (SOI) ranking. A cluster sample of all outliers from 2014 were further reviewed. Demographics, % TBSA ± MV, insurance status, discharge (D/C) placement, social supports, cognitive impairments, mental illness, and substance abuse status were reviewed. ELOS, SOI, and case mix index (CMI) were compared to inlier cases of that same time period for statistical significance using the student t-test. Results: A total of 2596 patients were admitted over the 3 year period; approximately 4% were outliers (Table 1). There were 36 outliers in 2014. Demographic findings are in Table 2. Nine patients received multiple facility placement denials resulting in D/C delays. Patients D/C'd to shelters required healed wounds at D/C. There were no statistical differences found between the inlier and outlier groups in 2014 for ELOS, SOI or CMI, p-values: 0.35, 0.51 and 0.50, respectively. Conclusions: Lack of surgical and medical acuity in these outliers was surprising. Using MV as a proxy for critical illness, only 14% were ICU patients. Lack of family support was a large barrier to D/C especially in parallel with patients lacking financial resources for post hospital follow up or a location to D/C. Psychiatric illness, cognitive impairment, and/or substance abuse greatly limited D/C facility selection. Further investigation is warranted into how LOS of these patients can be decreased and resources optimized. Applicability of Research to Practice: Directly applicable. Table. No title available. View Large Table. No title available. View Large Table. No title available. View Large Table. No title available. View Large 26. Frailty Scores Worsen During Hospitalization of Elderly Patients and Lead to Poor Outcomes E. Curtis, MD, K. Romanowski, MD, A. Barsun, MSN, CNP, T. Palmieri, MD, FACS, FCCM, D. Greenhalgh, MD, FACS, S. Sen, MD, FACS UC Davis Medical Center and Shriners Hospitals for Children, Sacramento, CA; University of Iowa, Iowa City, IA Introduction: Physiologic deterioration leads to frailty in elderly patients, impacting their ability to recover fully from a burn injury. Previous evidence shows that high frailty scores on admission are associated with poor outcomes in elderly burn patients. Although burn patient physical and mental status often deteriorate during hospitalization, changes in frailty during the acute hospitalization for a burn injury has not previously been studied. We hypothesize that frailty scores worsen during hospitalization in elderly burn patients and are associated with an increased need for skilled nursing facilities (SNF) after discharge. Methods: We performed a two-year retrospective review of all elderly (≥65 years) burn-patients admitted to our burn center. We excluded all patients who died during hospitalization. We collected data about the patient's demographic, burn injury, hospital course, and discharge disposition. We calculated a Canadian Study on Health and Aging Frailty Score (FS) on admission and at discharge for each patient. All mean values are represented as mean ± sd, and all median values are represented as median (IQR). Results: At total of 79 patients were included in the study. Mean age was 75 ± 8 years and median TBSA was 6.5 (3-13)%. Admission FS was 4.3 ± 1.2 increased to 5.1 ± 1.2 at discharge. On admission only 37% of the patients had a FS ≥5, however at discharge 66% of the patients had a FS ≥5. 35% of the patients were discharged to a SNF and 65% were discharged home. Patients discharged to a SNF were older (77 ± 9 vs. 73 ± 7 years) and suffered a larger burn injury (11 (6-17) vs. 4 (2-10)% TBSA) than patients who were discharged home. Additionally, both admission FS (5.2 ± 1 vs. 3.9 ± 1) and discharge FS (6 ± 0.8 vs. 4.6 ± 1) were significantly higher in patients discharged to a SNF. Controlling for the effect of age and TBSA, both admission FS (OR 3.4 (CI 1.7-6.3)) and discharge FS (OR 3.4 (CI 1.7-6.7)) were independently associated with discharge to SNF. Conclusions: Frailty is a significant factor in recovery for elderly burn patients. Frailty worsens during hospitalization and is an independent factor for outcomes for elderly burn patients. Applicability of Research to Practice: Assessing risk of outcomes for elderly burn patients. 27. Factors That Cause Delays in Initiation of Burn Multi-Center Studies - How Can We Improve the Process? K. Falwell, BSN,RN, M. Lawless, MSN, RN, T. Curri, CCRC, S. Sen, MD, FACS, D. Greenhalgh, MD, FACS, T. Palmieri, MD, FACS, FCCM University of California Davis, Sacramento, CA Introduction: Multi-site research yields high quality information for improving care. The Multi-Center Trials Group (MCTG) is a multidisciplinary group of American Burn Association (ABA) members committed to this very mission. However, getting the research off the ground is one of the biggest hurdles encountered by investigators, which has significant impact on overall enrollment and study conduct. The purpose of this project is to describe the length of time required to initiate a multi-center study. Methods: Twenty national and international burn centers were selected to participate in this multi-center prospective trial. As lead site, our efforts to manage study timelines began with dissemination of protocol and involved facilitating study initiation processes and tracking progress. During the period that submissions were under review, participating site research staff were trained on all aspects of study conduct. We tracked progress and length of time that it took for sites to obtain local IRB approvals, secondary approvals that were required by the funding agency, execution of contracts, length of time to begin screening once all approvals had been obtained, and finally, the time between screen start and enrollment of first subject at each site. All median values are median (IQR). Results: One site withdrew prior to IRB initiation. Of the nineteen remaining sites, the median time to IRB approval was 42 weeks (IQR 20-65). Median time for second level approval mandated by the funding agency was an additional 33 weeks (IQR 22-47). Contracting delays that extended beyond regulatory approvals occurred at nine sites, with a median additional delay of 9 weeks (IQR 6-34). Once all required approvals were obtained, it took a median of 8 weeks (IQR 3-14) before the first patient was screened. Median length of time between screen start and first enrollment was 7 weeks (IQR 3-12). The median time from protocol dissemination to first enrolled subject was 111 weeks (IQR 89-147). Both time to IRB approval (r=0.47) and time to funding agency approval (r=0.75) significantly correlated to the time needed to first enrollment. Conclusions: Even with careful planning, initiation of multi-site study can take up two years to start. There may be several causes for this; however, time to regulatory approval appears to be the major factor. Applicability of Research to Practice: Anticipating inevitable delays and executing strategies that would streamline regulatory approval at the outset of study implementation may help to increase length of time for actual study conduct to ensure that enrollment goals are met within the proposed study timeline. External Funding: USAMRAA Contract#W81XWH-08-l-0760. 28. Burn Size Measurement Using Proportionally Correct 3D Models of Pediatric Patients S. Thumfart, PhD, M. Giretzlehner, PhD, P. Wurzer, MD, J. Höller, MSc, M. Ehrenmüller, MA, K. Pfurtscheller, MD, H. L. Haller, MD, L. P. Kamolz, MD, PhD, K. Schmitt, MD, D. Furthner, MD Johannes Kepler University Linz, RISC Sofiware GbmH, Hagenberg, Austria; Johannes Kepler University, RISC Sofiware GbmH, Hagenberg, Austria; Shriners Hospitals for Children, Galveston, TX; Ludwig Boltzmann Institute for Clinical-Forensic Imaging, Graz, Austria; University of Applied Sciences, Statistics, Steyr, Austria; Children's Burn Unit, University Children's Hospital and Medical University of Graz, Graz, Austria; AUVA Trauma Hospital UKH Linz, Linz, Austria; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria; Children's Hospital LFKK Linz, Department of Pediatrics, Linz, Austria Introduction: The estimation of a pediatric patient's total body surface area burned (TBSA-B) is challenging due to varying size and body proportions during growth. Adaptations of the rule of nines and Lund Browder charts for children have been published to address the anthropometric differences. These standard methods however are subject to high inter-rater variance and overestimation of the affected area. To enable precise three dimensional (3D) body surface area measurements, we generated 12 proportionally correct 3D models which were integrated into a program for measuring the TBSA-B of pediatric patients. Methods: A set of 24 body measurements was obtained from 2529 pediatric patients, aged 0-17 years. Each measurement was normalized by body height to obtain proportions. A correlation cluster analysis revealed key proportions that were used to obtain an age partition with high proportion stability. For each age range we generated a 3D model using an optimization plugin written for a human character modelling program. Finally the 3D models were imported into a burn documentation program, where each model is rescaled to match the real patient's height and weight while preserving the model's proportions. Results: The cluster analysis revealed five proportion groups with high intra-group correlation. One representative per group (head-circumference, chest-circumference, leg-length, waist-breadth and sitting-height) was chosen to analyze changes during growth. This resulted in six age groups (0-1, 1-2.5, 2.5-4, 4-6, 6-11.5, 11.5-18 years) with stable proportions. Finally the median body-measurements were used to generate six proportionally correct 3D models for each sex. Conclusions: To our knowledge this is the first approach to generate proportionally correct pediatric models for TBSA-B estimation. We show that body proportions can be clustered without negative intra-group correlation. The revealed age partitions with stable proportions call for further research whether age groups commonly used for rule of nines and Lund Browder charts should be modified. Applicability of Research to Practice: By looking at the raw numbers the clinical relevance of our research becomes visible. For instance the models demonstrate that the area of the head is changing from 14.7% (6 months) to 6.3% TBSA (14 years), while the relative BSAs of extremities increase during growth. Precise burn wound size estimation for pediatric patients is only possible when these proportion changes are considered appropriately. External Funding: The presented research was funded by the Upper Austrian Government. Figure. View largeDownload slide Figure. View largeDownload slide 29. Implementation of a Nurse-Driven Foley Removal Protocol and the Impact on Catheter Associated Urinary Tract Infections and Device Utilization Rates D. Roggy, RN, S. Tuvell, RN, N. Fitzgerald, RN, BSN, K. Gabehart, RN, MSN, R. Sood, MD, FACS Richard M. Fairbanks Burn Center, Indianapolis, IN Introduction: Catheter associated urinary tract infection (CAUTI) is the most frequent health care acquired infection (HAI) in the United States accounting for 30% of all HAIs. Treatment of CAUTI and its possible complications is costly ranging from $600 - $1200. In August 2014, physicians, infectious disease, and nursing in our hospital developed and approved a Nursing-Driven Foley Removal Protocol in an effort to decrease the incidence of CAUTI throughout the facility. The protocol allows a registered nurse to discontinue an indwelling urinary catheter without a physician's order if the patient does not meet indications for usage. Indications for usage include: Monitor post-operative fluid status, accurate I/Os, management of acute urinary retention, neurogenic bladder, or bladder outlet obstruction, urologic surgeries and procedures, avoid contamination of an open sacral or perineal wound in an incontinent patient, comfort care in terminally ill patients, hemodynamic instability, and acute renal failure. Our burn center, performed education to our staff and residents and fully implemented the protocol in November 2014. Methods: A retrospective review of our Performance Improvement data was performed focusing on CAUTI data from 11/2013 through 08/2015. The data was divided into two groups. Group A is data from 11/2013 - 10/2014 and Group B is data from 11/2014- 08/2015. The two groups were compared for the actual number of CAUTIs during each time period and the device utilization rate. Results: As seen in Table 1, the number of CAUTIs between Group A and Group B had a statistically significant decrease following the implementation of the Nurse-Driven Foley Removal Protocol. We also noted a decrease in our device utilization rate following implementation of the new protocol. Conclusions: Implementation of the Nurse-Driven Foley Removal Protocol has contributed to a decrease in our number of CAUTIs and our utilization of indwelling catheters. Our burn team has come to the conclusion that the best way to prevent a CAUTI is to avoid the use of indwelling catheters and if they are clinically indicated, discontinue use as soon as possible. Applicability of Research to Practice: CAUTI is the leading hospital acquired infection. The RN-Driven protocol implemented in our institution has provided positive results for our unit. Table. No title available. View Large Table. No title available. View Large 30. Beginning to Define Burn-Specific Outcome Measures: Surgical Experience of Two Verified Burn Centers G. M. Lewis, MD, FACS, I. Faraklas, BSN, S. Dissanaike, MD, FACS, Y. Zhai, MPH, G. Graves, B. Walker, BA, D. Ha, BS, A. Cochran, MD, FACS, FCCM University of Utah Department of Surgery, Salt Lake City, UT; Texas Tech University Health Sciences Center, Lubbock, TX Introduction: The American Burn Association's initiative to create a Burn Quality Improvement Program (BQIP) seeks to define key quality metrics based on hospital acquired conditions, burn-specific outcome measures, patient experience survey results, and staff satisfaction surveys. The aim of this study is to describe the surgical experience at two verified burn centers as a basis for developing burn-specific outcome measures. Methods: With IRB approval, we retrospectively reviewed adults admitted to two ABA-verified burn centers between January 2008 to December 2014 with >20%TBSA burn injury. Study data included demographics, hospital course, outcomes, and was collected using the REDCap electronic data capture tool. Results: Three hundred and thirty-four subjects were included in this study. Demographic data is depicted in the table. Study subjects underwent their first operative excision a median of 3 days after admission (IQR 1-5 days) and required a median of 2 operations to achieve definitive closure (IQR 1-5 operations). 240(72%) of study subjects required autograft, 62 (19%) required temporary graft placement, and 43(13%) required Integra® prior to definitive closure. Failure rates were 22%(53/240) for autograft, 37% (23/62) for temporary graft placement, and 38% (16/43) for Integra®. Complications included pneumonia (24%, n=79), urinary tract infection (11%, n=36), wound complication (5%, n=15), unplanned intubation (5%, n=17), and sepsis (6%, n=20). Of note, hospital length of stay per %TBSA was 0.89 days/%TBSA (IQR 0.67-1.3). Most patients readmitted to the hospital (29%, n=65) were unplanned (78% of readmissions, 51/65). Conclusions: This study provides a preliminary foundation for benchmarking surgical management by examining surgical outcomes and complications in burn care. Creation of consensus definitions of complications and a validated, risk-adjusted database would help generate quality metrics specific to burn care. Applicability of Research to Practice: Define surgical outcomes and quality metrics in alignment with the BQIP initiative. Table. No title available. View Large Table. No title available. View Large 31. The Impact of the Continuity of Nursing Care on Nurse Sensitive Indicators and Patient Satisfaction E. A. Rathjen, RN, MSN, C. Chaves, RN, MSN, D. Voigt, MD Saint Elizabeth Regional Medical Center, Lincoln, NE Introduction: Nurse sensitive indicators (ventilator associated pneumonia/events, central line infections, and catheter associated urinary tract infections) and patient satisfaction are important indicators for quality of care as reimbursements are based on these measures. Numerous studies discuss "knowing" the patient yet none link the outcomes for patients relative to the number of different nurses caring for a patient during their hospitalization. The purpose of this retrospective review is to determine what effect the continuity of nursing assignments has on patient satisfaction scores and nurse sensitive indicators. Methods: A sample of patients from our burn unit is chosen each month. Inclusion criteria is a greater than 5 day length of stay in the burn center. Nursing assignments are pulled from the assignment system. An index is calculated with the number of different nurses caring for the patient over the number of possible shifts during the patient's stay. Our self-selected goal, as no standard of measurement has been established, is 0.7 or lower. This translates to a patient with 10 assigned shifts and 7 different nurses caring for them. Patient satisfaction data as reported by HealthStream is utilized. Data for nurse sensitive indicators as reported to NDNQI are utilized for pressure ulcers, ventilator associated conditions, central line, and catheter associated infections. All data was correlated using Pearson's Correlation. Results: Data analysis shows a statistically significant correlation between the nurse continuity ratio and the patient satisfaction questions: explanation of new medication side effects (at the 0.05 level), and being treated as a whole person (at the 0.01 level). Correlations that approached but did not reach statistical significance include: nurses explaining purpose of new medications and responsiveness of nurses to bathroom requests. Correlations for pressure ulcer and ventilator associated conditions were not computed as this burn unit had zero incidents resulting in constant variables that could not be analyzed. Conclusions: This burn unit has had 10 quarters of no hospital acquired pressure ulcers, no ventilator associated pneumonia's, and below the NDNQI benchmark central line infections, utilization, and catheter associated infections and utilization. This information has demonstrated to us that nurses in this department are technically competent but our failure to show statistically significant differences in many patient satisfaction questions highlights a deficiency in relationship development. Applicability of Research to Practice: Further research should be done to further demonstrate existing relationships between the continuity of nursing care and patient outcomes both in the technical and patient satisfaction areas. 32. Assessment of Outreach by a Regional Burn Center: Utilization of Resources Should Be Part of Education for Referring Providers N. H. Carter, MD, C. Leonard, ACNP-C, L. Rae, MD Vanderbilt University Medical Center, Nashville, TN Introduction: Prehospital and early management are critical to thermal injury outcomes. We engage in outreach education including advanced trauma life support (ATLS) and advanced burn life support (ABLS) for our catchment area. The aim of this study is to evaluate the effectiveness of our outreach efforts and identify areas for improvement in pre burn center care and resource utilization. Methods: We initiated a retrospective chart review of all adult and pediatric transfers to our regional burn center from July 2012 to July 2014. Quality metrics for initial management per ABLS guidelines were recorded. We analyzed the use of helicopter and fixed wing medical transport, and patients discharged within 48 hours to evaluate potential improvements in resource utilization and use of referral criteria for inpatient versus outpatient clinic. Results: In two years, our burn center admitted 1291 patients including 667 (52%) who were transferred from referring hospitals. Of these, 489 (73%) were transported by ground ambulance, 123 (18%) by helicopter, and 20 (3%) by fixed wing aircraft. Burn size (BSA) was not documented in 293 (44%) of transferred patients. Among 373 patients with BSA recorded by the referring facility, 165 (44%) were more than 5% BSA different from the burn center assessment, and 28 (7%) had BSA overestimated by more than 20%. Fluid boluses were given to 278 (42%) patients prior to arrival at the burn center. Of the 68 adult patients with BSA greater than 20%, 32 (47%) received fluids at a calculated resuscitative rate and 42 (62%) received fluid boluses although only seven had hypotension. Among 111 patients who arrived intubated, 17 (15%) and 42 (38%) were discharged home within 24 hours and 48 hours respectively. Of total inpatient transfers, 227 (34%) and 391 (58%) were discharged to home within 24 and 48 hours of transfer respectively. In a subset analysis of 143 patients who arrived by air, 18 (12%) and 52 (36%) were discharged home within 24 and 48 hours respectively. The estimated transport cost associated with these 52 patients was greater than $1,200,000. Conclusions: Outreach education efforts should emphasize the need to calculate BSA to determine who needs fluids and that bolus fluids are only for hypotension. As well, the difference between referral criteria and transfer criteria should be a focus of education for improved resource utilization. Applicability of Research to Practice: Feedback to referring hospitals is a requirement of the ACS committee on trauma. Outreach education should emphasize the importance of calculating BSA, avoiding fluid boluses in the absence of hypotension and clarifying ABA burn center referral criteria to include recommendations for inpatient vs. outpatient referrals for resource utilization. 33. Effects of Early Combinatorial Treatment of Autologous Split-Thickness Skin Grafts in Red Duroc Pig Model Using Pulsed Dye Laser and Fractional CO2 Laser J. K. Bailey, MD, FACS, J. J. Kim, PhD, B. N. Blackstone, PhD, D. M. Dunham, PhD, F. Imeokparia, MD, C. Stucken, MD, S. P. Smith III, MD, H. M. Powell, PhD The Ohio State University Wexner Medical Center, Columbus, OH Introduction: Use of the Pulsed Dye Laser (PDL) is increasing, as is the support of the use of the fractional CO2 laser (FxCO2). Although there is growing support for higher-quality clinical studies, there has been a dearth of application to animal models with which the effectiveness could be more easily studied in detail. Methods: Eight female red Duroc pigs (FRDP) received 8 standardized, third degree burns that were then excised and autografted. The wound sites were treated with PDL, FxCO2, or both at 4, 8, and 12 weeks post grafting. Nondestructive measurements and punch biopsies were done at weeks 4, 8, 12, and 16. Results: After 2 therapy sessions, scars treated with the FxCO2 laser and FxCO2 laser + PDL appeared to be less wrinkled, thinner, and less contracted than PDL alone and the non-treated controls. Conclusions: Just as seen in humans, split thickness skin grafts undergo significant secondary contracture and this happens relatively soon after grafting. In the FRDP model of skin grafting, early application of the PDL, FxCO2, or combinatorial application is well tolerated by the skin graft and reduces secondary contraction. This data suggests that laser therapy may be better directed as a preventative adjunct, rather than as a treatment plan of hypertrophic scarring and secondary contracture of split-thickness skin grafts. Applicability of Research to Practice: Applicability to Practice: Laser treatment may decrease skin graft contracture in burn patients. External Funding: Research was supported by a grant from the CCTS at OSU #UL1TR))1070. Table. No title available. View Large Table. No title available. View Large 34. Adipose Stem Cells Delivered in Fibrin Hydrogels as Adjuncts to Meshed Autografts Prevent Contraction and Enhance Angiogenesis of Deep-Partial Thickness Burn Wounds D. M. Burmeister, PhD, R. Stone II, PhD, N. L. Wrice, MS, A. Laborde, S. C. Becerra, MS, S. Natesan, PhD, R J. Christy, PhD U.S. Army Institute of Surgical Research, Fort Sam Houston, TX Introduction: In cases of extensive burn wounds, donor site availability is often limited, resulting in the need to mesh autografts to expand wound coverage. We hypothesize that the ensuing wound contraction, along with donor site morbidity may be circumvented using tissue engineering technologies. We have previously shown that applying PEGylated fibrin (PEG-fibrin) hydrogels with human adipose-derived stem cells (ASCs) to excisional wounds in nude rats enhances angiogenesis. Here, we investigate the effectiveness of the combination of ASCs and PEG-fibrin hydrogel in a porcine model of debrided burn wounds. Methods: Deep-partial thickness burns created on the dorsum of anesthetized Yorkshire pigs were debrided on post-injury day 4 and treated with: split thickness skin grafts (STSG); meshed STSG at 1:1.5 (mSTSG); mSTSG + PEG-fibrin; and mSTSG + PEG-fibrin with ASCs at 1x105, 5x105, and 1x106 cells per 3cm diameter wound. Photographs and biopsies were taken on post-burn days 10, 14, 21, and 42, with euthanasia on post-burn day 42. Excised tissue was processed for routine histopathology and western blot analysis. Results: On day 42, treatment with mSTSG resulted in significantly more contraction of wounds (88.9 ± 5.6 % of original area) compared to those treated with STSG (109.3 ± 5.0% of original area) and mSTSG + PEG-fibrin (110.6 ± 6.9% of original area). When ASCs were delivered to the wounds in PEG-fibrin, the size of blood vessels counted via histopathology on day 10 post-injury increased in a dose dependent fashion and accelerated angiogenesis compared to wounds treated with mSTSG and no cells. Furthermore, the size of blood vessels significantly correlated with CD31 protein levels (r=0.69. P<0.0042). Conclusions: PEG-fibrin hydrogels were able to prevent the contraction seen when skin grafts applied to burn wounds were meshed. Moreover, PEG-fibrin hydrogels could also be used to deliver ASCs, which accelerated angiogenesis in a dose-dependent fashion. The ultimate goal in investigating the combination of ASCs and PEG-fibrin is to generate vascularized skin equivalents to improve graft integration and mitigate scar formation. Applicability of Research to Practice: This biomaterial and stem cell technology shows great promise as an adjunct to autografting in cases where meshing grafts is needed. External Funding: Medical Research and Materiel Command (MRMC) provided funding for this project. 35. Elastin is Differentially Regulated by Pressure Therapy in A Porcine Model of Hypertrophic Scar B. Carney, BS MedStar Health Research Institute, Washington, DC Introduction: Beneficial effects of pressure therapy in for hypertrophic scars (HTSs) have been reported, but the mechanisms of action are not fully understood. This study evaluated elastin, a component of the extracellular matrix (ECM) that contributes to scar pliability. We assessed whether changes in Vancouver Scar Scale (VSS) scores of pressure treated scars were related to differential regulation of elastin in the scar after treatment. Methods: Full thickness excisional wounds were created on the flanks of duroc pigs and formed HTSs. Subsequent scars were assessed weekly by VSS, and biopsies were taken. At Day 70 post injury, a mountable device, applying 30 mmHg of constant pressure, was used to treat the scars. Scars were separated into treatment (device mounting and treatment), and sham (device mounting and no treatment) groups. The treatment lasted two weeks, and the device was removed at Day 84. Scars were continually assessed through Day 126. A colorometric, protein level assay was used to quantify differences in elastin content. Verhoeff-Van Geison (WG) staining was used to visualize elastin fibers. Results: Pressure treatment resulted in lower VSS scores compared to sham-treated scars (p<0.05). Of the 4 parameters assessed using the VSS, pliability (VSSP) was a key contributor to differences between groups. At Day 70, before treatment VSSP=2. Without treatment, sham-treated scars became less pliable by Day 84 (VSSP=3), while pressure treated scars became more pliable (VSSP=1). This trend continued through Day 126 where VSSP= 1.5 and VSSP=2.5 in pressure and sham treated scars respectively. The percentage of elastin in scars at Day 70 was increased from the amounts in baseline skin (5.11% vs. 3.03%). At Day 84, after two weeks of pressure treatment, the percentage of elastin increased to 5.56% and continued to increase through Day 126 to 6.07%. Sham-treated scars did not have this increase in elastin quantity, with percentages of elastin equal to 2.96% and 3.84% at Days 84 and 126. WG staining corroborated the protein level findings and allowed for the visualization of the alignment of elastin fibers. Conclusions: Pressure treatment results in increased protein level expression of elastin compared to sham-treated scars. These findings further characterize the ECM's response to the application of pressure as a treatment. Applicability of Research to Practice: Elastin changes after pressure underscores the importance of this protein in normal skin regeneration and enriches current understanding of pressure's mode of action. Pressure application can be optimized by tailoring specific treatments that may vary on a case-by-case basis. This will contribute to the furthering of rehabilitation practices and contribute to positive improvements in patients' psychosocial complications. External Funding: NIH/NIBIB 1R15EB01343901. 36. Transcriptional Analysis Reveals Evidence of Chronically Impeded ECM Turnover and Epithelium-To-Mesenchyme Transitions in Scar Tissue Giving Rise to Marjolin's Ulcers S. Sinha, S. Su, M. Workentine, PhD, N. A. Agabalyan, PhD, J. A. Biernaskie, PhD, V. Gabriel, MD, MSc, FRCSC University of Calgary, Calgary, AB, Canada Introduction: Marjolin's ulcer (MU) is an aggressive malignancy arising within chronic wounds. A major cause is unhealed burn injuries. This results in well-differentiated squamous cell carcinoma (SCC). This study aimed to elucidate transcriptional changes leading to malignancy by investigating differentially expressed genes in squamous cells present in a SCC compared to MU. Methods: MU tumour cells were isolated from histologic confirmed biopsy of SCC on unhealed burn scar. Epithelial cells (EC) adjacent to the tumour were co-isolated and SCC cell line was commercially purchased. mRNA from all three samples was isolated and its expression was quantified using RNA-Seq. Threshold of Iog2fold change>2 in either directions was considered ‘differentially expressed’ (Figure IB). Results: PCA indicates variation among the three groups (Figure 1A). Heat maps of 665 differentially expressed genes in MU vs EC (Figure 1C) and 1694 differentially expressed genes in MU vs SCC (Figure ID) are presented. Linkage of genes by GO terms using KEGG (Figure 2A,C) and Reactome (Figure 2B,D) are presented. Conclusions: Our analysis revealed two key insights about chronic wound microenvironment conducive to ulceration. First, in EC vs MU comparison, downregulation of COL and MMP families (circled in Figure 2A,B) suggests chronically impeded ECM turnover giving rise to a fibrotic microenvironment. ECM turnover is imperative during wound healing and its prolonged dysregulation can be linked to carcinogenesis. Second, in SCC vs MU comparison, dysregulation of cadherin mediated cell-cell adhesions (circled in Figure 2C,D) is suggestive of epithelium-to-mesenchyme transitions (EMT), similar to those during development. Additionally, 15 genes in TGFβ pathway, a suppressor of EC growth, where enriched in MU compared to SCC. Acquiring the ability to perform EMT can be responsible for high metastatic rate in MU tumours (30-40%) compared to SCC (.5-3%). Applicability of Research to Practice: This study has direct implications for screening therapeutic agents which halt or prevent non-healing wounds from undergoing malignancy. External Funding: This work was supported by Collaborative Research and Innovation Opportunities grant by Alberta Innovates Health Solutions (AIHS) to VG and JB, and an AIHS summer studentship to SS. Figure. View largeDownload slide Figure. View largeDownload slide 37. Improvement of Hypertrophic Scarring Upon Application of a Novel Liquid Skin Substitute in Fibrotic Animal Model A. Ghahary, PhD, R. Hartwell, PhD University of British Columbia, Vancouver, BC, Canada Introduction: It is well established that any delay in burn wound epithelialization increases the risk of hypertrophic scar formation. This is based on the fact that when a burn wound is epithelialized within 2-3 weeks, only 22% of the anatomically site-matched wounds become fibrotic; however, this increases to 78% when a wound is epithelialized later than 21 days. Application of a scaffold that can rapidly integrate with the uneven injured wound bed is likely to accelerate the wound healing process and prevent hypertrophic scar formation. Recently we formulated a soluble form of rapidly polymerizing collagen that could be freeze-dried at neutral pH to result in a powdered version of a skin substitute. Upon rehydration, the powder would result in a liquid that could form a solid scaffold within a wound site. It is our working hypothesis that filling up wounds with our recently developed reconstitutable skin substitute system would promote healing and prevent hypertrophic scarring in a fibrotic rabbit ear model. Methods: Punch wounds (6mm) were generated on rabbit ears and remained either untreated or filled up with a temperature sensitive liquid reconstituteable, biohybrid-Collagen-GAG scaffold which solidifies within 20-30 min. upon its application at the wound site. The wounds were monitored daily and evaluated for epithelialization time, tissue cellularity, healing outcome and angiogenesis. Results: Wounds treated with our liquid skin substitute were found to exhibit significantly faster epithelialization, reduced cellularity and reduced scar elevation index (1.24 ± 0.05 vs. 1.64 ± 0.14, p<0.0) as compared to that of untreated wounds. Further, significant increases in vasculature (6 vs. 2 vessels/hpf; p<0.05) were also noticeable in gel treated wounds. Conclusions: The results demonstrated that the use of in situ forming scaffold improved healing outcome in full thickness rabbit ear wounds. Applicability of Research to Practice: As a liquid skin substitute, it can easily be sprayed onto the wound bed, providing rapid integration with uninjured tissue to which epithelial cells can migrate and promote healing and thereby reducing hypertrophic scar formation in burn patients. External Funding: A. Ghahary has received.funding for this project from the Canadian institute of Health Research (CIHR). 38. A Decorin Adenoviral Gene Vector to Improve Remodeling of Cultured Skin Substitute Collagen Scaffolds P. Kwan, MD, FRCSC, J. Ding, MD, PhD, E. E. Tredget, MD, MSc, FRCSC University of Alberta, Edmonton, AB, Canada Introduction: Cultured skin substitutes can improve survival for large burns. Currently dermal fibroblasts (DF) are harvested from skin biopsies with no stratification by DF subpopulation, although research suggests superficial DF are regenerative and deep DF are profibrotic. We hypothesized that differences in DF subpopulation would affect collagen scaffold remodeling, and deep DF remodeling behavior would mimic that of superficial DF following decorin gene vector treatment. Methods: Matched superficial and deep DF were taken from abdominoplasty specimens, and deep DF treated with a control or decorin adenoviral vector. Fibroblast proliferation and adhesion was studied using a crystal violet assay. Decorin was measured using enzyme-linked immunoassay. Gene expression was measured using reverse transcription quantitative polymerase chain reaction. Collagen scaffold remodeling was characterized by collagen fibril thickness, as measured using picrosirius red staining and circularly polarized microscopy, and collagen orientation index, as measured using confocal microscopy and fast Fourier transformation. Student's t-test was used; values given as mean ± standard error; statistical significance at P < 0.05. Results: Gene vector treatment did not adversely affect fibroblast proliferation and adhesion. Decorin was significantly upregulated by vector treatment of deep DF. Deep DF had significantly higher levels of transforming growth factor beta (TGF-beta) and connective tissue growth factor (CTGF) than superficial DF (6.16 ± 0.18 versus 1.00 ± 0.03, P < 0.001; and 4.51 ± 0.76 versus 1.18 ± 0.50, P < 0.02), but this was reversed by treatment with our gene vector (1.97 ± 0.30 and 1.92 ± 0.68, P < 0.001). Collagen fibrils of deep compared to superficial DF remodeled scaffold were significantly thicker (2.19 ± 0.09 versus 1.66 ± 0.12 μrn, P < 0.002), but treatment reversed this (1.39 ± 0.06 μm, P < 0.001), and collagen orientation index of deep compared to superficial DF remodeled scaffold was significantly higher (0.252 ± 0.016 versus 0.101 ± 0.030, P < 0.001), but treatment also reversed this (0.0100 ± 0.029, P < 0.001). Conclusions: Decorin gene therapy significantly upregulates decorin production, and does not adversely affect fibroblast proliferation or adhesion. It significantly downregulates both TGF-beta and CTGF production by deep DF. This may contribute to the significant improvements in collagen scaffold remodeling by treated deep DF, which mimic the remodeling by superficial dermal fibroblasts in both collagen fibril thickness and collagen orientation index. Applicability of Research to Practice: Modification of cultured skin substitutes using gene therapy may improve wound healing, and reduce scarring. External Funding: Financial support was received from the Firefighter's Burn Trust. 39. Circulating Cells are Precursors of Heterotopic Ossification J. M. Peterson, BS, S. Agarwal, MD, S. J. Loder, BS, J. Li, MD, D. Cholok, BA, K. Ranganathan, MD, S. C. Wang, MD, PhD, B. Levi, MD University of Michigan, Ann Arbor, MI; University of Michigan Medical School, Ann Arbor, MI Introduction: Heterotopic ossification (HO) is the pathologic development of extraskeletal bone in soft tissues following traumatic injury. While some molecular mechanisms of HO pathogenesis have been elucidated, the origin and identity of cellular HO precursors is yet unknown. Via the establishment of chimeric circulation by parabiosis, we sought to identify and characterize circulatory precursors of HO using an established murine model of trauma-induced HO in mixed wild type and reporter parabionts. Methods: Background-matched female mice were used as recipients in parabiosis with the following female reporters: (CAG-luc-GFP) L2G85Chco/J (L2G85), (UBC-GFP)30Scha/J (Ub-GFP), Cdh5-cre/ROSA26tdT (Cdh5-cre), and Scx-cre/ROSA26mTmG (Scx-cre). After surgical union, two weeks were allowed for establishment of circulatory chimerism. HO was then induced by 30% total body surface area partial thickness burn and hindlimb Achilles' tendon transection. Bioluminescent imaging of L2G85 parabiont was performed after luciferin injection. Pairs were euthanized 3-12 weeks post-trauma and hindlimb cryosections were imaged by fluorescent microscopy. Results: Bioluminescence of L2G85 recipient hindlimb confirmed chimerism. Ub-GFP(+) reporter cells were observed in Ub-GFP recipient HO marrow, endosteum, and fibroproliferative zones with intermittent contribution to cartilaginous zones. Cdh5-cre(+) reporter cells were observed diffusely throughout Cdh5-cre recipient HO zones. Both Scx-cre(+) and Scx-cre(-) reporter cells were found in the fibroproliferative zones of Scx-cre recipient HO. Conclusions: The presence of fluorescent reporter cells in fibroproliferative, cartilaginous, and osseous HO zones reveals that circulatory precursors contribute to HO development. Diffuse Cdh5-cre expression in HO suggests a hematopoetic compartment lineage of endothelial and possibly mesenchymal HO tissue. Scx-cre expression in fibroproliferative HO zones confirms that circulatory precursors take on mesenchymal properties, verifying the potential for precursors to assume diverse phenotypes upon integration at the site of HO formation. Applicability of Research to Practice: Identification of a circulating HO precursor highlights a specific target for therapeutic intervention. Figure. View largeDownload slide Figure. View largeDownload slide 40. Cultured Human Melanocytes in Engineered Skin Substitutes Provide Rapid Restoration of Natural Skin Color after Transplantation to Full-Thickness Wounds S. T. Boyce, PhD, C. M. Lloyd, BS, M. C. Kleiner, MS, D. M. Supp, PhD University of Cincinnati, Cincinnati, OH; Shriners Hospitals for Children, 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 for elective scheduling of transplantation. The objective of this study was to optimize methods for culture and cryopreservation of hM for restoration of skin color in grafted ESS. Methods: Fibroblasts, keratinocytes, and hM were isolated and cultured from de-identified surgical discard skin. Cells were cryopreserved, recovered into culture, expanded in number and inoculated sequentially onto biopolymer scaffolds in two different media ("Standard", or Organ Culture Medium, "OCM") for epidermal morphogenesis. After 10-14 days, ESS with or without 1.0e4/cm2 added hM (ESS-P) were grafted to full-thickness wounds in immunodeficient mice (n = 5-10/group). At 2-12 weeks after surgery, ESS and ESS-P were photographed for image analysis of pigmented area, and evaluated with a Mexameter to determine pigment density. At euthanasia, healed skin was removed, and subjected to en face immunostaining of the basal epidermis with a melanocyte-specific marker to determine hM frequency and distribution. Values for hM distribution and pigment density were compared to the original tissue biopsy. Statistical analysis was performed using repeated-measures ANOVA. Results: ESS-P incubated in OCM medium were visibly pigmented in vitro, and developed significantly greater (p<0.05) pigmented area at weeks 2-4, and greater pigment density at weeks 2-6 than ESS-P incubated in Standard medium. All ESS-P conditions generated fully-pigmented skin with pigment density that was significantly greater than donor skin. Average percentage pigmentation approached 100% by 6 weeks after transplantation. Similarly, hM density and distribution were 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 indicate that pigmentation may be restored fully by transplantation of autologous melanocytes in ESS-P grafted to full-thickness wounds, and that hM proliferate after transplantation to restore normal cell density and pigment transfer to keratinocytes. Importantly, incubation in vitro in OCM stimulates earlier pigmentation in vivo. 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: This study was supported by the US Department of Defense through the Armed Forces Institute for Regenerative Medicine (Contract W81XWH-13-2-0054), and by Shriners Hospitals for Children (Grant #84050). 41. Ventilating the Burn Patient with Acute Respiratory Distress Syndrome (ARDS): ARDSNet vs. What Actually Happens Y. Ching, MD, D. Wood, RRT, L. Tremblay, MD, FRCSC, R. Cartotto, MD, FRCSC Ross Tilley Burn Centre, Toronto, ON, Canada Introduction: The ARDSNet ventilation protocol was developed among critically ill non-burn patients with ARDS, but it is not known if this approach is suitable in burn patients with ARDS. The purpose of this study was to evaluate the application of the ARDSNet protocol in adult burn patients with ARDS. Methods: Retrospective review at an adult regional ABA-verified burn center (BC) of patients with Berlin-defined ARDS. We attempt to initiate the ARDSnet strategy at the start of conventional mechanical ventilation (CMV) in all patients. We examined CMV from the day of ARDS onset until CMV termination, defined as > 48 consecutive hours without ventilator support. Tidal volume (VT) is in ml/kg predicted body weight. Values are reported as either mean ± SD, or median (Q1-Q3), where appropriate. Results: We studied 69 subjects [age 49.5 ± 15.6 years, %TBSA burn 31 (22.8-47.0), % TBSA full thickness burn 20 (5.3-35.5), with inhalation injury in 66.7%]. Overall duration of ventilation in survivors was 21 (13-34) days. Mortality was 14.5%. ARDS developed on post burn day 3 (2-5), and was mild in 33%, moderate in 61%, and severe in 6%. Assist control-volume control (ACVC) was started in 59/69 subjects (86%) within 24 hours of admission, achieving VT 6.8 (6.2-7.4) ml/kg and plateau pressure (Pplat) 20.8 ± 3.9 cm H2O. By ARDS onset, ACVC was in use in only 30/69 subjects (43%), and continued for 25 (6.8-47.3) hours with Pplat of 23.1 ± 4.1 cm H2O, before conversion to another mode. Total CMV hours during ARDS were distributed 5.3% on ACVC, 34.6 % on Pressure Controlled Ventilation (PCV), and 60.1% on Pressure Support Ventilation (PSV). Overall, while on ACVC, VT and Pplat were 6.1 (6.0-7.0) mL/kg and 23.9 ± 5.0 cm H2O respectively. During PCV, VT was 7.7 (7.2-8.5) ml/kg and peak pressure was 28.4 (27.3-31.9) cm H2O. On PSV, VT and respiratory rate (RR) were 9.3 (8.1-10.9) ml/kg and 18.1 ± 4.2 breaths/min, respectively. During CMV for ARDS, PaCO2 was 43.7 ± 5.2 mmHg and pH was 7.40 (7.39-7.43). An SpO2 of 98.4 (97.4-99.0)% and a PaO2 of 104.1 (98.8- 111.0) were achieved using an FiO2 0.38 [(0.35-0.4l),range 0.3-0.73] , and Positive End Expiratory Pressure (PEEP) 9.3 (7.9-10.4) cm H2O. PEEP was set 2.2 ± 1.5 cm H2O greater than ARDSNet-recommended PEEP at each FiO2 level. Ten subjects were rescued with high frequency oscillatory ventilation (FiO2 0.81 ± 0.19, P:F ratio 94 ± 31, and oxygenation index 29 ± 11 on CMV). Conclusions: Adherence to ARDSNet was poor. Early conversion from ACVC to another mode was common and not based on elevated Pplat. On PCV VT and peak pressure were at the high end of the acceptable range. On PSV VT was > 8ml/kg PBW and appears to have been titrated to the RR. Higher than recommended PEEP was used. Applicability of Research to Practice: Strict application of ARDSNet may not be achievable in all burn patients with ARDS. 42. The Influence of Operative Time and Hypothermia in Burn Surgery N. Ziolkowski, MD, A. Rogers, MBBCh, MMed, S. Shahrokhi, MD, FRCSC, W Xiong, MSc, B. Hong, BHSc, S. Patel, B. Trull, MD, M. Burnett, BSc(Hons), M. Jeschke, MD, PhD University of Toronto, Toronto, ON, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; University of Ottawa, Ottawa, ON, Canada; University of Guelph, Guelph, ON, Canada Introduction: Intraoperative hypothermia has been shown to be a risk factor for increased infections and blood loss in general surgery. Also, prolonged surgical duration has been associated with increased infection and length of hospital stay. Therefore, it seems evident that duration of surgery is linked with hypothermia, and consequently with increased postoperative complications. Burn patients are known to be more susceptible to hypothermia, and despite a paucity of literature on the impact of operative duration on outcomes, most burn surgeons will apply arbitrary time or surface area limits. The objectives of this study were to investigate relationships between operative time, intraoperative hypothermia and complications. Methods: We conducted a retrospective cohort study of 772 patients requiring burn surgery over a ten year period in an ABA-verified centre. Data included demographics, operative details, and complications. Statistical analysis consisted of a modified Poisson model for relative risk and was adjusted for TBSA, co-morbidities and age. Results: Out of 772 patients, 618 were included. 71% were males, mean age of 47 years and a mean TBSA of 14%. Intraoperative hypothermia (under 35oC) is significantly associated with operative duration beyond three hours (relative risk 1.79;95%CI=1.21-2.65,p=0.0036). When operative time exceeds three hours, the risk of hypothermia increases by 79%. Longer operative times (>3.5 hours) are significantly associated with adverse clinical outcomes (PE, MODS, ARDS, death) [relative risk 1.39,95%CI=1.06-1.82,p=0.0158], and infections (wound infection, pneumonia and sepsis) [relative risk 1.29;95 %CI=1.04-1.62,p=0.0229]. Adverse clinical outcomes are significantly associated with hypothermia for patients with burn injuries greater than 20% TBSA (relative risk 1.37;95%CI 1.01-1.86,p=0.0402). Conclusions: Prolonged acute burn surgery is related to hypothermia and complications. Every effort should be made to limit operative duration, especially in large burns, and to avoid hypothermia with a protocolized, multidisciplinary approach. Strategies to improve operative efficiency, while still maintaining excellent standards of burn surgery, should be implemented. Applicability of Research to Practice: Our data suggest that vigilant attention to prevent hypothermia using evidence-based strategies and a multidisciplinary approach to reduce operative times may reduce post-operative complications. External Funding: Canadian Institutes of Health: Research # 123336CFI Leader's Opportunity Fund: Project # 25407 National Institutes of Health: 2R01GM087285-05A1. 43. Do Pre-Existing Conditions Affect Survival from Burns? V. K. Chopra, MD, P. Q. Bessey, MD, FACS, J. C. Gardenier, MD, A. Rabbitts, MS, RN NewYork Presbyterian/Weill Cornell Medical Center, New York, NY Introduction: Age, burn size, and inhalation injury are primary determinants of survival from burns. An adverse influence of pre-existing conditions on survival seems intuitively likely, but has been demonstrated inconsistently. A recent review suggested that the validated Charlson Co-morbidity Index (CCMI), was an independent predictor for death in addition to the revised Baux score (RBS) in a sub-population of burn patients. The purpose of the current study was to determine whether CCMI was a significant risk factor in a more general population of adult burn patients. Methods: All patients age 18 and above admitted during a 20 month period were identified. Age, burn size (TBSA), inhalational injury (IHI), and outcomes were recorded. Preexisting corn-morbidities were identified and CCMI was calculated for each patient. Age plus TBSA was determined, and the RBS calculated by adding a fixed factor for the presence of IHI. Logistic regression was used to determine the influence of these parameters on inpatient death. Results: A total of 826 patients were admitted during the study period. There were 30 inpatient deaths (3.6 ± 0.7%, mean ± SEM). CCMI was twice as high for deaths as it was for survivors (2.8 ± 0.4 vs 1.1 ± 0.1, p<0.0001). Non-survivors were also older (69.8 ± 3.6 years vs 46.4 ± 0.6, p<0.0001) and had larger burns than survivors (32.6 ± 5.1 % TBSA vs 4.2 ± 0.3, p<0.0001). IHI was also more common (33 ± 9 % vs 8 ± 1, p<0.0001). Death was strongly associated with CCMI (AUC 0.75, P<0.0001), and also with age and burn size (AUC 0.96, P<0.0001), and with the RBS (AUC 0.97, p<0.0001). The CCMI was strongly associated with age (R2 = 0.57, p<0.001). When CCMI was included with RBS in a logistic model, however, it had no apparent additional influence (Odds Ratio 0.88 ± 1.14, p=0.33). Conclusions: Age is strongly associated with the presence of pre-existing co-morbid conditions, so that it can serve as a proxy for them. Thus in a statistical model of death in a general population of burn patients, pre-existing conditions appear to have little additional influence. Age, burn size, and the presence of IHI, reflected in the RBS, are the primary determinants of death following burn injury in adults. Applicability of Research to Practice: Informs efforts at estimating risk in patients following burns. 44. Oxandrolone with Propranolol Decrease Cardiac Stress in Burned Children P. Wurzer, MD, R. P. Clayton, BS, L. K. Branski, MD, C. R. Andersen, MS, L. P. Kamolz, MD, PhD, L. C. Woodson, MD, PhD, O. E. Suman, PhD, C. C. Finnerty, PhD, D. N. Herndon, MD, FACS Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria; Department of Anesthesiology, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX Introduction: Burn injury, covering more than 20 % of the total body surface area (TBSA), is associated with increased cardiac stress and reduction of lean body mass. The combination of hyperdynamic circulation and hypermatabolic patter is associated with greater myocardial oxygen consumption and can lead to myocardial dysfunction. Oxandrolone, a synthetic anabolic steroid, reduced the catabolism and improved lean body mass in a studied burn population. Propranolol, a non-selective (β-1, (β-2 adrenergic receptor antagonist, is routinely used in the non-burned population to reduce cardiac work. The aim of this study was to quantify the impact of a combination of oxandrolone and propranolol (OxProp) on myocardial function as measured by the PiCCO system (Pulse Index Continuous Cardiac Output, Pulsion Medical Systems, Munich, Germany) in severely burned children. Methods: Children with burns over 20 % TBSA and ages between one and 18 years were consented to this IRB approved study. Patients were randomized to OxProp (n=17) or control (n=46). Prospectively collected hemodynamic measurements were obtained using the PiCCO system at our pediatric burn center from 2005 to 2015. Cardiac index (CI), cardiac output (CO), extravascular lung water index (ELWI), heart rate (HR), mean arterial pressure (MAP), systemic vascular resistance index (SVRI), stroke volume (SV), cardiac work (CW), and rate pressure product (RPP) were compared between standard of care treated patients and patients who received a combination of oxandrolone (0.l mg/kg twice per day) and propranolol (2-4mg/kg/day). Mixed multiple linear regressions were applied and a 95 % level of confidence was assumed. Results: Groups showed no significant difference for age, % TBSA burn or CO, ELWI, SV, and SVRI prior to treatment. Age predicted HR, CW, CI, MAP, and RPP were significantly reduced in the OxProp treated group (p<0.05). There was no evidence of any impact of the OxProp treatment on CO, ELWI, SV and SVRI. Conclusions: In this study we show, using PiCCO to monitor cardiac function, that a combination therapy of OxProp reduces myocardial oxygen consumption and therefore cardiogenic stress, induced by severe burn injury in children. Applicability of Research to Practice: The combination of a synthetic anabolic steroid and propranolol may reduce cardiac stress, and further preserve lean body mass as previously published. External Funding: This study was supported by the National Institutes of Health (P50 GM060338, UL1TR000071, T32 GM008256, RO1-GM056687, RO1-112936), the Shriners Hospitals for Children (71008, 80100, 84080) and the United States Department of Defense (W81XWH-14-2-0162). 45. The Survivability of Steven Johnson Syndrome with Burn Unit Treatment Algorithm: A 14 Year Experience M. McCullough, MD, W. Garner, MD University of Southern California, Los Angeles, CA Introduction: The diffuse epidermal exfoliation seen in Steven Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) is similar to skin loss in second degree burns, and many of these patients are referred for treatment at burn centers. Treatment can differ markedly from center to center, and mortality can range from 25 to 70%, including a considerable morbidity. However, our experience over a 15 year period from 2000 to 2015 with 40 patients, found a mortality rate of only 10%. Methods: Records were reviewed for all patients admitted to our burn unit between 2000 and 2015 and 40 patients were identified with biopsy proven SJS or TENS. Cases were reviewed for age, gender, initial and greatest TBSA, SCORTEN on admission, time to transfer to burn unit, causative drug, pre-existing medical condition, length of stay and morbidity and mortality. All data was entered and analyzed in the SPSS statistical software package. Results: Our treatment algorithm focused on early referral to a burn unit, immediate discontinuation of the offending drug, fluid resuscitation, nutritional supplementation, and meticulous wound care. Silver based dressings were applied to the affected skin and changed every 3 days. Steroids were tapered and discontinued if initiated at an outside facility (58% of patients), and starting after 2001, all patients received a course of IVIG. All patients received fluid resuscitation and the majority received supplemental tube feeds (69%). Average time to transfer to a burn unit was 3.36 days. Average age was 45.9, TBSA 46.3% and admission SCORTEN 2.06. Average length of total stay was 17.1 days and length of ICU stay 15.9. 37% of patients discharged to home while 44% were transferred to another facility for further rehabilitation. In patients discharged home with complete resolution of skin lesions, time to healing was an average of 14 days. Conclusions: With our 10% mortality rate in 40 patients, our study represents a relatively large study population while maintaining a low mortality rate. The demographic data from our study largely aligns with the existing literature, and we feel that our low mortality rate is due to our treatment algorithm, rather than less severe pathology in our patient population. This claim is supported by a mortality ratio of 1.68, based on the predicted deaths from the admission SCORTEN criteria and the actual observed deaths in our series (Table 1). This ratio proves a significantly improved mortality than would be expected based on disease severity on admission. Applicability of Research to Practice: We believe our study proves the survivability of the disease with our treatment algorithm in patients with reasonable premorbid condition and intact immune function, and we propose this algorithm as a model for other centers treating this challenging patient population. 46. A Rolling Hill Is Better than a Jagged Mountain During Burn Resuscitation J. Salinas, PhD, C. A. Fenrich, BS, M. L. Serio-Melvin, MS, RN, L. C. Cancio, MD, FACS, E. A. Mann-Salinas, MS, PhD, W C. Peterson, MD, I. R. Driscoll, MD, K. K. Chung, MD U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX Introduction: Fluid resuscitation of burn patients with injuries greater than 20% of their total body surface area (TBSA) is the standard of care during the initial 24 to 48 hours post burn. The objective of this study was to examine the effect of continuous large changes in fluid rates (jagged mountain) versus resuscitations that had minimal changes from hour to hour (rolling hill). Methods: We performed a retrospective review of 203 patients admitted to our burn intensive care unit from December 2007 to April 2013 who were resuscitated using our computer decision support system. An individual slope (rate of change) value was computed for all hours between 1 and 24 by calculating the absolute difference between hourly infusion volumes. Large slopes indicate a larger change in infused volumes for each hour (either up or down). Univariate analysis was performed on the slopes in 8 hour intervals and overall 24 hours of resuscitation. Values for mortality, ventilator days, ICU days, and hospital days were compared with slope calculations to determine effects of changes in volume to outcomes. Results: Analysis showed an overall mean change of 100 ± 72 ml/hr for the initial 24 hours. There was significant reduction in rates of change from the initial 8 hours to hours 9-16 and hours 17-24 (155 ± 167 ml/hr, 107 ± 82 ml/hr, 58 ± 69 ml/hr, p<0.05). Quartile analysis showed the 50 percentile to be at 85 ml/hr. Values < 85 ml/hr were labeled as a "rolling hill" (RH) resuscitation (low variability) and values >=85 were considered a "jagged mountain" (JM) resuscitation (high variability). Outcome analysis revealed a significant difference in mortality outcomes (33% vs. 66%, p<0.01), ICU days (20 days vs. 32, p<0.01), and ventilator days (12 days vs. 20 days, p<0.01) between the 2 groups with the RH group having better outcomes in all measures. There was no difference in hospital days between groups. Conclusions: This analysis showed that there is a decrease in the magnitude of changes in the fluid-infusion rate as the 24-hour resuscitation proceeds. In addition, we showed that a large variability in fluid-infusion rate is associated with negative outcomes during burn resuscitation compared with patients on a rolling hill trajectory. Applicability of Research to Practice: Adequate fluid titration during burn resuscitation is critical to improving outcomes. This study showed that large changes in fluid rates from hour to hour during the initial 24 hours is an indicator of a difficult resuscitation and needs to be considered in the patient management plan. External Funding: This work was funded by the US Army Combat Casualty Care Research Program. Figure. View largeDownload slide Figure. View largeDownload slide 47. Prophylactic Enoxaparin Dosing Strategies and Incidence of Venous Thromboembolism in Burn Patients A. C. Fritschle Hilliard, PharmD, BCPS, T. A. Walroth, PharmD, J. T. Gibbs, MD, D. Roggy, RN, J. A. Whitten, PharmD, BCPS, D. R. Foster, PharmD, R. Sood, MD, FACS Eskenazi Health, Indianapolis, IN; Indiana University, Indianapolis, IN Introduction: The objective of this study was to evaluate prophylactic enoxaparin dosing strategies in adult burn patients based on antifactor-Xa levels. We compared enoxaparin dose titration based on antifactor-Xa levels to a published dosing equation utilizing total body surface area (TBSA) burn and body weight. Methods: This retrospective study included acute burn patients from August 1, 2012 to January 27, 2015 who were initiated on enoxaparin for VTE prophylaxis with a TBSA burn of 10% or greater. Enoxaparin dosing was titrated based on antifactor-Xa levels. Primary outcome measurements included percentage of patients who achieved goal prophylactic antifactor-Xa level at any time and incidence of VTE. A post-hoc analysis was performed on all patients comparing the dose calculated according to a published dosing equation [enoxaparin dose (mg every 12 hours) = 22.8 + 3.3 x (TBSA/10) + 1.89 x (weight/10)] with the actual dose required to achieve goal prophylactic antifactor-Xa level. Results: Sixty-four patients were included for review. Of these, 42 (66%) attained an antifactor-Xa level within the target prophylactic range during admission. Five patients (8%) developed a VTE, with three (5%) of the thrombi deemed to be clinically significant. The median (IQR) total daily enoxaparin dose for patients who achieved a target antifactor-Xa level was 0.51 mg/kg (0.41-0.64), which was significantly lower than the equation calculated dose of 0.58 mg/kg (0.51-0.72) (p<0.001). While this dose is higher than approved dosing recommendations, no patients experienced clinically significant bleeding. In patients who did not achieve goal antifactor-Xa level, enoxaparin doses were significantly lower than the equation calculated doses (p=0.005). Conclusions: Majority of patients included achieved goal antifactor-Xa level with a low incidence of VTE. The enoxaparin dosing equation may have resulted in more patients achieving target prophylactic antifactor-Xa levels; however, the calculated dose may have resulted in larger doses than necessary. Based on this data 0.5 mg/kg (divided every 12 hours) appears to be an appropriate starting dose for prophylactic enoxaparin, but antifactor-Xa levels are still needed due to high interpatient variability inherent to burn injury. Applicability of Research to Practice: This study may improve enoxaparin dosing for VTE prophylaxis in adult burn patients, as our results suggest approved dosing recommendations do not provide appropriate factor-Xa inhibition in this population and support the use of higher doses with antifactor-Xa monitoring. To our knowledge, no prior studies have evaluated the published dosing equation which we found may not accurately predict appropriate dosing in all burn patients. 48. Burn Patients with Stress Induced Hyperglyeemia Are at Greater Risk for Sepsis and Death P. L. Bosarge, MD, P. Hu, MD, R. Griffin, PhD, C. V Ellis, MD, J. D. Kerby, MD, PhD University of Alabama at Birmingham, Birmingham, AL Introduction: Hyperglycemia in burn patients is associated with an increased risk of infection, sepsis, and death. Intensive treatment has been shown to improve outcomes, but may result in hypoglycemia, which can also increase morbidity and mortality. In a trauma population, stress induced hyperglyeemia (SIH) is associated with increased mortality compared to normoglycemic nondiabetics and diabetic hyperglycemics (DH). We sought to determine if a similar difference existed among burn patients. Methods: Admission glycosylated hemoglobin (HbAlC), glucose levels, and comorbidity data were collected for patients with burn injuries admitted between September 2009 and December 2014. Diabetes mellitus (DM) was determined by patient history or admission HbAlc of 6.5% or greater. SIH was determined by the absence of DM and admission glucose of 200 mg/dL or greater. Cox proportional hazards models adjusted for age, race, total burn surface area (TBSA), and presence of inhalation injury estimated risk ratios (HRs) and associated 95% confidence intervals (CIs) for outcomes of interest. Models were further stratified by TBSA <20% and >20% to examine effect modification. Results: During the study period, a total of 2,026 patients were included in the study group. A total of 167 patients were admitted with hyperglycemia; 72 (43.1%) were diagnosed with SIH and 95 (56.9%) were diagnosed with DH. Compared to normogylcemic, nondiabetic patients, SIH patients had increased rates of pneumonia (HR 1.75; 95% CI, 1.04-2.79), sepsis (HR 3.25; 95% CI, 1.50-7.03), and mortality (HR 3.93; 95% CI, 2.43-6.37). These associations were limited to those with TBSA ≤20%, a group in which SIH patients had a 9-fold increased rate of sepsis (HR 9.34; 95% CI, 2.41-36.15) and a near 6-fold increased rate of death (HR 5.87; 95% CI, 2.08-16.55) compared to normoglycemic patients. There was no association between SIH and outcomes of interest among patients with TBSA ≥20%, and these associations were not observed among the DH population. Conclusions: Among burn patients, the admission presentation of SIH is associated with increased rates of sepsis and mortality. These associations were more pronounced in patients with minor burns, and were not observed in patients with DH when stratified into major and minor burns. Hyperglycemia that is stress related, but not related to diabetes, appears to signify a major risk factor in the outcomes following burn injury. Further studies are needed to determine if the treatment of SIH rather than DH may lead to improved outcomes. Applicability of Research to Practice: Those patients suffering burn injuries should be evaluated for the presence of SIH or DH. Those with SIH are at higher risk of pneumonia, sepsis and death and may warrant intensive hyperglycemia treatment. 49. Combined Oxandrolone and Propranolol Treatment Improves Skeletal Muscle Nitrogen Balance in Severely Burned Children by Blunting Proteolysis T. Chao, MS, D. N. Herndon, MD, FACS, C. Porter, PhD, O. E. Suman, PhD, L. S. Sidossis, PhD University of Texas Medical Branch, Galveston, TX Introduction: Severe burn result in prolonged hypermetabolism and skeletal muscle catabolism. Propranolol has been shown to blunt the hypermetabolic stress response to burns while oxandrolone was shown to improve muscle protein synthesis efficiency. However, the effect of combined oxandrolone and propranolol therapy on muscle fractional synthesis (FSR) and breakdown (FBR) rates are not known. In this placebo controlled clinical trial, we hypothesize that the combined treatment of oxandrolone and propranolol (oxprop) will improve skeletal muscle protein turnover in pediatric burn patients. Methods: We studied 24 pediatric patients with severe burns (≥ 30% total body surface area; TBSA) during their inpatient hospitalization. Patients were randomized to placebo (14 control) or oxprop (10). Protein kinetics were determined with bolus injections of 13C6 and 15N phenylalanine at 2 and 4 weeks post-injury. Skeletal muscle biopsies were obtained from the m. vastus lateralis. Plasma and muscle intracellular and bound protein pool enrichments were determined by gas chromatography-mass spectrometry (GCMS). A Wilcoxon matched-pairs signed rank test was performed within groups. Significance was determined at p<0.05. Results: Patients were similar in age (8 ± 6yr) and TBSA (53 ± 17% vs 48 ± 8%) in the control and oxprop group. Muscle FSR significantly increased from 2 to 4 weeks post injury in oxprop (0.08 ± 0.01%/h to 0.13 ± 0.02%/h, p<0.05) but not in control (0.13 ± 0.04%/h to 0.13 ± 0.02%/h, p=0.54). FBR significantly decreased from 2 to 4 weeks post-injury in oxprop (0.20 ± 0.02%/h to 0.14 ± 0.02%/h, p<0.05), but not in control (0.27 ± 0.05%/h to 0.28 ± 0.04%/h, p=0.50). The concomitant increase in FSR and decrease in FBR resulted in a significant improvement in net protein balance in oxprop (-0.12 ± 0.03%/h to -0.01 ± 0.02%/h, p<0.05) but not in control (-0.14 ± 0.03%/h to -0.12 ± 0.04%/h, p=0.71). Conclusions: Combined oxandrolone and propranolol therapy significantly improves skeletal muscle protein turnover in pediatric burn patients during their hospitalization. The mechanism by which this is achieved is an increase in muscle FSR but in particular, a blunting of muscle FBR. Applicability of Research to Practice: Combined treatment with a (β-blocker and testosterone analogue may preserve muscle mass in severely burned individuals during the acute hospital course. External Funding: NIH (P50 GM060338, R01 GM056687, R01 HD049471 and T32 GM008256), NIDILRR (90DP00430100) and Shriners Hospitals for Children (84080, 84090, 71006, 71008 and 71009) grants. 50. Direct in Vivo Measurements of Regional and Whole Body Glutamine and Glutamate Metabolism Following Eneteral and Parenteral Administration in Burned Patients and Healthy Humans Y. Chi Sr., MD, J. Chai, MD, PhD, A. Fischman, MD, PhD, H. Yin, MD, PhD, C. Shen, MD, PhD, R. Tompkins, MD, ScD, Y. Yu, MD, PhD Shriners Hospitals for Children, Boston, MA; The First Affiliated Hospital of PLA General Hospital, Beijing, China; Massachusetts General Hospital and Shriners Hospitals for Children, Boston, MA Introduction: The possible benefit of nutritional support with glutamine (GLN) supplementation in surgical patients has been debated for at least two decades. While multiple large scale evidence-based outcome studies have been designed and carried out at this moment, the present study aims at quantitatively assessing the major biochemical pathways of GLN-glutamate(GLT) metabolism in vivo in different regions of the body after their parenteral (IV) and enteral (IG) administrations in severely burned(B, n=9; TBSA 79 ± 9%) and healthy(H, n=8) subjects using stable isotope tracer techniques. The questions raised are 1) Does B consume (or require) more GLN as compared to H? 2) Which organ/tissues may likely consume (or benefit from) GLN supply after burn injury? 3) Can GLT be an endogenous source for GLN de novo synthesis? The quantitative in vivo information of the inter-organ fate of GLN-GLT metabolism will complement the findings of outcome studies. Methods: Each subject received primed constant infusions of L-[2-15N]-GLN (IV) and L-[1-13C]-GLT (IG) for 3.5h, followed by second 3.5h of infusions in which the routes were switched. The rates of total metabolic fluxes (Q), the interconversions between GLN- GLT in whole body, splanchnic (SP, gut and liver) and non-splanchnic (NSP) regions in both B and H were assessed based on the plasma enrichments of L-[2-15N]-GLN, L-[1-13C]-GLT, L-[1-13C]-GLN (derived from [1-13C]-GLT) and L-[2-15N]-GLT (derived from L-[2-15N]-GLN) determined by gas chromatograph mass spectrometry. Results: The major findings were: B vs. H, 1) significantly increased total metabolic rates of either IG and IV GLN and GLT. 2) significantly increased rates of GLN and GLT utilization by SP following IG administration, accompanied with significantly increased GLN-GLT conversion; however the rate of GLT to GLN conversion remains unchanged. 3) significantly increased contribution of the SP region in GLN-GLT conversion. Conclusions: The quantitative in vivo biochemistry suggests: 1) GLN requirements, especially that for the SP organs increased in B vs. H; 2) IG GLN supplementation better meets increased requirements at whole body level and SP organs. 3) GLT does not seem a good pre-cursor for GLN to meet its increased requirements in B. Applicability of Research to Practice: Our findings support clinical use of enriched GLN in burn care. External Funding: Grants. NIH P50 GM 21700, SHCC 84070 Natural Science Foundation of China NSFC. Table. No title available. View Large Table. No title available. View Large 51. Safety and Efficacy of Intraoperative Nutrition Support in a Pediatric Burn Unit C. Sunderman, MS, RD, CNSC, M. Gottschlich, PhD, RD, C. Allgeier, DTR, L. James, MS, G. Warden, MD Shriners Hospitals for Children, Cincinnati, OH Introduction: Multiple surgical procedures warranted by patients with extensive thermal injuries impede delivery of adequate nutrition support leading to caloric deficits, weight loss, delayed wound healing and increased length of stay. The small intestine is the optimal site to feed post-burn because of the reduced risk of aspiration and superior gastrointestinal tolerance. The standard practice at our institution for >20 years has been to continuously infuse post pyloric enteral nutrition during surgery. The purpose of this study was to examine the safety and efficacy of intraoperative enteral nutrition support post-burn. Methods: A retrospective chart review of pediatric patients with injuries >30% TBSAB provided a 20-year (1995-2014) safety assessment (incidence of aspiration) associated with intraoperative feeding; along with a detailed analysis (2010-2014) of tolerance and efficacy (constipation, diarrhea, emesis, length of stay, nutrition support, surgery days, weight trends, visceral protein levels). Descriptive statistics were used to present data, and a paired t-test was used to compare admission and discharge body weights. Results: The 20-year review confirmed the safety of intraoperative feeding as the assessment of 1187 patients revealed no incidence of aspiration. The data review for 5 years (2010-2014) revealed that enteral nutrition support was provided over a mean of 41.3 days and during an average 7.4 surgeries. The average medical length of stay was 51.0 days. Patients maintained an average 92% of their admit weight at discharge, with a mean weight change of 2.5kg (p<.0001). At the time of last surgery, patients had a mean Prealbumin of 18.1mg/dL and C-reactive protein of 7.5mg/L. Conclusions: Enteral nutrition has been safely provided with marginal intolerance during surgical procedures over the past 20 years. Continuous nutrition support with negligible interruption is integral to meet nutrient needs for wound healing, preservation of weight and nutritional parameters and optimize length of stay in pediatric patients with extensive thermal injuries. Applicability of Research to Practice: With appropriate protocol implementation and anesthesiology support, pediatric burn patients that warrant enteral nutrition support can safely be fed intraoperatively and improve clinical outcomes. Table. No title available. View Large Table. No title available. View Large 52. Total Protein Loss in Severely Burned Adults W. Martini, PhD, H. Pidcoke, MD, PhD, B. Shields, RD, LDN, CNSC, M. Dubick, PhD, S. Wolf, MD, FACS, K. Chung, MD US Army Institute of Surgical Research, Ft Sam Houston, TX; San Antonio Military Medical Center, Ft Sam Houston, TX; UT Southwestern Medical Center, Dallas, TX Introduction: Although the hypermetabolic state has been extensively described in the pediatric burn population, protein metabolic characterization in severely burned adults is unclear. Using stable isotope infusion technique, the rate of appearance of essential amino acids, such as phenylalanine, has been considered to be representative of total protein breakdown in vivo. This study quantified total protein breakdown in severely burned adults and normal volunteers, using stable isotope technique. Methods: Ten patients (27 ± 4 years; 91 ± 6kg) with burn of 51 ± 3% total body surface area burn were consented and enrolled into an institutional review board approved prospective study at the Burn Intensive Care Unit of the United States Army Institute of Surgical Research. The isotope study was performed on 18 ± 4 days after burn, when those patients reached hemodynamic and physiological steady state. On study day, a primed (12 μmol/kg) constant infusion of stable isotope 1-13C-phenylalanine (0.2 μmol/kg/min) was performed for 8 hours. During the infusion, vital signs were recorded and arterial blood samples were drawn every hour. The isotopic enrichments of phenylalanine in blood samples were used to calculate the rate of appearance of phenylalanine, using gas chromatography and mass spectrometry analysis. Ten normal healthy volunteers (37 ± 7years; 74 ± 5 kg) were included with the same isotope infusion and blood samplings as the control group. Results: Burned adults had higher heart and respiratory rates (120 ± 2 vs. 73 ± 5 (control) beats/min, 23 ± 2 vs. 15 + 1 (control) breaths/min, both p<0.05) prior to initiation of the studies. Plasma isotopic enrichments of l-13C-phenylalanine reached steady state within 1h of the isotope infusion in both burn and control groups. The rate of appearance of endogenous phenylalanine, reflecting total protein breakdown, was 1.84 ± 1.10 μmol/kg/min in the burn group, compared to 0.64 ± 0.04 μmol/kg/min in the control group (p<0.05). Conclusions: At 18 days post severe burn, total protein breakdown is nearly 3-fold greater to that of healthy controls. Applicability of Research to Practice: Intervention efforts are warranted to minimize the accelerated total protein loss in these patients. 53. Farnesyltransferase Inhibitor Reverses Burn-Induced Metabolic Derangements and Basal mTORCl Activation in Mouse Skeletal Muscle H. Nakazawa, MD, PhD, T. Tanaka, MD, PhD, N. Kuriyama, MD, Y. Yu, MD, PhD, A. J. Fischman, MD, PhD, J. Martyn, MD, R. Tompkins, MD, ScD, M. Kaneki, MD, PhD Massachusetts General Hospital, Harvard Medical School, Charlestown, MA; Shriners Hospitals for Children, Boston, MA; Massachusetts General Hospital, Harvard Medical School, Boston, MA Introduction: Metabolic derangements are a major complication of burn injury and affect the clinical outcome of burn patients. These metabolic alterations include insulin resistance, hyperglycemia, hyperlactatemia, increased glutamine consumption and muscle wasting. However, it is not clear how these alterations relate to each other. Recent studies have shown that glutaminolysis activates mTORCl and vice verse. mTORCl activation causes insulin resistance and induces hypoxia-inducible factor (HIF)-lα expression, leading to increased lactate production and glutaminolysis. Of note, a recent study has shown that mTORCl activation promotes protein breakdown and muscle wasting, although mTORCl activity is necessary for protein synthesis. We have demonstrated in mice that burn increases farnesyltransferase (FTase) expression and abundance of farnesylated proteins in muscle and that FTase inhibitor, FTI-277, prevents burn-induced insulin resistance. Here we show that burn increased basal mTORCl activity and HIF-la expression in mouse muscle, which were reversed by FTI-277. 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 starting at 2 h after burn or sham-burn. At 3 days post-burn, rectus abdominis muscle was excised under anesthesia for biochemical analyses. Results: Burn increased basal (exogenous insulin-naïve) phosphorylation of mTOR, p70S6K, S6 and 4EBPl, indicating activation of mTORC1 in muscle at 3 days post-burn. However, insulin failed to further increase phosphorylation of these molecules, consistent with insulin resistance. Expression of HIF-lα and its downstream genes as well as plasma lactate levels were increased by burn. The metabolome analysis indicated increased glutaminolysis after burn. FTI-277 reversed these alterations in burned mice. In contrast, FTI-277 did not alter these parameters in sham-burned mice. Conclusions: Our data show that burn increased basal mTORC1 activity, HIF-lα expression, lactate production and glutaminolysis in mouse muscle. These results suggest that burn-induced basal mTORC1 activation may increase HIF-lα expression, which, in turn, enhances mTORC1 activity by increasing glutaminolysis, forming a vicious cycle. It is conceivable that the inhibition of this vicious cycle may underlie the insulin-sensitizing effects of FTI-277 in burned mice. Applicability of Research to Practice: Our study provides scientific rationale to help develop a clinical trial of FTI to reverse or ameliorate insulin resistance and metabolic alterations, including hyperlactatemia and increased glutaminolysis, in burn patients. External Funding: NIH (P50GM021700), Shriners Hospitals for Children (85800). 54. Cytosolic and Mitochondrial Proteolysis Contribute to Muscle Wasting in Burn Patients J. O. Ogunbileje, PhD, D. N. Herndon, MD, FACS, C. Porter, PhD, M. Chondronikola, PhD, RD, T. Chao, MS, T. A. Zimmers, PhD, B. B. Rasmussen, PhD, L. S. Sidossis, PhD University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX; Indiana-Purdue University, Indianapolis, IN Introduction: Burn trauma is associated with prolonged hypercatabolic state. Muscle cachexia, resulting from an imbalance between protein synthesis and breakdown contributes to morbidity. The present study was performed to further elucidate the molecular mechanisms underlying muscle cachexia in adult burn male patients. Methods: Muscle samples collected from five males (29 ± 14 years) with total burn surface area of 69 ± 19 % were studied. Four age matched men (24 ± 5 years) as controls. Skeletal muscle fractional synthesis (FSR) and breakdown (FBR) were determined by using infusing stable isotopes of phenylalanine. Phosphorylated mammalian target for rapamycin complex I (mTORC1) serine 2448, S6 ribosomal protein ser240/244 (p-rS6 ser240/244), Eukaryotic translation initiation factor 4E-binding protein 1 thr37/46 (4EBP1-thr37/46), ribosomal protein S6 kinase 1 thr389 (p70S6 kinase thr389), eukaryotic elongation-factor-2 kinase thr56 (eEF2 thr56), Lon peptidase 1 (LONP1), YME1-like 1 ATPase (YME1L1), nuclear factor-erythroid 2-related factor 1 and 2 (NFE2L1 & NFE2L2), proteasome 20S α + β, proteasome 20S 2C, and proteasome 26S subunit, non-ATPase, 14 (PSMD14) were determined using western blot technique. Results: Both muscle FSR (59%, P<0.05)) and FBR (76%, P<0.01) were elevated in burn patients, resulting in significantly greater muscle protein catabolism in burn patients vs. controls (0.11 ± 0.02 vs. 0.05 ± 0.01 %/hr, P<0.01). mTORC1(Ser 2448), 4EBP1thr37/46, and rS6 ser240/244, eEF2 thr56 were hyper-phosphorylated in burn patients (p<0.05). Expression of p-eEF2K and p-p70S6Kl thr389 was similar between groups. Though, proteasome subunit a type 1 (PSMA1) and PSMD14 proteasome were more expressed in burn patients, they were not statistically significant between groups (p=0.063 and p=0.055, respectively). Proteasome 20S α + β was ~50% higher in burn patients (p<0.05) while NFE2L1 & NFE2L2 were significantly lower when compared with controls (p=0.008 and p=0.042, respectively). LONP1 and YME1L1, markers of mitochondrial protein degradation were ~60% higher in burn patients (p<0.01). Conclusions: Our data show that concurrent activation of mTOR signaling and FSR parallel increased proteasome activities and FBR in skeletal muscle of burn patients. In addition to this augmented cytosolic proteolysis, we present novel data indicating that protein degradation in burn patients also takes place in mitochondria. Collectively, this study suggests increased protein degradation in cell cytosol and mitochondrial contributes to muscle cachexia in burn patients. Applicability of Research to Practice: A robust understanding of the molecular events leading to increased protein turn over and muscle wasting in burn patients is required to develop novel treatment strategies. External Funding: NIH (P50 GM060338, R01 GM056687, R01 HD049471 and T32 GM008256), NIDILRR (90DP00430100) and Shriners Hospitals for Children (84080, 84090, 71006, and 71009) grants. 55. Kinetics of Trace Element Losses Through Burn Wound Exudation: Are Burn Requirements Due for Revision? P. Jafari, PharmD, PhD, M. Augsburger, PhD, A. Thomas, PhD, D. Haselbach, MD, W. Raffoul, MD, PhD, L. Applegate, PhD, M. Berger, MD, PhD Lausanne University Hospital, Epalinges, Switzerland; Lausanne University Hospital, Lausanne, Switzerland Introduction: Major burn patients develop severe metabolic alterations with an intense inflammatory response that increase their nutrient requirements to face massive tissue repair. Exudative losses of various nutrients including trace elements (TE) complicate the assessment of their requirements and have been shown to cause acute deficiencies. We aimed at measuring with actual analytical methods the exact TE content of exudates to improve the TE repletion strategy. Methods: Inclusion of patients admitted to the burn-ICU of the Lausanne burn center. Exclusion criteria: age <18years, infectious co-morbidities. Intravenous TE supplementation was by protocol. Exudate collection method: the wound bed was covered with an occlusive dressing with a silicon drain placed underneath and connected to a sterile collecting bottle. The latter was connected to mural suction and a continuous negative pressure was applied at -125 mmHg. The aspiration and collection was continuous. Sampling was done by changing the reservoir twice per day and the dressing was changed every 48-72 hours. Seventy TE were measured in the samples by inductively coupled plasma mass spectrometry (ICP-MS). Losses were normalized for TBSA. Blood samples were collected daily for TE determination Results: Twenty-two patients were included between December 2013 and May 2015. Patients were aged 46 years (mean), burned 28% TBSA. Average exudation period was 5.5 days (range, 3-8 days) with maximum losses between days 1 and 4 post trauma. Serum levels of essential TE were below or in the lower limit of normal reference ranges. Essential TE exudative losses were superior to recommended doses for parenteral nutrition (Cu 924mcg, Zn 2300mcg, Se 134mcg, Mg 19mcg, Cr 2.8mcg, Mn 3.5mcg, Fe 1600mcg, V 0.74mcg, Co 0.19mcg, Br 919mcg, Mo 1.45mcg; data are expressed as total loss per total burn surface (m2) ) on day 1 Conclusions: We had previously analyzed the exudative losses of three TEs, and shown the importance of the replenishment of these elements in burn patients. Using new techniques, we have recently analyzed the TE concentration in exudate samples that were directly and continuously collected from burn wound. We determined daily losses of 70 TEs including essential TEs from day one post burn. This study shows that despite standard IV supplementation of patients by TEs, the serum levels only corrected to lower normal ranges. Our data suggests that the supplementation protocols for all the essential TEs should be revised, and adapted to the kinetics of exudative TE losses during the first week post trauma. Applicability of Research to Practice: Define the specific TE requirements in major burns. 56. Uncoupling Protein 2 and 4 Induction in Skeletal Muscle of Burn Victims is Associated with Mitochondrial Thermogenesis and Hypermetabolism C. Porter, PhD, D. N. Herndon, MD, FACS, J. O. Ogunbileje, PhD, N. Bhattarai, BS, K. D. Capek, MD, F. J. Bohanon, MD, P. T. Reidy, PhD, O. E. Suman, PhD, B. B. Rasmussen, PhD, L. S. Sidossis, PhD University of Texas Medical Branch, Galveston, TX Introduction: Skeletal muscle mitochondrial thermogenesis plays a putative role in burn-induced hypermetabolism. To date, a mechanistic understanding of this response is lacking. We hypothesize that inner mitochondrial uncoupling proteins (UCP) mediate mitochondrial thermogenesis in skeletal muscle of burn victims. To test this hypothesis, we determined mitochondrial thermogenesis and UCP 1-4 expression in muscle from hypermetabolic burn patients and non-burned individuals. Methods: Patients with burns covering >30% of their total body surface area (TBSA) were studied at approximately 2 and 4 weeks post injury. Young healthy individuals served as non-burned controls. Metabolic rate was determined in burn victims by respiratory gas exchange. Mitochondrial respiration was determined in the leak, coupled and uncoupled state in permeabilized myofiber bundles. The mRNA expression of UCP1, 2, 3 and 4 gene expression was determined in muscle samples. Results: Twenty one patients (20±l4 yr) with burns covering 55 ± 20% of their TBSA were studied at 11 ± 5 (Study 1) and 26 ± 11 (Study 2) days post-injury. Twelve healthy individual (26 ± 5 yr) were studied as controls (Con). Metabolic rate was elevated by 47 ± 7% (P<0.001) and 43 ± 5% (P<0.001) at study 1 and 2, respectively. Whole-body hypermetabolism was accompanied by a decline in muscle oxidative phosphorylation at Study 1 (38.5 ± 2.4 pmol/s/mg, P<0.01), and Study 2 (24.0 ± 2.6 pmol/s/mg, P<0.001), compared to Con (48.9 ± 5.4 pmol/s/mg). Mitochondrial thermogenesis calculated as a percentage of maximal respiration (leak respiration/uncoupled respiration) was greater in burn patients at Study 1(29 ± 2%, P<0.01) and Study 2 (38 ± 4%, P<0.001) when compared to Con(18 ± 2%). Compared to Con, we observed a 3.4- and 4.4-fold induction in UCP2 mRNA expression at Study 1 and 2, respectively (P<0.01). UCP4 mRNA expression was elevated at Study 1 (1.8-fold) and 2 (2.5-fold) compared to Con (P<0.01). UCP1 and 3 expression were not altered by burn. Conclusions: Skeletal muscle mitochondrial thermogenesis accompanies whole-body hypermetabolism in burn victims. Here, we identify the inner mitochondrial membrane carrier proteins UCP2 and UCP4 as novel molecular mediators of this pathophysiological adaptation. Applicability of Research to Practice: Identification of the molecular mediators of the pathophysiological stress response to burn injury provides targets for future therapeutic interventions. External Funding: Funded by NIH (P50 GM060338, R01 GM056687, R01 HD049471, R01 AR049877, T32 GM008256 and the Institute for Translational Sciences at UTMB, supported in part by a Clinical and Translational Science Award [UL1TR000071] from the National Center for Advancing Translational Sciences), NIDILRR (90DP00430100) and Shriners Hospitals for Children (84080, 84090, 71006, and 71009) grants. 57. Health-Related Quality of Life Following Burn Injuries: A Comparison of Patient-Reported Outcomes Measures R. D. Reusche, MD, MPH, N. L. Costa, MT(ASCP), B. Levi, MD, J. Waljee, MD, MPH University of Michigan, Ann Arbor, MI Introduction: Capturing health-related quality of life (HRQOL) metrics following burn injuries is challenging. Although several instruments have been developed to measure specific elements of recovery, little is known about their contribution to HRQOL and psychosocial functioning. In this context, we sought to compare the differences in condition-specific and generic patient-reported outcome measures (PROMs) in this population. Methods: We surveyed 53 patients at a multidisciplinary burn clinic from August 2015-September 2015. To be included the participants had to be ≥ 18 years of age, able to read English, and answer surveys autonomously. Patients completed three PROMs: A 70-point Patient and Observer Scar Survey Scale(POSAS)-(range: 7-no issues, 70-severe scar problems), a 200-point Burn Specific Health (BSHS)-(200-no issues, 40-extreme problems), Patient Reported Outcomes Measurement Information System Global (PROMIS 1 and 2), 2-parts, a 20-point scale(2-no issues, 20-severe), and a 35-point scale (35-no issues, 7-severe). We used IBM SPSS Statistics 23 to run descriptive statistics, and multiple univariate analyses looking at mean scores, standard deviation, and significance of each survey independently. Trends were identified for each analysis to determine which demographic group reported their health most favorably within each survey. Results: A total of 53 patients met inclusion criteria and completed all burn surveys. There were n=39 (74%) male, and n= 14 (26%) female patients, age range of 43 ± 17.8. Survey results were categorized by age (Table 1), and gender. Categorizing by gender, males scored 40.1 ± 13.9, and females 40.5 ± 19.5 taking the POSAS, males scored 151.5 ± 43.9 and females 14l.2 ± 54.7 taking the BSHS, and males scored 10.2 ± 6.8, and 25.7 ± 7.4 and females 13.5 ± 8.7 and 24.5 ± 6.5 taking the PROMIS 1 and 2 respectively (Figure 1). Conclusions: Providing burn patients one survey limits the ability to effectively assess their overall well-being. Patients taking POSAS showed little difference between genders. Females taking the BSHS and PROMIS surveys reported worse outcomes than males. Stratifying by age, those 18-30 reported the best outcomes taking POSAS, yet the worst outcomes taking the BSHS and PROMIS. Applicability of Research to Practice: These results show one survey may contradict results on another within the same patient population. If using PROMs for immediate clinical feedback, it is beneficial they cover multiple areas of patient HRQOL. Figure. View largeDownload slide Figure. View largeDownload slide 58. Burn Treatment Videos on Youtube: An Analysis of Content Quality and Accuracy S. Perez, BA, W Lee, RN, S. Romo, BA, M. Lydon, RN, P. H. Chang, MD, FACS Shriners Hospitals for Children, Boston, MA Introduction: Patients are more frequently using Youtube as the initial source for medical information, especially for treatment of medical conditions. Burns are a common injury for which millions every year seek medical treatment. In this study, we examined the burn treatment resources available through one popular online site, Youtube. Methods: A Youtube search was designed to simulate what a non-medical person would look for seeking information about initial treatment of burn wounds. The search was done between the dates of 3/16/2015 to 5/6/2015 using the terms "burn treatment" and "burn first aid". A total of 32 videos were identified. Unrelated, repeated and non-English videos were excluded from the initial cohort of 32 videos, narrowing the group to 28. Videos were examined as to audio quality, quality of directions provided, quality of video teaching, and source of the video, as well as views statistics. Video raters utilized a burn diagnosis and treatment checklist scale for assessing the video quality. Accuracy was assessed by burn team specialists at an ABA-verified burn center. Data was analyzed using ANOVA, chi-square and correlation. Results: Only 4 of 28 videos were by physicians; the remainder were either by journalists, non-physicians, or patient testimonials. 5 of 28 videos lacked any instruction as to initial first-aid or burn management. The average video duration was 7.9 min ± 10.4 min [0.97-47.03 minutes]. The number of views ranged from 2,074 up to 183,831 with subscribers to each video ranging from 35 to 379,217. The accuracy of information contained in the videos varied widely with only 3/28 videos containing no misinformation and one video with 7 questionable or incorrect facts [range 0-7]. Conclusions: The production quality and the accuracy varies widely. Youtube videos provide a significant multiplier as to the reach of an individual provider, as some videos have been viewed by hundreds of thousands of viewers. Applicability of Research to Practice: Burn care providers need to be aware of where patients are obtaining initial treatment information and the potential for misinformation. Table. No title available. View Large Table. No title available. View Large 59. An Intervention Bundle to Facilitate Return-To-Work for Burn-Injured Workers S. A. Brych, BS, G. J. Carrougher, RN, MN, T. N. Pham, MD, FACS, S. P. Mandell, MD, MPH, N. S. Gibran, MD, FACS University of Washington, Seattle, WA Introduction: Rates of return-to-work (RTW) after burn injury vary. A recent systematic review of the burn literature reported that nearly 28% of all adult burn survivors never return to any form of employment. These authors called for interventions designed to assist survivors' ability to function in an employed capacity (Mason et al., JBCR 2012). In 2010, our burn clinic instituted an intervention bundle aimed to return the injured worker to employment within 90 days of the insurance claim. The interventions include patient/family education focused on recovery and not disability, employer contact by the vocational rehabilitation counselor, physician recommendations for work accommodations, provision of an employee status letter and activity performance evaluation (APE). The purpose of this study is to report on the efficacy of this program. Methods: Following Institutional Review Board (IRB) approval, we reviewed medical records of adult subjects injured on-the-job who received care at a single regional burn center from June 2010 through July 2015. We collected patient and injury characteristics, outpatient vocational rehabilitation (VR) services, and number of bundle elements completed. The primary outcome of interest was rate of return to work by 90 days. Results: A total of 338 individuals met entry criteria. The table provides patient and injury characteristics, as well as VR interventions/services. All patients received employer letters and APE documentation. RTW rate was 94% with an average of 24 total days from injury to RTW post-injury. Conclusions: Utilizing an intervention bundle involving the patient, the employer and the burn clinic, injured workers achieved a high rate of return to work within 90 days. Although we cannot correlate individual bundle components to outcome, we postulate that the combination of employer/employee engagement and flexibility (i.e., modified duties) contributed to the success of this program. Applicability of Research to Practice: Use of similar vocational rehabilitation interventions may aid clinicians in assisting adult burn survivors in their efforts to return to gainful employment. These strategies are particularly relevant to those survivors injured on-the-job but may also be helpful to any burn survivor who was employed prior to injury. External Funding: National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR), grant #90DP0029-01-00. Table. No title available. View Large Table. No title available. View Large 60. One Center's Example of the Use of an Outpatient Burn Registry: Comparison Between Daily Versus Weekly Burn Dressing Care and Time to Return to Work R. Coffey, RN, MSN, CNP, A. Bigley, RN, R. Penny, PA-C, C. Casavant, BSN, J. K. Bailey, MD, FACS, L. M. Jones, MD The Ohio State University Wexner Medical Center, Columbus, OH Introduction: In 2012, the American Burn Association convened a consensus symposium to define burn-specific outcomes in five areas: functional outcomes, nutrition, psychological outcomes, resuscitation, and wound repair. The purpose of this study was to demonstrate how an outpatient burn registry can be used to examine patient outcome. The exemplar used was to compare the time to return to work (RTW) for burn patients treated with a daily versus weekly dressing. Methods: A retrospective chart review was done using our newly developed burn outpatient database. Included were patients seen between January 1, 2014 and December 31, 2014, were ≥18 years of age and were employed prior to their injury. Data collected included patient demographics, details of the burn injury, interventions, and date of re-entry into the work force. Results: Of the 131 patients that met inclusion criteria the mean TBSA was 3.6% (range .25% - 28.7). Patients were treated with either a seven day silver dressing (57 patients), daily dressing changes with a topical agent (33 patients) or with a combination of the long acting silver and daily topical dressings (41 patients). Of the 16 patients who had OR 9 had combination dressings, 5 had daily topical dressings and 2 had long acting silver dressings. Patients with topical antibiotics and combination dressings had larger TBSA (.25 - 28.75%) vs those in long acting silver dressings (0.25% - 22.25%). Differences in TBSA in those injured at work was significantly less than those injured at home 2.48 vs 4.32 (p = 0.0493). Overall time off work for all patients was 29.13 days (SD ± 27.14 range 2 -146 days). Average RTW for patients with 7 day silver dressings was 19.1 days (SD ± 13.43), those with daily dressings was 29.52 days (SD ± 29.6), and those with a combination of both dressings 43.15 days (SD ± 33.1). No significant differences were found in those without and with work related injuries in days to RTW (mean 26.84 days vs mean 32.29 days p = .2583), or mean age (36.6 year vs 35.7 years p= 0.6851) and total number of outpatient visits (3.13 visits vs 3.7 visits p = 0.1653). Conclusions: The use of an outpatient burn registry is beneficial to examine treatment options and outcomes such as time to return to work. Tracking of outcomes will provide opportunities to improve practice. Applicability of Research to Practice: This demonstrates the use of outpatient burn data to examine outcomes. Having an outpatient registry will be a rich source of data. 61. Experience and Implementation of Regional Anesthesia Protocol in Burn Patients J. He, MD, A. L. Wojahn, BS, J. Lovich-Sapola, MD, J. Eismon, MD, A. Khandelwal, MD MetroHealth Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH Introduction: Regional anesthesia (RA) has been shown to be a safe and effective alternative for pain management in burn patients after skin grafting. However, prior studies focused primarily on donor site pain and lower extremity grafts. This study describes the use of RA at a regional burn center and the implementation of a RA protocol. Methods: Burn patients with age >14 that underwent RA from 2014 to 2015 at a regional burn center were analyzed. Based on study results and current literature, a RA protocol was created and implemented. Mean and median in this study are presented as mean ± standard deviation and median (25th-75th percentile), respectively. Results: A total of 15 patients met the study criteria. Mean age was 4l±16; 73% of them were male. Flame burn was the most common mechanism (33%). Median total body surface area burnt was 5% (3%-9.8%). A total of 26 courses of RA were used in these patients as shown in Table 1. No adverse reaction to local anesthetic (LA) or procedure complications were found. Temporary paresthesia occurred in 2 courses (7.7%). After establishing safety, a comprehensive, multi-disciplinary, and evidence-based RA protocol was implemented for all adult burn patients that need skin harvesting/grafting. Patients with LA allergy and coagulopathy are excluded. Use of Single Injection (SI) versus Catheter Infusion (CI) is determined jointly by the burn surgeon and anesthesiologist based on patient and treatment factors. Although all extremities are eligible for RA, the number is limited by the maximum safe dose of LA and possible phrenic nerve involvement. All procedures are performed with ultrasound guidance. Anesthesiologist determines patient-specific block approach, choice of LA and dosing. Patients are monitored for complications. Those with CI are assessed daily until catheter removal. All patients, besides those with femoral blocks, are encouraged to ambulate with assistance immediately post-procedure (PP) and on PP day 1 for SI and CI patients respectively. Infusion rate is adjusted to facilitate early ambulation. Standard venous-thromboembolic prophylaxis may be used. Conclusions: This study demonstrates that RA is safe for both upper and lower extremity pain management in burn patients. This fostered the implementation of a comprehensive and evidence based RA protocol. Further studies are required to assess the benefit of RA along and specific technical details. Applicability of Research to Practice: To inspire adaptation of RA protocol in other burn centers throughout the country. Table. No title available. View Large Table. No title available. View Large 62. Water-Friendly Adjunctive Virtual Reality Pain Distraction for Pediatric Burn Patients During Wound Debridement in the ICU Tubroom M. Gonzalez, BS, H. G. Hoffman, PhD, R. Peña, MD, M. Bernardy, RN, W. Beck, RN, S. Bermea, A. Hinojosa, L. Rosenberg, PhD, M. Rosenberg, PhD, D. R Patterson, PhD, W. J. Meyer, MD University of Texas Medical Branch, Galveston, TX; University of Washington, Seattle, WA; Shriners Hospitals for Children, Galveston, TX Introduction: Uncontrolled pain during medical procedures is a worldwide problem. This study explored whether adjunctive non-pharmacologic immersive virtual reality distraction reduces the pain of children with large severe burn wounds during debridement in the ICU tubroom. Methods: Subjects were seventeen children (95% were Hispanic) aged 8 to 17 (mean = 13) with large severe burn injuries (mean = 40% TBSA) reporting worst pain intensity of 5 or higher on a 10 point scale. A portable battery-powered water-friendly VR system was used, which has no physical contact between the burn patient and the VR goggles. The VR experience involved looking into the VR goggles, gliding through an illusory 3d snowy canyon named SnowWorld (www.vrpain.com), and shooting snowballs at virtual snowmen, woolly mammoths and flying fish. Using a within-subject design, each patient received pain meds + No VR vs. pain meds + yes VR during different portions of the same wound care session (treatment order randomized). After wound care, patients rated pain during wound debridement with No VR, and pain during VR, on five graphic rating scales: Time spent thinking about pain during wound care, pain unpleasantness, worst pain intensity, lowest pain, and fun during wound care. Results: Using paired t-tests (see Table 1), patients ratings of pain during wound care were significantly lower during VR than during no VR on all pain measures, and patients reported significantly more "fun during wound care" while in VR. Conclusions: Results provide converging preliminary evidence that VR can help reduce pain during wound debridement in the ICU hydrotank. Applicability of Research to Practice: VR distraction has potential to help reduce pain levels of pediatric patients with large severe burns during wound care in the ICU. External Funding: This research was financed through a Shriners Hospitals for Children grant (award ID #71011-GAL). The water-friendly VR system was made available by Dave Patterson, University of Washington, Seattle. Table. No title available. View Large Table. No title available. View Large 63. Clues for Analgesic and Anti-Inflammatory Effects of Acupuncture on Burn-Trauma: Does Acupuncture Affect the Amounts of Interferon Gamma in the Experimental Burn-Wound Model? A. Abali, MD, T. Cabioglu, MD, H. Ozdemir, MD, G. Moray, MD, M. Haberal, MD Baskent University, Ankara, Turkey Introduction: Burn wound is one of the main sources for ‘systemic inflammatory response’ (SIRs) and ‘inflammatory pain and distress’ in burn trauma. IL-6 is a well-known actor in both situations. Interferon gamma (IFN-g) is a well-known cytokine which initiates the abnormal cytokine-changes in SIRs to burn-trauma. In our previous studies, we have demonstrated that acupuncture decreases ‘pain and distress scores’ and it decreases the amounts of IL-6 of the burn wounds in the experimental deep-partial thickness burn model. Here, we aimed to evaluate amounts of IFN-g in the mentioned burn-wound samples to confirm the effects of acupuncture on SIRs as well as inflammatory pain. Methods: Thirty-two male Sprague-Dawley rats had been divided into four equal-sized groups: B1-group (burns/ observation during 1h after injury); BA1-group (burns/ acupuncture/observation during 1h after injury); B7-group (burns/observation during 7 days after injury); and BA7-group (burns/acupuncture/observation during 7 days after injury). A preliminary study had been performed to create a partial-thickness contact-burn model: A brass plate (16cm2) which had been heated up to 250°C and a contact period of 5s had been found to be appropriate for induction of partial-thickness contact-burns on the dorsa of the rats. Animals in B1-group and BA1-group had been sacrificed 1 hour after burn-induction. Animals in B7-group and BA7-group had been sacrificed 7 days after burn-induction. In B7-group and BA7-group wound-dressings had been changed on every alternate-day. In BA1-group and BA7-group, acupuncture points around the burn wounds and the acupuncture points on related dermatomes had been used. Acupuncture had been repeated in every wound-dressing change for BA7-group. Before scarification, burn wounds had been excised for immunohistochemical staining of IL-6. In the present study, those excised samples were immunhistochemically stained for IFN-g. Amounts of IFN-g were evaluated semiquantitatively (mean ± SEM) Results: Our data indicated that B7-group had the highest amount of IFN-g (1.25 ± 0.16) (p.05). Conclusions: According to our results, acupuncture seems to reduce IFN-g amounts as well as IL-6 amounts in the experimental partial-thickness burn wounds. Applicability of Research to Practice: Our findings may refer to contributor role of acupuncture in modulation of systemic/ local inflammatory response to burn trauma as well as burn-injury related pain and distress. Further studies are required. 64. Satisfaction with Pain Management in Burn Patients A. J. Singer, MD, A. Amit, MBBS, H. C. Thode Jr, PhD, S. Sandoval, MD Stony Brook University, Stony Brook, NY Introduction: Burns are among the most painful conditions known to mankind. However, prior studies have suggested that patients with burns may not always receive adequate analgesia. We determined burn patient satisfaction from pain management in a burn unit and explored factors that predicted dissatisfaction with pain management in order to identify areas for improvement in pain control. Methods: Study Design—prospective observational burn registry. Setting—regional burn center with approximately 175 annual burn admissions. Patients—patients admitted to the burn unit between 2009-2014 included in the institutional burn registry. Measures—standardized collection of demographic and clinical information was performed by a trained burn registrar. Patients were specifically asked whether they were satisfied with their pain management and whether they desired more frequent or higher dosing of analgesics. Data Analysis—univariate and multivariate analyses were performed to explore the association between potential predictor variables and dissatisfaction from pain management. Results: During the study period 1159 burn patients were entered in the registry; 872 (75%) answered the question whether they were satisfied with pain control as an inpatient. Their mean age was 28+/-22 years; 57% were male, 68% were white, and 16% were Hispanic. 3% of cases had chemical burns and 1 % had electrical burns, the remaining patients had thermal burns. Of the 832 patients with thermal burns 49% were scalds, 25% were hot contact burns, 21% were from flame/fire, and the remainder were cold contact, frostbite, radiation, vapor, or unspecified (< 2% each). 17% of patients had burns to the head/ face/neck, 21% to the trunk, 60% to the upper extremities, and 31% to the lower extremities. Median TBSA was 3%, IQR 1-5 (range <1 to 55%). Of all patients, 9% were dissatisfied with inpatient pain control. Of these patients, 61% would prefer stronger medications and 37% would prefer more frequent dosing. The only factor associated with dissatisfaction with pain management was age. Dissatisfied patients were older (36+/-18 vs. 28 +/-22 years (P<0.001). Burn type, size, location, and pain severity were not associated with dissatisfaction with pain management. Only age remained a predictor of dissatisfaction with pain management on multivariate analysis (OR 1.02 per year of age, 95% CI, 1.01 to 1.03). Conclusions: Most burn patients admitted to a regional burn center are satisfied with their pain management. Only older age was associated with dissatisfaction with pain management. Applicability of Research to Practice: Burn practitioners should ask their patients if pain management is satisfactory and consider more potent or frequent dosing of analgesics, especially in older patients. External Funding: Suffolk County Volunteer Firefighters Burn Center Fund, Inc. 65. Assessment of the Role of Peer Support Groups in Psychosocial Recovery from Burn Injury: A Life Impact Burn Recovery Evaluation (LIBRE) Study B. Grieve, BA, G. D. Shapiro, PhD (c), MPH, L. Wibbenmeyer, MD, FACS, A. Acton, RN, BSN, A. Lee, PhD, M. Marino, MPH, A. Jette, PhD, J. C. Schneider, MD, L. E. Kazis, ScD, C. M. Ryan, MD, FACS Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; Phoenix Society of Burn Survivors, Grand Rapids, MI; Bentley University Department of Mathematical Sciences, Waltham, MA; Center for the Assessment of Pharmaceutical Practices (CAPP), Department of Health Policy and Management, Boston University School of Public Health, Boston, MA; Massachusetts General Hospital and Shriners Hospitals for Children, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA Introduction: Depression, anxiety and feelings of isolation can form the deepest and most painful scars for burn survivors. Peer support groups and individual psychotherapy have long been recognized as vital to a survivors emotional healing and successful societal reintegration. Although there is qualitative data on the role of support groups in burn recovery, there is limited large-scale empirical data. Therefore, we examined differences in community reintegration outcomes between burn survivors who reported past or current attendance at a peer support group and those who did not. Methods: LIBRE-192 was administered to 402 adult burn survivors with ≥5% TBSA burned or burns to critical areas. Subjects were recruited nationally from burn clinics, peer support, burn meetings, direct mailings, the Internet and social media. Items were scored using a 5-point Likert scale; higher scores denoted better outcome. Factor analysis was used to identify key dimensions underlying 8 conceptual domains previously postulated based upon the WHO ICF: Recreation and Leisure, Work and Employment, Relating with Strangers, Sense of Purpose, Family Roles, Informal Relationships, Sexual Relationships, and Romantic Relationships. Demographic and clinical characteristics were compared between support group attendees vs non-attendees. Unweighted mean scores of all items in each domain were compared between the groups using AN OVA. Linear regression models adjusted for significant demographic and clinical variables to evaluate the impact of support group attendance on domain scores. Results: Current or past support group attendance was reported by 220 (54.7%) of the respondents. Attendees were more likely to be male (55.5% vs 43.8%, p= 0.02), to have larger total body surface area burned (24.1% vs 14.6% TBSA, p=0.05) and to be > 10 years from injury (52.7% vs 47.2% > 10 years from injury, p<0.01). Those who attended at least one support group had significantly higher mean scores (p≤.02) in 5 domains: Recreation and Leisure (mean score = 4.01 for support group participants vs. 3.77 for non-participants); Work and Employment (4.34 vs. 4.11); Relating with Strangers (3.85 vs. 3.58); Sense of Purpose (4.28 vs. 3.85); and Informal Relationships (4.15 vs. 3.97). These differences remained significant after adjustments for gender, TBSA and time since injury Conclusions: This is the first reported association between peer support group attendance and outcomes in burn survivors. Results suggest the potential benefits of support groups on burn recovery. Applicability of Research to Practice: The findings of this study encourage burn centers to explore the potential importance of peer support groups as a clinical modality and to develop these programs where they are not available. External Funding: The contents of this abstract were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research, NIDILRR grant number 90DP0055. NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this abstract do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. 66. Trajectories of Physical Health-Related Quality of Life in Adults Following Burn Injuries S. A. Wiechman, PhD, F. D. Bocell, PhD, D. Amtmann, PhD, K. A. McMullen, MPH, L. Rosenberg, PhD, M. Rosenberg, PhD, G. J. Carrougher, RN, MN, K. Kowalske, MD, C. M. Ryan, MD, FACS, D. Herndon, MD, FACS, J. C. Schneider, MD, N. S. Gibran, MD, FACS University of Washington/Harborview Medical Center, Seattle, WA; University of Washington/Rehabilitation Medicine, Seattle, WA; University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX; University of Texas Southwestern, Dallas, TX; Massachusetts General Hospital, Spaulding Rehabilitation Hospital, Harvard Medical School, Shriners Hospitals for Children, Boston, MA; Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, MA Introduction: The purpose of this study was to identify trajectories of physical health over time and to identify predictors of these trajectories. Methods: Adults with burn injuries responded to a self-report assessment (Physical Component score of the SF-12; PCS) of quality of life pre-burn injury, and at 6, 12, and 24 months after discharge. TBSA, demographics, background information and scores from the Community Integration Questionnaire (CIQ),Satisfaction with Life Questionnaire (SWL), and the Satisfaction with Appearance Scale (SWAP) were all used to determine membership in a particular class. Growth Mixture Modeling (GMM) was used to model PCS scores over time. GMM identifies individual trajectories that are similar to each other (classes), but differ on average from other mean trajectories. Results: We had an n= 939, 72% male,64% non-Hispanic white, average age = 44 years, average TBSA = 20%. Four classes emerged with distinct mean trajectories. All classes experienced a drop in physical health from pre-burn to discharge. Both Class 1(75%) and Class 2 (16%) reported near average physical function pre-burn, dropping at discharge, with Class 1 subsequently improving and Class 2 showing no significant change over time. Class 3 (5%) and Class 4 (4%) both reported below average pre-burn physical health, with Class 4 returning to their low baseline and Class 3 improving to above pre-burn levels. TBSA, gender, previous physical disability, CIQ score, SWAP score and being retired were significant predictors of class membership. Conclusions: Class 2 is an obvious point of intervention as they report no improvement in physical health over the 24 mos post burn period and end up lower than their baseline. Class 4 is also a target for intervention with a goal of improving their low physical health to a more average level. Of particular interest is Class 3 that reports low preburn physical health and ends with higher scores at 24 months. This highlights the potential for post-traumatic growth and further research on this class will give us valuable information. Applicability of Research to Practice: This study will allow us to determine the risk and protective factors of each trajectory. Those who are retired with lower premorbid physical health, who are not integrating into the community, and who are not satisfied with their appearance are at higher risk for lower physical function after a burn injury and may need more intensive intervention. External Funding: This research was supported by a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research #90DP0029-01-00. 67. Patient Reported Outcomes & Return to Work in Individuals with Pre-Burn Injury Drug or Alcohol Abuse C. M. Thompson, MD, G. J. Carrougher, RN, MN, J. C. Schneider, MD, K. J. Kowalske, MD, J. A. Fauerbach, PhD, D. N. Herndon, MD, FACS, N. S. Gibran, MD, FACS University of Washington, Seattle, WA; Spaulding Rehabilitation Hospital, Boston, MA; University of Texas Southwestern, Dallas, TX; Johns Hopkins University, Baltimore, MD; Shriners Hospitals for Children, Galveston, TX Introduction: The incidence of drug & alcohol (ETOH) abuse among patients with thermal injuries has been reported to approach 30%. Whereas studies have found that these patients have longer hospital stays, higher rates of infection, & greater mortality, no publication has reported long-term health or employment status. The purpose of this study was to summarize the health & employment status of these patients for 2 years post-injury using two validated patient-reported outcomes (PRO) instruments. Methods: The sample consisted of adults ≥18 years with burn injury that required surgery & who completed the SF-12® Health Survey Physical (PCS) & Mental (MCS) component summaries & the Satisfaction With Appearance Scale (SWAP) at discharge & at least 1 time point at 6, 12, or 24 months post-injury (1993-6/2015). Chi-square and Wilcoxon Mann Whitney tests analyzed differences in subject & injury characteristics, PROs, & employment status pre- & post-injury. Results: A total of 1779 subjects met inclusion criteria (Table 1). Subjects who self-reported drug &/or ETOH abuse in the year prior to injury had lower MCS scores pre-injury, at discharge, & at every follow-up time point compared to subjects that did not report abuse. They had lower PCS scores at 6 & 12-month follow-up, Table 2. Subjects who reported drug/ETOH abuse also had higher SWAP scores at discharge & at 6-month follow-up indicating less satisfaction with their appearance. Subjects who were employed pre-injury had lower rates of returning to work if they reported drug/ETOH abuse in the prior year. Conclusions: Patients who worked at the time of injury & reported pre-injury drug &/or ETOH abuse were less likely to return to work in the 1st 2 years after a burn injury, relative to workers not reporting abuse. Factors associated with self-reported drug/ETOH abuse, compared to non-abusers, include higher %TBSA, longer hospital length of stay, more operations, lower perceived physical and psychosocial quality of life & great dissatisfaction with appearance. Applicability of Research to Practice: These data highlight the need for additional vocational resources & counseling to facilitate community reentry & return to work for this at-risk burn patient population. External Funding: The National Institute on Disability, Independent Living and Rehabilitation Research, grant #90DP0029-01-00 & #90DP0053. 68. The Psychological Impact of First Burn Camp in Nicaragua L. L. Tropez-Arceneaux, PsyD, A. A. Castillo, BA, E. Murillo, MPH, S. Valladares, BSc, PT, B. G. Jerez, BS, I. L. Icaza, MD, MPH Aproquen Pediatric Burn Hospital, New Orleans, LA; Aproquen Pediatric Burn Hospita,l Managua, Nicaragua Introduction: Asociacion Pro-Ninos Quemados de Nicaragua (APROQUEN) is a comprehensive burn center that provides a holistic and integrated approach to treating burns. APROQUEN has set the standards internationally with acute treatment for burns, intensive care, reconstructive surgeries, nutritional care, rehabilitation, occupational therapy and psychological treatment. APROQUEN is excelling within Central and South America with life saving techniques and quality of care. APROQUEN also recognizes that the treatment of a child with a burn injury surpasses physical care to include psychological treatment for the complete well being of the child. It is necessary to provide the tools necessary to reintegrate the child back into their environment. APROQUEN developed and implemented the first burn camp in Latin America, "Confio en Mi" (I trust myself). The camp theme focused on self-esteem. The camp program included theory (educational) and practice (applied) components where the campers through "classroom type" activities had the opportunity to reflect and share with other campers and camp staff on self- esteem, depression, and anxiety. Methods: Participants were children who survived major burns (N = 33; 58% female; ages 12-25; 61% <18) and were shown to have difficulty socializing. Comprehensive interviews were conducted to ensure fit for camp. 42% of the campers had not slept away from home since the burn injury. Mean TBSA= 20% and mean age at time of burn injury was 13. The majority of campers (46%) endured flame burn injuries with 24% having scald injuries. Mean years post burn = 4.8 + 3.2. Most campers (40%) were enrolled in secondary school, 30% in elementary school and 21% in college. Standardized measures (CDI-2 Parent Form and Child Form; Rosenberg Scale, APROQUEN Burn Camp Measure Parent and Child Form, Beck Anxiety Inventory and Beck Depression Inventory) were given to all campers prior to attending camp. The same measures were given 2 weeks after the camp and again at 6 months. Results: Paired samples T-Tests were conducted and significance was set at p < 0.05. Conclusions: The results indicate that Camp Confio en Mi had a significant impact on campers level of anxiety, depression and self-esteem. Future burn camps are an important part of the continued advancement of post pediatric burn care in Nicaragua. Applicability of Research to Practice: This study reveals the importance of future researches necessity to focus on generalizing the results of this study to other children who have experienced similar burn injuries. External Funding: Puma Foundation funded the burn camp. Table. No title available. View Large Table. No title available. View Large 69. Self-Inflicted Burn Injuries in the Urban Setting: Etiologies and Outcomes O. P. Mushin, MD, M. D. Esquenazi, BS, T. A. Smith, LMSW, D. E. Bell, MD University of Rochester Strong Memorial Hospital, Rochester, NY Introduction: Self-inflicted burns are rare causes of injury, accounting for 0.9% of burns in the United States as estimated by the National Burn Repository. While rare, the physical and psychosocial ramifications of these injuries are lasting. This study examines the etiologies and outcomes of self-inflicted burns in an urban setting. Methods: A retrospective chart review was conducted for an urban burn center from 2011 to 2015. Patients included sustained self-inflicted injuries. Data points included demographics, psychiatric comorbidities, injury circumstance, self-harm history, burn characteristics, hospital days (LOS), treatment, and outcomes. This was compared to a cohort of admissions during the same time frame matched for age and TBSA. Results: Thirty-four patients comprised the self-inflicted burn cohort. Average age was 32 years (range 10-69) in a 53% female, 82% Caucasian, 100% single population. Average TBSA was 2.80 ± 5.14 cm2 with most injuries on upper and lower extremities. Patients often presented with altered mental status (53%) due to psychiatric illness or intoxication. Most patients presented over 24 hours after the time of injury (56%). Incidents were claimed as suicide attempts in 24% of cases and suicidal ideation was present in 47% of cases. Previous self-harm was confirmed in 26% of patients and 49% of injuries were premeditated. Most patients required psychiatric assistance (74%). A high rate of social work (82%) was necessary for family support, crisis intervention, and socioeconomic needs. Compared to control, self-inflicted burn victims had higher rates of substance abuse (35% vs. 13%, p<0.05), longer LOS (11.3 vs. 5.3 days, p<0.01), longer ICU LOS (1.8 vs. 0.2 days, p<0.01), and lower rates of insurance (15% vs. 42%, p<0.001). Patients also exhibited a higher need for excision and grafting (41% vs. 20%, p<0.01), with 98+/-1.2% graft take. Conclusions: In the urban setting, risk factors for self-inflicted burn injuries include psychiatric comorbidities, substance abuse, and non-married status. Self-inflicted burn injuries often occur in premeditated acts amongst a population with high rates of psychiatric illness and intoxication. Despite small TBSA, these patients are more likely to require operative intervention and expanded institutional resources. Increased counseling of at-risk populations may help to decrease this potentially preventable method of injury. Applicability of Research to Practice: Self-inflicted burns are avoidable injuries requiring a high level of acute and chronic care. Early psychiatric and social work involvement including crisis management both for the patient and the patient's family is a prudent management tool in this setting. Counseling for at-risk patients is suggested to reduce primary and recurrent self-inflicted burn injuries. 70. Evaluation of a School Re-Entry Video Program G. P. McMillan-Law, OT, L. Forbes, OTR/L, MSc Health Science Centre, Winnipeg, MB, Canada Introduction: School is integral to a child's life, and returning after a burn injury often causes anxiety. The goal of a school reentry program (SRP) is to prepare the survivor, family, school staff and peers for the transition back to school. Literature supports the benefits of SRPs, mainly through anecdotal reports. To address our remote population, we created a standalone school re-entry video program (SRVP), Still the Same: Returning to School After a Burn Injury, in 2009. Focus group and pilot testing ensured a quality video with appropriate content. The objective of this study was to evaluate the SRVP and utilize feedback to guide improvements. Methods: This qualitative study used a phenomenological approach to explore the experiences of burn survivors, caregivers and school staff who received an SRVP. A purposive sample was used. The interview script was developed in consultation with an adult burned as a child. After ethics approval, in-depth, semi-structured interviews were conducted (in person, telephone or videophone). Interviews were audio taped and transcribed. Data were analyzed by coding and organizing into common themes; data collection ended at theme saturation. Strategies to enhance rigour included separate coding by both interviewers and member checking with a survivor, caregiver and school staff. Results: Twelve interviews were completed: 4 burn survivors (age range 6-14 years at SRVP; 7-17 years at interview), 4 caregivers and 4 school staff. Several major themes emerged. Participants related that: an SRVP decreased survivors' anxiety; they would encourage survivors to have an SRVP; video content is appropriate and helps increase empathy/understanding and answer questions in a supportive environment; individualizing the SRVP is necessary (timing, audience, format); and supportive school staff are required. Participant advice included that: the SRVP be introduced to survivors early in hospitalization and to school staff prior to discharge; it is helpful for families to take the video home; the SRVP include audience exploration of therapy devices; and if possible, a hospital professional be present at the SRVP; at minimum, support to school staff is required. School staff suggested communication with a single school contact. Conclusions: Information learned has led to improvements to the SRVP, including repackaging and the creation of a protocol to guide hospital staff organizing the SRVP. This study supports the need for every young survivor to have access to an SRP, helps to justify hospital staff resources required, and contributes to the literature on evaluation of SRPs for burn survivors. Applicability of Research to Practice: This study confirmed that our SRVP meets the needs of the survivor and caregiver. With increased hospital staff support and communication, it better meets the needs of school staff. External Funding: Children's Hospital Foundation of Manitoba, through a Child Health Advisory Committee grant. 71. The Effects of a Community-Based Exercise Program on Mental Health in Severely Burned Children R. Pena, MD, M. Rosenberg, PhD, C. R. Andersen, MS, M. Gonzalez, BS, D. N. Herndon, MD, O. E. Suman, PhD, W. J. Meyer, MD University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX Introduction: Physical activity is associated with numerous health benefits for severely burned children, but little is known about the long-term effects of physical activity on mental health. The purpose of this study was to compare the benefits of the In-hospital Exercise Program (EX) and the Community Based Exercise Program (COMBEX) on long term psychosocial and physical outcome. We hypothesize there would not be a difference between the groups. Methods: Severely burned children between the ages of 7-18 years with ≥40% Total Body Surface Area (TBSA) who had participated in a COMBEX Program or an In-hospital Exercise Program (EX) were included in this study. The Child Health Questionnaires (CHQ-Child/CF87 and Parent/PF28) were used to assess changes in quality of life from discharge to 1 year post-burn. CHQ-CF87 includes 87 items and the CHQ-PF28 includes 28 items. Concepts common to the parent and child self-report version include the following: physical functioning, general health, pain, mental health, self-esteem, behavior, role/ social limitations - physical, emotional, or behavioral, family limitations, family cohesion, and change in health. The parent form also includes two additional scales: emotional impact and time impact. The questionnaires were given in English or Spanish as applicable and significance for change was set at p≤ 0.05. Higher scores indicated better health and quality of life. Results: Data were completed for 18 patients, (n=9 EX and n=9 COMBEX). Demographic and TBSA were similar in both groups. Both the CHQ-CF 87 and CHQ-PF28 document that the EX and COMBEX groups improved significantly between discharge and 1 year. At discharge the EX group had a higher mean score than the COMBEX group on CHQ-CF 87 in physical functioning (p=0.04) and Role/social limitations -emotional (p=0.009) and was also higher on the CHQ-PF28 on Bodily pain /discomfort (p=0.05). However at 1 year the COMBEX group was not different from the EX group on the CHQ-CF 87 but was higher than EX group on CHQ-PF28 in Family Cohesion (p=0.05). Therefore the COMBEX group performed at least as well as the EX group. Conclusions: The study showed that the proposed COMBEX program is feasible and beneficial for improving physical function as well as maintain psychosocial and mental health. The results show some improvements with the use of the COMBEX group with respect to optimizing function and health in severely burned children. Applicability of Research to Practice: Recuperating severely burned children can receive effective results from either a COMBEX or an EX program. External Funding: External Funding NIH: P50 GM060388, R01 HD049471, R01 HD049471-08S1NIDRR H133A120091SHC 71006,71009, 84080. 72. The Presence of Scarring in the Burn Model System National Database: Risk Factors and Psychosocial Implications J. Goverman, MD, FACS, E. Bittner, MD, PhD, K. Mathews, BA, N. Gibran, MD, FACS, D. Herndon, MD, FACS, O. E. Suman, PhD, K. Kowalske, MD, W. J. Meyer, MD, C. Ryan, MD, FACS, J. C. Schneider, MD Massachusetts General Hospital and Shriners Hospitals for Children, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA; Massachusetts General Hospital and Shriners Hospitals for Children, Harvard Medical School, Boston, MA; Massachusetts General Hospital, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA; University of Washington, Seattle, WA; University of Texas Medical Branch, Galveston, TX; UT Southwestern, Dallas, TX; Massachusetts General Hospital, Shriners Hospitals for Children, Boston, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA Introduction: Widespread and severe post-burn scarring is common, but the risk factors and effects of such scars are still poorly understood. This study aimed to determine risk factors for symptomatic burn scars based on demographic and medical variables, to describe the frequency of scar problems up to two years after injury, and to analyze the impact of burn scars on long-term functional, psychosocial, and reintegration outcomes. Methods: A retrospective analysis was conducted on 960 patients (2,440 anatomic burn sites) using the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Burn Model System (BMS) database between January 1994 and May 15, 2006. Basic demographics of the study population were analyzed and predictors of hypertrophic scarring (HTS, defined as a raised or thick scar at any time point) were determined using multivariate analysis. Regression analysis was also used to evaluate the impact of HTS on psychosocial outcomes with respect to the Community Integration Questionnaire, the Satisfaction with Life Scale, the Short Form-12, and the Distress Scale. Results: The study population was primarily white (65%) and male (72%), mean age 44 +/- 15 years, and mean TBSA burned of 20 +/- 18%. Figure 1 shows the frequency of scar symptoms over a two-year time period. Predictors of HTS included head & neck burn, hand burn, number of trips to the operating room, and leg grafts (p<0.05). The presence of HTS was not associated with the Community Integration Questionnaire scores or Satisfaction with Life scores; but was associated with Distress scores and the SF12 (mental, but not physical scores) (p<0.05). Conclusions: In this large, longitudinal, multicenter cohort of burn survivors the presence of scarring changes little over the first two years post-burn and HTS is associated with significant patient distress. Studies are needed to examine the impact of novel treatments for HTS, such as fractional CO2 laser, on long term outcomes including that of distress. Applicability of Research to Practice: The risk factors identified here can potentially be used for targeted interventions aimed at improving quality of life after burn injury for those with scars. This study demonstrates the need for continued support of burn survivors in order to decrease the distress that accompanies hypertrophic scarring. External Funding: The contents of this manuscript were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DP0035). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this manuscript do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. 73. Treatment of Pediatric Burn Scars Using Laser Therapy: Early Insights J. Zuccaro, MSc, D. Stephens, MSc, C. Kelly, RN (EC), MN, NP, J. Fish, MD, MSc, FRCSC Hospital for Sick Children, Toronto, ON, Canada Introduction: A new era of outcomes for pediatric burn patients has begun as survival rates have significantly increased in high-income countries. Unfortunately, complete restoration of burn and graft sites may be limited by the development of hypertrophic scarring. Laser therapy is the newest form of scar modulation available and early evidence has demonstrated its potential benefits. However, literature regarding the use of laser therapy to improve scars in children is highly limited. Thus, this study presents our early experience using Pulsed Dye and Carbon Dioxide lasers to treat pediatric patients at our burn center. Methods: The data presented in this study was collected from patients who prospectively enrolled in the laser therapy database initiated at our institution. Information regarding demographics, burn treatment, scar management, laser procedure details, Vancouver Scar Scale (VSS) scores, Toronto Pediatric Itch Scale (TPIS) scores, before-after photos, and adverse events was collected for each patient. All procedures used Pulsed Dye laser therapy (PDL) and/or Carbon Dioxide laser therapy (CO2) and were carried out in the operating room under neuroleptic anesthesia by a single burn surgeon and nurse practitioner. The treatment period for this study was between August 2014 and August 2015. Results: 50 patients (mean age: 7.5; mean TBSA: 13.5%; mean Fitzpatrick Skin Type: 2.5) were treated with laser therapy (PDL=5; CO2=35; both=63) over a total of 103 sessions. The average number of sessions was 2.1 and the average interval between treatments was 122 days (SD, 56.7). Most scars resulted from scalds (30%) and flame burns (12%). The majority of scars were located on the arms (21%) and torso (21%). Total VSS decreased from 6.9 (SD, 2.2) to 5.3 (SD, 2.2) between the first and second laser procedures. The VSS score for pliability showed the largest decrease with a mean difference of 0.8 (p<0.001) between procedures. TPIS scores also significantly decreased with a mean difference of 0.5 (p<0.05) between procedures. No adverse events were reported. Conclusions: This is one of the very few studies to examine the use of both PDL and CO2 laser therapy in a pediatric population. Overall, laser therapy appears to significantly improve symptomatic burn scars. However, without objective scar assessments (ultrasound, cutometry, etc.), it is difficult to determine the effectiveness of laser therapy in the absence of bias. Thus, future research at our institution will focus on integrating both subjective and objective measures to assess how scars change after each laser treatment. Applicability of Research to Practice: The data collected in this study contributes to the growing body of evidence that suggests laser therapy is a beneficial treatment that should be considered alongside current scar rehabilitation practices. 74. 10 Years of Experience in Managing Burn Ankle Deformities in Children T. Huang, MD, FACS, D. Herndon, MD, FACS University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX Introduction: Integumentary destruction due to burns of an ankle is the cause of cicatricial contractures. The task of reconstructing a resultant deformity can be difficult; non-surgical manipulation of an angulated ankle is generally ineffective while the conventional approach of wound coverage such as skin grafting may not be useful. A transpositional random fascio-cutaneous flap mobilized from an area adjacent to the ankle has been found to be a useful technique in reconstructing ankle deformities. Methods: A total of 192 ankle contractures were treated in 113 children between 2004 and 2013. The patients were followed and the outcome was assessed until 2015. There were 61 boys. While the youngest was 2 years of age, the oldest child was 15 years old; the mean age was around 8 years. Results: The common deformities noted were dorsiextension deformity resembling that of talipes equinus and dorsiflexion deformity similar to talipes calcaneus; they were 40% and 25% respectively of the deformities noted. A transpositional fascio-cutaneous (FC) flap mobilized from an area adjacent to the ankle was used to cover the wound resulted from surgical release of contracture. The flap donor site was grafted with a partial skin graft only if primary closure of the wound is not possible. Splinting and/or physiotherapy were not needed once the wound healing was completed. While problems such as bleeding and infection were not encountered in all, re-operation was necessary in 14 because of recurrent joint contracture or an open wound because of flap loss. Of 113 children treated, 95 were seen regularly after the surgery. While the longest length of follow-up was 11 years, the shortest was 0.8 years. The mean length was 4.6 years. Conclusions: The conventional techniques; i.e., non-surgical joint manipulation, surgical release and skin grafting technique is ineffective in correcting angulating deformities of a burn ankle. The ineffectiveness is thought to be attributable to soft tissue deficit around ankle. In addition to restoration of joint movement, coverage of an open wound consequential to surgical release is therefore, essential in ankle reconstruction. A FC flap mobilized from the area adjacent to an affected ankle is a useful approach in caring for the patients. Morbidities were minimal. Applicability of Research to Practice: High. 75. Autologous Fat Grafting Does Not Improve Burn Scar Appearance: A Prospective, Randomized, Blinded, Placebo-Controlled, Pilot Study J. I. Ramirez, MD, P. Maguina, MD Shriners Hospitals for Children, Sacramento, CA Introduction: Thermally-injured tissue has limited ability to regenerate healthy skin. Adipose tissue contains multipotent progenitor cells and has been used to regenerate damaged non-adipose tissue, such as cartilage and muscle. Autologous adipose tissue grafts have been used to induce skin repair in patients with severe radiation injury, improving skin appearance. We conducted a randomized split-scar pilot study to evaluate the use of autologous adipose tissue grafts to induce skin repair and improve the appearance of mature burn scars. Methods: Subjects with mature burn scars scheduled to undergo surgical reconstruction at a pediatric burn unit were recruited to participate in the study. Enrollment goal was ten patients. During scheduled reconstructive surgery, a separate scar not originally scheduled for surgery was selected for treatment in the study. Half of this scar was injected with autologous fat graft and the other half was injected with saline solution. Randomization was used to select the scar half to be injected with either fat or saline. Adipose tissue was harvested from the abdomen or thigh. Scar injection was performed using standard (Coleman) technique. Appearance of the two scar halves was assessed, six to twelve months later, by a blinded independent evaluator using the Vancouver Scar Scale. The scar halves were also compared for their "look" and "feel" by the patient, who was blinded to treatment. Results: A total of nine patients were enrolled in the study. Complete data for analysis was available on eight of the nine patients; one patient was lost to follow-up. Six of the eight scars evaluated showed no difference in Pigmentation or Vascularity score after treatment with either fat or saline. One scar had a higher Pigmentation score for the half treated with saline and one scar had a higher score for the half treated with fat (see Table). One scar had a higher Vascularity score for the half treated with saline and one scar had a higher score for the half treated with fat. Relative scores for Pliability and Height similarly showed no clear difference by treatment with fat or saline. Results for patient qualitative assessment showed no clear improvement with fat grafting. Conclusions: There is no clear improvement in burn scar appearance after treatment with autologous adipose-derived cells. Applicability of Research to Practice: Autologous fat grafting using current standard technique is not clinically beneficial for improvement of burn scar appearance. Table. No title available. View Large Table. No title available. View Large 76. Reconstruction Of The Burnt Breast - From Childhood To Motherhood N. S. Piccolo, MD, M. Piccolo, MD, PhD, M. Piccolo, MD, PhD Pronto Socorro para Queimaduras, Goiânia, Goiás, Brazil Introduction: Tissue expansion is one of the most common techniques used for treatment of burn sequellae. Implants available locally follow the international standards for shapes and volumes and do not always "match" the shape of the defect to be treated and usually do not generate enough tissue to really gain advancement in a multi plane or multi direction format. This series of cases, with evolution from childhood to adulthood, including motherhood, discusses the evolution of the technique over these past several years. Methods: This retrospective study analyses 96 female patients with burns involving the anterior trunk who underwent reconstruction with one or more expanders, in two or more procedures, during the last 20 years. In 2006, the method evolved to the surgical placement of large rectangular tissue expanders (600 or >cc) on a "V" or "L" shaped manner with at least 1/3 of the prosthesis overlapping each other, obtaining in such a manner an exponential gain of tissue on the "tip" of the "V" , following the same principle of the several times published in the past "croissant" shaped expanders. Occasionally, expanders were overlapped in a "fallen dominoes" sequence Results: 96 patients were submitted to 246 expansions, with an average of 3, 2 expanders per patient, per procedure. Results were considered final when the patient did not want to operate anymore. 8 patients underwent full term pregnancy, being able to breast feed from at least one reconstructed breast. 52 patients were benefitted with the overlapping expanders technique. These patients presented surgically superior results when compared to similar cases where similar expanders were used, but not terminally superposed. All of these latter patients present a larger gain than similar cases with separated (justaposed) tissue expanders. Conclusions: There are still limitations of the expanders prosthesis format and volume, when planning greater advancements and resections, mainly within areas of the body where more than one plane advancements are needed such as neck, shoulder, thorax or breast. In this last one, with the compound difficulty of one not desiring to "compress" or deform the breast mould with a tight advanced tissue. Although we have not been able yet to mathematically demonstrate the actual gain of tissue with this recent idea in this ongoing study, there is more easiness in the flap advancement and more natural results when considering the breast mould and retractional deformities. These cases clearly indicate the need for constant endeavours of the plastic surgeons aiming at full recovery of the anatomical, as well physiological and emotional components of the sequellae patients. Applicability of Research to Practice: The use of superposed tissue expanders augment exponentially the amount of expanded tissue, allowing for advancement in multiple planes. 77. The Utility and Versatility of Perforator-Based Propeller Flaps in Burn Care C. M. Teven, MD, J. Mhlaba, BS, A. O'Connor, MSN, L. J. Gottlieb, MD, FACS University of Chicago Medicine, Chicago, IL Introduction: The majority of surgical burn care involves the use of skin grafts. However, there are instances when flaps provide superior outcomes both in the acute setting and for post-burn reconstruction. Several options exist (eg, Z-plasty; VY flaps; fasciocutaneous, muscle, or musculocutaneous flaps; free flaps), each with associated benefits and shortcomings. Rarely discussed in the context of surgical burn care, the perforator-based propeller flap is an important option to be considered. The purpose of this study is to describe and expand upon the indications for use of the perforator-based propeller flap in surgical burn care. Methods: An IRB-approved review was performed on patients whose burn care included the use of a perforator-based propeller flap at our institution from May 2007 to April 2015. Patients of all ages were eligible for inclusion. Charts were reviewed for patient characteristics, burn injury, indications for flap use, operative details, complications, additional procedures, and outcome. Results: Twenty-one perforator-based propeller flaps were used in the care of seventeen burn patients (Table). Six flaps (29%) were used in the acute phase of care for coverage of exposed joints, tendons, cartilage, and bone; coverage of open wounds; and preservation of range of motion (ROM) by minimizing scar/graft contracture. Fifteen flaps (71%) were used for reconstruction of post-burn deformities including coverage of chronic wounds, coverage after scar contracture release, and to improve or preserve ROM. The majority of flaps (94% at follow-up) exhibited stable soft tissue coverage and/or good or improved ROM of adjacent joints. Three cases (14%) of partial flap loss and one case of total flap loss (4%) required return to the operating room. One patient required an additional procedure for continued contracture after surgery. Three patients were lost to follow-up. Conclusions: Perforator-based propeller flaps provide reliable vascularized soft tissue for coverage of vital structures and wounds, contracture release, and preservation of ROM across joints. Our series supports their utility in both the acute and reconstructive phases of burn care. They are versatile, safe, relatively easy to harvest, and useful anywhere on the body where a perforator vessel is present. Applicability of Research to Practice: There are numerous indications in acute and reconstructive burn surgery for which the perforator-based propeller flap is an excellent option. It should be part of the armamentarium of all burn surgeons. 78. Burn Depth Assessment: Laser Doppler Imaging (LDI) vs. Enzymatic Debridement S. Monstrey, MD, PhD, J. Verbelen, RN, H. Hoeksema, PT Ghent University Hospital, Ghent, Belgium Introduction: Surgery is universally accepted as the treatment of choice for deep dermal and full thickness burns. Ample evidence exists on the role of laser Doppler imaging (LDI) in accurate assessment of wound healing potential (HP) and burn depth. A predicted healing time of > 3 weeks is generally considered as an indication for surgery. Recently, a new bromelain-based enzymatic agent has become available on the market allowing for early non-surgical eschar removal of deep burns. Direct inspection of the selectively debrided wound bed has been reported to provide a very accurate assessment of the burn depth. We investigated the correlations and differences of these two methods for assessing burn depth. Methods: Twelve patients with deep dermal and full-thickness burns on clinical assessment were first scanned with LDI and then underwent selective enzymatic eschar removal. Wound treatment immediately after debridement was provided with allograft skin followed by surgical coverage for full-thickness wounds and conservative therapy with an enzyme-alginogel (eventually in combination with a hydrocortisone cream) in burns with a still intact deep dermal layer. Aftercare with pressure garments and silicone was started at the time of wound closure. Results: LDI showed major areas of deep burns with a HP of >21 d in 10 of the 12 patients. After enzymatic debridement, only 3 patients demonstrated a true full thickness burn necessitating surgical coverage. In contrast to our routine treatment protocol where early tangential excision and skin grafting is performed in all burns with a predicted HP > 21d, the 7 other patients with deep burns on LDI epithelialized with conservative measures within 2.5 to 6.5 weeks. Scar hypertrophy, even in the patients with prolonged healing times, was minimal or absent. Conclusions: LDI predictions where accurate in terms of healing time but early enzymatic eschar removal allowed for a more precise burn depth assessment of the deep dermal wounds by direct visual assessment of the debrided wound bed resulting in a more informed decision on further treatment. Possible advantages of this new procedure are reduced need for surgery and anesthesia, less blood loss, less donor site morbidity and less scar formation. Disadvantages include: difficult logistic implementation of this new procedure, a long debridement procedure requiring adequate analgesia, prolonged wound healing and uncertain scar outcomes. Applicability of Research to Practice: The preliminary results of this study indicate that enzymatic debridement of the burn eschar allows for a more accurate burn depth assessment than LDI, and also question the 21 day healing time paradigm as an indication for surgical therapy. 79. 10 Years of Experience in Using a Nasolabial Axial Skin Flap Technique to Manage Cicatricial Lower Eyelid Deformities in Burn Children T. Huang, MD, FACS, K. Capek, MD, D. Herndon, MD, FACS University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX Introduction: Grafting of a defect consequential to scar releasing procedure is the conventional method of repairing burn eyelid deformities. Although the outcome achievable with this technique is satisfactory, tightness around the grafted sites and/or recurrent contracture are not uncommon. A skin flap oval in shape fabricated with an intact vascular supply in the area along the nasolabial line has been used to reconstruct burned lower eyelid deformities. The experience gained over the past 10 years formed the basis of this report. Methods: (A) Surgical technique - An oblong and ovally shaped skin flap is fabricated in the area along the nasolabial line. The length vs. width ratio can exceed 4-6:1; the exact flap size is determined by the size of lower eyelid defect. The flap is rotated cephalad and laterally to make up the tissue defect created. (B) Patient materials - This modality of treatment was used 118 times in 83 children. The youngest was 2 years of age and the oldest was 19 years old. The mean age was 9.52 years. There were 57 boys. Results: Cicatricial ectropion was the most common complaints and was the most common indication for the use of this technique; it was used in 109 eyelids; i.e., 92.37%. Of 83 children treated, 5 did not return for follow up evaluation. 78 were regularly followed; the length varied between 0.5 years, the shortest and 11 years the longest. The average was 4.97 years. Although the patients did not encounter the problems such as infection, hemorrhaging, and flap loss, re-release was needed in 14 lids because of recurrent contracture. Conclusions: The nasolabial skin flap technique has been used to reconstruct burn lower eyelid deformities in burn patients for the past 10 years. The approach appeared to provide an outcome that is functionally and in part aesthetically satisfactory outcome. Applicability of Research to Practice: High. 80. A Preliminary Report of a Prospective Study Evaluating Outcomes of Burn Scars Treated with Laser Therapy M. Jacobs, RN, MSN, D. Roggy, RN, R. Sood, MD, FACS Richard M. Fairbanks Burn Center, Indianapolis, IN Introduction: Hypertrophic scaring after burn injury can be extremely painful, cause profound itching, and affect the way the patient view themselves and how the outside world perceives them. Recently, laser therapy has been added as a modality for scar modulation for our patients. In December 2014, we initiated a prospective IRB approved study to evaluate the outcome of scars treated with fractional CO2 laser therapy (FLT) utilizing objective and subjective tools. We report our preliminary data results on the patients that have all three treatments. To date, we have 22 subjects currently enrolled in the study. Six patients (4 adults; 2 children) have completed all three treatments. Methods: All subjects were consented to participate in the study. The study entailed a series of three laser treatments minimally 4-6 weeks apart with scar measurements and POSAS form completion performed prior to each laser treatment and four weeks after the last FLT. Demographic information was gathered at the beginning of the study. Scar measurements that included color, pliability, and scar thickness; and completion of the POSAS form were obtained prior to each laser therapy session and four weeks after the third laser treatment. The measurements of color, pliability, and scar thickness were measured with the Colorimeter, Cutometer, and ultrasound. Results: As seen in Table 1, there were significant improvements in the Patient and Observer POSAS scores and measured skin density. There was a decrease in scar thickness but this data was not considered statistically significant that may be related to small sample size. There were no significant changes to Pliability or Color when measured with the Colorimeter and Cutometer. However, in all of the Patient POSAS ratings, all subjects rated their scars to be closer in color to their normal skin and rated their scars felt more like their normal skin. Conclusions: In this small group, our early findings show that Patient and Observer POSAS scores and measured skin density had statistically significant improvements following FLT. Pliability and Color when objectively measured are not significantly improved. However, the subjects and observers perceived the burn scars to have significantly improved. Due to the low number subjects included in this data set, we suspect more statistically significant differences will be observed. Applicability of Research to Practice: There is no literature that describes outcomes with objective measurements. Table. No title available. View Large Table. No title available. View Large 81. Impact of Early Surgical Intervention on In-Hospital Burn Costs and Complications: 10-Year Retrospective Propensity-Scored Analysis of a Nationwide Database A. Y. Li, MS, K. C. Rustad, MD, Y L. Karanas, MD Stanford University School of Medicine, Stanford, CA; Stanford Hospital & Clinics, Stanford, CA Introduction: Management of burn wounds has continued to stress early tangential excision of burn tissue and closure. We present a 10-year cost-analysis within a national database to support these practices. Methods: Patients undergoing surgical intervention for burns in the Nationwide Inpatient Sample between 2002 and 2011 were identified and stratified based on location of injury, depth of burn, and TBSA involved. Early intervention was defined as OR excision within 5 days of admission. Outcome variables were selected to evaluate efficiency and efficacy of early versus delayed surgical intervention. Patients with and without early surgical intervention were propensity-score matched on demographics, comorbidities, and injury characteristics to minimize bias and confounding by a 1:5 greedy-match algorithm centered on the logit of propensity score. Significant results reported were defined as alpha of 0.05. Results: Between 2002 and 2011, 102,257 patients were admitted for burns. 12,272 (12.0%) were first degree, 57,665 (56.4%) were second degree, and 32,245 (31.5%) were third degree. 27,888 (27.3%) underwent surgical management during their hospitalization, of which, 3,630 (13.0%) were delayed. In a multivariate analysis, patients with second degree (OR 1.11) and third degree (OR 2.57) burns were more likely to receive early surgical intervention. TBSA between 20-50% were more likely to undergo early debridement (OR 1.42-1.73) in addition to multiple burns involving trunk (OR 1.29), lower limb (OR 1.20), and face (OR 1.13). Burns with <10% TBSA were less likely to have early intervention (OR 0.67). Patients with early excision experienced a shortened mean hospitalization period (11.5 vs 25.5 days) and decreased total hospital charges ($79,948 vs $177,389). Overall total operations per hospitalization were not significantly different between groups. Mortality rate was decreased in the early intervention cohort (3.4% vs 4.7%). Additionally, complication rates for local wound infection (8% vs 17%), sepsis (5% vs 11%), arrhythmias (6% vs 9%), pulmonary complications (9% vs 18%), and urinary complications (4% vs 9%) were all also significantly decreased. Conclusions: We demonstrate the fiscal and clinical advantages of continued aggressive surgical treatment of burns. Given successful matching, our observed delays in surgical management likely reflect local differences in resource availability and surgeon preferences. Applicability of Research to Practice: Taken together, our findings strengthen the need to facilitate early care of burn patients at capable institutions with readily accessible burn resources. 82. Developing Nurse Competency and Clinical Reasoning: An Evidence-Based Toolkit for Preceptor Development M. G. Barba, BSN, RN, K. K. Valdez-Delgado, BSN, RN, H. L. Greeley, RN, J. R. Robbins, MSN, RN, E. A. Mann-Salinas, RN, PhD, S. Boyer, RN, M.Ed, FAHCEP U.S. Army Institute of Surgical Research, Fort Sam Houston, TX; Tripler Army Medical Center, Honolulu, HI Introduction: Our center identified the need for an evidence-based (EB) precepting program to transition experienced nurses to burn specialty. The purpose of this project was to develop and implement an evidence-based Preceptor Development Program (PDP) for experienced Burn Center staff nurses to improve Preceptor knowledge and Preceptee satisfaction. Methods: Following a formal literature review we selected the EB VT Nurses in Partnership (VNIP) clinical coaching PDP. A unit policy and Preceptor Candidate (PC) agreement was developed to outline prerequisites, assessment criteria, and define roles and responsibilities. Preceptor Expertise Evaluations (PEE) to assess proficient practice were completed by PC, a peer, and nurse leader; score of ≥2 on a 5-point scale was required. PCs attended the comprehensive 2-day VNIP course. Critical care and wound knowledge tests were administered and scores above the unit average were required; remediation was provided as needed. A probationary period was complete after successfully orienting a new hire and obtaining a final PEE score of > 3. Preceptees evaluated the original and revised programs using the Preceptorship Evaluation Survey (PES) with a 1-5 Likert scale on: socialization, job satisfaction, role model, management support, feedback, teacher, program support and adult learner. Formal Preceptor recognition was provided. Results: From SEPT 2012 to MAY 2014, 33 Burn Center staff attended the VNIP course and trained as formal Preceptors; 21 completed the probationary period (12 ICU and 9 PCU; 14 RNs and 7 LVNs; total 64%). Nursing experience was 14 ± 7.6 years with an average burn nursing experience of 7 ± 5.3 yrs. (n=18 responses). Precepting experience was 5.9 ± 6.1 years; 12 preceptors (57%) reported VNIP as the only preceptor training they had received. Of the 21 who completed the entire program, 11 (52%) failed to achieve the benchmark average for critical care knowledge (ICU RN = 84%, PCU; RN = 75%, and LVN = 70%); 3 (14%) individuals failed to achieve the benchmarked wound test. PES scores for Preceptees completing orientation prior to (n = 17) compared to after implementation (n = 25) differed in: feedback, teacher and program support (p < 0.05, respectively). Conclusions: A structured PDP, codified in unit policy, clarifies roles and expectations, decreases variance among preceptors in specialty practice, and directly affects the ability to train a competent new employee in a consistent fashion despite changes in unit leadership over time. Applicability of Research to Practice: Comprehensive Preceptor development can improve the quality of the transition of experienced nurses to the burn specialty. External Funding: Triservice Nursing Research Program grant #HT9404-12-l-TS08. 83. Contracture Severity at Hospital Discharge: A Burn Model System National Database Study M. Godleski, MD, J. Goverman, MD, FACS, K. McMullen, MPH, P. C. Esselman, MD, N. S. Gibran, MD, FACS, O. E. Suman, PhD, D. N. Herndon, MD, FACS, R. K. Holavanahalli, PhD, C. M. Ryan, MD, FACS, J. C. Schneider, MD University of Toronto, Toronto, ON, Canada; Massachusetts General Hospital and Shriners Hospitals for Children, Boston, MA; University of Washington, Seattle, WA; University of Washington School of Medicine, Harborview Medical Center, Seattle, WA; University of Texas, Galveston, TX; University of Texas Medical Branch, Galveston, TX; University of Texas Southwestern Medical Center, Dallas, TX; Spaulding Rehabilitation Hospital, Boston, MA Introduction: Soft tissue contracture is a common complication of burn injury and can cause significant barriers to functional recovery and rehabilitation for burn survivors. Establishing anticipated range of motion (ROM) outcomes will help to guide studies evaluating the prevention and treatment of contractures. To this end, hospital discharge ROM data from patients with burn-associated contracture from the Burn Model Systems (BMS) database were evaluated as a potential benchmark of contracture outcomes. Methods: The National Institute on Disability, Independent Living, and Rehabilitation Research BMS database collected information on burn-associated contracture between 1994 and 2003. This data was retrospectively analyzed for all patients discharged with a contracture. Sixteen areas of impaired movement were reviewed from the shoulder, elbow, wrist, hand, hip, knee, and ankle joints. Summary statistics were generated and divided into groups by total body surface area (TBSA): less than 20%, 20-40%, and greater than 40%. Contractures were reported as both mean absolute loss of ROM in degrees and percent of total normal ROM. Results: A total of 8,789 contractures were analyzed from 970 patients. The population had a mean age of 28.9 years, a mean TBSA of 30.7%, and was 74.6% male. Documented contractures ranged from relatively small to near-complete loss of motion as summarized in Table 1. For example, loss of elbow extension was found to be 12, 17, and 20 degrees for the less than 20%, 20-40%, and greater than 40% TBSA groups, respectively; this indicates a loss of 9%, 12%, and 14% of full normal range of motion for each of the TBSA groups, respectively. In contrast, shoulder abduction was found to be 45, 60, and 80 degrees across the three subgroups, demonstrating a loss of 25%, 33%, and 44% respectively. Conclusions: The data presented illustrates an anticipated degree of ROM loss for a burn survivor with contracture upon discharge from a group of regional burn centers. Like any morbidity or mortality statistics, the goal of burn care is to strive for no contractures. However, these numbers reflect a potential standard for anticipated outcomes based on TBSA that reflects the realistic challenges of contracture prevention during the period of initial hospitalization. Applicability of Research to Practice: This analysis may serve as a historical control for future contracture prevention and treatment efforts for rehabilitation caregivers working with burn survivors. External Funding: The contents of this abstract were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DP0035). 84. Pulsed-Xenon Ultraviolet Light Disinfection in a Burn Unit: Impact on Environmental Bioburden, Multidrug-Resistant Organism Acquisition and Healthcare Associated Infections C. M. Green, MD, D. W. Johnson, J. C. Pamplin, MD, K. N. Chafin, MBA, RN, C. K. Murray, MD, H. C. Yun, MD San Antonio Military Medical Center, Fort Sam Houston, TX; U.S. Army Institute for Surgical Research, Fort Sam Houston, TX Introduction: Patients in the burn intensive care unit (BICU) are highly susceptible to infection due to their depressed immune systems and loss of the skin barrier. Portable pulsed xenon ultraviolet disinfection (PPX-UVD) may reduce healthcare associated infections (HAI) including Clostridium difficile infections (CDI), though few data inform healthcare environments such as the BICU, where other multiple drug resistant organisms (MDRO), particularly gram negative rods (GNR), predominate. Methods: PPX-UVD was used for 3 months after standard cleaning of patient and operating rooms (ORs) in a 16 bed American Burn Association accredited BICU that is part of a 450 bed tertiary care academic medical center. Settle and touch plates (air and high touch surfaces) in patient rooms and ORs were obtained after standard cleaning, then pre-and post-PPX-UVD. Hospital infection surveillance data using National Healthcare Safety Network-defined central line associated bloodstream infections, catheter associated urinary tract infections, and ventilator associated pneumonias, as well as MDRO acquisition and CDI cases, were evaluated during use and for 3 month control periods before, after, and one year prior. Results: One hundred and ten touch plates from 5 sites in ORs and inpatient rooms, and air samples via settle plates (33 pre-and 30 post-PPX-UVD) were obtained after standard cleaning, pre- and post-PPX-UVD. Post PPX-UVD, the percentage of samples with growth decreased (54% vs 35%, p=0.02), as did the mean colony count/sample (2.8 pre- vs 1.6 post-, p=0.03). Of the 379 colonies identified, all but 4 were common skin commensals; neither of 2 GNR were MDRO. HAI and MDRO (both overall and GNR) data revealed no significant trends during the PPX-UVD trial period compared to control periods. However, pre-PPX-UVD intervention in the BICU, the CDI rate was 6.5/10,000 occupied bed days (median time between cases of HAI CDI 40 days (range 2-148)). Since PPX-UVD use, no HAI CDI has occurred in the BICU from 5 days after onset of device initiation through the end of the 3 month washout period. This period represents the longest interval with no cases of HAI CDI in the BICU between 2013 and 2015. Conclusions: A significantly decreased environmental bioburden, attributable to reductions in skin commensals, was observed with PPX-UVD. No environmental MDRO or changes in the rate of HAI or MDRO GNR acquisition were observed. Applicability of Research to Practice: The apparent reduction in CDI suggests a role in the BICU for PPX-UVD and bears further investigation. 85. Randomized Comparison of Packed Red Blood Cell-To-Fresh Frozen Plasma Transfusion Ratio of 4:1 Versus 1:1 During Acute Massive Burn Excision L. Galganski, MD, S. Sen, MD, FACS, D. G. Greenhalgh, MD, FACS, T. L. Palmieri, MD, FACS, FCCM UC Davis Medical Center and Shriners Hospitals for Children, Sacramento, CA Introduction: Major burn excision is associated with a 2% blood volume loss per percent excised; hence, massive blood loss (>50% total blood volume) frequently occurs during major burn excisions. This prospective randomized controlled trial compared the impact of a 4:1 versus a 1:1 packed red blood cell-fresh frozen plasma (PRBC/FFP) transfusion strategy on outcomes in children with >20% total body surface area (TBSA) burns. Methods: Children with >20% TBSA burns were randomized to a 1:1 or 4:1 PRBC/FFP ratio during burn excision. Parameters measured on admission included demographics, burn size, and Pediatric Risk of Mortality (PRISM) scores. Laboratory values recorded preoperatively, 1 hour, 12 hours, 24 hours, and one week postoperatively included prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), fibrinogen, protein C, and antithrombin C (AIII). Total number of blood products transfused during operative interventions and during hospitalization were recorded. Results: A total of 45 children were enrolled, 22 in the 1:1 and 23 in the 4:1 group. The groups were similar in age, TBSA, and PRISM at admission. Preoperative fibrinogen, AIII, protein C, hemoglobin, PT/PTT, INR, and platelets were similar between groups. A total of 358 products were given in the 1:1 group compared to 401 in the 4:1 group. In the first two major excisions, the 1:1 group received significantly more FFP per patient (3.43 ± 0.55 U vs. 1.39 ± 0.33 p<0.001) and fewer PRBC (3.47 ± 0.53 U in 1:1 group vs. 4.13 ± 0.55 U in 4:1 group). The 1:1 group used 84 U FFP and 77 U PRBC compared to 34 U FFP and 90 U PRBC in the 4:1 group. At one hour postoperatively, PT and PTT were lower and Protein C and AIII were higher in the 1:1 group. Conclusions: A 1:1 PRBC/FFP transfusion strategy, compared to a 4:1 strategy decreased intraoperative PRBC use, likely due to higher AIII and protein C and lower PT and PTT from the increased FFP transfusion. Applicability of Research to Practice: Table. No title available. View Large Table. No title available. View Large 86. The Effects of Burn Size on Long-Term Community Reintegration Outcomes: A Life Impact Burn Recovery Evaluation (LIBRE) Study W. Hickerson, MD, G. D. Shapiro, PhD, J. Jeng, MD, FACS, V. Joe, MD, A. F. Lee, PhD, A. Acton, RN, BSN, M. E. Merino, MPH, J. C. Schneider, MD, L. E. Kazis, ScD, C. M. Ryan, MD, FACS Firefighters' Regional Burn Center, University of Tennessee Health Science Center, Memphis, TN; McGill University, Montreal, QC, Canada; Mount Sinai Health Care System, New York, NY; University California Irvine Medical Center, Irvine, CA; Bentley University Department of Mathematical Sciences, Waltham, MA; Phoenix Society for Burn Survivors, Grand Rapids, MI; Center for the Assessment of Pharmaceutical Practices (CAPP), Department of Health Policy and Management, Boston University School of Public Health, Boston, MA; Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA; Massachusetts General Hospital and Shriners Hospitals for Children, Boston, MA Introduction: Burn size is a profound determinant of mortality and early outcomes following injury. While all burn survivors are at risk for difficulties with community reintegration as an outcome, community reintegration as a function of burn size has not been previously reported. Methods: The LIBRE-192 was administered to 402 adult burn survivors with ≥5% BSA burned or critical area burns. Items were on a 5-point Likert scale; higher scores denoted better outcome. Factor analysis identified the key dimensions underlying 8 conceptual domains based on a well established WHO International Classification of Function: Recreation and Leisure, Work and Employment, Relating with Strangers, Sense of Purpose, Family Roles, Informal Relationships, Sexual Relationships, and Romantic Relationships. Demographic and clinical characteristics were summarized using descriptive statistics. Mean burn size (burned surface area, BSA) was compared among demographic characteristics using ANOVA. Correlations were computed between BSA and unweighted mean scores of all items in each domain as well as factor scores. Results: Self-reported burn size was available for 357/402 subjects. Mean BSA was 42%±23 (SD). Age at time of survey, race/ethnicity, education level, marital status, and current work status were not associated with BSA. Males had larger BSA than females (45%±23 vs. 40%±23BSA, p=0.02). Subjects with burns to critical areas had larger BSA than those without (45%±23 vs. 32%±22 BSA, p<0.01). Longer time from burn injury also was associated with larger BSA (p for trend <0.01). Larger BSA was associated with worse outcomes for Engagement in Physical Activities (r=-.24, p<0.01), and Performance at Work and Impact of Fatigue and Stress (r=-.19, p<0.01). Interestingly, larger BSA was associated with better outcomes for Enjoyment of Activities and Doing New Activities (r=.11, p=0.04), Comfort Talking with Strangers (r=.19, p<0.01), and Enjoyment of Sexual Relationships (r=.18, p<0.01). Conclusions: Results suggest that burn survivors experience difficulties with community reintegration. However, those difficulties are not always related to burn size. Unexpectedly, survivors with large burns had similar ability to reintegrate into the community compared to those with small burns, however they faced additional challenges related to fatigue and physical function. One hallmark of the human condition is profound resilience that is reflected by findings of improved outcomes in selected areas among those with larger burns. Applicability of Research to Practice: Subjects with large burns who experience fatigue or have decreased physical function might need additional long-term clinical support to foster community reintegration. External Funding: The contents of this abstract were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research, NIDILRR grant number 90DP0055..NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS)..The contents of this abstract do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. 87. The Perceptions of Pediatric Burn ICU Nurses Regarding Family Participation on Rounds Z. Panagakos, BSN,RN, K. Prelack, PhD, RD, H. Garrigan, BS, P Chang, MD, FACS, R. Sheridan, MD, FACS Shriners Hospitals for Children, Boston, MA Introduction: The American College of Critical Care Medicine suggests that family members of patients have the opportunity to be present on daily rounds. Few studies investigate the attitudes and perceptions of nurses regarding family participation on rounds (FPR). Pediatric burn intensive care units (ICU's), given social concerns or frank discussions of procedures, may be particularly challenging, causing nurses to be hesitant about FPR. We surveyed our nursing staff on various aspects of FPR before and after implementation of this practice. Methods: A brief survey (SI) was distributed to the 30 nurses of a 12-bed pediatric burn ICU before the floor adopted a policy of FPR. This survey consisted of 12 Likert scale questions (1-5 from strongly disagree [1] to strongly agree [5]) and 3 open ended questions designed to assess attitudes and expectations of this change. The primary focus clusters were impact of FPR on: 1) round procedures 2) family anxiety; and 3) communication and trust. After 10 months of FPR, the same survey (S2) was re-distributed to 30 nurses to evaluate whether their opinions had changed. Data is described using frequencies and weighted averages. Comparisons are made using Chi-square analysis. Results: Seventeen nurses completed both SI and S2 indicating a 57% response rate. Scores in weighted averages are listed in Table 1. Initial nursing attitudes with respect to impact on patient care were not positive. For SI, 58.9% were neutral or agreed that FPR would be disruptive; and 76.5% agreed that FPR would increase time spent on rounds. Following a trial of FPR, their perception improved, as indicated by a decline in weighted average scores. At the time of S2, 100% of nurses disagreed that FPR prolonged rounds; and 81.2% disagreed that FPR was disruptive. Nursing attitude regarding the impact of FPR on communication increased from 52.9 to 80%; and on trust from 52.9 to 80%. Perceptions of family anxiety before and after FPR did not significantly change. Conclusions: Nurses surveyed agreed that family presence on rounds can be readily implemented in pediatric burn ICU's with little disruption or prolongation to rounds. Perceived benefits are improved communication and increased trust among family members. Applicability of Research to Practice: This study can educate pediatric burn ICU nurses on misconceptions and benefits of FPR. Table. No title available. View Large Table. No title available. View Large 88. A New Predictive Risk Score for Acute Kidney Injury in Electric Burns N. Navarrete-Aldana, MD, N. Rodriguez, MPH Hospital Simon Bolivar, Bogota, Colombia; Pontificia Universidad Javeriana, Bogota, Colombia Introduction: Acute Kidney injury (AKI) in burn patients expressed by transient oliguria and/or minor acute creatinine elevations has been shown to be associated with increased mortality. In electrical injuries in addition to the superficial burns, destruction of deeper structures produce rhabdomyolysis syndrome, which is characterized by muscle necrosis and release of intracellular muscle constituents into the circulation. Acute kidney injury associated with myoglobinuria is the most serious complication of rhabdomyolysis, and it may be life-threatening. The main goal of this study was to establish the incidence to early AKI (eAKI) in the first week post electric trauma and to develop and validate a prediction risk score (PRS) specific to eAKI. Methods: A Retrospective derivation cohort study was conducted in a Burns reference hospital in a middle-income country. Data were obtained for adult patients admitted within the first 48 hours post electrical burns. AKI Network criteria were used as outcome variable definition. In the derivation phase, six a priori factors potentially related were evaluated. A multiple logistic regression model using a puposeful selection strategy was used. The performance of the model was assessed using calibration and discrimination measurements. We used resampling techniques in order to do the model internal validation. A new PRS for estimating eAKI was developed using regression shrunk coefficients. The scoring system was stratified into four risk categories Results: Of the 456 patients studied, 5.5% had eAKI. The mean age was 34.4 years. 57 patients had TBSA >20%. The gender was not associated to eAKI in the univariable analysis. The CPK (>15.000 U/L) is asociated in the univariable (OR:2.54), but not in the multivariable analysis. Four independent clinical predictors were found: age (OR 1.04); TBSA (1.04); presence of hypotension (3.84) and Compartimental syndrome (3.06). The model performed well (C statistic: 0.844). The overall rate of correct classification was 94.6%. The area under the ROC curve was 0.789. The internal validation was performed on 1000 samples (bootstrap method). There were no differences between the final multivariable model and bootstraping coeficients. The discriminatory powers were very similar (ROC area: 0.787). The risk factors for eAKI constituted the TBSA, Age, Compartimental syndrome, Hypotension: (TACHY) score, yielding a score of 0-103. The estimated probability compared with the observed eAKI was 2.0% and 1.4% for low risk, respectively, 4.6% and 5.3% for moderate, 8.8% and 10.3% for high, and 21.8 and 18.0% for very high risk Conclusions: The risk of eAKI in Electric burns can be rapidly and accurately predicted by the TACHY score Applicability of Research to Practice: Mitigate eAKI by initiating treatment or preventive strategies in high-risk patients. 89. Combining Store-and-Forward Pictures and Videoconferencing for Outpatient Burn Follow-up Care E. G. Brownson, MD, C. Cannon, RN, C. M. Thompson, MD, S. E Mandell, MD, MPH, G. Fudem, MD, N. S. Gibran, MD, FACS, M. Caceres, RN, BSN,T. N. Pham, MD, FACS University of Washington Regional Burn Center, Harborview Medical Center, Seattle, WA Introduction: Our regional burn center serves a wide catchment area, which creates major challenges in follow-up care. In 2006, we implemented a store—and—forward protocol ("BurnPics") for established patients to email photographs in order to verify healing and range of motion. Starting August 2014, we established an additional videoconferencing follow—up system for select patients. The purpose of this quality improvement project was to evaluate BurnPics and videoconferencing utilization over the past 12 months. Methods: We reviewed records of patients enrolled in the BurnPics program from August 2014 through July 2015, including patient and injury characteristics, state of residence, distance from a burn center, successful BurnPics use (defined by at least one photo received), and patient disposition after BurnPics. We also reviewed videoconference enrollment, utilization, provider time, and revenue generation. We analyzed all data using descriptive statistics. Results: There were 398 patients enrolled in BurnPics, with a median age of 29 (IQR 13-50) and median burn size of 2% (IQR 1—6) body surface area. Most patients resided instate (82%), followed by adjacent catchment states (7, 4, 3% respectively). Median distance from residence to burn center was 67 miles (IQR 29-228). Of 299 patients who sent at least one photo, 160 (54%) were subsequently followed on an as-needed basis, 52 (17%) also returned for in-person clinic visits, 49 (16%) also underwent videoconferencing visits, 21 (7%) were lost to follow—up, and 17 (6%) remain active in the program. In the past 12 months, 53 patients underwent 85 videoconferencing visits; 30 visits (35%) were billable and generated income, 27 visits (32%) were post-operative follow-ups, and 28 visits (33%) were not billable due to out-of-state residence. Median time spent per patient video-visit was 46 minutes (IQR 35-60), which includes set-up, nursing, provider and therapy time. Median time spent with burn care providers was 11 minutes (IQR 7-14). Conclusions: The BurnPics program mitigates the challenges of follow-up burn care in our region. This platform allows for patients to submit pictures, and selects individuals who require additional follow-up. Videoconferencing creates minimal additional time burden on providers, and allows timesavings for both patients and clinic workflow. Additional revenue from videoconferencing may justify providers pursuing interstate licensing in the future as the volume of tele—visits grows. Applicability of Research to Practice: Use of both store—and— forward picture programs and videoconferencing visits may be useful for other burn centers in outpatient follow-up care. 90. Burning Ambition: Blending Process Improvement and Design Thinking to Achieve the Quadruple Aim C. Bell, MS, RN, M. Holden, MSN, B. Gomez, BS, M. Rove, BS, R. Pierce, MD, A. J. Wiktor, MD University of Colorado Denver School of Medicine, Aurora, CO; University of Colorado Hospital, Aurora, CO Introduction: In June 2015, our burn center was tasked with opening a freestanding burn clinic on an accelerated timeline. Our aim was to establish a highly efficient, financially sound clinic that would increase access to care, reduce emergency department visits, and provide quality care while improving provider and staff satisfaction. We describe a method for expanding ambulatory burn clinic care access in 2 weeks while striving for the quadruple aim (quality, decreased cost, improved patient experience and staff joy). Methods: Blends of design for improvement and innovation methodologies including DMAIC (define, measure, analyze, improve, and control) were employed. A Kaizen event was conducted to scan our current state. Value stream mapping highlighted areas of opportunity to both improve the current system and create new systems. Rapid process improvement multidisciplinary meetings were utilized to create a future state, with eventual integration of both current and future states. Multidisciplinary meetings took into consideration both staff and patient needs to optimize quality care with workforce demands. Bimonthly PDSA (plan, do, study, act) cycles were conducted to identify areas of success and those needing ongoing improvement. Clinic demographic data such as patient visits, no-show visits, and emergency department visits were compared. Results: After clinic opening, patient visits increased from 41/week to 51/week (p = 0.003; 95% confidence interval [CI],49.02 to 52.31), growing clinic volume potential by 20% and improving access to care. Nurse triage access calls increased by 40% from previous. No-show visits decreased from 8/week to 6/week (p = 0.044; 95% confidence interval [CI], 3.93 to 7.73). Emergency department visits decreased from 5/week to 4/week (p= 0.17; 95% [CI], 2.72 to 4.97). Net promoter score surveys reflect a positive and engaged clinic staff. Conclusions: Multidisciplinary team based process improvement processes made meaningful improvements in our clinic on a rapid timeline. These concepts can be applied in various situations to achieve change in the status quo. This process impacted not only efficiency, but the culture of the clinic. We were able to move from a reactive mindset of putting out day to day fires to proactive mindset that focused on creating systems that keep our clinic in a state of flow. Applicability of Research to Practice: Pursuit of quadruple aim (Quality, Decreased Cost, Patient Experience, and Staff Joy) is possible with focused use of process improvement and design methods. 91. Anesthetic Practices for Laser Rehabilitation of Pediatric Hypertrophic Burn Scars B. M. Wong, BHSc, J. Keilman, MD, FRCPC, J. Zuccaro, MSc, C. Kelly, RN (EC), MN, NP, J. Fish, MD, FRCSC The Hospital for Sick Children, Toronto, ON, Canada Introduction: Ablative carbon dioxide laser therapy and pulsed dye laser therapy has led to significant clinical improvements in the rehabilitation of hypertrophic burn scars. However, laser therapy is associated with appreciable pain, particularly among pediatric patients. Although clinical consensus suggests using general anesthesia for pediatric laser procedures, guidelines that denote the specifics of perioperative care are lacking. The WHO recommends using a three-step analgesia approach: opioid-sparing regimens ± adjuvants, less potent opioid regimens ± non-opioids and/or adjuvants, and finally potent opioid regimens ± non-opioids and/or adjuvants. The aim of this study is to determine whether a difference exists in postoperative pain outcomes in pediatric patients who receive intra-operative opioid regimens compared to patients who receive opioid-sparing regimens for laser therapy of hypertrophic burn scars. Methods: We reviewed 94 pediatric laser procedures, of which 54 met inclusion and exclusion criteria. We included patients <18 years of age who had an ASA score of 1 or 2, and excluded procedures for which post-operative pain was unknown (n=39) or general anesthesia was not elected (n=l). After controlling for analgesic adjuvant confounders, 36 cases remained. We compared opioid regimens to opioid-sparing regimens. The primary outcome was the presence or absence of post-operative pain. We performed a chi-square analysis on dichotomous variables. Additionally, we described our general anesthesia induction regimens for 92 cases. Results: There was no difference between the likelihood of post-operative pain when intra-operative opioid regimens (n=28) were given compared to opioid-sparing regimens (n=8). X2 (1, n=36) = 0.0396, p=0.8423. Further, there was no difference between short-acting (n=16), long-acting (n=7), or combination (n=5) intra-operative opioids compared to opioid-sparing regimens (n=8) in the likelihood of post-operative pain. 82% (n=72) of laser procedures had anesthetic induction via an inhalational agent. 51% (n=47) had an inhalational agent followed by IV induction. Conclusions: Despite the small sample size, the low number of post-operative pain cases is encouraging. Ultimately, the preliminary data presented in this study provides a foundation for establishing anesthetic guidelines for laser procedures in pediatric patients with symptomatic burn scars. Specifically, the potential to deliver adequate perioperative care via an opioid-sparing regimen ± adjuvant should be considered. Applicability of Research to Practice: With the growing practice of laser therapy for symptomatic scar rehabilitation, this quality improvement project enables the clinical team to optimize patient safety, healthcare efficiency, and patient care. 92. Assessing Primary Care Trainee Comfort in the Diagnosis and Management of a Thermally Injured Patient S. Q. Vrouwe, MD, S. Shahrokhi, MD, FRCSC University of Toronto, Toronto, ON, Canada Introduction: Thermal injuries are common and the majority of patients initially present to primary care physicians. Despite being a part of the objectives of training in Emergency Medicine (EM) and Family Medicine (FM), previous work has shown that gaps exist in the delivery of care to the thermally injured. This has the potential to lead to poorer patient outcomes and unnecessary healthcare costs. It follows that quality improvement measures are best directed at current trainees who have yet to begin independent practice. In this setting, specialists in Burn Care can maximize the potential benefit of an educational intervention. Methods: An electronic survey was sent to all trainees in EM and FM at our institution at the end of the 2014-15 academic year. Plastic Surgery trainees were included as a control group. Demographics and educational/clinical experience were assessed. Trainee comfort level with the care of a thermally injured patient was measured on a five-point Likert scale across 15 domains. Preferences for possible educational interventions were also ranked. Descriptive statistics and the Kruskal-Wallis Test were used, where p < 0.05 was considered statistically significant. Results: The overall survey response rate was 27.4% (117/427). EM and FM trainees estimated a median 2.0 and 0.0 hours of total didactic instruction, respectively. During that academic year, EM and FM trainees cared for a median 5.0 and 1.0 patients, respectively. In terms of comfort levels, significant differences were noted across all 15 domains when compared to Plastic Surgery trainees, with the ABA referral criteria, indications for fluid resuscitation, initial dressing care, indications for antibiotics, frostbite, chemical burns and electrical burns scoring the lowest. Preferences for educational interventions were ranked and found to be significantly different, with clinical rotations and traditional lecture scoring the highest with EM and FM trainees, and podcasts, online modules, and smartphone apps scoring the lowest. Conclusions: Emergency Medicine and Family Medicine trainees are on average not comfortable in the diagnosis and treatment of a thermally injured patient. This may be attributed to limited clinical exposure and didactic teaching during their postgraduate training. Relevant clinical rotations were the preferred teaching modality, followed by traditional lecture, with less interest in newer forms of medical education. Applicability of Research to Practice: This is the first study to explore the state of medical education on thermal injuries in Emergency Medicine and Family Medicine postgraduate trainees. There exists an opportunity for specialists in Burn Care to offer rotations to primary care trainees and provide high quality and clinically relevant teaching. 93. Process Improvement to Reduce Burn Patient Emergency Department Length of Stay H. M. Schaewe, MSN, RN, C. Shanti, MD, J. D. Klein, MD Children's Hospital of Michigan, Detroit, MI Introduction: Burn patients at our institution receive their initial burn care on the burn unit regardless of the size of the burn and whether they are admitted or being treated as outpatients. Patients presenting to our emergency department (ED), particularly those with burns less than 10% TBSA, spent excessive time in the ED before being transfered to the burn unit to receive definitive burn care. The average ED length of stay (LOS) was 206 minutes. In order to provide more prompt care for our burn patients, we needed to create a new process. Methods: The burn program director met with the ED division chief to create an algorithm to get the patients registered, processed through the ED, and transferred to the burn unit within 60 minutes. Each burn patient is registered and has a basic assessment, IV started, and a dose of pain medication. The burn unit charge nurse is notified and the patient is transported to the treatment room on the burn unit. Education of the ED and burn unit staff of the new process was undertaken including proper timely documentation to ensure accuracy of the data we planned to collect. We used the documented time of patient registration in the ED as the start time and the first timed documentation on the burn unit as the stop time. Results: During the education period, the average ED LOS was 142, 116, 180, 117, and 144 minutes for the five months prior to implementation. After implementation, the ED LOS was 87, 76, 80, and 64 minutes for the first four months. We implemented this process in 2007. To prove success and consistency, we looked at the average ED LOS for our burn patients for the month of July for the last 12 years. We chose July because it is a busy month and the beginning of the year for many trainees. This represents a challenging time to maintain consistent workflow. Starting in 2004 and ending in 2015, the average ED LOS were 204, 159, 255, 80, 82, 60, 71, 80, 72, 74, 81, and 60 minutes. A significant change was noted in 2007, the year of implementation, which we have been able to sustain for the last 9 years. Conclusions: This process improvement project allowed us to provide timely and consistent care to all our burn patients presenting to our ED. This has translated to better patient care and family satisfaction. Clear definition of objectives, comprehensive education, and consistent follow-up are essential to implement any new process and have sustainable success. Applicability of Research to Practice: Improving time of delivery of care to burn patients presenting to the emergency department. 94. Teamwork System Based Nurse-Driven Rounds Improve Patient Safety Culture and Nursing Assessment of Patient Status A. Khandelwal, MD, L. Inman, RN, T. Coffee, ACNP-C MetroHealth Medical Center, Cleveland, OH Introduction: Ineffective communication accounts for over 50% of the adverse events in hospitals throughout the United States. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence based teamwork system designed to improve quality of care, patient safety and increased the efficiency of healthcare services - the key strategy being communication development. In addition, nurse-driven rounds have been shown to foster clear patient care plans, improved staff satisfaction and improved patient safety. We sought to evaluate the impact of a TeamSTEPPS driven rounding process. Methods: After all staff members were trained in TeamSTEPPS, the burn center created a nurse-driven rounding system. Pre-implementation and post-implementation 5-point Likert Surveys based on the Agency for Healthcare Research and Quality (AHRQ) Survey on Patient Safety Culture were administered focusing on the impact that nurse-driven rounds would have. Patient safety and communication were evaluated. In addition day-shift nurses were queried over a four-week period pre-implementation and post-implementation regarding their patient-specific assessment on several burn-focused areas. Results: Pre-implementation response rate was 43% of nursing staff. Post-implementation response rate was 94%. Responses used to assess patient safety demonstrated an improvement in each question and an overall 33% improvement from an average of 3.03 to 4.03 out of five. Questions used to assess communication likewise demonstrated an improvement in each individual question and an overall 57% improvement, from 2.8 to 4.4 out of five. The greatest positive difference was noted whether "patient safety problems existed in the unit" and if "staff members were afraid to ask questions when something is not right." The least positive difference was in whether "procedures and systems are good in preventing errors from happening" and if "staff speaks up if they see something negative affecting patient care." Pre-TeamSTEPPS, 37% of nurses were unsure if their patient was on antibiotics or what specifically was being treated, which improved to only 5% post-TeamSTEPPS. Post-TeamSTEPPS, there were no nurses who were unsure of the therapy plan/splint schedule, wound care plan or overall plan for the patient. Conclusions: Teamwork based systems combined with nurse-driven rounds can greatly impact patient safety culture in burn units and virtually eliminate uncertainties nurses may have about patient assessment. Applicability of Research to Practice: Teamwork driven system will benefit patient care through safety and communication. 95. Geographic Modeling for Children at Risk for Home Fires and Burns C. Lehna, PhD, S. Furmanek, MPH, C. Hanchette, PhD University of Louisville, Louisville, KY Introduction: Burn injuries pose preventable mortality and morbidity to children aged five years and younger. More effective prevention education strategies could be targeted to this age group based on a geographic model that predicts areas of high risk. The purpose of this study was to develop and validate a risk model for fires and burns among parents and their children under five years of age in one north central Kentucky County, using cartographic modeling and geographic information systems. Methods: A literature search identified eight risk factors for pediatric burns: gender (male), age, parental age, race (black), education, socioeconomic status, home value, and year home built. These risk factors are available from the U.S. Census at the census tract level. Using cartographic modeling, a model was developed using the 2008-2012 American Community Survey data. Modeled risk was categorized as low, medium, high and severe. Statistical validation was performed with fire dispatch data. Results: Geographic areas with high and severe risk were located in the western half of the county, with severe risk concentrated in the northwest (See figure). Fire rate showed significant spatial autocorrelation validating the cluster of increased risk in our model. The summed risk model was strongly correlated with the fire incidence rates (r = 0.714, p < 0.001). One-way analysis of variance (ANOVA) testing revealed significant differences between each risk category except low and medium risk. Sixty percent of the variance in fire rate was accounted for by our risk factors; the most significant predictors were race (β = 0.54, p < 0.001), education (β = 0.38, p < 0.001), and year home built (β = -0.17, p = 0.005). Conclusions: Potential risk for home fires and pediatric burns in the county show spatial relationships. This model can be used as a strong predictor of fire risk. The literature search had strong support of gender (male), and age risk factors; the model found socioeconomic (year home built, education) and racial factors to be the strongest predictors. This may be due to the differences between ecological-level versus individual-level studies. Applicability of Research to Practice: Using validated models, areas can be identified to focus resources and effort in home fire safety prevention education. Validated models are a great tool to evaluate and maximize the effectiveness of promotion activities, ensuring that people in areas at risk are receiving services and programs. External Funding: This study was funded by the Federal Emergency Management Agency Fire Prevention and Safety Grant #EMW-2012-FP-01181. Figure. View largeDownload slide Figure. View largeDownload slide 96. Pediatric Cooking-Related Burn Injuries K. Viega, BS, D. Greenhalgh, MD, FACS, T. Palmieri, MD, FACS, FCCM, S. Sen, MD, FACS UC Davis Medical Center and Shriners Hospitals for Children, Sacramento, CA; UC Davis Medical Center and Shriners Hospitals for Children, Sacramento, CA Introduction: The kitchen is the most common location for pediatric burn injuries in the house and cooking related activities are the most common mechanisms for injury. Our aim was to analyze the severity of burn injuries during cooking related activities. We hypothesized that stovetop and oven burn injuries would be most severe and have higher need for skin grafting. Methods: We performed a 10-year retrospective review of all cooking related pediatric (≤18 years) burn injuries that required admission to our burn unit. We collected data on patient demographic, mechanism of injury, extent of injury, hospital course, and need for surgery. We divided cooking burn mechanisms as the following: scald from hot beverages (HB), cooking hot liquid (i.e. soup, pasta) (COOK), and contact with a stove or oven (STOVE). Results: A total of 778 patients were included in the study. Median age 1.9(1.3-4) years and median TBSA was 7(4-11)%. COOK was the most frequent mechanism (73%) followed by HB (20%) and STOVE (7%). Patients injured in HB (1.4(1.2-1.9) years) activities were significantly younger than COOK (2.2(1.4-4.3) years) and STOVE (2.4(1.2-8.6) years). STOVE patients suffered worse burn injuries with a median 3rd degree TBSA of 5(2-23.5)% compared to COOK (2(2-7)%) and HB (2(2-2)%. A significantly higher proportion of STOVE patients required skin grafting (67%) than COOK (28%) or HB (9%). Using multivariate logistic regression to adjust for age and TBSA, both COOK (OR 2.8 (CI 1.5-5)) and STOVE (OR 24.5 (CI10.7-56)) mechanisms were associated with an increased need for skin grafting. Conclusions: Contact burn injuries with a stove or oven and cooking hot liquids such as soup are often severe injuries in children and frequently require skin grafting. Prevention efforts should be directed toward improved safety policy and education to reduced the incidence and severity of theses injuries. Applicability of Research to Practice: Risks of cooking related burn injuries. 97. The Effect of Illicit Drug Use on Outcomes Following Burn Injury E. I. Hodgman, MD, S. E. Wolf, MD, FACS, B. D. Arnoldo, MD, FACS, H. A. Phelan, MD, FACS, M. W. Cripps, MD, K. R. Abdel-Fattah, MD University of Texas Southwestern Medical Center, Dallas, TX Introduction: Illicit drug use is common among patients admitted following burn injury. We sought to evaluate whether drug abuse detected at the time of admission resulted in worse outcomes, including mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, and duration of ventilator support. Methods: The National Burn Repository (NBR) version 8.0 main and drug screen databases were queried for data on all patients with drug testing results available (including negative results). Patients admitted for non-burn injuries or with elective readmissions were excluded from analysis. Demographics and clinical characteristics were compared between those who used illicit drugs and those who did not. Propensity scoring was performed to control for age, alcohol use, burn size, gender, and etiology of burn. Results: A total of 20,989 patients had drug screen result data available, of which 11,642 (55.5%) tested positive for at least one drug of abuse. The most commonly used substances include opiates (n=7050, 33.6%), stimulants including cocaine and/ or amphetamines (n=3430, 16.3%), and marijuana (n=3222, 15.4%). Patients with a positive drug screen were more likely to have sustained a flame burn (53.2 vs 48.4%) and less likely to have been scalded and 10.7 vs 21.0%, p<0.001). Average burn sizes tended to be larger in patients who have used drugs (11.2 vs 9.5 % TBSA, p<0.001). Injuries were more likely to be self-inflicted or a suicide attempt if the patient had used drugs (2.8 vs 1.7%, p<0.001). Univariate analysis demonstrated that drug use resulted in significantly longer hospital and ICU LOS (14.2 vs 11.4 and 8.5 vs 5.6 days, respectively, p<0.001), but did not increase the risk of mortality (5.7 vs 5.2, p=0.08). In contrast, the mortality rate among patients positive for EtOH alone as nearly double (10.5%) that of patients who had taken both drugs and alcohol (5.4%), illicit drugs alone (5.8%), or neither drugs nor alcohol (5.0%, p=0.001). After propensity score adjustment, drug use did not significantly impact mortality, hospital LOS, or duration of ventilator support, but did increase the average ICU LOS by 1.2 days (p=0.001). Conclusions: Drug use does not affect mortality, hospital LOS, or duration of ventilator support among burned patients. After controlling for burn size, age, mechanism of injury, and gender, patients with a positive drug screen had an average increase in ICU LOS by one day. Applicability of Research to Practice: This is a description of the impact of illicit drug abuse on the general burns population. External Funding: This project is funded through DOD grant #W81XWH122074 and the generous support of Sons of the Flag and the Pettis family. 98. Effect of Fireworks Laws on Pediatric Fireworks Related Burn Injuries J. Myers, PhD, C. Woods, MD, C. Lehna, PhD University of Louisville, Louisville, KY Introduction: Changes in US fireworks laws have allowed younger children to purchase fireworks; and allowed individuals to purchase more powerful ones. The purpose of this study is to examine the epidemiology of pediatric fireworks-related burn injuries among a nationally representative sample of the US for the years 2006-2012. Methods: We examined inpatient admissions for pediatric (<20 years of age) firework-related burn patients from 2006-2012 using the Nationwide Inpatient Sample; and examined ED admissions using the Nationwide Emergency Department Sample. Both data sources are part of the Healthcare Cost and Utilization Project (HCUP). Trajectories over time were evaluated. Results: A total of 3193 injuries represented an estimated 90,257 firework-related burn injuries treated in the US from 2006 to 2012. A majority of injuries were managed in the ED (n=2008, 62.9%). The incidence modestly increased over time; increasing from 4.28 per 100,000 population in 2006 to 5.12 per 100,000 population in 2012, p=0.019. However, definitively, the proportion of injuries requiring inpatient admission (28.9% in 2006 to 50.0% in 2012, p<0.001) and mean length of stay (LOS) in the hospital (3.12 days in 2006 to 7.35 days in 2012, p<0.001) significantly increased over time, while the mean age decreased over time (12.1 years old in 2006 to 11.4 years old in 2012, p=0.006). Conclusions: Pediatric fireworks-related burn injuries have increased in incidence, apparent severity of injury, the proportion requiring hospitalization and LOS (in the hospital) in a time period of relaxed fireworks laws in the US. Fireworks laws may need to be revisited by policy-makers. Applicability of Research to Practice: The results from the current study may suggest fireworks laws may need to be revisited by policy-makers. 99. A Five Year Retrospective Comparison of the Presentation and Clinical Sequelae for Non-Inflicted, Negligent, and Inflicted Pediatric Burns Z. J. Collier, BA, J. C. Glick, MD, L. J. Gottlieb, MD, FACS University of Chicago, Chicago, IL Introduction: Inflicted burns are one of the leading causes of abuse-related fatalities in children with up to 50% of children mistakenly returned to abusive homes suffering re-abuse. Because of the mortality risk and high chance for abuse recurrence, it is critical that inflicted burns are identified early on in order to guide appropriate medical and child welfare management. Previous studies proposed historical and mechanistic features that correlated with non-accidental etiologies, but most of these studies used non-comparative and/or poorly-powered data. Additionally, none of those studies rigorously examined differences in burn severity as well as hospital course or follow-up issues. As a result, this study utilized comparative data from a five-year period at the burn center along with expert analysis from Child Protective Services (CPS) to provide higher level evidence supporting classical findings and elucidating new features with respect to burn severity and required interventions. Methods: A five year (2009-2014) retrospective chart review of pediatric burns treated by the verified burn center was cross-referenced with the respective CPS evaluations to construct a multi-disciplinary de-identified database. Results: There were 408 pediatric burns. The average age was 2.9 years ranging from 0.04 to 17 years old. Overall, 232 (57%) were male and 330 (81%) were African American. CPS review determined that 345 burns were non-inflicted (NIF), 30 were from negligence (NEG), and 33 were inflicted (IF). In comparing NIF to NEG and/or IF burns, statistical significance was present in regards to variables including historical inconsistency, burn age, family structure, appropriate first aid, prior DCFS history, burn size and depth, burn location, concomitant injury, surgical interventions, complications, length of stay, missed follow-up, and subsequent ED visits. In the tables, superscript 1 or 2 implies significance between NIF and NEG or IF, respectively. Superscript 3 implies significance between NEG and IF. Conclusions: In addition to re-affirming classical features of abusive burns, this study confirms appreciable differences in burn severity, interventional sequelae, and short/long-term outcomes. Applicability of Research to Practice: Utilization of the differentiating historical and clinical features between non-inflicted and negligent or inflicted burns is crucial for appropriating etiology-specific social and medical services. 100. Poverty Is Associated with an Increased Risk for Burn Injuries in Women but Not Men in the United States D. J. Ha, MS, E. Larumbe-Zabala, PhD, S. Dissanaike, MD, FACS Texas Tech University Health Sciences Center, Lubbock, TX Introduction: Poverty, with its associated lack of education & employment, infrastructure deficits and overcrowding, is known to increase the risk for burn injury worldwide. Poverty and socioeconomic status also appear to impact the gender distribution of burn injury globally, with women forming the majority of the patients in developing countries, while men are predominant in technologically advanced regions. However, the impact of poverty on gender distribution within regions of a developed country such as the United States has not been evaluated. It is also commonly assumed that burn injury is increased among lower socio-economic status (SES) groups; we attempted to evaluate the actual incidence of burns among socioeconomic groups and with regards to gender distribution in a heterogeneous population in the US. Methods: A retrospective review of patients with TBSA >15% admitted to a regional burn center 2005-2012. Socioeconomic status (SES) was assessed using a previously validated method of calculating the percent below poverty level at each zip code, based on census data from the 2013 US Census Bureau. The percentages were categorized into three groups: Upper SES (27.7%). Percentage of women affected in each group was compared. Chi-squared (χ2) tests and Analysis of variance (ANOVA) were performed using Stata 13.1. Results: There were 256 (75.3%) men and 84 (24.7%) women in this cohort. Average TBSA and age were similar between groups (Table 1). Burns occurred equally frequently within each SES category, with 33% in upper (106), 34% middle (111), and 33% in lower SES (105) patients; this correlates with the demographics of the general population in this region. The proportion of women injured was significantly affected by SES. Women formed 15% of patients from the highest SES, 21% from middle SES and 36% from the lowest SES - a significant and linear increase (χ2 = 13.8513, p=0.001) with increasing poverty. Conclusions: While poverty did not appear to increase the risk of burn injury overall in a mixed population in the US, it was associated with a significant increase in the risk of burn injury in women. Applicability of Research to Practice: Poverty influences the gender distribution of burns in regions of the US; this has implications for burn prevention efforts and requires further exploration as to etiology. Table. No title available. View Large Table. No title available. View Large 101. Disparities in Self-Reported Outcomes Among Racial and Ethnic Minority Groups Following a Major Burn Injury R. K. Holavanahalli, PhD, A. Sanchez, BS, K. J. Kowalske, MD University of Texas Southwestern Medical Center, Dallas, TX Introduction: The objective of this study was to examine if disparities exist in injury demographics and self-reported functional outcomes among racial and ethnic minority groups following a major burn injury. Methods: Data for this study is part of an ongoing prospective longitudinal study of burn survivors (n=1311) who were ≥ 15 years of age and consented to participate at time of discharge from hospital, 6, 12, and 24 months post injury. In addition to subject and injury demographics, data included standardized self-report functional assessment tools such as the SF-12 (a generic measure of health status) Physical (PCS) and Mental (MCS) Component summary scales, Community Integration Questionnaire (CIQ), Satisfaction with Life (SWL). The sample included White, Non-Hispanic (n=771), Black, Non-Hispanic (n=245), and Hispanic (n=295). Chi-Square analysis for all nominal level variables and one-way analysis of variance (ANOVA) for all interval level variables was used to evaluate the relationship between the 3 ethnic groups, injury demographics and self-reported functional outcomes. Bonferroni Post Hoc Comparisons were used to evaluate pair-wise differences among the means. Results: The results of chi-square analyses revealed statistically significant associations between ethnicity and the following variables - gender, burn etiology, residence and living situation at time of burn injury, employment status, concomitant medical problems, history of drug and alcohol abuse, circumstances of injury, location of injury, sponsor of care, and employment status at 6,12, and 24 months post injury. The results of the oneway ANOVA showed poorer functional outcome among Blacks when compared to White, non-Hispanics and Hispanics. The SF-12 scores for all 3 groups remained below the population norm score of 50 at all assessment time points. Conclusions: Disparities exist in burn injury demographics and self-reported outcomes among racial and ethnic minority groups. Applicability of Research to Practice: The findings identifying disparities in burn injury demographics and outcomes can be useful for prevention efforts and treatment interventions. External Funding: The contents of this abstract were developed under a grant from the Department of Health and Human Services, NIDILLR grant # 90DP0042. 102. Psychosocial Outcomes 10 Years Post-Burn: A Life Impact Burn Recovery Evaluation (LIBRE) Study J. Goverman, MD, FACS, A. Lee, PhD, G. D. Shapiro, PhD (c), MPH, A. P. Houng, MD, FACS, M. Marino, MPH, A. Acton, RN, BSN, A. Jette, PhD, J. C. Schneider, MD, L. E. Kazis, ScD, C. M. Ryan, MD, FACS Massachusetts General Hospital and Shriners Hospitals for Children, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA; Bentley University, Waltham, MA; McGill University, Montreal, QC, Canada; New York Presbyterian Weill Cornell Medical Center, New York, NY; Boston University School of Public Health, Boston, MA; Phoenix Society of Burn Survivors, Michigan, MI; Department of Health Policy and Management, Boston University School of Public Health, Boston, MA Introduction: Few studies have examined the time to community reintegration following burn injuries. Using long term psychosocial outcomes, we describe and compare survivors > 10 years post burn to those ≤ 10 years and changes after 10 years. Methods: The LIBRE-192 was administered to 402 adult burn survivors with ≥5% TBSA burned or burns to critical areas. Higher scores denoted better outcomes. Exploratory factor analysis identified the dimensions underlying 8 domains (Figure) and separate models were constructed for each. The study population was divided into those >10 vs. those ≤10 years since burn. Demographic and clinical characteristics were compared using Pearson chi-square tests. Unweighted mean scores of all items in each domain, as well as factor scores, were compared for those ≤10 years and >10 years post-burn using ANOVA. For domain means and factor scores that differed significantly in bivariate relationships, linear regression models were constructed with adjustment for age, gender, race/ ethnicity, education, marital status, work status and burn size. Separate multivariable regression models were constructed to evaluate changes in the time since burn for those with burns after 10 years. Results: Of the respondents, 50.4% (198) were ≤10 years post-burn (4.1 ± 2.8 years) and 49.6% (195) were >10 years post-burn (29.9 ± 15.6 years, range 10-75 years). Populations did not differ with respect to gender or burns to critical areas; however the >10 year group was significantly older, more educated, more often married, working, and had slightly larger size burns. Mean scores in each of the domains except Sense of Purpose were significantly higher in the >10 year group. Within the >10 years age group, no additional significant changes were noted in the longer term survivors after adjustment for age, gender, race/ ethnicity, education, marital status, work status and burn size. Conclusions: While community reintegration post burn is highly specific to the individual, the LIBRE-192 provides a vehicle for measuring this outcome. Based on this work, measures of community reintegration are better for survivors >10 years post burn than those ≤10 years. Beyond 10 years of injury, these measures appear not to change. Applicability of Research to Practice: This data provides evidence that, over the first 10 years of their long-term recovery, burn survivors can expect significant psychosocial improvements that impact community reintegration. External Funding: National Institute on Disability, Independent Living, and Rehabilitation Research, NIDILRR grant number 90DP0055. 103. Burn Therapy Department Structure: Potential Implications for Supporting the Burn Rehabilitation Mission D. O. Murray, MPT, D. J. Lorello, DPT, K. J. Richey, RN, BSN, K. N. Foster, MD, MBA, FACS Arizona Burn Center, Phoenix, AZ Introduction: The American Burn Association (ABA) utilizes the American College of Surgeons publication "Resources for the Optimal Care of the Injured Patient", as well as the ABA's own revised criterion deficiencies to guide verification of burn centers. Language in each document addresses allocation of therapy resources and structure of therapy departments. After years of operating with burn therapists in general physical and occupational therapy departments, administration at our health system agreed to separate the burn therapists from the general therapy department in the form of a burn therapy cost center. Methods: Metrics for burn therapy as a stand-alone cost center were tracked for 14 months and compared to 14 months of metrics tracked for therapy as part of the general therapy department. Comparisons were done using the two-tail t-test, with unequal variances for general therapy and burn therapy cost center data. Results: There was a significant reduction in the percentage of missed patients achieved after reorganizing burn therapy, from 9.75% to 4.51%, p=.029. Considering the ABAs concern that therapy resources identified for the burn center are actually serving in that capacity, we found a significant decrease in the non-burn caseload assigned to burn therapists after they were restructured into a burn therapy cost center, with the percentage of caseload dropping from 3.18% to 0.80%, p=.0009. Conclusions: Reorganizing burn therapists into a distinct cost center may promote their utilization to support the burn patient care commitment, as is encouraged by the ABA. Specifically, therapists in a department organized in such a fashion missed fewer burn therapy treatments, and treated a lower percentage of non-burn center patients versus when part of the general therapy department. Applicability of Research to Practice: Burn centers should consider the impact therapy department structure upon the burn rehabilitation mission. The burn center verification process could encourage distinctly separate therapy cost centers in support of burn care. Table. No title available. View Large Table. No title available. View Large 104. Exercise in Warm Environmental Conditions Increases Cardiovascular Demand in Burn Survivors C. G. Crandall, PhD, S. A. Romero, PhD, D. Gagnon, PhD, P. Y. Poh, PhD, A. N. Adams, MS, N. L. Kennedy, RN, BSN, H. Ngo, BS, K. J. Kowalske, MD University of Texas Southwestern Medical Center, Dallas, TX Introduction: Greater increases in heart rate and cardiac output are essential cardiovascular adjustments during exercise in warm environments in healthy non-burned individuals. It is unknown if the cardiovascular system of burn survivors can respond adequately to the cardiovascular demands of exercise in warm environments. This project tested the hypothesis that in burn survivors cardiovascular responses during submaximal exercise will be enhanced when that exercise is performed in a warm environment, relative to a thermoneutral environment. Methods: Ten well healed burn survivors (6 females, mean±SD; age: 35 ± 12 years; weight 80 ± 24kg), with an average of 51 ± 21% of their body surface area burned (range: 22-85%) participated in this study. On separate days, subjects performed steady state exercise at a fixed workload (50 watts) in thermoneutral (24°C, 30% humidity) and warm (40°C, 30% humidity) environmental conditions. Oxygen uptake, heart rate, cardiac output, and blood pressure were obtained after a minimum of 30 min rest within each environment, as well as at steady state during exercise. Results: Prior to exercise, blood pressure, heart rate, and cardiac output were similar between thermal conditions (data not shown). Despite exercise being performed at the exact same oxygen uptake and for the same duration between thermal conditions, heart rate and cardiac output were significantly greater during exercise in warm environmental conditions, while mean arterial pressure was not different (see Table 1). Conclusions: Even at relatively low workloads, exercise in warm environmental conditions resulted in greater cardiovascular demand, as evidenced by greater increases in heart rate and cardiac output, relative to when it was performed in thermoneutral environmental conditions. Applicability of Research to Practice: Exercise is beneficial in the rehabilitation of burn survivors. The current data clearly show that the cardiovascular system of burn survivors responds adequately to submaximal exercise in warm environments. These findings suggest that burn survivors can safely meet the cardiovascular demands of submaximal exercise, even when it is performed in warm environments. External Funding: NIH - R01GM068865 Table. No title available. View Large Table. No title available. View Large 105. Post-Operative Early Range of Motion of Hand Grafts S. K. Shingleton, MS, RN, I. R. Driscoll, MD, W. S. Dewey, PT, B. T. King, MD, J. L. McCorcle, PA-C, J. C. Graybill, MD, J. C. Pamplin, MD, R. Richard, PT, MS U.S. Army Institute of Surgical Research, Fort Sam Houston, TX; Brooke Army Medical Center, Fort Sam Houston, TX Introduction: Range of motion (ROM) outcomes following burn injury and skin grafting (SG) positively correlate to total rehabilitation time. Hand burns requiring split thickness skin grafts (STSG) are often immobilized for at least 3 days after SG in our burn center to prevent graft loss. Post-operative (Post-op) lengths of stay (LOS) are often ≥5 days. We evaluated the safety of early hand ROM on post-op day (POD) 1 after STSG. Methods: This process improvement project was guided by the FOCUS-PDCA model. An opportunity to increase therapy time to new hand STSG was identified after reviewing evidence of skin recruitment. A team of therapists, wound nurses and physicians was assembled, a clinical practice guideline and order-set were developed, and staff education was provided. Patients with hand SG who were able to actively participate in therapy were identified. The therapist and nurse observed STSG placement and dressing application intra-operatively. All hand STSG were dressed in a silver nylon glove, an outer absorbent layer and resting hand splint. Starting on POD1, dressings were removed and hand ROM was performed with direct SG visualization. Photos were taken, dressings and splints were reapplied. Descriptive statistics were used to examine outcomes. Results: 17 patients from OCT 2014 to JUN 2015 for a total of 34 patient visits were reviewed. One patient had a small area of SG movement noted POD1 without SG loss. No SG disruption occurred during ROM or dressing changes. The order set was utilized 76% of the time. Post-op LOS decreased from 5 days in the 1st quarter to 4 in the 3rd quarter (Graph). Conclusions: Early ROM of hand STSG starting on POD1 is safe for experienced burn team members to perform. The multidisciplinary approach was key to this program's success. Additional findings included a perceived reduction in edema and earlier return of full hand ROM (Figure). Applicability of Research to Practice: ROM outcome has been correlated with the amount of therapy patients receive. Early post-op hand ROM after STSG is safe and feasible and adds crucial therapy minutes to a patient's treatment program. Prospective research is needed to evaluate if early post-op ROM reduces risk of contracture, lowers cost, and improves long-term outcomes. Figure. View largeDownload slide Figure. View largeDownload slide 106. A 12-Week Exercise Program After Acute Hospitalization Is Beneficial, but Are Benefits Present 2 Years Post Burn? P. Wurzer, MD, C. D. Voigt, MD, C. R. Andersen, MS, R. P. Mlcak, PhD, L. P. Kamolz, MD, PhD, D. N. Herndon, MD, FACS, O. E. Suman, PhD Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX; Respiratory Care, Shriners Hospitals for Children, Galveston, TX; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria Introduction: Severe burns, of more than 30 % of the total body surface area (TBSA), are associated with loss of lean body mass, muscle strength (MSTR) and reduced cardiopulmonary fitness (CPF). These decreases are caused by an increased muscle catabolism and prolonged inactivity. Our group has published that a 12-week exercise program performed subsequently after acute hospitalization was beneficial for muscle rehabilitation. However, it is not known if these beneficial effects of an exercise program for severely burned children remain at two years post-burn. Methods: Children with burns covering more than 30 % TBSA, with ages between seven and 18 years who received standard of care in the ICU (intensive care unit) were consented to this IRB approved study. Patients were able to choose between a voluntary 12-week exercise program (exercise group) and no exercise (control group) directly after discharge from the acute burn unit. We prospectively assessed MSTR, as peak torque per lean leg mass (LLM), using a Biodex Isokinetic Dynamometer (Shirley, NY, USA) and CPF as maximal oxygen consumption (VO2 max) using an Ultima CPX™ metabolic stress testing system from MGC Diagnostics (St. Paul, MN, USA). In addition, lean body mass index (LBMI) and LLM were recorded using a Dual-energy X-ray absorptiometry device from Hologic (Waltham, MA, USA). All endpoints were assessed at discharge, after 12-weeks and 24-months post-burn. Both groups were compared using ANOVA for repeated measures and the level of significance was defined at p<0.05. Results: One hundred thirty-three patients, 89 in the exercise group and 44 in the control group were studied. As expected, the MSTR and VO2 max increased significantly only in the exercise group after the 12-week program (p<0.01). However MSTR and VO2 max increased significantly in both, the exercise and the control group, throughout the 24-month period (time effect, p<0.05). A significantly higher LBMI was observed in the exercise group at two years post-burn (p<0.05) compared to the control group. Differences between both groups in absolute levels of VO2 max and MSTR had narrowed at the two year follow-up time point (p=0.29 and p=0.35; for VO2 max. and MSTR respectively). Conclusions: A voluntary 12-week exercise program showed significant improvements in exercise performance after ICU stay. However, the difference in performance is greatly narrowed with further recovery time (24-month post-burn). Continued participation in exercise activities is recommended in order for exercise-induced adaptations to continue to occur. Applicability of Research to Practice: An exercise program for pediatric burn survivors plays an important role in early post-burn muscle recovery; long-term training strategies are warranted to continue to improve LBMI, MSTR and CPF. External Funding: This study was supported by the National Institutes of Health (P50 GM060338, UL1TR000071, T32-GM008256, R01-GM056687, R01-GM112936, R01-HD049471), the Shriners Hospitals for Children (71006, 71008, 71009, 80100, 84080) and the United States Department of Defense (W81XWH-14-2-0162). 107. Cutaneous Functional Units Predict Range of Motion Recovery with Therapy I. S. Parry, MS, PT, D. Greenhalgh, MD, FACS, T. L. Palmieri, MD, FACS, FCCM, S. Sen, MD, FACS Shriners Hospitals for Children, Sacramento, CA Introduction: Cutaneous Functional Units (CFU) have shown a strong correlation with number of burn scar contractures in patients surviving burn injury, however the relationship of CFU involvement to ROM has not been established. We hypothesized that greater CFU involvement will be associated with less range of motion (ROM) achieved in the associated area. The primary aim of this study was to determine if CFUs correlate with total loss of motion prior to and throughout a six-month period of therapy. Secondarily, we evaluated if standard goniometry techniques correlated with 3-D motion analysis of ROM during functional tasks. Methods: Subjects with known axilla(e) contractures received therapy for six months. Their upper body injuries were photographed and their shoulder and elbow ROMs were measured at baseline and throughout the intervention period using two objective means of measurement: standard goniometry (gROM) and 3-D motion analysis during functional tasks (fROM). Distribution of burn was diagramed on an electronic mapping system to determine the extent of CFU involvement. Multi-variate linear regression analysis was conducted to determine if CFU is an independent variable to predict baseline and maximum gROM and fROM. Results: It was found that CFU predicts fROM at baseline and both gROM and fROM at maximum motion achieved (Table 1), thus indicating that the more area of CFU affected by burn injury, the less ROM recovery observed. CFU did not correlate with baseline gROM which may indicate that other factors are associated with initial limitation (ex. pain, guarding) as measured by standard goniometry. There was no relationship between gROM and fROM which suggests that standard goniometric techniques are not predictive of ROM during functional tasks. Conclusions: CFUs can be used to predict maximal recovery in patients undergoing extensive therapy. The ability to predict outcome is crucial to effective clinical decision making and efficient allocation of time and resource for therapy. Furthermore, our results show that standard goniometric techniques of measuring ROM are not adequately correlating with limitations in motion as measured with 3D motion analysis during functional tasks. This contradicts a common clinical assumption that standard goniometry values are representative of functional limitations in motion. This information can be used for improved evaluation and treatment planning. Applicability of Research to Practice: Improves clinical decision making and challenges common methods of ROM measurement. Table. No title available. View Large Table. No title available. View Large 108. Profile of Patients Without Burn Scar Contracture Development R. Richard, PT, MS, A. Santos, PhD, W. Dewey, PT U.S. Army Institute of Surgical Research, JBSA Ft Sam Houston, TX Introduction: Many references report the problem and incidence of burn scar contracture (BSC) development. Few reports exist that describe cases of successful burn rehabilitation (rehab) outcomes of patients (pt) who avoided BSC development. A missing link when evaluating a burn pt from a rehab perspective is the ability to define pt populations that are at low risk of developing a BSC. The purpose of this study was to delve into the demographic and burn injury parameters and rehab course of burn survivors who were discharged from their acute hospitalization without having developed a BSC. Methods: Characteristics of adult pts were abstracted from a database of an IRB approved multicenter, prospective study that collected medical, hospital and rehab information on pts relative to the development of BSC at hospital discharge. Thirteen verified burn centers contributed data between 2010-13. Thirty-seven variables were investigated. Descriptive statistics were used for analysis. Results: From a study population of 307 pts, 56 pts (18%) who had a total of 688 potential BSC sites were discharged from their acute hospitalization without BSC. Table 1 is a partial listing of factors/variables that describe the characteristics of this non-contracted pt group. Flame was the most common burn source in this predominately adult male (73%) group. The pts as a whole (84%) were high school or higher graduates, had few previous health issues and suffered no concomitant injury. Three pts were diagnosed with an inhalation and 5 pts were ventilated for a brief time. Median burn size was relatively small (5.5%) but with ~50% of the area skin grafted. The largest total body surface area (TBSA) burn was 29%. The greatest number of potential BSC sites was 46. Pts received 31 minutes of rehab/day or 6 minutes per potential BSC site. Pts were rated as having a high pain tolerance and highly compliant with rehab. Few pts were splinted (18%). Conclusions: These results are a first-time description of a subset of hospitalized pts with burns who are at low risk of developing BSC. Pts who did not develop BSC were medically uncomplicated and received adequate rehab intervention for a majority of time they were hospitalized. Applicability of Research to Practice: This information begins to establish a clinical perspective on a subset of burn patients who are least likely to develop a BSC and may assist in rehab staffing and patient time requirements for burn rehab treatment. ExternalFunding: Department of DefenseW81XWH-08-l-0683. Table. No title available. View Large Table. No title available. View Large 109. Long-Term Patient Reported Outcomes in Patients with Head and Neck Burns: A Burn Model System National Database Study I. Sinha, MD, D. Bharadia, MD, S. Wiechman, PhD, N. Gibran, MD, FACS, K. Kowalske, MD, W. Meyer III, MD, D. N. Herndon, MD, FACS, C. M. Ryan, MD, FACS, J. C. Schneider, MD Brigham and Women's Hospital, Boston, MA; University of Washington, Seattle, WA; UT Southwestern Medical Center, Dallas, TX; University of Texas Medical Branch, Galveston, TX; Massachusetts General Hospital, Boston, MA; Spaulding Rehabiltation Hospital, Boston, MA Introduction: Facial burn injury can be associated with a decrease in quality of life. This study evaluates the effect of head and neck (H and N) burns on patient reported outcomes using validated surveys. Methods: A retrospective analysis was conducted using the National Institute on Disability, Independent Living and Rehabilitation Research Burn Model System database between 1996 and 2015. Demographic and clinical characteristics were compared for those with and without H and N burns. The following measures were examined at 6 and 24 months post-burn: Satisfaction With Life (SWL), Community Integration Questionnaire (CIQ), Satisfaction With Appearance (SWAP), SF-12 Physical Component Score (SF-12 PCS), and SF-12 Mental Component Score (SF-12 MCS). Logistic regression analysis examined for the presence of H and N burns, and controlled for age, gender, burn size, and total body surface area (TBSA) grafted. Results: A total of 989 patients with H and N burns (mean±SD age 29.0 ± 21.2 years) was compared to a cohort of 692 burn patients without H and N burns (age 35.9 ± 21.6 years). TBSA burned was higher in patients with HN burns than without (34.6%± 21.3 versus 14.7%± 15.8, p<0.01). Six months post-burn, 15.1% of H and N burn survivors were employed, as compared to 20.5% survivors without H and N burns (p<0.01). At 6 months, SWAP (33 versus 23.2, p<0.01) and SF-12 PCS (42.7 versus 44.3, p=0.05) were significantly worse for survivors with H and N burns. At 24 months post-burn, SWAP score remained worse in survivors with H and N burns (31.7+18.5) versus survivors without H and N burns(23.5 + 16.8, p<0.01). Linear regression demonstrated that HN burns are associated with worse SWAP scores (p<0.01). SWAP, SWL, CIQ, and SF-12 PCS scores improved significantly between 6 and 24 months in H and N burn patients. Conclusions: Visible burns can be both physically and emotionally devastating. H and N burn patients were similar to non-HN burn survivors in their satisfaction with life and ability to integrate into the community, but they exhibit a higher rate of dissatisfaction with their appearance and are slower to return to employment. Treatment of these patients must involve psychosocial counseling as well as reconstructive surgical interventions to address appearance following HN burn injury. Applicability of Research to Practice: H and N burn patients should receive long term counseling after injury and should be referred for reconstructive interventions. External Funding: National Institute on Disability, Independent Living, and Rehabilitation Research 90DP0035. 110. Shake It Off: A Randomized Study of the Effect of Whole Body Vibration on Pain in Healing Burn Wounds J. J. Ray, MD, A. D. Alvarez, OT, S. L. Ulbrich, MSPT, S. Lessner-Eisenberg, MSPT, S. S. Satahoo, MD, J. P. Meizoso, MD, C. A. Karcutskie, MD, N. Namias, MD, MBA, FACS, L. R. Pizano, MD, MBA, FACS, C. I. Schulman, MD, PhD, MSPH University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL Introduction: Whole body vibration (WBV) has been shown to improve strength in extremities with healed burn wounds. Our objective is to study the effect of WBV on pain. We hypothesize that in patients with healing burn wounds of the extremities, WBV during rehabilitation compared to standard therapy, reduces pain. Methods: Patients with ≥1% total body surface area (TBSA) burn to one or more extremities from 10/2014-8/2015 were randomized to vibration (VIBE) or control groups. Each burned extremity was tested separately within the assigned group. Patients underwent one to three therapy sessions (S1, S2, S3) consisting of 5 upper and/or lower extremity exercises with or without WBV. Pain was assessed pre-, mid-, and post-session on a scale of 1-10. An independent t-test compared mid- and post- versus pre-pain score differences in each tested extremity on a scale of 1-10. Other continuous variables were compared using a t-test for parametric data (reported as mean±standard deviation) or a Mann-Whitney-U test for non-parametric data [reported as median (interquartile range)]. Categorical variables were compared using a chi-square or Fisher's exact test, as appropriate. Statistical significance was determined at alpha level 0.05. Results: Thirty-seven extremities were analyzed from a total of 26 subjects (VIBE n=20, control n=17). There were no significant differences between VIBE and control groups in age, gender, TBSA burn, TBSA burn in the test extremity, pain medication use prior to therapy session, or skin grafting prior to therapy session. At SI, S2, and S3, there was a statistically significant decrease in mid- and post-session pain compared to pre-session pain in VIBE versus controls (Table and Figure). Conclusions: Exposure to WBV decreased pain during and after physical therapy sessions. This modality may be applicable to a variety of soft tissue injuries in all stages of healing and warrants further investigation. Applicability of Research to Practice: Incorporating WBV into rehabilitation regiments may decrease pain thus facilitating participation and improving results from therapy. 110.1 Burn Rehabilitation a History Tied to the Growth of the American Burn Association K. J. Kowalske, MD UT Southwestern Medical Center, Dallas, TX Burn mortality improved in the early 1970's associated with development of topical antimicrobials and early excision of the burn wound. As even massive burns were surviving, it became clear that this alone was not a successful outcome. A small group of physiatrists and therapists interested in burns began advocating for positioning, splinting, casting, and early mobilization. Phala Helm, Steve Fisher and Elizabeth Rivers held sessions at the American Burn Association (ABA) meetings called "How I do it". These became so popular that in 1978, rehabilitation was designated as the first special interest group (SIG) and allotted a specific meeting time. Efforts at education provided benefit for those who attended the national meeting, but effective rehabilitation services where still rare. A 1982 survey showed most burn units were without dedicated rehabilitation therapists, and only 30% offered outpatient therapy. In 1990, after 20 years of lobbying and demonstrating the role for rehabilitation in burn care, it was incorporated into the logo of the ABA. In 2016, almost 10% of the ABA members are rehabilitation therapists, and rehabilitation topics are amply represented in the education symposium, plenary and post-graduate sessions, correlative sessions, and posters at each annual meeting. A Burn Rehabilitation Consensus Conference in 2008 defined areas of rehabilitation practice, but very few areas of scientific investigation. A State of the Science in Burns is planned for February, 2016 which will chronicle advances in burn rehabilitation, but more importantly will identify important gaps for investigation. 111. Use of a Temporary Biosynthetic Skin Subtitute (TBSS) in Stevens Johnson - Toxic Epidermal Necrolysis Syndrome (SJS-TEN) A. Rogers, MBBCh, MMed, E. Blackport, RN, R. Cartotto, MD, FRCSC Ross Tilley Burn Centre, Toronto, ON, Canada Introduction: Published experience with a TBSS for wound management in SJS-TEN consists of case reports and case series involving eight or fewer patients. The purpose of this study was to review our experience with the use of a TBSS for wound coverage in SJS-TEN. Methods: Retrospective review of all cases of SJS-TEN admitted to our adult regional ABA-verified burn center between Janl, 2000 and June 1, 2015. Epidermal debridement and TBSS application were performed at burn center admission. Antimicrobial dressings were applied to the TBSS daily. Healing was defined when dressings to ≤ 2% TBSA were required. All values are presented as the median (IQR), unless otherwise noted. Results: We identified 47 patients with SJS-TEN. The TBSS was applied in 24 subjects, with two distinct applications in one subject leading to 25 TBSS applications for evaluation. TBSS-treated subjects had a mean (± SD) age of 51.4 ± 21.7 years, with a %TBSA epidermal detachment of 39.5 (30-46), 63% were female and the admission SCORTEN was 3 (2-4, range 1-5). The diagnosis was SJS in 4%, SJS-TEN overlap in 25%, and TEN in 71%. Burn centre (BC) admission occurred 7 (5-10) days post onset of symptoms and 8/24 (33.3%) received steroids prior to BC admission. The TBSS was applied at BC admission in 18/24 subjects (82%), and between post admission days 1-4 in four subjects. The TBSS was applied to 35 (22-40) %TBSA (range 7-90) involving all anatomic areas including the head and neck. There were no complications, infections, premature removals, or TBSS-associated sepsis in 24/25 applications (96%). In one subject a sheet of the TBSS was removed due to sub-TBSS fluid collection, but with negative microbiological cultures. Time to healing was 13(12-16) days, burn center length of stay was 34(15.3-62.3) days, and in-hospital mortality was 25%. Subjects treated with dressings only (n=18) had a significantly smaller % TBSA epidermal detachment [10 (5-26.3), p<0.001)], and were predominantly diagnosed with SJS (50%) or SJS-TEN overlap (33%). They did not differ significantly from the TBSS-treated subjects in age (59.5 ± 18.2 years, p=0.338), pre-BC steroid administration [3/18 (16.7%), p= 0.224), days of symptoms pre-BC admission [7(4-10), p=0.798), and admission SCORTEN [ 2(2-3), p=0.597]. Time to healing among dressing-only subjects was not significantly different [12 (10-14.5) days, p=0.127]. Conclusions: The TBSS was applied to SJS-TEN subjects with more extensive epidermal detachment, had no significant complications, and generally facilitated epidermal healing in under 2 weeks from application. Applicability of Research to Practice: The TBSS should be used in the wound management of more extensive SJS-TEN, given the general benefits of skin substitutes and the excellent safety profile as demonstrated in this study. 112. Evaluation of a Cost-Saving Measure in the Burn Unit: 2.5% Mafenide Acetate Solution S. Zavala, PharmD, BCPS, A. Sanford, MD, FACS Loyola University Medical Center, Maywood, IL Introduction: Mafenide acetate, introduced in 1964, is an effective topical antimicrobial agent used for burn wound management. Mafenide has been the mainstay of burn wound topical management to reduce bacterial counts in burn wounds, and is associated with reduced mortality rates. A 5% solution is commonly used, despite data supporting the efficacious use of a 2.5% solution both in vitro and in vivo. A recent medication use evaluation conducted at our institution identified mafenide acetate solution as one of the highest-cost medications on formulary, totaling $188,000 in 2013. In 2014, Ibrahim, et al, found that the use of a 2.5% solution was not associated with increased bacteremia or wound infection, and contributed to a reduction in pharmacy expenditure. Our institution implemented this change on August 7, 2014. The objective of this noninferiority study is to examine the efficacy of a 2.5% mafenide acetate solution as compared to a 5% solution. Methods: This was a retrospective and prospective observational study including all burn patients (adult and pediatric) who received mafenide acetate solution for skin graft over a two year time period. A total of 1506 patients were admitted to the burn service during the study period and 201 patients were included in the study, with 108 receiving 5% solution, and 93 receiving 2.5% solution. The primary endpoint is a composite endpoint of treatment failure, occurrence of wound infection, and occurrence of bacteremia. Secondary endpoints include length of stay, length of stay in the intensive care unit, cost of mafenide therapy per patient, adverse events, treatment failure, wound infection, bacteremia, and in-hospital mortality. This study was approved by our Institutional Review Board. Results: Demographics were overall similar between groups, but the 2.5% mafenide group had a larger average total body surface area burned (9.09% vs 13.03%, P = 0.033), which contributed to the 2.5% mafenide group receiving more liters of mafenide solution during their hospital stay (P = 0.002) and no significant difference in the drug cost between groups. The composite endpoint showed no difference between mafenide groups (P = 0.669), as did the individual components of treatment failure (P = 0.559), wound infection (P = 0.568), and bacteremia (P = 0.139). No adverse drug reactions attributed to the study drug occurred. Conclusions: This study has demonstrated that the use of 2.5% mafenide acetate solution is equivalent to the 5% solution in terms of efficacy. This reduction in concentration used may also contribute to a reduction in pharmacy drug expenditure. Applicability of Research to Practice: Reducing the concentration of mafenide acetate solution from 5% to 2.5% may be a strategy for the burn team to help reduce healthcare costs while maintaining similar clinical outcomes. 113. Time Matters: Assessment of Limb/Digit Salvage Following Severe Frostbite on the Individual Patient Level R. M. Nygaard, PhD, A. L. Lambert Wagner, MD, FACS, M. L. Dole, MD, A. Lemere, MD, J. R. Gayken, MD, R. M. Fey, MD Hennepin County Medical Center, Minneapolis, MN Introduction: Severe frostbite is associated with high levels of morbidity through loss of digits or limbs. The aim of this study was to examine the salvage rate following severe frostbite injury. Methods: Frostbite patients from 2006-14 were identified in the prospectively maintained database at a single urban burn and trauma center. Patients with imaging demonstrating a lack of blood flow in limbs/digits were included in the analysis (N=73). The Hennepin Frostbite Score (in press) was used to quantify frostbite injury and salvage. This score provides a single value to assess each individual patient's salvage rate. Results: The majority of patients with perfusion deficits were male (80%) with an average age of 42y (range 1 l-83y). Patients requiring amputation tended to be older (p=0.002), have more tissue impacted by frostbite (p<0.001), and have a longer time from rewarming to thrombolytic therapy (p=0.001). A majority of patients (62%) received thrombolytic treatment. The percent of patients requiring amputation and the salvage rate was lower in patients treated with thrombolytics; however, the differences failed to reach statistical significance (p=0.092 and p=0.064, respectively). Salvage decreases as the time from rapid rewarming to thrombolytic therapy increases (Fig 1). Regression analysis demonstrates an additional 26.9% loss with each hour of delayed treatment (p=0.034). When the amount of tissue at risk for amputation is included in the model, each hour delay in thrombolytic treatment results in a 28.1% decrease in salvage (p=0.008). Conclusions: This study demonstrates a significant reduction in limb/digit salvage with each hour of delayed administration of thrombolytics in patients with severe frostbite. Applicability of Research to Practice: Following screening of patients with severe frostbite injury, thrombolytic therapy should be initiated as soon as safely possible. Ideally, treatment should be initiated within 4 hours of rapid rewarming; however, we observed some benefit in patients who received treatment up to 12 hours post-rewarming. Figure. View largeDownload slide Figure. View largeDownload slide 114. Proportion of Full Thickness to TBSA Burn Injury Predicts Overall Length of Burn Care More Precisely than TBSA Alone G. M. Lewis, MD, FACS, I. Faraklas, BSN, S. Dissanaike, MD, FACS, Y. Zhai, MPH, B. Walker, BA, D. Ha, BS, G. Graves, A. Cochran, MD, FACS, FCCM University of Utah Department of Surgery, Salt Lake City, UT; Texas Tech University Health Sciences Center, Lubbock, TX Introduction: The total duration of wound care required by a patient is an important aspect of burn care and impacts discussions with the patient and their family. Traditionally one day per percent TBSA burn injury has been offered as an expected length of stay. However, hospital LOS captures only one aspect of recovery from burn injury. The aim of this study is to determine length of wound treatment based on the characteristics of the burn injury. Methods: With IRB approval, we reviewed the charts of burn-injured adults with >20% TBSA and documentation of wound healing admitted to two ABA-verified burn centers between January 2008 to December 2014. Study data were collected and managed using the REDCap electronic data capture tool. We evaluated demographics, hospital course, and outcomes. Proportion of full-thickness to TBSA burn injury (F:T ratio) was documented for each patient and compared with time to heal, along with data from inpatient and outpatient visits. Results: 146 subjects met inclusion criteria. Median time to 95% healing of burn wounds was 3.7 days per % TBSA (IQR 2.5-6.7). We compared normal time to heal (NTH) (n= 110; <6.7 days per %TBSA or <75th percentile) with extended time to heal (ETH) (n= 36). Baux score, %TBSA, SOFA scores, ethnicity, body mass index, body surface area, and surgical outcomes were not significantly different between groups. However, subjects with NTH had a significantly higher proportion of partial thickness burns compared with ETH, who had a larger full thickness component to their burn wounds. (0.28 vs. 0.62; p=0.002). In the figure, time to heal per %TBSA was compared with F:T ratio. Conclusions: Proportion of full thickness to TBSA burn injury predicts time to heal more accurately than TBSA alone. This study is the first to describe time to heal as it relates to the composite burn injury versus total size of burn injury. Applicability of Research to Practice: This information about predicting time to healing guides discussions and manages expectations of patients and their family real-time. Figure. View largeDownload slide Figure. View largeDownload slide 115. Constructing Skin Graft Seams in Burn Patients: A Prospective Randomized Double Blinded Study K. Isaac, MD, N. Umraw, OT, R. Cartotto, MD, FRCSC Ross Tilley Burn Centre, Toronto, ON, Canada Introduction: At skin graft application it may be necessary to construct a seam between adjacent pieces of skin. Ultimately these seams form scars. Seams may be constructed either by approximating the graft edges (AP), or by overlapping the graft edges (OV). It is not known if one technique produces a superior seam scar. The purpose of this study was to compare seam scars between seams constructed using the AP and OV techniques. Methods: This was a prospective study in adult burn patients treated at an ABA-verified burn center. At skin graft application, study seams were divided in half. One half of the seam was made by approximating the graft edges (AP group) while the other half was made by overlapping graft edges (OV group), before identical staple or suture fixation of each half. Hence, each subject served as their own control in this within-subject design. The AP or OV technique was randomly assigned to the medial or lateral ends of transversely oriented seams or to the proximal and distal ends of longitudinally oriented seams. All seams were made by the same surgeon. At 3, 6, and 12 months post surgery, a blinded burn OT rated the two halves of each study seam scar using the Vancouver Scar Score (VSS). Subjects were also blinded and rated each half of their study seam using a 0 (poor) to 10 (excellent) visual analogue scale (VAS). All values are shown as the median (Q1-Q3). Results: There were 44 study seams among 19 subjects [age 51 (36-70) years, with % TBSA burn 10 (7-18), % BSA full thickness burn 8 (6-15), and with inhalation injury in 5.3%]. Study seams were constructed at 10 (4-15) days post burn. Study seam length was 14.5 (10.3-18.0) cm, with 25% transversely oriented and 75% longitudinally oriented, and with 35/44 seams (80%) between meshed grafts, and 9/44 (20%) between sheet grafts. There were no significant differences in the either the total VSS score between AP and OV seams (Table), or the individual VSS scores for height, pliability, vascularity, and pigmentation, at 3, 6, and 12 months. At 12 months, among the 30 study seams that were visible to the subjects, the VAS score for the AP seams was 9 (8.5-10) which did not differ significantly from the OV seams [9.5 (8.45-10), p=0.821]. Conclusions: There was no difference in the final seam scar quality between skin graft seams constructed using the AP or OV technique. Applicability of Research to Practice: Although seam scars are noticeable post grafting it appears that both the AP and OV techniques of seam construction lead to comparable scars, suggesting either technique is acceptable. Table. No title available. View Large Table. No title available. View Large 116. Clinical Results for Deep Partial-Thickness Burns Treatment with Cryopreserved Human NIKS Tissue Support Progression to Phase III Clinical Investigation 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, A. R. Comer, PhD, M. A. Lokuta, PhD, K. F Barbeau, BA, J. H. Holmes IV, MD Stratatech Corporation, Madison, WI; Mission Health Hospital Trauma Center, Ashville, NC; University of Wisconsin-Madison, Madison, WI; Arizona Burn Center, Phoenix, AZ; University of Texas Southwestern, Dallas, TX; U.S. Army Institute of Surgical Research, San Antonio, TX; Wake Forest Baptist Medical Center, Winston-Salem, NC Introduction: NIKS human skin substitute was designed as an alternative to surgical harvest of donor sites for autografting. It reproduces many features of skin providing wound coverage, barrier function and sustained expression of healing factors. Results of a completed clinical trial of NIKS tissue for treating DPT burns support progression to the phase III trial. Methods: A controlled, dose-escalation, multicenter trial examined the safety and efficacy of NIKS tissue to promote the healing of DPT burns that would otherwise be autografted. Subjects with 3-49% TBSA burns received up to 440 cm2 of refrigerated or cryopreserved NIKS tissue. Each subject had 2 areas randomized to autograft or NIKS tissue and a prospectively identified donor site for the NIKS tissue treated area. Primary endpoints were percentage of NIKS tissue-treated area requiring autografting by day 28 and wound closure at 3 months. Other assessments included safety, cosmesis, donor site pain, immunological responses, and presence of allogeneic NIKS tissue DNA. The magnitude of the clinical study data informed progression to and design of a phase III trial registration study of NIKS tissue. Results: The clinical trial outcome exceeded expectations. By day 28, no areas treated with refrigerated or cryopreserved NIKS tissue required autografting. Of the 28 per protocol subjects, 27 showed complete, durable closure of the NIKS tissue-treated site at 3 months. Eliminating the need for donor site harvest for the NIKS tissue-treated area, subjects showed reduced pain and improved cosmesis. No safety signal was seen. DNA from the NIKS tissue was not detected at 3 months indicating that the tissue does not implant but promotes autologous tissue regeneration and repair by the recipient's own cells. Conclusions: A single application of cryopreserved NIKS tissue to DPT thermal burns promoted autologous tissue regeneration without donor site harvest. The comparator design, choice of endpoints, and assessment in the intended population effectively demonstrated the utility of NIKS tissue in promoting wound healing in lieu of autograft. Similar elements are planned for a pivotal phase III trial of NIKS tissue in the healing of DPT burns. Enrollment is anticipated to begin in the second half of 2016. Applicability of Research to Practice: Data with NIKS tissue show substantial improvement for management of DPT burns. Cryopreservation increases shelf life, providing a safe, readily-available alternative to autograft treatment of severe burns. Data demonstrate the magnitude of clinical responses and provide the foundation for the selection of appropriate clinical endpoints for the phase III pivotal safety and efficacy trial of cryopreserved NIKS tissue for the treatment of DPT burns. External Funding: Grant, Armed Forces Institute of Regenerative Medicine (AFIRM). 117. Amputation Risk For Diabetics With Distal Lower Extremity Burns E. Y. Chen, MD, N. Toscano, MD, D. Bell, MD University of Rochester Medical Center, Rochester, NY Introduction: Our study aims to determine if diabetic patients are at increased risk of amputation following lower extremity burns compared to non-diabetic patients and to determine what factors may be predictive for risk of amputation in diabetics with lower extremity burns. Methods: This was a retrospective review of adult patients who were evaluated at a regional burn center for distal lower extremity burns between January 1, 2011 and April 29, 2015. Patients were included if they sustained burn injuries to the toe and/ or foot. Data collected included demographics, comorbidities including diabetes, details of burn injury, delay in presentation, time to wound closure, and mortality. Results: A total of 130 patients were eligible for study inclusion. Twenty seven percent of patients were diabetic while 73% were non-diabetics. Diabetics sustaining burn injuries to the distal lower extremity were older compared to non-diabetics (56.1 vs. 45.9, p=0.006). Diabetics had a longer delay in presentation compared to non-diabetics (8.8 vs. 4.8 days, p=0.028). Diabetics also had a longer duration of time to heal (69.8 vs. 26.9 days, p=0.0002). There was a greater chance for diabetics to have a diagnosis of peripheral arterial disease (p=0.0000), previous amputation (p=0.0001), end stage renal disease requiring hemodialysis (p=0.0007), and neuropathy (p=0.0000). Diabetics required skin grafting 60% of the time, compared to non-diabetics who required skin grafting 29.5% of the time (RR 2.04, 95% CI 1.35-3.07). Diabetics required amputation 22.9% of the time, compared to non-diabetics who required amputation 3.2% of the time (RR 7.24, 95% CI 2.03-25.75). Sub-group analysis of the diabetic patient population revealed that those with PVD or ESRD on HD were more likely to require amputation while those with neuropathy, smoking, or full thickness burn injuries to the toe and foot were more likely to require both STSG and amputation, although these associations did not reach statistical significance. The only statistically significant risk factor for amputation was peripheral neuropathy (RR 1.69, 95% CI 1.08-2.64). Conclusions: Diabetics tended to have a longer delay in presentation and a higher incidence of comorbidities. Diabetics took about 2.5 times longer to heal, were 2 times more likely to require skin grafting, and were 7 times more likely to require amputation when compared to non-diabetics. The diagnosis of peripheral neuropathy in diabetic patients conferred a statistically significant higher risk of amputation. Applicability of Research to Practice: When managing lower extremity burns in the diabetic patient, physicians should set reasonable expectations surrounding the potential need for amputation and make informed decisions with these patients regarding their multidisciplinary burn care. 118. The Impact of Burn Size and Other Factors on Wound Healing Rate M. E Rowan, PhD, M. F. Buehner, MD, J. C. Janak, PhD, C. A. Fenrich, BS, B. A. Shields, RD, LDN, CNSC, J. C. Pamplin, MD, J. Salinas, PhD, L. C. Cancio, MD, FACS, K. K. Chung, MD U.S. Army Institute of Surgical Research, JBSA Ft Sam Houston, TX Introduction: The ability to accurately track the progress of burn injuries is vital for effective burn management and to improve patient outcomes. In order to increase the accuracy of burn wound mappings, we developed a computer-based burn mapping program to document full- and partial-thickness burns and ongoing surgical treatment modalities. Our initial characterization of the computer-based program with data from 38 patients was undertaken to examine the relationship between wound healing and mortality, and this initial study showed that delayed wound healing was associated with significantly higher mortality. The goal of the present study was to extend the initial analyses using data from additional patients to examine the impact of burn size and other factors on wound healing rates. Methods: A retrospective analysis of data from 130 patients admitted to our burn center between August 2009 and March 2015 was conducted. All adult (≥18 years old) patients with a burn size of at least 20% TBSA and at least three computer-based wound mappings were included in the analysis. The data from the mappings was used to calculate average healing rates. Results: Patients were predominantly male (79%), civilians (88%), with a median age of 37.5 and body mass index of 28.5. Median length of stay was 34.5 days (20 ICU days) and overall mortality was 31.5%. The number of available computer-based wound mappings per patient varied (range: 3-45, median: 7), in part because the burn size varied widely (range: 20-99 %TBSA, median: 32 %TBSA). Survivors healed at a median rate of 0.9 %TBSA/day (IQR 0.7%, 1.2%), while non-survivors (on average) failed to heal, with a median rate of 0.0 %TBSA/day (IQR -0.8%, 0.2%). Large burns (≥30 %TBSA) healed at an average rate of 0.3 ± 0.1 %TBSA/day, while small burns (<30 %TBSA) healed at an average rate of 0.9 ± 0.2 %TBSA/day (p<0.0001). Elderly patients (> 65 years old) also healed more slowly than younger patients (18-39 years old) [0.2 %TBSA/ day (IQR-0.1%, 0.5%) vs 0.9 %TBSA/day (IQR 0.6%, 1.2%), respectively, p=0.01). Conclusions: Here we provide, for the first time, quantifiable data to support the anecdotal concept that large burns heal more slowly than small burns as average wound healing rates were inversely correlated with burn size. Average healing rates were also inversely correlated with age. Further analysis of the existing dataset will evaluate the impact of treatments, burn location, and other factors on healing rates. Applicability of Research to Practice: Wound healing is essential to survival. This computer-based tracking program provides visual information to clinicians on the progress, or lack thereof, towards wound healing, and could be further enhanced by providing numerical healing rates to the clinician to improve situational awareness and allow earlier intervention or changes 119. Selective Beta 3-Adrenergic Blockade Improves Terminal Maturation of Late Erythroblasts in Erythropoietin Resistant Anemia S. Hasan, PhD, A. Szilagyi, BS, R. L. Gamelli, MD, FACS, K. Muthumalaiappan, PhD Loyola University Medical Center, Maywood, IL Introduction: Patients with >10% TBSA burn suffer from erythropoietin (Epo) resistant anemia. Mechanisms of erythropoiesis leading to Epo resistant anemia in burn patients are poorly understood. While Epo is essential for effective bone marrow erythropoiesis, all erythroblasts (E) do not express Epo receptors. Only early stage E (cfu-E, pro-E and basophilic-E) and not late stage E (polychromatic-E, orthochromatic-E) express Epo receptors and respond to Epo dependent expansion. During late stage erythropoiesis, orthochromatic-E (O) matures into reticulocytes (R) after ejecting the nucleus. Therefore, R/O ratio can serve as an index of Epo-independent terminal maturation of late erythroblasts. Here we report in mouse model of burn, administration of propranolol (beta-non selective block) and SR59230A, (beta3- selective block) exhibited differential responses in improving early E and late E as well as maturation index in the bone marrow. Methods: B6D2F1 mice were divided into one sham and three burn groups with 15% TBSA scald burn. Burn mice were randomized to receive once daily injections of SR59230A or propranolol at 5mg or 25mg/Kg body weight respectively or vehicle for 6 days after burn. Mice were sacrificed on day 7, blood and femurs were harvested; total bone marrow cells (TBM) were probed for CD71 and Terl 19 expression by flow cytometry. TBM cells were gated as erythroid (Terll9pos), non-erythroid (CD71neg Terll9neg), pro-E (CD71pos Terll9neg) and late-E (CD71pos Terll9pos) subsets. Late-Es were further gated on a cell-permeable nuclear dye (Sytol6) to classify as nucleated late-E (O) and enucleated reticulocytes (R). HemaTrue veterinary analyzer was used to retrieve peripheral blood parameters. Results: Bone marrow erythroid cells were reduced with a reciprocal increase in nonerythroid cells after burn. A significant increase in pro-E indicated a robust Epo response to burn injury. Nonetheless, a staggering decline in late E was accompanied by significantly low maturation index resulting in low RBC count. Propranolol and SR59230A intervene at early and late stages of erythropoiesis respectively (table). Conclusions: Administering propranolol increases early erythroblasts after burn while SR59230A significantly restores late erythroblast maturation defects thereby increasing RBC counts in periphery. Applicability of Research to Practice: A combination beta-adrenergic blockade holds promise for treating Epo resistant anemia associated with burn. External Funding: NIH; R01DK097760 - 01A1 to KM. Table. No title available. View Large Table. No title available. View Large 120. Exercise Treatment Reversed Micro RNA Profile in Burn Rats with Hindlimb Unloading A. R. Cai, BA, J. Song, MD, P. B. Kumar, BS, A. J. Sehat, BA, M. R. Saeman, MD, L. A. Baer, MS, C. E. Wade, PhD, S. E. Wolf, MD, FACS UTSouthwestern Medical Center, Dallas, TX; University of Texas Health Science Center at Houston, Houston, TX Introduction: Micro RNA (miRNA) is a class of non-coding RNA that regulates gene expression by silencing messenger RNA. Burn induces muscle breakdown that is made worse by bed rest, while exercise has been found to alleviate this muscle atrophy. We hypothesize that the alteration of miRNA and target gene profiles contributes to skeletal muscle mass loss after burn, and exercise reverses the muscle atrophy. The purpose of our study was to characterize the miRNA profile correlated to gene expression in an animal model for burn and disuse, as well as miRNA changes seen with exercise. Methods: Forty-eight Sprague-Dawley rats were randomly assigned to sham ambulatory (SA), burn ambulatory (BA), sham hindlimb unloading (SH), and burn hindlimb unloading (BH) groups. Rats received 40% total body surface area scald burns or sham treatment, and they were placed in hindlimb unloading by tail harness, a model for bed rest, or ambulatory. Half of each group received twice daily resistance exercise for eight total groups (n=6 per group). After the 14-day treatment period, the plantaris muscles were harvested for miRNA and genomic data analysis. Results: Our results show that compared to the SA group, BA and SH independently upregulate 3- to 4-fold more miRNAs and genes than they downregulate. miRNA-182, -187-3p, and -155-5p rank among the most upregulated. Comparing the combination of B and H (BH) to SA reveals that miRNA-182, miRNA-187-3p, and gene Nr4a3 receive additive contributions from B and H. With exercise, miRNA-182 increased 10.06-fold, and miRNA-138-l-3p decreased 2.14-fold. In comparison, exercise in the BH group strongly downregulated miRNA-182 7.04-fold and miR-138-l-3p 6.57-fold. In a similar fashion, exercise upregulated genes Chad and Cpxm2 in SA, then downregulated them in BH. [Table 1] Conclusions: Burn and disuse additive contributions to miRNA and gene changes may explain the additional muscle atrophy burn patients experience with bed rest. Furthermore, exercise demonstrates a greater downregulation of miRNA and genes in BH compared to the SA group. Applicability of Research to Practice: Elucidating specific miRNAs' roles in muscle atrophy secondary to burn and bed rest opens the possibility of new markers and treatments targets. External Funding: This project is funded through DOD grant #W81XWH-13-l-0489 and the UT Southwestern Medical Student Summer Research Program Stipend. Table. No title available. View Large Table. No title available. View Large 121. Impact of Adipose-Derived Mesenchymal Stem Cells on Acute Respiratory Distress Syndrome after Smoke Inhalation Injury K. Ihara, MD, S. Fukuda, MD, B. Enkhtaivan, MD, R. Trujillo, MD, D. Herndon, MD, FACS, D. Prough, MD, P. Enkhbaatar, MD, PhD University of Texas Medical Branch, Galveston, TX Introduction: Smoke inhalation causes acute respiratory distress syndrome (ARDS) leading to high mortality and morbidity. To date, there is no therapy that reduces mortality from ARDS. The goal of the present study was to test the hypothesis that intravenously administered adipose-derived mesenchymal stem cells (MSCs) effectively ameliorate the severity of smoke inhalation-induced ARDS in a well-characterized clinically relevant ovine model. Methods: Ten female sheep (30-40 kg) were surgically prepared 5-7 days prior the study. ARDS was induced by 48 breaths of cooled cotton smoke inhalation under anesthesia and analgesia. Following the injury, sheep were placed on mechanical ventilator, resuscitated with lactated Ringer's solution and cardiopulmonary hemodynamics was monitored for 48 h in a conscious state. Then, the sheep were randomly allocated to two groups: 1) control: smoke injured, treated with a PlasmaLyte A, n=5); and 2) MSCs: Smoke inured, but treated with 5 million/kg of intravenous MSCs over 30min starting 1 h post-injury, n=5. Allogeneic MSCs were isolated from sheep subcutaneous fat tissue. [[Unable to Display Character: &#8232;]]Pulmonary gas exchange, pulmonary mechanics (airway pressures, lung compliance), lung lymph flow (an index of pulmonary vascular fluid flux), and protein in plasma and lung lymph were determined every 6hrs. Results: Pulmonary gas exchange was significantly improved by MSCs (PaO2/FiO2, MSCs vs control: 406 ± 45 and 262 ± 57 at 24hrs, 354 ± 56 and 150 ± 29 at 30hrs, p<0.05). The smoke-induced increases (2-fold) in peak and pause airway pressures were significantly attenuated by the MSCs treatment. The increases in lung lymph flow (9-fold) were also significantly attenuated by MSCs. The smoke inhalation-induced decrease in plasma protein and increase in lung lymph protein was reversed by MSCs as well (Table 1). Infusion of the MSCs did not affect pulmonary artery pressure and other hemodynamic variables. Conclusions: Therapy with adipose-derived MSCs prevented onset of moderate and severe ARDS. Applicability of Research to Practice: It should be considered as a safe and effective therapeutic option for burn patients with smoke inhalation injury. External Funding: Shriners HospitalSHC85100 and SHC84050. Table. No title available. View Large Table. No title available. View Large 122. Nebulized Racemic Epinephrine Reduces Ventilation-Perfusion Mismatch and Shunt Following Smoke Inhalation and Burns in Swine A. T. Dixon, BS U.S. Army Institute of Surgical Research, Fort Sam Houston, TX Introduction: The pathophysiology of smoke inhalation injury (SII) involves ventilation perfusion (V/Q) mismatch and, in severe injury, development of true shunt. We used the multiple inert gas elimination technique (MIGET) to investigate the effect of nebulized epinephrine on V/Q in a severe porcine model of SII which causes acute respiratory distress syndrome (ARDS). We hypothesized that nebulized epinephrine reduces shunt and V/Q mismatch. Methods: Female Yorkshire swine (weight, 40-50 kg) were anesthetized and received arterial and venous catheters and tracheostomy. Each animal was randomized to 1 of 3 groups: EPI (SII, flame burn, and epinephrine treatment, n = 6); INJ (SII and flame burn without epinephrine, n = 4); and CTRL (uninjured time controls, n = 4). Racemic epinephrine (11.25 mg) was administered over 30 min q 4 using the Aeroneb Pro ultrasonic nebulizer. For MIGET, all animals received a 5% dextrose solution into which 6 inert gases were dissolved. At baseline (BL), 1 hr post-injury (PI), and every 24 hrs till 72 hrs PI, 7 mL arterial blood and 30 mL mixed expired gas were analyzed via gas chromatography to determine excretion and retention levels for each inert gas. Blood flows to the following V/Q areas were calculated: shunt (QS, V/Q = 0), very low (Qvlow, 0 < V/Q < 0.001), low (Qlow, 0.001 < V/Q < 0.1), and normal (Qnorm, 0.1 < V/Q < 10). Groups were compared at each time point. Results: QS at BL was very low (0.5 ± 0.1%) in all groups. QS in EPI and INJ was higher than in CTRL at 48 (p<0.01) and 72 hrs (p<0.05), and lower in EPI than in INJ at 24 hrs (p<0.01). Qvlow was lower in EPI than in INJ at 48 (p<0.01) and 72 hrs (p<0.001). Qlow was lower in EPI than in INJ at 48 hrs (p<0.05). Increases in QS, Qvlow, and Qlow occurred at the expense of decreases in blood flow to Qnorm in EPI and INJ at 24 (p<0.005) and 48 hrs (p<0.01). PaO2-to-FiO2 ratios (PFR) for EPI and INJ were lower than in CTRL at 24, 48, and 72 hrs (p<0.005). There was a trend towards higher PFR in EPI than in INJ at 24 hrs (334 ± 74 vs. 236 ± 80), 48 hrs (177 ± 126 vs. 130 ± 71), and 72 hrs (246 ± 128 vs. 186 ± 5). Conclusions: Nebulized racemic epinephrine improved V/Q matching and reduced true shunt in severe ARDS due to smoke inhalation and burns. Applicability of Research to Practice: Taken together with other studies, this study indicates that nebulized racemic epinephrine may be effective in improving gas exchange following smoke inhalation injury and burns, and that a primary mechanism involves a reduction in blood flow to injured lung areas. 123. Age Related Changes in Cardiac Function and Inflammatory Processes in Response to Severe Burn Injury D. L. Carlson, PhD, S. Wolf, MD, FACS University of Texas Southwestern, Dallas, TX Introduction: Children are a vulnerable part of the population for whom the burden of burns are experienced for their lifetime. Burns in pediatric patients have impacts on metabolic markers, the heart, and other organs for years postburn. This experiment characterized and identified differences in cardiac response and inflammatory related alterations to burn in pediatric, adult and aged rats. Methods: Myocardial response following full thickness burns over 40% TBSA was determined by heart rate, and fractional shortening in pediatric (3 week ), adult (4 month) and aged (19-28 months ) rats. Burned animals received standard fluid resuscitation. ECHO was done at 0,2,4,8,12,and 24h after burn. Hearts and serum were collected. Troponin I, Caspase-1, 3, ASC, NLRP1, and inflammatory markers including TNF were measured. Results: Cardiac output, measured by fractional shortening decreased as compared to controls in all burned rats. The most significant change was in the pediatric rat: a 27% drop at 12h as compared to an 18% drop in other groups. In addition to significance, the pediatric rats demonstrated a longer period of cardiac dysfunction as compared to others. To measure inflammation associated with cardiac depression, TNF, IL-6, IL-1B and HMGB1 were measured from total serum and heart tissue. All markers of inflammation, except HMGB1 were elevated 2h post burn in all groups. No differences between groups were noted at early time points post injury, but significant elevations in TNF and IL-1B continued for 24h in pediatric rats. To correlate changes in the cardiac inflammasome with cardiac dysfunction, cardiac tissue was examined. In pediatric animals by 2h, ASC had doubled, and NLRP1 had decreased by 4.6%. In addition to NLRP1, following burn injury we began to detect NLRP3 in cardiac tissue as well as active caspase-1 in all burn groups. Conclusions: We observed differences in cardiac function as well as concentration and timing of expression of inflammatory markers, and inflammasome components in different aged groups of burned rats. The pediatric animal displayed the greatest changes in cardiac dysfunction and inflammation suggesting an exaggerated response as compared to both adult and aged population. Applicability of Research to Practice: As children have nearly three times the body surface area (BSA) to body mass ratio of adults, fluid losses are proportionately higher in children than in adults. We propose that our results suggest that pediatric patients are uniquely susceptible to burn shock, a combination of distributive and hypovolemic shock brought about by intravascular volume depletion, low pulmonary artery occlusion pressures, elevated systemic vascular resistance, and depressed cardiac output as a result of the differences in fluid loss and exaggerated inflammatory response. 124. Coenzyme Q10 Treatment Prevents Burn-Induced Skeletal Muscle Insulin Resistance and Reduces Sepsis-Induced Mortality in Mice H. Nakazawa, MD, PhD, M. Yamada, PhD, T. Tanaka, MD, PhD, N. Kuriyama, MD, Y. Yu, MD, PhD, A. J. Fischman, MD, PhD, J. Martyn, MD, R. G. Tompkins, MD, ScD, M. Kaneki, MD, PhD Massachusetts General Hospital, Harvard Medical School, Charlestown, MA; Shriners Hospitals for Children, Boston, MA; Massachusetts General Hospital, Harvard Medical School, Boston, MA Introduction: Coenzyme Q10 (CoQ10) is an essential cofactor for mitochondrial electron transport and its reduced form acts as an antioxidant. Deficiency of CoQ10 causes mitochondrial dysfunction and thereby exacerbates multi-organ dysfunction. We have shown that plasma CoQ10 concentrations are lower in surgical ICU patients than healthy controls. Our currently ongoing study in burn patients suggest that circulating and intracellular CoQ10 content may decline after burn. Here we studied the effects of CoQ10 on burn-induced insulin resistance and mortality after sepsis induction by cecum ligation and puncture (CLP) in mice. Methods: Male CD-I mice at 7-8 weeks of age received full-thickness third degree burn by immersing the trunk at 80 °C hot water or sham-burn, or underwent CLP or sham-operation under anesthesia. The mice were treated with reduced form of CoQIO (ubiquinol) (40 mg/kg, SC, b.i.d.) or placebo for 3 days starting at 2 h after burn, CLP, or sham-operation. To evaluate insulin signaling, 3 days post-burn, rectus abdominis muscle was excised at 5 min after insulin (0.3 U/kg, IV) or saline injection. At 16 h after CLP, liver, heart and kidney were collected for biochemical analyses. Results: Burn injury attenuated insulin signaling, as indicated by decreases in insulin-stimulated phosphorylation of Akt (p-Akt) and glycogen synthase kinase (GSK)-3β (p-GSK-3β) in muscle of placebo-treated mice as compared with sham-burn, although Akt and GSK-3β protein expression were not altered. CoQ10 increased insulin-stimulated p-Akt and p-GSK-3β two-fold in burned mice relative to placebo (p<0.01). Moreover, CoQ10 significantly reduced the mortality of septic mice and improved bacterial clearance at 16 h after CLP as compared with placebo. These results suggest that CoQ10 may mitigate sepsis-induced immune dysfunction. CoQ10 ameliorated hyperlactatemia and increase in plasma HMGB1 levels at 3 days or 16 h after burn or CLP, respectively. Furthermore, CoQIO decreased neutrophil organ infiltration and inflammatory response in liver, heart and kidney of septic mice. Conclusions: Our data show that CoQ10 treatment prevented skeletal muscle insulin resistance in burned mice and improved survival of septic mice, which paralleled amelioration of hyperlactatemia and increased circulating HMGB1 levels. These data raise the possibility that CoQ10 may improve the clinical outcome of burn patients by ameliorating insulin resistance, hyperlactatemia, systemic inflammation and immune dysfunction. Applicability of Research to Practice: These results provide scientific rationale for a clinical study to evaluate the safety and efficacy of CoQ10 supplementation to ameliorate insulin resistance and metabolic alterations and improve immune function in burn patients. External Funding: NIH (P50GM021700), Shriners Hospitals for Children (85800). 125. Burn Injury Induces Augmentations in the Endothelial Glycocalyx in a Dose Response Manner J. N. Luker, MD, MPH, B. C. Carney, BS, A. Day, BS, J. Zhang, BS, A. Alkhalil, PhD, L. T. Moffatt, PhD, L. S. Johnson, MD, FACS, J. W. Shupp, MD The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC Introduction: The endothelial glycocalyx (EGL) is a complex and highly dynamic layer coating the luminal surface of vasculature and contributing to the maintenance of vessel integrity. Syndecan-1 is a proteoglycan comprising the backbone of the glycocalyx and is shed as a result of shear forces and other biological stressors. Previous research has demonstrated that shedding of the EGL and the ensuing vascular hyperpermeability plays an important role in the pathophysiology of hemorrhagic shock. Systemic impacts such as shock and coagulopathy remain poorly understood in burn injury. Few studies have investigated the role of EGL dysfunction in thermal injury. To better understand the effect of thermal injury on glycocalyx degradation, we utilized a murine scald injury model to investigate whether burn injury would alter the integrity and function of the EGL. Methods: C57BL/6 mice were thermally injured to either a l0% TBSA or 25% TBSA wound. Sham animals were treated identically but without injury and used as controls at each time point. Animals were euthanized immediately post injury (hour 0), or at hours 2, 4, 8 or 12 after injury. Plasma levels of shed syndecan-1 were quantified using ELISA. At the time of necropsy, injured skin, lungs, and liver were harvested and biopsies were immunofluorescently stained with syndecan-1 (CD138) antibodies to visualize the effect of burn injury on the EGL structure. Results: More syndecan-1 was quantified in the plasma of thermally injured mice compared to sham animals. In the 10% injury group, there was 1.15, 1.12, 2.24, 2.09 and 1.64 times more syndecan-1 shed at hours 0, 2, 4, 8, and 12 respectively than in control animals. Fold change compared to controls at hours 4, 8, and 12 was significantly increased from hour 0 (p=0.0034, p=0.0169, and p=0.0413 respectively). In the larger injury group, there was 1.31, 1.64, 2.43 and 2.03 times more shed syndecan-1 at hours 0, 2, 4 and 8. This was significantly increased by hour four when compared to Hour 0 (p=0.0209). A peak in shed syndecan-1 levels occurred at hour 4 and a decrease at subsequent time points in both injury groups. Conclusions: Thermal injury causes shedding of syndecan-1 in a rodent scald injury model. Increased syndecan-1 shedding was associated with injury severity and a relationship seen over time Applicability of Research to Practice: The endothelial glycocalyx is a very important component of the vascular endothelium. Understanding burn induced damage of glycocalyx is essential to better treating shock and refining fluid resuscitation regimes in burn injury. This work provide further insight into quantifying damage to the glycocalyx in burn injury and underscores the impact of glycocalyx damage on treatment paradigms, healing and patient outcomes. 126. Model Development of Inhalation Injury and Burns in Ambulatory Swine with Long-Term Follow Up D. M. Burmeister, PhD, B. Beely, RT, A. Batchinsky, MD, B. Jordan, RN, MS, M. Mclntyre, BS, L. Cancio, MD, FACS, R. Christy, PhD U.S. Army Institute of Surgical Research, Fort Sam Houston, TX Introduction: Large total body surface area (TBSA) burns can have fatal effects due to multiple organ dysfunction, and concomitant inhalation injury can exacerbate symptoms and lead to lung failure. Although large animals are often used to study burns and smoke inhalation, they are usually instrumented and intubated. The current study describes initial studies in which pigs are recovered from anesthesia following a combination of a large TBSA burn and moderate smoke inhalation. Methods: In one cohort of animals (B+S) room temperature pine bark smoke was instilled into the lungs of anesthetized swine until 50% COHb levels were reached as determined non-invasively with Massimo's SpCO® probe. Afterwards, full thickness burns were created using brass blocks (9x15 and 5x5 cm) heated to 100°C and applied to 35% TBSA for 30 seconds. In another cohort of animals (B), only the thermal injury was performed. CT scanning and bronchoscopy with bronchoalveolar lavage were performed pre- and post- injury (PI), as well as on days 2, 7, and 14 PI. Results: In B+S animals, coughing and tachypnea, along with irritation and mild edema to the upper airways revealed by bronchoscopy all resolved by day 2. CT scanning revealed an acute but mild increase in pulmonary density in B+S animals with a pronounced sectoral increase in density in the areas of bronchoalveolar lavage on day 2. Significant hyperthermia (39.3 ± 0.18°C and 39.6 ± 0.17°C in B and B+S groups, respectively) was seen out to 14 days post-injury. Similarly on day 14 PI, heart rates were increased to 141 ± 25% and 125 ± 16% of baseline values in B and B+S groups, respectively. Circulating white blood cells were elevated in both groups, and on day 7 were 30.9 ± 2.9 x 103cells/μL and 27.6 ± 3.2 103cells/μL in the burn alone and tandem burn + inhalation injury groups, respectively. Acute kidney injury was also seen on day 2 PI as evidenced by higher blood urea nitrogen levels, (15.4 ± 1.4mg/ dL and 15.0 ± 1.4mg/dL in B and B+S groups, respectively), but was also not significantly different between groups. Conclusions: We have demonstrated the feasibility of studying mild inhalation injury combined with contact burn by evaluating long term follow up effects in conscious, ambulatory pigs. Systemic inflammation (e.g., cytokines) and ensuing effects on multiple organs via histopathology will be the province of upcoming investigation. Future studies will concentrate on altering/enhancing the extent of injury, as well as lengthening the time of study to examine long-term outcomes. Applicability of Research to Practice: This model will be utilized for isolating the specific effects of thermal and inhalation injuries, as well as examining therapies (e.g., stem cells, small molecules, or other biologics) directed at treating SIRS and associated MODS in burn patients. External Funding: US Army Medical Research and Materiel Command (MRMC) provided funding for this project. 127. Thermal Stability of Mafenide and Amphotericin B Topical Solution E. Randall, PharmD, K. Niece, PhD, F. Santana, PharmD, K. S. Akers, MD Brooke Army Medical Center, JBSA Fort Sam Houston, TX; U.S. Army Institute of Surgical Research, Fort Sam Houston, TX; U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX Introduction: Mafenide is a broad-spectrum topical antibacterial agent proven to reduce mortality by preventing burn wound sepsis. The package insert recommends that mafenide solutions prepared from powder can be stored at 20-25°C for up to 28 days but should be discarded within 48 hours of opening the container. In our center, amphotericin B (AMB) is added (2 μg/mL) to target invasive fungal organisms, with the combined solution (SMAT) stored at 40°C to match the ambient air temperature. To reduce costs while maintaining efficacy, we studied the impact of alternate storage temperatures and durations on the antimicrobial activities and concentrations of SMAT constituents. Methods: Solutions of 2.5% and 5% mafenide acetate, with and without AMB 2 μg/mL, were reconstituted in sterile water. Sterile water was used as a control. Solutions were stored in 1 liter pharmaceutical bottles at 2°C, 25°C or 40°C for 0, 2, 7, 14, 30, 45 or 90 days. After each storage period, mafenide activity against Staphylococcus aureus ATCC 25923 and Pseudomonas aeruginosa ATCC 27853 was determined by bioassay, and concentrations were assayed by HPLC. AMB activity of SMAT was similarly determined using Candida albicans ATCC 60193 and Aspergillus sp. (clinical isolate). Results: Mafenide concentration did not decrease in any storage condition or solution for up to 90 days. In contrast, storage of SMAT at 40°C resulted in a 90% decrease in AMB concentration by day 2. Mafenide did not completely suppress the growth of S. aureus, P. aeruginosa or C. albicans in our assay, and no clear temperature dependency was observed. Growth of Aspergillus sp. was not inhibited at day 0, and thus not tested further. Conclusions: The AMB component of 2.5% and 5% SMAT stored at 40°C has a short shelf life, which can be extended by storage at lower temperatures. Mafenide in aqueous solution resists thermal decomposition when stored between 2° and 40°C. Applicability of Research to Practice: Elevated ambient temperatures found in burn ICUs can compromise the integrity of some antimicrobials over time. Consideration should be given to storage conditions for antimicrobial solutions to preserve their maximal activity. Further work is needed to determine the role for topical agents in preventing fungal infection in burn patients. 128. Liver Injury is Associated with Mortality in Patients with Toxic Epidermal Necrolysis Syndrome M. E. Seaton, MD, S. Honari, RN, BSN, M. Careres, RN, BSN, A. Dai, BS, T. Pham, MD, FACS, S. Mandell, MD, MPH, N. S. Gibran, MD, FACS University of Washington, Seattle, WA Introduction: Toxic Epidermal Necrolysis Syndrome (TENS) is an acute severe skin disease that causes sloughing of the skin and results in a high rate of mortality. In addition to the skin, TENS is known to affect other organ systems. Whereas liver injury in TENS has been reported, its incidence and its effects on outcomes are not well characterized. The purpose of this study was to evaluate an association between hepatic dysfunction and mortality in the setting of TENS. Methods: We performed an IRB-approved retrospective cohort study of subjects with TENS admitted to our regional burn center between 2007 and 2014. Subjects with a history of end-stage liver disease or chronic hepatitis were excluded. Elevated liver function tests (LFTs) were determined on admission and defined as aspartate aminotransferase (AST) > 40 u/L, alanine aminotransferase (ALT) > 40 u/L, alkaline phosphatase (ALP) > 98 u/L, and total bilirubin > 1.3 mg/dL. The severity-of-illness score for TEN (SCORTEN) was calculated for each subject. Logistic regression was performed to compare those with elevated LFT's to those with normal LFT's with mortality as the primary outcome. Results: Sixty-two subjects were included in the study. Table 1 summarizes the subjects' characteristics. Multivariate logistic regression analysis that adjusted for SCORTEN indicated that elevated AST is an independent predictor of mortality in subjects with TENS (OR 21.3, p=0.044) (Table 2). Other elevated LFT's were not associated with mortality. Conclusions: Elevated AST is an independent risk factor for mortality among subjects with TENS. Applicability of Research to Practice: In addition to SCORTEN, clinicians should consider AST when determining the prognosis of patients the TENS. External Funding: NIH R01GM089704. Table. No title available. View Large Table. No title available. View Large Table. No title available. View Large Table. No title available. View Large 129. Interim Data from the Inhalation Severity Injury Scoring System (ISIS) Trial - the ISIS Study Group K. N. Foster, MD, MBA, FACS, K. J. Richey RN, BSN Arizona Burn Center, Phoenix, AZ Introduction: Inhalation injury can be defined as injury to and physiologic malfunction of the respiratory tract as a result of inhaling the heat, fumes, and aerosolized productions of combustion. Burn subjects with concomitant inhalation injury demonstrate increased morbidity and mortality compared to burn subjects without inhalation injury. The goal of this multicenter study is to develop a standardized scoring system for inhalation injury that can be used both to quantify and predict inhalation injury severity in adults. This is an interim report of the entire cohort of enrolled patients. Methods: Data from burn patients enrolled in the Inhalation Severity Injury Score (ISIS) study at nine burn centers were evaluated. Inhalation injury was diagnosed based on history, physical exam, lab data, and bronchoscopy findings. Inhalation injury severity was scored on a scale of 1-5 for carbon staining, edema, secretion, and erythema. Data collected included demographics, burn and inhalation injury data, and outcomes. Outcome data included mortality, ventilator days, bronchoscopy score, carboxyhemoglobin, number of days to the start of weaning, investigator assessments, length of stay and discharge disposition. Descriptive data was calculated. Results: There were 99 subjects enrolled with inhalation injury. Average age was 49 years, 60% male, and mean total body surface area burned was 22% ± 25, (range 0 - 89%). Average vent time was 11 days ±15, (range 0 - 108) and hospital LOS 29 days, with 1 subject still inpatient. Average total bronchoscopy score was 7 (range 0 to 14). Average investigator assessment score for degree of inhalation injury on a scale of 1 to 10 (1 = no injury, 10= worst injury) at 72 hours post injury was 4.6 ± 2.8 (range 0-10) and at hospital discharge 3.81 ± 2.53. Average carboxyhemoglobin was 9.68 ± 11.4 (range 0.3-53.7) with 27 subjects having a level ≥ 10. Discharge disposition was 38 to home, 34 to an outside facility and 19 deaths. Conclusions: These Interim data from ISIS demonstrate the demographic data from patients with inhalation injury admitted to participating burn centers. Relationship of these parameters and outcomes to bronchoscopic scoring, CT scoring, and inflammatory mediators will be described. Applicability of Research to Practice: The most recent ABA State of the Science meeting recognized that development of an inhalation injury scoring system was the number one research priority for inhalation injury in burn patients. This study attempts to accomplish just that. External Funding: American Burn Association Combat Casualty Grant - Department of Defense. (#W81XWH122074) 130. Facial Burns Received While Smoking on Home Oxygen Results in Significant Mortality M. D. Esquenazi, BS, D. E. Bell, MD University of Rochester Strong Memorial Hospital, Rochester, NY Introduction: Prescribing home oxygen therapy (HOT) to smokers continues to produce preventative burn injuries. Inhalational injury is often assumed within this population, leading to rapid intubation. This study analyzes the outcomes associated with burn injury due to smoking on HOT. Methods: Retrospective chart review was conducted at a level I trauma and regional burn center from June 2007 to April 2015. Data-points included demographics, TBSA, intubation status and circumstances, hospital days (LOS), hospital charges, excision and grafting needs, and outcomes. HOT burns were stratified based upon intubation status. Further, HOT burns were compared to facial burns due to another explosive cause matched by TBSA and age. Results: A total of 64 HOT burn admissions, representing 57 patients, were identified comprised of a 59% male, 89% Caucasian population. Average burn size was 1.71% TBSA (range, 0.09-19.03%) with average 2nd-degree of 1.01% TBSA and 3rd-degree of 1.69% TBSA. When compared to the facial burn control, HOT burns produced a significantly higher rate of intubation (30% vs. 10%, p<0.01) with associated longer hospital stay (11 vs. 5 days, p<0.05) and higher rate of mortality (11% vs. 0%, p<0.05). HOT burn intubation rate was 30%, all performed before admission to burn unit. Intubations were performed in the following setting: 52% at the scene, 26% in the emergency department, and 21% at outside hospitals. Reason for intubation was seldom recorded. In comparing intubated to non-intubated HOT cases, TBSA was found to be matched. Intubated HOT cohort was found to be statistically older (69 vs. 63 years, p<0.05), require an increased LOS (27 vs. 3 days, p<0.005) and ICU LOS (5 vs. 0.15 days, p<0.05), undergo more excision and grafting (74% vs. 8%, p<0.0001), and produce higher cost ($134,576 vs $9,537, p<0.0001). Mortality was exclusively seen within intubated patients, amounting to 11% of all HOT burns (37% of the intubated sub-group). Conclusions: Burns due to smoking on HOT have multiple grave repercussions. When compared to facial burns from other explosive etiologies, HOT burns have a higher rate of intubation, LOS, cost, and mortality. Intubation for HOT burn patients is often performed before admittance to the burn unit and is also associated with a significantly higher rate of mortality and morbidity. Applicability of Research to Practice: Prescribing HOT to smokers should be done with extreme diligence and intensive education. HOT, while critical for many patients, may be inappropriate in the setting of noncompliance. 131. Revisiting the Role of Increasing Ambient Temperature During Burn Care: A Systematic Review of the Literature J. A. Rizzo, MD, M. P. Rowan, PhD, I. R. Driscoll, MD, R. K. Chan, MD, K. K. Chung, MD U.S. Army Institute of Surgical Research, Fort Sam Houston, TX Introduction: Increasing the ambient temperature during care of the severely burned in the operating room and intensive care unit (ICU) is among the few important recommendations listed in the clinical practice guidelines for the care of combat related burns for the purpose of mitigating the loss of thermoregulation and prevent hypothermia in the short-term and to attenuate the consequences of hypermetabolism long term. A systematic review was performed to evaluate the scientific support for this recommendation and to examine and reflect on any second or third order adverse effects. Methods: Electronic databases were searched using a predefined search strategy of both human and animal studies. Studies examining the ambient temperature of the operating room or ICU room were included in both burned and non-burned patients and published articles on thermoregulation of the burned patient were examined. Evidence quality was assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Results: One hundred four papers were identified that examined temperature in burned patients in the operating room or ICU. Manual evaluation of the papers for relevance to the topic yielded 15 papers. These papers, all human studies with a majority written before 2000, evaluated the various aspects of increased heat loss in burned patients and evaluated different ways to maintain core temperature, including increasing ambient temperature. When applying the GRADE criteria, evidence quality was low/very low. Papers examining ambient temperature in the non-burned population revealed 146 human studies and 184 animal studies, which were narrowed after manual evaluation to 43 and 11, respectively. Again when applying the GRADE criteria, evidence quality was low. A few studies examined the possible adverse effects of exposure to increased ambient temperature, such as increased rates of infection. Conclusions: The current evidence on the value of increasing ambient temperature during care of the severely burned in the operating room or ICU is scarce with minimal human data to show benefit, lack of controlled clinical trials, and with almost no investigation of potential adverse effects. Currently, no definite conclusion can be reached about its effectiveness. Applicability of Research to Practice: Investigation into the risks and benefits of raising room temperature during the care of the severely burned needs to be expanded. 132. Home Oxygen Therapy Related Burns: An Outcome Comparison Based on Location of Intubation J. Meyerson, MD, R. Coffey, RN, MSN, CNP, L.M.Jones, MD The Ohio State University Wexner Medical Center, Columbus, OH Introduction: Home oxygen therapy (HOT) can lead to burn injuries if a patient smokes during treatment. The total body surface area of these injuries are often small, involving the face with patients undergoing subsequent intubation for airway protection. Studies have demonstrated a lack of inhalation injury in this population with resulting complications of unnecessarily placing end-stage lung disease patients on ventilators. No study, to our knowledge, has focused on the location (designated burn center vs. not) of intubation of HOT-related burn (HOTRB) patients and outcomes. Methods: A retrospective study of all HOTRB patients admitted to our burn center from 2006-2015 was performed. Data collected included age, sex and intubation versus non-intubation, location of intubation by emergency medical services or outside hospitals (OSH) or our burn center (BC), and indications for intubation, bronchoscopy findings and complications related to intubation. Outcomes included ICU length of stay (LOS), hospital LOS and ventilator days. Results: A total of 79 patients presented to our institution with a HOTRB. Groups were split into intubated and non-intubated patients. In total, 34% of patients presenting with HOTRB injuries were intubated. Of this number 68% were intubated by OSH prior to transfer with the remaining 32% being intubated at our BC. Patients that were intubated versus non-intubated had on average a longer LOS of 9.7 vs. 2.6 days (p<0.0001), longer ICU LOS of 5.75 vs. 0.6275 days (p<0.0001) and a greater number of days on a ventilator 4.5 vs. 0.0 days (p<0.001). No patient in our study demonstrated inhalation injury on bronchoscopy. Most common complications from intubation resulted in ventilator acquired pneumonia and tracheostomy. The location of intubation over the time of our study demonstrated an increasing trend with the percentage of patients being intubated at OSH vs. BC of HOTRB admissions (29% vs. 8.6%, p<0.048, 2006-2015). The difference in this trend of 4.3% continued to expand from the first half of the study (11.9% vs. 6.9%, p=0.52, 2006-2010) to the most recent 5 years with a difference of 37% (47.3% vs. 10.3%, p<0.029, 2010-2015). Conclusions: The morbidity associated with HOTRB injuries include longer hospital LOS, ICU stays and more ventilator associated complications. No study to date has compared these populations based upon location of intubation. There is an increasing number of HOTRB patients being intubated at outside hospitals or by EMS prior to getting to the burn center over the past 10.5 years. Applicability of Research to Practice: Indications and algorithms for intubation of HOTRB patients need developed and evaluated. Community education for EMS and OSH personnel must be implemented to provide best practice for this population. 133. The Use of Verapamil to Treat the Hypermetabolic State in Pediatric Burn Patients R. A. Rodriguez, BA, F. J. Bohanon, MD, C. R. Andersen, MS, P. Stevens, BA, C. C. Finnerty PhD, W. Meyer, MD, D. N. Herndon, MD, FACS Shriners Hospitals for Children, Galveston, TX Introduction: Pediatric burn survivors with large burn injuries often become hypermetabolic. This state is characterized by increased cardiac work, which presents as hypertension and tachycardia. In an investigation to find alternative treatments to decrease heart rate in pediatric burn patients, verapamil was administered to pediatric burn patients with ≥30% of total body surface area burned. Methods: Twenty one pediatric patients with ≥30% of total body surface area burned and experiencing episodes of tachycardia and hypertension were identified and treated with verapamil. The systolic blood pressure (BP), diastolic BP, mean arterial pressure (MAP), and heart rate (HR) were averaged over 5 or more days before (pre-drug), during (during drug), and after (post-drug) verapamil administration. Univariate statistical analyses were performed using R statistical software. Significance was set at (p<0.05). Results: Verapamil was administered for 11.4 ± 9.9 days at an average dose rate of 3.5 ± 2.4 mg/kg/day. HR declined by 2.7 beats per minute (bpm) for every additional year of subject age (p=0.002). At the post-drug time interval, the HR was 12 bpm lower than at the pre-drug time interval (p=0.0001). However, there was no significant difference between the pre-drug HR and during drug HR (p=0.08). The mean systolic BP increased by 1.2 mmHg for each additional year of age (p=0.03). There was no change in mean systolic BP from the pre-drug to the post-drug time interval. There was not a significant difference in diastolic BP between the pre- and during drug time intervals (p=0.09). Diastolic BP was 7.7 mmHg higher at the post-drug time interval compared to the pre-drug time interval (p=0.0005). There was no significant difference in MAP at any time interval or due to any covariate. Arterial mean pressures were 74.9 ± 8.6 mmHg pre-drug, 71.4 ± 7.2 during drug and 79.1 ± 11.2 mmHg in the post-drug period. One patient had an adverse reaction attributed to the verapamil which was discontinued. Conclusions: Verapamil is not effective for treating episodes of tachycardia and hypertension that are induced by a severe burn injury in pediatric burn patients. Applicability of Research to Practice: This preliminary investigation demonstrates that verapamil should not be used to treat post-burn hypertension and tachycardia in severely burned patients. External Funding: NIDILRR 90DP00430100, NIH P50-GM60338, NIH R01-GM56687, NIH T32-GM8256, NIH UL1TR000071, and Shriners Hospitals for Children (84080, 71009, 71008, 71006, 79141). 134. Fresh Frozen Plasma (FFP) and Burn Resuscitation T. F. Huzar, MD, FACS, T. C. George, PA-C, MSHS, MSPH, PhD, J. Harvin, MD, R. A. Lawless, MD, J. M. Cross, MD, FACS, D. J. Freet, MD, FACS, B. A. Cotton, MD, MPH, C. E. Wade, PhD, J. D. Love, DO, FACS University of Texas Health Science Center Houston, Houston, TX Introduction: The goal of fluid therapy during burn resuscitation is to maintain global tissue perfusion in the face of massive systemic inflammation, fluid extravasation, and intravascular hypovolemia. Early initiation of fluid resuscitation is the gold standard in the management of burn shock. Isotonic crystalloids have been the fluid of choice for over 50 years, although over-resuscitation with its use has been a concern due to increased risk of morbidity and mortality. Burn surgeons have incorporated colloid infusions in their burn resuscitation protocols to limit total crystalloid volume used. FFP is a colloid shown to lower the incidence of over-resuscitation, when combined with crystalloid infusions, during burn resuscitation. The purpose of this study is to determine the effects of FFP on total crystalloid volume required during burn resuscitation. Methods: We conducted a retrospective review of all patients admitted to our burn center between 1/2010 and 4/2015. Exclusion criteria included patients with <20% TBSA burns, < 18 years-of-age, and burn patients with poly-trauma. Patients resuscitated with FFP and crystalloids were matched for age and TBSA% in a 1:2 manner and compared against patients resuscitated with crystalloids alone. Acute burn resuscitation was defined as 0-24 hours post burn injury. Results: Eight patients were resuscitated with a combination of FFP and crystalloids. The control group consisted of 16 matched patients. There were no significant differences in age, gender, weight, TBSA, or percentage of third degree burns. The FFP group had a higher rate of inhalational injury, although significance was not reached (6[75%]; 6 [38%], p=0.193). The FFP group received significantly lower volumes of crystalloids during resuscitation (7,955 mL [IQR 6,250, 8,990]; 11,746 mL [IQR 8,975, 15,445]). The median amount of FFP administered was 2,205 mL (IQR 1,930, 2,960). There were no significant differences in mortality, hospital length of stay, ventilator or ICU days. However, the FFP group had lower rates of acute kidney injury (25% vs 50%), multi-organ dysfunction syndrome (13% vs 38%), pneumonia (0 vs 38%) , and septic shock (0 vs 25%), although these did not reach statistical significance (this may represent a type II error due to sample size). Conclusions: In this pilot study, administration of FFP was associated with a greater than seven liter reduction in crystalloid administration and less complications than crystalloid alone. The use of FFP during burn resuscitation appears to significantly decrease overall crystalloid volume required during our burn resuscitations. Applicability of Research to Practice: The use of FFP may decrease overall volume of crystalloids given in burn resuscitation and decrease the risk of over-resuscitation. 135. Comparison of Novel Predictors of Burn Sepsis Versus the American Burn Association Sepsis Criteria J. Yan, BSc(Hons), M. A. Burnett, BSc(Hons), J. Bian, BSc(Hons), W Xiong, MSc, S. Shahrokhi, MD, FRCSC, M. G. Jeschke, MD, PhD Sunnybrook Health Sciences Centre, Toronto, ON, Canada Introduction: The major contributor to mortality in severe burn is sepsis. Despite this, the diagnosis of sepsis remains challenging. The American Burn Association (ABA) sepsis diagnostic criterion was developed in 2007 to enable and standardize the definition of burn sepsis. In 2013, a study by Mann-Salinas et al. proposed novel criteria suggested being more predictive than the ABA criteria, but this formula has not been verified. Our aim is to compare the sensitivity of the ABA criteria against these novel criteria. Methods: This study was a single institution review of 28 patients admitted to an ABA-verified burn center between 2010-2014 with &gt20% TBSA burns. All patients were diagnosed as septic by the prospective clinical diagnosis of the medical staff. Both ABA and the novel criteria were then each applied using patient records to determine whether sepsis could be diagnosed with these conditions. Analysis was performed using McNemar X2, spearman correlation and logistic regression under SPSS. Results: McNemar X2 demonstrated no significant difference in sensitivity between the two sets of criteria (p=0.180). However, the ABA criteria diagnosed 23/28 (82.1%) of the septic patients while the novel criteria was only able to diagnose 18/28 (64%). Within the ABA criteria, spearman correlation showed that only the hyperglycemic condition significantly correlated with sepsis (r=0.434, p=0.021). Within the novel criteria, hypotension (&lt60mmHg) (r=0.600, P=0.0001) and vasoactive medication use (r=0.701, P&lt0.001) were found to strongly correlate with the onset of sepsis. Based on logistic regressions, the most significant predictors for sepsis from both criteria were hyperglycemia (p=0.027), hypotension (p=0.011) and vasoactive medication use (p=0.010). Conclusions: Though neither set of criteria significantly differed in sensitivity for sepsis, the novel criteria excluded 50% more patients overall than the ABA criteria. The lack of significance may be due to a limited study size, but this signal suggests the ABA criteria overall could be actually more predictive than the novel criteria. Applicability of Research to Practice: Developing the most accurate criteria clinicians can use to diagnosis burn sepsis is first step to prompt medical intervention and better patient prognosis. External Funding: Canadian Institutes of Health Research # 123336.CFI Leader's Opportunity Fund: Project # 254072R01GM087285-05A1. 136. The Association Between Coagulopathy and Early Ventilator-Associated Pneumonia Among Burn Patients D. Younan, MD, M. Thompson, MD, J. C. Crosby, MD, R. Griffin, PhD, A. Papoy, MD, J. Kerby, MD, PhD University of Alabama in Birmingham, Birmingham, AL Introduction: There are approximately 40,000 burn injuries requiring hospitalization and over 3,400 burn injury-related deaths in the United States annually. The incidence of Ventilator- associated pneumonia (VAP) increases with duration of mechanical ventilation, which is often prolonged in severe burns. We hypothesized that coagulopathy in burn patients is associated with increased risk of VAP. Methods: In this matched case-control study of data from 2007-2011, cases of early VAP were identified from our burn registry. Early VAP was defined as patients immediately intubated following injury and diagnosed with VAP within 5 days of admission. Patients were classified as being non-coagulopathic (NC) or having coagulopathy (defined as INR ≥ 1.2) either at admission (AC) or at 24-hours following admission (i.e., latent coagulopathy [LC]). For each case, up to three controls were matched based on age±5 years, race, and sex. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between coagulopathy and early VAP. In a post-hoc analysis, models were stratified to examine effect modification by age. Results: From 2007 to 2011, 100 cases of early VAP were identified. Among the 100 early VAP cases and 297 matched controls, patients with LC were 26 times as likely to develop early VAP (OR 26.55, 95% CI 10.56-66.76) compared to NC patients. This association remained, though weaker, after adjusting for TBSA, age, and length of hospital stay (OR 12.85, 95% 4.54-36.39). There was effect modification by age (p=0.0162), with the association for patients with LC being present only among those aged younger than 60 years (OR 23.54, 95% CI 4.08-135.97). There was no association noted between AC and early VAP. Conclusions: In this population of burn patients, latent coagulopathy was associated with early VAP independent of age, race, sex, TBSA, and hospital length of stay. This association was present only among those aged younger than 60 years. Applicability of Research to Practice: The findings in our study will increase awareness of the significance of coagulopathy in this patient population. 137. Clinical Distribution of Microorganisms Causing Infection in Burn Patients K. Lima, BS, M. Holland, Z. Godwin, BS, N. Tran, PhD, T. Palmieri, MD, FACS, FCCM, D. Greenhalgh, MD, FACS University of California Davis, Davis, CA Introduction: Burn related mortality is frequently associated with sepsis. The knowledge of the type, frequency, and source of infections could greatly improve identification and treatment of sepsis in burn patients. Our goal is to characterize the distribution of microbes detected in burn patients and identify common sources of infection and sepsis. Methods: We conducted a retrospective review of an existing dataset containing daily vital signs, microbiological cultures, and antimicrobial therapy from 169 adult (age≥18 years) patients with ≥20% total body surface area burns from four burn centers across the United States. Pathogens identified by microbiological culture (i.e., blood, wound, respiratory, or tissue) were recorded. The pathogen type, time of infection, microbial species, and infectious sources were analyzed. Additionally, antimicrobial administration and dosing according to culture status was evaluated to assess treatment efficacy. Results: In total, 1,792 pathogens were detected by microbiological culture. Of these, 47.3% were Gram positive (GP) bacteria, 32.9% were Gram negative (GN) bacteria, 18.4% were fungi, and 1.3% were viruses. The most prevalent GP microorganism was Staphylococcus species, representing 50.8% of the 848 found by microbiological culture. Within this species, 21.7% were coagulase negative Staphylococcus, 17.5% were methicillin-susceptible S. aureus (MSSA), and 11.6% were methicillin-resistant S. aureus (MRSA). Notably, of the 60 patients positive for MSSA, 90% were empirically treated with vancomycin upon indication of GP cocci growth. Prevalent GN bacteria included Pseudomonas aeruginosa (26.79% of GN species) and Escherichia coli (12.0% of GN species). Time for onset of GP, GN, versus fungal infections from admission was not significantly different. With respect to the 1,748 sources included in this study we found that 31.2% of cultures were respiratory, 21.9% were wound swabs, 17.4% were tissue cultures, 11.9% were blood cultures, 6.5% were urine cultures, and 11.0% were from other various sources. Conclusions: Our study revealed pathogen distribution to be similar to prior studies with the most frequently isolated GP and GN pathogens being S. aureus and P. aeruginosa respectively. Empiric antimicrobial therapy for suspected MRSA infections were found to be largely unnecessary due to the time delay for pathogen identification. There were no discernable patterns to onset of GP, GN, or fungal infections. Applicability of Research to Practice: The predominant pathogens causing infection in clinical settings are constantly changing, partly due to advancements in antimicrobial therapy. Providing data on what microorganisms, and their sources, are currently most prominent can be utilized in clinical settings to improve empiric antibiotic treatment. External Funding: USAMRMC Combat Casualty Grant from the Department of Defense. 138. The Association of Physical Exam Findings and Inhalation Injury E B. Kumar, BS, E. I. Hodgman, MD, A. R. Cai, BA, A. J. Sehat, BA, S. E. Wolf, MD, FACS University of Texas Southwestern Medical Center, Dallas, TX Introduction: Previous studies have suggested that the "classic" signs of inhalational injury are neither sensitive nor specific. Our goal was to evaluate the ability of these signs to predict inhalation injury in our population. Methods: After obtaining Institutional Review Board approval, we reviewed the records of all patients admitted to a regional Level One burn center from June 2013 through June 2014. Physical exam findings, diagnosis of inhalation injury, and outcomes were analyzed using χ2 and Fisher's exact test as appropriate. Results: A total of 664 patients were admitted during the study period. Of those, 36 were documented as having an inhalation injury, however only 27 (75%) patients underwent bronchoscopy to confirm the diagnosis. Virtually all patients with an inhalation injury sustained a flame injury (n=35, 97.2%); one patient had an airway injury as a result of an electrical burn. Physical exam revealed the presence of carbonaceous sputum in 40 patients, singed nasal hairs in 87 patients, hoarseness in 13 patients, nasal or oral mucosal injury in 30, and stridor in 7. Presence of carbonaceous sputum (2.6 vs 68.6%, p<0.0001), burns to the head and/or neck (42.0 vs 61.1%, p=0.025), singed nasal hairs (11.6 vs 50.0%, p<0.0001), and mucosal injury (3.45 vs 28.1%, p<0.0001) were each associated with an inhalation injury. On subset analysis of patients who underwent bronchoscopy, only carbonaceous sputum was predictive of an inhalation injury (25.0 vs 71.43%, p=0.0002). The sensitivity and specificity of carbonaceous sputum was 80% and 100%, respectively, yielding a positive predictive value of 1.00 and a negative predictive value of 0.64. Conclusions: Carbonaceous sputum is highly suggestive of the presence of an inhalational injury, with 80% sensitivity and 100% specificity. Patients with carbonaceous sputum should be monitored closely for signs of airway compromise or respiratory distress. Applicability of Research to Practice: These results demonstrate that some, but not all, of the "classic" signs of inhalation injury have good predictive ability. External Funding: This project is funded through DOD grant #W81XWH122074 and the generous support of Song of the Flag and the Pettis family. 139. Body Mass Index Demonstrates Increasing Trends of Complications Including Mortality in Adult Burn Patients L. Willand, MA, J. Armstrong, BS, B. Gonzalez, MSc, K. Carey, BS, M. Afshar, MD, M. J. Mosier, MD, FACS, FCCM Loyola University Chicago Stritch School of Medicine, May wood, IL; Clinical Research Office (CRO) Loyola University Medical Center, Maywood, IL; Clinical Research Office (CRO) Loyola University Chicago, Maywood, IL; Division of Pulmonary and Critical Care Medicine, Loyola University Health Sciences;Department of Public Health Sciences, Loyola University School of Medicine, Maywood, IL; Loyola University Department of Surgery, Maywood, IL Introduction: Obesity rates continue to increase and obesity has been shown as a predictor of morbidity and mortality after burn injury; however, mild obesity may improve survival. This "obesity paradox" deserves further investigation to clarify how different stages of obesity may affect clinical outcomes. Methods: We conducted a retrospective review of 345 adult burn patients over a 17 month period. Body mass index (BMI) was stratified according to World Health Organization definitions: < 18.5, 18.5 to 29.9, 30 to 34.9, 35 to 39.9, and >40. Associations of clinical and demographic variables and BMI groups were assessed using Pearson's Chi-Square Tests or Fisher's Exact Tests for categorical variables, Wilcoxon-Rank Sum Tests for continuous variables in which medians were compared for two groups, or Kruskall-Wallis Tests for continuous variables in which medians were compared for more than two groups. Significance of trends was analyzed using Cochran-Armitage Tests for Trend for categorical variables, Cuzick Tests for Trend for continuous variables (medians), and Generalized Linear Models for continuous variables (means). Results: Mortality was not significantly different among BMI groups. However, as BMI increased it had a direct relationship with mortality (P-Trend=0.03), increased rate of infection (P-Trend=0.01), pneumonia (P-Trend=0.02), UTI (P-Trend=0.04), and AKI (P-Trend=0.04), though less acute respiratory distress syndrome (P-Trend=0.02), and greater incidence of tracheostomy (P-Trend=0.02) with increasing BMI. Conclusions: Overall, obesity was not associated with increased morbidity and mortality, though subgroup analysis suggested that morbidly obese patients have an increased risk of mortality compared to other BMI groups and infectious complications trended greater with increasing BMI. Applicability of Research to Practice: This study emphasizes the increasing risk of complications relating to increasing BMI. Recognition of this trend by practitioners and caregivers may allow for increased prophylactic measures and monitoring and reduction of complicating events, patient suffering, and resource utilization. 140. Mean Platelet Volume is a Marker for Mortality in Burn Patients A. Jain, MD, B. Chan, PhD, N. Tran, PhD, T. Palmieri, MD, FACS, FCCM, K. Cho, PhD, D. Greenhalgh, MD, FACS, S. Sen, MD, FACS UC Davis, Sacramento, CA Introduction: Despite modern burn care and advances in critical care, mortality following burn injury remains high. Various models to prognosticate outcome after burn injury are available, however there are no dynamic markers to predict outcomes of patients as they progress through their hospital course. Elevated mean platelet volume (MPV) has recently been associated with inflammation and increased mortality in critically ill patients. We hypothesize that an elevation of MPV following burn injury will be an independent marker for mortality following burn injury. Methods: We performed a retrospective study of all adult (>18 years of age) burn patients admitted to our regional burn center from 2010 to 2014. We included only patients who were admitted for over one week and had at least two complete blood count (CBC) analysis drawn during the first week of admission. Collected data included: age, %TBSA, length of ICU stay, length of mechanical ventilation, mortality, and CBC. All mean values are mean ± standard deviation. All median values are: median (interquartile range). Results: A total of 384 patients were included in the study. Mean age and TBSA were 50 ± 18 years and 14.6 (7.5-26.5)%. The mortality rate was 6.7%. Non-survivors were significantly older (60 ± 18 vs. 49 ± 18) and had a larger TBSA (36.5 (26.3-56) vs. 14(7.3-24)%) than survivors. There were no differences in MPV during the first 5 days of admission between non-survivors and survivors. However, MPV in non-survivors was significantly elevated on the 6th (8.5 ± 1.1 vs. 8 ± 0.8 fL) and 7th (8.5 ± 1.2 vs. 7.8 ± 0.8 fL) day of admission. Multivariate logistic regression analysis adjusting for age and TBSA shows that the MPV on both admission day 6 (OR 1.8 (CI 1.1-3.1)) and day 7 (OR 2.1 (CI 1.25-3.52)) is an independent marker for increased risk of death. Conclusions: MPV is a biomarker for increased risk of death in burn-patients during the first week of admission. MPV may be a dynamic biomarker that reflects increased inflammation leading to poor outcomes in burn patients. Applicability of Research to Practice: Mean platelet volume can be a useful indicator to predict outcome in a severely burned patient during the hospital stay. Further studies to define how mean platelet volume represents the severity of inflammatory state are needed. 141. Outcomes Following the Use of Nebulized Heparin for Inhalation Injury (HIHI Study) A. M. Mclntire, PharmD, BCPS, S. A. Harris, PharmD, BCPS, J. A. Whitten, PharmD, BCPS, A. C. Fritschle-Hilliard, PharmD, BCPS, D. R. Foster, PharmD, R. Sood, MD, FACS, T. A. Walroth, PharmD Eskenazi Health, Indianapolis, IN Introduction: Inhalation injury (IHI) causes significant morbidity and mortality in burn victims due to local and systemic effects. Nebulized heparin promotes improvement in lung function and decreased mortality in IHI by reducing the inflammatory response and fibrin cast formation. The study objective is to determine if nebulized heparin 10,000 units improves lung function and decreases mechanical ventilation duration, mortality, and hospitalization length in IHI. Methods: This retrospective, case-control study evaluated efficacy and safety of nebulized heparin 10,000 units administered within 48 hours of confirmed IHI in mechanically ventilated adults. Nebulized heparin 10,000 units was administered Q4H for 7 days, or until extubation if sooner, alternating with albuterol and a mucolytic. Patients were matched on a case-by-case basis by percent total body surface area (%TBSA) burn involvement and age to patients from a historical group with IHI before heparin protocol implementation. The primary outcome was duration of mechanical ventilation. Secondary outcomes included lung injury score (LIS), ventilator-free days in the first 28 days, 28-day mortality, length of stay, VAP incidence, bronchoscopy incidence, and reported clinically significant bleeding events requiring therapy disruption. Results: Data was collected in 20 patients, 10 received nebulized heparin and 10 historical controls. Two patients from each group died or were discharged on the ventilator. Data were analyzed separately with (1) all subjects included and (2) subjects who died/were discharged on the ventilator excluded. No statistical difference was noted in either comparison of median duration of initial mechanical ventilation (15 ± 23.3 vs. 10.5 ± 15.8 days [p=0.622] or 17.3 ± 13.7 vs. 15.1 ± 12.2 days [p=0.733] respectively). Patients in the heparin group had a non -significant increased number of median ventilator-free days in the first 28 days (20 ± 19.3 vs. 13 ± 19.5 days, p=0.490). Median length of hospitalization was shorter with heparin although no statistical difference was found (17 ± 16.3 vs. 25.5 ± 32.3 days, p=0.596). There were no differences in LIS during the first 7 days, 28-day mortality, VAP rate, or incidence of bleeding. Conclusions: Nebulized heparin 10,000 units produced a nonsignificant reduction in duration of mechanical ventilation and length of hospital stay in adults with IHI. Nebulized heparin 10,000 units was safe and did not result in increased bleeding events. Applicability of Research to Practice: To our knowledge, this is the first case-control study with cohorts matched based on age and %TBSA involvement which are factors contributing significantly to morbidity and mortality in IHI. Future efforts include continuing to assess outcomes in case-control matched patients in a larger sample. 142. A Fifteen-Year Retrospective Review of Clinical and Psychosocial Outcomes Following Electrical Injuries N. Radulovic, BSc(Hons), M. A. Burnett, BSc(Hons), M. G. Jeschke, MD, PhD Sunnybrook Health Sciences Centre, Toronto, ON, Canada Introduction: While electrical injuries account for only a small portion of all burn admissions, they can have substantial physical and psychosocial implications. These short and long-term effects have not been extensively studied or documented, therefore, this study aims to determine these adverse outcomes and additionally compare between low voltage (LV) and high voltage (HV) groups. Methods: Review of 194 patients admitted to a single ABA-verified burn centre following an electrical injury between 2000-2015. Records were reviewed for information pertaining to patient demographics, burn etiology and clinical and psychosocial outcomes. Results: Males represented 96% of cases, with a mean age of 41 years. 61% of injuries were from LV sources (&ltl000) while 36% were due to HV (&gtl000V) . HV injuries had a greater incidence of complications when compared to the LV group. Most notably, HV injuries resulted in an increased number of cases of rhabdomylosis (13% vs. 0%, p=0.0001), compartment syndrome (17% vs. 3.4%, p=0.0019) and amputations (29% vs. 2.5%, p=0.0001). There was no significant difference in mortality between HV and LV injuries (4.3% vs. 0.8%, p=0.l443). More patients required rehabilitation following HV injuries (61%) compared to 42% of patients in the LV group (p=0.0235). Furthermore, 24% of all patients experienced some form of psychological alteration (i.e. memory loss, flashbacks, PTSD, depression) following the acute injury period, with 8.3% requiring formal counselling and 6.7% requiring psychiatric medication. Additionally, 80% of injuries were work-related, with 3.2% of these patients requiring retraining, 9.5% requiring schedule or duty modifications, 7.6% unable to return to work during the first year post-burn and 1.9% unable to do so five years following injury. 3.8% of these patients were permanently unable to return to their previous employment. Conclusions: Electrical injuries result in impairments that surpass the acute injury period. While HV injuries are associated with a greater incidence of complications, longer hospital stays and more extensive rehabilitation, long-term psychosocial effects are present in both voltage groups. The majority of burns are work-related, highlighting the importance of proper employment training and use of protective equipment when working with any electrical voltage. Applicability of Research to Practice: Education emphasized in the workplace regarding preventative measures is vital. Furthermore, patient education and monitoring concerning psychological outcomes that are prevalent among this burn population need to be stressed early on. External Funding: Toronto Hydro and OEN. 143. Prevalence of Herpesviridae Viremia in Pediatric Burn Patients C. D. Voigt, MD, P. Wurzer, MD, K. Capek, MD, C. R. Andersen, MS, L. K. Branski, MD, W Muses, MT(ASCP), H. K. Hawkins, MD, PhD, C. C. Finnerty, PhD, D. N. Herndon, MD, FACS, J. O. Lee, MD, FACS University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX; Shriners Hospitals for Children, Galveston, TX Introduction: Previous studies have noted herpes virus reactivation in burn patients, who display a peculiar type of immunosuppression. Burn intensive care units have reported prevalence figures as high as 55% in major burns. We are interested in what role this viral infection/reactivation plays in burn convalescence. Methods: For this IRB-approved retrospective review, inclusion criteria of the base population was a length of stay less than 7 days and burn size greater than 20%. Included patients were tested for herpesviridae viremia via polymerase chain reaction when deemed clinically indicated by the treating physician. Clinical triggers for testing in these patients included: herpetiform lesions, unexplained graft loss/skin donor site conversion, clinical criteria for burn sepsis minus an apparent source per bacteriologic culture, or unexplained leukocytosis. Testing (whole blood, via reference laboratory) was performed when clinical triggers were recognized. We report 95% confidence interval for the base population and the tested patients' demographics, as well as viremia prevalence in the tested patients. Likelihood ratios (LR) compared the burn type and gender distributions in the base population with those observed in the test positive and test negative groups. Results: Between May 2014 and September 2015, 28 patients had blood specimens panel-tested for Herpes Simplex Virus 1 and 2 (HSV 1 & 2), Varicella Zoster Virus (VZV), Cytomegalovirus (CMV), Epstein-Barr Virus (EBV), and Human Herpes Virus-6 (HHV-6). No cases of HSV or VZV viremia were observed. The prevalence of CMV, EBV, and/ or HHV-6 DNAemia was 35.7%. There were no apparent associations between viremeia and length of stay, burn size, gender, or burn mechanism. In viremic patients, copy numbers ranged from less than 100 to over 4000 copies/mL. Conclusions: A large portion of tested patients presented with a clinically detectable CMV, EBV, or HHV-6 viremia. Our sample size is limited and should be seen as preliminary data for future clinical trials and investigation into the host and pathogen factors conditioning the incidence and clinical impact of herpesviridae viremia. Applicability of Research to Practice: Previously unrecognized systemic viral infections/reactivations are occurring in pediatric patients with major burns. This preliminary data strongly supports a need for future clinical trials and investigation into the host and pathogen factors conditioning the incidence and clinical impact of herpesviridae viremia. External Funding: This study was supported by the National Institutes of Health (P50 GM060338, UL1TR000071, T32-GM008256, R01-GM056687, R01-GM112936, R01-HD049471), the Shriners Hospitals for Children (71006, 71008, 71009, 80100, 84080), and the Department of Health and Human Services NIDILRR - Disability and Rehabilitation Research Program (DRRP): 90DP0043-01-00. 144. A Review of 26 Cases of Frostbite in an ABA-Verified Burns Center A. McKenna, MBBCh, MSc, FRCS, FRCS(Plast), M. Burnett, BSc(Hons), A. Rogers, MBBCh, MMed, M. Jeschke, MD, PhD Ross Tilley Burn Centre, Toronto, ON, Canada Introduction: Accidental cold-related injury is a potentially life-threatening condition that can lead to significant morbidity and life-long effect. An increase in participation in outdoor activities and the epidemic of homelessness coupled with a statistically significant worsening of freezing weather conditions has led to an increase in both the incidence and severity of frost bite injury. The aim of this study is to identify the different resuscitative requirements, management challenges and potential complications in this thermal injury group. Methods: A REB approved chart review of all patients admitted to an adult regional American Burn Association-verified burn center in the last 10 years. All patients were included. The diagnosis of frost bite was made clinically by a staff burns physician and the severity of frostbite was further delineated by tissue biopsy and bone scans in certain cases. Demographic, etiologic, critical care, surgical and outcome data was recorded and analyzed with descriptive statistics. Results: 26 patients were admitted, aged 18 to 86 years with a median age of 32. 10 patients were hypothermic on arrival with an average exposure to freezing temperatures of 6 hours (1 - 24). Most cases were 3rd degree and the TBSA ranged from 1 - 55%. 50% of cases were associated with intoxication, 27% were homeless, 23% were sports related and 19% had suffered an MVA in the snow. TBSA >13% required fluid resuscitation above maintenance fluid, blood transfusions +/- inotropic support. Some patients required up to 12 liters IVF/day for 6-19 days until normal physiology returned. 5 patients were ventilated (3 - 34 days) one required HFO ventilation. 9 patients required 2 or more surgical procedures and 16 amputations were performed. There were 14 critical care complications; 3 rhabdomyolysis, 2 AKI, 1 SVT, 1 ARDS, 3 VAP, 1 bacteraemia, 1 heart failure, 2 catheter associated UTI and 1 brachial plexus palsy. There were 12 wound infection/healing complications and in all patients the time to healing was prolonged (32 - 133 days). There was one mortality in the group and he died due to acute congestive heart failure. The LOS/TBSA was 0.24 - 33 (median 7 days/%TBSA). Conclusions: Frostbite in the young male population is associated with sports or alcohol in contrast with the older patients whose injury is associated with MVA or homelessness. Our major cases of frostbite required fluid resuscitation, critical care management and multiple extensive surgeries. Our frostbite injuries are associated with a high wound complication rate (46%) prolonged time to healing and prolonged LOS in comparison to their burn injury counterparts. The incidence and severity of these cases has increased dramatically in the last 3 years. Applicability of Research to Practice: There is little evidence in the literature to support clinical practice in this area. 145. Concordance Between Emergency Physicians and Burn Surgeons on Estimation of Burn Size P. B. Doshi, MD, J. Maggin, MD, T. Huzar, MD, FACS, R. Banuelos, MD University of Texas Health Science Center at Houston, Houston, TX; Beth Israel Deaconess Medical Center-Department of Emergency Medicine, Boston, MA Introduction: Mortality in major burn injury is often attributed to a complex inflammatory shock state for which the mainstay of treatment is fluid resuscitation. The resuscitation of burn shock in contrast to other forms of shock is complicated as over-resuscitation can lead to severe morbidity. Appropriate burn resuscitation, often initiated in the emergency department, is dependent upon accurate estimation of total body surface area (TBSA) affected. Previous studies have shown that community emergency physicians (EP) are poor judges of TBSA. We sought to measure the concordance in estimation of TBSA between EP and burn surgeons at a major academic center. Methods: A retrospective analysis of the Burn registry at a major academic burn center was performed between 1/1/2012-1/31/2013, with additional chart review to determine the estimation of burn size by the EP and burn surgeon. The estimation of the burn size was collected from the documented TBSA in the EMR by the EP and the burn surgeon. A total of 262 patients who presented to the emergency department with acute burn injury were assessed with final count of 215 patients with matched pairs of TBSA estimation by both EP and burn surgeons included. To evaluate the measures of agreement on the estimation of TBSA, TBSA was divided into 7 groups, 0-10%, 11-20%, 21-30%, 31-40%, 41-50%, 51-75% and >75%. The agreement between the EP and burn surgeons was evaluated using the weighted kappa coefficient. Results: Majority of the patients in this cohort presented with a thermal burn, with 11% having concomitant inhalational injury. The overall in-hospital mortality in this cohort was 5.7%. The weighted kappa for agreement between EP and burn surgeon was 0.739, suggesting moderate to substantial agreement (P<0.001). Additionally, the interquartile range of the difference in estimation was 0-4.5%, suggesting that 50% of the time the difference was <5% in the estimated TBSA between the EP and burn surgeon. Conclusions: There is moderate to substantial agreement in the estimation of TBSA in burn patients between EP and burn surgeons at an academic center. The difference majority of the time is <5%, suggesting that the estimation in TBSA is not likely to be the major reason for challenges in the resuscitation of burn patients. Applicability of Research to Practice: The concern for inadequate burn size estimation by EPs should likely not be the focus of quality improvement for early resuscitation of burn patients in an academic center. Table. No title available. View Large Table. No title available. View Large 146. Getting the Burn Team to Play from the Same Playbook: Understanding Clinician Perception of Patient Condition J. Pamplin, MD, S. Murray, MSN, M. Serio-Melvin, MS, RN, J. Aden, PhD, T. Huzar, MD, FACS, S. Wolf, MD, FACS, K. Chung, MD, E. Mann-Salinas, RN, PhD U.S. Army Institute of Surgical Research, San Antonio, TX; Memorial Hermann Hospital Texas Medical Center, Houston, TX; University of Texas Southwestern Medical Center, Dallas, TX Introduction: Critical care of burn patients requires a multiprofessional team of clinicians to effectively collaborate in order to ensure optimal outcomes. Effective teamwork necessitates team members share common goals. Establishing goals requires a shared mental model of a patient's current condition, anticipated future state, and treatments to bridge the two. A Better understanding of how clinicians understand patient condition, and ultimately treatment priorities, could improve teamwork, communication, and patient outcomes. Methods: This study was part of a prospective, mixed methods protocol to understand clinician perspectives about patient condition and treatment priorities in order to create tools that improve clinician decision making, teamwork, and communication according to the Phases of Illness Paradigm. Tools were created through iterative surveys, interviews, focus groups, and pilot testing. To identify the impact of these tools on the mental models that clinicians form about patient condition, we asked clinicians to identify their patient's current and anticipated condition the following day by marking a continuous scale from "Most sick/Could die today" to "Least sick/Could transfer from the ICU today." These continuous scales divided into ten equal parts and the location of a clinician's mark upon them was scored from 10 (most sick) to 1 (least sick). We then evaluated the variance of the differences between clinician perspective before beginning the project (pre-baseline), before implementing tools (baseline), and six months after implementing tools. Results: The average variance in the number of points on a 10 point scale reflecting clinician perception of a patient's current and anticipated condition was as follows: pre-baseline, ±1.73 and ±1.37; baseline, ±1.38 and ±1.33; and six months, ± 0.7 and ±0.76 (see graph). The decreased variance between perceptions over the study period was statistically significant for both current and anticipated condition (ANOVA, P = 0.01). Conclusions: Introducing tools that help clinicians asses a patient's current condition and anticipated best treatments according to the Phases of Illness Paradigm resulted in improved agreement about patients' current and anticipated condition. Applicability of Research to Practice: Improving the team's perception of a patient's current and future state has the potential to improve teamwork by creating a better, shared mental model of the patient and care priorities. External Funding: This project is supported by a grant from the US Army Medical Research and Materiel Command Telemedicine and Advanced Technology Research Center (TATRC) (W81XWH-13-2-0011) 147. Hydroxyethyl Starch Use in Severe Burn Injuries Is Not Associated with Increased Kidney Injury or Mortality J. Heard, BS, A. Gibson, MD, PhD, K. Pape, PharmD, BCPS, K. Romanowski, MD,T Granchi, MD, FACS, H. Bedri, MD, E. Assimacopoulos, BS, B. Grieve, BS, J. Liao, PhD, L. Wibbenmeyer, MD, FACS University of Iowa Hospitals and Clinics, Iowa City, IA; University of Wisconsin Department of Surgery, Madison, WI Introduction: Hydroxyethyl starch (HES) is a nonionic starch-derived volume expander that is used in the treatment and prevention of shock in critically ill patients. While early studies showed potential for improved outcomes, subsequent meta-analyses in non-burn populations concluded that use of HES was associated with increased risk of mortality and kidney injury requiring dialysis. Therefore, we sought to determine outcomes associated with a HES-based resuscitation protocol in severe burns. Methods: This was a retrospective analysis of burn patients admitted to an ABA verified burn center from 1/09 to 9/12. Patients who died within 24 hours were excluded. The resuscitation protocol calls for weight-based HES (6% hetastarch 670/0.75 in 0.9% sodium chloride) for all burns with >25% total body surface area burned (TBSA). Variables collected include basic demographics, vital signs, lactic acid and creatinine levels, nephrotoxins, surgeries, fluids, urine output, mortality, ventilator/pressor days, length of stay, and mortality prediction scores. RIFLE criteria were used to characterize acute kidney injuries (AKI) based on high and low creatinine (sCr) values. Descriptive statistics were used to evaluate HES related outcome variables. Results: Preliminary results show that 68 patients received an average of 1,246 cc (15.6 cc/kg) of HES during their admission, of which 95% was given by hospital day 3. Their average TBSA was 35% and length of stay was 24 days. They averaged 28.7 L of crystalloid total, which corresponds to 4.0 and 2.1 cc/kg/tbsa of crystalloid in the first 24 hours and three days, respectively. During their admission, over half (36/68, 53%) had risk of AKI (1.5x low sCr), a third (22/68, 32%) had AKI (2x low sCr), and one patient (1.5%) required dialysis. The mortality rate was 18% (12/68). The average predicted mortality using the rBaux score was 18.3% (mean rBaux = 90.0). Conclusions: A burn resuscitation protocol that utilizes HES was not associated with increased risk of renal injury or death compared to rates reported in the literature. Although not directly comparable, the rates of AKI risk and AKI were nearly identical to other studies looking at HES use in non-burned critically ill patients; however, the rate of dialysis in this population was four times less than reported in those studies. In burns specifically, an AKI incidence rate of 32% falls within the 25-33% range reported in the burn literature. A mortality rate of 18% in burn patients who received HES was no more than the 18.3% expected based on predicted mortality calculations using the rBaux score. A study comparing this population to one who did not receive HES is currently underway to determine more meaningful conclusion. Applicability of Research to Practice: This could change burn resuscitation practices. 148. Evaluating Pre-Hospital Intubation Practices for Patients with Burn Injury A. R. Cai, BA, P. B. Kumar, BS, A. J. Sehat, BA, E. I. Hodgman, MD, S. Vanek, RN, S. E. Wolf, MD, FACS UT Southwestern Medical Center, Dallas, TX Introduction: Anecdotally, we have noted that a number of burn patients arriving either by emergency medical services or as a transfer from an outside facility are intubated, and that many can be extubated within 24 hours. The purpose of our study is to evaluate the rates of pre-hospital intubation among patients in the local region and to characterize the patients. Methods: We reviewed all consecutive admissions from June 2013 through June 2014 at a regional Level One burn center for all data points. Exclusion criteria included: patients admitted electively, readmissions, or those with non-burn lesions. Demographics and outcomes for patients who were intubated before arrival or within 24 hours of admission were compared using χ2, Fisher's exact test, and the Kruskal-Wallis test as appropriate. Results: During this one-year period, 664 patients were admitted. Of these, 112 were intubated within the first 24 hours, including 79 intubated prior to arrival, and 34 intubated after arrival. Reasons for pre-hospital intubation included airway protection (n=16), altered mental status (n=4), burn size (n=3), presence of carbonaceous sputum or facial injury concerning for airway compromise or inhalation injury (n=38), respiratory distress (n=12), and unknown (n=6). Four patients had a dislodged endotracheal tube (ETT) on evaluation at our hospital, including 2 mainstem intubations, 1 esophageal intubation, and 1 patient with the ETT cuff at the vocal cords. Thirty-four patients intubated by paramedics or at an outside hospital were extubated within 1 day of arrival, suggesting an inappropriate intubation rate of 43.0%. Six of these failed extubation, resulting in re-intubation within 72 hours. In contrast, only 34 patients were intubated after arrival, of which 7 were extubated within 24 hours. There was no difference in average burn size (27.8 vs 27.7% total body surface area, p=0.75) or incidence of inhalation injury (17.7 vs 20.2%, p=0.75) between patients intubated prior to admission and those intubated within 24 hours after admission. Patients intubated after arrival had a longer ICU length of stay (16.9 vs 13.7 days, p=0.012) and hospital length of stay (28.4 vs 17.7, p=0.002), but not ventilator days (9.3 vs 8.0, p=0.07). Conclusions: Pre-hospital providers in our catchment area appear to have an aggressive approach to intubating patients after burn injury. We believe that many burn patients can be successfully managed with non-invasive airway support. Applicability of Research to Practice: These results demonstrate a need for improved education of providers and/or revisions of the current intubation protocol for burn patients to prevent excessive intubation. External Funding: This project is funded through DOD grant #W81XWH122074 and the generous support of Sons of the Flag and the Pettis family. 149. Transition from Intravenous to Subcutaneous Insulin in Adult Burn Patients M. K. Doolin, PharmD, T. A. Walroth, PharmD, S. A. Harris, PharmD, J. A. Whitten, PharmD, BCPS, A. C. Fritschle-Hilliard, PharmD Eskenazi Health, Indianapolis, IN Introduction: Glycemic control decreases morbidity and mortality in critically ill patients. This is specifically important in burn injury, as the disease process differs in severity and duration compared to other critical illnesses. However, limited guidance exists regarding the transition from intravenous (IV) to subcutaneous insulin. A validated protocol for transition is necessary since glycemic variability, hyperglycemia, and hypoglycemia adversely impact patient outcomes. Methods: The objective of this study was to determine a safe and effective method to transition adult burn patients from IV to subcutaneous insulin. This retrospective, observational study included adults admitted to our burn center from January 1, 2011 to September 1, 2014. Patients were stratified into three groups according to their initial dose of basal subcutaneous insulin as a percentage of the prior 24-hour IV requirements (group stratification: 0-49%, 50-69%, ≥ 70%). The primary outcome was the percentage of blood glucose (BG) concentrations within target range (70-150 mg/dL) in the first 48 hours following transition. Secondary endpoints included incidence of hypoglycemia (< 70 mg/dL), severe hypoglycemia (< 40 mg/dL), hyperglycemia (> 150 mg/dL), severe hyperglycemia (> 200 mg/dL), and glucose variability (change in mean absolute BG per hour). Results: A total of 251 BG concentrations from 16 patients were included for review. The stratified groups were well-matched in terms of demographics and confounders. In terms of the primary endpoint, the 50-69% group achieved the highest rate of BG concentrations in goal range (94%) (p = 0.016). The group transitioned to ≥ 70% had the highest rate of hypoglycemia (6%) (p = 0.418). No severe hypoglycemia was observed in any group. The rates of hyperglycemia were 22%, 4%, and 14% in the 0-49%, 50-69%, and≥ 70% groups, respectively (p = 0.013). Both the 0-49% and ≥ 70% groups had one severe hyperglycemic event, with none in the 50-69% group. Conclusions: Converting to 50-69% of the prior 24-hour IV insulin requirements was the safest and most effective transition method. The results of this study will be utilized to implement a pharmacy-driven protocol at the study institution to transition burn patients to 50-69% of their 24-hour IV insulin requirements as basal subcutaneous insulin. Applicability of Research to Practice: Currently, there is limited guidance regarding an optimal strategy to transition from IV to subcutaneous insulin. A validated method for this transition is imperative as the complications of an inaccurate subcutaneous insulin dose may impact glycemic control and thus morbidity and mortality. The study findings suggest burn patients should be transitioned to 50-69% of their 24-hour IV insulin requirements as basal subcutaneous insulin. 150. Do Neutral Pressure Needleless Connectors Decrease Central Venous Catheter Occlusions Requiring Tissue Plasminogen Activator Administration as Compared to Positive Pressure Needleless Connectors in Pediatric Burn Patients? K. Marren, RN, BSN, D. Tung, PharmD, J. M. Weber, RN, MSN, M. Gorman, RN, MSN, A. O'Brien, MSN, CNP, P. Chang, MD, FACS, R. Sheridan, MD, FACS Shriners Hospitals for Children, Boston, MA Introduction: Central venous catheter thrombotic lumen occlusion is a common complication resulting in the use of tissue plasminogen activator (tPA) to restore patency of the catheter. Style of needleless connector (neutral or positive pressure) may be related to incidence of thrombotic lumen occlusion. Our institution changed from positive pressure needleless connector (PPNC) to neutral pressure needleless connector (NPNC) in January 2015. We evaluated the effect of NPNC on the frequency of tPA usage. Methods: A chart review of all patients with PPNC CVCs was conducted from January through June of 2014 and all patients with NPNC CVCs from January through June of 2015. Their charts were reviewed for age, total body surface area burned (TBSA), CVC site, number of days catheter in place and if tPA was administered. In addition, data on the incidence of central line associated bloodstream infection (CLABSI) was collected concurrently by the infection control coordinator. This project was undertaken as a quality improvement initiative, per Institutional Review Board guidelines. Results: From January to June 2014, there were 20 patients with 60 CVCs inserted. From January to June 2015, there were 12 patients with 42 CVCs inserted. There were no statistically significant differences between the two groups except for location of catheter placement. Use of tPA was significantly higher in catheters with PPNC than those with NPNC (58.3% vs. 35.7%, p = 0.03). CLABSI was also lower in the NPNC catheters (3.2/ 1000 CVC days vs. 6.4/1000 CVC days, p = 0.60). This did not reach statistical significance related to small sample size. Expenditures for tPA in the six-month period in 2015 was reduced by $3,802 or 55% from the six-month period in 2014. Conclusions: Transition to NPNC was associated with reduced CVC lumen occlusion, reduced tPA use and decreased incidence of CLABSI in this population. Applicability of Research to Practice: This retrospective chart review demonstrated that NPNC have decreased problems with CVC occlusion and clotting resulting in decreased exposure to tPA. This has also decreased costs for tPA and decreased incidence of CLABSI in this population. This retrospective study should be validated in a larger prospective study. Table. No title available. View Large Table. No title available. View Large 151. Pharmacist's Role in Resuscitation of Acute Burn Patients in the Emergency Department T. A. Walroth, PharmD, Z. Moon, S. Miller, M. Blair, PharmD, BCPS, A. Mclntire, PharmD, BCPS, S. Harris, PharmD, BCPS, K. Jasiak, PharmD, BCPS Eskenazi Health, Indianapolis, IN Introduction: Involvement of pharmacists in trauma resuscitation has improved patient safety, decreased adverse drug events, and decreased time to medication administration per the ASHP Guidelines on Emergency Medicine Pharmacist Services. Only one study has examined the pharmacist's role in ED trauma resuscitation, with none published regarding burn resuscitation. ABLS guidelines provide little direction for medication management or the pharmacist's role in this setting. Our objective was to determine the type of interventions pharmacists perform during ED burn resuscitations and examine provider acceptance. Methods: This retrospective, observational study included adult burn patients brought to the ED for acute burn resuscitation from 10/27/14-9/30/15. Patients were excluded if a pharmacist was not present. Primary outcome was percentage of interventions accepted by a provider. Secondary outcomes included number of interventions per patient, types of interventions, and most common interventions. Results: Forty patients were included. Mean age was 45 yrs ±14, 73% were male, and median TBSA was 14.5% (4.1-22.3). IHI was present in 45% of patients and 50% were transferred from an OSH. For the primary outcome, 100% of the 207 interventions requiring prescriber approval were accepted. Including another 342 interventions not requiring an order, 585 total interventions were completed, resulting in a mean of 15 ± 7 interventions per patient. Interventions most frequently affected IV fluids (72.5%), analgesic infusions (50%), sedative infusions (45%), and analgesic bolus doses (40%). Pharmacists most frequently assisted in drug selection (47%) or dose/rate determination (40%). Most common interventions not requiring an order were: removal of medications from automated cabinets (95%), hand-off communication to receiving pharmacist (85%), and medication preparation (78%). Conclusions: An interdisciplinary team is integral in managing acute burn patients in the ED. This study identified opportunities for pharmacist contribution in this setting with 100% acceptance rate of interventions. Pharmacists routinely assisted in drug selection or dose/rate determination. Interventions most commonly affected fluids, analgesics, and sedatives, which are essential in burn resuscitation and pharmacists have the expertise to hone these therapies. Allowing pharmacists to focus on these roles during resuscitation enables ED staff to perform other tasks. Applicability of Research to Practice: This is the first study to describe the pharmacist's role during resuscitation of burn patients in the ED and interventions optimizing pharmacotherapy regimens. The potential exists to add formal recommendations to ABLS training regarding the pharmacist's role in this setting. 152. Over-Resuscitation Following Acute Pediatric Burn Injury and Impact on Outcomes A. Nagpal, MD, M. Moore-Clingenpeel, MAS, R. Thakkar, MD, R. Fabia, MD, PhD, J. Lutmer, MD Nationwide Children's Hospital, Columbus, OH Introduction: Over-resuscitation occurs frequently in the first 24 hours after acute pediatric burn injury; however its impact on outcomes remains poorly described. We tested the hypothesis that children who are over-resuscitated (> 6ml/kg/% total body surface area (TBSA)) in the first 24 hours are more likely to experience respiratory failure, hemodynamic instability, additional support devices, prolonged mechanical ventilation (MV), PICU length of stay (PLOS), and hospital length of stay (HLOS). Methods: A retrospective chart review of pediatric patients (0-18 years) sustaining ≥15% TBSA burn, admitted to our tertiary intensive care unit from 2010-2015 and resuscitated via the modified Parkland formula was conducted. Goal urine output (UOP) was 1-1.5 mL/kg/hr for children less than 30kg and 30-50ml/hr for children greater than 30kg. Results: Twenty-one patients were divided into two groups by resuscitation volume received to assess potential effects of over-resuscitation. Ten patients (48%) received > 6ml/kg/%TBSA and were assigned to the high fluid group (HFG). Eleven patients (52%) received <6ml/kg/%TBSA and were assigned to the low fluid group (LFG). Groups were comparable in terms of inhalational injury (p=0.08), flame burn (p>0.99), and scald burns (p>0.99). There was no difference in UOP between groups (p=0.22). There was no difference in the rate of respiratory failure, hypotension, or vasoactive use between groups (p=0.36, p=0.67, p=0.36 respectively). Odds of requiring an invasive device were not higher in the HFG (arterial lines p=0.67, peritoneal drains p=0.63, chest tubes p = >0.99, and CVL p=0.07). After controlling for burn severity, no significant association with MV days or PLOS was found (p=0.16 and p= 0.65 respectively). However, HLOS was 1.6 times longer (p=0.04, 95% CI 1.02-2.39) in the HFG. Conclusions: In the present study, over-resuscitation in the first 24 hours after pediatric burn injury was not associated with an increased rate of respiratory failure, days of mechanical ventilation, hemodynamic instability, or need for invasive device support. Applicability of Research to Practice: The relationship between total resuscitative volume in the first 24 hours and outcomes following pediatric burn injury remains unclear. Future studies should focus on persistent fluid overload beyond this time point in order to fully appreciate its impact on adverse outcomes. 153. Morbidity and Mortality Post-Burn Injury S. Rehou, MS, K. Smith, RN, MHA, M. Jeschke, MD, PhD Sunnybrook Health Sciences Centre, Toronto, ON, Canada Introduction: The purpose of this study was to explore the changes in morbidity and mortality in adult patients admitted to a regional burn center over a sixteen-year period. We hypothesize that recent advances in burn care and implementation of standardized protocols have translated to improved morbidity and mortality in burn patients. Methods: Observational cohort study of all burn patients admitted to our regional burn center between 2000 and 2015. Patients were adults (≥ 18 years of age) admitted within 4 days of an acute burn injury. Patients were stratified into two groups by era; past: 2000-2009 and present: 2010-2015. Associations between era and outcomes were assessed with Cox proportional hazards for time to death, adjusting for TBSA, inhalation injury, age, and sex; P<0.05 was considered significant. Results: Patient characteristics are outlined in Table 1. A total of 2009 patients met inclusion criteria. Mean age was 45 (SD 18), median TBSA was 8 % (IQR 4-16%) and median LOS was 13 days (6-21). A greater percentage of patients were on a mechanical ventilator in the present time period (32% vs. 37%; p=0.036), whereas median ventilator days decreased from 12 days (IQR 3-23 days) to 7 days (IQR 2-17 days; p<0.001). The incidence of complications including graft loss, bacteremia, ARDS, pneumonia, and renal failure decreased over time (p<0.001). Overall, mortality declined from 5% (n=62) in 2000-2009 to 3% (n=25) in the present time period. After adjusting for patient demographics and injury severity, the recent era was associated with a significant decline in 90-day mortality (HR 0.38; 95% CI 0.24-0.62; p < 0.001). Conclusions: A substantial improvement in burn care has occurred at our institution within recent years. Despite comparable age, TBSA, and higher rate of inhalation injury, mortality has significantly declined, which is associated with the implementation of protocols and critical care bundles. Applicability of Research to Practice: Clinical outcomes demonstrate the need for sustained efforts to identify the pathophysiological processes; the opportunity remains to maximize survival rates. External Funding: CIHR #123336; CFI Leader's Opportunity Fund, Project # 25407; NIH RO1 GM087285-01. 154. Enzymatic Debridement as a Non-Traumatic Alternative for Safe Early Escharectomy B. Presman, MD, I. Tocco-Tussardi, MD, R. Heedman, MS, F. Huss, MD Uppsala Burn Centre, Uppsala, Sweden Introduction: Early escharectomy stands as a cornerstone in modern burn treatment. Most deep burns are debrided in the OR by tangential excision. While effective, the procedure is demanding in terms of personnel, and traumatic, involving heat and blood loss, and either loss of viable tissue or insufficient debridement. With tangential excision blood losses can easily reach 100 ml per % TBSA excised with profound effects on the patient especially if unstable. The recently introduced enzymatic debridement with NexoBridTM (NXB) has been stated to be effective, fast, selective, safe, and to reduce the surgical burden of the patient. Thus NXB could offer a selective non-traumatic alternative for early eschar removal and easier diagnostics. Methods: The aim of the study was to investigate the effectiveness of NXB in providing a safe and effective early escharectomy with limited blood loss in burns requiring surgical debridement. Patients treated with NXB at our Burn Centre were reviewed retrospectively, from November 2014 to September 2015. Results: Nine patients were enzymatically debrided (3:6 F:M). Seven out of nine patients were under mechanical ventilation due to unstable conditions. Hemoglobin and hematocrit values pre-and 48 hours post-application showed no statistical significant differences (mean Hb pre: 141.1 mg/dL, post: 102.6 mg/dL (p=0.11); mean difference: 39.0 mg/dL; mean Htc pre: 42.5%, post: 29.9% (p=0.64); mean difference: 13%). The fact that patients were NXB treated during the acute phase implies that the Hb and Htc values also decreased due to the resuscitation. This was shown by a mean increase in body weight of 19.05% with a mean fluid balance of +16743 mL over the same time frame. Debridement effectiveness was satisfactory, with no need for re-application of NXB or further escharectomy of treated areas. Conclusions: NXB allowed early, effective, and safe debridement, saving time in burn treatment. Application was performed bedside thus abolishing the need for OR time and personnel engagement. Our study population was still limited and we continue to investigate NXB prospectively to find supporting evidence on NXB as a valid alternative to conventional surgical SOC for deep partial and full thickness burns. Applicability of Research to Practice: The results for NXB were encouraging in terms of safety and efficacy of debridement and suggested particular usefulness in the early treatment of unstable patients. Table. No title available. View Large Table. No title available. View Large 155. Sodium Variability Increases Mortality in Severe Burn Injury J. I. Ramirez, MD, B. Chan, PhD, N. Tran, PhD, T. L. Palmieri, MD, FACS, FCCM, D. Greenhalgh, MD, FACS, K. Cho, PhD, S. Sen, MD, FACS UC Davis Medical Center and Shriners Hospitals for Children, Sacramento, CA Introduction: Dysnatremias are associated with increased mortality in critically ill patients. Hypernatremia in burn patients is also associated with poor survival. Based on these findings, we hypothesized that high plasma sodium variability is a marker for increased mortality in severely burn-injured patients Methods: We performed a retrospective review of adult burn patients with a burn injury of 15% TBSA (total body surface area) or greater from 2010 to 2014. Measurements: All patients included in the study had at least 3 serum sodium levels checked during admission. We used multivariate logistic regression analysis to determine if hypernatremia, hyponatremia, or sodium variability independently increased the odds ratio (OR) for death. Results: 212 patients met entry criteria. Mean age and %TBSA for the study was 45 ± 18 years and 32 ± 19. 29 patients died for a mortality rate of 14%. Serum sodium was measured 10,310 times overall. The median number of serum sodium measurements per patient was 22. Non-survivors were older (59 ± 19 vs. 42 ± 16 years) and suffered from a more severe burn injury (50 ± 25% vs. 29 ± 16 %TBSA). While mean sodium was significantly higher for non-survivors (138 ± 3 milliequivalents/liter (meq/l)) than for survivors (135 ± 2 meq/l), mean sodium levels remained within the laboratory reference range (135 to 145 meq/l) for both groups. Non-survivors had a significantly higher median number of hypernatremic (>145 meq/l) measurements (2 vs. O). Mean standard deviation of the sodium measurements was significantly higher in non-survivors (4 ± 1.5) than survivors (2.7 ± 1). Adjusting for TBSA, age, ventilator days, and ICU stay, the mean of the standard deviations of the sodium measurements for each patient was associated with a significantly increased risk of death (OR 3.02 (95% confidence interval (CI) 1.4 to 6.7)). Conclusions: Increased variability in plasma sodium is independently associated with death in severely burned patients. Applicability of Research to Practice: Assessing severity of critical illness. 156. Bioavailability of Coenzyme Q10 Supplementation in Burn Patients: A Randomized, Double-Blind, Placebo-Controlled Study N. Kuriyama, MD, E. A. Bittner, MD, PhD, K. Mathews, BA, J. T. Schulz, MD, PhD, J. Goverman, MD, FACS, M. Kaneki, MD, PhD Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Surgery, Division of Burns, Massachusetts General Hospital, Harvard Medical School, Boston, MA Introduction: Coenzyme Q10 (CoQ10) is a nutrient and an essential cofactor for mitochondrial respiration and the reduced form of CoQ10 acts as an antioxidant. Deficiency of CoQ10 causes mitochondrial dysfunction and thereby exacerbates multi-organ dysfunction. We have shown that plasma CoQ10 concentrations are significantly lower in surgical ICU patients than healthy controls. Moreover, CoQ10 administration prevented burn-induced insulin resistance and improved survival after sepsis induction in mice. The aim of this trial is to study the bioavailability of CoQ10 in burn patients with and without supplementation. Methods: A randomized, double-blind, placebo-controlled study of CoQ10 was approved by the IRB and is actively enrolling adult patients with burn injury (> 5%TBSA) (Clinical Trial.gov Identifier: NCT 02251626). Patients received reduced form of CoQ10 (ubiquinol, 1,800 mg/day) or placebo for up to 4 weeks during hospitalization. Blood samples were collected prior to supplementation and every 3 days thereafter. CoQ10 concentration (μg/mL) and reduced-to-total CoQ10 ratio (reduced CoQ10%) in plasma (n=18 patients) and CoQ10 content (μg/mg protein) in peripheral blood mononuclear cells (PBMCs) (n=11 patients) were measured. Results: The interim analysis showed that in the placebo group there were trends toward declines in CoQ10 levels in plasma and PBMCs after the first blood collection; however, statistical significance was not achieved perhaps due to the paucity of the number of patients (n=9 for plasma, n=6 for PBMCs). Plasma reduced CoQ10% significantly declined in a time-dependent manner compared with the first blood collection in the placebo group, suggesting the development of oxidative stress. In the CoQ10 group, supplementation significantly increased plasma CoQ10 concentration and reduced CoQ10% (p<0.01, n=9). CoQ10 supplementation appeared to increase CoQ10 content in PBMCs, but statistical difference was not found (n=5). There were no adverse events. Conclusions: CoQ10 supplementation increased circulating total and reduced CoQ10 concentrations. In contrast, in the placebo group, plasma reduced CoQ10% significantly decreased and CoQ10 levels in plasma and PBMCs tended to decline. These results suggest that burn injury may decrease plasma and intracellular CoQ10 content, which can be reversed by CoQ10 supplementation. Applicability of Research to Practice: It is anticipated that this study will identify CoQ10 deficiency in burn patients and confirm bioavailability of CoQ10 supplementation. These results are expected to warrant a large clinical study to evaluate the safety and efficacy of CoQ10 supplementation to ameliorate mitochondrial dysfunction, oxidative stress and metabolic derangements after burn injury. External Funding: Sponsored by Kaneka Corp. 157. Improving Patient Access To Burn Care: 1-800-4 Trauma K. Gabehart, RN, MSN, D. Roggy, RN, R. Sood, MD, FACS Richard M. Fairbanks Burn Center, Indianapolis, IN Introduction: As one of only two adult burn centers in our state, full open access in our catchment area is essential. Our organization is a designated Level I trauma center and has maintained full burn center verification standards since 1997. In order to maintain easy access to our burn center we partnered with the trauma service at our organization to establish a direct number to care for outside facilities wanting to transfer burn and or trauma patients. Prior to the implementation of the direct transfer line, transferring facilities were often routed through different sources and people with no consistent algorithm or practice. Methods: Discussions with senior leadership, marketing and the trauma service were initiated to establish a toll free number for direct transfers from outside facilities. This number was marketed statewide in addition to surrounding communities across state lines. The purpose of this number is to provide direct communication between care providers without delay 24 hours a day 7 days a week. A scripted algorithm is used when a call comes in on this line, and the call is directly connected to the burn physician or advanced practice provider on staff to accept the burn transfer and assist in coordination of care. These calls are documented by the operator as well as recorded for performance improvement purposes in the event the call is dropped or disconnected. Results: Since 2014, 160 calls for the burn center have resulted in burn transfers. While it is unclear if these calls would have been routed through a different number without a toll free number, it is clear to our organization that outside facilities prefer the ability to reach someone directly. With this process we have the ability to address performance improvement issues with the transfer based from recorded phone calls. The promotion of this line has improved outreach opportunities, direct input to pre-hospital burn care and allowed for networking and increased transfer agreements with outlying facilities. Conclusions: Direct lines of communication are essential for community outreach and access to patient care. This direct link avoids delays in care and transfer. The direct line also connects the transferring facility with a burn care provider rather than a provider not familiar with the specialized needs of our patient population and allows for performance improvement concerns to be addressed rapidly. Future consideration: Some calls coming into the line have requested direct connection to the outpatient clinic therefore expanding the need to market our toll free clinic number. Applicability of Research to Practice: Direct lines of communication are essential for community outreach and access to patient care. 158. Creation and Implementation of the Clinical Coordinator Role J. Biller, RN, K. Brown, DNP, RN, NEA-BC, D. Francis, MS, RN-BC, ACNS-BC The Ohio State University Wexner Medical Center, Columbus, OH Introduction: Changes in the health care system have challenged organizations to provide cost effective quality care while delivering optimal patient outcomes. The clinical coordinator is a role focused on coordinating the efforts of the interdisciplinary care team and assuring a comprehensive care plan is utilized to guide the hospital stay to provide high quality care and reduce the risk of readmission. Methods: An interdisciplinary team was formed to define and develop the clinical coordinator role. Core competencies were defined and project goals and outcomes were defined. These included patient satisfaction, readmission rates and length of stay (LOS). Data from the HCAHPS discharge survey was used to measure patient satisfaction. Results: Since implementation of the clinical coordinator role eleven months ago our unit's overall patient satisfaction scores have increased 2.7%. Doctor / patient communication has increased 4.1%. Patient satisfaction with the discharge process has improved 5.0%. Care transitions between inpatient and home has increased 6.0%. Length of stay and readmission rates have also decreased. Conclusions: The role of the clinical coordinator improves the process and quality of care as well as improves patient satisfaction. Applicability of Research to Practice: The information obtained from the evaluation of this role can contribute to better efficiency in health care delivery. 159. Improving Teamwork and Resiliency of Burn Center Nurses Through a Standardized Staff Development Program M. F. Christiansen, RN/LPN/BSN, A. Wallace Jr., RN/LPN/BSN, J. M. Newton, RN/LPN/BSN, E. A. Mann-Salinas, RN, PhD U.S. Institute of Surgical Research, Fort Sam Houston, TX Introduction: Studies have shown that higher levels of teamwork improve nursing satisfaction in acute care units. Positive relationships among all care providers have been shown to improve quality of patient care and job satisfaction. Other studies have shown that stress resiliency influences job satisfaction by influencing job stress and psychological empowerment. The purpose of this project was to develop a training platform for nursing staff education and teambuilding. Program objectives included improving nurse satisfaction, increasing resiliency, building unit cohesion, enhancing morale and increasing staff awareness of unit performance. Methods: All staff members were given an eight hour "training" day; half of the day was devoted to lecture/education while the other half focused on team building and resiliency. Training was provided by various guest speakers and lecturers, as well as unit leadership. At the end of the day, participants were encouraged to complete an evaluation and all activities were scored on a 10-point Likert scale, with 10 representing the most informative. Results: Participants scored the activities very high, with a total average score of 9.15 (n=246). The activity that scored the highest was a discussion on unit performance metrics, with a score of 9.50 (n=4l). The activity that rated the lowest was a computer teambuilding session, at 8.83 (n=4l). Overall, staff agreed that the training day both increased awareness of unit performance (9.41, n=4l) and unit cohesion/healthy work environment (9.56, n=4l). Conclusions: The staff development day was a success and plans are underway to make the program a biannual event. The first event met our objectives of building unit cohesion and increasing satisfaction and morale. Many staff members commented that they are looking forward to the next training event. Applicability of Research to Practice: Teamwork and resiliency are essential for the successful functioning of inpatient units, especially in the high-stress, military and burn environment. "Staff Development Day" can be a successful training platform for improving these skills. Future research could build on this pilot project to adapt the framework for other units. 160. Diversity of Adult Donor Site Dressings Throughout the American Burn Association Facilities C. F. Scarborough, BSN,RN, H. M. Aguridakis, BSN,RN, M. E. Robbins, BSN,RN, A. S. Roman, MSN, RN, E. A. Mann-Salinas, RN, PhD U.S. Army Institute of Surgical Research, Fort Sam Houston, TX Introduction: The world of burn care is evolving and as a part of this change, the products available for wound care are progressing as well. Donor sites, a common consequence burns, are surgically created lesions from which healthy skin is harvested for transplantation to non-viable areas. At this time, there is not a single standardized dressing that promotes moist wound healing, decreased pain, and improved healing time. The purpose of this project was to learn more about what other certified burn care centers are using for donor site wound care and look for trends in dressing selection. Methods: A list was generated of all ABA accredited burn centers (n=56); each adult burn center in the United States was contacted via telephone. A short, four-question interview was conducted with each charge nurse or alternate available nurse about wound care practices in their facility. The questions included information on donor site dressings that were currently being used, whether the dressing choices were physician specific, past dressing successes/failures, and the utilization of wound care teams or specialists on each unit. Results: Feedback was provided by 55 burn centers (98%). A large number of dressings were being used in donor site care; no one dressing or method was agreed upon by all burn care professionals. At least 18 different dressing types were used throughout the burn community. Fifteen additional dressings were trialed but not continued. The two most common dressings being utilized for donor care were occlusive petroleum gauze (49%, n=27) and adhesive silver foam (47%, n=26). Almost half (44%, n=24) of the dressing choices were based on provider specific selection, rather than a standard policy or procedure. Lastly, the majority of wound care was being performed by bedside nurses, not Wound Ostomy Continence nurses, physicians, or designated specialists. Conclusions: Few facilities reported concrete standards of practice or guidelines on donor site care. Donor sites continue to be a topic of concern since creating this new wound often leads to increased pain and healing time in an already vulnerable population. With differences in technique, product, and protocol, there are countless variations in donor site care that have been attempted, all with no clear consensus. Applicability of Research to Practice: Donor site dressing selection is important and should consider potential pain for the patient, ease of use for both the patient and nurse, and healing time. Decreased pain and improved healing time could correlate with reductions in narcotic use, risk of infection, and hospital stay, metrics which equate to money saved for the facility. If providers are able to decrease variance of care and practice, and create evidence-based standardization, there may be potential for improved patient outcomes. 161. Use of a Relaxation Room to Reduce Stress for Nurses S. E. Anderson, LPN, T. C. Hardin, BSN,RN, N. W Caldwell, RN, C. F. Scarborough, BSN,RN, A. S. Roman, MSN, RN U.S. Army Institute of Surgical Research, San Antonio, TX Introduction: The healthcare profession, particularly nursing, is fundamentally built on the treatment and care of sick or diseased persons in various settings. Nurses in any setting inherently incur stress in the workplace. While stress has been statistically proven to increase functionality and critical performance skills, it has also been linked to conditions such as burnout syndrome and compassion fatigue. Research demonstrates that burnout often results in decreased quality of care for patients, lowered morale and increased absenteeism. Continuous stress also contributes to increased turnover rates, resulting in a strong financial burden to health-care systems. The purpose of this project is to assess stress, energy levels, and muscle tension experienced by burn center nursing staff. Methods: This performance improvement project provided all burn center nursing staff a secluded room equipped with two massage chairs, dim lighting, and a soothing sound machine. Users were provided a survey to complete before and after a minimum 15-minute relaxation period. The survey tool utilized a 0-10 Likert scale, with 10 indicating greater levels of stress and energy. The tool also collected information about how often staff experienced muscle tension (pre-relaxation) and if the room was beneficial (post-relaxation). Results: The survey was completed by 30 staff nurses who used the room. Pre-relaxation room stress averaged 5.9 ± 2 (range 2-9) and energy averaged 5.2 ± 2.2 (range 1-10). Post relaxation scores averaged 3.9 ± 2.2 (range 1-7) for stress, a 34% reduction, and 6.3 ± 2.1 (range 2-9) for energy, a 21% improvement. Only 4 (13%) burn nurses reported rarely or never experiencing daily muscle tension. With the exception of one person who had difficulty with a chair, all users stated the room was beneficial. Conclusions: A 15-minute respite appears to be a viable option for decreasing stress and increasing energy levels of staff nurses working in a burn unit. The room was beneficial for most staff and has potential for reducing the effects of muscle tension, relaxation and the potential side effects of tension. Applicability of Research to Practice: With implementation of a relaxation area, employers have the opportunity to improve the work environment and potentially increase staff satisfaction and improve patient outcomes. 162. Taking the OR "On the Road", Lessons Learned from Surgical Procedures Done at the Bedside in the Burn ICU A. Sanford, MD, FACS, S. Valtman, RN, BSN Loyola University Medical Center, Maywood, IL Introduction: Quite often, operating room schedules become full with surgical procedures and a burn case may be minor or low priority. It is also important to adhere to the principle of early excision of burn wounds, but some patients are too ill to travel to an operating suite, and the OR needs to come to them in order to get adequate surgical debridement. Lessons learned while performing these procedures from open tracheostomy to debridement and xenografting in an unconventional setting are shared. Methods: Initial development of a routine team of Surgeons, Anesthesiologists , OR and bedside nurses as well as Respiratory Therapists is fundamental. Early communication of plans and need to use an alternate setting is undertaken. Assignments of staff need to be made allocating experienced team members for the trip to the Burn ICU. Routine equipment lists must be made out, but also extra supplies that might not be available need to be obtained and brought along, otherwise delays disrupt the flow of the procedure. We have found closing the Burn ICU to visitors and using another adjacent, empty room facilitates completion of the procedure and maintaining patient privacy. Room set up and operative planning must accommodate the confined space of an ICU room, while providing and equivalent surgery that would be performed in a conventional OR. Anesthetic agents must be planned for total IV delivery of pain and analgesic medicines. Harvesting of skin or using a dermatome for debridement needs to be planned using technologies available at the bedside. Xenograft was chosen for wound coverage because of its ease in preparation and not needing to be meshed at the bedside during the procedure. Results: Experience developed doing 5-10 bedside tracheostomies/year was used to perform bedside debridement of one arm and one leg with xenografting in a patient too ill to travel to an operative suite, providing adequate, temporizing wound care. We had complete take of the xenograft while attempting to stabilize the patient from multi system organ failure. Conclusions: Utilizing teamwork and experience for bedside surgical debridement is an alternative to conventional OR care in exceptional circumstances. Applicability of Research to Practice: We encourage innovative solutions to difficult surgical problems. Not all surgical debridement can or should be done in the Burn ICU, but there are cases when it will clearly benefit the patient. 163. Implementation of a New Practices and Interventions and Their Impact on Central Line Associated Blood Stream Infections N. Fitzgerald, RN, BSN, K. Gabehart, RN, MSN, D. Roggy, RN, R Sood, MD, FACS Richard M. Fairbanks Burn Center, Indianapolis, IN Introduction: Central line associated blood stream infections (CLABSI) continued to be a problem in the Richard M. Fairbanks Burn Center despite a multidisciplinary effort to decrease the rates. Changes in the unit started in 2010 with the roll-out of nurse champions and best practice bundles, followed by the addition of CHG disk; however even with these changes our rates remained high. In 2013 the additional step of adding a continuous bathing alcohol cap to all ports on central lines after which lower rates of CLABSI were noted. Methods: Standardized practice for inserting central lines and caring for them were initiated in 2010 within the burn center. The nurses received education with regards to best practice care for lines and monthly auditing of these practices was initiated. In 2011 after seeing some changes in rates for CLABSI in the burn center the decision was made to look for additional ways to decrease our CLABSI rate given compliance with best practice guidelines but CLABSI rates that remained above the benchmark. The addition of the CHG disk did not decrease our rates so in 2013 it was determined that the burn center would trial a alcohol cap to determine if it would help to decrease our CLABSI rate. Results: With the addition of the alcohol cap there was a decrease in CLABSI rates from 13.34 in 2012 to 6.74 in 2013; in 2014 our rate remained lower than previous years at 10.84%. Conclusions: The addition of a multidisciplinary approach to decreasing the rate of CLABSI in our unit was beneficial however it was not sufficient to drive our rate below the desired benchmark. The introduction of the alcohol cap for continuous bathing of each access port of the central line made a significant difference in our overall CLABSI rate since we started utilizing it. Monitoring of CLABSI rates and best practice standards will continue. Applicability of Research to Practice: All Burn patients are at risk for infection. Peripheral access can be difficult at times and necessitate central venous access. Implementation of new interventions is important to decrease the incidence of CLABSI. 164. Wound Care RN Process Improvement Project T. L. Lerew, BSN, N. S. Gibran, MD, FACS, D. M. Kyles, MS, RN, G. J. Carrougher, RN, MN University of Washington Regional Burn Center at Harborview Medical Center, Seattle, WA Introduction: In 2014, our Burn Center's practice of utilizing a certified nursing assistant (CNA) as the second wound care team member transformed due to changes within their scope of practice. We opted to replace the CNA with a burn center RN who would aid the primary RN with daily wound care, patient education and post procedural assessment. The purpose of this process improvement project is to evaluate this practice change by assessing RN perception of: a) efficacy of RN time, b) change from anticipated to realized benefits, and c) HCAHPS patient satisfaction data. Methods: Two online confidential surveys were developed by the nurse manager exploring staff perceptions concerning this practice. The dayshift RN staff was informed of the forthcoming change in practice. A description of the role and duties of the Wound Care RN was developed and posted; staff education followed. All dayshift RNs were asked to complete a pre-implementation survey (June 2014) and a post-implementation survey 9 months following program implementation. HCAHPS data was compared pre- and post- program implementation. Results: Seventy seven percent (20/26) and 82% (18/22) completed the pre- and post-implementation surveys online, respectively. The report of anticipated and realized benefits of the program is outlined in the table. Only one benfit (effiency in wound care) demonstrated marked improvement. A comparison of HCAHPS data for the year prior to program implementation (July 2013-June 2014) to the year after implementation (July 2014-June 2015), demonstrated improvement in Overall Rating (50th to 71 stile), in Willingness to Recommend (75th to 85thile) and Nursing Communication (49th to 66thile). Conclusions: Evaluating the success of any new healthcare program is important; key to this evaluation is the inclusion of those most affected by the change and to assure confidentiality in the evaluation. For this Wound Care Program in which two RNs provide direct patient care during daily wound care, dayshift RN staff identified some improvement beyond what was anticipated. The largest gain concerned efficiency of wound care. Unfortunately, most anticipated benefits were not realized, providing areas for continued improvement and staff involvement in the evolution of this program. Of most concern is that staff does not perceive an improvement with patient satisfaction despite HCAHPS data. Applicability of Research to Practice: Implementation of a similar process of care may result in improved patient satisfaction, and efficiency of RN time during wound care for other burn centers. Table. No title available. View Large Table. No title available. View Large 165. A Financial Review Process to Grow a Burn Center K. Gabehart, RN, MSN, D. Roggy, RN, L. Blue, RN, MSN, R. Sood, MD, FACS Richard M. Fairbanks Burn Center, Indianapolis, IN Introduction: In order to grow and sustain a burn center, medical and nursing leadership must play an active role at all levels including the day to day administrative operations in addition to patient care. As leaders are put into burn center administrative positions there is often little to no orientation to hospital finances and management. In an attempt to increase efficiency and budget productivity for all departments on an organizational wide level, the medical and nursing leadership team in our burn center was asked to begin high level operational review meetings with members of finance and our organization's senior leadership. Methods: Since 2012, quarterly meetings have been held with burn service leadership, Associate Vice President of finance and the Chief Nursing Officer of senior leadership. The purpose of these meetings is to review the financial and operational activities occurring within our department over the course of the year and to help ensure accomplishment of organizational goals. These reviews are intended to ensure that the department is both effective and efficient in departmental operations as it relates to outcomes, resources and minimizing costs. Through review of monthly line by line budget items the burn leadership team has the opportunity to provide face to face variance explanations and educate members of senior leadership. Results: Through this two fold approach of standardized review and nurse auditor involvement, our burn center was able to build better communication and working relationships with key members of our organization. We have improved documentation standards to decrease charge write offs and have continued documentation improvements through ongoing education from nurse auditors to the front line staff. Through the audit process we have identified and captured missed charges from documentation. Through the nurse auditor review we have captured nearly $680,000 additional dollars in documented inpatient revenue alone. In addition, we have improved understanding of burn care needs and day to day operations among senior leadership and improved our accountability and understanding of senior leaderships financial goals for the organization. Conclusions: Having active engagement in all day to day operations of the burn center is critical for success. Ongoing review of the business operations of the burn center result in profitable and positive interactions. The approach to operational reviews with senior leadership has been an effective way to monitor efficiency and productivity. In addition such interactions has allowed opportunity for bidirectional education for all parties involved as it relates to burn clinical needs and financial implications. Applicability of Research to Practice: Having active engagement in all day to day operations of the burn center is critical for success. 166. Evaluating End-Tidal Carbon Dioxide (etCO2) Monitoring Effectiveness during Burn Wound Care in Non-Intubated Patients S. L. Weimer, BSN University of Colorado Hospital, Broomfield, CO Introduction: Moderate sedation is part of daily wound care plan for non-intubated patients. Using standard monitoring equipment may result in late signs of oversedation and ineffective breathing. End-Tidal Carbon Dioxide (ETCO2) monitoring provides immediate feedback during patient sedation. ETCO2 is commonly used in procedure areas and is valuable for assessing breathing effectiveness in patients receiving intravenous agents that cause respiratory depression. This research study's purpose is to describe the nurse's sedation and analgesic therapy management of non-intubated patients during burn wound care when ETCO2 is used. Methods: This IRB approved study involves observing the burn nurse and technician during wound care of a non-intubated patient. Observations included: nurse administration of sedation and analgesia; patient monitoring, airway rescue maneuvers, and pain/sedation assessments. This descriptive observational study compares pre-and post- intervention of ETCO2 monitoring. Primary outcome measures are: adverse breathing/airway events, pain measurements and sedation effectiveness. 22 nurses and 4 technicians were observed pre-ETCO2. ETCO2 education was completed via online module and skills demonstration. 17 nurses and 4 technicians were observed post-ETCO2 introduction. Post data collection should be completed by 12/2015. Results: Patients observed pre-intervention: flame burn injury (mean TBSA = 16%); average age: 34; and 66% reported history of alcohol, marijuana, or benzodiazepines. Nursing demographics: practice experience 0.533 years and burn experience >0.5-18 years. Burn technician experience 3.5=20 years. Average burn treatment time was 55 minutes (range: 21-100 min.). Preliminary data analysis pre-ETCO2 intervention observations found 3 adverse airway events. No patients required advanced airway support or reversal agents. However, SpO2 and breathing assessments were below normal requiring airway rescue maneuvers and supplemental oxygen. Patients' (N=10) sedation was assessed to be RASS -2 to 0; pain scores were ≤ than pre-burn treatment pain scores. Results for post-ETCO2 data will be complete spring 2016. in time for presentation. Conclusions: Preliminary analysis found wide variation in nursing practice in management of non-intubated patients requiring burn wound care sedation. Final conclusions will be made post final data collection. Applicability of Research to Practice: Burn wound care is a painful but essential to wound healing. Describing burn wound care practice to understand benefits of ETCO2 for non-intubated patients receiving intravenous agents that cause respiratory depression may provide insight into best monitoring practice. 167. Comparative Retrospective Analysis of Long-Term Scarring, Dyspigmentation and Itching Outcomes of Partial-Thickness Paediatric Scalds Treated with Conventional Dressings, Biobrane®, ReCell® and Split Skin Grafting at a Regional Burn Centre D. Othman, MBBS, E. Cochrane, MBBS, A. Raza, MBBS, M. Anwar, MBBS Pinderfields Hospital, Wakefield, United Kingdom Introduction: This is a retrospective analysis of 100 partial thickness paediatric scalds treated with five different modalities; dressings, Biobrane®, Recell®, Recell® with Biobrane & Split skin grafting. The study aimed to establish prescence of differences in long term outcomes, including scarring (hypertrophic and keloid scarring) and dyspigmentation (hypopigmentation and hyperpigmentation) in these groups. Methods: Review of 100 consecutive cases treated between 01/03/2010 & 31/07/2011 at Pinderfields Hospital Regional Burns Centre, in Wakefield, UK. The patients were followed up for 3-4 years by the MDT team in the scar clinic. Results: As shown in the table below, the scarring outcomes were statistically superior in the dressings group, the combined Biobrane and Recell group and the Recell group, compared to the Biobrane & the Split skin grafting groups. For Dysigmentation, The Groups of Biobrane, Recell & combined Biobrane & Recell showed higher risks of dyspigmentation compared to dressings & split skin grafting groups. For Itching, There was a statistically significant reduced risk of itching in the Recell group (0%), compared to relatively similar risks in all other groups. Conclusions: Recell significantly reduces the risk of post burn itching symptoms compared to other treatment modalities such as dressings, Biobrane, & Split skin grafting. Recell has similar scarring risks compared to dressings treatment, however, significantly reduced risk compared to Biobrane and skin grafts. For dyspigmentation, Recell has reduced that risk compared to Biobrane, but not to dressings group &skin grafting group. Applicability of Research to Practice: There is a statistically significant reduced itching complications in groups treated with Recell in paediatric burns. This study suggests a larger prospective randomised study to explore this outcome, and other comparative outcomes including scarring and dyspigmentation in the different treatment groups including dressings, Biobrane, Recell, combined Biobrane and Recell, and skin grafting group. Table. No title available. View Large Table. No title available. View Large 168. Dangers of Summertime Recreational Fires M. K. Donovan, MS, RN, PNP-BC, J. Fabbri, MS, RN, PNP-BC, S. Romo, BA, P Chang, MD, FACS, J. Weber, RN, MSN, R. L. Sheridan, MD, FACS Shriners Hospitals for Children, Boston, MA Introduction: Burns caused by fire pits and campfires seem to have increased in frequency over the last few years. The rising popularity of backyard fire pits draws children in too close, like moths to a flame, resulting in contact burn injuries to feet, hands and posterior thighs/legs. Methods: Using a data registry bank maintained by the outpatient department of a tertiary burn care facility, we conducted a quality improvement retrospective review of patients with burn injuries caused by fire pits, bonfires, or camp fires. Our primary analytic sample included patients <18 years of age who were injured between the years 2014 and 2015. Data collection elements included: age, gender, burn site and total body surface percentage (TBSA), and circumstances surrounding the injury. Results: Fifty-nine patients were included in this review. Eighteen (30%) were injured in 2014 and forty-one (70%) were injured in 2015. This population included 33 males (56%) and 26 females (44%). The average age was 6.9 years old (+5.1) and the average TBSA was 2.5% (ranging from 0.20% to 21%). The majority of injuries occurred in the summer months of July (32%) or August (29%). The burn injuries resulted from fire pits (34%), hot coals (22%), fire rings or covers (17%), grills (15%), or "other" (12%) (i.e. portable fireplace, flame, combustion). One-way AN OVA post hoc analyses showed that burned by a grill we significantly younger (2.8 years old) than patients burned by fire pit (8.1 years old), fire covers/rings (7.4 years old), or "other" (8.2 years old); p<0.05.Twenty-nine (49%) patients' hands were involved, thirteen (22%) patients' feet were involved, ten patients' (17%) arms were involved, and eight (14%) patients' legs were involved. The majority of patients (91%) had second degree burns. Seventeen (29%) injuries were recorded as having been caused by patients falling or tripping into a fire pit or campfire. Conclusions: Burn injuries from recreational fires affect young children, putting especially hands and feet at risk. Proper education about how to use recreational fire pits and grills is necessary and more vigilant supervision around fire pits and campfires, with all age groups, needs to be stressed. Most of these children do not require surgery and can be managed in the outpatient setting. Preventing these injuries is an opportunity for burn unit community outreach. Applicability of Research to Practice: When developing educational brochures for health care providers and patients, anticipatory guidance surrounding care around outdoor fires and burns should be included. 169. Online Information of Initial Burn Treatment: A LIDA Analysis M. Paz, BA, W Lee, RN, S. Romo, BA, M. Lydon, RN, P H. Chang, MD, FACS Shriners Hospitals for Children, Boston, MA Introduction: When injured, patients frequently use online searches to find out the initial treatment for their condition. The quality of online information varies widely. In this study, websites for initial burn treatment found on two major search engines were rated with regards to accessibility, usability, and reliability. Methods: The phrases "burn treatment", "burn first aid", "burn care", and "how to treat a burn" were searched on Google and Bing on 2/11/2015 and 4/29/2015; top 10 results of each search were recorded. Out of the 40 articles recorded, 24 unique articles for Google and 19 for Bing were analyzed using the LIDA Instrument v. 1.2 (Minervation, Ltd.), which uses a series of questions to score the accessibility, usability, and reliability of health websites. Accessibility covers ability of desired audience to access site and reflect "best practice" in design. Usability rates how easy for users to find out desired information and cost in time and resources to use the site. Reliability reflects whether the website keeps up to date with the best current knowledge. LIDA defines a good website with composite score 90%; a moderate website is 50-89%; a bad website scores below 50%. Results: Of the total 24 websites identified on Google, four were from an ABA verified burn center or the ABA itself; the remainder were from medical personnel or made by non medical consumer reports. The average accessibility score was 86% (63-98%), usability was 75% (42-92%), reliability was 64% (20-87%), and the average total score was 78% (62-91). The average accuracy score for these websites was 55% (3-97%) , and only three of the websites achieved a composite score of 90% or greater. On Bing, 19 distinct websites were found, with only one from an ABA verified burn center. Average accessibility score was 86% (59-98%), usability 71% (42-92%), reliability 62% (7-87%), and the average composite score was 76% (41-91%), with only one website having a composite score > 90%. On both search engines, the top two search results were Web MD and Mayo Clinic. Conclusions: The majority of burn treatment information is posted by non verified burn centers or non burn-specialist organizations. While most websites have good accessibility, the usability and reliability vary considerably. Applicability of Research to Practice: The LIDA tool allows individual burn centers to assess the quality of their website. There is a need for the ABA and ABA verified burn centers to increase the ranking of their websites on search engines. Table. No title available. View Large Table. No title available. View Large 170. How to Heal the Small Non-Healing Problem Burn - Two New Office Based Techniques in Clinical Practice S. A. Blome-Eberwein, MD, D. Boorse, RN, CPNP, P. Pagella, RN, CPNP Lehigh Valley Hospital, Allentown, PA Introduction: Whether the patient has a "rest-defect" at discharge or lost a small area of graft, or has a small area of full thickness burn but takes blood thinners for a fresh cardiac stent¼every burn provider knows those cases that are "not really good candidates for skin grafting". Yet, these types of wounds often take months to heal and can cause a significant economic burden, both from loss of income and from chronic wound care. Recently two new office based methods have been introduced that enable us to close these types of wounds quickly and efficiently. One method relies on a postage-stamp size classic split thickness graft that is processed into 1mm micro-grafts, the other relies on epidermal blister grafts that are harvested in a fractional micro graft fashion. Both techniques have been approved for use in chronic wound care. We have collected three case reports for each of these methods in burn patients in order to introduce these innovative techniques to other burn providers. Methods: Six patients with non-healing difficult wounds were treated, three with fractional blister grafting and three with micro-grafting technique. All procedures were performed in an outpatient setting with little or no topical anesthetic and no systemic anesthesia Results: All wounds healed. There were no donor site complications. Pain was evaluated between 1 and 3 out of 10 Lickert scale, 3 only for the injection of local anesthetic. Conclusions: Both techniques provide a valuable alternative to chronic wound care or classic skin grafting for small "problem" wounds and -patients in the outpatient burn center population. The micro-graft technique has the added benefit of fibroblasts in the applied cells, but leaves a donor site. The epidermal blister graft donor site heals without any visible skin change, but does not provide dermal elements to the wound. Both techniques warrant further evaluation regarding their specific indication. Applicability of Research to Practice: Immediate. 171. Evaluation of Child Life Distraction Techniques on Procedure-Related Distress and Satisfaction Measures in the Outpatient Setting S. Arnold, BS, CCLS, C. Dahling, BS, CCLS, L. James, MS, G. D. Warden, MD, M. M. Gottschlich, PhD, RD Shriners Hospitals for Children, Cincinnati, OH Introduction: While play therapy has had a presence at our hospital since 1968, only recently has child life been actively engaged within the outpatient setting. Certified child life specialists (CCLS) prepare patients for medical interventions by facilitating coping mechanisms through age-appropriate education, emotional support, therapeutic play and diversion techniques. Diversion therapy redirects attention from a stressful situation to something associated with enjoyment. The purpose of this study was to describe patient satisfaction and utility of CCLS services in the clinic and examine age-based distraction intervention preferences. Methods: A survey was randomly distributed in 2015 to 50 patients/caregivers. Evaluation used descriptive statistics to characterize demographics, type of distraction therapy and effectiveness and patient satisfaction. Comparisons were made among age groups (<3, 3-7 and >7 years old) by χ2 tests. Results: 50 children (mean age: 3.5 years; range 0.4 - 16 years) undergoing outpatient medical procedures related to acute burns (n=37) versus other (n=13 burn rehabilitation, plastic/ reconstructive surgery) were studied (Table 1). Mean time of hospital-directed care was 63.6 days; 11 patients had prior CCLS experience while 39 had not. A disproportionate number of injuries involved hands (49%), yet hand-held interventions were selected with frequency. Among distraction methods used, iPad was the most popular initial selection for children > 3 years old. 100% (n=50) of patients/families would use CCLS therapy in the future. Conclusions: This study provides evidence that children receiving treatment in the outpatient setting benefit from distraction therapy. It is clear that CCLS services is a valuable adjunct to care and makes a positive contribution to patient/ family satisfaction. It is speculated that these services also benefit clinical outcomes. More research should be devoted to the study of effectiveness of distraction techniques on pain, stress, drug utilization, recovery time and cost of care. Applicability of Research to Practice: Distraction services provided by outpatient CCLS represent an effective means to impact the quality of patient care by improving satisfaction measures. Continued surveillance of outpatient data is needed if we are to better understand how to provide best practice while reducing medication requirements and clinic costs and physician time. Table. No title available. View Large Table. No title available. View Large 172. Burn and NexoBrid™: Our Experience M. Palombo Sr., MD, G. Delli Santi, MD, S. Moroni, MD, T. Anniboletti, MD, C. Maestrini, MD, M. Cempanari, MD, M. Floris, MD, P. Carni, MD, E Falombo, MD, PhD Sant'Eugenio Hospital, Rome, Italy Introduction: For Burn burn/thermal injury the standard treatments include the use of surgery like escharotomy and autograft. The use of NexoBrid™ comparative with traditional surgery is the target of our study. The escharectomy surgery involves removing necrotic tissue until it reaches a viable plan. Depending on the depth of the burn we can be divided in such a procedure escharectomy bypass superficial and deep fascial. NexoBrid™ is a product that contains 2g or 5g of concentrate of proteolytic enzymes enriched in bromelain, corresponding to 0.09 g/g concentrate of proteolytic enzymes enriched in bromelain after mixing (2g/22g gel or 5g/55g gel). The proteolytic enzymes are a mixture of enzymes from the stem of Ananas comosus (pineapple plant). This procedures allows us to obtain the chemical escharectomy and selective reaching a plan safeguarding vital dermal those areas that have been affected by the thermal damage to a lesser extent therefore, wounds with areas of full-thickness and deep burn should be autografted as soon as possible after NexoBrid™ debridement Methods: The study began in May 2015 and was divided into two time phases trial. We included in our studies 29 patient including burn between 5 and 15 % degree treated with NexoBrid™. First phase/pre-treatment phase diagnosis and analysis of burn injuries: after careful vision and documentation with photographic record of the lesion we made medical history and survivior evaluation. After 24 hours we apllied NexoBrid™ on the wound and removed after 4 hours. We use NexoBrid™ and we approach to early escharotomy reduce the time of hospitalization. We observe that the procedure with this product It allows us to reduce blood loss during surgery. Results: No adverse reactions to NexoBrid™ treatment were found in all treated patients, the injury was treated while a significant improvement from both aesthetic and functional point of view were observed. We reduced the hospitalization of our patients by 8%. Conclusions: From the resulting data it appears that NexoBrid™ alone allows a significant improvement of burn patient management. It'is certainly a viable alternative to traditional surgery and often in combination with this it enhances healing and ensures greater performace. We are therefore encouraged to continue this study Figure. View largeDownload slide Figure. View largeDownload slide 173. First Aid Methods in Burns and Clinical Outcomes at Our Institute C. Aydogan, MD, A. Abali, MD, E. Turk, MD, M. Haberal, MD Baskent University, Ankara, Turkey Introduction: First aid is emergency care or treatment given before regular medical aid can be obtained. It must be readily available, easy to use by the general public and not hinder professional examination or treatment of the wound at a later date. In the case of burns, first aid should provide analgesia and ideally halt the progression of injury. Our aim in this retrospective study is to investigate how the type of first aid method, practicability of first aid methods, and factors derived from the victims and healthcare professionals influence clinical outcomes. Methods: A retrospective study was conducted between January 1, 2010 and March 15, 2015 at our university burn centers. Because the majority of burn accidents are managed in outpatient burn clinics and because we want to standardize the injury mechanism only outpatient scald burns were included the study. 1180 outpatient scald burns were included the study. Demographics, scene, first aid methods, the duration of the first aid, who administered the first aid, education, admission time, burn management at admission, anatomic region of the injury, complications, surgeries, healing time, accident time and pain scores were the parameters that we investigated. Patient records (charts) and control examinations were used for collecting patient data. All patients were examined and managed by the same 2 burn surgeons. The patients were divided into groups as follows: admission on first day, later admission, patients had running cold water, patients had no running cold water, patients had Burnshield® cooling therapy and patient had no Burnshield® cooling therapy. All patients had standard burn wound management. Results: The ratio of patients who received first aid was 76.9%. The ratio of running water in first aid was 47.3%. The ratio of patients who were admitted on the first day was 42.6%. Patients admitted on the first day who had running water as first aid and who had Burnshield® cooling therapy had significantly reduced healing time, fewer complications and lower pain scores when compared with those patients who had none of these factors (p<0.05). Conclusions: Even if this study was a retrospective clinical study it is important to emphasize how first aid methods affect clinical outcomes. Another important result for this study was how inappropriate burn wound managements in the first 24 hours could affect the healing time negatively. Applicability of Research to Practice: Education for prevention of burns and first aid in burns are the crucial steps in these accidents. When the accidents occur, stopping the burning process and cooling of the wound prevents the further damage, morbidity and mortality. Effective first aid methods in burns must be easy and fast for practicability. 174. The Pegasus Study: A Qualitative Exploration of Experiences and Expectations of Pressure Garment Therapy S. H. Wright, PhD, L. Jones, PhD, N. Moiemen, MB, Bch (Hons), MRCS, J. Mathers, PhD University of Birmingham, Birmingham, United-Kingdom; University Hospital Birmingham, Birmingham, United Kingdom Introduction: Pressure garment therapy (PGT) is an established treatment for the prevention and management of scars following burns injury in adults and children. However, there is limited evidence of the effectiveness of PGT. In addition, there have been few studies of patients' and parents of paediatric patients' experiences of PGT. Pegasus is a feasibility study to determine the acceptability and the design of a future full-scale randomised controlled trial. Pegasus includes a pilot trial, an attitude survey with burns service staff and nested qualitative work with staff, patients and parents of paediatric patients. This presentation will focus on patients' and parents' experiences and expectations of PGT. Methods: Semi-structured interviews were conducted with patients and parents of paediatric patients at seven burns services. Participants included patients and parents of paediatric patients who were currently undergoing PGT, as well as those who had completed therapy, some several years previously. Interviews explored participants' experiences of burns rehabilitation and specifically PGT and the impact PGT had on their own and their families' lives. Interviews were recorded, transcribed and analysed thematically. Results: Thirty five patients and 20 parents of paediatric patients participated in an interview. Participants reported a range of advantages and disadvantages of PGT. For example, pressure garments provided a physical barrier for patients between their injured skin and the environment and some experienced relief at not seeing and being reminded of their scars. However, PGT was time consuming and impacted negatively on the lives of patients and their families. Expectations of PGT varied from the estimated time in garments to the anticipated impact of PGT on their or their child's scars. Some participants felt their expectations had been met but this was not the case for all. Conclusions: The findings demonstrate a complex interplay of positive and negative aspects to patients' and parents' experiences of PGT. Experiences and expectations of PGT are discussed in relation to the limited evidence base. This qualitative study has implications for how clinicians communicate with patients and parents and how expectations of PGT can be realistically managed. Applicability of Research to Practice: Our furthered understanding of patients' and parents' experiences and expectations of PGT has the potential to lead to positive changes in practice and knowledge sharing between clinicians and patients. External Funding: The study is funded by the National Institute for Health Research (NIHR) Health Technology Assessment Programme, Grant Reference No.: 12/145/04. The Pegasus research team acknowledges the support of the NIHR Clinical Research Network. 175. Cost of Outpatient Burn Care Supplies: Where Can Patients Find the Best Deal? K. Hannigan, RN, D. Topliffe, RN, A. Swan-Mahony, RN, MHA, P H. Chang, MD, FACS Shriners Hospitals for Children, Boston, MA Introduction: The majority of burn injuries seen in medical settings usually require outpatient burn care which involves daily dressing changes. Medical practitioners often direct dressing changes which involve several different supplies which can lead to a significant cost to patients. Our study sought to evaluate the typical cost a family would incur with 1 week of dressing changes to treat common burn injuries to children. Methods: Typical treatment regimens for a superficial partial thickness scald burn to the chest of a toddler and a superficial partial thickness contact burn to the palm of the hand of a toddler were devised. The research team then went out to selected stores to do a price check of the supplies on the same day (26 September 2011). Additionally, the supplies were shopped for on a popular online website on the same day. Results: For the scenario of scald burn to the toddler chest, the national pharmacy chains were 33% more expensive than the national big box retailer and 103% more than the online website. For the scenario of toddler contact burn to the hand, the national big box chain was the most expensive. The most expensive dressing item was Kerlix gauze. A strategy to shop for the cheapest prices of each individual item would potentially save $3.63 (7% off the online website price) for the toddler scald regimen and $8.78 (11% off the online website price). However, this analysis does not include the cost of time and money to physically travel to the various stores. Additionally, shipping costs from the online website were not included. Conclusions: Patients may generally save considerable money by obtaining their supplies from online sources, especially if they have paid for a membership plan that offers free shipping. Otherwise, prices of supplies vary widely across different stores; shopping at different stores can optimize the savings. Applicability of Research to Practice: This information will help practitioners give practical recommendations to patients as to where to purchase dressing supplies. Table. No title available. View Large Table. No title available. View Large 176. A Multidisciplinary Clinical Advancement Program Promotes Excellence in Burn Care S. White, BSN,RN, K. Prelack, PhD, RD, T. Cloonan, LCSW, M. McEttrick-Maloney, RN, BSN Shriners Hospitals for Children, Boston, MA Introduction: Professional development improves staff retention, enhances job satisfaction, and promotes a excellence in the workplace. In a hospital setting, clinical advancement is a well-established program available customarily to nursing staff. In 2007, our hospital developed a multidisciplinary clinical advancement program (MCAP), focused on promoting professional development, in the areas of research, program development, evidenced based policy work, and community outreach. This often translated into excellence in burn care. We reviewed the various activities and accomplishments among members participating in our MCAP and how they impacted our quality of care. Methods: Sixty-eight participants in the MCAP, we reviewed portfolios from a random sampling of participants (n=15). Activities and projects within the areas of community, patient care, policy work, program development and research were recorded. Additional descriptors on the impact of these activities on outcome or patient satisfaction were assessed. Results: Among the 68 participants the distribution according to discipline was: Nurse (42), Rehabilitative Services (10), Child Life (7), Care Coordination (5), and Nutrition (2). Forty percent participated in policy and program development; 30% participated as principle investigators in research with publications and invitation to speak; 40% participated in community outreach. Some areas of improvement in our hospital as a result of MCAP included: development of therapeutic outings and psychosocial support among patients leaving the hospitals, creating of coping "tool kits", improving surgical wait times, development of the Braden scale, management of tracheostomies. Research activities included micronutrient intakes, burn prevention in Ukraine, and the impact of psychosocial interventions on self-esteem and confidence. Conclusions: A multidisciplinary clinical advancement program, encourages clinical staff to promote burn excellence through a variety of hospital wide initiatives including program development focused on anxiety and self-esteem, clinical research and enhancing clinical guidelines and standards. Applicability of Research to Practice: Information from this study can be used to justify development of clinical advancement programs in other pediatric burn care settings. 177. The PACU PCA Project; Triple P D. Lai, MD, C. Alphonso, MD U.S. Army Institute of Surgical Research, Fort Sam Houston, TX Introduction: PACU recovery times for perioperative patients returning to impatient wards can be long for certain patient populations following burn surgery. In our center, we noticed that patients already dependent on Patient Controlled Anesthesia (PCA), those with burns 8% TBSA or greater, and patients taking chronic opioids, tramadol, or pregabalin tended to have perioperative pain that was more difficult to control and resulted in longer PACU recovery times. As a result, we conducted the PACU PCA Project (Triple P), a process improvement project. Methods: After collecting retrospective data for cases performed during a six month period prior to project start, we educated at-risk patients and provided them a PCA using a standard order set (hydromorphone 0.4mg IV q 8min no basal rate, no lock out) upon PACU arrival after elective burn operative procedures. Following the operation and after meeting standard recovery criteria, patients were transported back to the ward with the same PCA provided upon arrival to the PACU and on 2L oxygen per nasal cannula. We then collected prospective data for six months and compared post-operative ward pain scores and PACU times before and after initiating the project. Results: The initiation of PCA in PACU following burn surgery in at-risk patients significantly reduced PACU length of stay (LOS). Table. No title available. View Large Table. No title available. View Large Conclusions: Patients receiving PCA education and a PCA upon PACU arrival spent significantly less time in the PACU with equivalent pain control compared to a matched historical cohort. PACU LOS following implementation of this process was equivalent for patients undergoing non-burn surgical procedures. Applicability of Research to Practice: Reducing PACU LOS using simple interventions may reduce resources and cost and may improve patient satisfaction by returning patients to a less intensive care environment sooner. 178. Intranasal Anxiolytic and Pain Medication Use in a Pediatric Burn Unit K. A. Doan, PharmD, P. Plowman, RN, R. Sood, MD, FACS Riley Hospital for Children at Indiana University Health, Indianapolis, IN; Indiana University, Indianapolis, IN Introduction: Appropriate pain and anxiety management is essential in the care of a pediatric patient with a traumatic burn injury. Poor anxiety and pain control can increase the risk of post-traumatic stress disorder in these patients, making the long term care difficult to manage. Historically intravenous (IV) administration was considered the preferred route of administration but newer, less-invasive routes with similar efficacy have become better options in select patients. Methods: In response to improving pain and anxiety management in our pediatric patients, the multidisciplinary team (physician, nurse and pharmacist) reviewed options for administering these medications in patients that currently did not have IV access but yet still required medications with a quick onset of action. Intranasal (IN) administration offers the advantages of similar onset and duration of action and efficacy of an IV medication, but is less invasive. A protocol was developed by the multidisciplinary team to provide guidelines and instructions for use of IN administration in pediatric burn patients using the atomized delivery technique. Patients included in the protocol were greater than 6 months of age without IV access that required pain/anxiolytic management and a burn injury involving less than 5% Total Body Surface Area (TBSA). Patients excluded in the protocol were those less than 6 months of age or the presence of facial/nasal burns that would interfere with medication administration. Medications utilized are fentanyl (using the IV product 50mcg/ml) and midazolam (using the IV product 5mg/ml). Appropriate monitoring parameters and administration technique was described. All unit nurses were trained and educated to the protocol procedures and to the atomizing device. The protocol also followed the institution's procedural sedation and analgesia policy. Results: The protocol was adopted by the multidisciplinary team. Multiple clinical scenarios have been identified by the team as to benefiting from IN administration ranging from initial patient presentation (prior to IV access being obtained) to those patients that IV access is no longer indicated. Conclusions: Utilizing a multidisciplinary team, IN midazolam and fentanyl can be utilized for effective pain and anxiolytic management in a pediatric burn patient. IN administration can limit the number of invasive procedures required (i.e. IV access) and/or effectively pretreat the patient prior to the procedure. Applicability of Research to Practice: IN administration offers a less-invasive administration technique for pain and anxiolytic medication with a similar onset and duration of action when compared to IV administration. 179. Liposomal Bupivacaine for Postoperative Analgesia in Burn Donor Sites: A Case Series Report C. Alphonso, MD, S. Leazer, MD, D. Bitner, MD U.S. Army Institute of Surgical Research, Fort Sam Houston, TXX Introduction: Post-surgical pain management following skin grafting in burn patients is cardinal for proper wound healing and recovery. Although typical local anesthetics such as bupivacaine provide effective analgesia, their duration of action remains limited (2-8hs). Studies have shown that a single-dose of liposomal bupivacaine provides effective local analgesia for up to 72 hrs. The use of liposomal Bupivacaine as a local post-op analgesic in burn donor sites is a novel approach to donor site pain. This case series reports on 5 patients, in whom liposomal bupivacaine was used in the donor site. Methods: Skin grafts were collected from the antero-lateral thigh of 5 patients presenting various degrees of burn injury. Preparation for surgery was performed in the usual manner. Pitkins solution (lactated ringers with 1:1 million epinephrine) is typically infiltrated subcutaneously in the donor site prior to harvest to tense the donor area to provide better graft quality. In these patients 20ml (266mg) of liposomal bupivacaine was diluted in up to 250ml of normal saline and infiltrated subcutaneously to the donor site prior to harvest. Post-op donor site pain was assessed using a classic Pain Assessment Scale (PAS) at 1,4, 8, 12, 24, 36, 48, and 72 hours post-op. Results: Table. No title available. View Large Table. No title available. View Large * No score denotes that a donor site pain score was not obtained for unknown reason. The skin-grafting procedures were uncomplicated. All donor sites healed properly with no signs of inflammation, hemorrhage or infection. No adverse effects were reported. Patients tolerated the operative interventions well. Conclusions: The intra-op infiltration of donor sites with liposomal bupivacaine was feasible, safe, and effective in maintaining post-operative analgesia for up to 72 hrs. A Larger cohort including a control population is warranted. Applicability of Research to Practice: This preliminary report will serve as a platform for a larger prospective study. We believe that liposomal bupivacaine is a promising alternative to standard local anesthetics and opioids in the post-operative pain management of burn patients undergoing split-thickness autologous skin-graft surgeries. If this approach is proven to be effective on a larger scale, it will improve pain management in burn patients and reduce morbidities associated with pain, delayed wound healing, and prolonged use of opioids. 180. Effect of Virtual Reality Distraction Therapy on Pain and Anxiety in Adult Patients Undergoing Complex Dressing Changes: A Randomized Controlled Trial D. Mazzacano Searles, RN, BSN, T. McSherry, RN, BSN, M. Atterbury, RN, BSN, E. Helmold, RN, BSN, S. Gartner, RN, BSN, C. Schulman, RN, MS Legacy Emanuel Hospital, Portland, OR Introduction: The goal of this study is to determine the effect of immersive virtual reality (IVR) as an adjunct to systemic therapy on pain and anxiety in adult patients undergoing painful burn and other wound dressing changes. Methods: The study was a randomized controlled trial with the subjects as their own control. Eighteen subjects were randomly assigned to two sequential dressing changes (36 dressings total), one with IVR and one without IVR. For each dressing change, subjects were pre-medicated with intravenous narcotics based on standard ideal body weight; they received further doses as needed for breakthrough pain. During the experimental dressing change, patients also wore VR goggles and participated in an immersive, computer generated, interactive, 3-dimensional virtual world. Before and after each dressing change, individuals rated their pain and anxiety using a visual analog scale (VAS) and were asked questions to evaluate their experience. Results: No statistical differences in pain and anxiety were found between the two treatments (p>0.05). However, the number of breakthrough pain events during dressing changes was significantly lower in the dressing change with IVR, with the total amount of IV fentanyl needed being 30-50% lower in the IVR group. The majority of the subjects (75%) found IVR helpful and indicated they would want to use it again. Conclusions: Immersive virtual reality is an effective non-pharmacologic adjunct to conventional care in managing the pain associated with burn and wound dressings, warranting further research in burn and wound patient populations. Applicability of Research to Practice: Use of IVR during painful dressing changes shows the potential to reduce the need for narcotic pain control, and to improve patient satisfaction with the procedures. 181. Selection of Pain and Sedation Medications for Dressing Change: A Survey of American Burn Association (ABA) Burn Centers R. Meyers, BS, A. Kovac, MD, M. Wyatt, MD, D. Allen, MD, M. Pena, BSN,RN, K. Northrop, BSN,RN, J. Lozenski, MD, D. Bhavsar, MD University of Kansas Medical Center, Kansas City, KS Introduction: Care and management of pain and sedation for the burn patient undergoing dressing change can be difficult and challenging. Variations appear to exist in the selection of medications for pain and sedation prior to and during burn dressing change. Methods: To determine if variations exist in the selection and use of pain and sedation medications for burn dressing change, a survey via the internet using Survey Monkey was directed to ABA Burn Center physicians and nurse managers involved in the regular care of burn patients. 18 questions regarding pain and sedation management were presented and all responses were anonymous. This study received exempt status from our IRB and approval from the ABA Survey Committee. Results: 232 responses were received with 72% RN, 10% RN Practitioners and 18% MD, in centers with 22% Adult only, 12% Peds only and 66% both Peds and Adult patients. 80% of centers had >200 patients/year. 68% always used a premed. For PO premeds, dilaudid or a combination of opioid + non-opioid were most frequently used. The most common IV premed opioids were morphine or fentanyl. The most common premed anxiolytics were ativan or midazolam. 68% always used a long acting opioid for pain control. Anesthesia regimen was decided case by case 47% or by specific protocol 24% of the time. Protocol was followed 18% always or 55% most of the time. It was felt that a patient's procedural pain was adequately controlled 2% always, 20% mostly, 60% sometimes, and 18% rarely. The pain regimen was altered most of the time in 25% of cases or 2% all the time. Providers differed regarding preferred use of agent, dose and route 44% sometimes, 39% rarely and 6% never. Deep sedation was felt to be needed 4% most of the time, 60% sometimes, 27% rarely and 10% never. Ketamine (50%) was the most common agent used for deep sedation followed by propofol (32%). Most to least common monitor was: l-O2Sat (most), 2-BP, 3-ECG, 4-ETCO2 (least). A dedicated anesthesiologist was consulted most frequently (33%) on a case by case basis following prior failure or excess pain/anxiety as elicited by the patient. When to consult was determined by the surgeon or intensivist. Occasional use of an anesthesia provider or acute pain service, respectively, occurred 36% or 16% of the time. Conclusions: Management of burn patient's pain and sedation for dressing change is difficult and variations in approach exist among different burn centers. Applicability of Research to Practice: A burn patient's analgesia and sedation for dressing change needs individualized care on a case by case basis. Providers must be responsive to pain intensity alterations or escalations. Consultation with acute pain or anesthesia physicians may be needed for difficult patients with comorbidities, drug dependence or prior pain/ sedation medication failure. 182. Low Dose Ketamine as an Adjuvant Analgesic in Burn Patients J. Mehta, MD, MBA, D. Amaro-Drieger, BA, P. Patel, MD, T. Huzar, MD, FACS University of Texas Houston, Houston, TX Introduction: Low dose Ketamine is currently a standard of care at many US hospitals as an adjuvant non-opioid for pain management. Low-dose ketamine infusions have been shown to effectively reduce morphine requirements in the first 24 hours after surgery, limit opioid related side effects, and have minimal to no side effects. Methods: As an NMDA receptor antagonist, low dose Ketamine has been demonstrated to have an opioid sparing effect in many patients and we hypothesized it would benefit burn patients in a similar manner. We retrospectively reviewed the outcomes of 16 unintubated IMU and floor status patients who received continuous low dose ketamine infusions in our Burn Unit for reductions in their numeric rating scores (NRS) for pain at rest and their ability to tolerate bedside dressing changes. Patients received 48 to 96 hours of continuous low dose Ketamine infusions, ranging between 0.1 to 0.25 mg/kg/hr based on actual body weight. All these patients were followed by the Acute Pain Medicine service and placed on a scheduled multimodal analgesic regimen with a minimum of two non-opioid agents, in addition to low dose Ketamine. Results: We found that when added to a multimodal analgesic regimen, low dose Ketamine reduced pain at rest, as reported by patients, by 3 to 4 points on the NRS scale. Additionally, patients reported an increased ability to tolerate bedside dressing changes and improved overall satisfaction with their care. Conclusions: Based on these early outcomes, we believe low dose Ketamine offers an exciting low-cost, safe medication for the burn unit that may improve patient experience, pain control, and limit costly visits to the OR for dressing changes. Applicability of Research to Practice: Additional prospective studies should be performed to assess whether low dose continuous infusions of Ketamine can improve patient experience, pain control, and limit costly visits to the OR for dressing changes. 183. Porcine Small Intestinal Submucosa (SIS) Decreases Postoperative Pain for Skin Graft Donor Site and Improves Aesthetic Outcome A. Desrosiers III, MD Marquis Plastic Surgery, Miami, FL Introduction: Currently, management of donor sites for split thickness skin grafts ranges from nonadherent dressings, nonocclusive dressings, frequent dressing changes, etc. The common complaint from patients is often the pain of the donor site from the skin graft, much more than the actual surgical site itself. Several other papers in the literature have described several biological acellular skin dressings or extracellular matrices (ECMs) for decreasing patient's perceived wound pain from the donor site of the skin graft. This case examines a patient who had porcine small intestinal submucosa (SIS) used as a covering for part of the donor site; the other aspect of the donor site was treated with the standard occlusion dressing. Our hypothesis was that the SIS would decrease wound piain. Methods: This case examines a patient who was a 22 year old male sustained multiple gunshot wounds to the upper extremity and required multiple skin grafts. The chosen donor site was the anterior thigh and the split thickness grafts were harvested in the standard fashion. The patient had porcine small intestinal submucosa (SIS) used as a covering for part of the skin graft donor site; the other aspect of the donor site was treated with the standard occlusion dressing. Thus, all factors were otherwise controlled (same patient, same extremity, same type of wound, same surgical procedure). Results: Postoperative, the patient was evaluated on the standard Faces Pain scale. On postoperative day number 1, the patient complained of pain 0 out of 10 on the donor site that was treated with the porcine small intestinal submucosa (SIS). He complained of 10 out of 10 pain on the donor site treated with the standard occlusive dressing. The patient was re-evaluated one week later; again, he complained of 0 out f 10 pain at the donor site treated by the porcine small intestinal submucosa (SIS). In contrast, he still had a pain of 7 out of 10 in the donor site treated with the standard occlusive dressing. Conclusions: Other reports have described that the porcine small intestinal submucosa (SIS) and other biologic dressings decreased patient pain from donor sites from skin grafts. Although this is only one patient case report, all factors were controlled, and we concluded that the porcine small intestinal submucosa (SIS) decreased postoperative pain in the donor site from the skin graft. Applicability of Research to Practice: This has broad application potentially for many surgeons performing skin grafts. Donor site morbidity is a significant complaint from patients who have skin grafts. If the porcine small intestinal submucosa (SIS) can decrease pain in the donor site, more research should be performed in this area. 184. The Patient's Experience with Skin Grafting After Cutaneous Burn Injury? Donor-Site Preferences L. O. Roussel, BA, J. S. Khouri, MD, A. Lidder, BS, D. E. Bell, MD University of Rochester Medical Center, Rochester, NY Introduction: Split-thickness skin grafts (STSG) are considered standard of care in the treatment of burn injuries. Few studies have evaluated patient preferences for donor site location in patients that have previously had a STSG. We seek to assess patient preferences regarding skin graft donor site location in patients that have previously undergone split-thickness skin grafting to treat burn injuries. Methods: Retrospective chart review and patient surveying of all patients over the age of 18 that underwent a split-thickness skin graft from 2013- 2015. Survey content included questions about skin graft donor site location, patient feelings and experience with skin grafting as well as specific preferred donor site identified by participants. Statistical analysis was utilized to determine any association between patient demographics and experience with skin grafting, and preferred skin graft donor site. Results: The most common prior skin graft donor site locations were anterior thigh (n=24) and lateral thigh (n=19). When asked to choose the hypothetical location of a skin graft donor site, 42 of the 43 enrolled patients indicated that they would pick the same location of their prior donor site. The main factors influencing their decision were concern with visible scarring or discoloration in everyday clothing (n= 28) and concern with visible scarring or discoloration in a bathing suit (n=3). Conclusions: Patients that have previously had a skin graft prefer anterior donor sites. Applicability of Research to Practice: This research highlights the important factors in the selection of a donor site as perceived by patients undergoing skin grafting. 185. Hot Water Bag Scald Burns of Geriatric Patients: An Unusual Cause of Scald Burns C. Aydogan, MD, A. Abali, MD, E. Turk, MD, M. Haberal, MD Baskent University, Ankara, Turkey Introduction: Hot water bags (HWB) are commercially produced and consist of a plastic material. It is filled with boiling water. Its capacity is 1-1.5 liters. It is very cheap and can be bought from any medical market and pharmacy in Turkey. There is no legal restriction of its usage in Turkey. There is no consensus for its usage but the majority of people believe it has benefit for relief of some types of pain. It is usually used for back pain, lower back pain, and abdominal pain. We can say that it is usually used for physiotherapy. However, in our opinion HWBs are not so innocent and are a cause of scalding burns in the geriatric population. Methods: We retrospectively reviewed 92 HWB scald burns in geriatric patients at our center between 2012 and 2015. We reviewed demographic data, affected anatomic regions and treatment modalities. Results: The majority of the patients were female (58.38%). All the accidents happened at home. The mean age of the patients was 66.18 ± 2.95 years (range 59-83 years). The mean TBSA affected of the patients were 3.18 ± 0.21%. Lower extremities, lower back, back, genital area, and abdomen were the most frequently reported anatomic regions affected. Most patients had second degree burn wounds (83.54%). The majority of the patients were treated with conventional dressing methods and only 23.4% of the patients were treated with debridement and grafting procedures. The majority of the patients used HWBs for lower back pain and for heating the feet because of diabetic neuropathy. The majority of accidents occurred from tearing of the bags due to compression. Geriatric patients have reduced reflexes and additional comorbidities. These factors also play a role in the occurrence of this kind of trauma. Conclusions: HWBs are easily purchased with no scientific consensus about their indications for use. These bags usually keep somewhere at home after their first use and often exceed their expiration dates. In this study we detected that these devices are not controlled by the governments and many people do not have any idea about their proper usage. Difficult anatomic regions for burn treatment like genitalia, lower back and back can be affected by this kind of trauma. Applicability of Research to Practice: Our aim in this study is to attract attention to an unusual cause of scald burns in geriatric patients. 186. Looking for Answers Beyond the Scald: A Cross-Sectional Survey J. Burgess, BSc(Hons), C. M. Cameron, PhD, K. Watt, PhD, R. Kimble, MBChB, FRACS Centre for Children's Burns & Trauma Research, University of Queensland, Brisbane, Australia; CONROD Injury Research Centre, Griffith University, Meadowbrook, Australia; James Cook University, Townsville, Australia Introduction: In most developed countries, hot beverage scalds are the leading cause of burn injuries in young children, accounting for 1 in 5 of all burns treated. The high incidence of these scalds make it an important paediatric public health issue, yet is often overlooked in research and injury prevention. The aim of this study was to elicit detailed information on the setting, supervision, mechanism and first aid use in children presenting at a major paediatric burns unit in order to inform a hot beverage scald prevention campaign. Methods: A cross sectional survey delivered via an iPad, to parents and caregivers of children aged 0 to 36 months presenting as inpatients or outpatients at a major paediatric burns unit with a hot beverage scald. Parents were approached to participate at the time of their child's first dressing change. A non-probability convenience sampling method was used with the goal of capturing all presentations over a 12-month period. Results: Data collection will finish in November 2015. To date, 65 surveys have been completed, with an expected annual total of 80 completions. Results to date confirm the main mechanism of injury being the child pulling the cup of hot liquid over themselves, and the majority of injuries happen in the child's home. The supervising factors of the parent/caregiver will be analysed by determining the attention and proximity of the caregiver when the injury occurred. Burn first aid use and knowledge will be determined by what, if any, first aid was applied at the scene, and why the caregiver chose that treatment. Conclusions: To better understand the factors contributing to hot beverage scalds in young children, this study questioned parents whose child had recently experienced such an injury to describe in detail the situation and circumstances surrounding the injury. Gathering and analyzing this information will highlight any patterns in the aetiology of these scalds. Applicability of Research to Practice: Findings from this study will be used to inform a hot beverage scald prevention intervention aimed at parents and caregivers of children under the age of three. By better understanding the situation in which these scalds occur, along with parents supervising behaviour and understanding/use of burn first aid, we may be able to curb the high incidence of these injuries in the very young. 187. Factor Structure of the Life Impact Burn Recovery Evaluation Questionnaire (LIBRE-192) G. D. Shapiro, PhD, A. Lee, PhD, A. Jette, PhD, J. C. Schneider, MD, M. Rossi, MA, M. Soley-Bori, MA, M. Marino, MPH, F. Amaya, MPH, R. Soria-Saucedo, MD, MPH, A. Acton, RN, BSN, C. M. Ryan, MD, FACS, L. E. Kazis, ScD McGill University, Montreal, QC, Canada; Bentley University, Waltham, MA; Boston University School of Public Health, Boston, MA; Massachusetts General Hospital, Boston, MA; Phoenix Society for Burn Survivors, Grand Rapids, MI Introduction: Objective measurement of quality of life following burn injury requires the development and validation of standardized instruments. The 192-item Life Impact Burn Recovery Evaluation Questionnaire (LIBRE-192) was created to measure the social impact of burns in line with a previously established conceptual framework consisting of eight domains (Recreation and Leisure, Work and Employment, Relating with Strangers, Sense of Purpose, Family Roles, Informal Relationships, Sexual Relationships, and Romantic Relationships), based upon the WHO International Classification of Function. Using factor analysis, the present study validated the conceptual framework with empiric data to establish the construct validity of the LIBRE-192. Methods: Exploratory factor analyses were run separately on the items comprising each domain. Factor analysis with varimax orthogonal rotation was used to identify the most conceptually meaningful factors. The number of factors was reduced as necessary to assure a sufficient number of items loading on each factor with an eigenvalue of 1.0. Names for the factors were determined through a consensus process with clinicians. Results: A total of 25 factors among the 8 different domains were identified. Most of the domains each displayed a separate factor structure of three to five factors. Examples of factors identified include Engagement in social activities, Engagement in physical activities, Enjoyment of activities and doing new activities (Recreation and Leisure domain); Performance at work / impact of fatigue and stress, Focus and handling stress at work, Relationships and communicating at work (Work and Employment domain); and General comfort around strangers, Comfort talking with strangers, Not being bothered by behavior of strangers (Relating with Strangers domain). Cronbach's alpha coefficients were credible >0.75 (for 20 of 25 factors). Communalities were good (>0.40 for 93% of items). Total variance explained by each factor structure for the 8 domains ranged from 51% to 66%. Conclusions: The LIBRE-192 measures a broad range of concepts relating to the social impact of burns. Factors identified are consistent with the conceptual framework used to develop the LIBRE-192. Factor analyses supports the construct validity of the eight questionnaire domains. Applicability of Research to Practice: This instrument can be used to track outcomes of burn survivors, to identify individuals with sub-optimal outcomes, and to provide patient-centered estimates of treatment efficacy. This work improves the ability to clinically interpret data derived from the LIBRE-192. External Funding: National Institute on Disability, Independent Living, and Rehabilitation Research, NIDILRR grant number 90DP0055. 188. Evaluation of the Professional Quality of Life and Health Risk of Employees at a Pediatric Burn Center C. Allgeier, DTR, M. M. Gottschlich, PhD, RD, L. James, MS, H. Madsen, RN, BSN, E Warner, MD, FACS Shriners Hospitals for Children, Cincinnati, OH Introduction: Compassion fatigue (CF) is characterized by decreased compassion satisfaction (CS) and high rate of secondary traumatic stress (STS) resulting in burnout (BO). Symptoms of CF include depression, sleep difficulties and poor self-care. Rate of CF is reported as high as 86% in critical care nurses. Research on CF has primarily focused on nurses, physicians and social workers. The purpose of this study was 1) to determine rates of CS, BO and STS of hospital employees at a pediatric burn center stratified by patient vs support role 2) determine if rates of CS and STS correlate with negative self-care behaviors. Methods: In June, 2015 a 10 question health history and the Professional Quality of Life (ProQOL v5) (validated self-measure of CS, BO and STS) were distributed to 267 employees. Outcomes were assessed using Student's t-test and the χ2 test. Results: Surveys returned included 84 health surveys (31.5%) and 79 ProQOL (29.6%). Results were analyzed using the sum scores for CS, BO and STS. The majority of CS and BO sums fell in the average sector with no statistical difference between clinician vs non-clinician groups (Table 1). STS sums were low but statistically significant (p=.0264) with higher instance in the clincal group. Rate of self-reported depression was similar between groups at 12%, double the national rate of 5.8% (National Institute of Mental Health). Sleep was inadequate in both groups (average 6.62 hours vs suggested 8 hours of sleep for adults > 21 years). No statistical difference between groups was seen in self-reported medical diagnosis, eating habits and exercise. Conclusions: Results of the ProQOL sums paired with high rates of depression and altered sleep suggest the risk for CF is not limited to direct patient care staff and the risk is just as significant for indirect care givers. It is speculated that the average rates of STS and CS in non-clinical employees may be attributed to vicarious traumatization while clinical staffs increased risk may be in response to direct patient care over prolonged periods of time. Applicability of Research to Practice: CF,BO and STS represent noteworthy risks for healthcare organizations. Hospital management must recognize while CF and STS occurs rapidly, if left untreated they will manifest to BO resulting in compromised patient care and poor QOL for employees. Prevention strategies include providing employees access to resources as stress management, mindfulness, adequate vacation time and maintaining a healthy diet to decrease risk for CF. Table. No title available. View Large Table. No title available. View Large 189. Satisfaction with Appearance in Young Children at 5 and 10 Years Post-Burn D. Patel, BS, M. Rosenberg, PhD, L. Rosenberg, PhD, K. Epperson, RN, BSN, C. R. Andersen, MS, D. N. Herndon, MD, FACS, W. Meyer III, MD Shriners Hospitals for Children and University of Texas Medical Branch, Galveston, TX; University of Texas Medical Branch, Galveston, TX Introduction: Little is known about very young children's long-term satisfaction with appearance as they recover from burn injury. The purpose of the study was to examine the perception of appearance at 5 and 10 years post-burn for children who were younger than 5 at time of burn. Methods: We looked at the NIDRR database for patients who were treated acutely at this pediatric burn center from January 1997 to the present. Three age/time groups were examined (children younger than 13 at 5 years post-burn; children younger than 13 at 10 years post-burn; and children age 14-15 at 10 years post-burn). The Satisfaction with Appearance Scale (SWAP) was used. Parents/Caretakers responded to the questionnaire for children younger than 13 and children ages 14-15 completed their own questionnaire. A Mixed Analysis of Variance model was used to examine the relation between outcome and the age/time group while adjusting for covariates (gender, age at burn, TBSA) and blocking on subject to compensate for repeated measures. Differences among age/time groups were assessed by Tukey-adjusted contrasts. Significance was set at p < 0.05. Individual items were analyzed to determine whether the mean score differed from 4 (neutral) at all time points, with an adjusted alpha of .05/3=.017. Results: Out of 818 patients, n=161 patients answered at least one of the SWAP questions and had demographic information. None of the patients responded to the entire questionnaire at all time points. The study focused on 161 patients, 100 males (62%) and 61 females (38%). The mean age of burn was 2.6 ± 1.4 years and mean TBSA burned was 51% ± 17.2. Comparison of children younger than 13 at 5 and 10 years revealed statistically significant differences in response to comfort in the presence of family (p < 0.002), which indicated that parents/caretakers perceived that patients were more comfortable at 10 years post-burn. No significant differences between age/time groups were evident for the remaining SWAP questions. On each individual item there was a trend towards improvement over time. On the items that inquired about satisfaction with appearance of the neck and satisfaction with appearance of the chest, the trend towards improvement was statistically significant (p < 0.004) for all groups. On the item that inquired about satisfaction with appearance of the legs, the trend towards improvement was statistically significant for children younger than 13 at 5 years (p < 0.012) and 10 years (p < 0.004). Conclusions: The results revealed that young pediatric burn survivors were more comfortable around family members at 10 years follow-up. In general, patients showed positive though non-significant trends in almost all areas of satisfaction with their appearance. Applicability of Research to Practice: Children and their parents appear to adapt well over time to burn injury scars. External Funding: National Institute on Disability and Rehabilitation Research Grant #H133A120091; National Institute on Disability, Independent Living, and Rehabilitation Research #NIDILRR-90DP0043-01-00. 190. The Impact of Burn Injury on Relating with Strangers: A Life Impact Burn Recovery Evaluation (LIBRE) Study C. Obionwu Jr., MD, J. C. Schneider, MD, G. D. Shapiro, PhD, A. Lee, PhD, M. Marino, MPH, A. Acton, RN, BSN, A. M. Jette, PhD, L. E. Kazis, ScD, C. M. Ryan, MD Tufts University School of Medicine, Boston, MA; Spaulding Rehabilitation Hospital, Charlestoum, MA; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; Bentley University, Department of Mathematical Sciences, Waltham, MA; Boston University School of Public Health, Boston, MA; Phoenix Society of Burn Survivors, Grand Rapids, MI; Center for the Assessment of Pharmaceutical Practices (CAPP), Boston University School of Public Health, Boston, MA; Massachusetts General Hospital and Shriners Hospitals for Children, Boston, MA Introduction: Relating with strangers is an important component of community reintegration after burns. The present study aims to assess the patient characteristics associated with difficulties relating with strangers after burn injury. Methods: The LIBRE-192 was administered to 402 adult burn survivors with ≥5% TBSA burned or burns to critical areas (hands, feet, face, or genitals). Each item is scored on a 5-point Likert scale (1 to 5) with higher scores denoting better outcome. The Relating with Strangers domain contains 22 items. Demographic and clinical characteristics of the population were analyzed. Individual items and mean scores of all items in the domain were examined and compared to other domain scores. Logistic regression analyses were used to measure associations between demographic and clinical characteristics and scores in the Relating with Strangers domain. Results: The population had a mean age of 46.2 years (std. dev. = 16.2), mean time since injury of 16.9 years (SD = 17.1), and was 50% male, 79% Caucasian and 48% married. The mean Relating with Strangers domain score was 3.72 ± 0.88; this was the lowest score of the eight LIBRE domains. The two items with the lowest scores (percent of subjects with 1 or 2 on the scale 1-5) were "It bothers me when strangers feel sorry for me" (44.1%) and "Stares from strangers bother me" (40.1%). In adjusted regression analyses, male gender (p<0.01) and higher education level (p=0.01) were associated with higher scores on Relating with Strangers. Relating with Strangers scores were not associated with time since injury, age or burn size in adjusted analyses. Conclusions: Relating with strangers is an important long-term community reintegration challenge associated with gender and education level. Applicability of Research to Practice: These findings highlight the long-term challenge of interacting with strangers and may alert the clinical community to future interventions to address this issue. External Funding: The contents of this abstract were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research, NIDILRR grant number 90DP0055..NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS)..The contents of this abstract do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. 191. Ethical Issues in Identical Twin-to-Twin Skin Grafting M. Gerrek, PhD, C. Ngana, MA, T. Coffee, ACNP-C, C. Brandt, MD, FACS, C. Yowler, MD, FACS, FCCM, A. Khandelwal, MD MetroHealth Medical Center, Cleveland OH Introduction: Identical twin-to-twin (ITT) skin grafting, although rare, can present significant ethical challenges. This became apparent to the authors when they were presented with such a case. Yet, there is limited guidance provided in the literature for the ethical management of these cases. Methods: We reviewed all published case reports on ITT skin grafting in burn care, considered our own ITT case, and reviewed the literature on the relevant ethical issues, even in cases in which the literature was outside the realm of burn care. In addition, a multidisciplinary team was tasked with determining the salient ethical issues in ITT cases. Results: A total of 16 published cases of ITT skin grafting were found, along with 2 cases of identical triplet-to-triplet skin grafting. Only two of the ITT cases, both pediatric, considered the ethical issues involved. The team distinguished between the ethical issues that arise in all ITT skin grafting case and those that arise solely in pediatric cases. The ethical issues that arise in all cases include: (1) Skin grafts are not considered transplants and therefore are not covered by the same rules and regulations as solid organ transplants (2) Identification and confirmation of identical twins (3) Indications for ITT skin grafting (4) Consent process for the donor (5) Consent process for the recipient (6) Need for Donor Advocates (7) Optimal timing of surgery (8) Indications for ITT skin grafting in the elderly (9) Emotional and psychological risks to the recipient The ethical issues specific to pediatric cases are: (1) Assent/consent of potential minor donors (2) Emotional and psychological risks to donors (3) Assent/consent to potential minor recipient Proposed clinical and ethical guidelines are discussed in detail. Conclusions: Previous reports do not adequately address the ethical issues that arise in managing ITT skin graft cases. Furthermore, there is no discussion of the ethical issues in identical triplet-to-triplet skin graft cases. The authors propose the term "monozygotic sibling" (MZS) skin grafting as a classification for all skin graft cases which involve monozygotic siblings. Formal clinical and ethical guidelines need to be established to ensure proper management of these cases in the future. Applicability of Research to Practice: While rare, monozygotic sibling skin grafts do occur in burn care. It is important that further ethical consideration be given to these cases and formal guidelines for management be developed. 192. The Use of Growth Mixture Modeling to Determine Trajectories of Mental Health in Adults with Burn Injuries S. Wiechman, PhD, F. D. Bocell, PhD, D. Amtmann, PhD, K. A. McMullen, MPH, M. Rosenberg, PhD, L. Rosenberg, PhD, R. Holavanahalli, PhD, C. M. Ryan, MD, FACS, J. C. Schneider, MD, D. Herndon, MD, FACS, G. J. Carrougher, RN, MN, N. S. Gibran, MD, FACS University of Washington/Harborview Medical Center, Seattle, WA; University of Washington/Department of Rehabilitation Medicine, Seattle, WA; University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX; University of Texas Southwestern, Dallas, TX; Massachusetts General Hospital, Spaulding Rehabilitation Hospital, Harvard Medical School, Shriners Hospitals for Children, Boston, MA; Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA Introduction: The purpose of this study was to determine trajectories of mental health over time and to identify predictors of these trajectories. Methods: Adults with burn injuries responded to a self-report survey (mental composite score of the SF-12; MCS) about mental health prior to burn injury and up to 2 years post injury (6, 12, and 24months). TBSA, demographics, scores from the Community Integration Questionnaire, Satisfaction with Life Questionnaire (SWL), and the Satisfaction with Appearance Scale were all used as predictors in the model. Growth Mixture Modeling (GMM) was used to model MCS scores over time and group similar individual trajectories into latent classes of people. GMM does not assume that a mean trajectory of change is a good representation of mental health after burn injury for the whole sample, but infers membership in a certain class. Results: We had an N=939; 72% male, 64% Non-Hispanic White, Mean age=44, Mean TBSA=20%. Two classes emerged with different mean trajectories. The largest class (91 %) reported above average mental health pre-burn injury with a statistically non-significant change over the course of the study. A smaller group (9%) reported below average mental health scores pre burn injury and a statistically significant better mental health at 24 months. Physical disability before the injury, drug abuse, Hispanic ethnicity, unemployment, and SWL scores were all significant predictors of class membership. Conclusions: The majority of patients (91%) report their pre-injury mental health to be above average and remains relatively stable after the injury and two years later. But 9% of the patients reported below average mental health scores prior to their injury and improved mental health after the burn. This data is highlights the potential for posttraumatic growth and areas for future research. It suggests that engagement with the medical system via a traumatic injury may help those who might be previously homeless or lacking in services to get needed services and make positive changes. Applicability of Research to Practice: This data can help us to identify those class of patients most in need of intervention and the risk and protective factors of each class. External Funding: This research was supported by a grant from the National Institute on Disability, Independent Living and Rehabilitation Research, NIDILRR#90DP0029-01-00. 193. A Multi-Center Investigation of Psychosocial Distress in Young Children up to Two Years Post Burn D. Patel, BS, L. Rosenberg, PhD, M. Rosenberg, PhD, K. Epperson, RN, BSN, S. Wiechman, PhD, C. R. Andersen, MS, C. M. Ryan, MD, FACS, J. C. Schneider, MD, D. N. Herndon, MD, FACS, W J. Meyer III, MD Shriners Hospitals for Children and University of Texas Medical Branch, Galveston, TX; University of Texas Medical Branch, Galveston, TX; University of Washington/Harborview Medical Center, Seattle, WA; Massachusetts General Hospital; Spaulding Rehabilitation Hospital; Harvard Medical School; Shriners Hospitals for Children, Boston, MA; Spaulding Rehabilitation Hospital, Boston, MA Introduction: Children five and younger are at high risk of sustaining severe burns. Little is known about their long-term psychosocial outcomes. The purpose of this study was to examine and quantify long-term psychosocial distress in young children Methods: In a long-term multicenter study, parents of children 5 or younger at the time of burn were asked to rate the child's level of distress on 12 variables at discharge, 6, 12, and 24 months. Distress was measured on a 10 point rating scale, 10 representing high distress. A mixed Analysis of Variance model was used to examine the relation between distress and time adjusting for covariates (gender, age at burn, TBSA), blocking on subject as a means of controlling for repeated measures. Differences among times were assessed by Tukey-adjusted contrasts. Questions relevant to this sample from the Community Integration Questionnaire were examined and summarized with frequency counts and percentages. Significance was set at p < 0.05. Results: Data were collected from 1997-2015. Parents of 76 children answered the first distress question at all-time points. This was 6.4% of the eligible sample. The sample included 43 (57%) males and 33 (43%) females. Primary causes of injury were scald (46%) and flame (42%) burns. The mean age at time of burn was 3 ± 2 years. The mean percent total body surface area (TBSA) burned was 34 + 20, and mean length of hospital stay 28 ± 23 days. There was a significant decrease in children's pain from discharge (mean of 4.1) to two years (1.6), p < 0.0001. There was a decrease in sleep disturbance from discharge (mean of 3.6) to one year (1.8) and two years (1.6), p < 0.0001. Itching decreased from discharge (mean of 5.2) to two years (3.2), p < 0.0001.Parents of children who were older reported having more concerns about their child's appearance and there was no evidence this perception changed with time. Children's range of motion and strength improved at all-time points. Concerns about temperature sensitivity, uncomfortable scars, changes in skin color, recovery time, use of pressure garments, family's financial problems did not significantly change. There were no differences in participation in leisure activities at follow-up. Conclusions: Distress due to pain, itch and sleep disturbance decreased with time while range of motion and strength improved. Parents of older pre-school children were concerned about their child's appearance. Additional data collection is needed to improve the generalizability of the findings. Applicability of Research to Practice: This questionnaire is a useful way of identifying parents' perceptions regarding the causes of distress of young children with burns. It is important to be aware that parents of older pre-school children were more concerned with body image and appropriate interventions need to be planned. External Funding: National Institute on Disability and Rehabilitation Research Grant #H133A120091; National Institute on Disability, Independent Living, and Rehabilitation Research #NIDILRR-90DP0043-01-00. 194. Characteristics of Patients Admitted for Frostbite in an Urban Burn Medical Center S. Zavala, PharmD, BCPS, K. McElligott, LCSW, W. Bruce, BS, E. Madrzyk, BS, A. Baldea, MD Loyola University Medical Center, Maywood, IL Introduction: Frostbite has historically been considered a problem encountered by the military, but in recent decades, increased participation in outdoor activities and an increase in the homeless population have resulted in a rise in frostbite. Additionally, intoxication and mental illness are increasingly identified as risk factors for frostbite. This study seeks to describe the demographic characteristics, disposition, and clinical outcomes of patients admitted for the treatment of frostbite in an urban setting. Methods: A retrospective chart review was performed on all patients admitted for frostbite over 7 years. A total of 103 patients were included. The data collected includes demographic data, number of digits affected, number of digits amputated, length of stay, medications used, delay in presentation, delay in discharge, disposition on discharge, cost of admission, and time to follow up. Descriptive statistics were used. This study was approved by our IRB. Results: Of 103 patients admitted for frostbite, 17.5% of patients were uninsured and 34% were insured with Medicaid. 19.4% of patients were homeless. 73 patients (70.9%) were first admitted to an outside hospital, resulting in an average delay of 1.76 days to admission to our burn center. Past medical history included psychological/psychiatric disorders (28.2%), cardiac (19.4%), substance abuse (16.5%), diabetes mellitus (12.6%), and seizures (6.8%). 32 patients (31.1%) had a confirmed intoxication on admission. 90.3% of patients received silver sulfadiazene, 33% received gabapentin, 12 patients received ibuprofen, 6 received aspirin, and 7 received alteplase. Of 799 total digits affected by frostbite, 145 (18.15%) required amputation. The average length of stay was 7.85 days. The average cost per admission was $39,049. There was a delay in discharge for 10 patients. Disposition on discharge was predominately to home (65%), although some patients were discharged to reside with a friend or family member (7.8%), to a skilled nursing facility (2.9%), inpatient psychiatric facility (2.9%), or homeless shelter (2.9%). 65% of patients followed up in our outpatient clinic, averaging 58 days to first visit. Conclusions: Frostbite in an urban region affects a significant number of patients who are homeless, intoxicated, or mentally ill. Discharge may be delayed due to these factors as well as a lack of insurance. A significant number of digits required amputation, and many patients required follow up in our outpatient clinic. Applicability of Research to Practice: Identifying patients early in their admission who may be difficult to place upon discharge may minimize delays in discharge, and reduce length of stay and cost of admission. The cost of prescriptions upon discharge should be a consideration for patients who are homeless or uninsured. 195. Geographic Influences on Social Reintegration after Burn Injury: A Burn Model System National Database Study N. Faoro, RN, P. H. Chang, MD, FACS, K. McMullen, MPH, P. Esselman, MD, R. Holovanahalli, MD, D. Herndon, MD, FACS, C. Ryan, MD, FACS, J. Schneider, MD Brigham and Women's Hospital, Boston, MA; Shriners Hospitals for Children, Boston, MA; University of Washington Medical Center, Seattle, WA; University of Washington School of Medicine, Seattle, WA; University of Texas Southwestern Medical Center, Dallas, TX; Shriners Hospitals for Children, Galveston, TX; Massachusetts General Hospital, Boston, MA; Spaulding Rehabilitation Hospital, Boston, MA Introduction: The influence of geography on long term functional outcomes is an underexplored area. The purpose of this study is to examine regional differences in patient reported functional outcomes. Methods: A retrospective analysis was conducted using the National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System national database between 1993 and 2015. Subjects over the age of 18 were included. Three geographic groups within the United States (Northeastern, Southern & Western) were created using a revised breakdown of the American Burn Association regional map. Measures of functional outcomes at 12 months post-burn were assessed using the following metrics: Community Integration Questionnaire (CIQ), SF-12 Physical and Mental Health Scales (PCS & MCS), Satisfaction with Appearance (SWAP) and Satisfaction with Life (SWL). Omnibus t-test and chi-square tests were used to assess for statistical differences in the outcomes measures by region. Multivariate linear regression analysis was used to assess for differences in outcomes by region and adjusted for age, gender, ethnicity and burn size. Results: There were a total of 1269 adult burn survivors with outcome measures at twelve months (320: Northeast; 471: Southern; 478: Western) with a mean age of 43.5, mean TBSA of 20.4 and 70.7% male. There were statistically significant differences by region for each of the outcome measures. In adjusted linear regression analyses geographic region was a statistically significant predictor of SWL (p=0.006), CIQ (p=0.038), and SF-12 PCS (p=0.000). Geographic region was not associated with SWAP (p=0.34) and SF-12 MCS (p=0.21) in adjusted analyses. Conclusions: Geographic region was a statistically significant predictor of functional outcomes at one year post-burn. Given the number of participating centers and the fact that all geographic regions are not represented in the NIDILRR database, additional data is needed to corroborate and verify the generalizability of these findings. Applicability of Research to Practice: Understanding trends in regional influences on burn survivor functional outcomes can be a useful tool to assess national standards of care and guide resource allocation. External Funding: The contents of this abstract were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DP0035). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this abstract do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. 196. Satisfaction with Life After Burn: A Burn Model System National Database Study J. Goverman, MD, FACS, K. Mathews, BA, K. McMullen, MPH, D. Herndon, MD, FACS, W. Meyer, MD, J. A. Fauerbach, PhD, S. Wiechman, PhD, G. J. Carrougher, RN, MN, C. Ryan, MD, FACS, J. C. Schneider, MD Massachusetts General Hospital and Shriners Hospitals for Children, Boston, MA; BMS National Data and Statistical Center, Seattle, WA; The University of Texas Medical Branch, Galveston, TX; Johns Hopkins Medicine, Baltimore, MD; Northwest Regional Burn Model System, Seattle, WA; Spaulding Rehabilitation Hospital, Boston, MA Introduction: While mortality rates after burn injury are low, rates of physical and psychosocial impairment remain elevated. Clinical research is focusing on reducing morbidity and optimizing quality of life. This study examines self-reported satisfaction with life scores in a longitudinal, multicenter cohort of survivors of major burns. Risk factors associated with satisfaction with life scores are identified. Methods: Data from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Burn Model System (BMS) database, for burn survivors greater than 9 years old from 1994 to 2014, were analyzed. Demographic and medical data were collected on each subject. The primary outcome measures were the individual items and total Satisfaction With Life Scale (SWLS) scores at time of hospital discharge (pre-burn recall period) and 6, 12, and 24 months post burn injury. The SWLS is a validated 5-item instrument with items rated on a 1-7 Likert scale. The differences in scores over time were determined and scores for burn survivors were also compared to that of a non-burn, healthy population. Step-wise regression analysis was performed to determine predictors of SWLS scores at different time intervals. Results: The SWLS was completed at time of discharge (1,129 patients), 6 months post-burn (1,231 patients), 12 months post-burn (1,123 patients), and 24 months post-burn (959 patients). There were no statistically significant differences between these groups in terms of medical or injury demographics. The majority of the population was Caucasian (62.9%) and male (72.6%), with a mean TBSA burned of 22.3%. Mean total SWLS scores for burn survivors were unchanged and significantly below that of a non-burn population at all examined time points after burn injury. Although the mean SWLS score was unchanged over time, a large number of subjects demonstrated improvement or decrement of at least one SWLS category. Gender, TBSA burned, LOS, and school status were associated with SWLS scores at 6 months; scores at 12 months were associated with LOS, school status, and amputation; scores at 24 months were associated with LOS, school status, and drug abuse. Conclusions: In this large, longitudinal, multicenter cohort of burn survivors, satisfaction with life after burn injury was consistently lower than that of non-burn injured norms and mean SWLS scores did not improve over the two year follow-up period. This study demonstrates the need for continued efforts to improve patient-centered long term satisfaction with life after burn injury. Applicability of Research to Practice: The risk factors identified here can potentially be used for targeted interventions aimed at improving satisfaction with life. External Funding: The contents of this manuscript were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DP0035)..NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS)..The contents of this manuscript do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. 197. An Examination of Yoga Intervention with Pediatric Burn Survivors A. Conn, MS, M. S. Hall, MS, K. Quinn, MS, CCLS, B. Wiggins, RN, BSN, C. Memmott, MSW, T. A. Brusseau Jr, PhD University of Utah, Salt Lake City, UT Introduction: Burn injuries have a major impact on the survivors' physical and psychological functioning. In pediatric burns, the consequences persist long after the injury. The objective of this study is to evaluate an existing yoga kids program to gain better understanding of the physical and psychosocial effects of a yoga practice among children with burn injuries. Methods: Thirty campers participated in a series of 4 (one hour) yoga sessions during the summer of 2014. Nationally trained Instructors had taught children's yoga in the Southwestern U.S. for at least 10 years. A Yoga Evaluation Questionnaire (YEQ), designed for children, was used to evaluate perceptions of somatic and cognitive anxiety before and after each Yoga session. Camper's age ranged from 6-12 years old with burn severities ranging from 5-75%. Results: A dependent samples t-test was used to test for differences between composite pre and post-intervention scores for both somatic and cognitive anxiety. Significant effects emerged for somatic anxiety t(29)= -4.24,p<.001, d=.77, and cognitive anxiety t(29)= -4.188, p<.001, d=.76. For both cognitive and somatic anxiety the post-intervention composite mean scores were significantly higher, indicating a reduction in somatic and cognitive anxiety. Conclusions: This study suggests that participation in a Yoga program may lower perceptions of cognitive and somatic anxiety in pediatric burn survivors. Further, Yoga is one technique that may compliment the short and long term treatment of burn injuries. Applicability of Research to Practice: Managing of post burn stress for pediatric burn survivors. 198. "Not Milking the System" Men's Narratives of Planning to Return to Work After a Burn Injury S. Thakrar, MA, M. I. Medved, PhD, D. Hiebert-Murphy, PhD, J. Sareen, MD, J. Brockmeier, PhD, S. Logsetty, MD University of Manitoba, Winnipeg, MB, Canada; University of Manitoba; The American University of Paris, France, Winnipeg, MB, Canada; University of Manitoba, Winnipeg Health Sciences Center, Winnipeg MB, Canada; Firefighters Burn Unit, Winnipeg Health Sciences Centre; University of Manitoba, Winnipeg, MB, Canada Introduction: Burn survivors face many challenges as they re-enter the workforce including functional difficulties, pain, and psychosocial issues. Given that 70% of burn-survivors are male, it is important to understand the gendered difficulties faced by men as they prepare to return to work (RTW). This poster examines how men experience and understand the process of making decisions about their RTW during recovery. Methods: Fifteen men aged 18 to 60 years old with burns affecting 1-30% TBSA participated in two semi-structured interviews prior to their RTW. Men were asked to discuss their work environment, what difficulties they anticipated returning to work, and what they had done to prepare themselves for their RTW. A narrative methodology was used to analyze the interviews. Interviews were transcribed verbatim and analyzed for emerging themes based on an idiographic basis. Themes were then checked by a team of researchers for credibility. Results: Three themes from participants' narratives were explored: 1. The men felt pressure to RTW prior to being fully healed and did not want others to believe they were taking advantage of WCB or insurance benefits ("milking the system"). 2. Many of the men expressed dislike for modified RTW plans as they felt over-skilled for these jobs. Many wished to return to their old tasks as soon as possible. 3. The men shifted much of the burden of making plans and decisions about their RTW to their doctor, WCB worker, or employer in the early stages of planning. In doing so, they at times withheld information about their condition or their work environment in order to RTW early. Their stories reflected them being more collaborative in making these decisions as their time to RTW approached. Conclusions: Men's work is a strong aspect of their identity and there are many gendered pressures which men experience in making decisions to RTW. These may help explain why they may not fully participate in shared planning about their RTW. Applicability of Research to Practice: The recent surge in interest in collaborative medical decision making has proposed the importance in understanding how and when burn survivors want to participate in planning to RTW and what pressures they face in doing so. We make suggestions about how to approach the topic of planning to RTW with burn survivors and suggest possible topics to cover during these important discussions. External Funding: Fellowships/scholarships for first author:Manitoba Health Research FoundationManitoba Graduate ScholarshipManitoba Firefighter's Burn Fund. 199. Staff Health Risk Assessment at a Pediatric Burns and Plastic Surgery Hospital M. M. Gottschlich, PhD, RD, H. Madsen, RN, BSN, L. James, MS, C. Allgeier, DTR, P. Warner, MD, FACS Shriners Hospitals for Children, Cincinnati, OH Introduction: Despite expertise directed to the holistic health of our burn, reconstructive and rehabilitative patients, little is known about the physical/mental status of staff. The objective of this study was to perform a health assessment of hospital staff and to identify correlates of risk based on demographic categories. Methods: A 12-question survey was distributed to employees (n = 238) of a pediatric burns and plastic surgery hospital. Descriptive statistics characterized gender, age, anthropometries, conditions of disease, stress, nutrition, exercise, risky behaviors and barriers to health. Data were stratified by age and weight groups; outcomes were assessed using Student's t-test, Wilcoxon rank sum test and χ2 test. Results: Of 124 returned surveys (52.1% response rate), 104 (84%) were female, mean age 45.2 years + 1.07; range 20-80 years. Study sample had low tendency to engage in risky behavior assessed by nonsmoker rate of 97% (120/124) and seat belt use of 98% (121/124), although fast food was popular (median 1.5 times/week). Of concern, 37.2% of hospital workers were obese (mean BMI = 30.4 + 2.2), 22% hypertensive, 60% stressed and 16% depressed. Increasing age was associated with hypertension (p=.0278), while obesity (p=.0019) and depression (ns) rates fell. Stress was high among all 5 age groups. Proportion of workers who exercised > 5 times/week was low (21.8%). Self-reported barriers to healthy eating and exercise: time (58.6%), ease of packaged/fast food (65.5%), fatigue (56.8%) and no exercise companion (69%). Many respondents indicated a desire to participate in worksite-based health and wellness programs. Conclusions: Significant precursors to disease (e.g. obesity, hypertension, stress, depression, insufficient exercise, fruit/ vegetable intake) were identified. Action plans that promote physical activity, healthy eating and stress reduction could have a positive influence on weight, blood pressure and psychological measures. These data provide insight into the wellness needs of hospital staff and suggest value of health surveillance and initiatives. Applicability of Research to Practice: Procedures to identify health risk of hospital workers are essential to improve staff health and job effectiveness as well as to promote positive social climate at the workplace. Given the impact of chronic disease on employee health and well-being, productivity, and health care coverage costs, wellness programs and resources are advisable within the hospital setting. Table. No title available. View Large Table. No title available. View Large 200. Predicting Adolescents' Intentions to Engage in Fire Risk Behaviors J. Mentrikoski, PhD, C. Duncan, PhD, P. Enlow, MS, R. Majestro, MA, M. Wilson, R. Bainbridge, C. Perlick, BSN,RN, A. Aballay, MD, FACS Akron Children's Hospital, Akron, OH; West Virginia University, Morgantown, WV; Spalding University, Louisville, KY; West Penn Allegheny Health System, Pittsburgh, PA Introduction: Although adolescents make up nearly 30% of the burn injury cases treated in emergency departments in the United States, little research has examined possible correlates (e.g., attitudes, knowledge) of adolescent fire-risk behavior (e.g., using accelerants to start a fire, playing with fireworks). To facilitate a better understanding of adolescent fire-risk behavior, the current study examined the utility of a theoretical model, Ajzen's Theory of Planned Behavior (TPB), in explaining adolescents' intentions to engage in fire-risk behaviors, while controlling for relevant background variables (e.g., demographic, adolescent psychopathology) Methods: A total of 222 youth (M age = 14.60 years; range = 13-19; 60% male) were recruited from public schools in rural and urban areas in the United States. During school classes, participants completed two study measures (i.e., the Fire and Burn Injury Safety Questionnaire and the TPB Questionnaire) that were created for the purposes of this study. Participants also completed standardized questionnaires that assessed demographic variables, adolescent psychopathology, parental monitoring, and adolescent risk-taking. Results: Using a multiple regression analysis, the TPB significantly predicted adolescents' intentions to engage in fire-risk behaviors (F(3, 207) = 42.84, p < .001, R2 = .38). Specifically, adolescents' attitudes toward engaging in fire-risk behaviors ((β = .49, p < .01) and the social pressure they perceived from others (e.g., parents, friends; P = .18,p<.01) emerged as significant predictors of their intentions to engage in fire-risk behaviors. These results suggest that youth who had positive attitudes (e.g., engaging in fire-risk behaviors is fun) towards fire-risk behaviors and who believed significant others would approve of them engaging in fire-risk behaviors tended to have more intentions to engage in these behaviors. The TPB was able to account for the variance in adolescents' intentions over and above several control/background variables (e.g., SES, gender, parental monitoring), with the exception of sensation-seeking (|3 = .13, p < .05) and rebellious behavior β = .18, p < .05). Conclusions: Findings from this study suggest that the TPB, specifically attitudes toward fire-risk behaviors and perceived social pressure from others, significantly predicted adolescents' intentions to engage in fire-risk behaviors. Applicability of Research to Practice: Risk for burn injuries varies as a function of children's developmental level. Results from this study can be used to inform the design of effective and targeted prevention programs aimed specifically at adolescents. External Funding: West Virginia University Department of Psychology Student Research FundWest Virginia University Eberly College Doctoral Student Research Program. 201. Narratives of Burn Injury: Patients' Reflections After 5 Years A. Childress, PhD, P. J. Gonzalez, BA, W J. Meyer, MD, M. A. Carter, PhD Baylor College of Medicine, Houston, TX; University of Texas Medical Branch, Galveston, TX Introduction: Pediatric burn injury survivors who are also research participants have important insights into their experiences of being seriously injured and their healing processes that need to be shared with clinicians and researchers in order to improve patient care and ensure appropriate treatment of research participants. As research ethicists embedded in a clinical research team that is investigating the body's metabolic response to severe burn injuries, we conducted a study that broadens the definition of "response" to include psychosocial, spiritual, existential, and moral dimensions of patients' lives. Methods: Each enrolled participant met the following inclusion criteria: ≥ 20% TBSA burn, > 12 years old, and > 5 years post burn. We have conducted a number of semi-structured interviews lasting 30-45 minutes, which have been recorded, transcribed, and translated. Participants were asked to reflect on their experiences and describe them to the interviewer. Our qualitative research project explores patients' stories with the aim of using these findings to inform ethical guidelines that protect human research subjects while promoting responsible scientific inquiry. Results: Our subject pool was drawn from pediatric patients (M=15, F=8) who ranged in age from 13.75-25.25, sustained burn injuries comprising 22-95% TBSA, and were 5.5-9.75 years post burn. Participants discussed a wide range of themes including: changes in self-image, healing strategies and obstacles, research participation and motivation, and feelings of acceptance or stigmatization. In addition, participants reflected on some of the cultural differences between the US and their country of origin that have affected their response to their injuries. Conclusions: Overall, patients who were injured at a younger age reported less difficulty dealing with the psychosocial and existential issues that accompanied the sudden change in their body image. A substantial number of research participants did not recall participating in research. Applicability of Research to Practice: Participants commented on a variety of interventions that they thought might help them heal physically, psychologically, and spiritually. Additional psychological services, including young adult support groups or peer mentoring may help patients' cope with their experiences of stigma and discrimination based on appearance. These suggestions could form the basis of changes to clinical practice. Table. No title available. View Large Table. No title available. View Large 202. Close Relatives of Adult Burn Survivors' Satisfaction with an Acute Burn Care Information Guide C. Gourlay, BSc, A. Desjardins, BSc, M. Boucher, BSc, S. Bond, PhD University of Montreal Hospital Center, Montreal, QC, Canada Introduction: Families are increasingly regarded as a central component in supporting burn survivors with their healing process. However, they also frequently find themselves powerless in that situation and they don't know what to do. It has been suggested that family members should receive exhaustive information in order to help them cope with the issues burn survivors are facing and to enhance their understanding of the patient's multiple needs. Such information should then be helpful in providing support. In this line, the present study focused on the satisfaction with an information guide addressed to close relatives and designed by burn care professionals. Methods: Twenty-four burned patients' adult close relatives were given an educational guide (80 pages) at the moment of admission to the burn unit. This guide contained detailed information about the functioning of the burn unit, the physical and psychological aspects of burn care, as well as the treatment and rehabilitation process. At the time of the burn survivor's discharge, participants completed a 10-item questionnaire assessing their satisfaction with the information received. Results: Close relatives were predominantly female (83%) with a mean age of 44.1 years. Half of the participants were the spouses of the burn survivor. The majority (92%) of the 24 burn patients accompanied by the participants were male, with a mean age of 37.1 years and a mean burned TBSA of 22% (range 3-60%). Overall, the results show that the majority of the close relatives were greatly satisfied with the information guide. More precisely, 96% of the relatives would suggest to other family members to read this manual and reported that the clear and short sentences written in an accessible language facilitated their comprehension. Also, 92% reported that the guide was useful to them. Although the guide contained detailed information about all aspects of burns, 79% of participants asked for further information. Conclusions: The guide was clearly appreciated by the close relatives of burn survivors. Results from the present study reiterate the need for information at the time of the acute phase of burn care. Based on the principles of family-centered care, the implementation of this tool is recommended as a routine intervention for families in burn settings. Applicability of Research to Practice: A tool such as the proposed exhaustive information guide designed specifically for the close relatives of burn survivors in burn settings is easy to use and highly valuable as it helps them understand the patient's situation, which in turns help improve the quality of the support they can provide. External Funding: This work was supported by a firefighter foundation for burn survivors ($35 000). 203. Usefulness of a System for Feedback of Patient Reported Outcomes in Children with Burns S. Romo, BA, M. Murphy, PhD, L. Kazis, ScD, A. Dominguez, M. Lydon, RN, C. M. Ryan, MD, FACS, P. Chang, MD, FACS, A. Swan-Mahony, RN, MHA, R. L. Sheridan, MD, FACS Shriners Hospitals for Children, Boston, MA; Boston University School of Public Health, Boston, MA; Northeastern University, Boston, MA; Massachusetts General Hospital, Boston, MA Introduction: The Burn Outcomes Questionnaire (BOQ) is a widely used, reliable, and valid patient reported outcome measure assessing children's recovery from burn injuries. The BOQ measures twelve physical and psychosocial domains. While the BOQ has demonstrated its responsiveness to changes over time and usefulness as a population-based instrument, the feedback of BOQ scores for individual patients to clinicians during outpatient encounters only started last year. This study assesses the feasibility and usefulness of a feedback system that delivers BOQ results to clinicians in "real time" after parents have completed the BOQ on an iPad prior to an outpatient visit. Methods: The BOQwas administered to the parents of children, aged 5-18 years old, receiving outpatient care at a pediatric burn hospital using iPads running TonicHealth© software. A brief psychosocial measure known as the Pediatric Symptom Checklist was completed along with the BOQ, jointly referred to as the BOQ+P Eligible patients completed the BOQ+P prior to their outpatient visit. The results of the BOQ+P were then given to the attending clinician before the patient visit. Our primary analytic sample included patients with TBSA >5% or burns to critical areas (e.g. face, feet). Clinician perception of the BOQ+P feedback system was evaluated using six Likert scale questions and one open-ended question after the patient encounter. Parent perception and satisfaction were separately evaluated using eight Likert scale questions and four open-ended questions. Results: Of the 19 patients enrolled (mean TBSA 19%), 9 (47%) of the patients had their results reviewed by a physician, 8 (42%) by a nurse practitioner, and 2 (11%) by a registered nurse. Following the patient encounter, the majority of clinicians reported that they had found the BOQ+P data useful (95%) and helpful in stimulating conversations with the parent/ patient (74%). Additionally, 89% of the clinicians reported that they would recommend this feedback system to their colleagues. They did not, however, agree that BOQ+P feedback had a direct impact on the course of treatment. Parent perception of the BOQ feedback system was separately assessed after the patient encounter. The majority of parents rated the iPad as "very easy to use" and all said that they "strongly agree" (27%) or "agree" (73%) that they would recommend the iPad to another parent of a child with a burn injury. Conclusions: Results from the clinician and parent debriefing questionnaires suggest that the BOQ+P feedback system is perceived as helpful and easy to use. Applicability of Research to Practice: This study suggests that the routine collection of BOQ+P data could provide clinicians with useful information during outpatient encounters with children recovering from burns. External Funding: Shriners Hospitals for Children. 204. Burn Survivor Support in a State with Low Density Population N. E. Johnson, PhD, S. Loen, ACNP-C, A. Pauley, MSN, RN, B. Werling, BSN,RN, S. Bruce, BSN,RN, L. Miguel, CCLS, J. Boyd, MSN, RN, J. Schneider, BSN,RN, C. L. Olmsted, MD, J. Heard, BS, L. Wibbenmeyer, MD, FACS University of Iowa Hospitals and Clinics, Iowa City, IA; Sanford Health, Sioux Falls, SD Introduction: Providing psychosocial support to burn survivors and their families post-discharge can be challenging when the burn treatment center serves a large geographical area with low population density. Attending monthly burn support groups at the burn treatment center is not practical for many survivors. The Burn SurvivorsTogether program was initiated as a means to provide support to a greater number of survivors and family members through annual multi-site regional gatherings. Methods: The state was divided into three regions. A city was chosen as the meeting site in each region based on the willingness of a local fire department to partner with the burn treatment center and burn foundation to host the events at a fire station. The goals of the program were to: 1) connect members of the burn community in a geographical area, 2) educate members of the burn community about resources, support opportunities, and burn community events, and 3) plant the seeds for ongoing social and support events in each region. Gatherings were promoted in the following ways: social media, group emails, fliers distributed in burn clinic, and invitations sent by mail. Participants were asked to evaluate the event at its completion. Responses were presented in a Likert format with l=Strongly Disagree and 5=Strongly Agree. Results: There were 73 participants in 2014 and 89 in 2015. Participants included: pediatric and adult burn survivors, family members of survivors, family members of those who died as the result of a burn, burn care providers, and members of the fire service/EMS. Through voluntary written evaluations, participants have indicated that they find the Burn Survivors Together gatherings to be beneficial. The first question, "This event was enjoyable," had a response of 4.79. The second question, "This event was helpful," had a response of 4.65. The third question, "I would attend another event like this one," had a response of 4.81. The evaluation also included open-ended questions designed to elicit detailed feedback. The question "What did you find most helpful or enjoyable about this event?" yielded answers referring to connecting or re-connecting with others in 39 of 62 responses. The next most common answer related to education about support resources (14 of 62 responses). Conclusions: When a burn treatment center serves a large geographical area, holding burn survivor support events at regional sites that are more accessible to survivors and their families is an effective way to promote a sense of community and provide education regarding resources. Applicability of Research to Practice: Burn treatment centers serving a large geographical area can increase the availability of psychosocial support for patients and families post-discharge by sponsoring regional gatherings. 205. Burn Specific Health Scale - Brief (BSHS-B): Translation and Validation into Brazilian Portuguese M. Piccolo, MD, PhD, A. Gragnani, MD, PhD, R. Piccolo-Daher, MD Pronto Socorro para Queimaduras, Goiania, Goids, Brazil; Escola Paulista de Medicina, UNIFESP, São Paulo, São Paulo, Brazil Introduction: Progressive increases in burn trauma survival rates have shifted attention to patient rehabilitation and post trauma quality of life. The assessment of quality of life is strongly dependent on reliable instruments for its measurement. A literature review has revealed that the Burn Specific Health Scale-Brief (BSHS-B) is the instrument most commonly used worldwide. Objectives: We set out to translate the BSHS-B into the Portuguese language, adapting it culturally to the Brazilian population, and testing its psychometric properties. Methods: The questionnaire was translated into Portuguese, culturally adapted and tested for reproducibility, face, content and construct validity. The translated version was tested on 92 burn injury patients. Results: Internal consistency was tested by means of Cronbach's alpha (0,85). Pearson correlation coefficients were significant at three time points of the reliability analysis. Construct validity was performed correlating the BSHS-B questionnaire with the Burn Specific Health Scale-Revised (BSHS-R), BurnSexQ-EPM/UNIFESP, and with the Rosenberg Self-Esteem Scale and Beck's Depression Inventory. A significant correlation was observed between BSHS-B domains and BSHS-R, Rosenberg and Beck domains. A significant correlation was also observed between BSHS-B and the BurnSexQ-EPM/UNIFESP social comfort and body image domains. Conclusions: BSHS-B questionnaire was translated into Portuguese; it is a reliable tool, also in this language, showing face, content and construct validity. The instrument has been named BSHS-B-Br. Applicability of Research to Practice: To evaluate Brazilian Portuguese speaking burn patients' quality of life on several domains and to compare with other studies of patients in different countries. To follow changes in quality of life of survivors in different stages of the post cure period. 206. Impact of Burns on Family Function: A Life Impact Burn Recovery Evaluation (LIBRE) Study A. P. Houng, MD, FACS, G. D. Shapiro, PhD (c), MPH, J. Jeng, MD, FACS, A. Lee, PhD, A. Acton, RN, BSN, M. Marino, MPH, A. Jette, PhD, J. C. Schneider, MD, L. E. Kazis, ScD, C. M. Ryan, MD, FACS New York Presbyterian Weill Cornell Medical Center, Weill Cornell Medical College, New York, NY; McGill University, Montreal, QC, Canada; Mount Sinai Health Care System, New York, NY; Bentley University, Waltham, MA; Phoenix Society for Burn Survivors, Grand Rapids, MI; Boston University School of Public Health, Boston, MA; Massachusetts General Hospital and Shriners Hospitals for Children, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA Introduction: We postulate that the strength of family support should be an important factor in burn survivor recovery and societal reintegration. This has been an under-appreciated aspect of burn care, with few prior studies helping to identify patients who are at risk for poor recovery. We selected relevant questions focusing on family-relationships, and identified the clinical and demographic characteristics related to family support post burn injury. Methods: The LIBRE-192 was administered to 402 adult burn survivors with ≥5% TBSA burned or burns to critical areas. Each item was on a 5-point Likert scale. Higher scores denote better outcomes. Factor analysis was used to identify the key dimensions grounded with the established WHO International Classification of Function. Separate models were constructed for each dimension of family function as the dependent variable. Demographic and clinical characteristics of the study population were explored using statistics. Bivariate associations were examined between the domains and items of family support with demographic and clinical characteristics. Unweighted mean scores of all items as well as factor scores were compared between strata of the independent variable using ANOVA. For means of the items and factor scores that differed significantly by strata of the independent variable, linear regression models were constructed with adjustment for age, gender, race, education level, marital status, TBSA, critical areas, and time since injury. Results: The mean score of all questionnaire items varied significantly by the independent variables (Tab 1). Of these, race, education level, marital status, burns to critical area, and time since burn showed statistically significant differences (p<0.05). TBSA, gender, and age did not show a difference. Significant associations for education level, marital status, and burns to critical areas persisted in adjusted linear regression analysis. Burn survivors with higher educational attainment, those in a long-term committed relationship, and those with a greater time since burn injury all scored better in their family functioning. Conclusions: Family functioning is an important aspect of recovery. Education and longer duration since burn injury coupled with a committed relationship contribute to better family functioning. Applicability of Research to Practice: This data can be used to identify a subset of burn patients who may benefit from additional interventions to support successful family reintegration. External Funding: The contents of this abstract were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research, NIDILRR grant numbe
TI - Abstracts
JF - Journal of Burn Care & Research
DO - 10.1097/01.bcr.0000483036.52429.db
DA - 2016-05-01
UR - https://www.deepdyve.com/lp/oxford-university-press/abstracts-KCdrsVCLTS
SP - S67
EP - S300
VL - 37
IS - suppl_1
DP - DeepDyve
ER -