Calgary Firefighters Burn Treatment Centre Annual Report 2015-2016

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2015-2016

Calgary Firefighters Burn Treatment Centre

Annual Report

Report Generated by: Kali Gordon, CHIM Burn Data Analyst, Trauma Services

Table of Contents ALBERTA HEALTH SERVICES ...... 4 MEDICAL DIRECTOR’S MESSAGE ...... 5 EXECUTIVE SUMMARY 2015/2016 ANNUAL REPORT ...... 6 SPECIAL ACKNOWLEDGEMENTS ...... 7 WHAT WAS THE BURN TEAM UP TO IN 2015/2016?...... 8 Clinical ...... 8 Education ...... 8 Quality Assurance/Improvement ...... 9 Research ...... 9 HOW DO WE COLLECT OUR DATA? ...... 11 What is the Burn Registry? ...... 11 Who qualifies for the Burn Registry? ...... 11 How do you identify a burn patient? ...... 11 What data is collected? ...... 11 Why is this data collected? ...... 11 How reliable is the data? ...... 12 STATISTICS AND OUTCOME DATA ...... 13 WHO EXPERIENCED BURN INJURY & NON-BURN RELATED INJURIES IN 2015/2016?...... 14 Admissions ...... 14 Admission Source ...... 19 Admission Status ...... 20 ICU Admissions ...... 21 HOW DID THE PATIENTS GET TO THE FOOTHILLS MEDICAL CENTRE? ...... 24 Mode of Transportation ...... 25 WERE ANY PATIENTS UNDER ANY INFLUENCE OF ALCOHOL OR DRUGS? ...... 26 ETOH ...... 26 Drug Use ...... 27 HOW LONG DID THE PATIENTS STAY IN FMC? ...... 27 Total Hospital Days (LOS) ...... 27 WHAT INJURIES DID THE PATIENTS SUSTAIN? ...... 28 Diagnoses ...... 28 Inhalation Injury ...... 29 HOW WERE THE PATIENTS’ INJURIES TREATED? ...... 30 Operative Interventions ...... 30 3

HOW DID THESE INJURIES OCCUR? ...... 32 Etiology of Injury ...... 32 External Cause of Injury ...... 33 WHERE DID THE INJURIES OCCUR? ...... 34 Place of Occurrence ...... 34 WHERE WERE OUR PATIENTS DISCHARGED TO? ...... 35 Discharge Disposition ...... 35 Mortality ...... 36 Resource Utilization ...... 38 Insurance ...... 39 OUTPATIENT BURN TREATMENT SERVICES ...... 40 APPENDIX A ...... 41 APPENDIX B ...... 44 APPENDIX C ...... 45

ALBERTA HEALTH SERVICES

Our Mission

To provide a patient-focused, quality health system that is accessible and sustainable for all Albertans.

Our Values

We show kindness and empathy for all in our care, and for each other.

We are honest, principled and transparent.

We treat others with respect and dignity.

We strive to be our best and give our best.

MEDICAL DIRECTOR’S MESSAGE

It’s truly my privilege to serve as the Medical Director of the Calgary Firefighters’ Burn Treatment Centre. It’s a role that connects me with a wide variety and huge number of very special people.

The multidisciplinary team of nurses, allied health professionals, and physicians is dedicated and talented and are often complimented by patients on the care they deliver, which makes me extremely proud to know them all.

The support of the Calgary Firefighters’ Burn Treatment Society continues to grow, and continues to generously contribute to funding our clinical, educational, and research activities. Our relationship with the Firefighters is one that I treasure.

Finally, and the reason that we do what we do…our patients. As Dr. Ross Tilley, a mid-20th century pioneer in Canadian burn care said, these are “tough patients with tough problems”. Their resilience in overcoming adversity and indeed triumphing in the face of adversity is an ongoing source of inspiration to me, and I believe, to this team as we continue to do our best to provide the best possible outcomes for survivors of burn injury.

The following report outlines the activities of the burn program this past year.

Respectfully submitted,

D.A. Nickerson, BSc, MD, FRCSC, FACS Medical Director, Calgary Firefighters’ Burn Treatment Centre

EXECUTIVE SUMMARY 2015/2016ANNUAL REPORT

Since 1978 The Calgary Firefighters Burn Treatment Centre at the Foothills Medical Centre cares for people from Southern Alberta, Southeastern British Columbia and Southwestern Saskatchewan that sustain burn injuries. The Burn Centre which is located on unit 30/31 is a twenty six bed unit with eight of the rooms being specifically designed to provide excellent burn treatment for the acutely burned, non-ventilator dependent adult patient.

It takes an expert team that consists of plastics surgeons, a burn physiatrist, physician residents, a psychologist, nurses, therapists, dietitian and a social worker so we can meet the complex needs of our burn patients. Our multidisciplinary team meets weekly in burn rounds to review patients’ progress and clinical goals. Our team extends to the ICU where they care for the critically injured burn patients. Together in the burn care committee we continue to focus on the best possible patient outcomes through the development of best practices and education that can improve the patient and family transition from the ICU to the burn center.

This tremendous team effort also includes the long-standing collaboration with the Calgary Firefighters Burn Treatment Society (CFBTS). Their commitment to fundraise enables equipment, education, research and burn survivor resources. Recently, with their support the burn clinic was renovated to meet the rehabilitation needs of the patients once they are able to return home, as well as those with burns that do not require hospitalization.

The CFBTS recognizes the importance of successful reintegration back to the community and adjusting to a new way of life. Their support has enabled an active burn survivor support group that offers resources for burn survivors and their families. I would like to acknowledge and share my appreciation to the Society, as well as the burn survivors that are trained as formal peer supporters and those team members that volunteer their time to facilitate this group.

Once again thank you to the Data Analysts and the Trauma Services team that enable this report and the burn registry.

Tanya Miller BN, RN Unit Manager PCU 30/31 Foothills Medical Centre Alberta Health Services

SPECIAL ACKNOWLEDGEMENTS

Dr. Duncan Nickerson, Medical Director, Plastic Surgery Dr. Vincent Gabriel, Physical Medicine and Burn Rehabilitation Ms. Christine Vis, Manager, Trauma Services and Unit 44 Ms. Tanya Miller, Unit Manager, U30/31 Ms. Lindsay Burnett, Clinical Nurse Educator, U30/31 Ms. Sametta Cole, Occupational Therapist, U30/31 & Burn Rehabilitation Ms. Johanna Atienza-Serrano, Burn Analyst, Trauma Services Ms. Kali Gordon, Burn Analyst, Trauma Services

WHAT WAS THE BURN TEAM UP TO IN 2015/2016?

Clinical

As outlined in the body of the report, we looked after over 100 inpatients with burns and other complex soft tissue injuries and skin loss. We also cared for nearly 500 outpatients with relatively minor thermal injuries. Physician led outpatient burn clinic every Tuesday and Wednesday morning, with therapy and wound care coverage 7 days a week. The Burn Care Committee that was established in 2014 continues to meet every second month. The membership includes providers from the ICU, burn unit, burn clinic, and infection prevention. The committee introduced a nurse driven fluid resuscitation protocol for patients requiring an ICU admission. The wound swab screening practice standard was also updated. In 2015 Burn Clinic area located in the Rehab area underwent a major facelift. The renovations sponsored by the CFBTS created more space and improved the flow of patients through the treatment area.

Education

Through the burn program, roughly 2 dozen medical students and roughly 3 dozen medical and surgical residents received exposure to the principles of operative and non-operative burn care. 12 Registered Nurse and 7 Licensed Practice Nurse students completed their final practicums on the unit. We also had 5 nursing groups participate in a clinical practicum as part of their educational program. We had 3 Undergraduate Nursing Employees (UNE) employed for the summer months to help with increased burn volume. Hiring UNEs has proven to be a good retention strategy as the UNEs transition to graduate nurses and eventually RNs. To be prepared to help in the burn unit the UNEs receive a day long burn education session. The rehabilitation group meets weekly in an ongoing effort to mentor new staff, review best practice standards, and engage in educational presentations. One Physiotherapist achieved their Diagnostic Imaging designation. Weekly multidisciplinary rounds that includes educational presentations. Burn orientation took place in January 2016 and was a joint program with ICU. Approximately 14 nurses attended the orientation. The American Burn Association (ABA) meeting was held in Chicago, IL April 20-24, 2016. Several burn team members from the burn unit, ICU, rehabilitation department, research lab, and firefighters attended. 4 nurses from the unit attended the 14th Biennial Canadian Association of Burn Nurses conference in Moncton, New Brunswick in September. Our unit educator was the CABN president for the last 2 years, and the other 3 nurses that attended hold executive or council positions

Quality Assurance/Improvement

Data Management

Canadian Burn User Research Network (CBURN) continues to meet bi-monthly via teleconference to discuss new initiatives and to exchange information to improve data quality across Canada. Oct. 20th 2015: Burn Database DEMO. NTRACS V6 went live in summer 2015. Toronto, Montreal and Edmonton are the only burn hospitals that have upgraded to version 6 to date. Nov. 18th 2015: Burn Registry and the Burn Admission Form were presented to the ICU Burn Committee Meeting 6 burn survivors/ family members and 2 burn unit staff attended the World Burn Congress in Indianapolis, IL in October 2015 funded by the CFBTS. Offer a variety of resources to assist with challenges faced by patients and families after a burn injury and to support the successful reintegration back to the community, they include library of books and videos, social events, access to social worker and psychologist, monthly support group, and a peer support program. The burn survivor support group had an active year with good participation at the monthly meetings, a September picnic at Bowness Park and Christmas dinner hosted at Win Sports. Calgary is the only Canadian Burn Centre to offer the Phoenix Society Survivors Offering Assistance in Recovery (SOAR) program. 7 burn survivors are formal trained SOAR peer supporters and AHS FMC hospital volunteers. This peer support program assists others in adapting to the burn injury through sharing of similar experiences that is available to patients, families and support persons. The burn unit social worker, an occupational therapist, and the clinical nurse educator received the SOAR coordinator training, bringing us to 7 SOAR coordinators. 6 burn survivors/ family members and 2 burn unit staff attended the World Burn Congress in Indianapolis, IL in October 2015 funded by the CFBTS.

Research

The Biernaskie Skin Regeneration and Wound Healing Laboratory has published a total of 11 peer-reviewed papers. Within these works we have developed a novel xenograft model of human split thickness skin grafting, human stem cell labeling using lentiviral vectors and novel imaging and biomechanical testing procedures that will enable objective measurement of skin graft function in our future studies. We are completing the final year of our AIHS CRIO grant with an additional 4 manuscripts that are being prepared for publication. Training Highly Qualified Personnel - We currently supervise 6 graduate students (4 PhD and 2 MSc) and 3 postdoctoral fellows. We graduated 1 PhD student and 2 Postdoctoral fellows who successfully completed their training. Our trainees presented 16 poster presentations at various international scientific meetings.

During the ABA meeting in Chicago our team received 2 awards: Lindsay Burnett, together with her collaborators E. Carr, D. Tapp, S. Raffin-Bouchal and Drs. Jenny Horch, Jeff Biernaskie, and Vince Gabriel received honor for their paper: Patient Experience Living with Split Thickness Skin Grafts (Burns, 2014 Sept, 40(6):1097-1105), as one of the seven most important articles to appear in that journal in 2014.Sam Su, a research student, together with Sarthak Sinha and supervisor Dr. Vince Gabriel, won Best in Category for their poster, Evaluating the validity and reliability of 3-D imaging for the non-invasive volume assessment of hypertrophic scar.

HOW DO WE COLLECT OUR DATA?

What is the Burn Registry? The Burn Registry is an electronic database system based on the American Burn Association NTRACS Version 5 Data Dictionary. The registry contains information of all burn patients admitted to the Foothills Medical Centre. The information is collected and analyzed for internal reporting and will be available for use for future research purposes.

Who qualifies for the Burn Registry? To qualify for the Burn Registry, a patient must be admitted as an inpatient to the Foothills Medical Centre with a diagnosis of a burn injury or a non- burn related injury. Patients who have sustained inhalation injuries, with or without burn injuries, are also qualified. Other non-burn injuries are also captured in the registry, by virtue of having a diagnosis that requires the specialized care available in the burn treatment center, including the following:

TENS (toxic epidermal necrolysis) SJS (Steven Johnson Syndrome) Purpura fulminans Friction/Degloving injuries Acute soft tissue infections (i.e. Necrotizing Fasciitis, Fournier’s Gangrene, etc.) IV infiltration Calciphylaxis Other qualifying non-burn injuries primarily treated by the burns/plastics service

Patients who are readmitted – planned or unplanned – are also captured in the Burn Registry.

How do you identify a burn patient? A burn patient is a patient who has sustained an injury caused by fire/flame, scalding, contact with hot object, electrical burns, chemicals, radiation, friction and other mechanisms such as hot steam or gas. Burn injuries are determined by size and severity using the Lund and Browder chart. The size of a burn is measured as a percentage of the total body surface area (TBSA). Assessment of the depth of a burn injury is dependent on the temperature of exposure and the duration of exposure. Burns are classified as epidermal (superficial), partial thickness (superficial partial thickness or deep partial thickness), and full thickness injuries. Indeterminate burn injuries are burns that are yet to be determined to be deep partial thickness or full thickness burns. Indeterminate burns are continuously assessed during the patient’s admission to determine its depth and course of care.

What data is collected? Data collected includes patient demographics, admission information, burn injury data including the mechanism and circumstances of injury, ICD-9 diagnosis and intervention, Lund & Browder chart, complications and hospital outcomes.

Why is this data collected? The information collected for the Burn Registry is retrieved for analysis and internal quality improvement initiatives within the unit and Trauma Services, solely for the purpose of providing the highest standard of care of the patient.

How reliable is the data? Reports and queries generated from the Burn Registry and Data Integration, Measurement and Reporting (DIMR) are examined by the analyst to identify any discrepancies in the data. Any errors are corrected in the registry to ensure data quality and consistency. Burn Admission data is dependent on the integrity of the information captured on the Burn Admission Form and the patient’s health record. The role of the burn data analyst is to ensure that the quality of burn data is accurate and consistency and reflects ABA reporting.

Calgary Firefighter’s Burn Treatment Unit Foothills Medical Centre

STATISTICS AND OUTCOME DATA 2015-2016

WHO EXPERIENCED BURN INJURIES & NON-BURN RELATED INJURIES IN 2015/2016?

Admissions Admissions include all patients who have experienced burn injuries or non-burn related injuries admitted at the Foothills Medical Centre (FMC) from April 1, 2015 to March 31, 2016. The following chart presents the number of patients who were qualified for the burn registry by month.

A total number of 124 patients were qualified for the burn registry this fiscal year. This includes burn admissions (95) and non-burn admissions (29). This includes burn and non-burn patients who were readmitted and admitted for reconstruction.

Burn Admissions by Month

2012-2013 2013-2014 2014-2015 2015-2016

20 19

16 1515 14 14 13 13 13 12 12 12 11 11 1111 11 10 10 10 9 9 9 8 8 8 8 8 8 7 7 7 7 7 7 7 7 6 6 6 6 6 5 5 4 4 4 4 3 3 3 3 3 3 2 2

0 APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR

There were a total of 95 burn patients admitted to the Foothills Medical Centre, 19% decrease from the previous fiscal year. Burn admissions include smoke inhalation patients with or without burn injuries. 15

Non- Burn Admissions by Month

2012-2013 2013-2014 2014-2015 2015-2016 7

6 6

5 5 5

4 4 4 4 4

3 3 3 3 3 3 3 3 3 3

2 2 2 2 2 2

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR

There were a total of 29 non-burn patients admitted to the Foothills Medical Centre- there was an increase of 9 admissions from the previous fiscal year.

By Gender The following table shows the number of admissions by gender for 2015- 2016. Males outnumber females in burn and non-burn cases by approximately a 2:1 ratio.

Burn Admissions by Gender

Male Female Total 100 95

80 63 60

40 32

0 Male Female Total

Non- Burn Admissions by Gender

Male Female Total 40

20 18 11

0 Male Female Total

Age Distribution by Gender Age Distribution by Gender in Burn Patients

Males Females 18 16 14 12 10 8 6 4 2 0

Age Distribution by Gender in Non Burn Patients

Males Females 4

The average age of patients admitted to Foothills Medical Centre was 44.7 years old.

The highest number of burn injuries occurred in the 21-50 age range.

By Condition There are specific non-burn diagnoses that are captured into the burn registry. These conditions include specified diagnoses determined by the ABA data dictionary (i.e. Toxic epidermal necrolysis, Steven Johnson syndrome, Purpura fulminans, Friction/Degloving injuries, acute soft tissue infections such as Necrotizing fasciitis and Fournier’s gangrene) as well as other specified conditions treated by the Plastic Surgery service.

Non- Burn Admissions by Condition

Other, 2, 7%

Necrotizing fasciitis, 7, 24%

Friction burn , 5, 17%

Degloving, 7, 24%

Frostbite, 8, 28%

There were no admissions attributed to Steven Johnson Syndrome this fiscal year. The conditions counted under the “other” were a Graft vs Host reaction and Streptococcal Toxic Shock Syndrome.

Admission Source This refers to where the patient came from prior to arriving at the Foothills Medical Centre. Internal sources include patients who have been referred from another service or outpatient clinic within FMC. External sources include patients who have been transferred from another facility after being seen in an emergency department. Unreferred sources include patients who arrived at the emergency department via private vehicle or ambulance from the scene of injury.

Admission Source: Burns

2012-2013 2013-2014 2014-2015 2015-2016

120 105 100 86 85 75 80 56 60 42 40 30 30 33 23 23 25 28 24 19 18 20

0 Internal External Unreferred Total

Admission Source: Non- Burns

2012-2013 2013-2014 2014-2015 2015-2016 30 26 26 25 20 20 16 15 13 11 12

10 8 8 7 7 3 4 5 3 3 3

0 Internal External Unreferred Total

Admission Status The following table presents the admission status of the patient upon arrival at the Foothills Medical Centre (FMC). Only one admission status is possible per patient admission.

Readmissions This category classifies patients who are readmitted to FMC, and may be planned or unplanned. These patients are not included under the burn and non-burn categories throughout this report.

Reconstructions This category classifies burn and non-burn patients who are admitted to FMC for reconstructive surgery. This includes patients who did not have previous admission related to the reconstruction (i.e. childhood scars) or patients who require ongoing surgery for complex conditions. These patients are not included under the burn and non-burn categories throughout this report.

Initial Admission 2012-2013 2013-2014 2014-2015 2015-2016 burns 75 86 105 85 non-burns 12 20 19 26 Readmission planned burns 0 0 0 0 non-burns 1 3 0 0 unplanned burns 0 0 4 7 non-burns 0 2 1 2 Reconstructive surgery admission burns 0 1 2 3 non-burns 0 0 0 1 TOTAL 88 112 131 124 21

ICU Admissions ICU Admissions: Burns

2012-2013 2013-2014 2014-2015 2015-2016 200 180 160 140 120 100 80 60 40 20 0 ICU Admissions ICU Days Ventilator Days 2012-2013 11 95 77 2013-2014 18 183 156 2014-2015 23 189 153 2015-2016 9 117 87

Burns: Average ICU days: 13 days Range: 1 - 37 days

ICU Admissions: Non-Burns

2012-2013 2013-2014 2014-2015 2015-2016 140 120 100 80 60 40 20 0 ICU Admissions ICU Days Ventilator Days 2012-2013 6 22 18 2013-2014 2 13 9 2014-2015 5 116 100 2015-2016 7 40 24

Non-burns:

Average ICU days: 5.7 days

Range: 1-10 days

Admissions by Occupation

Occupation Burns Non- Burns Architecture/ Engineering 2 Arts/ Design/ Entertainment/ Sports/ Media 1 Building/ Ground/ Cleaning/ Maintenance 5 Business/ Financial Community/ Social Services Computer/ Mathematics Construction/ Extraction 9 3 Education/ Training/ Library 1 Farm/ Fish/ Forestry 2 Food Prep/ Service 1 1 Healthcare Support Health Practitioners/ Technician 2 Installation/ Maintenance/ Repair 2 Legal Life/ Physical / Social Sciences Management Military Specific 1 1 Oil & Gas Industry 2 1 Personal Care & Service Production 4 Protective Services Sales and Related Student 3 1 Transportation/ Material Moving 4 1 Unemployed (Disabled, Retired, Below School Age) 37 10 Other 5 1 Unknown 6 5 TOTAL 85 26

HOW DID THE PATIENTS GET TO THE FOOTHILLS MEDICAL CENTRE?

Hospital Transfers Patients who are transferred to the Foothills Medical Centre are referred by another hospital either within the province or outside of the province. Police/Fire Fixed-wing Ground Helicopter Private/Public Dept. (non- REFERRING HOSPITAL Ambulance Ambulance Ambulance Vehicle/Walk-in ambulance) No Referring Hospital - 31 4 49 - Within Alberta Airdrie Regional Health Centre Banff Mineral Springs Hospital 1 Brooks Health Centre 1 Canmore General Hospital 1 1 Cardston Health Centre 1 Chinook Regional Hospital 1 1 Claresholm General Hospital Didsbury Hospital 1 Drumheller Health Centre Fort Macleod Health Centre High River General Hospital Innisfail Health Centre Medicine Hat Regional Hospital 1 1 Oilfields General Hospital 3 Okotoks Health and Wellness Centre Olds Health Care Centre 1 Peter Lougheed Centre 2 Pincher Creek Health Centre 1 Red Deer Regional Centre 1 Rocky Mountain House Health Centre Rockyview General Hospital 2 Sheldon M. Chumir Health Centre South Health Campus 1 Strathmore District Health Services Sundre Hospital and Care Centre 3 Taber and District Health Centre 1 University of Alberta Hospital Vulcan Community Health Centre Out of Province Queen Victoria Hospital-BC Sparwood Health Centre-BC 1 Out of Country Desert Regional- Palm Springs, CA, USA 1 TOTAL 2 54 6 49 0 25

Mode of Transportation Emergency transport to the Foothills Medical Centre can arrive via ‘Ground’ or ‘Air’.

In cases where multiple modes of transportation were used, air transportation would take precedence.

Mode of Transportation

Burns Non-burns 90 80 70 60 50 40 30 20 10 0 Private/Walk- Police/Fire Fixed wing Ground Helicopter Total in Dept. Burns 2 42 4 37 0 85 Non-burns 2 12 0 12 0 26

WERE ANY PATIENTS UNDER ANY INFLUENCE OF ALCOHOL OR DRUGS?

ETOH The following chart presents how many patients were tested positive for ETOH use upon admission.

ETOH Use by Month

Burns Non-Burns 5 4 4 4 3 3 3 2 2 2 2 2 2 1 1 1 1 1 1 1 1 # of patients 1 0 0 0 0 0 0 0 0

The chart below presents the number of patients that exceeded the Alberta alcohol legal limit upon admission.

*The Alberta limit for ETOH consumption is 80 mg/dL (17 mmol/L).

# of Patients > Alberta ETOH Legal Limit

Burns Non-burns 3

1 1 1 1 1 1 1 1 1 # of patients

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

*Based on: https://myhealth.alberta.ca/health/pages/conditions.aspx?hwid=hw3564&#hw3588 27

Drug Use This field indicates if any drug use may have occurred prior to the injury. Laboratory results were obtained from Sunrise Clinical Manager and patient chart documentation.

BURNS NON-BURNS 2012- 2013- 2014- 2015- 2012- 2013- 2014- 2015- 2013 2014 2015 2016 2013 2014 2015 2016 Barbiturates Cannabis 1 1 Dissociative Agents Opiates 3 4 2 Sedatives-Hypnotics 1 1 Stimulants-Amphetamines 1 1 Tricyclic Antidepressants Other Drugs 8 2 5 1 2 3 1 Testing Not Performed 64 84 95 81 9 25 16 22 Tested, All Results 1 1 1 Negative TOTAL 75 86 105 85 13 26 20 26

HOW LONG DID THE PATIENTS STAY AT FMC?

Total Hospital Days (LOS)

BURNS NON- BURNS 2012- 2013- 2014- 2015- 2012- 2013- 2014- 2015- 2013 2014 2015 2016 2013 2014 2015 2016 Total Hospital Days 998 1684 2050 1356 218 570 501 491 Average Length of Stay 13.5 19.6 19.5 15.9 15.6 21.9 25.1 18.9 (days) Range 1-65 1-138 1-466 1-241 1-60 1-87 1-167 1-130

WHAT INJURIES DID THE PATIENTS SUSTAIN?

Diagnoses The depth of a burn injury declares itself over time. The following table presents the final diagnoses captured within the patient’s health record. The burn injuries are classified as superficial burns, superficial partial/deep partial thickness burns and full thickness burns. Burn injuries classified in the ‘Other’ category includes injuries where the location of the injury does not further determine the depth of the injury.

By Depth & Location The following table presents the depth and location of a burn injury based on the Most Responsible Diagnosis (MRDx). MRDx is the diagnosis or condition that can be described as being most responsible for the patient’s stay in hospital. Burn depth is captured from the deepest to superficial burn injuries.

Partial Thickness Superficial Full Thickness Other TOTAL (Superficial/ Deep) Eye & Adnexa 0 (940.*) Face, Head, Neck 1 10 3 14 (941.*) Trunk 2 9 12 23 (942.*) Upper limb 7 14 21 (943.*) Wrists & Hands 4 5 9 (944.*) Lower limbs 5 12 17 (945.*) Internal organs 1 1 (947.*) TOTAL 85

Note: Each patient may have one or more burn depth and location per admission and is not presented in the table above. 29

By TBSA Burn Diagnoses by Total Body Surface Area (TBSA)

2012-2013 2013-2014 2014-2015 2015-2016 70 63 60 55 57 54 50

30 1920 20 1514 10 6 4 3 3 4 3 2 1 1 2 0 2 2 0 1 1 1 1 0 1 0 0 0 1 0 0 2 0 <10% 10-19% 20-29% 30-39% 40-49% 50-59% 60-69% 70-79% 80-89% >90

Note: The table above does not include patients with smoke inhalation, eye burn and superficial burn injuries.

The average total body surface area (TBSA) this fiscal year was 8.1%.

Inhalation Injury Patients who sustained an inhalation injury with or without burn injury were captured in the burn registry.

Inhalation Injury # of Burn Patients 2012-2013 2013-2014 2014-2015 2015-2016

Yes with burn injury 5 10 16 9 without burn injury 0 2 1 0 No 70 74 88 76 TOTAL 75 86 105 85

HOW WERE THE PATIENTS’ INJURIES TREATED?

Operative Interventions

INTERVENTIONS PERFORMED IN BURN PATIENTS Total # Patients with OR Procedures 68 Total # of OR visits 185 Intervention Codes # of occurrence 31.1* Temporary tracheostomy 2 39.7* Endovascular repair of vessel 1 76.7* Reduction of facial fracture 1 78.5* Internal fixation of bone without fracture reduction 1 79.3* Open reduction of fracture with internal fixation 3 80.4* Division of joint capsule, ligament, or cartilage 1 83.1* Division of muscle, tendon and fascia 1 84.0* Amputation of upper limb 1 84.1* Amputation of lower limb 1 86.0* Incision of skin and subcutaneous tissue 3 86.1* Diagnostic procedures on skin and subcutaneous tissue 1 86.2* Excision or destruction of lesion or tissue of skin and subcutaneous 14 tissue 86.5* Suture of other closure of skin and subcutaneous tissue 1 86.6* Free skin graft 84 86.7* Pedicle grafts or flaps 1 86.8* Other repair and reconstruction of skin and subcutaneous tissue 2 86.9* Other operations on skin and subcutaneous skin tissue 72 93.5* Other immobilization, pressure and attention to wound 3 TOTAL 193

There were 68 burn related visits to the OR this fiscal year; however, each visit may have involved multiple procedures.

INTERVENTIONS PERFORMED IN NON BURN PATIENTS Total # of OR visits 26 Total # of OR Procedures 38 Intervention Codes # of occurrence 04.4* Release of carpal tunnel 2 04.79 Other neuroplasty 1 77.69 Excision of lesion or tissue of bone 1 70.94 Insertion of biological graft 2 83.21 Biopsy of soft tissue 1 84.0* Amputation of upper limb 2 84.1* Amputation of lower limb 3 86.2* Excision or destruction of lesion or tissue of skin and subcutaneous tissue 14 86.6* Free skin graft 16 86.7* Pedicle grafts or flaps 2 86.8* Other repair and reconstruction of skin and subcutaneous tissue 1 86.9* Other operations on skin and subcutaneous tissue 15 93.5* Other immobilization, pressure and attention to wound 5 TOTAL 65

There were 26 non-burn related visits to the OR this fiscal year; however, each visit may have involved multiple procedures.

HOW DID THESE INJURIES OCCUR?

Etiology of Injury The mechanism of injury is divided into the following categories: fire/flame, scald, contact with hot object, chemical, electrical injury, skin disease, other burn and other non-burn injuries. Skin disease refers to any skin related condition which includes Necrotizing Fasciitis, Fournier’s Gangrene and Steven Johnson syndrome. ‘Other burn’ consists of other forms of burn injuries not classified elsewhere including injuries with multiple etiologies. ‘Other non-burn’ includes friction burns and degloving injuries as classified by the ABA.

Etiology of Injury for Burns

Other burn, 2, 2%

Electrical , 2, 2%

Chemical, 2, 3% Flame/Fire, 50, 59% Contact with Hot Object, 6, 7%

Scald, 23, 27%

Etiology of Injury for Non- Burns

Necrotizing Fasciitis, 7, 27%

Other non- burn, 19, 73%

External Cause of Injury The external causes of injury are classified by E-codes based from the ICD-9 classification system. The E-codes indicate the environmental events, circumstances and conditions of the patient’s injury.

ICD 9 EXTERNAL CAUSE CODE BURN NON BURN 2015-2016 2015-2016 E804* Fall in, on, or from railway train 0 0 E811* Motor vehicle traffic accident involving re-entrant collision with another 0 0 vehicle E812* Other motor vehicle traffic accident involving collision with motor vehicle 0 0 E813* Motor vehicle traffic accident involving collision with other vehicle 0 0 E814* Motor vehicle traffic accident involving collision with pedestrian 0 0 E815* Other motor vehicle traffic accident involving collision on the highway 0 1 E816* Motor vehicle traffic accident due to loss of control, without collision on 0 3 the highway E817* Noncollision motor vehicle traffic accident while boarding or alighting 0 0 E818* Other noncollision motor vehicle traffic accident 1 0 E819* Motor vehicle traffic accident of unspecified nature 0 0 E820* Nontraffic accident involving motor-driven snow vehicle 0 0 E821* Nontraffic accident involving other off-road motor vehicle 1 0 E825 Other motor vehicle nontraffic accident of other and unspecified nature 1 1 E829* Other road vehicle accidents 0 0 E838* Other and unspecified water transport accident 0 0 E878* Surgical operation and other surgical procedures as the cause of abnormal reaction of patient, or of later complication, without mention of 0 0 misadventure at the time of operation E888* Accidental Falls 0 1 E890* Conflagration in private dwelling 1 0 E891* Conflagration in other and unspecified building or structure 0 0 E892 Conflagration not in building or structure 4 0 E893* Accident caused by ignition of clothing 14 0 E894* Ignition of highly flammable material 6 0 E895 Accident caused by controlled fire in private dwelling 1 0 E896* Accident caused by controlled fire in other and unspecified building or 0 0 structure E897 Accident caused by controlled fire not in building or structure 8 0 E898* Accident caused by other specified fire and flames 6 0 E901* Excessive cold 0 7 E907 Lightning 1 0 E917* Other Accidents 0 1 E919* Accident caused by machinery 0 2 E923* Accident caused by explosive material 8 1 E924* Accident caused by hot substance or object, caustic or corrosive material 28 0 and steam E925* Accident caused by electric current 2 0 E958* Suicide and self-inflicted injury by other and unspecified means 1 0 E968* Assault by other and unspecified means 2 0 N/A 0 9 TOTAL 85 26 34

WHERE DID THE INJURIES OCCUR?

Place of Occurrence It is important to review a breakdown of where burn and non-burn injuries occurred as it gives an area of where an increase of awareness for prevention is needed.

Place of Occurrence: Burns

2012-2013 2013-2014 2014-2015 2015-2016 75 67

60 54

46 47 45

1313 15 9 9 7 8 6 8 6 6 4 3 4 5 4 4 3 4 3 3 4 0 1 0 2 2 0 00 2 1 0 0 0 1 2 0 Home Farm Quarry or Industrial Place for Street and Public Residential Other Unknown Mine Places and Recreation Highway Building Institution Premises or Sport

Place of Occurrence: Non- Burns

2012-2013 2013-2014 2014-2015 2015-2016 15 12 10 10 8 7 6 6 6 5 5 4 4 3 2 2 2 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Home Farm Quarry or Industrial Place for Street and Public Residential Other Unknown Mine Places and Recreation Highway Building Institution Premises or Sport

WHERE WERE OUR PATIENTS DISCHARGED TO?

Discharge Disposition Discharge Disposition: Burns

2012-2013 2013-2014 2014-2015 2015-2016 83 90 71 80 61 69 70 60 50 40 30 20 3 8 0 1 4 7 5 4 6 4 7 10 0 2 1 1 1 0 0 1 0 0 1 2 1 1 0 1 0 0 3 2 1 0

Discharge Disposition: Non- Burns

2012-2013 2013-2014 2014-2015 2015-2016

25 21 20 17 15 15 11 10 3 2 3 3 5 0 1 1 0 0 0 0 0 1 0 1 0 1 0 1 0 1 1 0 0 0 0 0 1 0 0 0 1 0

Mortality The mortality data includes all burn patients admitted in the emergency department, outpatient clinic, ICU and U30/31. All non-burn patient mortality includes patients who have deceased during their stay under the Plastics Service only.

Mortality by Gender: Burns Male Female

6 4 4 4 3 3 2 2 1 1 0 0 2012-2013 2013-2014 2014-2015 2015-2016

Mortality by Gender: Non- Burns Male Female

4 3 2 2 2 1 1 0 0 0 0 2012-2013 2013-2014 2014-2015 2015-2016

Etiology BURN MORTALITY BY ETIOLOGY 2012-2013 2013-2014 2014-2015 2015-2016 Etiology Fire/ Flame 6 4 6 0 Scald 0 0 1 1 Total # of deaths 6 4 7 1 Total # of patients 75 86 105 85 Mortality Rate 8.00% 4.60% 6.60% 1.18%

NON- BURN MORTALITY BY ETIOLOGY 2012-2013 2013-2014 2014-2015 2015-2016 Etiology Other non-burn 1 0 0 0 Skin Disease 1 1 3 3 Total # of deaths 2 1 3 3 Total # of patients 13 26 20 26 Mortality Rate 15.40% 3.80% 15.00% 11.54%

Cause of Death CAUSE OF DEATH Burn Non- Burn 2012- 2013- 2014- 2015- 2012- 2013- 2014- 2015- Cause 2013 2014 2015 2016 2013 2014 2015 2016 Burn Shock 1 2 Cardiovascular Gastrointestinal Multisystem Organ 4 2 3 1 1 3 Failure Neurologic Pulmonary 1 Renal Sepsis 1 1 1 3 Other 1 2 Total # of Deaths 6 4 7 1 2 1 3 3

Resource Utilization Any resource utilized by the patient during his or her stay is documented from a list of common resources as stated by the ABA. These resources may be completed in the operating room, ICU or at bedside.

RESOURCE UTILIZATION Resource Burns Non- Burns Advance Directives Allograft (Homograft) skin 3 1 Anabolic Agent Arterial catheter 5 5 Biological wound covering Central Venous Catheter 7 7 Chest Tube/Thoracotomy Cultured skin Dialysis- hemodialysis/CVVH 1 Dialysis- peritoneal ECMO and/or AVCOR Endotracheal intubation 8 4 Enteral feeding tube 3 Escharotomies 3 Fasciotomies 2 4 IGIV 1 Integra 1 Nitric Oxide PA/ Swan Ganz Catheter Paracentesis Plasma exchange/ exchange transfusion Total Parenteral Nutrition 1 Tracheostomy 3 Transfusion of blood 10 7 Transfusion of FFP 2 3 VDR Ventilation Xenograft (heterograft) skin TOTAL 48 33

A patient may have utilized one or more resources during his or her stay.

Insurance The primary source responsible for payment of service(s) provided to the patient admitted to the Foothills Medical Centre.

BURNS Insurance # of burn patients Provincial Healthcare Alberta 72 British Columbia 1 WCB Alberta 8 British Columbia 1 Uninsured 2 Out of Country 1 TOTAL 85

NON BURNS Insurance # of non-burn patients Provincial Healthcare Alberta 24 WCB Alberta 1 Department of Defense 1 TOTAL 26

OUTPATIENT BURN TREATMENT SERVICES

The Outpatient Burn Treatment Clinic provides treatment and rehabilitation of burn injuries including surgical grafting, graft revisions and major plastic repairs. Burn clinic patients are currently not captured in the burn registry. The data below is from Data Integration, Measurement and Reporting (DIMR).

The following is a brief summary of the burn clinic from this fiscal year:

There were a total of 1349 burn clinic visits which includes readmissions to the clinic. A total number of 496 patients were seen at the burn clinic.

OUTPATIENT BURN CLINIC Age Range TOTAL

Gender TOTAL Male 820 Female 529 TOTAL 1349

APPENDIX A

APPENDIX B

APPENDIX C

Burn Rounds Schedule 2015-2016 DATE TOPIC April 1, 2015 Strategies for avoiding secondary lung injury April 8, 2015 Principals of secondary burn reconstruction April 15, 2015 Sr Resident chooses & leads discussion of article from most recent JBCR April 22, 2015 Working Rounds Only - ABA in Chicago April 29, 2015 ABA in Review - Staff MDs May 6, 2015 ABA in Review - Residents May 13, 2015 ABA in Review - Nursing May 20, 2015 ABA in Review - OT/PT May 27, 2015 Abdominal Compartment Syndrome in the burn-injured patient June 3, 2015 History of skin grafting June 10, 2015 Non-surgical burn scar management June 17, 2015 Sr Resident chooses & leads discussion of article from most recent JBCR June 24, 2015 Flex week/Post-Doc presentations from Biernaskie Lab July 1, 2015 STAT holiday - no rounds July 8, 2015 Cyanide poisoning July 15, 2015 Splinting considerations in Acute Burn Injury July 22, 2015 The Burned Ear: Acute management and secondary reconstruction July 29, 2015 Sr Resident chooses & leads discussion of article from most recent JBCR August 5, 2015 Heterotopic Ossification August 12, 2015 Burn Scar Management: Laser and IPL Therapy August 19, 2015 Osseointegrated Implants in burn reconstruction August 26, 2015 Flex week/Post-Doc presentations from Biernaskie Lab September 2, 2015 Sr Resident chooses & leads discussion of article from most recent JBCR January 20, 2016 Hematologic response to Burn Injury January 27, 2016 Adrenal & Hepatic Responses to Burn February 03, 2016 Bone/Mineral/Phosphate changes February 10, 2016 Nutritional Support/Vitamins February 17, 2016 Modulating Hypermetabolic Response February 24, 2016 Organ Failure & Support March 02, 2016 Geriatric Burns March 09, 2016 Surgery for Burn Complications March 16, 2016 Electrical Injuries: Pathophysiology etc March 23, 2016 Electrical Injuries: Reconstruction March 30, 2016 Frostbite