Can We Really Predict Morbidity and Mortality in Burn Patients?* David G. Greenhalgh, MD, FACS Shriners Hospitals for Children Northern California; Firefighters Regional Burn Center; and Department of Surgery University of California, Davis Sacramento, CA
I
n this issue of Critical Care Medicine, Jeschke et al (1) from the Inflammation and the Host Response to Injury Glue Grant have reexamined their data and have concluded that there is a “cutoff ” burn size for mortality, sepsis, infection, and multiple organ failure of approximately 60% total body surface area (TBSA) burn for children (< 16 yr) and 40% TBSA for adults from 16 to 65 years. They conclude that burns larger than these designated sizes are high risk for morbidity and mortality, even in highly specialized centers. I commend the authors for gleaming data from the extensive work of the “Glue Grant.” The ultimate goal of the project was to prospectively collect data from five large burn hospitals and link these data to gene expression and protein production. The goal of linking molecular and cellular signaling to clinical outcome is an excellent and important one. This article, however, simply collects clinical data with the goal to predict a “cutoff ” for a marked increase in mortality (as the primary goal) and infection, sepsis, and multiple organ failure as a secondary goal. Although this goal is laudable, there are several issues that must be considered prior to making any conclusions about their study. The first question that one must ask is what does this cutoff burn size mean? Does it mean that one does not need to worry about smaller burns in that age group? Or is it just statistical analysis that indicates that the complication rate may go up significantly at a designated burn size? Clearly, children with burns of less than 60% TBSA get very sick and die, and the same is true for adults with less than 40% TBSA burns. As a matter of fact, it is the child with a relatively small burn who often surprises less experienced physicians with severe infections or sepsis. One would hate to have physicians outside of burn centers “feel comfortable” with children or adults with relatively small burns and miss a potentially life-threatening septic episode. One must agree, however, that the larger the burn, the harder it is to avoid sepsis and mortality, but one should monitor all large burns closely. The second question to be asked is—does a burn size change how you might treat a patient? Would one treat a 45% burn *See also p. 808. Key Words: burns; morbidity; outcomes; survival The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000842
918
www.ccmjournal.org
differently than a 70% burn? One must still aggressively excise and cover the wound, monitor for infection, and be aggressive with nutritional support. Although the treatment might be a little easier in a smaller burn, the treatment is still the same. The third concern is the surprisingly low number of patients enrolled in the study. In five centers, there were only 573 patients enrolled or 72 patients per year. There were only 226 pediatric and 324 adult patients. These limited numbers of patients make using the data less reliable compared to the current national databases such as the National Burn Registry of the American Burn Association (2, 3). The same Galveston group was able to collect data from almost twice the number of pediatric burn patients (4) and found the same result (which is not surprising since most of the patients in this study were from the same population). Most disappointing is the surprisingly low number of elderly patients (> 65 yr). They were only able to obtain consent from 23 elderly patients. As the elderly population is increasing, finding some type of predictor for mortality might be helpful. It is not clear why so few elderly were entered. Finally, the most important problem with this study, and all attempts to predict mortality, is selection bias. All of the patients included in this study had to be greater than 20% TBSA, be admitted in less than 4 days, and require some form of surgical intervention. Since, in the United States, the vast majority of burns admitted to hospitals are less than 10% TBSA and probably 85% are less than 20% TBSA. Eliminating these patients from any analysis must influence the results. Considering that the combined burn centers involved in the Glue Grant probably admit well over 1,000 patients per year, the low number included in the study is very disappointing. It would be helpful to know how many eligible patients failed to consent to the study. It must always be considered that any survival study of burns admitted to a burn center has bias since the patients must survive to make it to the tertiary referral area. Many people die before making it to a burn center. Expanding the inclusion to 4 days makes that bias more pronounced. The authors admit that Galveston patients dominate the pediatric data, which creates another obvious bias. Galveston admits predominantly children with extensive burns from Mexico. The children have to survive to make it to their facility and when they do, their outcomes are superb. Should that data be used for prediction of all pediatric burns in the United States when very few of the U.S. population are represented? It seems that it should not. Again, I commend the authors for being involved in a very important study, and this article provides statistically significant results, but the clinical relevance is not clear. Burn surgeons will treat patients with all burn sizes with the same degree of alacrity.
REFERENCES
1. Jeschke MG, Pinto R, Kraft R, et al; the Inflammation and the Host Response to Injury Collaborative Research Program: Morbidity and April 2015 • Volume 43 • Number 4
Editorials Survival Probability in Burn Patients in Modern Burn Care. Crit Care Med 2015; 43:808–815 2. Taylor S, Jeng J, Saffle JR, et al: Redefining the outcomes to resources ratio for burn patient triage in a mass casualty. J Burn Care Res 2014; 35:41–45
3. Taylor SL, Lawless M, Curri T, et al: Predicting mortality from burns: The need for age-group specific models. Burns 2014; 40:1106–1115 4. Kraft R, Herndon DN, Al-Mousawi AM, et al: Burn size and survival probability in paediatric patients in modern burn care: A prospective observational cohort study. Lancet 2012; 379:1013–1021
I’m Okay, You’re Not Okay: Moral Distress in Health Care as an Issue of Affective Perspective Taking and In-Group/Out-Group Tensions* Sandrijn van Schaik, MD, PhD Division of Pediatric Critical Care Medicine Department of Pediatrics University of California San Francisco San Francisco, CA
T
he moral distress construct encompasses a cognitiveemotional dissonance that occurs if a person’s own moral compass points in a different direction than what that person is required to do based on external forces. Moral distress is particularly prevalent in people who have limited authority over their actions, and in health care has therefore been mostly recognized among nurses and trainees (1–3). In this issue of Critical Care Medicine, Bruce et al (4) examine moral distress in the ICU and in particular explore how professionals in the ICU experience and respond to moral distress in the context of the team. They found that discordance between stakeholders was the most prominent source of moral distress, and not infrequently, this discordance occurred between different professionals (nurses vs physicians) or different disciplines (surgery vs ICU). Viewed through this lens, the moral distress issues described in the study essentially come down to issues of conflict between individuals and groups with different perspectives. That conflict occurs around ethical dilemmas is neither new nor surprising, but viewing such conflicts as cause of moral distress provides a different lens that offers potential paths to solving the conflict. In essence, by stating one experiences moral distress due to discordance in moral perspectives, one says “I am okay, but you’re not okay” and the distress is due to the fact that the “not okay” person dictates the actions of the “okay” person. If we want to mitigate moral distress, we may need to start by questioning the validity of this statement: how do we know who is okay and who is not? In other words, how does the person who suffers moral distress knows the *See also p. 823. Key Words: conflict; interprofessional teamwork; moral distress; perspective taking; social identity The author has disclosed that she does not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000857
Critical Care Medicine
“correct” moral answer to the dilemma at hand? Questioning this premise by careful exploration of how one knows one’s own stance to be correct and the opposing stance to be incorrect could potentially be an initial step toward resolution of the conflict. Affective perspective taking may be a useful strategy to better understand the other person’s (or group’s) stance. Affective perspective taking has been proposed as a term to replace the catch-all term empathy because it more specifically describes the process of adopting someone else’s perspective (5). It has been shown to lead to a decrease of stereotyping and negative attitudes toward other groups, both prevalent in health care. Such intergroup tensions can be explained by two related theories, social identity theory and self-categorization theory, which state that people self categorize to a group (the “in-group”), which they afford more favorable judgments than the “out-group” (6). In the current study, a lot of findings point toward in-group versus out-group tensions, with varying categorizations of who belongs to the in-group and the out-group. There is a particularly strong in-group versus out-group bias if it comes to surgeons, who in several examples as a group are put in a negative light. The study does not explore how the surgeons react to such perceptions, nor does it examine study participants’ explanations for the surgeon’s behavior with an affective perspective taking approach. This could have been accomplished if the authors would have performed an extra step of member-checking (7) and asked the study participants to react to the qualitative data extraction. Apart from adding validity to the data, this would have allowed for a deeper exploration of the issues underlying the intergroup/intrateam conflicts observed in the study. It should be noted that the intergroup/intrateam conflicts observed by Bruce et al (4) may have been aggravated by a lack of actual teamwork. Despite the surface appearance of team-based care, healthcare teams often do not engage in collaborative work. Teamwork in health care should involve individuals working interdependently to actively coordinate patient care, but often teams do not spend time together and have a culture that does not allow for all team members to have an equal voice (8). The team debriefing sessions suggested as a strategy to resolve intrateam discordance could potentially address some of these issues, as long as they are inclusive of all the stakeholders on the team and clear ground rules are established. The “constructive” www.ccmjournal.org
919
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
I
n this issue of Critical Care Medicine, Jeschke et al (1) from the Inflammation and the Host Response to Injury Glue Grant have reexamined their data and have concluded that there is a “cutoff ” burn size for mortality, sepsis, infection, and multiple organ failure of approximately 60% total body surface area (TBSA) burn for children (< 16 yr) and 40% TBSA for adults from 16 to 65 years. They conclude that burns larger than these designated sizes are high risk for morbidity and mortality, even in highly specialized centers. I commend the authors for gleaming data from the extensive work of the “Glue Grant.” The ultimate goal of the project was to prospectively collect data from five large burn hospitals and link these data to gene expression and protein production. The goal of linking molecular and cellular signaling to clinical outcome is an excellent and important one. This article, however, simply collects clinical data with the goal to predict a “cutoff ” for a marked increase in mortality (as the primary goal) and infection, sepsis, and multiple organ failure as a secondary goal. Although this goal is laudable, there are several issues that must be considered prior to making any conclusions about their study. The first question that one must ask is what does this cutoff burn size mean? Does it mean that one does not need to worry about smaller burns in that age group? Or is it just statistical analysis that indicates that the complication rate may go up significantly at a designated burn size? Clearly, children with burns of less than 60% TBSA get very sick and die, and the same is true for adults with less than 40% TBSA burns. As a matter of fact, it is the child with a relatively small burn who often surprises less experienced physicians with severe infections or sepsis. One would hate to have physicians outside of burn centers “feel comfortable” with children or adults with relatively small burns and miss a potentially life-threatening septic episode. One must agree, however, that the larger the burn, the harder it is to avoid sepsis and mortality, but one should monitor all large burns closely. The second question to be asked is—does a burn size change how you might treat a patient? Would one treat a 45% burn *See also p. 808. Key Words: burns; morbidity; outcomes; survival The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000842
918
www.ccmjournal.org
differently than a 70% burn? One must still aggressively excise and cover the wound, monitor for infection, and be aggressive with nutritional support. Although the treatment might be a little easier in a smaller burn, the treatment is still the same. The third concern is the surprisingly low number of patients enrolled in the study. In five centers, there were only 573 patients enrolled or 72 patients per year. There were only 226 pediatric and 324 adult patients. These limited numbers of patients make using the data less reliable compared to the current national databases such as the National Burn Registry of the American Burn Association (2, 3). The same Galveston group was able to collect data from almost twice the number of pediatric burn patients (4) and found the same result (which is not surprising since most of the patients in this study were from the same population). Most disappointing is the surprisingly low number of elderly patients (> 65 yr). They were only able to obtain consent from 23 elderly patients. As the elderly population is increasing, finding some type of predictor for mortality might be helpful. It is not clear why so few elderly were entered. Finally, the most important problem with this study, and all attempts to predict mortality, is selection bias. All of the patients included in this study had to be greater than 20% TBSA, be admitted in less than 4 days, and require some form of surgical intervention. Since, in the United States, the vast majority of burns admitted to hospitals are less than 10% TBSA and probably 85% are less than 20% TBSA. Eliminating these patients from any analysis must influence the results. Considering that the combined burn centers involved in the Glue Grant probably admit well over 1,000 patients per year, the low number included in the study is very disappointing. It would be helpful to know how many eligible patients failed to consent to the study. It must always be considered that any survival study of burns admitted to a burn center has bias since the patients must survive to make it to the tertiary referral area. Many people die before making it to a burn center. Expanding the inclusion to 4 days makes that bias more pronounced. The authors admit that Galveston patients dominate the pediatric data, which creates another obvious bias. Galveston admits predominantly children with extensive burns from Mexico. The children have to survive to make it to their facility and when they do, their outcomes are superb. Should that data be used for prediction of all pediatric burns in the United States when very few of the U.S. population are represented? It seems that it should not. Again, I commend the authors for being involved in a very important study, and this article provides statistically significant results, but the clinical relevance is not clear. Burn surgeons will treat patients with all burn sizes with the same degree of alacrity.
REFERENCES
1. Jeschke MG, Pinto R, Kraft R, et al; the Inflammation and the Host Response to Injury Collaborative Research Program: Morbidity and April 2015 • Volume 43 • Number 4
Editorials Survival Probability in Burn Patients in Modern Burn Care. Crit Care Med 2015; 43:808–815 2. Taylor S, Jeng J, Saffle JR, et al: Redefining the outcomes to resources ratio for burn patient triage in a mass casualty. J Burn Care Res 2014; 35:41–45
3. Taylor SL, Lawless M, Curri T, et al: Predicting mortality from burns: The need for age-group specific models. Burns 2014; 40:1106–1115 4. Kraft R, Herndon DN, Al-Mousawi AM, et al: Burn size and survival probability in paediatric patients in modern burn care: A prospective observational cohort study. Lancet 2012; 379:1013–1021
I’m Okay, You’re Not Okay: Moral Distress in Health Care as an Issue of Affective Perspective Taking and In-Group/Out-Group Tensions* Sandrijn van Schaik, MD, PhD Division of Pediatric Critical Care Medicine Department of Pediatrics University of California San Francisco San Francisco, CA
T
he moral distress construct encompasses a cognitiveemotional dissonance that occurs if a person’s own moral compass points in a different direction than what that person is required to do based on external forces. Moral distress is particularly prevalent in people who have limited authority over their actions, and in health care has therefore been mostly recognized among nurses and trainees (1–3). In this issue of Critical Care Medicine, Bruce et al (4) examine moral distress in the ICU and in particular explore how professionals in the ICU experience and respond to moral distress in the context of the team. They found that discordance between stakeholders was the most prominent source of moral distress, and not infrequently, this discordance occurred between different professionals (nurses vs physicians) or different disciplines (surgery vs ICU). Viewed through this lens, the moral distress issues described in the study essentially come down to issues of conflict between individuals and groups with different perspectives. That conflict occurs around ethical dilemmas is neither new nor surprising, but viewing such conflicts as cause of moral distress provides a different lens that offers potential paths to solving the conflict. In essence, by stating one experiences moral distress due to discordance in moral perspectives, one says “I am okay, but you’re not okay” and the distress is due to the fact that the “not okay” person dictates the actions of the “okay” person. If we want to mitigate moral distress, we may need to start by questioning the validity of this statement: how do we know who is okay and who is not? In other words, how does the person who suffers moral distress knows the *See also p. 823. Key Words: conflict; interprofessional teamwork; moral distress; perspective taking; social identity The author has disclosed that she does not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000857
Critical Care Medicine
“correct” moral answer to the dilemma at hand? Questioning this premise by careful exploration of how one knows one’s own stance to be correct and the opposing stance to be incorrect could potentially be an initial step toward resolution of the conflict. Affective perspective taking may be a useful strategy to better understand the other person’s (or group’s) stance. Affective perspective taking has been proposed as a term to replace the catch-all term empathy because it more specifically describes the process of adopting someone else’s perspective (5). It has been shown to lead to a decrease of stereotyping and negative attitudes toward other groups, both prevalent in health care. Such intergroup tensions can be explained by two related theories, social identity theory and self-categorization theory, which state that people self categorize to a group (the “in-group”), which they afford more favorable judgments than the “out-group” (6). In the current study, a lot of findings point toward in-group versus out-group tensions, with varying categorizations of who belongs to the in-group and the out-group. There is a particularly strong in-group versus out-group bias if it comes to surgeons, who in several examples as a group are put in a negative light. The study does not explore how the surgeons react to such perceptions, nor does it examine study participants’ explanations for the surgeon’s behavior with an affective perspective taking approach. This could have been accomplished if the authors would have performed an extra step of member-checking (7) and asked the study participants to react to the qualitative data extraction. Apart from adding validity to the data, this would have allowed for a deeper exploration of the issues underlying the intergroup/intrateam conflicts observed in the study. It should be noted that the intergroup/intrateam conflicts observed by Bruce et al (4) may have been aggravated by a lack of actual teamwork. Despite the surface appearance of team-based care, healthcare teams often do not engage in collaborative work. Teamwork in health care should involve individuals working interdependently to actively coordinate patient care, but often teams do not spend time together and have a culture that does not allow for all team members to have an equal voice (8). The team debriefing sessions suggested as a strategy to resolve intrateam discordance could potentially address some of these issues, as long as they are inclusive of all the stakeholders on the team and clear ground rules are established. The “constructive” www.ccmjournal.org
919
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
