Benchmarking outcomes in the critically injured burn patient

Matthew B Klein, Jeremy Goverman, Douglas L Hayden, Shawn P Fagan, Grace P McDonald-Smith, Andrew K Alexander, Richard L Gamelli, Nicole S Gibran, Celeste C Finnerty, Marc G Jeschke, Brett Arnoldo, Bram Wispelwey, Michael N Mindrinos, Wenzhong Xiao, Shari E Honari, Philip H Mason, David A Schoenfeld, David N Herndon, Ronald G Tompkins, Inflammation and Host Response to Injury, and Large-Scale Collaborative Research Program, Lily Altstein, Henry V Baker, Ulysses G J Balis, Paul E Bankey, Timothy R Billiar, Bernard H Brownstein, Steven E Calvano, David G Camp 2nd, J Perren Cobb, Alex G Cuenca, Joseph Cuschieri, Ronald W Davis, Asit K De, Philip A Efron, Brian G Harbrecht, Laura Hennessy, Jeffrey L Johnson, Stephen F Lowry, Ronald V Maier, Bruce A McKinley, Carol L Miller-Graziano, Joseph P Minei, Lyle L Moldawer, Ernest E Moore, Frederick A Moore, Avery B Nathens, Grant E O'Keefe, Laurence G Rahme, Daniel G Remick, Michael B Shapiro, Richard D Smith, Jason Sperry, John D Storey, Robert Tibshirani, Mehmet Toner, H Shaw Warren, Michael A West, Wing H Wong, Yong-Ming Yu, Matthew B Klein, Jeremy Goverman, Douglas L Hayden, Shawn P Fagan, Grace P McDonald-Smith, Andrew K Alexander, Richard L Gamelli, Nicole S Gibran, Celeste C Finnerty, Marc G Jeschke, Brett Arnoldo, Bram Wispelwey, Michael N Mindrinos, Wenzhong Xiao, Shari E Honari, Philip H Mason, David A Schoenfeld, David N Herndon, Ronald G Tompkins, Inflammation and Host Response to Injury, and Large-Scale Collaborative Research Program, Lily Altstein, Henry V Baker, Ulysses G J Balis, Paul E Bankey, Timothy R Billiar, Bernard H Brownstein, Steven E Calvano, David G Camp 2nd, J Perren Cobb, Alex G Cuenca, Joseph Cuschieri, Ronald W Davis, Asit K De, Philip A Efron, Brian G Harbrecht, Laura Hennessy, Jeffrey L Johnson, Stephen F Lowry, Ronald V Maier, Bruce A McKinley, Carol L Miller-Graziano, Joseph P Minei, Lyle L Moldawer, Ernest E Moore, Frederick A Moore, Avery B Nathens, Grant E O'Keefe, Laurence G Rahme, Daniel G Remick, Michael B Shapiro, Richard D Smith, Jason Sperry, John D Storey, Robert Tibshirani, Mehmet Toner, H Shaw Warren, Michael A West, Wing H Wong, Yong-Ming Yu

Abstract

Objective: To determine and compare outcomes with accepted benchmarks in burn care at 6 academic burn centers.

Background: Since the 1960s, US morbidity and mortality rates have declined tremendously for burn patients, likely related to improvements in surgical and critical care treatment. We describe the baseline patient characteristics and well-defined outcomes for major burn injuries.

Methods: We followed 300 adults and 241 children from 2003 to 2009 through hospitalization, using standard operating procedures developed at study onset. We created an extensive database on patient and injury characteristics, anatomic and physiological derangement, clinical treatment, and outcomes. These data were compared with existing benchmarks in burn care.

Results: Study patients were critically injured, as demonstrated by mean % total body surface area (TBSA) (41.2 ± 18.3 for adults and 57.8 ± 18.2 for children) and presence of inhalation injury in 38% of the adults and 54.8% of the children. Mortality in adults was 14.1% for those younger than 55 years and 38.5% for those aged 55 years and older. Mortality in patients younger than 17 years was 7.9%. Overall, the multiple organ failure rate was 27%. When controlling for age and % TBSA, presence of inhalation injury continues to be significant.

Conclusions: This study provides the current benchmark for major burn patients. Mortality rates, notwithstanding significant % TBSA and presence of inhalation injury, have significantly declined compared with previous benchmarks. Modern day surgical and medically intensive management has markedly improved to the point where we can expect patients younger than 55 years with severe burn injuries and inhalation injury to survive these devastating conditions.

Trial registration: ClinicalTrials.gov NCT00257244.

Conflict of interest statement

Conflicts of Interest

For all authors, none were declared.

Figures

Figure 1. Mortality versus age and %…
Figure 1. Mortality versus age and % TBSA
Mortality rates were plotted versus age (panel A) and % TBSA (panel B). The Lethal Dose 50 (LD50) is shown for each.
Figure 1. Mortality versus age and %…
Figure 1. Mortality versus age and % TBSA
Mortality rates were plotted versus age (panel A) and % TBSA (panel B). The Lethal Dose 50 (LD50) is shown for each.
Figure 2. Mortality for Glue Grant study…
Figure 2. Mortality for Glue Grant study patients compared with the NBR
Panel A shows the mortality rate by year for those patients in the Glue Grant study. Comparisons of mortality rates by TBSA quintile and age group (

Figure 2. Mortality for Glue Grant study…

Figure 2. Mortality for Glue Grant study patients compared with the NBR

Panel A shows…

Figure 2. Mortality for Glue Grant study patients compared with the NBR
Panel A shows the mortality rate by year for those patients in the Glue Grant study. Comparisons of mortality rates by TBSA quintile and age group (

Figure 3. Time to Recovery

(A) To…

Figure 3. Time to Recovery

(A) To the left of panel A, the age and…

Figure 3. Time to Recovery
(A) To the left of panel A, the age and burn size were plotted for each of the 541 patients in the Glue Grant study. From top to bottom, the centroid was plotted for age and burn size. To the right of panel B, the Denver organ failure scores were plotted for each time period up to 200 days. The patients can be considered as having no organ failure, in organ failure, or dead. There are four categories shown by Denver organ failure scores: no organ failure – 0 (blue), organ failure – 1–3 (purple), multiple organ failure – ≥4 (red), and dead (black). (B) The Kaplan-Meyer mortality curves and the organ recovery curves over the year post-injury are shown. At each time point, there are four patient possibilities plotted as the proportion of the total population: multiple organ failure (below dashed curve), organ failure (above dashed curve and below dotted curve), fully recovered (above dotted curve and below solid curve), or dead (above solid curve).

Figure 3. Time to Recovery

(A) To…

Figure 3. Time to Recovery

(A) To the left of panel A, the age and…

Figure 3. Time to Recovery
(A) To the left of panel A, the age and burn size were plotted for each of the 541 patients in the Glue Grant study. From top to bottom, the centroid was plotted for age and burn size. To the right of panel B, the Denver organ failure scores were plotted for each time period up to 200 days. The patients can be considered as having no organ failure, in organ failure, or dead. There are four categories shown by Denver organ failure scores: no organ failure – 0 (blue), organ failure – 1–3 (purple), multiple organ failure – ≥4 (red), and dead (black). (B) The Kaplan-Meyer mortality curves and the organ recovery curves over the year post-injury are shown. At each time point, there are four patient possibilities plotted as the proportion of the total population: multiple organ failure (below dashed curve), organ failure (above dashed curve and below dotted curve), fully recovered (above dotted curve and below solid curve), or dead (above solid curve).
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Figure 2. Mortality for Glue Grant study…
Figure 2. Mortality for Glue Grant study patients compared with the NBR
Panel A shows the mortality rate by year for those patients in the Glue Grant study. Comparisons of mortality rates by TBSA quintile and age group (

Figure 3. Time to Recovery

(A) To…

Figure 3. Time to Recovery

(A) To the left of panel A, the age and…

Figure 3. Time to Recovery
(A) To the left of panel A, the age and burn size were plotted for each of the 541 patients in the Glue Grant study. From top to bottom, the centroid was plotted for age and burn size. To the right of panel B, the Denver organ failure scores were plotted for each time period up to 200 days. The patients can be considered as having no organ failure, in organ failure, or dead. There are four categories shown by Denver organ failure scores: no organ failure – 0 (blue), organ failure – 1–3 (purple), multiple organ failure – ≥4 (red), and dead (black). (B) The Kaplan-Meyer mortality curves and the organ recovery curves over the year post-injury are shown. At each time point, there are four patient possibilities plotted as the proportion of the total population: multiple organ failure (below dashed curve), organ failure (above dashed curve and below dotted curve), fully recovered (above dotted curve and below solid curve), or dead (above solid curve).

Figure 3. Time to Recovery

(A) To…

Figure 3. Time to Recovery

(A) To the left of panel A, the age and…

Figure 3. Time to Recovery
(A) To the left of panel A, the age and burn size were plotted for each of the 541 patients in the Glue Grant study. From top to bottom, the centroid was plotted for age and burn size. To the right of panel B, the Denver organ failure scores were plotted for each time period up to 200 days. The patients can be considered as having no organ failure, in organ failure, or dead. There are four categories shown by Denver organ failure scores: no organ failure – 0 (blue), organ failure – 1–3 (purple), multiple organ failure – ≥4 (red), and dead (black). (B) The Kaplan-Meyer mortality curves and the organ recovery curves over the year post-injury are shown. At each time point, there are four patient possibilities plotted as the proportion of the total population: multiple organ failure (below dashed curve), organ failure (above dashed curve and below dotted curve), fully recovered (above dotted curve and below solid curve), or dead (above solid curve).
Figure 3. Time to Recovery
Figure 3. Time to Recovery
(A) To the left of panel A, the age and burn size were plotted for each of the 541 patients in the Glue Grant study. From top to bottom, the centroid was plotted for age and burn size. To the right of panel B, the Denver organ failure scores were plotted for each time period up to 200 days. The patients can be considered as having no organ failure, in organ failure, or dead. There are four categories shown by Denver organ failure scores: no organ failure – 0 (blue), organ failure – 1–3 (purple), multiple organ failure – ≥4 (red), and dead (black). (B) The Kaplan-Meyer mortality curves and the organ recovery curves over the year post-injury are shown. At each time point, there are four patient possibilities plotted as the proportion of the total population: multiple organ failure (below dashed curve), organ failure (above dashed curve and below dotted curve), fully recovered (above dotted curve and below solid curve), or dead (above solid curve).
Figure 3. Time to Recovery
Figure 3. Time to Recovery
(A) To the left of panel A, the age and burn size were plotted for each of the 541 patients in the Glue Grant study. From top to bottom, the centroid was plotted for age and burn size. To the right of panel B, the Denver organ failure scores were plotted for each time period up to 200 days. The patients can be considered as having no organ failure, in organ failure, or dead. There are four categories shown by Denver organ failure scores: no organ failure – 0 (blue), organ failure – 1–3 (purple), multiple organ failure – ≥4 (red), and dead (black). (B) The Kaplan-Meyer mortality curves and the organ recovery curves over the year post-injury are shown. At each time point, there are four patient possibilities plotted as the proportion of the total population: multiple organ failure (below dashed curve), organ failure (above dashed curve and below dotted curve), fully recovered (above dotted curve and below solid curve), or dead (above solid curve).

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