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Introduction Central line-associated bloodstream infections (CLABSI) remains a high risk for burn patients due to their compromised integumentary system. Additionally, identifying bloodstream infections secondary to a burn infection versus a central line remains a challenge. Literature review suggests multidisciplinary CLABSI bundles (MCB) demonstrate reduction of CLABSIs. This research looks at the use of a MCB compared to the application of the standard CLABSI bundle alone reduce CLABSI incidence and standardized infection ratios over the past two years in the Burn Center. We hypothesize a MCB will have sustained CLABSI SIR and incidence reduction over time. Methods Infection Prevention & Control CLABSI data collection on all burn patients pre-intervention (2017-2018) and post-intervention (2019-2020) were performed as a quality improvement project; IRB was not obtained. In addition to the CLABSI Bundle (optimal site, aseptic insertion, aseptic maintenance, timely removal, & education), MCB was also implemented in Qtr. 1, 2019. MCB includes necessity of line discussion during daily and multidisciplinary rounds, strategic blood culture collection upon admission/transfers for patients with existing central line, improved nursing and provider documentation of burn infection per CDC definitions, integration of CLABSI reviews in tiered Burn Quality Improvement Program, and universal zero CLABSI goal setting for RNs. Two-sample t-test will be used to compare results pre-intervention (2017-18) & post-intervention (2019-20). CLABSI incidence and standardized Infection ratio will be illustrated per year. Results The post-intervention CLABSI SIR data (M= 0.08, SD=0.11) significantly improved when compared to the pre-intervention CLABSI SIR data (M= 0.77, SD= 0.169), t(2)=4.72, p=0.02. The post-intervention CLABSI incidence data (M=0.5, SD=0.70) significantly improved when compared to the pre-intervention CLABSI incidence data (M=4.5, SD= 0.70), t(2)= 5.65, p= 0.01 Conclusions The combination of the CLABSI bundle with the MCB demonstrated favorable CLABSI SIR and incidence reduction, as literature suggests. Implementing multimodal, multidisciplinary interventions must be a priority for sustained CLABSI reduction. Considerations for future studies should measure length of catheter days, incidence of positive blood cultures on admission/transfers for patients with existing central lines, and incidence of burn infection rates with positive blood culture and an existing central line.

Introduction An institutional Burn Intensive Care Unit (ICU) Rounding Tool was implemented for both quality improvement data collection and trainee education. Forms are completed by trainee team members daily for all critically ill patients prior to teaching rounds. Gathered data are structured to facilitate evaluation of patient volume status, sepsis risk and ventilator management. The forms are then used to guide discussion among students, residents, mid-level providers, fellows, attending surgeons and other members of the multi-disciplinary rounding team. We conducted a series of interviews with trainees regarding their user experience to assess the tool’s educational utility. Methods A convenience sample of residents who had recently completed their Burn Surgery rotation were interviewed in a structured format. Questions focused on the form’s ease of use and comprehensibility. Emphasis was placed on the extent to which it stimulates learning while rounding. Additional feedback was sought for the purpose of improving the tool for continued use. Results Participants were post-graduate year one or two resident physicians training in General Surgery, Urology, Emergency Medicine or Anesthesia. Prior experience and comfort with ICU level care ranged from very little to moderate. All interviewees found the tool helpful in their patient assessments, though the current layout of the form was a frustration for many. Overall, they unanimously found the forms beneficial for preparation of patient presentations and felt that utilization during rounds facilitated learning. Conclusions Interviews with trainees on their burn surgery rotation demonstrate that implementation of an ICU Rounding Tool has provided educational benefit, particularly for those less experienced in intensive care. Feedback from this cohort will be used to improve the tool’s usability. Our next steps will include a more formal survey of all trainees involved since the inception of this project.

Introduction Sepsis following critical burn injury is an ominous development that can lead to death. Most patients will manifest a systemic inflammatory response syndrome (SIRS), even without being septic. This may obscure the clinical recognition of developing sepsis and delay the initiation of effective treatment. We developed a burn sepsis screening tool (BSST) to facilitate the recognition of developing burn sepsis. The purpose of this study was to review the utility of that tool. Methods The BSST was based on several clinical signs, laboratory values, and changes in physiologic support modalities associated with sepsis. It consisted of nine parameters that could be scored as indicating or not indicating sepsis or not applicable. If three were positive, the patient was identified as septic, and a search for a septic source was undertaken and treatment initiated. The BSST was completed on patients judged to be critically ill during morning rounds over a period of nine months. The values were transcribed into a secure web database and analyzed using SAS 9.4. Results There were 593 individual encounters on 31 critically ill patients with burns and/or inhalation injury for which the BSST was completed. The mean age of the patients was 57 ± 4 years (Mean ± SEM), and the burn size was 24 ± 15 % TBSA. Eleven patients were women (36%) and 7 patients had inhalation injury (23%). The expected case fatality was 21 - 30% depending on the statistical model used. Six patients (19%) died. The length of stay was 64 ± 10 days and ranged from 3 to 267 days. A patient was judged to be septic in only 45 of the daily encounters (8.0 % ± 1.1). There were 21 instances of a new septic event made in 12 patients. Episode of sepsis separated by at least 5 days of no sepsis, were considered to be a new septic event. There was a substantial amount of data that was missing or not applicable. There were no significant differences in the septic parameters on days with new sepsis diagnosis when compared to the day prior, or compared to all encounters in patients that were never septic. Patients deteriorated acutely between BSST completions on only two occasions and both were stabilized. Conclusions The BSST was used consistently to help evaluate the daily status of critically ill burn injured patients. The expected case fatality of the group was moderately high, based on statistical models derived from the ABA Burn Registry. The observed outcome was as good as or better than predicted. Acute decompensation was rare. The BSST added daily administrative work to rounds, and the data recorded were often incomplete. Although the BSST did not demonstrate any single clinical feature that identified the transition from SIRS to sepsis, it did add structure and rigor to daily rounds. That contributed to the effectiveness of rounds, and it may have been responsible, in part, for the favorable outcomes.

Introduction Pediatric patients, between the age of newborn and 18 years, require legal guardian consent for any surgical procedure. In some cases, despite medical advisement, guardians refuse excision and skin graft for a minor in their care. In these cases, extended healing times, re-admission, scaring, contracture and physical disability may ensue. Our study aims to review contributing factors of guardian refusal and explore the outcomes of such refusals. Methods Retrospective chart review of all pediatric patients admitted to a large verified burn center between January 2018 through May 2019 were reviewed for total body surface area (TBSA) burned, age, depth of wound, mechanism, MD recommendation for surgical procedure, operative procedures conducted and length of hospital stay (LOS). Results Of the 265 pediatric patients admitted to the Burn Service, 32 (12%) were recommended surgical intervention during their hospitalization. Of these, 25 (78%) guardians consented for surgical skin grafting procedures following recommendation; 3 (9%) guardians delayed treatment consent by an average of 5 days; and 4 (13%) refused surgical consent for skin grafting procedures entirely. The average TBSA for patients recommended for surgical intervention was 8.7, those who accepted surgical intervention had an average TBSA of 8.35, compared to the 11.25 TBSA who refused surgical intervention. Average inpatient length of stay for patients whose guardians consented to surgical intervention promptly was 15.8 days. Despite an average 5 day delay in consent, guardians who deferred consent for surgical intervention doubled their length of stay (31.1 inpatient days). The four guardians who refused recommended surgical intervention had an average inpatient stay of 8.25 days. This finding is consistent with multi-day dressing use and outpatient clinic management. Of note, the four patients that did not receive surgical intervention for burn wound management were linked by common cultural background. Conclusions Pediatric burn injury is both acute and chronic, and the shock of initial injury is often overwhelming for both the patient and the guardian. Furthermore, guardians are then asked to make surgical decisions for a minor in their care. The burn team needs to have a heightened awareness of the cultural norms in the communities they serve to ensure quality care deliverance and patient safety. Applicability of Research to Practice Directly Applicable.