Burns Current Awareness Newsletter

February 2016

Outreach Your Outreach Librarian can help facilitate evidence-based practise for

all Burns members of staff, as well as assisting with academic study and research. We can help with literature searching, obtaining journal

articles and books, and setting up individual current awareness alerts.

Literature Searching We provide a literature searching service for any library member. For those embarking on their own research it is advisable to book some

time with one of the librarians for a 1 to 1 session where we can guide you through the process of creating a well-focused literature research and introduce you to the health databases access via NHS Evidence.

Critical Appraisal Training We also offer one-to-one or small group training in literature

searching, accessing electronic journals, and critical appraisal/Statistics. These are essential courses that teach how to

interpret clinical papers.

For more information, email: katie.barnard@uhbristol.nhs.uk

Books Books can be searched for using SWIMS our online catalogue at

www.swims.nhs.uk. Books and journals that are not available on site or electronically may be requested from other locations. Please email

requests to: library@uhbristol.nhs.uk

Contents

1: Tables of Contents from February’s Burns

journals

2: New NICE Guidance

3: Latest relevant Systematic Reviews from

the Cochrane Library

4: Quick Exercise

5: Current Awareness database articles

Tables of Contents from Burns journals

If you require full articles please email: library@uhbristol.nhs.uk

Burns 2015 (Elsevier) February 2016, Volume 42, Issue 1

Journal of Burn Care & Research (LWW) January/February 2016, Volume 37, Issue 1

Injury Prevention (BMJ) February 2016, Volume 22, Issue 1 Plastic and Reconstructive Surgery (LWW) February 2016, Volume 137, Issue 2 Journal of Plastic, Reconstructive & Aesthetic Surgery (Elsevier) February 2016, Volume 69, Issue 2 Archives of Disease in Childhood (BMJ) February 2016, Volume 101, Issue 2 Pediatrics (HighWire) February 2016, Volume 137, Issue 2 Injury (Elsevier) January 2016, Volume 47, Issue 1 Trauma (Sage) January 2016, Volume 18, Issue 1

New NICE Guidance QS107 Preventing unintentional injury in under 15s

Latest relevant Systematic Reviews from the Cochrane Library

Discharge planning from hospital

Intranasal or transdermal nicotine for the treatment of postoperative pain

ClinicalSkills.net contains over 220 guidelines for procedures in both graphic and text format, including for Paediatrics. It is evidence based, double-blind peer

reviewed, and is quick and easy to use. Be aware, though, that it may not always reflect UH Bristol local practice.

You will need your OpenAthens login details to access ClinicalSkills.net. Register if needed here: https://openathens.nice.org.uk/ (you will need to be on a Trust PC).

Quick Exercise

Creating a search strategy Scenario: A 64 year old obese male who has tried many ways to lose weight presents with a newspaper article about ‘fat-blazer’ (chitosan). He asks for your advice.

1. What would your PICO format be?

Population/problem

Intervention/indicator

Comparator

Outcome

2. What would your research question be?

Taken from the Centre for Evidence Based Medicine

Find out more about constructing an effective search strategy in one of our Literature searching training sessions.

For more details, email library@uhbristol.nhs.uk.

Upcoming Lunchtime Drop-in Sessions

March (1pm)

Thurs 3rd Literature Searching Fri 11th Understanding articles Mon 14th Statistics Tues 22nd Information resources Weds 30th Literature Searching

February (12pm)

Fri 5th Literature Searching

Mon 8th Understanding articles Tues16th Statistics Wed24th Information resources

The Library and Information Service provides free specialist information skills training for

all UHBristol staff and students.

To book a place, email: library@uhbristol.nhs.uk

If you’re unable to attend we also provide one-to-one or small group sessions. Contact

library@uhbristol.nhs.uk or katie.barnard@uhbristol.nhs.uk to arrange a session.

Current Awareness database articles

If you require full articles please email: library@uhbristol.nhs.uk

Title: A Novel Cast Removal Training Simulation to Improve Patient Safety. Citation: Journal of surgical education, Jan 2016, vol. 73, no. 1, p. 7-11 (2016 Jan-Feb) Author(s): Brubacher, Jacob W, Karg, Jeffrey, Weinstock, Peter, Bae, Donald S Abstract: Cast application and removal are essential to orthopedics and performed by providers of variable training. Simulation training and practice of proper cast application and removal may reduce injury, optimize outcomes, and reduce health care costs. The purpose of this educational initiative was to develop, validate, and implement a novel simulation trainer and curriculum to improve safety during cast removal. In all, 30 thermocouples (Omega, Stamford, CT) were applied to a radius fracture model (Sawbones, Vashon, WA). After reduction and cast application, a saw (Stryker, Kalamazoo, MI) was used to cut the cast with temperature recording. Both "good" and "poor" techniques-as established by consensus best practices-were used. Maximal temperatures were compared to known thresholds for thermal injury; humans experience pain at temperatures exceeding 47°C and contact temperatures exceeding 60°C may lead to epidermal necrosis. Construct validity was evaluated by assessing novice (postgraduate year 1), intermediate (postgraduate year 3), and expert (pediatric orthopedic attending) performance. With the "good" technique, mean peak temperatures were 43°C + 4.3°C. The highest recorded was 51.9°C. With the "poor" technique, mean peak temperature was 75.2°C + 17.3°C. The maximum temperature recorded with the "poor" technique was 112.4°C. Construct validity testing showed that novices had the highest increases in temperatures (12.9°C). There was a decline in heat generation as experience increased with the intermediate group (9.7°C), and the lowest heat generation was seen in the expert group (5.0°C). A novel task simulator and curriculum have been developed to assess competency and enhance performance in the application and removal of casts. There was a 32.2°C temperature decrease when the proper cast saw technique was used. Furthermore, the "poor" technique consistently achieved temperatures that would cause epidermal necrosis in patients. Clinical experience was a predictor of decreased heat generation during cast removal. This task trainer allows instruction and safety monitoring of the casting technique. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Title: Scald Burns From Hair Braiding. Citation: Journal of burn care & research : official publication of the American Burn Association, Jan 2016, vol. 37, no. 1, p. e7. (2016 Jan-Feb) Author(s): Meizoso, Jonathan P, Ramaley, Stephen R, Ray, Juliet J, Allen, Casey J, Guarch, Gerardo A, Varas, Robin, Teisch, Laura F, Pizano, Louis R, Schulman, Carl I, Namias, Nicholas Abstract: Only one previous case report has described scald burns secondary to hair braiding in pediatric patients. The present case study is the largest to date of scald burns as a result of hair braiding in children and adults. Charts of all 1609 female patients seen at a single burn center from 2008 to 2014 were retrospectively reviewed to identify patients with scald burns attributed to hair braiding. Demographics, injury severity, injury patterns, and complications were analyzed. Twenty-six patients (1.6%) had scald burns secondary to hair braiding with median TBSA 3%. Eighty-five

percent of patients were pediatric with median age 8 years. Injury patterns were as follows: back (62%), shoulder (31%), chest (15%), buttocks (15%), abdomen (12%), arms (12%), neck (12%), and legs (4%). No patients required operative intervention. Three patients were admitted to the hospital. Two patients required time off from school for 6 and 10 days post burn for recovery. Complications included functional limitations (n = 2), hypertrophic scarring (n = 1), cellulitis requiring antibiotics (n = 1), and anxiety requiring medical/psychological therapy (n = 2). This peculiar mechanism of injury not only carries inherent morbidity that includes the risks of functional limitations, infection, and psychological repercussions but also increases usage of resources through hospital admissions and multiple clinic visits. Further work in the form of targeted outreach programs is necessary to educate the community regarding this preventable mechanism of injury.

Title: Mental and Physical Health Outcomes in Parents of Children with Burn Injuries as Compared with Matched Controls. Citation: Journal of burn care & research : official publication of the American Burn Association, Jan 2016, vol. 37, no. 1, p. e18. (2016 Jan-Feb) Author(s): Enns, Jessica, Gawaziuk, Justin P, Khan, Sazzadul, Chateau, Dan, Bolton, James M, Sareen, Jitender, Stone, James, Doupe, Malcolm, Logsetty, Sarvesh Abstract: Pediatric burn injuries are common, and the stress of caring for them can affect caregivers' health. This study's objective was to examine the rates of common mental and physical disorders of parents of burn-injured children (cases) compared with matched controls (controls). This is a population-based study linking the Regional Pediatric burn registry with administrative health information. Pediatric burn cases were matched 1:5 with control children from the general population based on age, sex, and geographical location then parents identified. One thousand and twenty-six parental cases and 4858 controls were identified. International Classification of Disease codes were used to identify diagnoses of common mental and physical disorders. Using rates of disease 2 years before and 2 years after the date of burn, the changes in the relative rates of health outcomes were compared between the cases and the controls. The cases had higher rates of postinjury mental and physical illness compared with the matches. However, it was found that controls also had increased rates postindex date and additionally cases had increased rates of preinjury illnesses. There was no difference in the relative rates of illnesses between the groups from pre- to post-index date. The higher rate of illness in cases postinjury could be explained by preinjury illness, and similar rate increases in the control cohort. Evaluation of the effect of a child's burn injury on parents should take into context the preexisting health of the parent. Socioeconomic factors associated with increased risk of burns may also be associated with adverse health outcomes.

Title: Sun Exposure and Sun Protection at Primary Schools in The Netherlands: A Cross-Sectional Study. Citation: Pediatric dermatology, Jan 2016, vol. 33, no. 1, p. 38-43 (January 2016) Author(s): Boog, Matthijs C, Nederend, Annelies, Ultee, Jetske Abstract: In The Netherlands, skin cancer incidence rates have dramatically increased during the last decades. Exposure to ultraviolet radiation is the most important environmental risk factor for developing skin cancer. The present study aimed to determine the level of sun exposure and sun

protection of children at Dutch primary schools. Registered members of an Internet panel of a private research company with a child 6 to 12 years of age completed a standardized questionnaire on sun exposure, sun protection and sunburn for their child on school days during the spring and summer. A total of 1103 parents completed the questionnaire. Most parents reported that their child spent 31 minutes to 1 hour (39.7%) or 1 hour to 1.5 hours (26.1%) outside at school during the spring and summer, 29.3% reported that sunscreen is always or often applied to the skin of their child in the morning on school days, 37% reported that they always or often paid attention to sun protection when selecting their child's outfit, 19.3% of the parents stated that their child could not play in the shade outside at school, and 19.9% of the parents reported that their child had ever had a sunburn at school. With most children, this consistent and repetitive pattern of sun exposure at school will probably lead to damage of exposed skin, because sun protection is insufficiently achieved among children during school days in the spring and summer. Future school-based interventions are necessary to alert and change behavior of parents, children, and primary school teachers. © 2015 Wiley Periodicals, Inc.

Title: Measuring distress in South African children during burns dressing changes: A pilot study. Citation: Physiotherapy theory and practice, Jan 2016, vol. 32, no. 1, p. 1-9 (January 2016) Author(s): Louw, Q, Firfirey, N, Grimmer, K, van Niekerk, S-M Abstract: To establish and trial a practical, evidence-based, sensitive, language-fair, and culture-fair test battery to measure South African children's distress during burns dressing change. We previously identified a broad test battery for pediatric procedural distress from the literature. This comprised child and parent heart rate; three instruments for observed distress behaviors-(1) Face, Legs, Activity, Cry, Consolability (FLACC); (2) Pain Behavior Check List (PBCL); and (3) Children's Hospital Eastern Ontario Pain Scale (CHEOPS); and dressing change time, number of nurses required, and nurses' perspectives of child's distress. A consecutive cohort of South African inpatient children with burns was recruited. In the first study, three observers independently piloted the broad set of measures on four children. This set was subsequently modified to increase practicality of application and measurement sensitivity. In the second study, the modified battery was tested on 16 children for sensitivity to different children's distress levels during burns dressing change phases. The modified test battery was comprised of the CHEOPS, dressing change time, number of nurses required, and nurses' qualitative perspectives of child's distress. In combination, these tests were practical and sensitive to children's distress. South African children's distress during burn dressing changes manifests in different ways. Adequate capture of it requires a comprehensive set of objective, observational, and qualitative measures, which are independent of language and culture.

Title: Estimating Sun Exposure of Children in Day Care Nurseries in South Oxfordshire, UK. Citation: Photochemistry and photobiology, Jan 2016, vol. 92, no. 1, p. 193-200 (January 2016) Author(s): Baczynska, Katarzyna A, Price, Luke L A, Higlett, Michael P, O'Hagan, John B Abstract: Exposure to ultraviolet radiation and sunburn during childhood and adolescence is linked to increased risks of melanoma and basal cell carcinoma later in life. Infants and toddlers are thought to be unusually vulnerable to UVR because of lower levels of melanin, a thinner stratum corneum and a higher surface area/body mass ratio. The aim of this study was to assess variations in the available erythema effective radiant doses to young children in day care nurseries in South

Oxfordshire, UK over 7 years between 2008 and 2014. The data were analyzed in three distinct seasons according to a series of realistic exposure scenarios taking into account nursery routines. The results indicate the time of year when high doses are to be expected and provide strong support for arguments in favor of raising public awareness of sun protection earlier in the year. © 2015 Crown copyright. Photochemistry and Photobiology © 2015 The American Society of Photobiology.

Title: The biochemistry of blister fluid from pediatric burn injuries: proteomics and metabolomics aspects. Citation: Expert review of proteomics, Jan 2016, vol. 13, no. 1, p. 35-53 (January 2016) Author(s): Zang, Tuo, Broszczak, Daniel A, Broadbent, James A, Cuttle, Leila, Lu, Haitao, Parker, Tony J Abstract: Burn injury is a prevalent and traumatic event for pediatric patients. At present, the diagnosis of burn injury severity is subjective and lacks a clinically relevant quantitative measure. This is due in part to a lack of knowledge surrounding the biochemistry of burn injuries and that of blister fluid. A more complete understanding of the blister fluid biochemistry may open new avenues for diagnostic and prognostic development. Burn insult induces a highly complex network of signaling processes and numerous changes within various biochemical systems, which can ultimately be examined using proteome and metabolome measurements. This review reports on the current understanding of burn wound biochemistry and outlines a technical approach for 'omics' profiling of blister fluid from burn wounds of differing severity.

Title: Perceived support in parents of children with burns. Citation: General hospital psychiatry, Jan 2016, vol. 38, p. 105-108 (2016 Jan-Feb) Author(s): Willebrand, M, Sveen, J Abstract: Children sustaining burns that require treatment in a burn center have a need for multiprofessional aftercare services over a prolonged time. So far, there is little research into satisfaction with care and support after pediatric burns. The aim was to investigate parents' perception of support after pediatric burn and associations with parent, child and injury characteristics. Parents (n=101) of children aged 0.4-17.8years completed questionnaires on support, parent's psychological symptoms and health of the child. Time since injury was 0.1-9.0years. Perceived lack of psychosocial, medical, societal or family support was reported by 21% of the parents. Lack of support was not associated with injury or sociodemographic characteristics, but it was significantly associated with parents' symptoms of general anxiety, depression and injury-related fear avoidance, as well as parents' ratings of their child's general health and heat sensitivity. Perceived support did not differ on account of burn severity or sociodemographic status. However, care providers should be more attentive to and supportive of parents signaling poorer general health in their child and cognitive beliefs that the child is at risk for harm when active and parents who themselves show signs of psychological symptoms. Copyright © 2016 Elsevier Inc. All rights reserved.

Title: Severe delayed skin reactions related to drugs in the paediatric age group: A review of the subject by way of three cases (Stevens-Johnson syndrome, toxic epidermal necrolysis and DRESS).

Citation: Allergologia et immunopathologia, Jan 2016, vol. 44, no. 1, p. 83-95 (2016 Jan-Feb) Author(s): Belver, M T, Michavila, A, Bobolea, I, Feito, M, Bellón, T, Quirce, S Abstract: Severe delayed drug-induced skin reactions in children are not common but potentially serious. This article describes aspects concerning the etiology, pathogenesis and clinical manifestations of these processes; it presents three paediatric cases, namely STS (Steven Johnson Syndrome), TEN (toxic epidermal necrolysis), probably related to amoxicillin/clavulanate and ibuprofen and DRESS (a drug reaction with eosinophilia and systemic symptoms) secondary to phenytoin; and in relation to them, the diagnosis and the treatment of these processes are discussed and reviewed. The AGEP (acute generalised exanthematous pustulosis) is also reviewed. The aetiological diagnosis of severe non-immediate reactions is difficult, and the value of current allergological testing is not well defined in these cases. Diagnosis is based on clinical history, the empirical risk of drugs to trigger SJS/TEN or DRESS, and the in vivo and in vitro testing of the suspect drug. Skin biopsy confirms that the clinical diagnosis and delayed hypersensitivity tests, especially the patch test and the lymphoblastic transformation test (LTT), may be important to confirm the aetiological diagnosis, in our cases emphasising the latter. These diseases can be life threatening (especially DRESS and TEN) and/or have a high rate of major complications or sequelae (SJS/TEN). The three cases described progressed well without sequelae. All were treated with corticosteroids, which is the most currently accepted treatment although the effect has not been clearly demonstrated. Copyright © 2015 SEICAP. Published by Elsevier Espana. All rights reserved.

Title: Economic burden of burn injuries in the Netherlands: A 3 months follow-up study. Citation: Injury, Jan 2016, vol. 47, no. 1, p. 203-210 (January 2016) Author(s): Hop, M Jenda, Wijnen, Ben F M, Nieuwenhuis, Marianne K, Dokter, Jan, Middelkoop, Esther, Polinder, Suzanne, van Baar, Margriet E, Dutch Burn Repository group Abstract: Burn care has rapidly improved in the past decades. However, healthcare innovations can be expensive, demanding careful choices on their implementation. Obtaining knowledge on the extent of the costs of burn injuries is an essential first step for economic evaluations within burn care. The objective of this study was to determine the economic burden of patients with burns admitted to a burn centre and to identify important cost categories until 3 months post-burn. A prospective cohort study was conducted in the burn centre of Maasstad Hospital Rotterdam, the Netherlands, including all patients with acute burn related injuries from August 2011 until July 2012. Total costs were calculated from a societal perspective, until 3 months post injury. Subgroup analyses were performed to examine whether the mean total costs per patient differed by age, aetiology or percentage total body surface area (TBSA) burned. In our population, with a mean burn size of 8%, mean total costs were €26,540 per patient varying from €742 to €235,557. Most important cost categories were burn centre days (62%), surgical interventions (5%) and work absence (20%). Flame burns were significantly more costly than other types of burns, adult patients were significantly more costly than children and adolescents and a higher percentage TBSA burned also corresponded to significantly higher costs. Mean total costs of burn care in the first 3 months post injury were estimated at €26,540 and depended on age, aetiology and TBSA. Mean total costs in our population probably apply to other high-income countries as well, although we should realise that patients with burn injuries are diverse and represent a broad range of total costs. To reduce costs of burn care, future intervention studies should focus on a timely wound healing, reducing length of stay and enabling an early return to work. Copyright © 2015 Elsevier Ltd. All rights reserved.

Title: Long-Term Skeletal Muscle Mitochondrial Dysfunction is Associated with Hypermetabolism in Severely Burned Children. Citation: Journal of burn care & research : official publication of the American Burn Association, Jan 2016, vol. 37, no. 1, p. 53-63 (2016 Jan-Feb) Author(s): Porter, Craig, Herndon, David N, Børsheim, Elisabet, Bhattarai, Nisha, Chao, Tony, Reidy, Paul T, Rasmussen, Blake B, Andersen, Clark R, Suman, Oscar E, Sidossis, Labros S Abstract: The long-term impact of burn trauma on skeletal muscle bioenergetics remains unknown. Here, the authors determined respiratory capacity and function of skeletal muscle mitochondria in healthy individuals and in burn victims for up to 2 years postinjury. Biopsies were collected from the m. vastus lateralis of 16 healthy men (26 ± 4 years) and 69 children (8 ± 5 years) with burns encompassing ≥30% of their total BSA. Seventy-nine biopsies were collected from cohorts of burn victims at 2 weeks (n = 18), 6 months (n = 18), 12 months (n = 25), and 24 months (n = 18) postburn. Hypermetabolism was determined by the difference in predicted and measured metabolic rate. Mitochondrial respiration was determined in saponin-permeabilized myofiber bundles. Outcomes were modeled by analysis of variance, with differences in groups assessed by Tukey-adjusted contrasts. Burn patients were hypermetabolic for up to 2 years postinjury. Coupled mitochondrial respiration was lower at 2 weeks (17 [8] pmol/sec/mg; P < .001), 6 months (41 [30] pmol/sec/mg; P = .03), and 12 months (35 [14] pmol/sec/mg; P < .001) postburn compared with healthy controls (58 [13] pmol/sec/mg). Coupled respiration was greater at 6, 12, and 24 months postburn vs 2 weeks postburn (P < .001). Mitochondrial adenosine diphosphate and oligomycin sensitivity (measures of coupling control) were lower at all time-points postburn vs control (P < .05), but greater at 6, 12, and 24 months postburn vs 2 weeks postburn (P < .05). Muscle mitochondrial respiratory capacity remains significantly lower in burn victims for 1-year postinjury. Mitochondrial coupling control is diminished for up to 2 years postinjury in burn victims, resulting in greater mitochondrial thermogenesis. These quantitative and qualitative derangements in skeletal muscle bioenergetics likely contribute to the long-term pathophysiological stress response to burn trauma.

Title: Need for Mechanical Ventilation in Pediatric Scald Burns: Why it Happens and Why it Matters. Citation: Journal of burn care & research : official publication of the American Burn Association, Jan 2016, vol. 37, no. 1, p. e1. (2016 Jan-Feb) Author(s): Mosier, Michael J, Peter, Tony, Gamelli, Richard L Abstract: Scald burns are the most common thermal injury among children. A small subset of pediatric scald burns are complicated by the need for mechanical ventilation (MV). Studies suggest that 4 to 5% of pediatric scald burns will require MV, and these patients tend to be younger with larger burns. Identifying why pediatric patients with scald burns require MV has remained unclear, and few studies have sought to elucidate possible mechanisms. After institutional review board approval, a retrospective review of all pediatric patients with scald burns admitted to the Burn Center between 2010 and 2013 was conducted. Variables collected included age, sex, weight, height, race, ethnicity, socioeconomic status or type of insurance, hospital length of stay, burn size and location, Department of Child and Family Services (DCFS) involvement, time to intubation from admission, reason for intubation, need for MV, duration of MV, need for operative intervention, 24-hour and 48-hour total fluid intake and urine output, glucose levels, infectious complications,

comorbidities, and mortality. Patients who required MV were then compared with those who did not require MV to identify statistically significant differences between groups. The MV patients (n = 6) and nonventilated patients (n = 339) did not show significant differences in regards to gender, body mass index, ethnicity, and type of insurance; however, MV patients were younger and had larger burns. The mean age of MV patients was 8.2 + 5.0 months compared with 40.7 + 45.2 months for non-MV (P = .002). The mean percentage of TBSA burn in MV patients was 17.3 + 9.0% compared with 4.5 + 3.9% for non-MV (P < .001). Burn location was significant, and 66.6% of MV patients had burns on the face or neck compared with 23.6% of non-MV (P = .015). MV patients were more likely to have been victims of child abuse, as DCFS was involved in 67% of MV patients vs 28% of non-MV patients (P = .036). Fifty percent of patients requiring MV had either a preceding upper respiratory infection, diagnosis of asthma, or congenital defects, compared with 6% of non-MV patients (P = .004). MV patients received more fluids for 48 hours compared with non-MV patients (2275.7 vs 1332.3 ml, P = .013) and had a higher 48-hour urine output (2.34 vs 1.34 ml/kg/hr, P = .013). Pediatric scald burns that require MV have an increased mortality risk and length of stay. MV patients were younger with larger burns. They received more fluids than non-MV patients, and child abuse, asthma, and stress hyperglycemia within the first 72 hours of injury were common among MV patients. Importantly, burn size and previous history of asthma were found to be independent predictors of the need for MV.

Title: The Effect of Burn Center Volume on Mortality in a Pediatric Population: An Analysis of the National Burn Repository. Citation: Journal of burn care & research : official publication of the American Burn Association, Jan 2016, vol. 37, no. 1, p. 32-37 (2016 Jan-Feb) Author(s): Hodgman, Erica I, Saeman, Melody R, Subramanian, Madhu, Wolf, Steven E Abstract: The effect of burn center volume on mortality has been demonstrated in adults. The authors sought to evaluate whether such a relationship existed in burned children. The National Burn Repository, a voluntary registry sponsored by the American Burn Association, was queried for all data points on patients aged 18 years or less and treated from 2002 to 2011. Facilities were divided into quartiles based on average annual burn volume. Demographics and clinical characteristics were compared across groups, and univariate and multivariate logistic regressions were performed to evaluate relationships between facility volume, patient characteristics, and mortality. The authors analyzed 38,234 patients admitted to 88 unique facilities. Children under age 4 years or with larger burns were more likely to be managed at high-volume and very high-volume centers (57.12 and 53.41%, respectively). Overall mortality was low (0.85%). Comparing mortality across quartiles demonstrated improved unadjusted mortality rates at the low- and high-volume centers compared with the medium-volume and very high-volume centers although univariate logistic regression did not find a significant relationship. However, multivariate analysis identified burn center volume as a significant predictor of decreased mortality after controlling for patient characteristics including age, mechanism of injury, burn size, and presence of inhalation injury. Mortality among pediatric burn patients is low and was primarily related to patient and injury characteristics, such as burn size, inhalation injury, and burn cause. Average annual admission rate had a significant but small effect on mortality when injury characteristics were considered.

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