Hospital Volume Outcome and Discharge Disposition of Burn Patients

In-hospital outcomes of paediatric burn injuries managed in children's hospitals compared to general hospitals

INTRODUCTION

In Australia and New Zealand, children with burn injuries are cared for in either general hospitals which cater to both adult and paediatric burn injuries or in children's hospitals. Few publications have attempted to analyse modern burn care and outcomes as a function of treating facilities.

AIM

The aim of this study was to compare in-hospital outcomes of paediatric burn injuries managed in children's hospitals to those treated in general hospitals that regularly treated both adult and paediatric burn patients.

METHODS

A retrospective cohort study of cases was undertaken using data from the Burns Registry of Australia and New Zealand (BRANZ). All paediatric patients with data for an acute or transfer admission to a BRANZ hospital and registered with BRANZ with a date of admission between 1 July 2016 and 30 June 2020 were included in the study. The primary outcome of interest was the acute admission length of stay. Secondary outcome measures of interest included admission to the intensive care unit and readmission to a specialist burn service within 28 days. The Alfred Hospital Ethics Committee granted ethical approval for this study (project 629/21).

RESULTS

A total of 4630 paediatric burn patients were included in the analysis. Approximately three quarters of this cohort (n = 3510, 75.8%) were admitted to a paediatric only hospital, while the remaining quarter (n = 1120, 24.2%) were admitted to a general hospital. A greater proportion of patients admitted to general hospitals underwent burn wound management procedures in the operating theatre (general hospitals 83.9%, children's hospitals 71.4%, p < 0.001). Patients admitted to children's hospitals had a longer median time to their first episode of grafting (children's hospitals 12.4 days, general hospitals 8.3 days, p < 0.001). The adjusted regression model for hospital LOS indicate that patients admitted to general hospitals had a 23% shorter hospital LOS, compared to patients admitted to children's hospitals. Neither the unadjusted or adjusted model for intensive care unit admission was significant. After accounting for relevant confounding factors, there was no association between service type and hospital readmission rates.

CONCLUSIONS

Comparing children's hospitals and general hospitals, different models of care seem to exist. Burn services in children's hospitals adopted a more conservative approach and were more inclined to facilitate healing by secondary intention rather than surgical debridement and grafting. General hospitals are more "aggressive" in managing burn wounds in theatre early, and debriding and grafting the burn wounds whenever considered necessary.

Massive Burn Injuries: Characteristics and Outcomes From a Single Institution

Massive burn injuries are a unique patient population with unique treatment paradigms. Data from 155 adult patients, admitted from 2009 to 2019, with >50% total body surface area burns (TBSA) were collected and analyzed. Average burn size was 70% TBSA and 63% had a concomitant inhalation injury. Approximately 30% of patients (46/155) transitioned to comfort care-only measures within 24 hours of admission. Standard treatment patients were younger (37 ± 13 vs 60 ± 19 years; p < .00001), male (94% vs 28%; p = .001) and had smaller TBSA (66 ± 13 vs 80 ± 16; p < .00001). Of the standard treatment group, 72 (66%) survived to discharge. Survivors had smaller TBSA (64 ± 13 vs 71 ± 13; p = .003), less third-degree TBSA (48 ± 25 vs 71 ± 13; p = .003) and lower incidence of renal failure requiring dialysis (22% vs 73%, p < .00001). Multivariate regression analysis showed that age (OR 1.05; p = .025), total TBSA (OR 1.07; p = .005), and renal failure (OR 10.2; p = .00005) were independently associated with mortality. Inhalation injury was not significantly associated with mortality. About 23% (35/155) of patients had a psychiatric condition on admission and 19% (30/155) of patients were burned attempting suicide. Patients with psychiatric conditions spent more time in the hospital (62 vs 30 days; p = .004), more time on ventilator (31 vs 12 days; p = .046), underwent more surgery (4 vs 2 operations, p = .03), and were less likely to die (34% vs 59%; p = .02). In summary, age, burn size, and renal failure were independently associated with mortality, with renal failure being the strongest factor. Psychiatric conditions are prevalent pre-injury and tend to require more inpatient care.

Does patient load affect clinical outcome of burn patients in specialized centers? An analysis of the German Burn Registry

Hospital volume has been identified as an independent outcome parameter for a number of medical fields and surgical procedures, and there is a tendency to increase required patient numbers for center verification. However, the existing literature does not support a clear correlation between patient load and clinical outcome in adult burn care and recent data from Germany does not exist. We therefore evaluated the effect of patient volume in German burn centers on clinical outcome. Patient data was extracted from the German Burn Registry from 2015 to 2018. For better inter-center comparability, solely burn patients with a TBSA ≥ 10% were included. Mortality, number of surgeries and length of stay (LOS) were evaluated with respect to burn center patient volume. Burn center volume was divided into two and three groups. A total of 2718 patients with a TBSA ≥ 10% were admitted to the participating 17 burn centers. Independent from the division of patient data into either 2 or 3 groups, the TBSA and ABSI score-related severity of burn injuries were comparable between groups. There was no significant difference in mortality due to center size. Nevertheless, patients treated in large volume burn centers showed a significantly increased LOS (+4.5 days, [1.9-7.2] CI, p = 0.001) and required significantly more surgeries (+0.5 surgeries [0.2-0.8] CI, p = 0.002) when compared to the small volume centers. A similar phenomenon regarding mortality and LOS (p 0.001) was observed after dividing the centers into two groups. Interestingly a division into three groups showed significant differences with the best outcome for patients in medium-volume centers. Nevertheless, mortality did not differ significantly. Therefore, our data demonstrates that in contrast to many other medical fields, outcome and mortality are not automatically improved in burn care by simply increasing the patient load, at least in centers treating 20-100 BICU patients/year.

Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care?

Regionalization has become a buzzword in US health care policy. Regionalization, however, has varied meanings, and definitions have lacked contextual information important to understanding its role in improving care. This concept review is a comprehensive primer and summation of 8 common core components of the national models of regionalization informed by text-based analysis of the writing of involved organizations (professional, regulatory, and research) guided by semistructured interviews with organizational leaders. Further, this generalized model of regionalized care is applied to sepsis care, a novel discussion, drawing on existing small-scale applications. This discussion highlights the fit of regionalization principles to the sepsis care model and the actualized and perceived potential benefits. The principal aim of this concept review is to outline regionalization in the United States and provide a roadmap and novel discussion of regionalized care integration for sepsis care.

The Impact of Plastic Surgery Volume on Inpatient Burn Outcomes

BACKGROUND

Acute burn care involves multiple types of physicians. Plastic surgery offers the full spectrum of acute burn care and reconstructive surgery. The authors hypothesize that access to plastic surgery will be associated with improved inpatient outcomes in the treatment of acute burns.

METHODS

Acute burn encounters with known percentage total body surface area were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Edition, codes. Plastic surgery volume per facility was determined based on procedure codes for flaps, breast reconstruction, and complex hand reconstruction. Outcomes included odds of receiving a flap, patient safety indicators, and mortality. Regression models included the following variables: age, percentage total body surface area, gender, inhalation injury, comorbidities, hospital size, and urban/teaching status of hospital.

RESULTS

The weighted sample included 99,510 burn admissions with a mean percentage total body surface area of 15.5 percent. The weighted median plastic surgery volume by facility was 245 cases per year. Compared with the lowest quartile, the upper three quartiles of plastic surgery volume were associated with increased likelihood of undergoing flap procedures (p < 0.03). The top quartile of plastic surgery volume was also associated with decreased odds of patient safety indicator events (p < 0.001). Plastic surgery facility volume was not significantly associated with a difference in the likelihood of inpatient death.

CONCLUSIONS

Burn encounters treated at high-volume plastic surgery facilities were more likely to undergo flap operations. High-volume plastic surgery centers were also associated with a lower likelihood of inpatient complications. Therefore, where feasible, acute burn patients should be triaged to high-volume centers.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Burn Center Referral Practice Evaluation and Treatment Outcomes Comparison Among Verified, Nonverified Burn Centers, and Nonburn Centers: A Statewide Perspective

The American Burn Association (ABA) has developed comprehensive referral criteria to determine which burn-injured patient should be transferred to burn centers. This was a retrospective analysis of burn injuries using Illinois inpatient and outpatient hospital data from 2010 to 2015. Multivariable logistic and linear regression models were developed to evaluate ABA burn center referral criteria adherence and to compare treatment outcomes among those treated in verified burn center (VB), nonverified burn center (NVB), and other facilities (OF). In this study, 66% of those treated in facilities without specialized burn teams met the ABA referral criteria. Patients who were older than the age of 40 years, lived farther from burn units, and were originally treated in level I trauma center without burn units were less likely to be transferred to burn centers. Those transported and treated in burn centers had overall better treatment outcomes including fewer infection complications (VB vs OF: adjusted odds ratio [aOR]: 0.5, 95% confidence interval [CI]: 0.4-0.6; NVB vs OF: aOR: 0.5, 95% CI: 0.4-0.6), fewer patients requiring additional care in skilled nursing/rehabilitation facilities (VB vs OF: aOR: 0.5, 95% CI: 0.4-0.6; NVB vs OF: aOR: 0.7, 95% CI: 0.6-0.9), shorter length of hospitalization (VB vs OF: β: -0.4, P < .001; NVB vs OF: β: -0.8, P < .001), and comparable in-hospital mortality (VB vs OF: aOR: 1.3, 95% CI: 0.97-1.7; NVB vs OF: aOR: 1.01, 95% CI: 0.7-1.5). While verified and unverified burn centers demonstrated better treatment outcomes, the data demonstrated a need to understand the barriers of adhering to ABA criteria and an improved regional burn center referral guidelines education.

Adult Cranioplasty and Perioperative Patient Safety: Does Plastic Surgery Facility Volume Matter?

ABSTRACT

Cranioplasty lies at the intersection of neurosurgery and plastic surgery, though little is known about the impact of plastic surgery involvement. The authors hypothesized that adult cranioplasty patients at higher volume plastic surgery facilities would have improved inpatient outcomes. Adult cranioplasty encounters were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Revision (ICD-9) codes. Regression models included the following variables: age, gender, race/ethnicity, Elixhauser Comorbidity Index, payer, hospital size, region, and urban/teaching status. Outcomes included odds of receiving a flap, perioperative patient safety indicators, and mortality. The weighted sample included 49,305 encounters with diagnoses of neoplasm (31.2%), trauma (56.4%), infection (5.2%), a combination of these diagnoses (3.9%), or other diagnoses (3.2%). There were 1375 inpatient mortalities, of which 10 (0.7%) underwent a flap procedure. On multivariable regression, higher volume plastic surgery facilities and all diagnoses except uncertain neoplasm were associated with an increased likelihood of a flap procedure during the admission for cranioplasty, using benign neoplasm as a reference (P < 0.001). Plastic surgery facility volume was not significantly associated with likelihood of a patient safety indicator event. The highest volume plastic surgery quartile was associated with lower likelihood of inpatient mortality (P = 0.008). These findings support plastic surgery involvement in adult cranioplasty and suggest that these patients are best served at high volume plastic surgery facilities.

The association of burn patient volume with patient safety indicators and mortality in the US

INTRODUCTION

Clinical volume has been associated with rate of complications and mortality for various conditions and procedures. We aim to analyze the relationship between annual hospital burn admission, patient safety indicators (PSI), line infections, and inpatient mortality. We hypothesize that high facility volume will correlate with better outcomes.

METHODS

All burn admissions with complete data for total body surface area (TBSA) and depth were extracted from the Nationwide Inpatient Sample from 2002-2011. Predictor variables included age, gender, comorbidities, %TBSA, burn depth, and inhalation injury. Surgically relevant PSIs were drawn from the Healthcare Cost & Utilization Project and included: sepsis, venous thromboembolic disease, hemorrhage, pneumonia, and wound complications. Outcomes were analyzed with regression models.

RESULTS

Of the 57,468 encounters included, 3.1% died, 6.3% experienced >1 PSI event, and 0.3% experienced a catheter-associated urinary tract infections or central line associated blood stream infections. The most frequent PSI was pneumonia followed by sepsis and VTE. Annual hospital burn admission volume was independently associated with decreased odds of mortality (OR 0.99, 95% CI 0.99-0.99, p < 0.001) and PSIs (OR 0.99, 95% CI 0.99-0.99, p = 0.031). There was no significant correlation with line infections. In both mortality and PSI models, age, %TBSA, inhalation injuries, and Elixhauser comorbidity score were significantly associated with adverse outcomes (p < 0.05).

CONCLUSION

There was a significant association between higher hospital volume and decreased likelihood of patient safety indicators and mortality. There was no observed relationship with line infections. These findings could inform future verification policies of US burn centers.

Does Increased Patient Load Improve Mortality in Burns?: Identifying Benchmark Parameters Defining Quality of Burn Care

INTRODUCTION

In burn care, as in other medical fields, there is a tendency to increase the required number of patients for center certifications. Does the increase in patient load automatically improve the quality of burn care? What are the benchmark parameters that have been shown to improve burn care?

METHODS

To answer these questions, Medline, Cochrane Library, and Livivo were searched from inception through January 2018 for all studies evaluating the influence of treatment parameters on outcomes in different burn care settings.

RESULTS

Fifteen studies were included in this systematic review. In adults, not a single study showed a decreased mortality due to a higher patient load. However, in children, 2 studies demonstrated a further decrease of the already low mortality due to an increase in patient load. In contrast to patient load, benchmark parameters that had a significant influence on the outcome of burn care for adults and children were: single bed isolation, residency programs, American Burn Association certifications of burn centers, speed of wound closure, and standard operating procedures for burn care.

CONCLUSIONS

This systematic review demonstrates that a clear correlation between patient load and mortality reduction in adult burn treatment is not supported by the existing literature, requiring future studies. In contrast, all efforts aiming to improve the quality of burn care, such as isolation of burn patients, speed of wound closure, American Burn Association verification and especially standard operating procedures for burn care improve survival and quality of burn care.

Volume-outcome relationship on survival and cost benefits in severe burn injury: a retrospective analysis of a Japanese nationwide administrative database

Background

Although it has been reported that high hospital patient volume results in survival and cost benefits for several diseases, it is uncertain whether this association is applicable in burn care.

Methods

We conducted a retrospective observational study on severe burn patients, defined by a burn index ≥ 10, using 2010–2015 data from a Japanese national administrative claim database. A generalized additive mixed-effect model (GAMM) was used to evaluate the nonlinear associations between patient volume and the outcomes (in-hospital mortality, healthcare costs per admission, and hospital-free days at 90 days). Generalized linear mixed-effect regression models (GLMMs) in which patient volume was incorporated as a continuous or categorical variable (≤ 5 or > 5) were also performed. Patient severity was adjusted using the prognostic burn index (PBI) or the risk adjustment model developed in this study, simultaneously controlling for hospital-level clustering. Sensitivity analyses evaluating patients who were directly transported, those with PBI ≤ 120 and those excluding patients who died within 2 days of admission, were also performed.

Results

We analyzed 5250 eligible severe burn patients from 737 hospitals. The PBI and the developed risk adjustment model had good discriminative ability with areas under the receiver operating characteristic curves of 0.86 and 0.89, respectively. The GAMM plots showed that in-hospital mortality and healthcare costs increased according to the increase in patient volumes; then, they reached a plateau. Fewer hospital-free days were observed in the higher volume hospitals. The GLMM model showed that patient volume (incorporated as a continuous variable) was significantly associated with increased in-hospital mortality (adjusted odds ratio [95% confidence interval (CI)] = 1.14 [1.09–1.19]), high healthcare costs (adjusted difference [95% CI] = $4876 [4436–5316]), and few hospital-free days (adjusted difference [95% CI] = − 3.1 days [− 3.4 to − 2.8]). Similar trends were observed in the analyses in which patient volume was incorporated as a categorical variable. The results of sensitivity analyses showed comparable results.

Conclusions

Analysis of Japanese nationwide administrative database demonstrated that high burn patient volume was significantly associated with increased in-hospital mortality, high healthcare costs, and few hospital-free days. Further studies are needed to validate our results.

Electronic supplementary material

The online version of this article (10.1186/s40560-019-0363-7) contains supplementary material, which is available to authorized users.

Neurosurgeon academic impact is associated with clinical outcomes after clipping of ruptured intracranial aneurysms

BACKGROUND

Surgeon-dependent factors such as experience and volume are associated with patient outcomes. However, it is unknown whether a surgeon's research productivity could be related to outcomes. The main aim of this study is to investigate the association between the surgeon's academic productivity and clinical outcomes following neurosurgical clipping of ruptured aneurysms.

METHODS

We performed a post-hoc analysis of 3567 patients who underwent clipping of ruptured intracranial aneurysms in the randomized trials of tirilazad mesylate from 1990 to 1997. These trials included 162 centers and 156 surgeons from 21 countries. Primary and secondary outcomes were: Glasgow outcome scale score and mortality, respectively. Total publications, H-index, and graduate degrees were used as academic indicators for each surgeon. The association between outcomes and academic factors were assessed using a hierarchical logistic regression analysis, adjusting for patient covariates.

RESULTS

Academic profiles were available for 147 surgeons, treating a total of 3307 patients. Most surgeons were from the USA (62, 42%), Canada (18, 12%), and Germany (15, 10%). On univariate analysis, the H-index correlated with better functional outcomes and lower mortality rates. In the multivariate model, patients under the care of surgeons with higher H-indices demonstrated improved neurological outcomes (p = 0.01) compared to surgeons with lower H-indices, without any significant difference in mortality. None of the other academic indicators were significantly associated with outcomes.

CONCLUSION

Although prognostication following surgery for ruptured intracranial aneurysms primarily depends on clinical and radiological factors, the academic impact of the operating neurosurgeon may explain some heterogeneity in surgical outcomes.

Inter-facility transfer of pediatric burn patients from U.S. Emergency Departments

PURPOSE

To describe the epidemiology of pediatric burn patients seen in U.S. emergency departments (EDs) and to determine factors associated with inter-facility transfer.

METHODS

We analyzed data from the 2012 Nationwide Emergency Department Sample. Current American Burn Association (ABA) Guidelines were used to identify children <18 who met criteria for referral to burn centers. Burn patient admission volume was used as a proxy for burn expertise. Logistic models were fitted to examine the odds of transfer from low volume hospitals.

RESULTS

In 2012, there were an estimated 126,742 (95% CI: 116,104-137,380) pediatric burn ED visits in the U.S. Of the 69,003 (54.4%) meeting referral criteria, 83.2% were in low volume hospitals. Only 8.2% of patients meeting criteria were transferred from low volume hospitals. Of the 52,604 (95% CI: 48,433-56,775) not transferred, 98.3% were treated and released and 1.7% were admitted without transfer; 54.7% of burns involved hands.

CONCLUSIONS

Over 90% of pediatric burn ED patients meet ABA burn referral criteria but are not transferred from low volume hospitals. Perhaps a portion of the 92% of patients currently receiving definitive care in low volume hospitals are under-referred and would have improved clinical outcomes if transferred at the time of presentation.

Burn center volume makes a difference for burned children

OBJECTIVES

Determine the relationship between the volume of burn admissions and outcomes for children with burns.

DESIGN

Retrospective review of the National Burn Repository from 2000-2009 using mixed effect logistic regression modeling.

SETTING

Tertiary burn centers in the United States.

PATIENTS

All children <18 years of age admitted with burn injury to a burn center submitting data to the National Burn Repository.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 210,683 records in the NBR from 2000-2009, 33,115 records for children ≤ 18 years of age met criteria for analysis; 26,280 had burn sizes smaller than 10%; only 32 of these children died. Volume of children treated varied greatly among facilities. Age, total body surface area burn, inhalation injury, and burn center volume influenced mortality (p < 0.05) An increase in the median yearly admissions of 100 decreased the odds of mortality by approximately 40%. High volume centers (admitting >200 pediatric patients/year) had the lowest mortality when adjusting for age and injury characteristics (p < 0.05).

CONCLUSIONS

Higher volume pediatric burn centers had lower mortality, particularly at larger burn sizes. The lower mortality of children a high volume centers could reflect greater experience, resource, and specialized expertise in treating pediatric patients.

Patient outcomes vs. service workload: an analysis of outcomes in the burn service of England and Wales

Background

Patient outcomes in specialist burns units have been used as a metric of care needs and quality. Besides patient factors there are service factors that might influence Length of Stay (LOS) and mortality, e.g. pressure on beds. Although the bed needs of UK hospitals have dropped significantly over the past three decades, with changes in policies and practices, recent reports suggest that hospitals have 90% bed occupancy for 48 weeks of the year. In the UK, the specialist burn injury service is organised so that patients are assessed on arrival at hospital, and those needing admission are found a nearby bed in a suitable unit through the National Burn Bed Bureau.

The aim of this study was to investigate the effect on outcomes of service pressures due to shortages of beds.

Methods

We took an extract of the anonymised patient data from the specialised burn injury database, iBID, and created a new database based on matching that data with bed availability data provided by the national Burn Bed Bureau. Cox proportional hazard modelling was used for analysis to investigate if there is an impact of bed occupancy (a proxy measure of workload) on LOS.

Results

Cox proportional hazard modelling indicated that half of the services in England and Wales are less likely to discharge a patient if the bed availability is high. Two of the services have abnormally high bed availability and LOS, therefore a model without these two services indicates a general reluctance to discharge patients when beds are available.

Conclusions

It is possible that the effect we observed is a result of gaming as service providers are paid by the number of admissions. In addition, providers many not all give the same level of accuracy of bed availability information to the NBBB: some may under report availability, for example at times of high pressure on staff. Furthermore, burn services may not empty beds to avoid being filled up by work from other specialties, thus making them unable to admit a burn when referred.

Referral Patterns in Pediatric Burn Patients

Though multiple studies have demonstrated superior outcomes amongst adult burn patients at verified burn centers (VBCs) relative to nondedicated burn centers (NBCs), roughly half of such patients meeting American Burn Association (ABA) referral guidelines are not sent to these centers. We sought examine referral patterns amongst pediatric burn patients. Retrospective review of a statewide patient database identified pediatric burn patients from 2000 to 2007 using International Classification of Disease (ICD-9) discharge codes. These injuries were cross-referenced with ABA referral criteria to determine compliance with the ABA guidelines. 1831 children sustained burns requiring hospitalization during the study period, of which 1274 (70%) met ABA referral criteria. Of 557 treated at NBCs, 306 (55%) met criteria for transfer. Neither age, gender, nor payer status demonstrated significant association with treatment center. VBCs treated more severely injured patients, but there was no difference in survival or rate of discharge home from NBCs versus VBCs. Studies to evaluate differences in functional outcomes between pediatric burn patients treated at VBCs versus NBCs would be beneficial to ensure optimization of outcomes in this population.

Relationship between timing of emergency procedures and limb amputation in patients with open tibia fracture in the United States, 2003 to 2009

BACKGROUND

The authors aimed to characterize patterns in the timing of initial emergency procedures for patients with open tibia fracture and examine the relationship between initial procedure timing and in-hospital amputation.

METHODS

Data were analyzed from the Nationwide Inpatient Sample, 2003 to 2009. Adult patients were included if they had a primary diagnosis code of open tibia fracture. Patients were excluded for the following reasons: they were transferred from or to another hospital, an immediate amputation was performed, more than one amputation was performed, no emergency procedure was documented, or they were treated at a facility that did not perform any amputations. The authors evaluated the association between timing of the first procedure and the outcome of amputation using multiple logistic regression, controlled for patient risk factors and hospital characteristics.

RESULTS

Of 7560 patients included in the analysis, 1.3 percent (n=99 patients) underwent amputation on hospital day 2 or later. The majority (52.6 percent) underwent the first operative procedure on day 0 or 1. In adjusted analyses, timing of the first operative procedure beyond the day of admission was associated with more than three times greater odds of amputation (day 1, odds ratio, 3.81; 95 percent CI, 1.80 to 8.07).

CONCLUSIONS

Delay of the first operative procedure beyond the day of admission appears to be associated with a significantly increased probability of amputation in patients with open tibia fracture. All practitioners involved in the management of these patients should seek a solution for any barrier, other than medical stability of the patient, to achieving early operative intervention.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

The effectiveness of regionalized burn care: an analysis of 6,873 burn admissions in North Carolina from 2000 to 2007

BACKGROUND

The effectiveness and benefits of regionalized trauma care are well substantiated; however, the effectiveness of regionalized burn care and potential benefits of burn center verification have not been fully validated.

STUDY DESIGN

This was a retrospective study of all acute burn admissions using a statewide discharge database from October 1, 2000, to September 30, 2007. Demographics, referral patterns, care practices, and outcomes were compared between 2 American Burn Association (ABA)-verified burn centers (VBCs) and the remaining 107 nonburn centers (NBCs) in North Carolina.

RESULTS

Overall, 6,873 adult burn patients required admission, with 79% of them meeting ABA burn center referral criteria. Of the 5,402 patients meeting ABA referral criteria, 43% were admitted to an NBC, and 25% of all NBC patients had burn operations. Burns admitted to NBCs tended to involve the hand/wrist and lower extremities. Older patients with comorbidities/concomitant trauma were more likely to be admitted to NBCs (p < 0.0001); however, larger burns were more likely to be admitted to a VBC (p < 0.0001). More NBC patients were discharged to nursing homes (p < 0.0001). Patients with Medicare were more likely to be admitted to NBCs (p < 0.0001), and uninsured patients or those with Workman's Compensation insurance were more likely to be admitted to VBCs (p < 0.0001), and payer status remained a significant predictor of treatment at a VBC on regression analysis.

CONCLUSIONS

This is the most comprehensive study of its kind and demonstrates that ABA burn center referral criteria are not always used for effective regionalized burn care or to ensure the best possible outcomes. Even with establishment of the burn center verification process, the mere presence of a VBC is insufficient for effective regionalized care. A greater emphasis is needed on the development of burn care systems.

Managing the relationship between quality and cost-effective burn care

In the modern era of fiscal prudence, managing the relationship between quality health care and cost reduction is a complex and challenging task for policy makers and health care providers. Health economics is an applied field that aids in assessing the feasibility of incorporating new interventions in a certain field. Applying these tools when allocating funds for burn care is even more complicated due to the lack of clinical data regarding the cost effectiveness of different aspects in burn care. Herein we review the existing literature and summarize different approaches for achieving cost effective health care in general and in burn care specifically. Special considerations to funds allocation in burn care are also discussed.

Analysis of admissions and outcomes in verified and nonverified burn centers

The American Burn Association instituted a burn center verification process to ensure optimal care for patients with burn injury. Limited data exist regarding differences in admissions and outcomes between verified (VC) and nonverified burn centers (NVC). The study purpose was to compare demographics, treatment, and outcomes of VC and NVC. The five VC were compared with the 12 NVC using data from California's discharge database for the year 2003. A total of 2867 patients were admitted to a burn center, 1645 to NVC (132/center), and 1222 (244/center) to VC. NVC admitted 1496 (91%) of their patients from local area and 118 (7%) from other acute care hospitals; in contrast, 948 (78%) of VC patients were local and 253 (21%) were transfers from other acute care hospitals. VCs admitted twice as many burns > or =80% total body surface area as NVC. VCs admitted more patients with face burns (18% VC vs 14% NVC, P < .001), had more patients on mechanical ventilation (12.4% VC vs 9.9% NVC P < .04), and performed fewer operations (61% VC vs 66% NVC, P < .006). Mortality rate was 3% in NVC and 4% in VC. During the study period verified centers in California admitted more patients per center and treated more severely injured patients than nonverified centers. Despite these differences, VC had mortality rates comparable to their nonverified counterparts. These findings support the need for additional studies evaluating the impact of verification on burn care.

Healthcare resource utilization and epidemiology of pediatric burn-associated hospitalizations, United States, 2000

The objective of this study was to describe the epidemiology and financial burden of burn-associated hospitalizations for children younger than 18 years in the United States. Retrospective data analysis of pediatric burn-associated hospitalizations was done using the Healthcare Cost and Utilization Project Kids' Inpatient Database for 2000. An estimated 10,000 children younger than 18 years were hospitalized for burn-associated injuries in the United States in 2000. These children spent an estimated 66,200 days in the hospital with associated hospital charges equal to USD 211,772,700. Total charges and length of stay for pediatric burn-associated hospitalizations in the United States during 2000 were associated with degree of burn, percentage of total body surface area burned, child's age, region of the United States, hospital location, and hospital type. Children 2 years old or younger were more likely to be nonwhite, be hospitalized for burns, and burn their hands/wrists, compared with children 3 to 17 years of age. Male children in both age groups were more likely to be hospitalized for burns than female children. Children 2 years old or younger were more likely to be burned by hot liquids/vapors and contact with hot substances/objects, while children 3 to 17 years were more likely to be burned by fire/flames. This study is the first national study on healthcare resource utilization for pediatric burn-associated hospitalizations to utilize the KID database. Burns are a major source of pediatric morbidity and are associated with significant national healthcare resource utilization annually. Future burn prevention efforts should emphasize implementing passive injury prevention strategies, especially for young children who are nonwhite and live in low-income communities.