- Email: [email protected]
Burn care in Los Angeles, California: LAC+USC experience 1994–2004
Burns 31S (2005) S32–S35 www.elsevier.com/locate/burns
Burn care in Los Angeles, California: LAC+USC experience 1994–2004 Warren L. Garnera,b,*, Matthew Reissa a
Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Southern California, Keck School of Medicine, CA, USA b Burn Unit, LAC+USC Medical Center, Los Burn Center, Room 12-700, 1200 N. State Street, Los Angeles, CA 90033, USA
Summary The LAC+USC Burn Center has admitted 3118 patients for treatment in the last 10 years. A majority of patients were young adults (1868), with the second largest group being small children (543). The ethnicity of the patients reflects the diverse nature of the population of Los Angeles County. Forty-eight percent of injuries were less than 5% TBSA and approximately 2% were greater than 60% TBSA. Eighty-two percent were accidental injuries. Sixty percent of admitted patients underwent skin grafting. Mortality was negligible in the group with burns over less than 10% of their body and very high (15/19), 79% in the most severely burned group. Further, there was a high correlation between age and mortality. Complications during treatment included: deep venous thrombosis 1% per year; pulmonary emboli in 5 patients; endotracheal tube dislodgment early or self-extubation about 1 month (11.3 per year); 4.5 patients per year who developed acute renal failure; abdominal compartment syndrome developed in 4.7 patients each year; heterotopic ossification was seen in 4 patients (0.4%); 4 patients (0.4%) developed stage II–IV pressure sores; hypothermia was present in 0.8% of patients. # 2004 Elsevier Ltd and ISBI. All rights reserved. Keywords: TBSA; LAC+USC Burn Center; Health maintenance organization
1. Introduction Los Angeles County is one of the larger urban centers in the United States with a population of just over 9.5 million people (2000, US Census data). It is split almost half and half between men and women 49.4– 50.6%, respectively. The community boasts a diverse population with about 4.6 million Caucasians, 4.2 million Hispanics, 1.1 million Asians, and just under 1 million African Americans. Approximately half of the patients with burn injuries in Los Angeles County, California, USA are treated at the LAC+USC Burn Center. This public hospital is part of the local county governmental health care system. It is one of three Burn centers in Los Angeles County. Torrance Memorial Hospital is a smaller center, and the third is located at Sherman Oaks Hospital, the Grossman Burn Center. These other two are private facilities. The medical care at Los Angeles County hospital (LAC+USC) is provided by physicians and * Corresponding author. Tel.: +1 323 226 7750; fax: +1 323 226 2290. E-mail address: [email protected] (W.L. Garner). 0305-4179/$30.00 # 2004 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2004.10.002
trainees from the University of Southern California. In addition, the Burn Center provides training for all of the General and Plastic Surgery residency programs in Los Angeles County.
2. Database and burn unit physical plant This study was done as a retrospective review of data from several different databases. The burn unit quality assurance database has gone through several revisions, but has consistent data since 2001. We currently use version 3.2 of the National TRACS/ABA Burn registry (National Trauma Registry of the American college of Surgeons and the American Burn Association). This database is very detailed and tracks mechanism of injury, drug use, and so on. In its current form this database describes burn unit patients over the last 36 months. The second database is the hospital information system, Affinity. This system is used for everything from data extraction to checking daily labs. This database covers a much greater time period. It is from this database that 10-year data were extracted.
W.L. Garner, M. Reiss / Burns 31S (2005) S32–S35
All information came from either the hospital database with an n = 3118 admitted patients over a 10-year period (07/01/1994–06/30/2004) or the shorter but more detailed burn unit database covering the last 3 years (01/01/2001–12/ 31/2003) with 951 patients. LA County serves a migrant and often undocumented population. This exacerbates the usual problems with data collection. Not all data points were always available for every patient. Averages were therefore derived based only on the number of patients for whom information was available. The inpatient Burn ward is a self-contained, Californialicensed Burn unit with ICU and regular ward beds, a dedicated operating room and on-site physical and occupational therapy. In addition, the unit has its own emergency visit and triage area. The Burn Service is also connected to and utilizes several outpatient clinics held in an adjacent building.
3. Patients treated During a 10-year time period (1994–2004) 3118 inpatients were treated for acute burn injury. An additional 158 patients were admission for related burn diagnoses including readmissions for infections, scar release or other reconstructive procedures. Of those patients who were admitted, 70% (2361) were men; 30% (1027) were women. The ethnically diverse nature of Los Angeles County is reflected in the ethnicity of the treated patients; 56% (1898) Hispanic, 18% (615) White, 18% (595) Black, 5% (177) Asian, 3% other. The age at admission of patients demonstrated relative increases in two age categories; one in the very young, 0–3 years of age (543), 16% of admissions and in adults, 22–55 (1868), 55% of admissions. Patients of other ages were also represented in the admissions. Children 4–9 of age account for 6% of admissions (204); young adults, 10–21, represent 11% of admissions (364), older adults, 56–70 of age (289) comprised 9% of admissions and the aged, 71 and over, 4% of admissions (120) of admissions (Fig. 1). During this same 10-year period LA+USC County Burn Center also provided 6694 follow up, outpatient visits. That is an average of 2.15 visits per patient. As stated above, our patient population includes a large portion of low income
Fig. 1. Age on admission.
S33
and often migrant and undocumented people (illegal immigrants). In general, these patients do not return at the usual rates for follow-up care. The management of health care within the American system also impacts our follow-up care. Through a contract with a local health maintenance organization (HMO) (Kaiser Permanente), we also provide acute burn care to the HMO members. This population follows up within their own HMO system, by their system’s plastic surgeons. Thus, this 2.15 follow up visits per person underestimates the actual health care utilization, both as the HMO patients may be following up within the HMO, and the rest of our population may not be in the same city, state, or even country to obtain follow up care.
4. Cause of burn Patients presented with burn injuries from a variety of etiologies. Most commonly, burns were considered to be accidental, and not related to work (82%). These included scalds with hot water, irons, explosions with gasoline or other flammable liquids, and others. 8.5% were related to or received while on the job. During this 10-year period, only four cases of arson were identified (0.44%). 6.6% of burns were the result of violent crimes. About half of these were cases of suspected child abuse. There were also a small number of suicide attempts (2%). Looking at data for the last 3 years 2.7% of Burns (n = 28) were directly attributable to drugs or alcohol, although many other patients had positive drug or alcohol lab tests on admission. The majority of these were patients aged 30–40 (64%). One of the more concerning public issues is the rising rate of Metamphetamine use all over the United States. Thirty-nine percent of these alcohol and drug related burns were received from presumed methamphetamine lab explosions. Also of note, these types of burn patients were almost exclusively men (96%), with only one woman in the last 3 years (as of 30 June 2004). Of note, she was the working with one of the men.
5. Severity of injuries 48% of admissions were for burns over 5% or less of the body. The most severe burns, 61% and up TBSA were only seen in 19 admits, 1.9% of patients. We received 331 (32%) patients with burns ranging from 6 to 14% TBSA. Fifteen to thirty percent of TBSA accounted for 12.4% of admissions, and finally 31–60% TBSA was 5.7% of admissions (Fig. 2). As one might expect, the severity of burn corresponds to length of stay. Among the most severely burned patients of course, mortality rises, but among those who do not die, this trend holds true. The average length of stay (LOS) was 7 days for burns of less than 10% TBSA. Those patients with10–19% TBSA burns stayed an average of 12 days, 20– 40% TBSA burns held people in the hospital an average of
S34
W.L. Garner, M. Reiss / Burns 31S (2005) S32–S35
Fig. 2. Admissions by TBSA burned.
24 days. Patients whose burns are 40–79% LOS averaged 37 days. Greater than this mortality rate rises to the point that average length of stay becomes meaningless.
about 1 month (11.3 per year). In addition, in the last 3 years, eight patients who were thought to be ready for extubation required re-intubated within 48 h of extubation (0.8%). There were 4.5 patients per year who developed acute renal failure requiring dialysis over this 10-year period (about 1.4%). Approximately, one third of these patients survived. Abdominal compartment syndrome developed in 4.7 patients each year. Heterotopic ossification was seen in four patients (0.4%). Four patients (0.4%) developed stage II–IV pressure sores. The experienced EMTs who transport patient who our Burn Unit and the nurses and anesthesiologists who treat them in our unit, understand the importance of patient temperature. Hypothermia (less than 35.68 for more than 2 h) was seen rarely, in 0.8% of patients.
8. Survival 6. Operative care Sixty percent (1874) of the patients underwent a surgical procedure, the majority split thickness skin grafts. The extent of the area skin grafted depended on the size of burn (%TBSA), area injured, availability of donor site and the ability of the patients to tolerate more extensive procedures and prolonged anesthesia. Surgical treatment of smaller areas of the body was most common in our center. Fifty-two percent of those patients underwent debridement and split thickness skin grafting of less than 10% of their body. This includes the treatment of smaller burn injuries and partial treatment of larger injuries for the reasons described above. Advances in anesthesia, sub dermal clysis with dilute epinephrine and the use of Integra has increased our ability to debride and graft larger burn areas in a single procedure. Twenty-four percent of our patients underwent treatment of 10–19% TBSA, 15% had treatment of 20–39% TBSA, and 8% had treatment of >40% TBSA. Eighty-three percent of patients underwent split-thickness skin grafting. The remainder of patients were treated with a variety of other procedures including full-thickness grafts, Integra, Transcyte, other skin equivalents or flaps of various kinds.
Overall, mortality of burn injury in Los Angeles County over the last 10 years was 5.5%. Survival for patients with burns less than 20% was 99%. General survival for individuals with 20–40% was 92%. For patients with TBSA 40–79% survival was 61%. Those with greater than 80% burns had a survival was only rate of 33%. Deaths in these burn size groups group were associated with drug (methamphetamine, crack, or heroine) and alcohol abuse, or increased patient age. Methamphetamine lab explosions were causal in 5/44 deaths in the last three years, accounting for 11% of deaths, while these patients included only 1.2% (11/951) of admissions. Mortality these patients was 45%. As has been well documented, mortality was also dependent on age. Note in Fig. 3 illustrating mortality and age the bump in the 30–40-year-old age group. Three of the ten deaths plotted were attributable to methamphetamine. Eliminating them would give a mortality rate of 3.8% smoothing out the curve, almost erasing the small spike in this age group. Mortality in the youngest group 0–10 is 0.9%, while in the oldest age groups we see a much higher death rate, patients aged 71–80 had a mortality of 20%, and those aged more than 81 years of aged had a 27% mortality rate. Severity of burn also clearly correlates with mortality. Mortality in the most severely burned group (those greater than 60% TBSA) was very high (15/19), 79%. In contrast, no
7. Complications Complications occur during the treatment of any group of patients. While our patients generally did well, complications did occur. Deep venous thrombosis was seen in approximately 1% (3.3) of patients per year. Confirmed pulmonary emboli were seen in five patients (0.5%). While low, these numbers are significant. We now give prophylaxis to adult, immobile patients for these problems with low molecular weight heparin. Maintaining the airway in a stable and secure manner was a consistent problem. Significant problems with endotracheal tube dislodgment early or selfextubation were distressingly frequent, with an incidence of
Fig. 3. Age and mortality.
W.L. Garner, M. Reiss / Burns 31S (2005) S32–S35
S35
patient rehabilitation they are transferred to a dedicated Rehabilitation facility Rancho Los Amigos. This Internationally-renowned center specializes in the rehabilitation of patients with numerous conditions, including burn injury. During the last 10 years, 1.8% of our patients have been transferred there for rehabilitation. 9.7% of patients were discharged with ongoing medical needs. These patients were either sent to other acute hospital facilities or mid level care facilities (SNFs, convalescence centers and nursing homes). A small number of patients left the facility against medical advice prior to completing treatment, and of course a certain number died (5.5%). Fig. 4. Percentage burn and mortality.
deaths were seen in the group with burns over less than 5% of their body (Fig. 4).
9. Discharge The majority of patients were discharged to their own home or shelter (80.2%). When patients need prolonged in-
10. Conclusions We conclude that most burn injuries can be successfully treated in an ethnically diverse and resource-poor government funded Burn Center. These outcomes are the result of the hard work of the nurses, therapists, operating room team and physicians dedicated to the care of these patients.
Burn care in Los Angeles, California: LAC+USC experience 1994–2004 Warren L. Garnera,b,*, Matthew Reissa a
Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Southern California, Keck School of Medicine, CA, USA b Burn Unit, LAC+USC Medical Center, Los Burn Center, Room 12-700, 1200 N. State Street, Los Angeles, CA 90033, USA
Summary The LAC+USC Burn Center has admitted 3118 patients for treatment in the last 10 years. A majority of patients were young adults (1868), with the second largest group being small children (543). The ethnicity of the patients reflects the diverse nature of the population of Los Angeles County. Forty-eight percent of injuries were less than 5% TBSA and approximately 2% were greater than 60% TBSA. Eighty-two percent were accidental injuries. Sixty percent of admitted patients underwent skin grafting. Mortality was negligible in the group with burns over less than 10% of their body and very high (15/19), 79% in the most severely burned group. Further, there was a high correlation between age and mortality. Complications during treatment included: deep venous thrombosis 1% per year; pulmonary emboli in 5 patients; endotracheal tube dislodgment early or self-extubation about 1 month (11.3 per year); 4.5 patients per year who developed acute renal failure; abdominal compartment syndrome developed in 4.7 patients each year; heterotopic ossification was seen in 4 patients (0.4%); 4 patients (0.4%) developed stage II–IV pressure sores; hypothermia was present in 0.8% of patients. # 2004 Elsevier Ltd and ISBI. All rights reserved. Keywords: TBSA; LAC+USC Burn Center; Health maintenance organization
1. Introduction Los Angeles County is one of the larger urban centers in the United States with a population of just over 9.5 million people (2000, US Census data). It is split almost half and half between men and women 49.4– 50.6%, respectively. The community boasts a diverse population with about 4.6 million Caucasians, 4.2 million Hispanics, 1.1 million Asians, and just under 1 million African Americans. Approximately half of the patients with burn injuries in Los Angeles County, California, USA are treated at the LAC+USC Burn Center. This public hospital is part of the local county governmental health care system. It is one of three Burn centers in Los Angeles County. Torrance Memorial Hospital is a smaller center, and the third is located at Sherman Oaks Hospital, the Grossman Burn Center. These other two are private facilities. The medical care at Los Angeles County hospital (LAC+USC) is provided by physicians and * Corresponding author. Tel.: +1 323 226 7750; fax: +1 323 226 2290. E-mail address: [email protected] (W.L. Garner). 0305-4179/$30.00 # 2004 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2004.10.002
trainees from the University of Southern California. In addition, the Burn Center provides training for all of the General and Plastic Surgery residency programs in Los Angeles County.
2. Database and burn unit physical plant This study was done as a retrospective review of data from several different databases. The burn unit quality assurance database has gone through several revisions, but has consistent data since 2001. We currently use version 3.2 of the National TRACS/ABA Burn registry (National Trauma Registry of the American college of Surgeons and the American Burn Association). This database is very detailed and tracks mechanism of injury, drug use, and so on. In its current form this database describes burn unit patients over the last 36 months. The second database is the hospital information system, Affinity. This system is used for everything from data extraction to checking daily labs. This database covers a much greater time period. It is from this database that 10-year data were extracted.
W.L. Garner, M. Reiss / Burns 31S (2005) S32–S35
All information came from either the hospital database with an n = 3118 admitted patients over a 10-year period (07/01/1994–06/30/2004) or the shorter but more detailed burn unit database covering the last 3 years (01/01/2001–12/ 31/2003) with 951 patients. LA County serves a migrant and often undocumented population. This exacerbates the usual problems with data collection. Not all data points were always available for every patient. Averages were therefore derived based only on the number of patients for whom information was available. The inpatient Burn ward is a self-contained, Californialicensed Burn unit with ICU and regular ward beds, a dedicated operating room and on-site physical and occupational therapy. In addition, the unit has its own emergency visit and triage area. The Burn Service is also connected to and utilizes several outpatient clinics held in an adjacent building.
3. Patients treated During a 10-year time period (1994–2004) 3118 inpatients were treated for acute burn injury. An additional 158 patients were admission for related burn diagnoses including readmissions for infections, scar release or other reconstructive procedures. Of those patients who were admitted, 70% (2361) were men; 30% (1027) were women. The ethnically diverse nature of Los Angeles County is reflected in the ethnicity of the treated patients; 56% (1898) Hispanic, 18% (615) White, 18% (595) Black, 5% (177) Asian, 3% other. The age at admission of patients demonstrated relative increases in two age categories; one in the very young, 0–3 years of age (543), 16% of admissions and in adults, 22–55 (1868), 55% of admissions. Patients of other ages were also represented in the admissions. Children 4–9 of age account for 6% of admissions (204); young adults, 10–21, represent 11% of admissions (364), older adults, 56–70 of age (289) comprised 9% of admissions and the aged, 71 and over, 4% of admissions (120) of admissions (Fig. 1). During this same 10-year period LA+USC County Burn Center also provided 6694 follow up, outpatient visits. That is an average of 2.15 visits per patient. As stated above, our patient population includes a large portion of low income
Fig. 1. Age on admission.
S33
and often migrant and undocumented people (illegal immigrants). In general, these patients do not return at the usual rates for follow-up care. The management of health care within the American system also impacts our follow-up care. Through a contract with a local health maintenance organization (HMO) (Kaiser Permanente), we also provide acute burn care to the HMO members. This population follows up within their own HMO system, by their system’s plastic surgeons. Thus, this 2.15 follow up visits per person underestimates the actual health care utilization, both as the HMO patients may be following up within the HMO, and the rest of our population may not be in the same city, state, or even country to obtain follow up care.
4. Cause of burn Patients presented with burn injuries from a variety of etiologies. Most commonly, burns were considered to be accidental, and not related to work (82%). These included scalds with hot water, irons, explosions with gasoline or other flammable liquids, and others. 8.5% were related to or received while on the job. During this 10-year period, only four cases of arson were identified (0.44%). 6.6% of burns were the result of violent crimes. About half of these were cases of suspected child abuse. There were also a small number of suicide attempts (2%). Looking at data for the last 3 years 2.7% of Burns (n = 28) were directly attributable to drugs or alcohol, although many other patients had positive drug or alcohol lab tests on admission. The majority of these were patients aged 30–40 (64%). One of the more concerning public issues is the rising rate of Metamphetamine use all over the United States. Thirty-nine percent of these alcohol and drug related burns were received from presumed methamphetamine lab explosions. Also of note, these types of burn patients were almost exclusively men (96%), with only one woman in the last 3 years (as of 30 June 2004). Of note, she was the working with one of the men.
5. Severity of injuries 48% of admissions were for burns over 5% or less of the body. The most severe burns, 61% and up TBSA were only seen in 19 admits, 1.9% of patients. We received 331 (32%) patients with burns ranging from 6 to 14% TBSA. Fifteen to thirty percent of TBSA accounted for 12.4% of admissions, and finally 31–60% TBSA was 5.7% of admissions (Fig. 2). As one might expect, the severity of burn corresponds to length of stay. Among the most severely burned patients of course, mortality rises, but among those who do not die, this trend holds true. The average length of stay (LOS) was 7 days for burns of less than 10% TBSA. Those patients with10–19% TBSA burns stayed an average of 12 days, 20– 40% TBSA burns held people in the hospital an average of
S34
W.L. Garner, M. Reiss / Burns 31S (2005) S32–S35
Fig. 2. Admissions by TBSA burned.
24 days. Patients whose burns are 40–79% LOS averaged 37 days. Greater than this mortality rate rises to the point that average length of stay becomes meaningless.
about 1 month (11.3 per year). In addition, in the last 3 years, eight patients who were thought to be ready for extubation required re-intubated within 48 h of extubation (0.8%). There were 4.5 patients per year who developed acute renal failure requiring dialysis over this 10-year period (about 1.4%). Approximately, one third of these patients survived. Abdominal compartment syndrome developed in 4.7 patients each year. Heterotopic ossification was seen in four patients (0.4%). Four patients (0.4%) developed stage II–IV pressure sores. The experienced EMTs who transport patient who our Burn Unit and the nurses and anesthesiologists who treat them in our unit, understand the importance of patient temperature. Hypothermia (less than 35.68 for more than 2 h) was seen rarely, in 0.8% of patients.
8. Survival 6. Operative care Sixty percent (1874) of the patients underwent a surgical procedure, the majority split thickness skin grafts. The extent of the area skin grafted depended on the size of burn (%TBSA), area injured, availability of donor site and the ability of the patients to tolerate more extensive procedures and prolonged anesthesia. Surgical treatment of smaller areas of the body was most common in our center. Fifty-two percent of those patients underwent debridement and split thickness skin grafting of less than 10% of their body. This includes the treatment of smaller burn injuries and partial treatment of larger injuries for the reasons described above. Advances in anesthesia, sub dermal clysis with dilute epinephrine and the use of Integra has increased our ability to debride and graft larger burn areas in a single procedure. Twenty-four percent of our patients underwent treatment of 10–19% TBSA, 15% had treatment of 20–39% TBSA, and 8% had treatment of >40% TBSA. Eighty-three percent of patients underwent split-thickness skin grafting. The remainder of patients were treated with a variety of other procedures including full-thickness grafts, Integra, Transcyte, other skin equivalents or flaps of various kinds.
Overall, mortality of burn injury in Los Angeles County over the last 10 years was 5.5%. Survival for patients with burns less than 20% was 99%. General survival for individuals with 20–40% was 92%. For patients with TBSA 40–79% survival was 61%. Those with greater than 80% burns had a survival was only rate of 33%. Deaths in these burn size groups group were associated with drug (methamphetamine, crack, or heroine) and alcohol abuse, or increased patient age. Methamphetamine lab explosions were causal in 5/44 deaths in the last three years, accounting for 11% of deaths, while these patients included only 1.2% (11/951) of admissions. Mortality these patients was 45%. As has been well documented, mortality was also dependent on age. Note in Fig. 3 illustrating mortality and age the bump in the 30–40-year-old age group. Three of the ten deaths plotted were attributable to methamphetamine. Eliminating them would give a mortality rate of 3.8% smoothing out the curve, almost erasing the small spike in this age group. Mortality in the youngest group 0–10 is 0.9%, while in the oldest age groups we see a much higher death rate, patients aged 71–80 had a mortality of 20%, and those aged more than 81 years of aged had a 27% mortality rate. Severity of burn also clearly correlates with mortality. Mortality in the most severely burned group (those greater than 60% TBSA) was very high (15/19), 79%. In contrast, no
7. Complications Complications occur during the treatment of any group of patients. While our patients generally did well, complications did occur. Deep venous thrombosis was seen in approximately 1% (3.3) of patients per year. Confirmed pulmonary emboli were seen in five patients (0.5%). While low, these numbers are significant. We now give prophylaxis to adult, immobile patients for these problems with low molecular weight heparin. Maintaining the airway in a stable and secure manner was a consistent problem. Significant problems with endotracheal tube dislodgment early or selfextubation were distressingly frequent, with an incidence of
Fig. 3. Age and mortality.
W.L. Garner, M. Reiss / Burns 31S (2005) S32–S35
S35
patient rehabilitation they are transferred to a dedicated Rehabilitation facility Rancho Los Amigos. This Internationally-renowned center specializes in the rehabilitation of patients with numerous conditions, including burn injury. During the last 10 years, 1.8% of our patients have been transferred there for rehabilitation. 9.7% of patients were discharged with ongoing medical needs. These patients were either sent to other acute hospital facilities or mid level care facilities (SNFs, convalescence centers and nursing homes). A small number of patients left the facility against medical advice prior to completing treatment, and of course a certain number died (5.5%). Fig. 4. Percentage burn and mortality.
deaths were seen in the group with burns over less than 5% of their body (Fig. 4).
9. Discharge The majority of patients were discharged to their own home or shelter (80.2%). When patients need prolonged in-
10. Conclusions We conclude that most burn injuries can be successfully treated in an ethnically diverse and resource-poor government funded Burn Center. These outcomes are the result of the hard work of the nurses, therapists, operating room team and physicians dedicated to the care of these patients.