Closure of Partial-Thickness Facial Burns with a Bioactive Skin Substitute in the Major Burn Population Decreases the Cost of Care

Introduction Management of partial-thickness burns of the face requires extensive healthcare resources, especially in the endotracheal-intubated patient, to control pain, avoid infection, and minimize scarring.1-4 Standard care for partial-thickness burns is the frequent application of antibiotic ointments and cleansing to avoid exudate buildup and infection.3,4 This process is not only time consuming but requires considerable analgesia and involves the potential for endotracheal tube dislodgement with patient movement. Immediate wound closure of the partial-thickness facial burn can now be achieved using a rapidly adherent, bioactive, bilayered skin substitute*.1,5 The authors have previously demonstrated the use of this skin substitute on facial burns to decrease pain and improve healing in a smaller group of patients who had mainly just facial burns. The purpose of this study was to determine whether the use of a bioactive skin substitute for partial-thickness facial burns in the presence of major burns, especially those requiring intubation, was not only beneficial but also cost effective relative to standard care for the facial burn. Methods Major burn patients with partial-thickness burns at least mid-dermal in depth were randomized into either standard care with topical antibiotics or closure with a skin substitute. Outcome parameters measured were patient pain during face care using the 0-to-10 pain scale (0 = no pain; 10 = worst pain)6 and time to 95-percent reepithelialization. The cost-analysis parameters measured were nursing costs, determined by nursing time spent on facial care; supplies, including the cost of the skin substitute and topical antibiotics; and medication costs, mainly analgesics and sedatives. An antibiotic ointment was used on the partial-thickness face burn except on burned ears where silver sulfadiazine was used. The antibiotic ointments and creams were applied and removed twice a day according to the study's protocol.3,4 The skin substitute was applied at the initial burn treatment procedure according to the protocol developed for its use. This protocol requires initial debridement of the burn using conscious sedation to obtain a clean wound bed after which the skin substitute is thawed, removed, cut to fit, and applied. This biologically active product is stored at -70° F in the burn center prior to application. After the skin substitute is applied, an initial light gauze dressing is applied. This dressing is removed 12 to 24 hours after the gauze is removed from the closed facial burn. Wound care includes removing a plasma exudate, which collects at the seams of the skin substitute. In addition, fluid is rolled from beneath the skin substitute to improve adherence. The process is usually only required at the first assessment at 12 to 24 hours. In this study, the burn center nurse coordinator and nurse research assistant collected the data regarding patient pain, nursing time, medications, etc. on a daily basis. Current hospital, pharmacy and burn center costs, not charges, were used. Nursing time for facial care was readily distinguished from care for the total burn area. Statistical Analysis Statistical differences between groups were determined by ANOVA using the Dunnetts t-test to compare groups at different time periods. Statistical significance was considered to be a p value less than 0.05. Results Patient care data. A total of 34 patients with major burns, including a partial-thickness facial burn, were randomized into one of the two groups. One group was treated with topical antibiotic agents, with facial care as needed. The other group's wounds were debrided and closed with the skin substitute. This group received subsequent care as needed. Eighteen patients, nine from each group, required initial endotracheal intubation. Patient characteristics are presented in Tables 1 and 2. Approximately two-thirds of the burns were caused by flames, often from an explosion. The remainder were large scald injuries that occurred mostly in the workplace. Facial burns were mainly mid-dermal in depth. Sixty percent of the facial burns included the ears. Mean group outcome data demonstrated that the pain during dressing changes was 7 ± 2 and 3 ± 1, respectively, for the standard and skin substitute groups, respectively. In the 0-to-10 pain scale, 0 represents no pain and 10 represents the worst pain. There was a significant decrease in pain among the skin substitute group. Healing time for the facial burns (95% reepithelialization) was 15 ± 4 days for the standard group and 9 ± 4 for the skin substitute group. The facial burns healed significantly faster with the skin substitute. There were no failures of initial skin substitute adherence nor need for reapplication. No facial or ear infections occurred in either group as evidenced by the fact that no quantitative swab culture exceeded 105 organisms/gram and no wound conversions occurred. Cost analysis. The study showed a significant decrease in nursing time costs and medications in the skin substitute group. Tables 2 and 3 provide a cost analysis. As shown in Figures 1 and 2, initial application requires a light compression dressing after which the substitute adheres and requires minimal care. The cost of supplies, which included the cost of the skin substitute, was higher in the skin substitute group. However, the cost of pain medication was lower. The net cost of the care of the facial burns to closure was significantly less using the skin substitute. The major differences were the daily nursing costs and the increased time to wound closure in the standard care group. Discussion Partial-thickness burns to the face, especially in the presence of a major body burn, require considerable facial care to control pain, avoid exudate buildup and infection, and thereby decrease the potential for scar formation.1-4 A temporary skin substitute can lead to immediate wound closure, decreasing pain and wound care, although this specific aspect has not been studied. The authors studied major burn patients with partial-thickness facial burns because of the ability to better assess outcome and care effectiveness of the facial burn itself. The standard of face care in this population is the use of topical antibiotic creams or ointments, which are removed and reapplied twice a day to avoid infection and dessication. Topical antibiotic use has the potential advantages of the decreased cost of the antibiotic agents compared to a temporary biologic skin substitute. However, the data presented indicates that this decreased cost is more than neutralized by the increased costs of nursing time, pain medications, and other drugs needed to remove and replace these agents. This well-adhering temporary skin substitute rapidly closes the burn wound after which face care is minimized to only removing the plasma exudate that occur at the seams. The rolling out of any exudate buildup beneath the substitute is required mainly on day one and is usually not required by day three. The disadvantage of using an open wound care technique on the face is the increased pain that occurs with removal and reapplication of the antibiotic agents. In addition, the majority of these agents impair wound healing including re-epithelialization. Also, an open wound causes a greater overall systemic "stress response" than a closed wound. Nearly half of our study population of facial burns also required endotracheal intubation due to concerns of a compromised upper airway from facial edema and smoke-inhalation-induced lung dysfunction. In this population, removal of wound exudate from a partial-thickness burn is time consuming and poses an increased risk because the patient may dislodge the endotracheal tube in response to the pain associated with this procedure. The use of the skin substitute not only diminishes the need for cleaning the face around the tube but also eliminates the startle reflex. Increased narcotics and sedation were needed in the standard facial care group, both of which can lead to the secondary complications of respiratory depression, hemodynamic changes, and ileus. Immediate closure of a partial-thickness facial burn improves patient comfort and requires less narcotics. Use of the skin substitute also improves healing as local wound trauma, dessication, bacteria colonization, and exudate are decreased.1,7,8,9 The skin substitute used in this study is a bilayered, biologically active, temporary skin substitute. An outer flexible knitted nylon is impermeable to bacteria but permeable to water vapor, which decreases environmental insults. The inner layer contains bioactive skin fibroblast products, especially human fibronectin, which produces a rapid adherence to a cleaned partial-thickness wound bed.1-5,10,11 The product is also very flexible and conformable. These properties produce an excellent adherence to the face where contour changes and movement require a rapid and tight adherence. Therefore, no daily wound trauma or colonization occurs, and a moisture layer is maintained between the inner adherent layer and the wound substitute surface, optimizing the healing environment. In all cases in our study, the skin substitute remained adherent and without infection, providing an optimum healing environment while requiring minimal care. The potential disadvantage of this temporary skin substitute is its use on a wound that has not been adequately debrided, which will impede adherence. Also, this agent is more difficult to use on a burn that has been treated open for 24 to 48 hours, because removing necrotic debris without general anesthesia is difficult. Therefore, early wound closure needs to be initiated in the early post-burn period to be effective. The use of a bioactive adherent skin substitute for management of partial-thickness facial burns in the presence of a major burn improves patient comfort and healing rate and is cost effective. * TransCyte®, Smith & Nephew, Inc., Largo, Florida