EDITORIAL
A Multi-institutional Benchmark of Burn Outcomes as a Spur to Further Improvements in Burn Care William G. Cioffi, MD and David T. Harrington, MD
U
sing a data set from the Inflammation and the Host Response to Injury Large-Scale Collaborative Research Program (NIH Glue Grant), Klein et al1 provide a challenging view of the modern treatment of burn injury and propose new paradigms for the care of these patients. The most interesting parts of the article are that the 6 participating centers in their study seem to outperform in terms of improved survivorship the remaining US burn centers that participate in the National Burn Repository and the idea that time to recovery (TTR) of organ dysfunction may be a marker of excellent clinical care for use in future studies. The authors have published a multi-institutional benchmark of burn outcomes. This benchmark is a remarkable accomplishment and will serve to spur further work on the Burn Quality Improvement Project currently underway by the American Burn Association. This rigorous data analysis will allow us to make the next important steps in improving burn care. The methodology of agreed-upon definitions for complications, data abstraction rules, and random sampling to double check accuracy of data are laudable. The 6 participating centers in this study followed 10 standard operating procedures (SOPs) that covered resuscitation strategies, blood glucose control, burn wound management, antibiotic prophylaxis, and others. In comparing their mortality with the National Burn Repository mortality data through a multivariant, stratified logistic regression, they found a 29% survival benefit for their patients. The authors suggest that this improvement in outcome may be secondary to compliance with the SOPs followed by the study centers. These findings are particularly important in the era of protocolized care, and studies such as this show that improved outcomes when such protocols are followed are important. The authors provided data on compliance of only 3 of their SOPs, and it would be helpful if in the future they provided more data on their compliance with all 10 SOPs so that burn care professionals may ferret out which of these is most important in improving outcomes. Finally, although the 6 participating centers should be commended on their adoption of these standards, it is certainly conceivable that some of the other 100 burn centers in the United States have adopted similarly effective or even more effective standards of care. Investigation as to the variance of practices from their 10 SOPs in other burn centers could be fruitful. Because of the rigor and thoroughness of the Glue Grant data, the authors have not just organ injury and dysfunction scores but also the natural history of these injuries. These data allowed them to comment on the TTR of organ dysfunction, which they propose may be a unique and reproducible marker of quality of care. This concept does have its proponents and is in keeping with that of other authors who have begun to explore the concept of “failure to rescue” as a marker of hospital quality. In the concept of failure to rescue, the patient who develops a complication is a patient of interest. It is argued that hospitals that are able to “rescue” these patients and avoid 30-day mortality are better performers than hospitals that do not “rescue” those patients. In TTR, return of organ function to normal after a period of dysfunction suggests that the underlying insult has been removed and the patient is receiving good care and returning to normal homeostasis. This TTR concept looks beyond normal definitions of complications and organ dysfunction and may be a better way to think about medical management across the time continuum. The graphic representation of TTR in their figures is brilliant and has great potential application for research and understanding of patient care. Before the authors go forward with their work on TTR, they should search for a better tool for organ dysfunction in children. The authors note that the children in their study had higher levels of organ injury but lower mortality. This strange paradox may be due to the children’s better physiologic reserve, as they contend, or it may be due to the Denver Organ Dysfunction Score not being an accurate measure of organ dysfunction in children. Because the Denver Organ Dysfunction Score has not been validated
From the Department of Surgery-Division of Trauma/Burns, Rhode Island Hospital, Providence, RI. Disclosure: The author declares no conflicts of interest. Reprints: William G. Cioffi, MD, Department of Surgery-Division of Trauma/Burns, Rhode Island Hospital, 593 Eddy St, APC/120, Providence, RI 02903. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/25905-0842 DOI: 10.1097/SLA.0000000000000664
842 | www.annalsofsurgery.com
Annals of Surgery r Volume 259, Number 5, May 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 259, Number 5, May 2014
in children, the authors could assess TTR in children by using a validated measure such as pediatric logistic organ dysfunction score. Although not perfect, this article serves to promote basic concepts; (1) treatment protocols are beneficial and could result in substantial decrements in morbidity and mortality, (2) investigating the
C 2014 Lippincott Williams & Wilkins
Editorial
TTR after development of organ dysfunction or complications may be a better way to judge overall quality of care.
REFERENCE 1. Klein MB, Goverman J, Hayden DL, et al. Benchmarking outcomes in the critically injured burn patient. Ann Surg. 2014;259:833–841.
www.annalsofsurgery.com | 843
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
A Multi-institutional Benchmark of Burn Outcomes as a Spur to Further Improvements in Burn Care William G. Cioffi, MD and David T. Harrington, MD
U
sing a data set from the Inflammation and the Host Response to Injury Large-Scale Collaborative Research Program (NIH Glue Grant), Klein et al1 provide a challenging view of the modern treatment of burn injury and propose new paradigms for the care of these patients. The most interesting parts of the article are that the 6 participating centers in their study seem to outperform in terms of improved survivorship the remaining US burn centers that participate in the National Burn Repository and the idea that time to recovery (TTR) of organ dysfunction may be a marker of excellent clinical care for use in future studies. The authors have published a multi-institutional benchmark of burn outcomes. This benchmark is a remarkable accomplishment and will serve to spur further work on the Burn Quality Improvement Project currently underway by the American Burn Association. This rigorous data analysis will allow us to make the next important steps in improving burn care. The methodology of agreed-upon definitions for complications, data abstraction rules, and random sampling to double check accuracy of data are laudable. The 6 participating centers in this study followed 10 standard operating procedures (SOPs) that covered resuscitation strategies, blood glucose control, burn wound management, antibiotic prophylaxis, and others. In comparing their mortality with the National Burn Repository mortality data through a multivariant, stratified logistic regression, they found a 29% survival benefit for their patients. The authors suggest that this improvement in outcome may be secondary to compliance with the SOPs followed by the study centers. These findings are particularly important in the era of protocolized care, and studies such as this show that improved outcomes when such protocols are followed are important. The authors provided data on compliance of only 3 of their SOPs, and it would be helpful if in the future they provided more data on their compliance with all 10 SOPs so that burn care professionals may ferret out which of these is most important in improving outcomes. Finally, although the 6 participating centers should be commended on their adoption of these standards, it is certainly conceivable that some of the other 100 burn centers in the United States have adopted similarly effective or even more effective standards of care. Investigation as to the variance of practices from their 10 SOPs in other burn centers could be fruitful. Because of the rigor and thoroughness of the Glue Grant data, the authors have not just organ injury and dysfunction scores but also the natural history of these injuries. These data allowed them to comment on the TTR of organ dysfunction, which they propose may be a unique and reproducible marker of quality of care. This concept does have its proponents and is in keeping with that of other authors who have begun to explore the concept of “failure to rescue” as a marker of hospital quality. In the concept of failure to rescue, the patient who develops a complication is a patient of interest. It is argued that hospitals that are able to “rescue” these patients and avoid 30-day mortality are better performers than hospitals that do not “rescue” those patients. In TTR, return of organ function to normal after a period of dysfunction suggests that the underlying insult has been removed and the patient is receiving good care and returning to normal homeostasis. This TTR concept looks beyond normal definitions of complications and organ dysfunction and may be a better way to think about medical management across the time continuum. The graphic representation of TTR in their figures is brilliant and has great potential application for research and understanding of patient care. Before the authors go forward with their work on TTR, they should search for a better tool for organ dysfunction in children. The authors note that the children in their study had higher levels of organ injury but lower mortality. This strange paradox may be due to the children’s better physiologic reserve, as they contend, or it may be due to the Denver Organ Dysfunction Score not being an accurate measure of organ dysfunction in children. Because the Denver Organ Dysfunction Score has not been validated
From the Department of Surgery-Division of Trauma/Burns, Rhode Island Hospital, Providence, RI. Disclosure: The author declares no conflicts of interest. Reprints: William G. Cioffi, MD, Department of Surgery-Division of Trauma/Burns, Rhode Island Hospital, 593 Eddy St, APC/120, Providence, RI 02903. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/25905-0842 DOI: 10.1097/SLA.0000000000000664
842 | www.annalsofsurgery.com
Annals of Surgery r Volume 259, Number 5, May 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 259, Number 5, May 2014
in children, the authors could assess TTR in children by using a validated measure such as pediatric logistic organ dysfunction score. Although not perfect, this article serves to promote basic concepts; (1) treatment protocols are beneficial and could result in substantial decrements in morbidity and mortality, (2) investigating the
C 2014 Lippincott Williams & Wilkins
Editorial
TTR after development of organ dysfunction or complications may be a better way to judge overall quality of care.
REFERENCE 1. Klein MB, Goverman J, Hayden DL, et al. Benchmarking outcomes in the critically injured burn patient. Ann Surg. 2014;259:833–841.
www.annalsofsurgery.com | 843
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
