Homelessness and Burns

Joan Chen, MS4

University of Washington School of Medicine

Harborview Medical Center Burn Service
 Aims

PART I PART II
• Epidemiology • Framing the Issue
• Who/ What • Injury Prevention
• Where/ When • Improving Outcomes
• Why/ How • Local Landscapes
• Medical Respite
• Outcomes • Housing
Existing Literature
 KIWANUKA 2019, Nationwide Inpatient Sample

KRAMER 2008, SEATTLE

TURKOWSKI 2003, NYC

KOWAL-VERN 2007, CHICAGO

Epidemiology VROUWE 2020, LA


Greater rate of assault and
self-inflicted injury
Flame, frostbite more likely
KIWANUKA 2019, Nationwide Inpatient Sample
KRAMER 2008, SEATTLE
TURKOWSKI 2003, NYC
KOWAL-VERN 2007, CHICAGO

Higher rates of mental illness

and substance abuse (EtOH > PSA) VROUWE 2020, LA

Mixed results in %TBSA

(Nationwide sample found more
likely to have full-thickness)
 KIWANUKA 2019, Nationwide Inpatient Sample

KRAMER 2008, SEATTLE

TURKOWSKI 2003, NYC

KOWAL-VERN 2007, CHICAGO

Outcomes VROUWE 2020, LA

 KIWANUKA 2019, Nationwide Inpatient Sample
No difference in mortality KRAMER 2008, SEATTLE

Longer LOS TURKOWSKI 2003, NYC

KOWAL-VERN 2007, CHICAGO
Less likely to follow up in clinic

More likely AMA VROUWE 2020, LA

Mixed results in management:

operative vs. non-operative;
# operations
Framing the Issue
• More likely to be black, female, unemployed, homeless
• No difference in age
• Greater %TBSA (25.3 v. 20.4)*
• Greater in-hospital mortality
• Greater psychological distress during hospitalization but not
follow-up
• Risk of death is three times that of patients without pre-existing
psychiatric disorders when adjusting for other confounders
• More likely to have in-hospital complications of pneumonia,
arrhythmia, septicemia, respiratory failure, UTI, renal failure, stroke
 Improving Outcomes:
Edward Thomas House Medical Respite
Est. 1996
34 beds

Outcomes Data CY 2018

• 564 admits
• 10,520 bed days
• Length of Stay 22 days average
• 13% directly placed in transitional or
permanent housing
• 126 patients initiated in chemical dependency
treatment
 Improving Outcomes:
Seattle Medical Respite Study:
180 days pre and post respite
Medical Respite
• 67% reduction in inpatient episodes
• 10% reduction in ED visits
• 50% reduction in ED encounters
resulting in inpatient admission
CMS Innovation Grant: Multicenter trial
• 35% increase in outpatient visits
• 45% decline in ED visits
• 35% decline in Hospital Admissions
• Every $1 invested in respite associated with
$1.81 cost avoidance for health system
 Injury Prevention:
Housing

• Marginally housed men and women reported significantly less

victimization than those who were homeless
• Homeless sex workers and homeless persons with mental illness
reported extremely high rates of assault
Injury Prevention:
Housing
What’s Next?
 References
• Kushel, M. B., Evans, J. L., Perry, S., Robertson, M. J., & Moss, A. R. (2003). No Door to Lock: Victimization Among Homeless and Marginally Housed
Persons. In Archives of Internal Medicine (Vol. 163, Issue 20, pp. 2492–2499). American Medical Association.
https://doi.org/10.1001/archinte.163.20.2492
• Turkowski, J. R., Rabbitts, A., Alden, N. E., Reilly, J., Santopietro, R., & Yurt, R. W. (2003). Homelessness: A Pre-Existing Comorbidity. Journal of Burn Care
& Rehabilitation, 24(suppl_2), S93. https://doi.org/10.1097/00004630-200303002-00102
• Hudson, A., Al Youha, S., Samargandi, O. A., & Paletz, J. (2017). Pre-existing psychiatric disorder in the burn patient is associated with worse outcomes.
https://doi.org/10.1016/j.burns.2017.01.022
• Kramer, C. B., Gibran, N. S., Heimbach, D. M., Rivara, F. P., & Klein, M. B. (2008). Assault and substance abuse characterize burn injuries in homeless
patients. Journal of Burn Care and Research, 29(3), 461–467. https://doi.org/10.1097/BCR.0b013e31817112b0
• Kaufman, M. S., Graham, C. C., Lezotte, D., Fauerbach, J. A., Gabriel, V., Engrav, L. H., & Esselman, P. (2007). Burns as a result of assault: Associated risk
factors, injury characteristics, and outcomes. Journal of Burn Care and Research, 28(1), 21–28. https://doi.org/10.1097/BCR.0B013E31802C896F
• Kowal-Vern, A., & Latenser, B. A. (2007). Demographics of the Homeless in an Urban Burn Unit. Journal of Burn Care & Research, 28(1), 105–110.
https://doi.org/10.1097/BCR.0B013E31802C88c4
• Vrouwe, S. Q., Johnson, M. B., Pham, C. H., Lane, C. J., Garner, W. L., Gillenwater, T. J., & Yenikomshian, H. A. (2020). The Homelessness Crisis and Burn
Injuries: A Cohort Study. Journal of Burn Care & Research, 41(4), 820–827. https://doi.org/10.1093/jbcr/iraa023
• Kiwanuka, H., Maan, Z. N., Rochlin, D., Curtin, C., Karanas, Y., & Sheckter, C. C. (2019). Homelessness and Inpatient Burn Outcomes in the United States.
Journal of Burn Care & Research, 40(5), 633–638. https://doi.org/10.1093/jbcr/irz045