Early excision and autografting are standard care for deeper burns. However, donor sites are a source of significant morbidity. To address this, the ReCell® Autologous Cell Harvesting Device (ReCell) was designed for use at the point-of-care to prepare a noncultured, autologous skin cell suspension (ASCS) capable of epidermal regeneration using minimal donor skin. A prospective study was conducted to evaluate the clinical performance of ReCell vs meshed split-thickness skin grafts (STSG, Control) for the treatment of deep partial-thickness burns. Effectiveness measures were assessed to 1 year for both ASCS and Control treatment sites and donor sites, including the incidence of healing, scarring, and pain. At 4 weeks, 98% of the ASCS-treated sites were healed compared with 100% of the Controls. Pain and assessments of scarring at the treatment sites were reported to be similar between groups. Significant differences were observed between ReCell and Control donor sites. The mean ReCell donor area was approximately 40 times smaller than that of the Control (P < .0001), and after 1 week, significantly more ReCell donor sites were healed than Controls (P = .04). Over the first 16 weeks, patients reported significantly less pain at the ReCell donor sites compared with Controls (P ≤ .05 at each time point). Long-term patients reported higher satisfaction with ReCell donor site outcomes compared with the Controls. This study provides evidence that the treatment of deep partial-thickness burns with ASCS results in comparable healing, with significantly reduced donor site size and pain and improved appearance relative to STSG.
The American Burn Association (ABA) has an established set of criteria for burn center referral to guide healthcare providers and improve patient outcomes. As U.S. healthcare becomes increasingly focused on improving quality of care (ie, pay-for-performance initiatives), assessing and monitoring the referral patterns to burn centers is critical in providing optimal burn care. Few studies have compared admission, treatment, and discharge patterns at burn centers and nonburn centers. Our goal was to compare practice and referral guidelines for patients with burn injuries by reviewing every discharge record in our state over a 2-year period. The study was conducted in a retrospective fashion using our state's hospital association patient database of International Classification of Diseases, 9th revision (ICD-9) discharge codes, querying 940.00 to 948.99, over the period of October 1, 2005, to September 30, 2007. Additional variables abstracted included the discharging hospital, outcome, race, gender, payor status, length of stay, procedures, and age. Adherence to referral criteria was established by comparing the discharge ICD-9 codes with the burn center referral criteria established by the ABA and American College of Surgeons Committee on Trauma in Guidelines for the Operation of Burn Centers. Injury patterns were analyzed using the 2 burn centers in our state and the remaining 107 nonburn centers providing care to burn patients. A total of 2036 adult patients aged 18 to 106 years sustained burn injuries requiring hospital admission, and 1416 (70%) met ABA referral criteria based on ICD-9 codes. Of the 1084 patients treated at burn centers, 88% met referral criteria. Of the 952 burns treated entirely at nonburn centers, 48% met referral criteria but were not transferred. The most common burns treated at nonburn centers included injuries to the hand, wrist, face, neck, and lower extremity. The mean number of criteria met by patients treated at nonburn centers was 1.5, and all deaths occurring at nonburn centers met referral criteria. A significantly higher percentage of patients with Medicare were not transferred from nonburn centers (P < or = .00001), and a significantly higher percentage of patients were discharged to nursing homes as opposed to home (P = .01) from nonburn centers. Forty-seven percent of the patients sustaining burn injuries in our state receive all of their acute inpatient care at nonburn centers, and almost half of these met ABA burn center referral criteria. Given the disparity in discharge placement and immediate availability of burn specialists in our state, all patients meeting ABA referral criteria should be referred to burn centers. More focused outreach and education for initial providers may help improve access and referral to burn centers.
Early recognition of the need for escharotomy and other decompressive therapies is imperative for experienced burn providers, as to avoid reversible tissue ischemia and necrosis. With full-thickness burns, the eschar that develops is largely noncompliant. The predictable edema that develops during resuscitation of larger burns increases the likelihood ischemia-inducing pressure, as the underlying tissues swell within noncompliant skin, resulting in burn-induced compartment syndrome. Conventionally, this has been treated with decompressive therapies, such as escharotomy. The most recent surveys have identified that the United States and Canada both face a shortage of practicing burn surgeons. In the event of a burn disaster, many nonburn surgeons would need to provide burn care, including decompressive therapies. We reviewed the literature to provide accurate, accessible, and applicable recommendations regarding this practice following burn injury for both the practicing burn surgeon and those that would provide care in the burn disaster.
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