Key points

Patient safety overview

Hippocrates may have recognized the importance of “First, do no harm” circa 400 bc , but the modern patient safety movement began in 1999, with the landmark publication of “To Err is Human” by the Institute of Medicine. In that report, the National Academy of Sciences estimated that 44,000 to 98,000 preventable deaths were due to medical errors each year. Shortly thereafter, in response to public pressure and the clear need to decrease adverse events, the Agency for Healthcare for Research and Quality defined 6 domains of health care quality that have now become the pillars for value creation: patient safety, clinical effectiveness, patient-centered care, providing timely and accessible care, improving efficiency, and correcting disparities by making health care equitable, regardless of geographic location or socioeconomic status. Today, patient safety is recognized as a distinct discipline that emphasizes preventing, reducing, reporting, and analysis of medical errors.

As we move to a value-based health care economy, replacing fee-for-service models that reward volume, quality and cost will be the key drivers that determine the value of services provided. Evidence-based medicine has evolved to not only improve patient outcomes and increase patient safety but also promote standardization of practices to reduce variability in care. Essentially, clinical practice guidelines, or “best practices,” form the backbone of evidence-based medicine, which relies on the best available research to help inform physicians regarding the best treatment plans for patients. Furthermore, patient rights and preferences are brought into medical decision making, creating integrated yet personalized treatment pathways.

In the field of burn care, culture often trumps data, but times are changing. Through national registries, multicenter trials, use of benchmarks, and prevention of such “never events” as pressure ulcers, wrong-site surgery, and catheter-related infections, burn centers are now becoming leaders of the patient safety movement. Without doubt, the pre-existing interdisciplinary team structure of burn care has fostered the development of clinical pathways that provide internal consistency and help establish national standards. This article reviews 5 areas in burn care that increasingly use evidence-based medicine to optimize quality and safety: resuscitation protocols, transfusion practices, vascular access, venous thromboembolic prophylaxis, and rational use of antibiotics.

Patient safety overview

Hippocrates may have recognized the importance of “First, do no harm” circa 400 bc , but the modern patient safety movement began in 1999, with the landmark publication of “To Err is Human” by the Institute of Medicine. In that report, the National Academy of Sciences estimated that 44,000 to 98,000 preventable deaths were due to medical errors each year. Shortly thereafter, in response to public pressure and the clear need to decrease adverse events, the Agency for Healthcare for Research and Quality defined 6 domains of health care quality that have now become the pillars for value creation: patient safety, clinical effectiveness, patient-centered care, providing timely and accessible care, improving efficiency, and correcting disparities by making health care equitable, regardless of geographic location or socioeconomic status. Today, patient safety is recognized as a distinct discipline that emphasizes preventing, reducing, reporting, and analysis of medical errors.

As we move to a value-based health care economy, replacing fee-for-service models that reward volume, quality and cost will be the key drivers that determine the value of services provided. Evidence-based medicine has evolved to not only improve patient outcomes and increase patient safety but also promote standardization of practices to reduce variability in care. Essentially, clinical practice guidelines, or “best practices,” form the backbone of evidence-based medicine, which relies on the best available research to help inform physicians regarding the best treatment plans for patients. Furthermore, patient rights and preferences are brought into medical decision making, creating integrated yet personalized treatment pathways.

In the field of burn care, culture often trumps data, but times are changing. Through national registries, multicenter trials, use of benchmarks, and prevention of such “never events” as pressure ulcers, wrong-site surgery, and catheter-related infections, burn centers are now becoming leaders of the patient safety movement. Without doubt, the pre-existing interdisciplinary team structure of burn care has fostered the development of clinical pathways that provide internal consistency and help establish national standards. This article reviews 5 areas in burn care that increasingly use evidence-based medicine to optimize quality and safety: resuscitation protocols, transfusion practices, vascular access, venous thromboembolic prophylaxis, and rational use of antibiotics.

Resuscitation protocols

A cornerstone aspect of large surface area burn injury is shock, characterized by both cellular edema and marked vascular permeability. Underhill and Cope and Moore provided the first clinical descriptions, with recommended therapeutic resuscitation methods. In 1968, Baxter and Shires described a more precise method of estimating the fluid requirement with experiments on dogs. Baxter confirmed his proposal in 1978 with a case series in human patients. As a consequence, it is now rare that patients suffer the sequelae of underresuscitation, and the concern is that overresuscitation is a more prevalent danger. Pruitt described this in 2000, warning practitioners against “fluid creep,” and Cancio and colleagues demonstrated that clinicians are much more likely to increase fluid rates for low urine output (UOP) than to decrease it for high levels.

The current emphasis is finding ways to limit resuscitation volumes, because the consequences of excessive administered volumes can be both morbid and lethal, for example, abdominal compartment syndrome, extremity compartment syndromes, and organ failure. Chung and colleagues, in a study of combat victims evacuated from the combat theater, concluded that starting with a lower calculation (2 mL/kg per% total body surface area [TBSA] vs 4 mL/kg per %TBSA) would result in lower overall volumes and may improve mortality. Their study was small and may suffer from selection bias, because only patients who survived the first days of injury and reached their center were included. Other methods to decrease resuscitation volumes are the use of colloid, and using alternative methods (than UOP) to guide resuscitation. Cochrane Reviews assert a 2.4 to 2.93 relative risk of death in burn patients resuscitated with colloid in addition to crystalloid. These results have been called into question by burn providers. A recent meta-analysis found instead that use of colloid resulted in fewer gastrointestinal and central nervous system complications and that it may reduce compartment syndrome and mortality. O’Mara and colleagues affirmed that intra-abdominal pressures were significantly lower in a colloid-resuscitated group. Most current protocols advise use of albumin after 12 to 24 hours after burn, as a method to reduce overall volume infused.

With regards to resuscitation endpoints, UOP has long been the primary clinical indicator. Recently, noninvasive cardiac indices, for example, transpulmonary thermodilution, have been suggested as a more effective method, and one that may decrease overall infusion volumes. A recent systematic review of a variety of alternative methods to determine resuscitation endpoints concluded that limited evidence exists that they resulted in improved outcomes.

Unfortunately, current practice is supported only by a panoply of small studies; no large-scale multicenter trial has been performed to determine optimal methods of resuscitation. The most recent consensus guidelines by the American Burn Association recommend starting resuscitation based on formulas of 2 to 4 mL/kg body weight per %TBSA during the first 24 hours, adjusting that rate based on UOP of 0.5 to 1.0 mL/kg/h in adults and 1.0 to 1.5 mL/kg/h in children, and using colloid beginning at 12 to 24 hours after injury. Hypertonic saline is considered high risk, and there is minimal risk and possible benefit to the use of ascorbic acid (high-dose vitamin C). Until large-scale studies improve on this knowledge, these recommendations provide the best practice for resuscitation in the thermally injured patient.

Transfusion practices

Patients with large surface area burns (>20%) nearly always require blood transfusions during their hospital stay, the number of which surpass those required by patients with other conditions. Reasons for this include acute red blood cell (RBC) destruction from thermal and inflammatory insults, suppressed marrow response to erythropoietin, substantial blood loss at each excision and graft procedure, and the repetitive phlebotomy to which all critically ill patients are subjected. There is a relationship of anemia to tissue hypoxemia, and in the burn patient, the “lethal triad” of coagulopathy, acidosis, and hypothermia can happen repetitively throughout the hospital course. It is thought that maintaining adequate hemoglobin (Hgb) will avoid acidosis by replacing the oxygen-carrying capacity of the circulating blood volume. However, in recent decades, it has become clear that blood transfusion is not without its risks, with studies demonstrating increased mortality and infectious complications directly related to the number of transfusions a patient receives. Lu and colleagues, in contrast, showed no mortality or infectious detriment in the burn-injured patient directly related to number of transfusions.

In the context of burn wound excision and grafting, standard efforts made to reduce blood loss include tourniquets on extremities and the subdermal injection of epinephrine-containing tumescent solutions. Although these have decreased blood transfusion requirements, they have not omitted them. Since the TRICC Trial (Transfusion Requirements in Critical Care), there has been a trend toward adopting a lower transfusion “trigger” for RBC transfusion. This multicenter trial compared using a transfusion threshold of Hgb 7 to Hgb 10. Investigators concluded that the lower threshold was at least as effective and possibly superior to the higher one, effectively changing practice. Kwan and colleagues came to similar conclusions in burn patients, demonstrating lower 30-day and in-hospital mortality with a lower threshold. Palmieri and colleagues repeated the study in pediatric burn-injured patients in a single center and confirmed that a restricted transfusion policy was safe in that population.

Having established a lower transfusion threshold of RBC for anemia, the question of coagulopathy in the setting of acute blood loss that accompanies excision and grafting is pertinent. Pidcoke and colleagues compared these procedures to the trauma patient and evaluated the direct effects of providing plasma and platelets on clotting times. Investigators demonstrated that plasma has a negligible effect in improving clot strength, and although platelets improved clot strength, it still remained below the reference range, concluding that blood product resuscitation is not hemostatic and is insufficient to address coagulopathy encountered during burn wound excision. Nonetheless, the PROPR Trial (Transfusion of Plasma, platelets and red blood cells in patients with severe trauma) provided evidence that transfusing blood products in a 1:1:1 ratio provides clinically improved rates of hemostasis at 24 hours. Palmieri and colleagues asked a similar question in burn-injured pediatric patients, comparing a ratio of 4:1 RBC to fresh frozen plasma to 1:1. Although the pilot study was underpowered, there was a trend toward higher hospital LOS, organ dysfunction, infection rates, and time to wound healing in the 4:1 group. The group concluded that this may be due to the detrimental effect of more units of RBC transfused. Cartotto and colleagues examined whether the storage defect of RBC would increase complications and mortality in thermally injured patients. Although they found no association with the age of transfused blood, their study confirmed that the volume of blood transfused was associated directly with more bloodstream infections and trended to lengthening the time to wound healing.

Two authors have pushed the bar further in attempting to avoid the detrimental effects of blood transfusion in thermally injured patients. A very small study by Sittig and Deitch used a transfusion trigger of Hgb less than 6 and found no adverse outcomes. Imai and colleagues proposed autologous blood transfusion. They compared a group with preoperative phlebotomy of 800 mL of blood, and replacement with 500 mL of lactated Ringers and 6 hydroxyethylated starch during excision and graft, replacing the blood after excision and graft harvest. The control group received allogeneic RBC transfusion per their normal protocol. The blood loss was similar in both groups, and no adverse outcomes occurred. They concluded this was safer, more likely to correct coagulopathy, and less expensive.

In conclusion, it is appropriate to recognize the risk associated with blood transfusion and make every effort to limit blood loss and implement restrictive transfusion strategies in the setting of care for the burn patient. Further study is warranted in the setting of the utility of plasma and platelet transfusions during excision and grafting as well as considering an even lower Hgb as a transfusion trigger in the burn-injured patient.

Central venous access

Burn intensive care units (ICUs) have higher rates of central line–associated bloodstream infections (CLABSI) than other ICUs. The National Healthcare Safety Network reported a rate for increased numbers of line infections of 2.8/1000 line-days. CLABSIs are associated with high cost, $11,000-$56,167, which is a reflection of the increased morbidity, length of stay (LOS), and occasionally, mortality, that they cause. For decades, burn surgeons have been aware of this risk, attributing it to several unique aspects of the thermally injured patient: (1) Lines are often placed on or near the burn wound; (2) Frequent transient bacteremia occurs during wound manipulation, that is, dressing changes, excision, and grafting; (3) Burn ICU LOS is prolonged. In light of these unique risk factors, rigorous measures to prevent CLABSIs are essential.

Centers for Disease Control and Prevention guidelines for prevention of CLABSIs are lengthy. A few notable aspects are worth mentioning. These include the use of 2% chlorhexidine gluconate (CHG) baths to reduce infection rate and the use of antibiotic impregnated catheters if the line is expected to remain in place more than 5 days or the rate of CLABSIs is not decreasing after a comprehensive strategy to reduce rates of CLABSI. They advise against the use of routine replacement of catheters to prevent catheter-related infections as well as the routine use of guidewire exchanges for nontunneled catheters to prevent infection. Both of these practices are routine among burn practitioners.

Burn surgeons are undecided on the ideal interval between line changes, but a number of studies have been published in support of intervals of 3 to 7 days, each demonstrating a cost/benefit analysis using binary comparison groups. No multicenter study is available to identify the optimal interval of line change. It is clear that lines left in place more than 8 to 10 days have a markedly increased infection rate, however. Two key studies demonstrate the benefit of chlorhexidine baths for reducing device-related infections. Climo and colleagues did a multicenter randomized, crossover trial over several types of ICU settings that demonstrated a reduction in both multidrug-resistant organism (DRO) infections and hospital-acquired bloodstream infections with 2% CHG impregnated washcloth baths. Popp and colleagues did a similar study in thermally injured patients with 0.9% chlorhexidine baths (236 mL bottle of CHG in 1 L sterile water), and eliminated CLABSI over the intervention period.

Another mode of reducing infection rates is to use antibiotic-impregnated lines. Weber and colleagues demonstrated a 50% reduction in line infection rates after changes to a protocol that used antibiotic (minocycline and rifampin) -impregnated lines. Chlorhexidine and Silvadene–impregnated lines are routinely used in the authors’ center. The primary concern with these lines is that they may increase rates of DRO infections. To date, there are no studies substantiating this concern in the burn population.

There is substantial evidence that using line placement and maintenance bundles and checklists consistently reduces line infection rates. Blot and colleagues demonstrated in a meta-analysis across multiple ICU types that the bundle/checklist was more effective than any other single intervention.

Finally, the role of peripherally inserted central catheters (PICC) is being investigated in the setting of burn injury. A recent review of the Trauma Registry for the American College of Surgeons in burn-injured patients demonstrated an equivalent rate of CLABSI in patients using PICC lines versus central venous catheter (CVC). Notably, the average duration of dwell was 15 days, which is much longer than most burn centers would leave a CVC. A small retrospective review by Barsun and colleagues demonstrated an infection rate of 12.9 per 1000 line-days in PICC lines placed through uninjured skin or healed burns/grafts. They concluded that line maintenance and rotation were warranted for PICC lines in the severely injured burn patient.

In conclusion, effective methods to decrease line infection rates in the thermally injured patient include using bundles/checklists, daily chlorhexidine baths, using antibiotic impregnated lines, and having a line change protocol of between 3 and 7 days. It is unknown what interval is ideal, and to date, there is no evidence that use of PICC lines decreases infection rates.