Cost/benefit analysis of initial cultures in the management of acute burns

The use of burn clinical pathways has helped to improve quality of care and decrease costs in the Burn Center. However, despite implementation of these pathways, certain 'ritual care' persists as part of the 'burn culture'. Specifically, the collection of wound cultures of acute burns at admission and the collection urine, blood, sputum, and wound cultures ('pan-culturing') on patients with temperatures greater than 38.5°C in the first 24 hours of admission are considered standard of care despite the lack of scientific data supporting these practices.

Purpose

The objectives of this study are to (1) establish the proportion and cost of cultures obtained in the first 24 hours after acute burn injury that yield positive microbiological cultures and (2) determine the utility of pan-culturing for temperatures greater than 38.5°C in the first 24 hours following burn injury.

Design

Retrospective, computer-assisted chart review.

Setting

University-based burn center.

Methods

The records of all burn injuries evaluated at the Burn Center or in the Emergency Department between 1/1997 and 1/1998 were retrospectively identified by ICD-9 release codes. Patients presenting with evidence of infection and pediatric burn patients were excluded. Data evaluated included: extent of burn injury, length of stay (LOS), documentation of initial cultures, culture results, and intervention/treatment.

Results

A total of 713 patients were identified. 598 charts met the inclusion criteria. 447 patients had LOS < 1 day and were primarily treated in the ED and discharged home. Wound cultures were obtained for 42 (10%) of these patients. Thirty cultures (71%) had no significant growth. Twelve cultures (29%) grew mixed, common skin flora. No patients in this group were pan-cultured. No patients in this group required antibiotic treatment on the basis of culture results. A total of 151 patients were admitted to the Burn Center with an average LOS of 3.9 days (range 2–125 days). In this group, 45 patients (30%) had wound cultures and 24 patients (16%) were pan-cultured in the first 24 hours of admission. One patient with a deep, open abdominal burn grew enterococcus species from the initial wound culture and was treated with antibiotics. No other patients had antibiotics ordered on the basis of cultures.

Conclusion

Clinical management of the acute burn is not altered by the results of routine wound cultures and pan-cultures obtained in the first 24 hours of admission. Management of patients with deep, abdominal wounds with potential contamination from bowel flora may prove an exception. The cost for a wound culture and gram stain at this hospital is $58.00 (US). Omitting initial cultures would result in potential savings of $16,686.00 (US) and would not compromise the quality of patient care.