Implementation of a Nurse-Driven Burn Resuscitation Protocol: A Quality Improvement Project
ABSTRACT Background Burn resuscitation, including titration of fluids and administration of colloids, is often driven by physicians' orders. Inconsistencies in burn resuscitation cause overresuscitation, which has adverse consequences. Methods Retrospective chart reviews were completed to evaluate fluid resuscitation and complications for 12 months before and after development and implementation of a nurse-driven burn resuscitation protocol. Results Before implementation of the protocol, results at 24 hours after injury indicated that 58% of patients were overresuscitated, had a serum level of lactate of at least 2 mmol/L (100%), and had complications (pulmonary edema 20%, abdominal compartment syndrome 7%, acute lung injury/acute respiratory distress syndrome 30%) within the first 5 days. Two outcomes differed from before to after implementation of the protocol: serum level of lactate at 24 hours (t(37.8) =2.38, P =.007) and central venous pressure at 48 hours (t(31) =2.27, P =.03). After implementation of the protocol, no patients had abdominal compartment syndrome develop. Conclusions Implementation of the nurse-driven burn resuscitation protocol improved nurses' awareness and assessment of fluid status during resuscitation and improved patients' outcomes.
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ABSTRACT: Between March 2003 and June 2007, our burn center received 594 casualties from the conflicts in Iraq and Afghanistan. Ongoing acute burn resuscitation as severely burned casualties are evacuated over continents is very challenging. To help standardize care, burn resuscitation guidelines (BRG) were devised along with a burn flow sheet (BFS) and disseminated via the new operational Joint Theater Trauma System to assist deployed providers. After the BRG was implemented in January 2006, BRF data were prospectively collected in consecutive military casualties with >30% total body surface area (TBSA) burns (BRG Group). Baseline demographic data and fluid requirements for the first 24 hours of the burn resuscitation were collected from the BFS. Percentage full thickness TBSA burns, presence of inhalation injury, injury severity score, resuscitation-related abdominal compartment syndrome, and mortality were collected from our database. Individual charts were reviewed to determine the presence of extremity fasciotomies and myonecrosis. These results were compared with consecutive military casualties admitted during the 2-year- period before the system-wide implementation of the BRG (control group). One hundred eighteen military casualties with burns >30% TBSA were admitted between January 2003 and June 2007, with n = 56 in the BRG group and n = 62 in the control group. The groups were different in age, but similar in %TBSA, %full thickness, presence of inhalation injury, and injury severity score. There was no difference in the rate of extremity fasciotomies or the incidence of myonecrosis between groups. The composite endpoint of abdominal compartment syndrome and mortality was significantly lower in the BRG group compared with the control group (p = 0.03). Implementation of the BRG and system-wide standardization of burn resuscitation improved outcomes in severely burned patients. Utilization of the joint theater trauma system to implement system-wide guidelines is effective and can help improve outcomes.The Journal of trauma 03/2008; 64(2 Suppl):S146-51; discussion S151-2. DOI:10.1097/TA.0b013e318160b44c · 2.96 Impact Factor
Article: Burn resuscitation[Show abstract] [Hide abstract]
ABSTRACT: Current guidelines outlining the resuscitation of severely burned patients, in the United States, were developed over 30 years ago. Unfortunately, clinical burn resuscitation has not advanced significantly since that time despite ongoing research efforts. Many formulas exist and have been developed with the intention of providing appropriate, more precise fluid resuscitation with decreased morbidity as compared to the current standards, such as the Parkland and modified Brooke formulas. The aim of this review was to outline the evolution of burn resuscitation, while closely analyzing current worldwide guidelines, adjuncts to resuscitation, as well as addressing future goals.Burns: journal of the International Society for Burn Injuries 07/2008; 35(1):4-14. DOI:10.1016/j.burns.2008.03.008 · 1.84 Impact Factor
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ABSTRACT: Fluid creep was recognized nearly a decade ago. Although many burn centers are now aware of fluid creep, it is not clear whether any reversal of this phenomenon has occurred. The purpose of this study was to examine whether we have made any headway in reversing fluid creep at our facility. This is a retrospective review of the first 48 hours of fluid resuscitation using the Parkland formula among patients with >/=15% TBSA burns admitted to our adult regional burn centre (BC) between January 1, 2000, and May 30, 2008. All values are reported as the mean +/- SD. There were 196 consecutive resuscitations available for analysis. Group characteristics were age 46 +/- 18 years, burn size 31% +/- 15% (range 15-81%), and full-thickness burn size 13% +/- 16%, with a 26% incidence of inhalation injury. The delay between injury and BC admission was 4.5 +/- 2.6 hours. During this time, a total crystalloid volume of 1.5 +/- 1.0 ml/kg/%burn, or nearly 40% of the recommended 24-hour Parkland volume, was administered. Total crystalloids given in the first 24 hours (prior to and within the BC) were 6.3 +/- 2.9 ml/kg/%TBSA, with 76% of all resuscitations receiving >4.3 ml/kg/%burn (the upper limit predicted by Baxter). Hourly urine output (UO) in the first 24 hours postburn was 1.2 +/- 0.7 ml/kg/h. There were minimal insignificant downward trends in the volume of resuscitation fluids and the mean hourly UO of the 194 cases over the 8-year period of the study. In contrast, use of colloids (5% albumin) and formal measurement of intraabdominal pressures increased during the same time period. Despite awareness of fluid creep, we have not substantially reversed this phenomenon, primarily because of failure to titrate down fluid infusion rates and by accepting higher than recommended UO. Excessive pre-BC fluid also continues to be a contributing factor.Journal of burn care & research: official publication of the American Burn Association 07/2010; 31(4):551-8. DOI:10.1097/BCR.0b013e3181e4d732 · 1.55 Impact Factor