Geospatial Mapping as a Guide for Resource Allocation Among Burn Centers in India

Severe burns in a resource-limited rural healthcare centre

A woman in her mid-30s presented to our 30-bed healthcare centre with extensive burns, hours after falling into a shallow pit of burning dried tea leaves. On arrival, there was no evidence of airway compromise. She was fully conscious but had signs of shock and hypovolemia. Forty-five per cent of the total body surface area was burned, including the face, neck, thorax, abdomen, upper limbs and thighs. The family refused referral to a burns centre and insisted on continuing treatment at our facility. Our hospital, not equipped to manage burns, was adapted to deliver effective, immediate care. After initial stabilisation, the patient was unwilling to remain hospitalised because of her husband's employment commitment. Subsequently, we were notified that the patient died within 1 month of discharge. This article highlights the importance of burns care facilities in rural India and the impact of a failure to access quality health on outcomes.

The Global Macroeconomic Burden of Burn Injuries

BACKGROUND

Standardized estimates of global economic losses from burn injuries are lacking. The primary objective of this study was to determine the global macroeconomic consequences of burn injuries and their geographic distribution.

METHODS

Using the Institute of Health Metrics and Evaluation database (2009 and 2019), mean and 95% uncertainty interval (UI) data on incidence, mortality, and disability-adjusted life-years (DALYs) from injuries caused by fire, heat, and hot substances were collected. Gross domestic product (GDP) data were analyzed together with DALYs to estimate macroeconomic losses globally using a value of lost welfare approach.

RESULTS

There were 9 million global burn cases (95% UI, 6.8 to 11.2 million) and 111,000 deaths from burns (95% UI, 88,000 to 132,000 deaths) in 2019, representing a total of 7.5 million DALYs (95% UI, 5.8 to 9.5 million DALYs). This represented welfare losses of $112 billion (95% UI, $78 to $161 billion), or 0.09% of GDP (95% UI, 0.06% to 0.13%). Welfare losses as a share of GDP were highest in low- and middle-income countries (LMICs) of Oceania (0.24%; 95% UI, 0.09% to 0.42%) and Eastern Europe (0.24%; 95% UI, 0.19% to 0.30%) compared with high-income country regions such as Western Europe (0.06%; 95% UI, 0.04% to 0.09%). Mortality-incidence ratios were highest in LMIC regions, highlighting a lack of treatment access, with southern sub-Saharan Africa reporting a mortality-incidence ratio of 40.1 per 1000 people compared with 1.9 for Australasia.

CONCLUSIONS

Burden of disease and resulting economic losses because of burn injuries are substantial worldwide and are disproportionately higher in LMICs. Possible effective solutions include targeted education, advocacy, and legislation to decrease incidence and investing in existing burn centers to improve treatment access.

The health workforce conundrum for burn care in Uttar Pradesh, India: a qualitative exploration

Delivering specialised care for major burns requires a multidisciplinary health workforce. While health systems 'hardware' issues, such as shortages of the healthcare workforce and training gaps in burn care are widely acknowledged, there is limited evidence around the systems 'software' aspects, such as interest, power dynamics, and relationships that impact the healthcare workforce performance. This study explored challenges faced by the health workforce in burn care to identify issues affecting their performance. Qualitative in-depth interviews were conducted with a purposively selected sample (n = 31, 18 women and 13 men) of various cadres of the burn care health workforce in Uttar Pradesh, India. Inductive coding and thematic analysis identified three major themes. First, the dynamics within the multidisciplinary team where complex relations, power and normative hierarchy hampered performance. Second, the dynamics between health workers and patients due to the clinical and emotional challenges of dealing with burn injuries and multitasking. Third, dynamics between specialised burn units and broader health systems are narrated in challenges due to inadequate first response and delayed referral from primary care facilities. These findings indicate that burn care health workers in India face multiple challenges that need systemic intervention with a multipronged human resource for health framework.

Navigating health systems for burn care: Patient journeys and delays in Uttar Pradesh, India

BACKGROUND

India has one of the highest burden of burns. The health systems response to burn care is sometimes patchy and highly influenced by social determinants. Delay in access to acute care and rehabilitation adversely affects recovery outcomes. Evidence on underlying factors for delays in care are limited. In this study, we aim to explore patients' journeys to analyse their experiences in accessing burn care in Uttar Pradesh, India.

METHODS

We conducted qualitative inquiry using the patient journey mapping approach and in-depth interviews (IDI). We purposively selected a referral burn centre in Uttar Pradesh, India and included a diverse group of patients. A chronological plot of the patient's journey was drawn and confirmed with respondents at the end of the interview. A detailed patient journey map was drawn for each patient based on interview transcripts and notes. Further analysis was done in NVivo 12 using a combination of inductive and deductive coding. Similar codes were categorised into sub-themes, which were distributed to one of the major themes of the 'three delays' framework.

RESULTS

Six major burns patients (4 female and 2 males) aged between 2 and 43 years were included in the study. Two patients had flame burns, and one had chemical, electric, hot liquid, and blast injury, respectively. Delay in seeking care (delay 1) was less common for acute care but was a concern for rehabilitation. Accessibility and availability of services, costs of care and lack of financial support influenced delay (1) for rehabilitation. Delay in reaching an appropriate facility (delay 2) was common due to multiple referrals before reaching an appropriate burn facility. Lack of clarity on referral systems and proper triaging influenced this delay. Delay in getting adequate care (delay 3) was mainly due to inadequate infrastructure at various levels of health facilities, shortage of skilled health providers, and high costs of care. COVID-19-related protocols and restrictions influenced all three delays.

CONCLUSIONS

Burn care pathways are adversely affected by barriers to timely access. We propose using the modified 3-delays framework to analyse delays in burns care. There is a need to strengthen referral linkage systems, ensure financial risk protection, and integrate burn care at all levels of health care delivery systems.

Health systems research in burn care: an evidence gap map

BACKGROUND

Burn injury is associated with significant mortality and disability. Resilient and responsive health systems are needed for optimal response and care for people who sustain burn injuries. However, the extent of health systems research (HSR) in burn care is unknown. This review aimed to systematically map the global HSR related to burn care.

METHODS

An evidence gap map (EGM) was developed based on the World Health Organization health systems framework. All major medical, health and injury databases were searched. A standard method was used to develop the EGM.

RESULTS

A total of 6586 articles were screened, and the full text of 206 articles was reviewed, of which 106 met the inclusion criteria. Most included studies were cross-sectional (61%) and were conducted in hospitals (71%) with patients (48%) or healthcare providers (29%) as participants. Most studies were conducted in high-income countries, while only 13% were conducted in low-and middle-income countries, accounting for 60% of burns mortality burden globally. The most common health systems areas of focus were service delivery (53%), health workforce (33%) and technology (19%). Studies on health policy, governance and leadership were absent, and there were only 14 qualitative studies.

CONCLUSIONS

Major evidence gaps exist for an integrated health systems response to burns care. There is an inequity between the burden of burn injuries and HSR. Strengthening research capacity will facilitate evidence-informed health systems and policy reforms to sustainably improve access to affordable, equitable and optimal burn care and outcomes.

Projecting 1 km-grid population distributions from 2020 to 2100 globally under shared socioeconomic pathways

Spatially explicit population grid can play an important role in climate change, resource management, sustainable development and other fields. Several gridded datasets already exist, but global data, especially high-resolution data on future populations are largely lacking. Based on the WorldPop dataset, we present a global gridded population dataset covering 248 countries or areas at 30 arc-seconds (approximately 1 km) spatial resolution with 5-year intervals for the period 2020-2100 by implementing Random Forest (RF) algorithm. Our dataset is quantitatively consistent with the Shared Socioeconomic Pathways' (SSPs) national population. The spatially explicit population dataset we predicted in this research is validated by comparing it with the WorldPop dataset both at the sub-national and grid level. 3569 provinces (almost all provinces on the globe) and more than 480 thousand grids are taken into verification, and the results show that our dataset can serve as an input for predictive research in various fields.

Scleral contact lenses for optimal visual recovery in a case of severe acid burn with total lagophthalmos

Chemical injuries can severely damage the ocular surface. We present the case of a man in his 40s with severe periocular chemical injury with total lid loss and severe exposure keratopathy. He sustained burns to 45% of his body surface area and needed tracheostomy and multiple full-thickness skin grafts. Both eyes required surgery, Boston type 1 keratoprosthesis and penetrating keratoplasty for the right and left eye, respectively. There was melting in the right eye and a persistent epithelial defect in the left eye. Eventually, we suggested 18 mm diameter scleral contact lenses for both eyes to aid in ocular surface stabilisation. His best corrected visual acuity improved significantly with the scleral lenses to 20/100 and 20/320 in the right and left eyes, respectively. This case demonstrates that scleral lenses can treat the complications of exposure keratopathy and can improve vision. Therefore, they may be considered for rehabilitation of the ocular surface in eyes with severe chemical periocular injuries.

Impact of COVID-19 and containment measures on burn care: A qualitative exploratory study

BACKGROUND

Burn care in India is limited by multiple constraints. The COVID-19 pandemic and the containment measures restricted access to non-COVID emergency conditions, including burns. The aim of this study was to explore the impact of the pandemic on burn care in India.

METHODS

Using the qualitative exploratory methods, we conducted in-depth interviews (IDI) with plastic and general surgeons representing burn units from across India. Participants were selected purposively to ensure representation and diversity and the sample size was guided by thematic saturation. Thematic analysis was undertaken adopting an inductive coding using NVivo 12 Pro.

RESULTS

19 participants from diverse geographic locations and provider types were interviewed. Three major emerging themes were, change in patient and burn injury characteristics; health system barriers, adaptation, and challenges; and lessons and emerging recommendations for policy and practice. There was change in patient load, risk factors, and distribution of burns. The emergency services were intermittently disrupted, the routine and surgical services were rationally curtailed, follow-up and rehabilitation services were most affected. Measures like telemedicine and decentralising burn services emerged as the most important lesson.

CONCLUSIONS

The ongoing pandemic has compounded the challenges for burns care in India. Urgent action is required to prioritise targeted prevention, emergency transport, decentralise service delivery, and harnessing technology for ensuring resilience in burns services.

Sparsity of burn centers and prolonged length of hospital stay: A nationwide study

INTRODUCTION

The optimal distribution of burn centers remains unclear. We aimed to determine the appropriate number of burn centers per population (density) and examined a nationwide registry with the hypothesis that low-density burn centers would be associated with unfavorable outcomes.

PATIENTS AND METHODS

A retrospective study was conducted using the Japanese Society of Burn Injury registry (2011-2021). Burn center density was defined as the number of burn centers per one million population in each prefecture, and centers were trisected on the basis of density. Hospital-free days until day 30 were compared between patients at high-, middle-, and low-density centers. Inverse probability weighting was conducted to adjust baseline characteristics, including age, burn mechanism, and burn severity.

RESULTS

We included 6764, 6209, and 2200 patients at high-, middle-, and low-density burn centers, respectively. After adjusting for patient demographics and burn severity, patients at high- and middle-density centers (≥0.4 centers per one million population) had longer hospital-free days compared with those at low-density centers (11 [0-23] vs 11 [0-23] vs 8 [0-22] days; p < 0.001).

CONCLUSIONS

Low burn center density (<0.4 centers per one million population) was associated with longer hospital stay, whereas no higher limit was determined.

Identifying Hospitals in Nepal for Acute Burn Care and Stabilization Capacity Development: Location-Allocation Modeling for Strategic Service Delivery

In Nepal, preventable death and disability from burn injuries are common due to poor population-level spatial access to organized burn care. Most severe burns are referred to a single facility nationwide, often after suboptimal burn stabilization and/or significant care delay. Therefore, we aimed to identify existing first-level hospitals within Nepal that would optimize population-level access as "burn stabilization points" if their acute burn care capabilities are strengthened. A location-allocation model was created using designated first-level candidate hospitals, a population density grid for Nepal, and road network/travel speed data. Six models (A-F) were developed using cost-distance and network analyses in ArcGIS to identify the three vs five candidate hospitals at ≤2, 6, and 12 travel-hour thresholds that would optimize population-level spatial access. The baseline model demonstrated that currently 20.3% of the national population has access to organized burn care within 2 hours of travel, 37.2% within 6 travel-hours, and 72.6% within 12 travel-hours. If acute burn stabilization capabilities were strengthened, models A to C of three chosen hospitals would increase population-level burn care access to 45.2, 89.4, and 99.8% of the national population at ≤2, 6, and 12 travel-hours, respectively. In models D to F, five chosen hospitals would bring access to 53.4, 95.0, and 99.9% of the national population at ≤2, 6, and 12 travel-hours, respectively. These models demonstrate developing capabilities in three to five hospitals can provide population-level spatial access to acute burn care for most of Nepal's population. Organized efforts to increase burn stabilization points are feasible and imperative to reduce the rates of preventable burn-related death and disability country-wide.