to be from 1.7% to 61.4% for patients
age 20 to 80 years or older with a
TBSAexceeding 20%.1The challenges
with burn resuscitation lie in the need
to administer large amounts of fluids
to provide effective tissue perfusion
without causing complications2of
overresuscitation such as abdominal
ment syndrome, acute lung injury, pul-
monary edema, and acute respiratory
distress syndrome (ARDS).
Many burn centers use formulas
to estimate fluid resuscitation needs.
The Parkland formula is commonly
used, along with the Brooke, Modi-
fied Brooke, and US Army’s Institute
of Surgical Research and Joint The-
ater Trauma System resuscitation for-
mulas.2,3Few protocols were foundin
publications describing comprehen-
sive burn resuscitation algorithms.4-6
A quality improvement project
was initiated in a burn intensive care
unit (ICU) at University of Colorado
Hospital, University of Colorado
Health, to develop and implement a
protocol for burn resuscitation that
was driven by nurses rather than the
previous standard, which required
Kyra Fahlstrom, RN, BSN, CCRN
Cameron Boyle, RN, MS, CCRN
Mary Beth Flynn Makic, RN, PhD, CNS, CCNS
Implementation of a
A Quality Improvement Project
(TBSA) injury. The National Burn
Repository1has reported a direct
correlation between higher mortality
rates in patients and advanced age,
TBSA burn exceeding 20%, and the
presence of inhalation injury. The
current mortality rate is estimated
ffective burn resuscita-
tion continues to evolve
with efforts to provide
optimal fluid resuscita-
tion to patients with
significant total body surface area
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 implemen-
tation of the protocol: serum level of lactate at 24 hours (t37.8=2.38, P=.007) and
central venous pressure at 48 hours (t31=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. (Critical Care Nurse. 2013;33:25-36)
©2013 American Association of Critical-Care Nurses
CriticalCareNurse Vol 33, No. 1, FEBRUARY 2013 25
This article has been designated for CNE credit.
A closed-book, multiple-choice examination
follows this article, which tests your knowledge
of the following objectives:
1. Identify the purpose and methods of fluid
resuscitation in burn patients
2. Describe the process and practice changes
involved in the nurse-driven burn resuscita-
tion protocol quality improvement project
3. Discuss how the nurse-driven burn resusci-
tation quality improvement project
improved the care of burn patients
CNEContinuing Nursing Education
the nurse to contact the physician for
each adjustment in administration
of fluids. The change in process was
to create a unit-based practice pro-
tocol that streamlined the process of
burn resuscitation, enabling more
efficient and timely fluid adjustments.
The nurse-driven burn resuscita-
tion protocol (NDBRP) was created
collaboratively by the interprofes-
sional team of the burn ICU. The
NDBRP is similar to other critical
care practice protocols in which the
prescribing provider provides
standing orders for treatment of set
parameters related to the patient (eg,
glucose levels). This burn resuscita-
tion practice protocol requires the
nurse to incorporate several param-
eters that reflect the patient’s current
response to fluid resuscitation and
determine fluid adjustments by incor-
porating the nurse’s clinical assess-
ment (eg, blood pressure, central
venous pressure, urine output, cur-
rent laboratory values) and protocol
orders. This article describes a qual-
ity improvement process that exam-
ined patients’ outcomes before and
after implementation of the NDBRP.
Despite much research on the
topic of burn resuscitation in the past
30 years, the practice has not changed
significantly.2,7Many formulas exist
to guide fluid resuscitation in burn
patients; however, a definitive con-
sensus on best practice has not been
achieved.2,6-10Best practice in burn
resuscitation is imperative because
effective fluid resuscitation will
decrease burn shock, tissue loss,
and organ damage and will reduce
morbidity and mortality.
The primary goal of fluid resus-
citation is to restore the circulating
blood volume and maintain perfu-
sion to all tissues during the period
of increased capillary permeability.11
When a patient has burns involving
more than 20% TBSA, the sympa-
thetic nervous system (fight or flight)
responds by increasing circulating
levels of catecholamines, initially
producing a hyperdynamic state.10,12
The inflammatory process that
ensues increases circulating levels
of inflammatory mediators, which
increase capillary permeability,
leading to global edema. Major fluid
and electrolyte losses occur as a result
of the capillary leak and loss of skin.
Hypovolemia is the result. Resusci-
tation is often guided by urine output,
hemodynamic parameters, and lab-
oratory values.11Delayed or inade-
quate fluid volume restoration results
in suboptimal tissue perfusion with
end-organ failure and death.8
Charles Baxter was instrumental
in developing the Parkland formula,
which is, today, the most frequently
used burn resuscitation formula.11
The Parkland formula itself has been
modified in various ways, including
the “consensus formula,” which uses
only lactated Ringer solution as a
resuscitation fluid. The Parkland for-
mula has been renamed the consen-
sus formula because it is the most
widely used resuscitation guideline.10,13
Baxter’s original formula included
the use of colloid infusion at 24 hours
to complete restoration of intravas-
cular volume.14One of the arguments
for using fresh frozen plasma as a
colloid during burn resuscitation is
that the molecule size of fresh frozen
plasma is greater than that of albu-
min, and albumin has a larger mole-
cule size than does crystalloid
solution (eg, lactated Ringer solu-
tion). Plasma proteins are needed to
maintain the oncotic force to coun-
teract the hydrostatic forces experi-
enced with burn shock.13Currently
the debate about whether to use
fresh frozen plasma, albumin, or
Recently, a trend in overresusci-
tation has been reported.7,16-18“Fluid
creep” is an adverse consequence of
overresuscitation, a term originally
coined by Pruitt.16Fluid creep is
described as clinical practice in which
more resuscitation fluid is adminis-
tered than is recommended by the
Parkland formula.7,19This phenome-
non has also been termed “supra-
associated with overresuscitation
include pulmonary edema, ARDS,
acute lung injury, abdominal hyper-
tension, abdominal compartment
syndrome, longer duration of mechani-
cal ventilation, and longer ICU stays.13
26 CriticalCareNurse Vol 33, No. 1, FEBRUARY 2013
Kyra Fahlstrom is a level III trauma nurse in the burn/trauma intensive care unit at University
of Colorado Hospital, Aurora.
Cameron Boyle is a nurse educator in the burn/trauma intensive care unit at University of
Colorado Hospital, Aurora.
Mary Beth Flynn Makic is a research nurse scientist at University of Colorado Hospital,
Aurora and an associate professor in the University of Colorado School of Nursing.
Corresponding author: Kyra Fahlstrom, RN, BSN, CCRN, University of Colorado Hospital, Mail Stop F796, 12605
East 16th Avenue, Aurora, CO 80045 (e-mail: email@example.com).
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, firstname.lastname@example.org.
findings from this project may not
be transferable to other burn ICU
Despite the mentioned limitations
experienced in this quality improve-
ment project, the high quality of the
project and our ability to obtain
meaningful data for critically exam-
ining the practice change were
apparent. The quality improvement
process used to examine practice
resulted in improved practice and
better outcomes for patients.
As a result of the NDBRP,
nurses appeared to have a height-
ened awareness of the process of
fluid resuscitation, including close
assessment of multiple fluid resusci-
tation end points that required rapid
reaction and changes in administra-
tion of intravenous fluids. The reg-
istered nurses demonstrated an
increased comfort with decreasing
intravenous fluid volumes while
meeting patients’ needs for tissue
perfusion. This increased comfort
was evident in the hourly fluid
changes according to the protocol
that resulted in an overall decrease
in fluid resuscitation volumes found
in this project (eg, 4.2 mL/kg per
%TBSA). The nurses appreciated
more the deleterious effects of both
underresuscitation and overresusci-
tation. Further exploration of fluid
resuscitation guidelines or unit pro-
tocols such as this NDBRP is
encouraged in burn units to continue
efforts to improve practice and out-
comes for burn-injured patients.
This quality improvement proj-
ect demonstrates how changes in
practice, specifically implementation
of a resuscitation practice protocol,
can be effectively implemented into
practice to improve patients’ out-
comes. The NDBRP increased nurses’
resuscitation accountability and
autonomy. Nurses can implement
evidence-based change in their prac-
tice areas by using similar quality
improvement methods. As a result
of this quality improvement project,
professional relationships, patients’
outcomes, and job satisfaction were
strengthened in this burn ICU. CCN
We thank the following individuals for providing
guidance and support for this project: Dr William
Mohr, medical director at Regions Hospital in St
Paul, Minnesota, and from the University of Col-
orado Hospital: Mary Holden, RN, MS, nurse man-
ager of the burn ICU; the burn ICU team; Dr
Gordon Lindberg, director of the burn ICU; Dr
Joshua Goldberg, burn surgeon; Dr Mary Berg,
director of the blood bank; Katie Fuenning, MS,
NREMT-B, burn trauma outreach coordinator; and
Vivienne Smith, RN, MS,informatics nurse specialist.
1. National Burn Repository Website. http://
Accessed March 28, 2012.
2. Greenhalgh DG. Burn resuscitation: the
results of the ISBI/ABA survey. Burns.2010;
3. United States Army Institute of Surgical
Research. Joint Theater Trauma System
(JTTS) Clinical Practice Guideline for Burn
Care 1. http://www.usaisr.amedd.army.mil
Revised May 2012. Accessed November 28,
4. Ennis JL, Chung KK, Renz EM, et al. Joint
theater trauma system implementation of
burn resuscitation guidelines improves out-
comes in severely burned military casual-
ties. J Trauma.2008;64(2):S146-S152.
5. Luo G, Peng Y, Yuan Z, et al. Fluid resuscita-
tion for major burn patients with the TMMU
6. Salinas J, Chung K, Mann E, et al. Comput-
erized decision support system improves
fluid resuscitation following severe burns:
an original study. Crit Care Med.2011;39(9):
7. Saffle JR. The phenomenon of “fluid creep”
in acute burn resuscitation. J Burn Care Res.
8. Alvarado R, Chung KK, Cancio LC, Wolf SE.
Burn resuscitation. Burns.2009;35(1):4-14.
9. Herschberger RC, Hunt JL, Brett D, et al.
Abdominal compartment syndrome in the
severely burned patient. J Burn Care Res.
10. Hayek S, Ibrahim A, Sittah GA, et al. Burn resus-
citation:is it straight forward or a challenge?
Ann Burns Fire Disasters.2011;24(1):17-21.
11. Greenhalgh DG. Burn resuscitation. J Burn
12. Makic MBF, Mann E. Thermal injuries. In:
McQuillan K, Makic MBF, Whalen E, eds.
Trauma Nursing: From Resuscitation Through
Rehabilitation.4th ed. Philadelphia, PA:
Saunders Elsevier; 2009:865-886.
13. Latenser B. Critical care of the burn patient:
the first 48 hours. Crit Care Med.2009;37(10):
14. Lawrence A, Faraklas I, Watkins H, et al. Col-
loid administration normalizes resuscitation
ratio and ameliorates “fluid creep”. J Burn Care
15. Perel P, Roberts I. Colloids versus crystalloids
for fluid resuscitation in critically ill patients
(review). Cochrane Database SystematicRev.
16. Pruitt BA. Protection from excessive resuscita-
tion: “pushing the pendulum back.” J Trauma.
17. Cartotto R, Zhou A. Fluid creep: the pendulum
hasn’t swung back yet! J Burn Care Res.2010;
18. Salinas J, Drew G, Gallagher J, et al. Closed
loop and decision-assist resuscitation of burn
patients. J Trauma.2008;64(suppl 4):S321-S332.
19. Faraklas I, Cochran A, Saffle J. Review of a
fluid resuscitation protocol: “fluid creep” is
not due to nursing error. J Burn Care Res.
20. Friedrich JB, Sullivan SR, Engrav LH, et al. Is
supra-Baxter resuscitation in burn patientsa
new phenomenon? Burns.2004;30(5):464-466.
21. Jenabzadeh K, Ahrenhoz DH, Mohr WJ.
Nurse driven resuscitation protocol in the
burn unit to prevent “fluid creep.” J Burn
Care Res.2009;30(2 suppl):S44-S160.
22. Cancio L, Chavez S, Alverado-Ortega M, et al.
Predicting increased fluid requirements dur-
ingthe resuscitation of thermally injured
patients. J Trauma.2004;56(2):404-414.
23. Klein MB, Hayden D, Elson C, et al. The asso-
ciation between fluid administration and
outcomes following major burn. Ann Surg.
24. Purdue G, Arnoldo B, Hunt J. Electrical injuries.
In: Herndon D, ed. Total Burn Care.Philadel-
phia, PA: Sanders, Elsevier; 2007:513-519.
25. Ivy ME, Atweh NA, Palmer J. Intra-abdomi-
nal hypertension and abdominal compart-
ment syndrome in burn patients. J Trauma
Injury Infection Crit Care.2000;49(3):387-391.
26. Nelson J, Cairns B, Charles A. Early extracor-
poreal life support as rescue therapy for
severe acute respiratory distress syndrome
after inhalation injury. J Burn Care Res.2009;
27. Posluszny JA, Conrad P, Halerz M. Surgical
burn wound infections and their clinical impli-
cations. J Burn Care Res.2011;32(2):324-333.
28. Muller MJ, Pegg SP, Rule MR. Derterminants
of death following burn injury. Br J Surg.
CriticalCareNurse Vol 33, No. 1, FEBRUARY 2013 35
To learn more about resuscitation, read
“Spirituality and Support for Family
Presence During Invasive Procedures and
Resuscitations in Adults” by Baumhover
and Hughes in the American Journal of
Critical Care, 2009;18:357-366. Available
Now that you’ve read the article, create or contributeto
an online discussion about this topic using eLetters.Just
visit www.ccnonline.org and click “Submit a response”
in either the full-text or PDF view of the article.
Learning objectives: 1. Identify the purpose and methods of fluid resuscitation in burn patients 2. Describe the process and practice changes involved in the
nurse-driven burn resuscitation protocol quality improvement project 3. Discuss how the nurse-driven burn resuscitation quality improvement project improved
the care of burn patients
Test ID C1313: Implementation of a Nurse-Driven Burn Resuscitation Protocol: A Quality Improvement Project
Objective 1 was met q q
Objective 2 was met q q
Objective 3 was met q q
Content was relevant to my
nursing practice q q
My expectations were met q q
This method of CNE is effective
for this content q q
The level of difficulty of this test was:
q easy q medium q difficult
To complete this program,
it took me hours/minutes.
1. Which of the following statements best describes the primary goal of burn
a. To stimulate the sympathetic nervous system and increase catecholamine production
to induce a hyperdynamic state
b. To restore circulating blood volume and maintain tissue perfusion
c. To increase interstitial fluids available for burn wound debridement
d. To elevate central venous pressure and dramatically increase preload
2. Burn patient fluid resuscitation is best achieved by using which of the following?
a. Normal saline and albumin
b. Lactated Ringer solution and fresh frozen plasma
c. Dextrose in 0.45% normal saline and fresh frozen plasma
d. Dextrose 5% and albumin
3. Which of the following best describes the consequences of overresuscitation and
a. Overresuscitation of the burn patient may result in cerebral edema, delirium, and
b. Acute kidney injury and malnutrition may occur due to fluid and electrolyte losses
and global edema.
c. Prolonged mechanical ventilation and intensive care unit days due to pulmonary
edema, acute lung injury, and acute respiratory distress syndrome
d. Profound metabolic acidosis due to capillary leak and metabolic derangement
4. Which of the following is the most widely used formula to calculate fluid resus-
citation for burn patients?
a. Winterc. Baxter
b. Cockcroft-Gault d. Parkland
5. Which statement best describes the purpose for developing a nurse-driven burn
resuscitation protocol (NDBRP)?
a. To increase fluid resuscitation because patients were often underresuscitated in the
b. To critically evaluate the effectiveness of the Winter formula
c. To compare complication rates with the previous physician-driven practice
d. To critically evaluate fluid management strategies for patients with <20% total body
surface area injury
6. Which of the following best describes which patients were excluded from the
NDBRP quality project and why?
a. Electrical burn and inhalation-only patients are difficult to determine internal injury
and fluid needs.
b. Coagulopathic patients with prolonged international normalized ratio require less
resuscitation fluids than most burn patients.
c. Patients with >20% total body surface area injury require physician-driven resuscitation
d. Patients with end-stage renal failure require dialysis with burn resuscitation.
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7. Which of the following best describes which data point is most likely directly
related to a quality project of an NDBRP?
a. Patient status and complications at 30 days after admission
b. Total amount of resuscitation fluids administered
c. Return to operating room for procedures
d. Mechanical ventilation days for the entire admission
8. Which of the following best describes the laboratory values monitored with
a. Serum sodium and serum osmolality to measure total body water deficits
b. Hemoglobin and hematocrit to measure for dilution
c. Lactic acid and base deficit to measure assessment of tissue perfusion
d. Serum creatinine and blood urea nitrogen to measure kidney function
9. Which of the following most accurately describes the findings of the nurse-
driven burn resuscitation quality project and fluid volume comparisons?
a. The fluid volumes given at 24 and 48 hours were the same between pre- and
b. The fluid volumes given at 24 and 48 hours were higher in the postimplementationgroup.
c. The fluid volumes given at 24 and 48 hours were lower in the preimplementation group.
d. The fluid volumes given at 24 and 48 hours were lower in the postimplementationgroup.
10. Which of the following is true when implementing an NDBRP?
a. A nurse-only practice group should be used to determine desired outcomes.
b. A physician group should be used to determine desired outcomes.
c. Comparison of complication rates of previous practice and practice postimple-
mentation is a desired variable.
d. Complication rates are not considered in desired outcomes.
11. Which of the following best describes team processes after implementation
of an NDBRP?
a. Decreased reliance on algorithm and standardization
b. Slowed achievement of resuscitation goals from previous practice
c. Lessened educational requirements after implementation
d. Increased team cohesion and communication in establishment of plan of care
12. Which of the following best describes nurses’ perceptions after implementation
of an NDBRP as a quality improvement process?
a. Nurses demonstrate reluctance to making adjustments that does not include
b. Nurses demonstrate increased comfort with fluid resuscitation and close assessment
required to make adjustments.
c. Nurses demonstrate decreased comfort with fluid resuscitation goals and
adjustments to fluid resuscitation.
d. Nurses demonstrate increased comfort with reliance on physician practice to
make fluid adjustments