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Introduction School-aged children between the ages of 5 and 12 years face new environments and experiences as they transition through grade school. They are still developing and learning as they engage within their home and carry these experiences into their school environment. This study is an assessment of the association between family relations and school outcomes in children 5 to 12 years of age as measured by the field-tested SA-LIBRE5-12 (School-Aged Life Impact Burn Recovery Evaluation), a new parent-reported outcome measure. Methods Within the social and family functioning domain of the SA-LIBRE5-12, 10 family relations and 13 school items were scored on a scale from 0 (Never) to 4 (Always). Scores were re-coded so that higher scores denote better functioning. An exploratory factor analysis (EFA) was conducted to confirm model fit. A regression model assessed the relationship between the school and family factors, controlling for demographic and clinical characteristics (child sex, race, ethnicity, age at survey completion, burn size, burns to critical areas, and pain severity). Results A total of 356 parents completed these items from the SA-LIBRE5-12. EFA resulted in four sub domains of family engagement, family stress impact, school success, and school difficulties. A univariate analysis of the demographic characteristics showed that the child being female (p=0.008) and non-white (p=0.0216) had a better mean score in school success (3.33 vs. 3.19 + 0.78 (SD) and 3.38 vs. 3.21 + 0.75 (SD), respectively). In addition, children with a burn size < 1% had better school difficulties score (3.76 vs 3.61 + 0.38, p=0.0018). Regression analysis showed positive correlations between family engagement and school difficulties (r=0.26, p< .0001), family engagement and school success (r = 0.56, p< .0001), family stress impact and school success (r=0.21, p< .0001) and family stress impact and school difficulties (r=0.49, p< .0001). Conclusions This study indicates that a cohesive family relationship and home life may promote productive school outcomes in children between the ages of 5 and 12 based on parent reported outcomes. Applicability of Research to Practice This research will provide burn care providers, parents, and teachers with greater insight into the relationship between a child’s current family relations and their success in school. Results will guide caregivers in fostering a productive and healthy family environment.

Introduction Hypermetabolism following a burn injury causes perturbations of key cardiopulmonary and cellular functions which often persist long-term. Patients are advised to increase caloric intake to address this hypermetabolic state. However, potential weight change implications from such blunt strategies are not well studied. We aimed to 1) determine factors associated with weight change from discharge and 2) understand their relationship to other physical and psychosocial measures over time. By doing so, more tailored approaches to healthy weight management could be devised. Methods Adult participants that were enrolled in the Burn Model System (BMS) National Database after 2015 were included in the analysis. Weight was collected and BMI calculated during admission and at 0.5, 1, 2, and 5 year follow-ups. Mixed models included repeated measures controlling for correlated error of the outcomes and were used to assess the association of weight change with demographic, injury factors and psychosocial measures over time. Results A total of 698 individuals were included in the analysis. Median age was 48 years (IQR 33, 59), 218 participants were female (31.2%), median TBSA injured was 10% (IQR 3, 25), and 388 sustained flame injury (55.6%). Median BMI was 26.75 kg/m2 (IQR 23.67, 31.05). During follow-up, 446 participants (64%) had a median weight gain from admission to last follow-up of 2kg (IQR -2, 6.3). There were significant differences in weight trajectory between BMS centers (p=0.0003), which was included in subsequent models. Sex, marital status, and race were not associated with weight change. Increases in burn size (p< 0.0001) and number of months working after injury (p=0.03) were associated with greater weight, while older age at time of injury (p< 0.0001) was associated weight loss. Greater weight gain was associated with higher PROMIS-29 Physical Function (p=0.002) and Neuro-QOL (p=0.03) scores (meaning better) after one year. PROMIS-29 Sleep Disturbance score was associated with weight change only between years 2-5 of follow-up (p=0.029), with higher sleep disturbance score associated with lower BMI. Conclusions Most people living with burn injury experienced a modest weight gain after injury. Weight trajectory was impacted by several demographic factors including age, burn size, and amount time spent working, as well as physical and psychosocial measures (PROMIS-29 Physical Function, Neuro-QOL). Applicability of Research to Practice These factors can be used to inform anticipatory guidance, diet recommendations, and exercise programs for people with burn injury. The impact of tracking weight and health goals with patients in the outpatient settings should be more closely examined.

Introduction Children ages 5 to 12 are in pivotal stages of psychological development as they become more self-aware. Body image can be a formation of both internal experiences and influences from the surrounding environment. This perceived image adapts during this age group and can be negatively impacted by the changes in physical appearance due to the burn injury. Previous research indicates older age and the presence of larger, visible burns can impact body image and self-esteem in the present and long-term. This study assessed the association between burn characteristics and the child’s ability to maintain positive body image in this age group using a new parent-reported instrument for assessment of child outcomes after burn injury. Methods Preliminary data was obtained from the School-Aged Life Impact Burn Recovery Evaluation (LIBRE)5-12 study, which is currently in stages of field-testing. Classic test theory methods were used to assess body image items (n = 13) from the Psychological domain. Each item was scored on a 5-point Likert scale ranging from 0 (never) to 4 (always). Data was recoded for selected items such that higher scores denote better functioning. Multivariate linear regression analyses measured the association between burn injury characteristics and body image (controlling for sex, race and ethnicity, burn injury to critical areas, total body surface area burned (TBSA), and age at survey completion). Mean body image score was calculated. Results Data was obtained from 356 surveys with completed body image items from parents of children with burns. The mean age at survey completion was 8.6 + 2.4 years and mean total body surface area burned (TBSA) was 9.2 + 13.9 with 55% male and 66% white. Items from body image subdomain were identified as a unidimensional scale (α = 0.91, item-total correlations >0.4, ratio of the 1st and 2nd eigenvalues = 4.98). The mean body image score was 3.5 + 0.6. The presence of a foot burn (p = 0.0099), genitalia burn (p = 0.0449) and TBSA >1% (p = 0.0013) resulted in a lower body image score (3.3 + 0.6, 3.1 + 0.8, and 3.4 + 0.7, respectively). In the regression model, age at survey completion was also associated with decreased body image score (β = 0.074, p < 0.0001). Conclusions Parents reported older school-aged burn survivors often had difficulty with body image. Presence of larger burn size and injury to critical areas also worsened body image. Applicability of Research to Practice Burn-care providers and family members can utilize body image score to understand the burn survivor’s current body image satisfaction and assist in fostering positive body image after burn injury through assessment and early intervention.

Introduction Following burn survivors in the community is critical to understand their problems and needs. Physical activities automatically recorded by smartphones have shown to be a convenient and burdenless method for post-discharge assessment. However, it is unclear if physical activities are associated with burn survivors’ physical and psychosocial outcomes. This study aims to examine the relationship between smartphone-tracked physical activities and scale-based outcomes. Methods Adult burn survivors living in the community were included in this study. A mobile application was downloaded to participants’ smartphones and automatically recorded daily number of steps, travel miles and activity minutes. Participants received weekly surveys assessing pain (Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity and Interference), depression (Patient Health Questionnaire (PHQ-8)), anxiety (PROMIS Anxiety) and social participation (Life Impact Burn Recovery Evaluation (LIBRE) Social Interactions and Social Activities). Correlation coefficients between physical activities and survey results were examined and interpreted as “very weak” (|r|≤0.19), “weak” (0.20≤|r|≤0.39), “moderate” (0.40≤|r|≤0.59), “strong” (0.60≤|r|≤0.79), and “very strong” (0.80≤|r|≤1.00). Results There were 24 burn survivors with an average of 24 years after injury included in this study. The 180-week data collected between November 2021 and August 2022 was analyzed. Daily number of steps, travel miles and activity minutes separately showed relationships with PROMIS Pain Intensity (r=-0.312, p< 0.001; r=-0.247, p=0.001; r=-0.239, p=0.001), PROMIS Pain Interference (r=-0.375, p< 0.001; r=-0.318, p< 0.001; r=-0.291, p< 0.001), PHQ-8 (r=-0.403, p< 0.001; r=-0.357, p< 0.001; r=-0.311, p< 0.001), PROMIS Anxiety (r=-0.310, p< 0.001; r=-0.209, p=0.007; r=-0.150, p=0.054), LIBRE Social Interactions (r=0.272, p< 0.001; r=0.291, p< 0.001; r=0.328, p< 0.001) and LIBRE Social Activities (r=0.381, p< 0.001; r=0.414, p< 0.001; r=0.404, p< 0.001). Conclusions Daily number of steps demonstrated a moderate correlation with depression while both daily travel miles and activity minutes showed moderate correlations with social participation. The results support that smartphone-tracked physical activities are related to burn survivors’ psychosocial outcomes. Applicability of Research to Practice This study may inform future use of smartphone-tracked physical activities to understand and track burn recovery and ultimately improve care.

Introduction Rehabilitation services improve the functional recovery of people who have experienced burn injury. Therapy services are often initiated during patients’ hospitalization and continue for months to years after discharge. However, numerous factors contribute to a patient’s overall complexity and functional impairments following discharge and need for Inpatient Rehabilitation (IR). Characteristics associated with longer IR stays have not been well explored. This study aimed to examine patient and clinical factors associated with length of IR stay. We hypothesized that burn severity, including size and location, as well as insurance payor will be associated with length of rehabilitation time. Methods Adult participants in Burn Model System National Database (1994-2022) who were discharged to IR following their hospital stay were included. A negative binomial regression analysis examined the association between IR days and demographic and injury characteristics including age, gender, burns to critical areas (head and neck, perineum, hand), payor, etiology, circumstance of injury, and range of motion deficits. A p-value less than 0.05 was considered significant. Results The study included 585 participants who were 72% male with mean age 46.1 (SD 16.8), and mean burn size 34.6% (20.5) total body surface area (TBSA). Average IR days were 22.8 (19.3). For every 1% increase in TBSA burned there was a 1% increase in IR days. Similarly, each additional 1 ventilator day was associated with an 1% increase in IR days. Electrical injuries were associated with 44% more IR days than flame injuries. Self-inflicted injuries were associated with 55% more IR days, while hand burns were associated with 18% decrease in IR days. Self-pay, philanthropy or other insurance coverage was associated with 37% fewer IR days. Of note, range of motion deficits were not significantly associated with IR days. Conclusions Longer IR stays were associated with greater burn severity, etiology (electrical), and circumstance (self-inflicted), all of which are markers of overall case complexity. Shorter IR stays were associated with specific injury location (hand), though reasoning for this needs further investigation. Payor type was also associated with shorter IR stay, which highlights risk of inequity in rehabilitation service delivery. Applicability of Research to Practice These findings can help clinicians set expectations regarding IP for patients and families, and advocate for strategies to deliver rehabilitation services more equitably.

Introduction Care discontinuity, or the care that is provided by disparate healthcare professionals when patients are readmitted to a hospital different than their original admission (non-index hospital), has been associated with worse outcomes among surgical patients. However, little is known about its effect on burn patients. Our aim was to determine the impact of care discontinuity on long-term outcomes in a national sample of burn patients. Methods The longitudinal Burn Model System National Database was queried from 1996 to 2021. All adult burn patients from participating sites were included. Care discontinuity was defined by having therapy or burn-related surgeries at non-index hospitals. The main outcomes were the physical (PCS) and mental (MCS) health component summary scores of the Veterans RAND 12 (VR-12) score at 6 and 12 months after injury. Multivariable regression was used to examine the association between care discontinuity and long-term outcomes, adjusting for patient characteristics and burn injury severity. Results A total of 1,866 burn patients were included. Mean age was 43.36 (SD 15.85) years, 73% were male and 76% were white. Mean PCS scores were 43.56 (SD 10.95) and 45.17 (SD 11.18); and mean MCS scores were 48.00 (SD 12.60) and 48.25 (SD 12.55) at 6 and 12 months, respectively. Care discontinuity was reported in 423 (22.6%) burn patients, who reported having therapy or burn-related surgeries at a non-index hospital. In adjusted analyses, care discontinuity was associated with worse PCS at both 6 months (Coefficient -2.18, 95% Confidence Interval [CI] -3.44 – -0.91, p=0.001), and 12 months (Coefficient -2.16, 95% CI -3.50 – -0.82, p=0.002), compared to patients having therapy/surgery at index hospitals. Care discontinuity was not associated with MCS scores at 6 (Coefficient 0.54, 95% CI -0.04 – 2.03, p=0.473) and 12 months (Coefficient -0.90, 95% CI -2.49 – -0.67, p=0.262). Conclusions Care discontinuity was significantly associated with lower physical health component scores at long-term follow up, but not with mental health component scores. Future studies should focus on developing strategies to ensure continuity of care and/or identifying out of system patients to provide targeted resources. Applicability of Research to Practice Understanding the implications of care fragmentation on longitudinal outcomes may help clinicians develop strategies to ensure care continuity and consequently better outcomes.

Introduction Social rehabilitation is a critical step in the recovery process post burn injury, yet there is limited published data on the topic. The LIBRE Profile was developed as a burn specific instrument to examine social participation outcomes across six domains. The objective of this study is to use the LIBRE Profile to measure social participation and explore the trajectories of recovery in each domain. Methods Data from the LIBRE Journey Study was analyzed, utilizing both the LIBRE Profile Computer Adaptive Test and fixed short forms. Demographic and clinical characteristics included age, gender, race, ethnicity, education, marital status, burn size and time since injury. LIBRE Profile scores collected at five time-points from baseline to two years, approximately 6 months apart, calculated score trajectories for each of the LIBRE Profile domains (Family and Friends (FF), Social Activities (SA), Romantic Relationships (RR), Sexual Activity (SX), Social Interactions (SI), and Work and Employment (WE)). Linear mixed models with the log of time since burn injury were applied to each domain, adjusting for demographic and clinical variables. Models were fit using the score trajectories with 95% confidence intervals to demonstrate change over time and significant impact of the covariates. Results Analyses included 454 participants with a mean age of 45.4 (SD 15.4) and mean burn size of 38.7% (SD 24.6). Time since burn injury ranged from 13 days to 71 years. All participants were included in analyses of the FF, SA, and SI, with 265, 292, and 288 participants included in the WE, RR, and SX domains based on screening questions for relevance, respectively. Multiple predictors were found to significantly effect LIBRE domain scores (Table 1), with all domain scores increasing with time since burn injury (p < 0.0001) and decreasing with an increase in burn size (p < 0.04), except for FF and RR. Conclusions Analyses showed significant improvement of social recovery post burn injury for both the short- and long-term in four of the six domains. Analysis of LIBRE Journey data demonstrates the social participation trajectories with findings that can establish future applications in clinical practice. Applicability of Research to Practice The LIBRE Profile is a tool used to monitor social participation after burn injury. Understanding the trajectories of social recovery after injury will inform and optimize both clinical care and resource allocation by providing the ability to benchmark an individual’s recovery with one’s peers.

Introduction Measuring physical, psychological, and social outcomes following childhood burn injury is important to understand the impact of the burn. Condition-specific outcomes are highly relevant in assessments for purposes of gauging early growth and development through parent-reported outcome measures (PROMs). Item content in existing PROMs for preschool children is limited and often covers only one construct. Computer adaptive tests (CATs) with advanced psychometric artificial intelligence technologies minimizes respondent burden and enables the creation of a comprehensive condition-specific instrument. This project developed a parent-reported CAT (Preschool1-5 Life Impact Burn Recovery Evaluation (PS-LIBRE1-5) Profile) to measure relevant outcomes after burn injuries in children aged one to under six years. Methods Responses to the field-tested PS-LIBRE1-5 Profile (188 items) were measured on a scale of frequency or ability levels. Scores were coded from 0 to 4 where higher scores reflected better functioning. Factor analysis and Partial Credit Models identified the items retained in the final item bank of each scale. Differential item functioning (DIF) determined if subgroups of burn survivors at the same ability level demonstrated different probabilities of responses. CAT simulations were conducted to estimate the mean score of each scale. The simulated CAT score and full item bank scores were compared based upon the score range, ceiling and floor effects, and marginal reliabilities. Results The child mean age was 3.0 + 1.5 years (n = 498), with primarily mothers (83%) responding. Average burn size and time since burn injury were 4.2% TBSA and 1.1 years, respectively. Analysis resulted in eight scales: Physical (27 items), Communication and language (20 items), Emotional wellbeing (16 items), Mood (11 items), Anxiety (13 items), Peer acceptance (7 items), Play (8 items), and Peer relations (9 items). Severe DIF by ‘age at survey completion’ was shown in 13 items. Ceiling effects were acceptable at < 14%. A CAT was created with the exception of four of the scales (Peer acceptance, Play, Mood, and Anxiety) due to limited item content in these scales’ full item bank. Marginal reliabilities were credible (0.83 to 0.90). CAT simulations revealed that administering the CAT would save the respondent about 14 minutes compared to administering the full item bank. Conclusions Final scales of the PS-LIBRE1-5 Profile contain 111 items and is a comprehensive measure that captures physical, communication and language, psychological, and social functioning of preschool burn survivors in the community. Applicability of Research to Practice This work lays the groundwork for developing a set of age-based CATs, adding to prior adult LIBRE project. The CAT aims to detect the progress of a child during burn recovery for use in clinical practice.

Introduction People with burn injury often experience long-term social participation challenges. A previous study explored demographic and injury variables predicting social participation outcomes after burn injury. This study aims to further examine post-traumatic growth, and physical and psychological symptoms as predictors of social participation. Methods This is a multi-center Burn Model System (BMS) study with a prospective cohort design. Adult BMS Database participants from July 2018 to April 2022 were included. Predictors were measured at 12- and 24-month after injury including Post-Traumatic Growth Inventory Short Form (PTGI-SF), Post-Traumatic Stress Disorder Checklist Civilian Version (PCL-C), Patient-Reported Outcomes Measurement Information System (PROMIS-29) Depression, Anxiety, Fatigue, Sleep Disturbance, Pain Interference and Heat Intolerance. Social participation outcomes were measured with Life Impact Burn Recovery Evaluation (LIBRE) Social Interactions and Social Activities at 24-month after injury. Multivariable regression analyses were conducted to assess the association between predictors and outcomes. Results A total of 158 burn survivors were included with an average age of 47 years and a mean burn size of 19.5% total body surface area. Significant predictors included PCL-C and PROMIS-29 Depression for LIBRE Social Interactions, and Heat Intolerance, PROMIS-29 Pain Interference and Depression, and PCL-C for LIBRE Social Activities. See Table 1 for details of regression results. Conclusions Overall, self-reported post-traumatic stress and depression are associated with limited social interactions while heat intolerance, pain interference, depression, and post-traumatic stress are related to fewer social activities. Applicability of Research to Practice This study improves our understanding of the multiple and modifiable factors which influence social participation after burn injury.