|Year : 2014 | Volume
| Issue : 2 | Page : 6-9
Impact of burn unit routine on outcome: A 5-year experience
Zainab Yunusa Kaltungo1, Olabisi Shakir Olajide1, Adamu Danladi Bojude2
1 Department of Surgery, Federal Teaching Hospital, Gombe, Nigeria
2 Department of Radiation Oncology (Medical Research), Federal Teaching Hospital, Gombe, Nigeria
|Date of Web Publication||15-Apr-2015|
Zainab Yunusa Kaltungo
Department of Surgery, Federal Teaching Hospital, Gombe
Source of Support: None, Conflict of Interest: None
Background: The burn unit, like any high dependency, unit is awash with multi-antibiotic resistant microbes, and the clinician is in a constant battle to prevent such infections from becoming established. After the elimination of hypovolemic shock as a cause of death, infections constitute the leading cause of morbidity and mortality in burn patients.
Aims and Objectives: This study aimed to determine the incidence of infection in our burn unit and to demonstrate how our burn unit routine leads to a low incidence of infection in our setting.
Materials and Methods: This is a retrospective review of the records of patients attended to between 2009 and 2013 in the burn unit of Federal Teaching Hospital, Gombe, Nigeria. Details of the treatment and follow-up data were obtained from patients' case files using a predesigned pro forma. All patients were within 24 h of burn and had wounds cleaned under general anesthesia before admission to the unit. In addition, all patients with major burns received infusion of glucose, potassium, and insulin (GKI). Antibiotics use was strictly regulated and was guided by known antimicrobial and sensitivity patterns.
Results: Thirty-three patients were admitted within the study period, of whom 27 patients had complete information and were analyzed. The mean age of the burn patients was 11 ± 16.7 (SD) years. There were 16 (59.3%) males and 11 (40.7%) females. Scalding and flame burns accounted for 20 (74.1%) and seven (25.9%) patients, respectively. Only four (14.8%) patients developed wound infection on admission (three were in the age range of 11 years and below, while one was 57 years old) and one patient had gastrointestinal tract (GIT) infection. One patient died from suspected thromboembolism within 24 h of burn, and 14 (51.8%) and 12 (44.4%) patients were discharged with and without residual burn wounds, respectively. The average burn surface area was 18.9%. The average length of stay (LOS) was 18.65 days and the average LOS per patient per percentage burn surface was 0.98 days. On follow-up at 2 weeks after discharge, four (14.8%) patients had delayed wound healing and seven (25.9%) patients developed hypertrophic scars.
Conclusion: Our findings indicate a low incidence of infection related complications and it appears that our burn unit routine may play a significant role.
Keywords: Antibiotics, burn wound, glucose, potassium, and insulin (GKI), infection, morbidity, mortality
|How to cite this article:|
Kaltungo ZY, Olajide OS, Bojude AD. Impact of burn unit routine on outcome: A 5-year experience
. Nigerian J Plast Surg 2014;10:6-9
|How to cite this URL:|
Kaltungo ZY, Olajide OS, Bojude AD. Impact of burn unit routine on outcome: A 5-year experience
. Nigerian J Plast Surg [serial online] 2014 [cited 2020 Jan 25];10:6-9. Available from: http://www.njps.org/text.asp?2014/10/2/6/155169
| Introduction|| |
The burn unit, like any high dependency unit, is awash with multi-antibiotic resistant microbes, and the clinician is in a constant battle to prevent such infections from becoming established. After the elimination of hypovolemic shock as a cause of death in burn patients, infections constitute the leading cause of morbidity and mortality and have hence been in the forefront of the challenges facing burn surgeons worldwide.
Commonly documented sites of infection in burn patients include the burn wound, the urinary tract in those with indwelling urethral catheters, the respiratory tract, the gut, and sites of thrombophlebitis in those with venous catheters (both peripheral and central). Documented infection rates at these sites vary from center to center, but overall, the incidence of sepsis-related episodes range 0.5-14.4 per 1,000 patient days in the Shriners Hospital (Shriners Hospital Boston, Massachusetts. USA). 
The aims of this study were to determine the incidence of infection in our burn unit and to demonstrate how our practice of preadmission "wound debridement" and infusion of glucose, potassium, and insulin (GKI) in major burn cases lead to the apparently low incidence of infection in our burn unit.
| Materials and Methods|| |
This is a retrospective review of all burn cases admitted to the burn unit from the inception of the unit at the Federal Teaching Hospital (formerly Federal Medical Centre; FTHG), Gombe, Nigeria from 2009 to 2013. Information collected from the patients' hospital records included biodata, details of treatment, and evidence of infection using a predesigned pro forma.
The burn unit of FTHG, a six-bed ward, was carved out of the high dependency unit within the male surgical ward. The following routine of our burn unit is strictly adhered to within the limits of available resources: On arrival at the Emergency Department, resuscitation of the patient commences with intravenous fluids, and samples are collected for baseline investigations such as the serum electrolyte and packed cell volume (this is repeated every hour until stable). It is used as one of the tools to measure adequacy of fluid resuscitation, urinalysis, and urine specific gravity. Liver function test and electrocardiogram (ECG) are routinely done only in patients with electrical burns or where otherwise indicated, as in patients with a history suggestive of cardiac or liver disease. Urethral catheterization is also done for all burns >5% of total body surface area (TBSA) by the emergency room physician. The patient is next reviewed by the surgical team on call (STOC), which usually comprises a house surgeon, a junior resident in the Surgery Department, and a senior registrar. If a need for escharotomy is identified, it is usually carried out by the STOC. Analgesia in the acute phase is administered with intravenous opiates. The team informs the burn unit to prepare for admission of the patient while he/she is taken to the operation theater, where the wounds are cleaned, blisters completely deroofed, and occlusive dressing applied, usually with silver sulfadiazine or povidone-iodine as a topical antimicrobial. On arrival at the burn unit, the patient is handed over to the burn unit team and treatment is continued on the basis of the burn unit guidelines. The patient is reassessed for the need for escharotomy and this is done if it has not yet been done. All antibiotics that were begun at referral are discontinued unless there is a reason to suspect inhalation injury or if the patient was on the same medication to treat another ailment prior to or coexistent with the burn injury. Intravenous access is routinely with via percutaneous intravenous cannula, and changed to a venous cutdown if the overlying skin is intact to avoid frequent intravenous cannulation. Venous cutdown is preferred in extensive burns and may be done through burnt skin if a suitable area of unburnt skin is not available. Intravenous lines are routinely changed after 48 h or at the slightest sign of thrombophlebitis. All patients with major burns by TBSA are put on GKI infusion at the ratio of 10:5:5 if there is no history or lab evidence of diabetes. Major burns by TBSA in our practice are >10% superficial burns in children, >15% superficial burns in adults, and >5% full-thickness burns in any patient and in all patients with electrical burns. Barrier nursing is the routine for all patients. Wound care for the trunk and limbs is with occlusive dressing with povidone-iodine and with silver sulfadiazine applied the to areas to be exposed: Head and neck, hands, feet, and external genitalia/gluteal areas. Hand burns are treated with "hand in glove" techniques, where the hand wound is painted with silver sulfadiazine cream and covered with transparent polythene gloves. The gloves are changed as frequently as required, depending on how much the wound oozes. Occlusively dressed wounds are only changed if the dressings are soaked or there is a reason to suspect a wound infection from a recorded fever, or in case of tachycardia. If a wound infection is suspected, a wound swab is immediately taken for microscopy, culture, and sensitivity (MCS); the dressing frequency is changed to daily and gradually reduced as the infection clears. Intravenous antibiotics are only used if the above regimen does not take care of a wound infection and the patient's vital signs do not return to baseline, or if the patient is a high risk patient, e.g. with poorly controlled diabetes or the sensitivity pattern has no oral formulation. Antibiotic choice is guided by known antimicrobial/sensitivity patterns. Wound dressing of patients is staggered as much as possible, with specific nurses being assigned to specific patients and not more than one wound dressed in 1 day. It is hoped that this will reduce the possibility of transfer of infection between patients. Patients are encouraged to ambulate within 24 h of admission and are seen by the physiotherapist daily until discharge. Oral intake is encouraged in all patients and their diet is guided by the dietician in an effort to ensure that the patient remain in anabolic balance. If a patient requires surgery, such as skin graft of the wound, they are not readmitted to the burn unit after surgery. Very young patients are often discharged with residual wounds for reasons including discharge on request, financial constraints, the wounds being judged by the clinician to likely heal without intervention, and complications on outpatient management.
The burn unit is fumigated every time there are no patients on admission, irrespective of the time of the last fumigation.
Data were analyzed using SPSS version 16.0 (SPSS version 16 produced by SPSS inc. IBM, USA).
| Results|| |
In all, 33 patients had been admitted within the study period, but only 27 had complete information; their records were analyzed. Of the six patients excluded from the study, three were discharged against medical advice, two were transferred to the open ward for financial reasons, and one was discharged during an industrial action by hospital staff. The median age of the patients was 3 years (ranging from 1 day to 58 years). There were 16 (59.3%) males and 11 (40.7%) females. Scald (20; 74%) and flame burn (7; 26%) patients accounted for the bulk of the patients. Prior to admission at our facility, three (11.1%) patients had had salt applied to the wound and 24 (88.9%) various other substances such as raw egg, lime, or pap. Three of the patients had been admitted at a referral hospital before transfer to our facility and four patients had an intravenous line in situ at the time of arrival in the accident and emergency unit. Eight (29.6%) patients had undergone some form of wound dressing at the time of referral, while four patients had been started on intravenous antibiotics at the referral hospital. The mean duration of admission was 18.65 days (range 1-69 days). The longest admission, of 69 days, was recorded in a patient with 30% burns, who was discharged with about one-third of his original wound yet to heal. The range of percentage burn as calculated from the Lund and Browder chart was 5-54% (standard deviation [SD] 14.9). Five patients had burns 50% TBSA and more, 13 (81.8%) had burns 15% TBSA and less. Five patients received intravenous antibiotics in the course of admission. Twelve (44.4%) patients underwent urethral catheterization, and one patient underwent escharotomy. Only four patients (14.8%) came down with wound infection, of whom three were below 11 years of age, and the fourth was 57 years old. Wound MCS results in these patients showed Staphlococcus aureus in two and Pseudomonas aeruginosa the other two. One patient had gastrointestinal tract (GIT) infection. One patient died of a suspected thromboembolism within 24 h of burn and admission.
| Discussion|| |
There have been several advances in the prevention, early detection, and treatment of burn wound infection, but most of these are not available in our setting due to our limited resources. Hence, our goal is to ensure the barest minimum wound infection thereby increasing the patients' chances of having uncomplicated wound healing. He is thus better able to withstand and resist such factors that cumulatively increase morbidity and mortality.
Many burn units include in their protocol and criteria for admission to the burn unit those injuries defined as acute burns; ,, the practice of strictly adhering to our protocol of not admitting to the burn unit any burn beyond the period of 24 h stems from the fact that the wound is known to be inoculated, and immunosuppression with its attendant sequelae are initiated ,, during this period. The burn wound is sterile immediately following the burn  but soon becomes colonized by skin flora. , As is the observed pattern, the very young and the elderly constitute a majority of burn admissions. ,,, In our series, 19 (70.37%) of our patients were in the range of 10 years of age and younger; it is an established fact that this group is more prone to burns and scalding in particular.  The challenges of managing this group of patients cannot be overemphasized, particularly in trying to keep down traffic in the burn unit and control infection while taking into consideration that the parent or primary caregiver usually has to be present most times. This is a particularly difficult problem to circumvent as most patients do "out-of-pocket spending," and payment for procedures, investigations, and other hospital fees are on a need-to-do basis.
The importance of early enteral feeding for the burn patient involves among other benefits the prevention of atrophy of the intestinal villi/lining and attendant translocation of bacteria. , It is because of these benefits that we encourage enteral feeding in our patients where there is no contraindication. Intensive insulin therapy/tight glycemic control in critically ill patients has been found to be associated with a reduced incidence of infection-related morbidity and mortality and to improve overall patient outcome. ,, Based on the above, we routinely place patients with major burns on GKI infusion and monitor the blood sugar hourly. Alternate samples are measured by glucometer on the ward and in the laboratory. The solution is titrated to achieve 5-6 mmol/L of blood sugar. This regimen is only used during the day and discontinued at 4 PM (when call duty starts), because the staff to run the samples from this time period are thin on the ground and there is the ever-present risk of hyper- and hypoglycemia if the blood sugar assay is not run as and when due.
The use of prophylactic antibiotics is discouraged; they are not used in our patients and have actually been found to lead to the emergence of resistant strains, , promote overgrowth of Clostridium difficile, , and worsen outcome in some burn patients, compared to their counterparts treated without prophylactic antibiotics. 
Prolonged hospital stay correlates well with the extent of burn and infection-related complications. The patient with the longest duration of hospital stay had 30% mostly full-thickness and deep dermal burns and also invasive infection of unexcised eschar. This patient was discharged with burn ulcers 15% TBSA as he/she had refused skin grafting at the time the wound was clean. The commonest organisms causing invasive burn wound infection and cellulitis were Pseudomonas aeruginosa and Staphylococcus aureus, as in the findings of Altoparlak et al. 
From the foregoing, the overall infection rate in our burn unit is 14.8%, which compares well with the results from highly specialized burn centers like the Shriners Hospital,  and our low infection-related mortality figures suggest that other burn units, particularly in the low-income settings, can learn a lesson or two from our practice.
| Conclusion|| |
Our findings suggest a relatively low incidence of established infection in our practices, and it appears that our burn unit routine may play a significant role in that.
| References|| |
Weber J, McManus A; Nursing Committee of the International Society for Burn Injuries. Infection control in burn patients. Burns 2004;30:A16-24.
Standard Operating Procedures for Burn Care Center PIMS Islamabad. Available from: http://www.pims.gov.pk/SOP-BCC.docx. [Last accessed on 2014 Aug 15].
Admission Criteria: Kimberley Burn Unit. Available from: http://www.kimberleyburnunit.blogspot.com/p/criteria-for-admission-in-kimberley.html. [Last accessed on 2014 Aug 15].
Clinical Practice Guidelines: Burn Patient Management. Available from: http://www.aci.health.nsw.gov.au/_data/assets/pdf_file/0019/162631/clinical_practice_guidelines_2012.pdf. p. 16. [Last accessed on 2014 Oct].
Church D, Elsayed S, Reid O, Winston B, Lindsay R. Burn wound infections. Clin Microbiol Rev 2006;19:403-34
Appelgren P, Björnhagen V, Bragderyd K, Jonsson CE, Ransjö U. A prospective study of infections in burn patients. Burns 2002;28:39-46.
Beetstra JE. Recognition and treatment of burn wound infection. Can Oper Room Nurs J 1986;4:28-32.
Bang RL, Gang RK, Sanyal SC, Mokaddas EM, Lari AR. Beta-haemolytic streptococcus infection in burns. Burns 1999;25:242-6.
Gibson CD Jr, Thompson WC Jr. The response of burn wound staphylococci to alternating programs of antibiotic therapy. Antibiot Annu 1955-1956;3:32-4.
Burn Foundation. Burn Incidence and Treatment in the United States: 1999 Fact Sheet. Allentown, PA: Burn Foundation; 1999. p. 1.
Burn Foundation. Adult Burn Fact Sheet. Philadelphia: Burn Foundation; 1999. p. 1.
Burn Foundation. Pediatric Burn Fact Sheet. Philadelphia: Burn Foundation; 1999. p. 1.
National Safe Kids Campaign (NSKC). Burn Injury Fact Sheet. Washington DC: National Safe Kids Campaign (NSKC); 2002. p. 42.
ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 2002;26(Suppl):1SA-138SA.
Jenkins ME, Gottschlich MM, Warden GD. Enteral feeding during operative procedures in thermal injuries. J Burn Care Rehabil 1994;15:199-205.
van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al
. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345:1359-67.
Vlasselaers D, Milants I, Desmet L, Wouters PJ, Vanhorebeek I, van den Heuvel I, et al
. Intensive insulin therapy for patients in paediatric intensive care: A prospective, randomised controlled study. Lancet 2009;373:547-56.
Jeschke MG, Kulp GA, Kraft R, Finnerty CC, Mlcak R, Lee JO, et al
. Intensive insulin therapy in severely burned pediatric patients: A prospective randomized trial. Am J Respir Crit Care Med 2010;182:351-9.
Altoparlak U, Erol S, Akcay MN, Celebi F, Kadanali A. The time-related changes of antimicrobial resistance patterns and predominant bacterial profiles of burn wounds and body flora of burned patients. Burns 2004;30:660-4.
Murphy KD, Lee JO, Herndon DN. Current pharmacotherapy for the treatment of severe burns. Expert Opin Pharmacother 2003;4:369-84.
Ergün O, Celik A, Ergün G, Ozok G. Prophylactic antibiotic use in pediatric burn units. Eur J Pediatr Surg 2004;14:422-6.
Smith DJ Jr, Thomson PD. Changing flora in burn and trauma units: Historical perspective-experience in the United States. J Burn Care Rehabil 1992;13:276-80.