Predicting Mortality in Severe Burns: A Comparison of Four Mortality Prediction Scores and the Role of Organizational Changes in the Croatian Burn Center

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors present a study with two aims: 1) evaluation of four burn prognostic scores (ABSI, Ryan, BOBI, and rBaux and 2) a comparison of patient outcomes for burn patients treated before and after organizational and protocol changes were made at a Croatian burn center.

 

I commend the authors on providing an interesting analysis of prognostic scores. As they point out, the study’s AUROC values, lower than those found in the original articles they cite, are quite likely attributable to the higher TBSA burns of the patients in their study. The authors appropriately discuss other factors (e.g. comorbidities, concomitant trauma injury, advances in burn care and resuscitation) that can affect mortality and potentially contribute to lower scores.

 

The study’s findings of reduced hospital and BICU LOS as well as duration of mechanical ventilation suggest a positive impact from the organizational and protocol changes. Though a causal relationship between the changes and results cannot be ascertained, the authors make a rational and convincing argument supporting the newer protocol.

 

Overall, no major shortcomings are identified in this manuscript. It provides a valuable contribution to the burn literature.

 

Quality of English: The grammar for most of the manuscript is very good.

 

Minor error on line 74: need to change “from 2023 to 2023” to “from 2023 to 2024”

 “The first period (from 2016 to 2022) was compared to the second (from 2023 to 2023) when a new organizational structure and protocols were introduced.”

 

Author Response

Dear Reviewer,

Thank you for your thoughtful review and encouraging words. Your feedback has been incredibly motivating, and it inspires me to continue my research in burn care. I am submitting the revised version of the paper, which has been updated in line with the suggestions from the second reviewer.

If you have any further comments on the corrected version, please feel free to address them.

Thank you once again for your support and guidance.

Best regards,
Agata Skunca 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

Thank you for the opportunity to review this paper.  It is an interesting read and tackles two issues: mortality prediction following major burn injury and optimising the delivery of care and its impact. The element of the paper that describes four mortality prediction models is robust, has relevant results and the authors have diligently explained the weaknesses associated with these models and the advantages and disadvantages of their use.  The second element of the paper regarding changing the model of care delivery I found very interesting and believe it would be of interest to the readership, but would like more detail in order to bolster the external validity of the paper.

Can I request that the authors address the following:

Line 15 - "and 149 burn patients" - this is a result and should be included in the later section.

Line 16 - "burned for 9 years" - this is a little vague and grammatically poor.  The date ranges would be more accurate.

Line 55-59 - I would like a little more detail regarding the Burn ICU and the hospital it is set in.  For example, what population does it cover, is it a "Burn Centre", is the BICU exclusively for burn injured patients, how many major burn admissions are there per year, how many beds, how is it staffed etc.

Line 68 - the term third-degree burn is generally not used in my local practice. Superficial, partial and full-thickness would be more appropriate.

Line 69 - LOS and BICU are defined in the abstract but not in the main text - should they be defined here?

Line 77-91 - This is the part of the paper I would like much more detail.

Line 77 - "BICU doctors rotated on a daily or weekly basis". What seniority are these doctors. Are they training grades or consultants/attendings. What specialty are they (burn surgeons, intensivists, anaesthetists, physicians, trauma specialists etc)?

Line 79 - "assigned to treat patients for a continuous period of 3 to 6 months". I struggle to understand how this would work. The discussion points out that this allows "monitoring of changes of clinical status each day" but this is surely not possible. How are weekends, annual leave and overnight duties covered?  I accept there has been change to introduce more consistency, but more detail is required.

Line 82 - protocolised approach to inhalation injury. What is the protocol? What are the treatments being delivered? What was the practice before the protocol?

Line 86 - "Emphasis on earlier discontinuation of sedation" - this should be standard practice in a modern ICU. Were there specific measures or protocols put in place (eg. daily sedation breaks, titration to targeted RASS). Additionally, reporting use of sedatives, days sedated, daily sedation scores etc would strengthen the manuscript, but I accept the authors may not have this data.

Line 88/89 - Aiming to reduce the duration of mechanical ventilation and shortening the time of antimicrobials. Again, these should be standards of care in modern ICU practice. Were specific protocols or measures put in place? More detail please.

Line 110 - percentage of full thickness couldn't be calculated.  Is this because the data was not recorded? If so, that should be stated rather than "couldn't".

Discussion: The authors have highlighted the weaknesses of the study in being able to draw firm conclusions regarding the apparent improvement in duration of mechanical ventilation and LOS being due to the changes in delivery of care model. However, it should also be highlighted that the "second period" patients were also younger and had a higher proportion of males.  These demographic and injury specific details (TBSA and inhalation injury) were not adjusted for in the anaylsis.

I believe the strength and interest of this study lies in the teams excellent attempts to change and improve the delivery of their care by ensuring consistency of medical staff and protocolising certain elements of care. Although this study cannot firmly state that any improvements seen with such small numbers are causally linked to these changes, the efforts made to improve the care should be commended. For this reason, I would like more focus and detail on the exact changes that took place.

Author Response

Dear Reviewer,

Thank you for your thoughtful review. I believe your feedback will greatly enhance my understanding and improve my future writing. I have addressed all of your suggestions and uploaded the revised version.

In comparing patient and injury characteristics between the two time periods, there was no statistically significant difference between the groups. This is why I initially did not make adjustments. I have now added p-values in the table to show the comparisons between groups for age, TBSA, presence of inhalational injury, and presence of full-thickness burns without stastistically significant difference.

If you have further corrections, let me know. 

Thank you once again for your guidance.

Best regards,
Agata Skunca

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

No concerns after revision. 

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for addressing the points raised.  I believe the greater detail regarding the protocols implemented and staffing changes add greatly to the manuscript.