Epidemiology of burn patients admitted in the Netherlands:: a nationwide registry study investigating incidence rates and hospital admission from 2014 to 2018

PURPOSE: The aim of this study was to gain insight into the epidemiology of burn patients admitted to a hospital without a burn center or referred to a burn center. METHODS: This retrospective, nationwide, cohort study included patients with burns or inhalation trauma, admitted between 2014 and 2018, from a national trauma registry. The primary outcome measure was admission to a hospital with or without a burn center. Secondary outcome measures were patient and injury characteristics, Intensive Care Unit (ICU) admission and length of stay, and hospital length of stay (HLOS). RESULTS: Of the 5524 included patients, 2787 (50.4%) were treated at a non-burn center, 1745 (31.6%) were subsequently transferred to a burn center, and 992 (18.0%) were primarily presented and treated at a burn center. The annual number of patients decreased from 1199 to 1055 (− 12.4%). At all admission locations, a clear incidence peak was observed in children ≤ 4 years and in patients of ≥ 80 years. The number of ICU admissions for the entire population increased from 201 to 233 (33.0%). The mean HLOS for the entire population was 8 (SD 14) days per patient. This number remained stable over the years in all groups. CONCLUSION: Half of all burn patients were admitted in a non-burn center and the other half in a burn center. The number and incidence rate of patients admitted with burns or inhalation trauma decreased over time. An increased incidence rate was found in children and elderly. The number of patients admitted to the ICU increased, whereas mean hospital length of stay remained stable. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00068-021-01777-y

The Role of Burn Centers in the Treatment of Necrotizing Soft-Tissue Infections:A Nationwide Dutch Study

Patients with extensive and complex wounds due to Necrotizing Soft-Tissue Infections (NSTI) may be referred to a burn center. This study describes the characteristics, outcomes, as well as diagnostic challenges of these patients. Patients admitted to three hospitals with a burn center for the treatment of NSTI in a 5-year period were included. Eighty patients (median age 54 years, 60% male) were identified, of whom 30 (38%) were referred by other centers, usually after survival of the initial septic phase. Those referred from other centers, compared to those primarily admitted to the study hospitals, were more likely to have group A streptococcal involvement (62% vs 35%, p = .02), larger wounds (median 7% vs 2% total body surface area, p &lt; .001), and a longer length of stay (median 49 vs 22 days, p &lt; .001). Despite a high incidence of septic shock (50%), the mortality rate was low (12%) for those primarily admitted. Approximately half (53%) of the patients were initially misdiagnosed upon presentation, which was associated with delay to first surgery (16 hours vs 4 hours, p &lt; .001). Those initially misdiagnosed had more (severe) comorbidities, and less frequently reported pain or blue livid discoloration of the skin. This study underlines the burn centers' function as referral centers for extensively affected patients with NSTI. Besides the unique wound and reconstructive expertise, the low mortality rate indicates these centers provide adequate acute care as well. A major remaining challenge remains recognition of the disease upon presentation. Future studies in which factors associated with misdiagnosis are explored are needed.</p

Application of hydrosurgery for burn wound debridement: An 8-year cohort analysis

Introduction: During the last decade, the Versajet™ hydrosurgery system has become popular as a tool for tangential excision in burn surgery. Although hydrosurgery is thought to be a more precise and controlled manner for burn debridement prior to skin grafting, burn specialists decide individually whether hydrosurgery should be applied in a specific patient or not. The aim of this study was to gain insight in which patients hydrosurgery is used in specialized burn care in the Netherlands. Methods: A retrospective study was conducted in all patients admitted to a Dutch burn centre between 2009 and 2016. All patients with burns that underwent surgical debridement were included. Data were collected using the national Dutch Burn Repository R3. Results: Data of 2113 eligible patients were assessed. These patients were treated with hydrosurgical debridement (23.9%), conventional debridement (47.7%) or a combination of these techniques (28.3%). Independent predictors for the use of hydrosurgery were a younger age, scalds, a larger percentage of total body surface area (TBSA) burned, head and neck burns and arm burns. Differences in surgical management and clinical outcome were found between the three groups. Conclusion: The use of hydrosurgery for burn wound debridement prior to skin grafting is substantial. Independent predictors for the use of hydrosurgery were mainly burn related and consisted of a younger age, scalds, a larger TBSA burned, and burns on irregularly contoured body areas. Randomized studies addressing scar quality are needed to open new perspectives on the potential benefits of hydrosurgical burn wound debridement

Hydrosurgical and conventional debridement of burns:randomized clinical trial

Background: Tangential excision of burned tissue followed by skin grafting is the cornerstone of burn surgery. Hydrosurgery has become popular for tangential excision, with the hypothesis that enhanced preservation of vital dermal tissue reduces scarring. The aim of this trial was to compare scar quality after hydrosurgical versus conventional debridement before split-skin grafting. Methods: A double-blind randomized within-patient multicentre controlled trial was conducted in patients with burns that required split-skin grafting. One wound area was randomized to hydrosurgical debridement and the other to Weck knife debridement. The primary outcome was scar quality at 12 months, assessed with the observer part of the Patient and Observer Scar Assessment Scale (POSAS). Secondary outcomes included complications, scar quality, colour, pliability, and histological dermal preservation. Results: Some 137 patients were randomized. At 12 months, scars of the hydrosurgical debrided wounds had a lower POSAS observer total item score (mean 2.42 (95 per cent c.i. 2.26 to 2.59) versus 2.54 (95 per cent c.i. 2.36 to 2.72; P =0.023)) and overall opinion score (mean 3.08 (95 per cent c.i. 2.88 to 3.28) versus 3.30 (95 per cent c.i. 3.09-3.51); P = 0.006). Patient-reported scar quality and pliability measurements were significantly better for the hydrosurgically debrided wounds. Complication rates did not differ between both treatments. Histologically, significantly more dermis was preserved with hydrosurgery (P < 0.001). Conclusion: One year after surgery scar quality and pliability was better for hydrosurgically debrided burns, probably owing to enhanced histological preservation of dermis

Patient-reported scar quality of donor-sites following split-skin grafting in burn patients: Long-term results of a prospective cohort study

Background: Skin grafting is the current gold standard for treatment of deeper burns. How patients appraise the donor-site scar is poorly investigated. The aim of this study was to evaluate long-term patient-reported quality of donor-site scars after split skin grafting and identify possible predictors. Methods: A prospective cohort study was conducted. Patients were included in a Dutch burn centre during one year. Patient-reported quality of donor-site scars and their worst burn scar was assessed at 12 months using the Patient and Observer Scar Assessment Scale (POSAS). Mixed model analyses were used to identify predictors of scar quality. Results: This study included 115 donor-site scars of 72 patients with a mean TBSA burned of 11.2%. The vast majority of the donor-site scars (84.4%) were rated as having at least minor differences with normal skin (POSAS item score ≥2) on one or more scar characteristics and the

Course of scar quality of donor sites following split skin graft harvesting: Comparison between patients and observers

There exists little to no data on the development of donor-site scars that remain after split skin graft harvesting. The objectives of this study were to (a) examine changes in characteristics of donor-site scar quality over time and (b) assess the agreement between patient-reported and observer-reported donor-site scar quality in a burn population. A prospective cohort study was conducted including patients who underwent split skin grafting for their burn injury. Patients and observers completed the Patient and Observer Scar Assessment Scale (POSAS) for the first harvested donor site at 3 and 12 months post-surgery. This study included 80 patients with a median age of 34 years. At 3 months post-surgery, the patients scored the POSAS items itch and color as most deviant from normal skin, both improved between 3 and 12 months (3.1 vs 1.5 and 5.0 vs 3.5, respectively [P <.001]). Other scar characteristics did not show significant change over time. The patients' overall opinion score improved from 3.9 to 3.2 (P <.001). Observers rated the items vascularization and pigmentation most severe, only vascularization improved significantly between both time points. Their overall opinion score decreased from 2.7 to 2.3 (P <.001). The inter-observer agreement between patients and observers was considered poor (ICC < 0.4) at both time points. Results of current study indicate that observers underestimate the impact of donor-site scars. This has to b

Long-term scar quality after hydrosurgical versus conventional debridement of deep dermal burns (HyCon trial): Study protocol for a randomized controlled trial

Background: Deep dermal burns require tangential excision of non-viable tissue and skin grafting to improve wound healing and burn-scar quality. Tangential excision is conventionally performed with a knife, but during the last decade hydrosurgery has become popular as a new tool for tangential excision. Hydrosurgery is generally thought to be a more precise and controlled manner of burn debridement leading to preservation of viable tissue and, therefore, better scar quality. Although scar quality is considered to be one of the most important outcomes in burn surgery today, no randomized controlled study has compared the effect of these two common treatment modalities with scar quality as a primary outcome. The aim of this study is, therefore, to compare long-term scar quality after hydrosurgical versus conventional tangential excision in deep dermal burns. Methods/design: A multicenter, randomized, intra-patient, controlled trial will be conducted in the Dutch burn centers of Rotterdam, Beverwijk, and Groningen. All patients with deep dermal burns that require excision and grafting are eligible. Exclusion criteria are: a burn wound 30%, full-thickness burns, chemical or electrical burns, infected wounds (clinical symptoms in combination with positive wound swabs), insufficient knowledge of the Dutch or English language, patients that are unlikely to comply with requirements of the study protocol and follow-up, and patients who are (temporarily) incompetent because of sedation and/or intubation. A total of 137 patients will be included. Comparable wound areas A and B will be appointed, randomized and either excised conventionally with a knife or with the hydrosurgery system. The primary outcome is scar quality measured by the observer score of the Patient and Observer Scar Assessment Scale (POSAS); a subjective scar-assessment instrument, consisting of two separate six-item scales (observer and patient) that are both scored on a 10-point rating scale. Discussion: This study will contribute to the optimal surgi

Burn mass casualty incidents in Europe: A European response plan within the European Union Civil Protection Mechanism

Background: Burn care is centralized in highly specialized burn centers in Europe. These centers are of limited capacity and may be overwhelmed by a sudden surge in case of a burn mass casualty incident. Prior incidents in Europe and abroad have sustained high standards of care through well-orchestrated responses to share the burden of care in several burn centers. A burn mass casualty incident in Romania in 2015 sparked an initiative to strengthen the existing EU mechanisms. This paper aims to provide insight into developing a response plan for burn mass casualties within the EU Civil Protection Mechanism. Methods: The European Burns Association drafted medical guidelines for burn mass casualty incidents based on a literature review and an in-depth analysis of the Romanian incident. An online questionnaire surveyed European burn centers and EU States for burn mass casualty preparedness. Results: The Romanian burn mass casualty in 2015 highlighted the lack of a burn-specific mechanism, leading to the late onset of international transfers. In Europe, 71% of respondents had existing mass casualty response plans, though only 35% reported having a burn-specific plan. A burns response plan for burn mass casualties was developed and adopted as a Commission staff working document in preparation for further implementation. The plan builds on the existing Union Civil Protection Mechanism framework and the standards of the WHO Emergency Medical Teams initiative to provide 1) burn assessment teams for specialized in-hospital triage of patients, 2) specialized burn care across European burn centers, and 3) medevac capacities from participating states. Conclusion: The European burn mass casualty response plan could enable the delivery of high-level burn care in the face of an overwhelming incident in an affected European country. Further steps for integration and implementation of the plan within the Union Civil Protection Mechanism framework are needed.publishedVersio

Health status and psychological outcomes after trauma: A prospective multicenter cohort study

Introduction Survival after trauma has considerably improved. This warrants research on non-fatal outcome. We aimed to identify characteristics associated with both short and long-term health status (HS) after trauma and to describe the recovery patterns of HS and psychological outcomes during 24 months of follow-up. Methods Hospitalized patients with all types of injuries were included. Data were collected at 1 week 1, 3, 6, 12, and 24 months post-trauma. HS was assessed with the EuroQol-5D-3L (EQ-5D3L) and the Health Utilities Index Mark 2 and 3 (HUI2/3). For the screening of symptoms of post-traumatic stress, anxiety and depression, the Impact of Event Scale (IES) and the Hospital Anxiety and Depression Scale (HADS) subscale anxiety (HADSA) and subscale depression (HADSD) were used. Recovery patterns of HS and psychological outcomes were examined with linear mixed model analyses. Results A total of 4,883 patients participated (median age 68 (Interquartile range 53–80); 50% response rate). The mean (Standard Deviation (SD)) pre-injury EQ-5D-3L score was 0.85 (0.23). One week post-trauma, mean (SD) EQ-5D-3L, HUI2 and HUI3 scores were 0.49 (0.32), 0.61 (0.22) and 0.38 (0.31), respectively. These scores significantly improved to 0.77 (0.26), 0.77 (0.21) and 0.62 (0.35), respectively, at 24 months. Most recovery occurred up until 3 months. At long-term follow-up, patients of higher age, with comorbidities, longer hospital stay, lower extremity fracture and spine injury showed lower HS. The mean (SD) scores of the IES, HADSA and HADSD were respectively 14.80 (15.80), 4.92 (3.98) and 5.00 (4.28), respectively, at 1 week post-trauma and slightly improved over 24 months post-trauma to 10.35 (14.72), 4.31 (3.76) and 3.62 (3.87), respectively. Discussion HS and psychological symptoms improved over time and most improvements occurred within 3 months post-trauma. The effects of severity and type of injury faded out over time. Patients frequently reported symptoms of post-traumatic stress. Trial registration ClinicalTrials.gov identifier: NCT02508675

Vuurwerkletsel in Zuidwest-Nederland rond de jaarwisseling 2017-2018

OBJECTIVE: To report the number of patients with firework-related injuries treated in December 2017 and January 2018 in a hospital in the south-west Netherlands trauma region, and to provide details about the types of firework used and the specific injuries. DESIGN: A prospective multicentre cohort study (NTR6793). METHODS: Patients of all ages with firework-related injuries were eligible for inclusion. The injury had to have been sustained between 1 December 2017 and 31 January 2018, and treated at a hospital in the south-west Netherlands trauma region (approximately 2.5 million inhabitants). Data were extracted from patients' medical files and additional information was obtained from patient interviews. RESULTS: Fifty-four patients were included. The majority were male (93%) and the median age was 15 years. Twenty-five (46%) patients were bystanders and 12 (22%) were injured by illegal fireworks. Fifty patients were injured by bangers (n=22) or decorative fireworks (n=28). The patients had a total of 79 injuries, of which 29 (37%) were localised to the upper extremity and 19 (24%) to the eyes. Most upper extremity injuries were burns (69%), primarily partial thickness. Of the eye injuries, 14 were caused by blunt trauma, seven by chemical trauma, and one by penetrating trauma. Three patients sustained indirect firework-related injuries. CONCLUSION: Between 1 December 2017 and 31 January 2018 in the south-west Netherlands trauma region mainly teenage males and bystanders sustained firework-related injuries. Most injuries were upper extremity burns and eye injuries, mainly due to legal fireworks and bangers or decorative fireworks. The extent of the sample indicatDoel Een volledig overzicht geven van het aantal vuurwerkslachtoffers dat in december 2017 en januari 2018 behandeld werd in een ziekenhuis in de traumaregio Zuidwest-Nederland, het gebruikte soort vuurwerk en de specifieke letsels. Opzet Een prospectieve, multicentrische cohortstudie (NTR6793). Methode Patiënten van alle leeftijden met vuurwerkletsel kwamen in aanmerking voor inclusie. Het letsel moest zijn ontstaan in de periode 1 december 2017-31 januari 2018 en zijn behandeld in een ziekenhuis in de traumaregio Zuidwest-Nederland (circa 2,5 miljoen inwoners). Gegevens werden verzameld vanuit het patiëntendossier en aanvullende gegevens werden verkregen tijdens een interview. Resultaten Er werden 54 patiënten geïncludeerd. Het overgrote deel betrof mannen (93%) en de mediane leeftijd was 15 jaar. 25 gewonden (46%) waren omstander en 12 mensen (22%) raakten gewond door illegaal vuurwerk. Van de 54 patiënten raakten er 50 gewond door knalvuurwerk (n = 22) of siervuurwerk (n = 28). De 54 geïncludeerde patiënten hadden 79 letsels; het letsel was 29 keer (37%) gelokaliseerd aan armen of handen en 19 keer (24%) aan de ogen. Letsel aan de arm of hand bestond voornamelijk uit brandwonden (69%), met name tweedegraads. Oogletsel werd 14 keer door stomp inwerkend geweld veroorzaakt, 7 keer door chemisch letsel en 1 keer werd het oog gepenetreerd. Er raakten 3 patiënten indirect gewond door vuurwerk. Conclusie In de traumaregio Zuidwest-Nederland raakten in de 2 maanden rond de jaarwisseling 2017-2018 vooral minderjarige mannen en omstanders gewond. Slachtoffers liepen met name brandwonden aan armen of handen of oogletsel op. De verwondingen waren met name het gevolg van legaal knal- en siervuurwerk. Door de omvang van de steekproef lijken de studiebevindingen goed te extrapoleren naar het gehele land