Injury Severity

Question: If a patient loses a limb in the process would that affect the TBSA at discharge since now he/ she has a body part that is missing? For example, if the patient comes with a 2.5% burn on the right hand and that hand gets amputated, at discharge that hand would be missing, therefore that burn area is not present anymore. Would the L&B still reflect that initial 2.5% TBSA?

Answer: Yes, in the case of a lost limb, the Lund & Browder would still be 2.5% 3rd degree to the Right hand. That area was burned and should be included even if amputated. 

Question: What is the correct way to fill out a Lund and Browder (L&B) chart at discharge. Is the percentage that IS NOT closed used or is the original TBSA used? For example, someone that came in with over 60% TBSA, but through the course of his admission was 90% closed. When the patient passed he only had 10% of open area. So is the amount of open area at discharge (10%) recorded?

Answer: "The Initial and Final L&B burn diagrams are both based on the total TBSA burn injury that the patient sustained.  The initial is used to calculate fluid resuscitation amounts and the exact areas that are second or third degree are not yet known at this time, as the burn wound is likely still progressing, thought the total TBSA burned is likely known.  The final burn diagram is the total TBSA burned with the exact amounts that are second and third degree calculated based on the what areas required grafting and which healed on their own.  If the patient dies before any or all grafting is done, the physician is the best source of how much of the burn was second and third degree.  See pages 69-70 in 2023 Data Dictionary. This is also going to be clarified in the 2024 Data Dictionary.

The final burn diagram has nothing to do with how much has healed or was grafted and how much remains open at the time of discharge.  That is recorded in a separate data field under outcomes. See: Percent Wound Closure at Time of Discharge on page 105. In the case of your patient with a 60% TBSA and 10% was still open at the time of discharge/death, you would fill in 90% was the Percentage of Wound Closure."

Total Burn Size 2nd Degree

Question: It was noted that Xenograft could not be categorized as partial or full thickness and then it is never the final graft, that it's used as a temporary graft. Is this how xenograft is defined? How should this be correctly entered when coding as a procedure.

Answer: Determination of a partial thickness (2nd degree) or full thickness (3rd degree) can be made by whether the: 1) the wound heals on its own or 2) requires a permanent wound cover like a split or full thickness skin graft or cultured epithelial autograft (CEA). Xenograft generally comes from pigskin and provides temporary coverage of a wound. The use of xenograft cannot determine what the depth of the wound is, as it can be used on both partial and full thickness injuries.

Question: If the only procedure done on a burn is with RECELL, is that burn considered 3rd degree?

Answer: You can use a treatment option to determine which areas are second and third degree, but you must know what the use is for the treatment. For example, any area covered using an autograft (either a spilt or full-thickness autograft) is used to provide permanent coverage for a third-degree wound (full or deep partial thickness). Likewise, any area covered by cultured epidermal autograft (CEA) is also used to provide permanent coverage of a third-degree wound.
RECELL is a spray-on preparation of autologous cells intended for use in coverage of full and deep partial-thickness wounds, used alone or with widely meshed autologous skin grafts. It can provide permanent coverage of the wound. It can potentially also be used as a temporary coverage over wounds that are second-degree. It would be best to ask the surgeon what the depth of the wound is in cases where RECELL is being used without any other type of autograft.
There are several other wound coverage agents, and some are for temporary coverage of second-degree wounds. If you are not familiar with the various treatments being used, you should consult your burn surgeon to determine if the wound is second or third-degree. In general, all third-degree areas require permanent coverage material like an autograft. The difficulty for some patients is if they die before the wounds declare themselves and are covered, in which case you should rely on the surgeon to determine which wounds are second-degree and which are third-degree.

Question: If a patient is admitted after being seen in clinic multiple times and has only one burn diagram from a clinic visit, can that burn diagram be used as the initial TBSA even though it was completed weeks prior to admission?

Answer: If this burn diagram represents accurately the initial TBSA, then yes it can be used. A final (ultimate) burn diagram, with the accurate total TBSA of what was second and what was third degree should also be completed.

Carboxyhemoglobin Level

Question: Should a carboxyhemoglobin level be drawn if there is not an inhalation injury?  Is there a time frame that a carboxyhemoglobin level should be taken? 

Answer: If a carboxyhemoglobin level was taken, you should document it. Many times, they may draw one to rule out that there was or was not an inhalation injury. Carboxyhemoglobin levels should be taken as soon as possible to guide care, especially if concerned with inhalation injury. Related to the Registry documentation, you should enter the first level taken.