Systems-based Practice in

B u r n C a re
Prevention, Management, and Economic
Impact of Health Care–associated Infections
Charles Scott Hultman, MD, MBAa,*,
David van Duin, MD, PhDb,
Emily Sickbert-Bennett, PhD, MPHc, Lauren M. DiBiase, MSc,
Samuel W. Jones, MDd, Bruce A. Cairns, MDd,
David J. Weber, MD, MPHb,c

KEYWORDS
 Systems-based practice  Burn injury  Patient safety  Quality improvement
 Health care–associated infections

KEY POINTS
 Age, size of burn, and presence of inhalation injury remain the key predictors of outcome after ther-
mal injury, but the development of health care–associated infections (HAIs) compromises out-
comes and increases morbidity and mortality.
 Many HAIs can be prevented, through rigorous application of patient safety protocols, standardi-
zation of care, vigilant monitoring, and quality improvement initiatives.
 Systems-based practice serves as both an analytical tool and an interventional opportunity, in
which an individual provider, functioning across interconnected microsystems, can leverage those
relationships to improve the function of the larger health care system.

INTRODUCTION outcomes and reducing morbidity and mortality

are the prevention and effective management of
The classic determinants of survival after thermal health care–associated infections (HAIs). Due to
injury are age, burn size, and presence of inhala- disruption of the integument, which provides a me-
tion injury, but infection remains the leading cause chanical and immunologic barrier to pathogens,
of mortality, ahead of burn shock and organ fail- patients with severe burns are at high risk for
ure.1 The American Burn Association estimates both local and systemic infections.
that 486,000 patients with burn injury require med- The Centers for Disease Control and Prevention
ical treatment in the United States annually, (CDC) identified HAIs as a preventable cause of
involving 40,000 hospital admissions and resulting morbidity and concluded appropriately that these
in 3275 deaths.2 Paramount to achieving improved infections represent a major threat to patient
plasticsurgery.theclinics.com

Presented, in part, at the 93rd Annual Scientific Meeting of the American Association of Plastic Surgeons,
Miami, FL, April 2014.
The authors have nothing to disclose.
a
Division of Plastic Surgery, University of North Carolina, Suite 7038, Burnett Womack, Chapel Hill, NC 27599,
USA; b Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC 27599, USA; c Hospital
Epidemiology, University of North Carolina, Chapel Hill, NC 27599, USA; d UNC Jaycee Burn Center, University
of North Carolina, Chapel Hill, NC 27599, USA
* Corresponding author.
E-mail address: [email protected]

Clin Plastic Surg - (2017) -–-

http://dx.doi.org/10.1016/j.cps.2017.06.002
0094-1298/17/Ó 2017 Elsevier Inc. All rights reserved.
2 Hultman et al

safety.3 The HAI Prevalence Survey, published in patients admitted to the University of North Car-
2014, exposes the full burden of this problem: olina (UNC) Jaycee Burn Center, from 1999 to
approximately 722,000 patients develop HAIs per 2012. The initial data set was obtained from a pro-
annum, accounting for approximately 75,000 in- spectively maintained institutional registry, which
hospital deaths.4 Although the incidence of HAIs was part of the National Burn Repository of the
has dropped considerably over the past decade, American Burn Association. This database was
due to improved surveillance, education, training, then cross-referenced and merged with a compre-
feedback, bundles, and checklists, 1 in 25 hospi- hensive, hospital-wide surveillance registry for all
talized patients still has at least 1 HAI on any given HAIs, as defined by the CDC, for catheter-
day. Prevention of HAIs, their early diagnosis, and associated urinary tract infections (CAUTIs) from
the rational use of antibiotics are largely respon- 2006 to 2012, central line–associated bloodstream
sible for these improved outcomes, all tangible infections (CLABSIs) from 1999 to 2012, ventilator-
benefits of systems-based practice (SBP), in associated pneumonias (VAPs) from 2004 to 2012,
which individual health care providers, teams, clin- and surgical site infections (SSIs) and skin and soft
ical microsystems, and the macro-organization tissue infections (SSTIs) from 2002 to 2012.
work together to improve patient safety. The study was conducted at the UNC Hospitals,
First introduced in 1999 by the Accreditation an 806-bed tertiary/quaternary care facility, which
Council for Graduate Medical Education, and later includes a 21-bed burn ICU plus another 20-bed
adopted by the American Board of Medical Spe- step-down unit for burns and wound care. Active
cialties as part of Maintenance of Certification, members of the UNC Jaycee Burn Center team
SBP is a clinical competency in which physicians include burn and plastic surgeons (all of whom
strive to understand how patient care relates to the are board certified in surgical critical care),
health care system, as a whole, and how to utilize dedicated anesthesiologists, infectious disease
and even leverage that system to improve the quality specialists, hospital epidemiologists, nurses profi-
and safety of patient care.5,6 SBP serves as both an cient in advanced burn care, occupational and
educational tool to measure and enhance perfor- physical therapists, nutritionists, pharmacists, rec-
mance of clinicians and an analytical model to reational therapists, social workers, and chaplains.
improve the overall health care system. In contrast Almost all patients were housed in single, isolated
to the competency of practice-based learning, ICU beds as well as semiprivate step-down beds
which asks, “How can I improve the care of my when stable for transfer. Burn wound precautions
own patients,” SBP poses the question, “How can for all patients included monitored hand hygiene,
I improve the system of care?” Because health gloves, and gowns, for all providers entering ICU
care is a complex, adaptive system, which contains rooms.
microsystems that are sometimes aligned but often
have competing behaviors, objectives, and oppor- Data Collection and Study Design
tunities, the importance of systems thinking cannot
be overstated. Understanding large organizations, The following data points were extracted from the
with their interacting, interrelated, and interdepen- burn center registry and the surveillance database
dent elements, improves health care not only at from hospital epidemiology: age, size of burn,
the patient level but also for populations of patients. presence of inhalation injury, incidence of HAI,
The purpose of this investigation is to analyze the identification of pathogens, length of stay (LOS),
impact of SBP on the outcomes of burn patients mortality, and total hospital charges. These data
who developed HAIs. Specifically, what measures to were used to
have been implemented to prevent and treat HAIs 1. Observe the incidence of HAI, CAUTI, CLABSI,
at the authors’ institution? What is the economic and VAP as a function of time
impact of the development of HAIs in these burn 2. Compare those patients who developed index
patients? In what areas has progress been made, SSIs/SSTIs with those who did not, from 2008
and where does work remain? Finally, what lessons to 2012
have been learned that can be extrapolated to other 3. Understand the changing distribution of patho-
health care systems, such that all burn patients can gens, from 2007 to 2012
benefit from the authors’ experience? 4. Create a financial model that would predict the
direct medical costs of developing HAIs, spe-
METHODS cifically at the authors’ burn center
Patient Population
Previously published CDC estimates for low,
The authors performed an institutional review high, and adjusted costs (pegged to the consumer
board–approved, retrospective cohort study of all price index) were used for comparison.7 Impact of
 Systems-based Practice in Burn Care 3

HAI on LOS was based on clinical practice guide- was used for continuous data, and 2-tailed c2
lines for treatment of SSI/SSTI, CAUTI, CLABSI, test analysis was used for categorical variables.
VAP, and Clostridium difficile infection (CDI). Statistical significance was assigned to P<.05.

Interventions RESULTS
Standard burn wound precautions (monitored Overall Health Care–associated Infections
hand hygiene, gloves, and gown) for all ICU pa- From 2007 to 2012, total number of admissions to
tients and all step-down patients with open the burn ICU increased from 737 to 1242 (Table 1),
wounds, were begun before the start of the study whereas the number of HAIs dropped from 88 to
period and were continued throughout the dura- 48 per year. Furthermore, the infection rate per
tion of the study. Quality improvement initiatives, 1000 patient-days decreased from 11.73 to 6.48
implemented at different time points from 1999 for all HAIs. Fig. 1 demonstrates that in 2008, the
to 2012, included education and training of all clin- authors introduced and maintained (1) strict, moni-
ical personnel, feedback loops with closure of tored, 2-pump hand-hygiene before room entry;
communication, clinical reminders (posters, flow- (2) a switch from paper to plastic gowns plus
charts, and fact sheets), introduction of clinical gloves, hat, and mask when inspecting wounds;
care bundles developed by the Institute for Health- and (3) isolation and semiquarantine of MDR pa-
care Improvement (IHI), procedural and patient tients (specifically Acinetobacter). Incidence of
safety checklists, empowerment to stop proced- HAIs, in the non–burn ICUs, dropped from 6 to
ure or ask questions, Team Strategies and Tools 4.5 infections per 1000 patient-days over this
to Enhance Performance and Patient Safety period.
training (designed by the Agency for Healthcare
Research and Quality), active surveillance and dis- Catheter-associated Urinary Tract Infections
tribution of HAI data to the health care team, utili-
zation of the Plan-Do-Study-Act model to improve Incidence of CAUTI peaked in 2007 to almost 6 in-
throughput, selective use of lean Six Sigma for fections per 1000 patient-days but rapidly
specific projects (such as management of declined to less than 3 infections per 1000
multidrug-resistant [MDR] HAI outbreaks), and patient-days (Fig. 2). To comply with guidelines
active participation in the monthly hospital infec- drafted by the Surgical Care Improvement Project
tion control committee. (sponsored by the Centers for Medicare &
Medicaid Services), in 2007 the authors started
Statistical Analysis removing indwelling urinary catheters within
24 hours after initial resuscitation or surgery. This
HAI rates for CAUTI, CLABSI, and VAP were calcu-
intervention had a direct, immediate, and lasting
lated as infections per 1000 patient-days, whereas
effect on reduction of CAUTIs in the burn ICU.
incidence of SSIs/SSTIs is reported as percent of
patients who developed a culture-documented
Central Line–associated Bloodstream
clinical infection. Surveillance data for the various
Infections
HAIs began at different starting points, depending
on when the CDC may have revised their diag- From 2000 to 2012, the incidence of CLABSIs
nostic criteria and reporting definitions. For the decreased from more than 20 to 2.5 infections
SSI versus non-SSI analysis, the Student t test per 1000 patient-days. Most likely, no specific

Table 1
Incidence of health care–associated infections in the burn ICU at University of North Carolina Hospitals,
2007–2012, with infection rate adjusted to 1000 patient-days

No. of No. of
Year No. of Admissions to Burn ICU HAIs Patient-days Infection Rate per 1000 Patient-days
2007 737 88 7500 11.73
2008 771 63 6003 10.49
2009 872 52 7415 7.01
2010 966 62 7393 8.39
2011 1312 56 7485 7.48
2012 1242 48 7402 6.48
4 Hultman et al

Fig. 1. Overall incidence of HAIs in the ICUs at UNC Fig. 3. Incidence of CLABSI in the ICUs at UNC, 1999 to
Hospitals. BICU, burn ICU; BID, twice per day. 2012. BICU, burn ICU; prep, peparation; RN, registered
nurse.

intervention accounted for this approximately 90% benefit of focusing on those HAIs that represented
reduction; rather, this was the result of multiple ini- a challenge and opportunity. Approximately
tiatives related to SBP (Fig. 3). In addition to full 15 years ago, the authors made deliberate at-
barrier precautions for central line placement, the tempts to standardize wound care protocols and
authors switched from betadine to chlorhexidine- decrease variability between faculty members, so
isopropyl alcohol for skin preparation, in 2000. that rotating medical students, new nursing staff,
The other important intervention, which occurred and changing residents could quickly integrate
in 2004, seems to be the rotation of central lines into team dynamics, without having to learn myriad
to a new site, with a fresh stick, every 3 days. Stan- options for wound care. As a result, wound care al-
dardization of site wound care, combined with use gorithms have remained consistent, the details of
of IHI-defined CLABSI bundles, allowed reaching a which include
very low infection rate, comparable to the other
ICUs at the authors’ hospital.  The use of topical silver sulfadiazine for all
open and unexcised burn wounds below the
Ventilator-associated Pneumonia neck
 The application of bacitracin to the face and
Unfortunately, from 2004 to 2012, incidence of
neck
VAP was variable from year to year, despite the
 The intraoperative placement of xenograft on
steady decline observed in the rest of the authors’
most partial-thickness scald burns, within
surgical and medical ICUs (Fig. 4). In 2008, the au-
36 hours of injury
thors introduced several measures to address
 Daily chlorhexidine baths with reapplication of
climbing VAP rates, such as serial bronchoscopy
topical antimicrobials
for inhalation injury, bronchoalveolar lavage to
 The early excision of deep partial-thickness
obtain pulmonary cultures, stress ulcer prophy-
and full-thickness burn wounds, 3 days to
laxis, and head of bed elevation. Preventing VAP
7 days after injury, after resuscitation is
continues to be a work in progress.
complete
Surgical Site Infections/Skin and Soft Tissue  The irrigation of skin grafts with sulfamylon and
Infections nystatin postoperatively, for 4 days to 5 days
 The initiation of silver nitrate at 4 days to
Although not the focus of the authors’ interven- 5 days postoperatively, if skin graft take is
tions, the incidence of SSIs and SSTIs dropped compromised
from almost 11% in 2004 to less than 1% in
2012 (Fig. 5). Such reduction may be a collateral

Fig. 4. Incidence of VAP in the ICUs at UNC, 2004 to

2012. BAL, bronchoscopic alveolar lavage; BICU,
Fig. 2. Incidence of CAUTIs in the ICUs at UNC, 2006 to burn ICU; bronch, bronchoscopy; cxs, cultures; HOB,
2012. BICU, burn ICU; OR, operating room. head of bed.
 Systems-based Practice in Burn Care 5

revealing that the organisms were genetically

linked, despite seeming to be epidemiologically
unlinked.9 At the end of the study period, in
2012, the most common organisms were Pseudo-
monas, Stenotrophomonas, Enterococcus, and
Staphylococcus aureus, in decreasing order
respectively.

Economic Impact
Fig. 5. Incidence of SSIs/SSTIs in the ICUs at UNC, 2002 CDC data from 2002, compared with 2011, indi-
to 2012. BICU, burn ICU. cated that total HAIs in the United States, per
year, dropped from 1.737 million to 722,000, with
Index Cases the greatest decreases observed in CLABSIs and
Although SSIs and SSTIs have become consider- CAUTIs (Table 3). The incidence of VAP, however,
ably less prevalent in the authors’ burn center pop- has not decreased and remains close to 50,000
ulation, the development of these infections is cases per year.3,4 Estimates for cost of care, pub-
associated with significantly worse outcomes. lished by the CDC in 2009, include low and high
From 2008 to 2012, 20 index cases, involving valuation as well as an estimate adjusted in
MDR organisms, were reported to hospital epide- conjunction with the consumer price index.7 For
miology. Compared with the 5143 nonindex pa- the authors’ model, an increased LOS, based on
tients, the 20 index cases with SSI or SSTI had a current clinical guidelines for therapy for SSI/
larger burn size (35.8% vs 7.2% total burn surface SSTI, CAUTI, CLABSI, VAP, and CDI, was
area), higher incidence of inhalation injury (40% vs assumed. Direct medical costs, which include
4.4%), greater mortality (30% vs 3%), and higher use of fixed assets, variable overhead, labor, and
direct medical costs ($325,000 vs $57,000). Refer supplies, were calculated for each HAI using a
to Table 2 for P values and SDs. conversion factor of $5199 per day of ICU care.
If the development of an HAI adds 10 days of hos-
Microbiology pital care, for example, then this would increase
the direct medical cost (excluding physician pro-
From 2007 through 2012, the microbiologic fessional fees) by $51,999, which is twice the
flora found in burn patients with HAIs varied CDC adjusted estimate of $25,903. All the pre-
considerably. Fig. 6 demonstrates that MDR Aci- dicted direct medical costs are greater than those
netobacter was particularly prevalent from 2008 estimated by the CDC, perhaps because thermally
to 2010. Across this 3-year period, the authors injured patients have both the burn and the HAI
experienced several outbreaks, which were due from which to recover.
to 3 distinct strains, with different genomes for
drug resistance.8 Likewise, beginning in 2010, DISCUSSION
the burn center experienced a prolonged
outbreak of carbapenem-resistant Enterobacter In summary, this article reports that HAIs in
and Klebsiella, with whole-genome sequencing burn patients, ranging from VAP to SSTIs, can

Table 2
Comparison of burn patients with index surgical site infections/skin and soft tissue infections versus
all other patients admitted, 2008–2012. Index case is defined as a burn wound infection reported to
hospital epidemiology, often involving MDR organisms

Surgical Site
Infections/Skin Total Burn Inhalation
and Soft Tissue Surface Length of Injury Death
Infections N Age (y) Area (%) Stay (d) (No., %) (No., %) Charges
Index cases 20 42.2  35.8  SD 22.1 94.2  8, 40% 6, 30% $325,000 
SD 22.0 SD 92.0 SD $313,000
Nonindex 5143 32.7  7.2  SD 11.6 12.0  225, 4.4% 155, 3.0% $57,000 
patients SD 22.5 SD 21.0 SD $113,000
P value .059 <.001 <.001 <.001 <.001 .012
6 Hultman et al

of patients that the health care system services,

and populations of patients beyond the reach of
a single health care system.
Domains of competence within SBP include6
1. Working effectively in various health care deliv-
ery settings and systems relevant to their clin-
ical specialty
2. Coordinating patient care within the health care
system relevant to the clinical specialty
3. Incorporating considerations of cost aware-
ness and risk/benefit analysis in patient care
4. Advocating for quality patient care and optimal
patient care systems
Fig. 6. Relative percentage of pathogens isolated 5. Working in interprofessional teams to enhance
from the burn ICU at UNC, 2007 to 2012. C. diff, Clos- patient safety and improve patient care quality
tridium difficile; E. coli, Escherichia coli; GNR, Gram 6. Participating in identifying systems errors and
negative rod, H. flu, Hemophilus influenza; Mucor, in implementing potential systems solutions
Mucormycosis; Staph aureus, Staphylococcus aureus; 7. Knowing how to advocate for the promotion of
Strep, Streptococcus. health and the prevention of disease and injury
in populations
substantially compromise outcomes, because
these complications are associated with longer Over the past 15 years, at the authors’ institu-
LOSs, increased mortality, and greater direct med- tion, slowly but unequivocally the incidence of
ical costs. HAIs are largely preventable, through HAIs in the burn center has decreased, resulting
surveillance, education, hand hygiene, and culture in improved survival and shorter LOSs, for the
change, especially device-related infections, such overall population of patients treated.1,10,11
as CLABSIs and CAUTIs. SBP, which allows indi- Although the rate of CLABSI has been reduced
viduals and clinical microsystems to navigate and dramatically,12 VAP continues to be a major clin-
improve the macro health care system, may be ical challenge,13 consistent with national data
one of the most powerful skill sets to effect change, from the HAI Prevalence Survey4 and CDC trends
because this permits a shift in culture toward pa- over time.3 One meta-analysis and systematic re-
tient safety and quality improvement. view confirmed that quality improvement interven-
Although considered a competency by accredit- tions were effective in decreasing the incidence of
ing councils, certifying boards, and hospital cre- CLABSI, in 41 of 43 before–after cohort studies, all
dentialing committees, SBP really serves as an of which met methodologic criteria established by
analytical tool to study the inefficiencies, con- the Cochrane Group.14,15 Initiatives that involved
straints, and defects of a system. Furthermore, implementation of care bundles and checklists
SBP empowers health care providers, at the indi- seemed to yield the stronger risk reductions
vidual level, to work within a complex system of compared with education and training, feedback
inter-related and interdependent microsystems, and empowerment, and clinical reminders. Other
to align their competing goals and objectives groups have studied the potential impact of
with those of the entire organization. In cases of chlorhexidine baths,16 standardization of antibiotic
burn care, HAIs represent a clinical challenge regimens,17 methicillin-resistant Staphylococcus
that is partially due to miscommunication, subop- aureus screening and eradication,18 high-
timal teamwork, and failure of smaller units to frequency percussive ventilation,19 adherence to
appreciate the nuances of how to provide the core ICU measures,20 and treatment in a dedi-
safest, most cost-effective, highest value care. cated burn ICU21 as interventions to prevent
SBP produces real results. In a sense, SBP is a HAIs in burn patients, with good to equivocal
bundle of interventions that focus on improving the results.
culture of an institution, by focusing on human One of the unexpected but positive findings in
capital as a critical resource. Clinicians not only the authors’ study is the dramatic reduction in
implement evidence-based guidelines for clinical the incidence of SSIs and SSTIs in burn patients
care but also develop them within the context of from 2004 to 2012, despite no specific, directed
an institution. The ultimate goal of SBP is the intervention designed to prevent these HAIs,
dissemination of new knowledge to improve the which dropped from almost 11% to less than
outcomes of patients at the bedside, groups of pa- 1%. Although wound infections have become far
tients treated in a specific clinical setting, cohorts less common, the clinical and economic toll
 Table 3
Economic impact of health care–associated infections in burn care

Estimated Estimated Centers for Centers for Disease Control

Infections in Infections in Disease Control Centers for Disease and Prevention Estimate, Increased
Infection United States, United States, and Prevention Control and Prevention Adjusted Using Consumer Length of University of North
Type 2002 (No.) 2011 (No.) Estimate, Low ($) Estimate, High ($) Price Index ($) Stay (d) Carolina Estimate ($)
All HAIs 1,737,125 721,800 16,359 19,430 25,903 10 51,990
SSI 290,485 157,500 10,443 25,646 34,670 7 36,393
CAUTI 449,334 93,300 589 758 1007 1 5199
CLABSI 92,011 15,600 5734 22,939 29,156 7 36,393

Systems-based Practice in Burn Care

VAP 52,543 49,900 11,897 25,072 28,508 14 72,786
CDI 178,000 123,100 5042 7179 6408 3 15,597
Each additional day at UNC Hospitals accrues an additional $5199 of direct medical costs (fixed 1 variable), excluding indirect and intangible costs. CDC estimates from 2009. LOS
estimated by authors.

7
8 Hultman et al

remains staggering. Patients who develop an in- 9. Kanamori H, Parobek CM, Juliano JJ, et al.
dex SSI/SSTI had a mortality of 30%, compared A prolonged outbreak of KPC-3-producing entero-
with 3% for nonindex cases. Furthermore, LOS bacter cloacae and klebsiella pneumoniae driven
was 94 days for the index group, compared with by multiple mechanisms of resistance transmission
12 days for the nonindex group, resulting in a at a large academic burn center. Antimicrob Agents
charge differential of $325,000 versus $57,000. Chemother 2017;61(2) [pii:e01516-16].
The authors speculate that the efforts to decrease 10. van Duin D, Strassle PD, DiBiase LM, et al. Timeline
the incidence of other HAIs, such as CLABSI and of health care-associated infections and pathogens
CAUTI, produced a scenario in which “a rising after burn injuries. Am J Infect Control 2016;44(12):
tide floats all boats.” It can reasonably be 1511–6.
concluded that the intentional efforts to improve 11. Weber DJ, van Duin D, DiBiase LM, et al. Health-
communication and teamwork, in the UNC Jaycee care-associated infections among patients in a large
Burn Center, improved SBP, through a culture shift burn intensive care unit: incidence and pathogens,
toward patient safety, quality, and value. Although 2008-2012. Infect Control Hosp Epidemiol 2014;
individual providers must accrue medical knowl- 35(10):1304–6.
edge and sharpen their patient care skills, SBP 12. van Duin D, Jones SW, Dibiase L, et al. Reduction in
may prove the most important competency a central line-associated bloodstream infections in pa-
health care system can purse, to meet its goal tients with burns. Infect Control Hosp Epidemiol
and public expectation to improve the health of 2014;35(8):1066–8.
populations. 13. Lachiewicz AM, Weber DJ, van Duin D, et al. From
VAP to VAE: implications of the new CDC definitions
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