Introduction Frailty is a state of increased vulnerability to health-related stressors and can be measured by summing the number of frailty characteristics present in an individual. Discharge institutionalization (rather than discharge to home) represents disease burden and functional dependence following hospitalization. Our aim was to determine the relationship between frailty and need for post-operative discharge institutionalization. Study Design Subjects ≥65 years undergoing major elective operations requiring post-operative ICU admission were enrolled. Discharge institutionalization was defined as need for institutionalized care at hospital discharge. Fourteen pre-operative frailty characteristics were measured in six domains: co-morbidity burden, function, nutrition, cognition geriatric syndromes and extrinsic frailty. Results 223 subjects (mean age 73±6 years) were studied. Discharge institutionalization occurred in 30% (66). Frailty characteristics related to need for post-operative discharge institutionalization included: older age, Charlson ≥3, Hematocrit <35%, any functional dependence, Up-and-Go ≥15 seconds, albumin <3.4 mg/dL, Mini-Cog ≤3, and having fallen within six-months (p<.0001 for all comparisons). Multivariate logistic regression retained prolonged timed up-and-go (p<.0001) and any functional dependence (p<.0001) as the variables most closely related to need for discharge institutionalization. An increased number of frailty characteristics present in any one subject resulted in increased rate of discharge institutionalization. Conclusions Nearly one in three geriatric patients required discharge to an institutional care facility following major surgery. The frailty characteristics of prolonged up-and-go and any functional dependence were most closely related to the need for discharge institutionalization. Accumulation of a higher number of frailty characteristics in any one geriatric patient increased their risk of discharge institutionalization.

Despite significant morbidity and mortality for major burns, palliative care consultation (PCC) is underutilized in this population. The purpose of this study is to examine the impact of a protocol using recommended “triggers” for PCC at a single academic burn center. This is a retrospective review of patient deaths over a four-year period. Use of life-sustaining treatments, comfort care (de-escalation of one or more life-sustaining treatments) and do not attempt resuscitation (DNAR) orders were determined. Use of PCC was compared during periods before and after a protocol establishing recommended triggers for early (&lt;72 hrs of admission) PCC was instituted in 2019. A total of 33 patient deaths were reviewed. Most patients were male (n=28, 85%) and median age was 62 years [IQR 42-72]. Median revised Baux score was 112 [IQR 81-133]. Many patients had life-sustaining interventions such as intubation, dialysis, or cardiopulmonary resuscitation, often prior to admission. Amongst patients who survived &gt;24 hrs, 67% (n=14/21) had PCC. Frequency of PCC increased after protocol development, with 100% vs. 36% of these patients having PCC before death (p=0.004). However, even during the later period, less than half of patients had early PCC despite meeting criteria at admission. In conclusion, initiation of life-sustaining measures in severely injured burn patients occurs prior to or early during hospitalization. Thus, value-based early goals of care discussions are valuable to prevent interventions that do not align with patient values and assist with de-escalation of life-sustaining treatment. In this small sample, we found that while there was increasing use of PCC overall after developing a protocol of recommended triggers for consultation, many patients who met criteria at admission did not receive early PCC. Further research is needed to elucidate reasons why providers may be resistant to PCC.

The usual duration of extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory distress syndrome is 7-10 days. Prolonged duration ECMO (defined as greater than 14 days) is increasingly being documented with native lung recovery or as a bridge to lung transplantation. We report a case of prolonged duration ECMO (6,364 hours, 265 days) requiring no complete circuit exchange. As critical care improves, prolonged ECMO will continue to pose unique technological and ethical challenges that test our expectations of this treatment modality. There is a critical need for diagnostic modalities to provide objective assessment of native lung recovery in patients requiring prolonged duration ECMO.

Acute kidney injury is common in patients with severe ARDS caused by pH1N1 infection. CRRT is a significant risk factor for increased mortality, but most patients who survived experienced full renal recovery.

Hepcidin serum concentrations are markedly increased on ICU admission, and decrease significantly over the course of the ICU stay (28 d). Decreased hepcidin concentrations are associated with increased reticulocyte response and decreased inflammatory response reflected by decreased interleukin-6 and C-reactive protein concentrations, but not with anemia resolution.

BSN RN and the Committee on Elderly Burn Care BACKGROUND Advances in burn care have led to significant improvements in the outcomes of burn patients except in the elderly: burn patients ≥65 years of age. 1,2 This is reflected in the LD50 for elderly burn patients, which has not significantly changed over the last three decades and is around 30 to 35% TBSA burn. 4,8 The lack of improvements is even more impactful when considering that elderly represent the fastest growing population, indicating the expected substantial increase in elderly burn patients over the next decades. Additionally, the amount of burn patients in elderly will not only grow due to the growing population of elderly but also have much higher incidence as elderly are at an increased risk for burn injuries due to thinning skin, decreased sensation, mental alterations, pre-existing comorbidities, and numerous other contributing factors. [1][2][3][4][5][6] The high risk of suffering from burns in the elderly population with the rapid growth of this population will require change to the burn treatment paradigm but, at this time, burn care providers lack treatment guidelines or protocols tailored to the special needs of the elderly burn patient. Complicating elderly burn care is the lack of knowledge about maintaining quality of life, independence, and acceptable long-term outcomes. 9,10 As aforementioned, despite the recognition of burn care providers regarding poor outcomes of elderly burn patients, reasons for these detrimental outcomes have yet to be determined. Unfortunately, until 2016, there were no concerted or directed research efforts to improve outcomes. In 2016, past President of the American Burn Association (ABA) Dr. Tredget held the State of Science meeting in Washington, DC, with elderly burn care being one of the main areas of interest and priorities. Subsequently a white paper was published in the Journal of Burn Care & Research (JBCR) that briefly delineated the perceived needs of elderly burn patients and areas ripe for investigations in order to improve outcomes. 11 In addition, ABA past Presidents Dr. Peck and Dr. Tredget initiated an ad hoc Committee on Elderly Burn Care, which changed to a standing committee in 2018.The Committee on Elderly Burn Care has met several times since its inception and has identified areas that require urgent attention and investigation by directed and extensive research. This publication reflects the committee members' expert opinion and literature review of current knowledge in elderly burn care and lists major areas for improvement along with opportunities for research. Due to the limited published data on the subject, this paper should serve as a spring board for future investigations and not as a consensus paper for specific care recommendations. The areas are structured as follows and are authored by members from the Committee on Elderly Burn Care: PREHOSPITAL

Telemedicine technology can be used to facilitate consultations from non burn-trained referring providers. However, there is a paucity of evidence indicating these technologies influence transfer decisions and follow-up care. In 2016, our regional burn center implemented a mobile phone app, which allows a referring provider to send photos of the wound along with basic demographic and clinical data to the burn specialist. A retrospective review was performed on consults to our regional burn center from a Level I trauma center approximately 70 miles away with a shared electronic medical record. Patients were considered to be “down-triaged” if they could be managed locally or if transfer could occur via personal vehicle instead of ground or air ambulance transport. During the two-year study period, 126 consultations were made for thermal injuries. 87 patients (69%) were referred using the Burn App. Overall, 49 patients (39%) were transferred. When the subset of intermediate size (1-10% TBSA) burns were considered (n=48), the Burn App allowed for successful “down-triage” of 12 patients (33%) referred through the app. No patient referred without the app could be “down-triaged” (p=0.02). Although 57 patients (44%) were recommended for outpatient follow-up, only 42% followed up. A mobile app can be used to successfully triage patients with intermediate size burn injuries to a lower acuity of follow up and transfer mode. However only a minority of patients triaged to outpatient management actually follow up with a regional burn center. Telemedicine efforts should focus on improving not only initial triage, but also after care.

BACKGROUND Burn injuries result in 50,000 annual admissions. Despite joint referral criteria from the American College of Surgeons (ACS) and American Burn Association (ABA), many severely injured patients are not treated at verified centers with specialized care. Only one prior study explores regional variation in access to burn centers, focusing on flight or driving distance without considering the size of the population accessing that center. We hypothesize that disparities exist in access to verified centers, measured at a population level. We aim to identify a subset of nonverified centers that, if verified, would most impact access to the highest level of burn care. METHODS We collected ABA data for all verified and nonverified adult burn centers and geocoded their locations. We used county-level population data and a two-step floating catchment method to determine weighted access in terms of total beds available locally per population. We compared regions, as defined by the ABA, in terms of overall access. Low access was calculated to be less than 0.3 beds per 100,000 people using a conservative estimate. RESULTS We identified 113 centers, 59 verified and 54 nonverified. Only 2.9% of the population lives in areas with no verified center in 300 miles; however, 24.7% live in areas with low access. Significant regional disparities exist, with 37.3% of the population in the Southern Region having low access as compared with just 10.5% in the Northeastern Region. We identified 8 nonverified centers that would most impact access in areas with no or low access. CONCLUSION We found significant disparities in access to verified center burn care and determined nonverified centers with the greatest potential to increase access, if verified. Our future directions include identifying barriers to verification, such as lack of fellowship-trained burn surgeons or lack of hospital commitment. LEVEL OF EVIDENCE Epidemiological, level III.