L. S. Nosanov1,2, M. M. McLawhorn2, L. Hassan2, T. E. Travis1,2, S. Tejiram1,2, L. S. Johnson1,2, L. T. Moffatt2, J. W. Shupp1,2 1MedStar Washington Hospital Center,Burn Center,Washington, DC, USA 2MedStar Health Research Institute,Firefighters’ Burn And Surgical Research Laboratory,Washington, DC, USA
Introduction: Etiologies contributing to burn graft loss are well studied, yet there exists no consensus definition of burn “graft loss”, nor a scale with which to grade severity. This study examines a single burn center’s experience with graft loss. Our institution introduced a graft loss grading scale in 2014 for quality improvement. We hypothesize that higher grades are associated with longer hospital stays and increased morbidity.
Methods: Following IRB approval, a retrospective review was performed for all burned patients with graft loss on departmental morbidity and mortality reports 7/2014–7/2016. Duplicate entries, wounds not secondary to burns, and chronic non-healing wounds were excluded. Data abstracted from the medical record included demographics, medical history, and details of injury, surgical procedures, graft loss, and clinical outcomes including hospital and ICU lengths of stay. Graft loss grades were assigned per institutional grading scale (Table 1). Photos of affected areas were graded by two blinded surgeons, and a linear weighted κ was calculated to assess inter-rater agreement.
Results: In the two-year study period, 50 patients with graft loss were identified. After exclusions, 43 patients were included for analysis. Mean age was 50.1 years, and the majority were male (58.1%) and African American (41.9%). Smoking (30.2%) and diabetes (27.9%) were prevalent. The most common mechanisms were flame (55.8%), scald (18.6%) and thermal (11.6%). Total body surface area (TBSA) involvement ranged 0.5–51.0% (mean 11.8±12.3 %). Grade 1 graft loss was documented in the chart of one patient (2.3%), Grade 2 in 15 (34.9%), Grade 3 in 12 (27.9%) and Grade 4 in 15 (34.9%). Seven patients had wound infections at diagnosis of graft loss. Reoperation was performed in 20 (46.5%). Hospital LOS ranged 9–81 days (mean 27.4±16.0 days), with ICU LOS ranging 0–45 days (mean 7.7±10.9 days). Hospital LOS was longer than predicted (by TBSA%) in 38 patients (88.4%). Seven patients experienced significant morbidities including two amputations. On image review, moderate agreement was reached between blinded surgeons (k = 0.44, 95% CI 0.11 – 0.65, p = 0.004).
Conclusion: Graft loss is a major source of morbidity in burn patients. In this cohort, reoperation was common and hospital LOS was extended. Use of a graft loss grading scale enables improved dialogue among providers and lays the foundation for improved understanding of risk factors. Results of this study will be used to guide revision of the institutional graft loss grading scale.
