The authors sought to increase the number of days when burn service patients receive 100% of prescribed enteral nutrition. The authors first performed a retrospective review of 37 patients (group 1) receiving enteral nutrition. The authors then created and implemented a nurse-directed feeding algorithm, placing patients into three age groups addressing maximum hourly infusion rates, high residual limits, initiating feeding, refeeding residuals, and replacing formula. The authors then performed a prospective review of 37 patients (group 2) fed utilizing the new algorithm. The amount of prescribed, infused, discarded, and missed feeds were recorded, as well as admitting diagnosis, age, gender, length of stay, ventilator days, infections, and mortality. All patients in group 1 (n = 37) received 100% of feeds 59.9% of prescribed days vs 76.5% in group 2 (n = 37; P = .003). Burn patients in group 1 (n = 26) received 100% of feeds 61.6% of prescribed days vs 85.4% in group 2 (n = 21; P < .001). The mean amount of hours tube feeds were held for surgery, procedures, clogged or dislodged tubes, in both historical control and the group using the restorative algorithm were the same. While there was a significant difference in burn size between groups (6.24 vs 18.39%, P = .01), there were no statistically significant differences in length of stay, ventilator days, or mortality. Implementation of a nurse-directed feeding algorithm improved delivery of enteral nutrition for all burn service patients, increasing the number of days when 100% of prescribed enteral nutrition is given.
Introduction With increased focus amongst hospital systems regarding the quality of care provided, there has been augmented awareness on minimizing unplanned 30 day hospital readmission rates. As part of our burn center’s internal quality improvement process, a discharge readiness checklist was developed to identify patients at high risk for readmission. Methods A 20 item checklist of potential risk factors was developed, and was then cross referenced to all patients readmitted within 30 days of discharge over a one year period (September 2018-August 2019). Retrospective chart review was used to determine how many checklist factors were positive for each patient. The primary outcome was determining the main risk factors leading to a high risk for readmission. Results During this time period, there were 683 admission to our burn center. A total of 13 patients led to a sum of 14 readmissions (2.0%). The age range of patients was between 37 and 84 years old, with a median and average age of approximately 59 years. The distribution of patients included 7 with burn injuries (50%), 6 with soft tissue infections (42.9%) and 1 with frostbite (7.1%). Traditional LACE (Length of stay, Acuity, Co-morbidities, ED visits) score calculation would have identified only 1 of 14 readmissions in the high risk category. Average LACE score was 8.1 for all patients. Of the 20 item checklist, the risk factors most commonly associated with readmission were lack of family support (12/14, 85.7%), surgery performed during index hospitalization (11/14, 78.6%), significant co-morbidities (11/14, 78.6%), location of injuries in difficult to access anatomical regions (8/14, 57.1%), poor nutritional status (6/14. 42.8%) and length of stay greater than 1 day per percent of total body surface area burn involvement (5/7, 71.4%). The average number of identifiable risk factors was 5.38 per patient (ranging from 2 to 9 risk factors per patient). Conclusions Traditional risk assessment scores (i.e. LACE) do not capture patients at high risk for readmission in a burn center. Development of an alternative checklist may help to identify these patients prior to discharge, with the potential to allocate additional resources to ultimately decrease 30 day readmission rates. Applicability of Research to Practice Decreased 30 day readmission rates would lead to overall cost savings and improved patient outcomes.
Introduction Scald injuries affect many vulnerable populations. We know that there is a relationship between time and temperature as to severity of injury. When one of the authors had their residential hot water heater replaced, it was set to an uncomfortable temperature, 134oF, until adjusted to a safe level. This highlighted the possibility of catastrophic injury from a simple household function like washing hands or taking a bath. As a result, we have undertaken efforts to assess locations where burn team members and their families are potentially exposed to excessively hot water and educate them as to methods to measure their water temperature and maintain it at safe levels. Temperature differences between 120oF and 130oF mean the difference between injury in minutes to seconds. Methods Using a Taylor Market Digital Candy Thermometer, the tap is run at maximum hot water for 2 minutes. With water still running, a volume of approximately one liter is collected and the thermometer is immediately immersed in the water with the temperature recorded once stable. Data was recorded at a variety of locations, including residential (of care team), hotels, and around a variety of taps through the hospital. Results Twenty sites were measured for water temperature. The average temperature recorded was 114.1oF, with a median temperature recorded 110.9oF. There were three recordings of water temperature greater than 120oF, with the highest recorded at 132.9oF. All of these sites were immediately informed of the risks and appropriate measures taken to adjust water sources to an appropriate temperature. Conclusions We as burn care professionals know what acceptable water temperatures are for taps in our personal spaces. Despite that it is possible that hazardous conditions can exist. Many areas of society are looking for the guidance of health care providers, and we need to start in our own homes to make that environment safe, and then take that message to our relatives and community. Applicability of Research to Practice This is a real world demonstration of the need to verify safety in our own homes and then take that message of prevention to vulnerable populations.
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