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Pre-hospital emergency burn management in Shanghai: Analysis of 1868 burn patients
burns 38 (2012) 1174–1180
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Pre-hospital emergency burn management in Shanghai: Analysis of 1868 burn patients Shi-zhao Ji, Peng-fei Luo 1, Zheng-dong Kong 1, Xing-feng Zheng, Guo-feng Huang, Guang-yi Wang, Shi-hui Zhu, Shi-chu Xiao **, Zhao-fan Xia * Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai 200433, People’s Republic of China
article info
abstract
Article history:
Background: There are few studies reporting the level of pre-hospital emergency manage-
Accepted 17 March 2012
ment of burn patients and related influencing factors in China. This study is a summary of our investigation on emergency education and people’s awareness about pre-hospital
Keywords:
emergency management of burn patients in Shanghai, China, and analyses key factors
Burns
influencing pre-hospital emergency management of burn patients.
Epidemiology
Methods: The survey was conducted by questionnaire in burn patients who sought initial
Scalds
clinical visits at the Burn Center of Changhai Hospital (Shanghai, China) between November
Pre-hospital emergency
2009 and December 2010, including demographic data, burn conditions, pre-hospital emer-
management
gency management and education about emergency burn management. Data were statisti-
Prevention
cally treated by SPSS software. Results: Altogether 1868 effective questionnaire forms were collected; 33.9% of these burn patients received cooling treatment before admission and 32.2% of them used ‘folk remedies’ or antibiotics to treat the wound surface. Only 12.2% of these burn patients had received education about the knowledge of emergency management, mainly through public media (38.2%), relatives and friends (24.6%), Internet (15.8%), workplace (11.4%) and schools (10.1%). The result of logistic regression analysis showed that emergency education, especially via Internet and workplace, played an important role in pre-hospital emergency management, and that different channels of emergency education affected different age groups of people: network and unit education mainly affected young adults, while relatives and friends mainly affected elderly people. In addition, educational level was an important factor favourably affecting ‘cooling therapy’. Conclusions: The level of emergency burn management and related education is relatively low in China at present, and it is therefore necessary to intensify education about prehospital emergency management to raise the level of emergency burn management. At the same time, more attention should be paid to age- and population-specific education. Finally, universal emergency education should be included in the national basic education as a longterm strategy. # 2012 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author. Tel.: +86 21 81873471; fax: +86 21 65589829. ** Corresponding author. Tel.: +86 21 81873474; fax: +86 21 65589829. E-mail addresses: [email protected] (Z.-f. Xia), [email protected] (S.-c. Xiao). 1 These authors contributed equally to the article with the first author. 0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2012.03.010
burns 38 (2012) 1174–1180
Burn injuries remain one of the main causes of disability and death [1], and at the same time they are injuries that can most likely be prevented. The incidence and mortality of burn injuries have been brought under effective control in developed or high-income countries, while about 90% of deaths caused by burn injuries in the world are from developing countries. Therefore, how to improve burn and fire prevention systems has become a main problem in developing countries [2]. As far as primary prevention of fires and burns is concerned, the main method at present is to improve the safety of materials and equipment to establish a safe surrounding environment [3]. However, as this method is closely associated with economic development and involves improvement in infrastructure, it is difficult for developing countries to completely adopt methods of developed countries at present [4,5]. Timely and rational pre-hospital emergency management plays an important role in alleviating tissue damage and improving the prognosis, and cooling therapy is considered the simplest and most effective way of emergency burn management [6,7]. However, there are few data concerning research in this aspect in China. The degree of awareness about emergency burn management and the level of pre-hospital emergency burn management remain unclear in China. In this study, we evaluated pre-hospital emergency management of burn injuries and related education in China, and analysed key factors affecting pre-hospital emergency management of burn injuries in China, in an attempt to provide a foundation for decision making in improving and raising secondary prevention of fires and burns.
1.
Methods
The Burn Center of Changhai Hospital affiliated to the Second Military Medical University (Shanghai, China) was founded in 1958, and now is one of the largest burn centres in China, and the Emergency Burn & Wound Center in Shanghai, mainly responsible for the treatment of burn injuries in Shanghai and its surrounding areas including Zhejiang, Jiangsu and Anhui provinces. In this study, we made an investigation by questionnaire in burn patients when he/she sought clinical visits first time at the Burn Center of Changhai Hospital between November 2009 and December 2010. Other than the baseline characteristics of the burn patients (age, gender, cause, area, depth, location, place and educational level), which were collected by the doctors during the consultations, five multiple-choice questions about pre-hospital emergency burn management were answered by the patients themselves with choosing one answer: whether or not the patient had been isolated from the source of injury, whether or not they had received cooling treatment and how long it lasted, whether or not they used external agents and what kind of external agents was used, whether or not they were sent to hospitals within 24 h and whether or not and from which channel the patients had received education. For children and old patients who lost the ability of living independently, questionnaire was conducted through their
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caregivers. Patients who suffered from electric shock injuries and hypothermal injuries and those who were complicated with inhalation injuries, pulmonary blast injuries, gas poisoning and other compound injures were excluded from the study. The admitting physician administered the questionnaire to patients. By virtue of the trust relationship between the doctor and the patient, the number of items on the questionnaire was relatively small, and the items did not involve personal privacy, no reliability questions were designed in the questionnaire and the validity was mainly controlled by the opinions from the experts. Data were analysed using SPSS16.0 software, and all data were expressed as frequency and percentage (n, %). Unordered categories were compared by Pearson’s Chi-square test, and ordered categories were compared by Mann–Whitney U test. Influencing factors were screened by logistic regression analysis (stepwise forward method, with entry level = 0.05 and removal level = 0.10; unordered multi-classification variables were defined as dummy variables; P values were calculated using Wald test). P values <0.05 were considered statistically significant.
2.
Results
2.1.
Burn epidemiological data
Altogether 1868 effective questionnaire forms were collected. The male/female ratio was 1.9:1. Most of these burn patients were children (0–14 years), and adolescents/adults (15–60 years). The main causes of burn were hot liquids and flames. Most of the burn cases were small and moderate area superficial second-degree burns mainly involving the four extremities and the trunk. Most of the burn accidents happened in homes and working places. Education of most patients and caregivers was mainly at the junior middle school level. The details are shown in Table 1.
2.2.
Pre-hospital emergency management
Most of the patients were immediately isolated from the source of burn and sent to hospitals for consultation within 24 h, and only 33.9% of them were treated by ‘cooling therapy’, and the duration of cooling therapy was less than 10 min in 88%. With respect to wound treatment, most patients did not use any drug or wound dressing; 32.2% patients improperly used disinfectants and antibiotics externally or ‘folk remedies’ including toothpaste, soy sauce, eggs, table salt or cooking oil (Table 2). Any external agent, which may cause secondary infection, bacterial imbalance or resistance or misjudgement of burn depth, was considered to be improper when used before hospital consultation, including some kitchen supplies (e.g. soy sauce, sugar, vinegar, salt, eggs, and oil), disinfectants and antibiotics (oral and intravenous antibiotics) and some others such as toothpaste or tea. Some specialised burn creams (e.g. silvercontained ointment) produced by the pharmacy company for treatment of burns were considered to be rational as well as clean gauze.
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burns 38 (2012) 1174–1180
Table 1 – Baseline characteristics of burn patients. Sex Female Male
645 (34.5%) 1223 (65.5%)
Age Children (0–14 yr) Adolescents and adults (15–59 yr) The elderly (60 yr) Educational level Primary school Middle school College Cause Hot fluids Flames Hot solids Chemical Electrical spark a b
703 (37.6%) 898 (48.1%) 267 (14.3%) 342 (18.3%) 1013 (54.2%) 513 (27.5%) 1011 435 238 100 84
(54.1%) (23.3%) (12.7%) (5.4%) (4.5%)
Burn area <10%TBSAa 10–30%TBSAa >30%TBSAa Burn depth Superficial 2nd-degree Deep 2nd-degree 3rd-degree Place Home Workplace Outdoor Locationb Head and neck Upper extremities Lower extremities Trunk Hips and perineum
1051 (56.3%) 483 (25.8%) 334 (17.9%) 1170 (62.6%) 425 (22.8%) 273 (14.6%) 1228 (65.7%) 396 (21.2%) 244 (13.1%) 445 902 870 658 344
(23.8%) (48.3%) (46.6%) (35.2%) (18.4%)
Total body surface area. Some patients have more than one location involved.
2.3.
Emergency education
Most patients (87.8%) had not received any education about emergency burn management. Those who had received related education reported that they mainly learnt the knowledge of emergency burn management via the channels of traditional media (38.2%) including newspapers, magazines and posters; relatives and friends (24.6%); Internet (15.8%); workplace (11.4%); and schools (10.1%). To explore the influence of emergency education on prehospital emergency burn management, the patients or caregivers of children and elderly patients were divided into
2.4. Association between pre-hospital emergency management and depth of burn injury
Table 2 – Pre-hospital emergency management. Immediate isolation from the source of injury No Yes Cooling treatment No Yes Duration of cooling treatment <10 min 10–20 min >20 min Agents for external use No external material used Folk remediesa Burn creamb and clean gauze Disinfectants and antibioticsc Others Hospital consultation within 24 h No Yes
135 (7.2%) 1733 (92.8%) 1234 (66.1%) 634 (33.9%) 558 (88.0%) 49 (7.7%) 27 (4.3%) 989 338 277 232 32
two groups (education group and non-education group) according to whether they had received emergency knowledge. There were no significant differences in the baseline characteristics (including demographic data, cause, location, area, depth and place) between the two groups (data not shown). Therefore, differences in pre-hospital emergency burn management were compared between the two groups. The results showed that patients in the education group were better than those in the non-education group with respect to prompt cooling treatment, duration of cooling treatment, rational use of external covers (burn cream and clean gauze) and hospital consultation within 24 h (Table 3).
(52.9%) (18.1%) (14.9%) (12.4%) (1.7%)
437 (23.4%) 1431 (76.6%)
Analysis of the association between post-burn emergency management and the depth of burn injury showed that the distribution of burn depth was significantly different between the two groups divided by whether or not they have adopted correct emergency management, such as whether or not isolated from the source of injury immediately, whether or not adopted prompt cooling treatment and whether or not used proper external agents. The depth of burn injury was superficial second degree in most patients who adopted correct emergency burn management, while the depth of burn injury was deep second degree or third degree in most patients who did not adopt emergency burn management correctly (Table 4).
2.5. Factors affecting pre-hospital emergency burn management
a
Folk remedies includes tooth-paste, soy sauce, eggs, table salt and cooking oil. b Burn cream represents some specialized burn creams produced by the pharmacy company for the family standing, e.g. silvercontained ointment. c Antibiotics includes oral and intravenous antibiotics except antibiotic ointment.
Using ‘immediate isolation from the source of injury’, ‘prompt cooling treatment’, ‘rational use of external agents’ and ‘hospital consultation within 24 h’ as the effect indicators for evaluating the level of pre-hospital emergency burn management, seven candidate factors that may affect the level of pre-hospital emergency burn management were
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burns 38 (2012) 1174–1180
Table 3 – Comparison of pre-hospital emergency management between the education group (EG) and non education group (NEG). Pre-hospital emergency management
NEG (n = 1640)
EG (n = 228)
P valuea
1520 (92.7%) 503 (30.7%)
213 (93.4%) 131 (57.5%)
0.687 <0.001 <0.001
447 38 18 1085 1231
111 11 9 181 200
Immediate isolation from the source of injury Cooling treatment Duration of cooling treatment <10 min 10–20 min >20 min Rational use of external agentsb Hospital consultation within 24 h
(27.3%) (2.3%) (1.1%) (66.2%) (75.1%)
(48.7%) (4.8%) (3.9%) (79.4%) (87.7%)
<0.001 <0.001
a
P values of EG vs. NEG were calculated using Pearson’s Chi-square test, except the duration of cooling treatment, for which Mann–Whitney U test was used. b Rational use of external agents was defined as using burn cream and clean gauze.
Table 4 – Association between pre-hospital burn emergency management and depth of burn injury. Immediate isolation from the source of injury No Superficial 2nd-degree Deep 2nd-degree 3rd-degree P valuea a
71 (52.6%) 37 (27.4%) 27 (20.0%)
Yes 1099 (63.4%) 388 (22.4%) 246 (14.2%) 0.010
Cooling treatment
No
Hospital consultation within 24 h
Rational use of external agents
Yes
No
749 (60.7%) 421 (66.4%) 302 (24.5%) 123 (19.4%) 183 (14.8%) 90 (14.2%) 0.035
Yes
No
337 (56.0%) 833 (65.8%) 146 (24.3%) 279 (22.0%) 119 (19.8%) 154 (12.2%) <0.001
Yes
283 (64.8%) 887 (62.0%) 101 (23.1%) 324 (22.6%) 53 (12.1%) 220 (15.4%) 0.187
P values were calculated using Mann–Whitney U test.
analysed in the logistic regression model, including age, burn area, burn location, cause, place, educational level and emergency management education (receiving or not). The results showed that emergency education was an important factor affecting the level of pre-hospital emergency burn management, especially with respect to cooling treatment. Age, education, cause and place of burn injuries also had different effects (Table 5).
2.6. Analysis of effective channels of education about prehospital emergency management To screen emergency place and knowledge,
out effective factors influencing pre-hospital management, age, burn area, location, cause, education channels (not receiving emergency traditional media, relatives and friends, Internet
Table 5 – Factors affecting the level of pre-hospital emergency burn management. Effect indicator
Risk factora
Immediate isolation from the source of injury Age Cooling treatment Chemicalsb Electrical sparksc Outdoorc Education Emergency management educationd Rational use of external agents Burn area Chemicalsb Electrical sparksb Emergency management educationd Hospital consultation within 24 h Chemicalsb Electrical sparksb Emergency management educationd
Odd ratio (95% CI)
Wald x 2
0.63 (0.43, 0.92)
5.83
0.016
P value
1.88 0.26 0.58 1.38 2.99
(1.22, (0.14, (0.42, (1.19, (2.24,
2.90) 0.51) 0.80) 1.61) 3.99)
8.26 15.92 10.83 18.16 54.73
0.004 <0.001 0.001 <0.001 <0.001
0.85 1.24 0.46 1.95
(0.75, (0.78, (0.29, (1.39,
0.96) 1.99) 0.73) 2.74)
6.68 0.82 11.04 14.85
0.010 0.366 0.001 <0.001
1.76 (1.01, 3.07) 2.37 (1.24, 4.55) 2.34 (1.55, 3.53)
3.96 6.75 16.30
0.047 0.009 <0.001
a Emergency education, age, burn area, location, cause, place and educational level of the patients or caregivers were used as the candidate factors and analysed by logistic regression model (stepwise forward method with entry level = 0.05 and removal level = 0.10). b ‘‘Cause’’ was defined as a dummy variable with ‘‘hot fluids’’ as reference category. c ‘‘Place’’ was defined as a dummy variable with ‘‘home’’ as reference category. d ‘‘ Emergency management education’’ was defined as dummy variable with ‘‘not receiving any education’’ as reference category.
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burns 38 (2012) 1174–1180
Table 6 – Logistic regression analysis of effective methods of education about pre-hospital emergency management. Effect indicator
Risk factora
Wald x 2
P value
2.98) 5.19) 11.57) 13.00) 9.03)
8.09 15.17 19.66 14.21 8.94
0.004 <0.001 <0.001 <0.001 0.003
3.78 (1.33, 10.77) 4.04 (1.20, 13.65)
6.20 5.05
0.013 0.025
2.80 (1.39, 5.64) 3.73 (1.14, 12.26)
8.30 4.71
0.004 0.030
3.54) 22.50) 34.60) 18.00)
2.58 17.95 11.69 8.51
0.108 <0.001 0.001 0.004
3.89 (1.16, 13.01) 8.33 (1.09, 63.39)
4.85 4.19
0.028 0.041
8.86 (1.20, 65.66)
4.55
0.033
5.27 (2.35, 11.79) 8.57 (2.95, 24.87)
16.30 15.63
<0.001 <0.001
4.20 (1.45, 12.18) 4.79 (1.10, 20.89)
6.96 4.34
0.008 0.037
6.20 (1.45, 26.42) 8.45 (1.12, 63.96)
6.08 4.27
0.014 0.039
Odd ratio (95% CI)
All patients Cooling treatment Traditional mediab Relatives and friendsb Internet educationb Workplace educationb School educationb
1.91 2.99 5.46 5.41 3.78
(1.22, (1.72, (2.58, (2.25, (1.58,
Rational use of external agents Internet educationb Workplace educationb Hospital consultation within 24 h Traditional mediab Internet educationb Adolescents and adults (15–59) Cooling treatment Relatives and friendsb Internet educationb Workplace educationb School educationb Rational use of external agents Internet educationb Workplace educationb Hospital consultation within 24 h Internet educationb The elderly (I60) Cooling treatment Traditional mediab Relatives and friendsb Rational use of external agents Traditional mediab Relatives and friendsb Hospital consultation within 24 h Traditional mediab Relatives and friendsb
1.77 8.40 9.51 5.64
(0.88, (3.14, (2.62, (1.76,
a Education channels, age, burn area, location, cause, place and educational level of the patients or caregivers were used as candidate factors for all patients; education channels, burn area, location, cause, place and educational level of the patients or caregivers were used as candidate factors for adolescents and adults group and the elderly group. These candidate factors were analysed by logistic regression model (stepwise forward method with entry level = 0.05 and removal level = 0.10). Only the results of education channels are listed in the table, and the other results were not shown in the table. b ‘‘Education channels’’ was defined as a dummy variable with ‘‘not receiving emergency education’’ as reference category.
and schools) were used as candidate factors for analysis in the regression analysis model. The results showed that all these education channels had positive protective effects, with the effect of Internet and workplace being most obvious. Further analysis on the basis of the age of the patients or caregivers showed that the effective channels of emergency education were different between young adults and elderly patients: the former were mainly affected by workplace and Internet, while the latter were mainly affected by relatives and friends and traditional media (Table 6).
3.
Discussion
The key point of burn injuries lies in prevention. A good security and prevention system can reduce the occurrence of burn injuries significantly, while timely and correct emergency management can alleviate the severity of burn injuries effectively [8]. The primary prevention of fires and burns focusses on ensuring safety of the surrounding environment
and reducing unsafe factors that may cause burn injures by installing fire alarms and water sprinklers; setting safe water and electrical equipment temperature; and using fire protection materials and equipment to minimise risk factors causing burn injuries [4]. However, as these measures are built on the prerequisite of improving the infrastructure and closely associated with social and economic development, it is difficult to spread them widely in developing countries at present. For this reason, intensifying secondary prevention and raising the level of emergency burn management have become the focus of burn prevention in these countries. In recent years, many studies have reported epidemiological distributions of burn injuries including aetiology and risk factors [9–13]. However, there are few studies reporting emergency burn management, especially about related factors affecting pre-hospital emergency management. The results of our investigation showed that most burn patients knew the essentials to escape from the source of burn injuries immediately and to go to hospitals for medical consultation within 24 h. However, there were still 23.4% burn patients who
burns 38 (2012) 1174–1180
did not go to hospitals for help until wounds deteriorated or infections occurred. Although about one-third of the patients used cooling treatment on the spot, the duration of cooling treatment was less than 10 min in most patients, and only 4.3% of the patients used cooling treatment for more than 20 min. About 32.2% of the patients used ‘folk remedies’ or antibiotics to treat the wounds. These results are similar to those reported in other developing countries such as Vietnam [7], Ghana [14], Cambodia [15] and Turkey [16]. Post-burn cooling treatment is recommended as the simplest and the most effective means of secondary prevention of fires and burns. Research has demonstrated that correct and effective cooling treatment can alleviate burn-induced tissue damage, reduce the hospitalisation rate and surgical skin grafting and lower medical costs. In addition, research has shown that the above ‘folk remedies’ could not protect burn wounds; rather they may induce allergic reactions or even deepen burn injuries [16–18]. Our investigation also showed that most burns were superficial second degree in patients who were immediately isolated from the source of injury, promptly used cooling treatment and treated burn wounds rationally, while most burns were deep second degree or third degree in those who did not treat the wounds timely and rationally. Although it suggests that timely and rational emergency burn management may alleviate the depth of burn injury, the definite causation relationship between them needs more effective evidence such as a further randomised controlled study or a prospective cohort study. In the present situation, the urgent task is to raise people’s awareness about emergency burn management and raise the public level of emergency burn management so as to improve secondary prevention of fires and burns. To determine the key factors affecting emergency burn management, we further investigated emergency education in these burn patients and found that most patients did not receive any education about emergency burn management, and, in those who had received emergency education, the knowledge about emergency management mainly came from traditional media, relatives and friends and Internet, and only about 20% of such education came from the workplace and schools, indicating that the situation in emergency education in China is worrying. Some studies [19] had demonstrated that multi-media campaigns through televisions, radios, books, magazines and posters could achieve good outcomes in raising the level of emergency management and reducing the hospitalisation rate of burn patients within a short time. It was found in our study that pre-hospital emergency management in burn patients who had received emergency education was significantly better than that in those who had not received emergency education, but there was no significant difference in burn depth between the two groups of patients (data not shown), which probably suggests that education from traditional media may have different influences on the level of emergency management. We therefore suggest that multimedia campaigns should be used as an accessory means to raise the level of emergency management in the contemporary period, and, at the same time, emergency education should be included in school, unit and family education systems as a fundamental strategy. In other words, universal
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emergency education should be taken as a long-term strategy in national basic education. The results of our further logistic regression analysis revealed that emergency education is the most important factor affecting pre-hospital emergency management, and age, educational level, cause, place and area of burn injury are also unneglectable factors affecting correct management of burn injuries. The age is an unfavourable factor affecting ‘immediate isolation from the source of injury’ (odds ratio (OR) = 0.63), especially in elderly patients who may not be able to escape from the source of injury due to sensory numbness from diabetes mellitus, hemiplegia and other underlying diseases. Educational level is an important factor affecting ‘prompt cooling treatment’ (OR = 1.38), probably because educated patients are more likely to use more scientific methods instead of ‘folk remedies’. In addition, burns from some special causes may affect emergency management in varying ways. For instance, chemical burn is a favourable factor affecting ‘cooling treatment’ (OR = 1.88) and ‘wound surface management’ (OR = 1.24), while electrical spark burn is an unfavourable factor affecting ‘cooling treatment’ (OR = 0.26) and ‘wound surface management’ (OR = 0.46), probably because chemical burn may easily produce a reflex of washing reaction that urges burn victims to remove the chemical from the skin surface, while electrical spark burn is easily mistaken as an electrical contact injury, where the patient is rarely aware that skin burn from electrical sparks also needs cooling treatment. In addition, chemical and electrical spark burns are relatively complex and more likely to produce phobia, which may urge patients to seek help from hospitals in time. Outdoor burn is an unfavourable factor for cooling treatment because of unavailability of water sources (OR = 0.58). With respect to the channels from which emergency knowledge is acquired, the effect of unit and network education is the most obvious, especially on cooling treatment. It was also found that most of the patients who obtained emergency knowledge from Internet usually sought help from Internet after they were injured by burns, suggesting that it is important to intensify unit education and establish emergency network platforms. Age stratification analysis showed that different age groups obtained emergency knowledge through different channels: network and unit education is an important and characteristic factor affecting pre-hospital emergency management in adolescents and young adults; relatives and friends is an important factor affecting elderly patients, in whom the influence of relatives and friends is even greater than that of traditional media (ORrelatives and friends = 8.57 vs. ORtraditional media = 5.27), suggesting that community health service systems play an important role in spreading knowledge in elderly people.
4.
Conclusion
Pre-hospital emergency management and knowledge publicity about emergency burn management remain at a relatively low level in China, and therefore emergency education is urgently needed at present. Network education and unit education are two main channels affecting the overall level of pre-hospital emergency management in the contemporary
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burns 38 (2012) 1174–1180
period. The channel of education should vary with age groups: education via Internet and workplace should be the main channels of education for young adults, while community education should be intensified in elderly people.
Conflict of interest There is no competing interests or conflicts in the present paper.
Acknowledgements This project was supported by the National Natural Science Foundation of China (C30600646, 81071555, 81120108015).
references
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Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Pre-hospital emergency burn management in Shanghai: Analysis of 1868 burn patients Shi-zhao Ji, Peng-fei Luo 1, Zheng-dong Kong 1, Xing-feng Zheng, Guo-feng Huang, Guang-yi Wang, Shi-hui Zhu, Shi-chu Xiao **, Zhao-fan Xia * Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai 200433, People’s Republic of China
article info
abstract
Article history:
Background: There are few studies reporting the level of pre-hospital emergency manage-
Accepted 17 March 2012
ment of burn patients and related influencing factors in China. This study is a summary of our investigation on emergency education and people’s awareness about pre-hospital
Keywords:
emergency management of burn patients in Shanghai, China, and analyses key factors
Burns
influencing pre-hospital emergency management of burn patients.
Epidemiology
Methods: The survey was conducted by questionnaire in burn patients who sought initial
Scalds
clinical visits at the Burn Center of Changhai Hospital (Shanghai, China) between November
Pre-hospital emergency
2009 and December 2010, including demographic data, burn conditions, pre-hospital emer-
management
gency management and education about emergency burn management. Data were statisti-
Prevention
cally treated by SPSS software. Results: Altogether 1868 effective questionnaire forms were collected; 33.9% of these burn patients received cooling treatment before admission and 32.2% of them used ‘folk remedies’ or antibiotics to treat the wound surface. Only 12.2% of these burn patients had received education about the knowledge of emergency management, mainly through public media (38.2%), relatives and friends (24.6%), Internet (15.8%), workplace (11.4%) and schools (10.1%). The result of logistic regression analysis showed that emergency education, especially via Internet and workplace, played an important role in pre-hospital emergency management, and that different channels of emergency education affected different age groups of people: network and unit education mainly affected young adults, while relatives and friends mainly affected elderly people. In addition, educational level was an important factor favourably affecting ‘cooling therapy’. Conclusions: The level of emergency burn management and related education is relatively low in China at present, and it is therefore necessary to intensify education about prehospital emergency management to raise the level of emergency burn management. At the same time, more attention should be paid to age- and population-specific education. Finally, universal emergency education should be included in the national basic education as a longterm strategy. # 2012 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author. Tel.: +86 21 81873471; fax: +86 21 65589829. ** Corresponding author. Tel.: +86 21 81873474; fax: +86 21 65589829. E-mail addresses: [email protected] (Z.-f. Xia), [email protected] (S.-c. Xiao). 1 These authors contributed equally to the article with the first author. 0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2012.03.010
burns 38 (2012) 1174–1180
Burn injuries remain one of the main causes of disability and death [1], and at the same time they are injuries that can most likely be prevented. The incidence and mortality of burn injuries have been brought under effective control in developed or high-income countries, while about 90% of deaths caused by burn injuries in the world are from developing countries. Therefore, how to improve burn and fire prevention systems has become a main problem in developing countries [2]. As far as primary prevention of fires and burns is concerned, the main method at present is to improve the safety of materials and equipment to establish a safe surrounding environment [3]. However, as this method is closely associated with economic development and involves improvement in infrastructure, it is difficult for developing countries to completely adopt methods of developed countries at present [4,5]. Timely and rational pre-hospital emergency management plays an important role in alleviating tissue damage and improving the prognosis, and cooling therapy is considered the simplest and most effective way of emergency burn management [6,7]. However, there are few data concerning research in this aspect in China. The degree of awareness about emergency burn management and the level of pre-hospital emergency burn management remain unclear in China. In this study, we evaluated pre-hospital emergency management of burn injuries and related education in China, and analysed key factors affecting pre-hospital emergency management of burn injuries in China, in an attempt to provide a foundation for decision making in improving and raising secondary prevention of fires and burns.
1.
Methods
The Burn Center of Changhai Hospital affiliated to the Second Military Medical University (Shanghai, China) was founded in 1958, and now is one of the largest burn centres in China, and the Emergency Burn & Wound Center in Shanghai, mainly responsible for the treatment of burn injuries in Shanghai and its surrounding areas including Zhejiang, Jiangsu and Anhui provinces. In this study, we made an investigation by questionnaire in burn patients when he/she sought clinical visits first time at the Burn Center of Changhai Hospital between November 2009 and December 2010. Other than the baseline characteristics of the burn patients (age, gender, cause, area, depth, location, place and educational level), which were collected by the doctors during the consultations, five multiple-choice questions about pre-hospital emergency burn management were answered by the patients themselves with choosing one answer: whether or not the patient had been isolated from the source of injury, whether or not they had received cooling treatment and how long it lasted, whether or not they used external agents and what kind of external agents was used, whether or not they were sent to hospitals within 24 h and whether or not and from which channel the patients had received education. For children and old patients who lost the ability of living independently, questionnaire was conducted through their
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caregivers. Patients who suffered from electric shock injuries and hypothermal injuries and those who were complicated with inhalation injuries, pulmonary blast injuries, gas poisoning and other compound injures were excluded from the study. The admitting physician administered the questionnaire to patients. By virtue of the trust relationship between the doctor and the patient, the number of items on the questionnaire was relatively small, and the items did not involve personal privacy, no reliability questions were designed in the questionnaire and the validity was mainly controlled by the opinions from the experts. Data were analysed using SPSS16.0 software, and all data were expressed as frequency and percentage (n, %). Unordered categories were compared by Pearson’s Chi-square test, and ordered categories were compared by Mann–Whitney U test. Influencing factors were screened by logistic regression analysis (stepwise forward method, with entry level = 0.05 and removal level = 0.10; unordered multi-classification variables were defined as dummy variables; P values were calculated using Wald test). P values <0.05 were considered statistically significant.
2.
Results
2.1.
Burn epidemiological data
Altogether 1868 effective questionnaire forms were collected. The male/female ratio was 1.9:1. Most of these burn patients were children (0–14 years), and adolescents/adults (15–60 years). The main causes of burn were hot liquids and flames. Most of the burn cases were small and moderate area superficial second-degree burns mainly involving the four extremities and the trunk. Most of the burn accidents happened in homes and working places. Education of most patients and caregivers was mainly at the junior middle school level. The details are shown in Table 1.
2.2.
Pre-hospital emergency management
Most of the patients were immediately isolated from the source of burn and sent to hospitals for consultation within 24 h, and only 33.9% of them were treated by ‘cooling therapy’, and the duration of cooling therapy was less than 10 min in 88%. With respect to wound treatment, most patients did not use any drug or wound dressing; 32.2% patients improperly used disinfectants and antibiotics externally or ‘folk remedies’ including toothpaste, soy sauce, eggs, table salt or cooking oil (Table 2). Any external agent, which may cause secondary infection, bacterial imbalance or resistance or misjudgement of burn depth, was considered to be improper when used before hospital consultation, including some kitchen supplies (e.g. soy sauce, sugar, vinegar, salt, eggs, and oil), disinfectants and antibiotics (oral and intravenous antibiotics) and some others such as toothpaste or tea. Some specialised burn creams (e.g. silvercontained ointment) produced by the pharmacy company for treatment of burns were considered to be rational as well as clean gauze.
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burns 38 (2012) 1174–1180
Table 1 – Baseline characteristics of burn patients. Sex Female Male
645 (34.5%) 1223 (65.5%)
Age Children (0–14 yr) Adolescents and adults (15–59 yr) The elderly (60 yr) Educational level Primary school Middle school College Cause Hot fluids Flames Hot solids Chemical Electrical spark a b
703 (37.6%) 898 (48.1%) 267 (14.3%) 342 (18.3%) 1013 (54.2%) 513 (27.5%) 1011 435 238 100 84
(54.1%) (23.3%) (12.7%) (5.4%) (4.5%)
Burn area <10%TBSAa 10–30%TBSAa >30%TBSAa Burn depth Superficial 2nd-degree Deep 2nd-degree 3rd-degree Place Home Workplace Outdoor Locationb Head and neck Upper extremities Lower extremities Trunk Hips and perineum
1051 (56.3%) 483 (25.8%) 334 (17.9%) 1170 (62.6%) 425 (22.8%) 273 (14.6%) 1228 (65.7%) 396 (21.2%) 244 (13.1%) 445 902 870 658 344
(23.8%) (48.3%) (46.6%) (35.2%) (18.4%)
Total body surface area. Some patients have more than one location involved.
2.3.
Emergency education
Most patients (87.8%) had not received any education about emergency burn management. Those who had received related education reported that they mainly learnt the knowledge of emergency burn management via the channels of traditional media (38.2%) including newspapers, magazines and posters; relatives and friends (24.6%); Internet (15.8%); workplace (11.4%); and schools (10.1%). To explore the influence of emergency education on prehospital emergency burn management, the patients or caregivers of children and elderly patients were divided into
2.4. Association between pre-hospital emergency management and depth of burn injury
Table 2 – Pre-hospital emergency management. Immediate isolation from the source of injury No Yes Cooling treatment No Yes Duration of cooling treatment <10 min 10–20 min >20 min Agents for external use No external material used Folk remediesa Burn creamb and clean gauze Disinfectants and antibioticsc Others Hospital consultation within 24 h No Yes
135 (7.2%) 1733 (92.8%) 1234 (66.1%) 634 (33.9%) 558 (88.0%) 49 (7.7%) 27 (4.3%) 989 338 277 232 32
two groups (education group and non-education group) according to whether they had received emergency knowledge. There were no significant differences in the baseline characteristics (including demographic data, cause, location, area, depth and place) between the two groups (data not shown). Therefore, differences in pre-hospital emergency burn management were compared between the two groups. The results showed that patients in the education group were better than those in the non-education group with respect to prompt cooling treatment, duration of cooling treatment, rational use of external covers (burn cream and clean gauze) and hospital consultation within 24 h (Table 3).
(52.9%) (18.1%) (14.9%) (12.4%) (1.7%)
437 (23.4%) 1431 (76.6%)
Analysis of the association between post-burn emergency management and the depth of burn injury showed that the distribution of burn depth was significantly different between the two groups divided by whether or not they have adopted correct emergency management, such as whether or not isolated from the source of injury immediately, whether or not adopted prompt cooling treatment and whether or not used proper external agents. The depth of burn injury was superficial second degree in most patients who adopted correct emergency burn management, while the depth of burn injury was deep second degree or third degree in most patients who did not adopt emergency burn management correctly (Table 4).
2.5. Factors affecting pre-hospital emergency burn management
a
Folk remedies includes tooth-paste, soy sauce, eggs, table salt and cooking oil. b Burn cream represents some specialized burn creams produced by the pharmacy company for the family standing, e.g. silvercontained ointment. c Antibiotics includes oral and intravenous antibiotics except antibiotic ointment.
Using ‘immediate isolation from the source of injury’, ‘prompt cooling treatment’, ‘rational use of external agents’ and ‘hospital consultation within 24 h’ as the effect indicators for evaluating the level of pre-hospital emergency burn management, seven candidate factors that may affect the level of pre-hospital emergency burn management were
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burns 38 (2012) 1174–1180
Table 3 – Comparison of pre-hospital emergency management between the education group (EG) and non education group (NEG). Pre-hospital emergency management
NEG (n = 1640)
EG (n = 228)
P valuea
1520 (92.7%) 503 (30.7%)
213 (93.4%) 131 (57.5%)
0.687 <0.001 <0.001
447 38 18 1085 1231
111 11 9 181 200
Immediate isolation from the source of injury Cooling treatment Duration of cooling treatment <10 min 10–20 min >20 min Rational use of external agentsb Hospital consultation within 24 h
(27.3%) (2.3%) (1.1%) (66.2%) (75.1%)
(48.7%) (4.8%) (3.9%) (79.4%) (87.7%)
<0.001 <0.001
a
P values of EG vs. NEG were calculated using Pearson’s Chi-square test, except the duration of cooling treatment, for which Mann–Whitney U test was used. b Rational use of external agents was defined as using burn cream and clean gauze.
Table 4 – Association between pre-hospital burn emergency management and depth of burn injury. Immediate isolation from the source of injury No Superficial 2nd-degree Deep 2nd-degree 3rd-degree P valuea a
71 (52.6%) 37 (27.4%) 27 (20.0%)
Yes 1099 (63.4%) 388 (22.4%) 246 (14.2%) 0.010
Cooling treatment
No
Hospital consultation within 24 h
Rational use of external agents
Yes
No
749 (60.7%) 421 (66.4%) 302 (24.5%) 123 (19.4%) 183 (14.8%) 90 (14.2%) 0.035
Yes
No
337 (56.0%) 833 (65.8%) 146 (24.3%) 279 (22.0%) 119 (19.8%) 154 (12.2%) <0.001
Yes
283 (64.8%) 887 (62.0%) 101 (23.1%) 324 (22.6%) 53 (12.1%) 220 (15.4%) 0.187
P values were calculated using Mann–Whitney U test.
analysed in the logistic regression model, including age, burn area, burn location, cause, place, educational level and emergency management education (receiving or not). The results showed that emergency education was an important factor affecting the level of pre-hospital emergency burn management, especially with respect to cooling treatment. Age, education, cause and place of burn injuries also had different effects (Table 5).
2.6. Analysis of effective channels of education about prehospital emergency management To screen emergency place and knowledge,
out effective factors influencing pre-hospital management, age, burn area, location, cause, education channels (not receiving emergency traditional media, relatives and friends, Internet
Table 5 – Factors affecting the level of pre-hospital emergency burn management. Effect indicator
Risk factora
Immediate isolation from the source of injury Age Cooling treatment Chemicalsb Electrical sparksc Outdoorc Education Emergency management educationd Rational use of external agents Burn area Chemicalsb Electrical sparksb Emergency management educationd Hospital consultation within 24 h Chemicalsb Electrical sparksb Emergency management educationd
Odd ratio (95% CI)
Wald x 2
0.63 (0.43, 0.92)
5.83
0.016
P value
1.88 0.26 0.58 1.38 2.99
(1.22, (0.14, (0.42, (1.19, (2.24,
2.90) 0.51) 0.80) 1.61) 3.99)
8.26 15.92 10.83 18.16 54.73
0.004 <0.001 0.001 <0.001 <0.001
0.85 1.24 0.46 1.95
(0.75, (0.78, (0.29, (1.39,
0.96) 1.99) 0.73) 2.74)
6.68 0.82 11.04 14.85
0.010 0.366 0.001 <0.001
1.76 (1.01, 3.07) 2.37 (1.24, 4.55) 2.34 (1.55, 3.53)
3.96 6.75 16.30
0.047 0.009 <0.001
a Emergency education, age, burn area, location, cause, place and educational level of the patients or caregivers were used as the candidate factors and analysed by logistic regression model (stepwise forward method with entry level = 0.05 and removal level = 0.10). b ‘‘Cause’’ was defined as a dummy variable with ‘‘hot fluids’’ as reference category. c ‘‘Place’’ was defined as a dummy variable with ‘‘home’’ as reference category. d ‘‘ Emergency management education’’ was defined as dummy variable with ‘‘not receiving any education’’ as reference category.
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burns 38 (2012) 1174–1180
Table 6 – Logistic regression analysis of effective methods of education about pre-hospital emergency management. Effect indicator
Risk factora
Wald x 2
P value
2.98) 5.19) 11.57) 13.00) 9.03)
8.09 15.17 19.66 14.21 8.94
0.004 <0.001 <0.001 <0.001 0.003
3.78 (1.33, 10.77) 4.04 (1.20, 13.65)
6.20 5.05
0.013 0.025
2.80 (1.39, 5.64) 3.73 (1.14, 12.26)
8.30 4.71
0.004 0.030
3.54) 22.50) 34.60) 18.00)
2.58 17.95 11.69 8.51
0.108 <0.001 0.001 0.004
3.89 (1.16, 13.01) 8.33 (1.09, 63.39)
4.85 4.19
0.028 0.041
8.86 (1.20, 65.66)
4.55
0.033
5.27 (2.35, 11.79) 8.57 (2.95, 24.87)
16.30 15.63
<0.001 <0.001
4.20 (1.45, 12.18) 4.79 (1.10, 20.89)
6.96 4.34
0.008 0.037
6.20 (1.45, 26.42) 8.45 (1.12, 63.96)
6.08 4.27
0.014 0.039
Odd ratio (95% CI)
All patients Cooling treatment Traditional mediab Relatives and friendsb Internet educationb Workplace educationb School educationb
1.91 2.99 5.46 5.41 3.78
(1.22, (1.72, (2.58, (2.25, (1.58,
Rational use of external agents Internet educationb Workplace educationb Hospital consultation within 24 h Traditional mediab Internet educationb Adolescents and adults (15–59) Cooling treatment Relatives and friendsb Internet educationb Workplace educationb School educationb Rational use of external agents Internet educationb Workplace educationb Hospital consultation within 24 h Internet educationb The elderly (I60) Cooling treatment Traditional mediab Relatives and friendsb Rational use of external agents Traditional mediab Relatives and friendsb Hospital consultation within 24 h Traditional mediab Relatives and friendsb
1.77 8.40 9.51 5.64
(0.88, (3.14, (2.62, (1.76,
a Education channels, age, burn area, location, cause, place and educational level of the patients or caregivers were used as candidate factors for all patients; education channels, burn area, location, cause, place and educational level of the patients or caregivers were used as candidate factors for adolescents and adults group and the elderly group. These candidate factors were analysed by logistic regression model (stepwise forward method with entry level = 0.05 and removal level = 0.10). Only the results of education channels are listed in the table, and the other results were not shown in the table. b ‘‘Education channels’’ was defined as a dummy variable with ‘‘not receiving emergency education’’ as reference category.
and schools) were used as candidate factors for analysis in the regression analysis model. The results showed that all these education channels had positive protective effects, with the effect of Internet and workplace being most obvious. Further analysis on the basis of the age of the patients or caregivers showed that the effective channels of emergency education were different between young adults and elderly patients: the former were mainly affected by workplace and Internet, while the latter were mainly affected by relatives and friends and traditional media (Table 6).
3.
Discussion
The key point of burn injuries lies in prevention. A good security and prevention system can reduce the occurrence of burn injuries significantly, while timely and correct emergency management can alleviate the severity of burn injuries effectively [8]. The primary prevention of fires and burns focusses on ensuring safety of the surrounding environment
and reducing unsafe factors that may cause burn injures by installing fire alarms and water sprinklers; setting safe water and electrical equipment temperature; and using fire protection materials and equipment to minimise risk factors causing burn injuries [4]. However, as these measures are built on the prerequisite of improving the infrastructure and closely associated with social and economic development, it is difficult to spread them widely in developing countries at present. For this reason, intensifying secondary prevention and raising the level of emergency burn management have become the focus of burn prevention in these countries. In recent years, many studies have reported epidemiological distributions of burn injuries including aetiology and risk factors [9–13]. However, there are few studies reporting emergency burn management, especially about related factors affecting pre-hospital emergency management. The results of our investigation showed that most burn patients knew the essentials to escape from the source of burn injuries immediately and to go to hospitals for medical consultation within 24 h. However, there were still 23.4% burn patients who
burns 38 (2012) 1174–1180
did not go to hospitals for help until wounds deteriorated or infections occurred. Although about one-third of the patients used cooling treatment on the spot, the duration of cooling treatment was less than 10 min in most patients, and only 4.3% of the patients used cooling treatment for more than 20 min. About 32.2% of the patients used ‘folk remedies’ or antibiotics to treat the wounds. These results are similar to those reported in other developing countries such as Vietnam [7], Ghana [14], Cambodia [15] and Turkey [16]. Post-burn cooling treatment is recommended as the simplest and the most effective means of secondary prevention of fires and burns. Research has demonstrated that correct and effective cooling treatment can alleviate burn-induced tissue damage, reduce the hospitalisation rate and surgical skin grafting and lower medical costs. In addition, research has shown that the above ‘folk remedies’ could not protect burn wounds; rather they may induce allergic reactions or even deepen burn injuries [16–18]. Our investigation also showed that most burns were superficial second degree in patients who were immediately isolated from the source of injury, promptly used cooling treatment and treated burn wounds rationally, while most burns were deep second degree or third degree in those who did not treat the wounds timely and rationally. Although it suggests that timely and rational emergency burn management may alleviate the depth of burn injury, the definite causation relationship between them needs more effective evidence such as a further randomised controlled study or a prospective cohort study. In the present situation, the urgent task is to raise people’s awareness about emergency burn management and raise the public level of emergency burn management so as to improve secondary prevention of fires and burns. To determine the key factors affecting emergency burn management, we further investigated emergency education in these burn patients and found that most patients did not receive any education about emergency burn management, and, in those who had received emergency education, the knowledge about emergency management mainly came from traditional media, relatives and friends and Internet, and only about 20% of such education came from the workplace and schools, indicating that the situation in emergency education in China is worrying. Some studies [19] had demonstrated that multi-media campaigns through televisions, radios, books, magazines and posters could achieve good outcomes in raising the level of emergency management and reducing the hospitalisation rate of burn patients within a short time. It was found in our study that pre-hospital emergency management in burn patients who had received emergency education was significantly better than that in those who had not received emergency education, but there was no significant difference in burn depth between the two groups of patients (data not shown), which probably suggests that education from traditional media may have different influences on the level of emergency management. We therefore suggest that multimedia campaigns should be used as an accessory means to raise the level of emergency management in the contemporary period, and, at the same time, emergency education should be included in school, unit and family education systems as a fundamental strategy. In other words, universal
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emergency education should be taken as a long-term strategy in national basic education. The results of our further logistic regression analysis revealed that emergency education is the most important factor affecting pre-hospital emergency management, and age, educational level, cause, place and area of burn injury are also unneglectable factors affecting correct management of burn injuries. The age is an unfavourable factor affecting ‘immediate isolation from the source of injury’ (odds ratio (OR) = 0.63), especially in elderly patients who may not be able to escape from the source of injury due to sensory numbness from diabetes mellitus, hemiplegia and other underlying diseases. Educational level is an important factor affecting ‘prompt cooling treatment’ (OR = 1.38), probably because educated patients are more likely to use more scientific methods instead of ‘folk remedies’. In addition, burns from some special causes may affect emergency management in varying ways. For instance, chemical burn is a favourable factor affecting ‘cooling treatment’ (OR = 1.88) and ‘wound surface management’ (OR = 1.24), while electrical spark burn is an unfavourable factor affecting ‘cooling treatment’ (OR = 0.26) and ‘wound surface management’ (OR = 0.46), probably because chemical burn may easily produce a reflex of washing reaction that urges burn victims to remove the chemical from the skin surface, while electrical spark burn is easily mistaken as an electrical contact injury, where the patient is rarely aware that skin burn from electrical sparks also needs cooling treatment. In addition, chemical and electrical spark burns are relatively complex and more likely to produce phobia, which may urge patients to seek help from hospitals in time. Outdoor burn is an unfavourable factor for cooling treatment because of unavailability of water sources (OR = 0.58). With respect to the channels from which emergency knowledge is acquired, the effect of unit and network education is the most obvious, especially on cooling treatment. It was also found that most of the patients who obtained emergency knowledge from Internet usually sought help from Internet after they were injured by burns, suggesting that it is important to intensify unit education and establish emergency network platforms. Age stratification analysis showed that different age groups obtained emergency knowledge through different channels: network and unit education is an important and characteristic factor affecting pre-hospital emergency management in adolescents and young adults; relatives and friends is an important factor affecting elderly patients, in whom the influence of relatives and friends is even greater than that of traditional media (ORrelatives and friends = 8.57 vs. ORtraditional media = 5.27), suggesting that community health service systems play an important role in spreading knowledge in elderly people.
4.
Conclusion
Pre-hospital emergency management and knowledge publicity about emergency burn management remain at a relatively low level in China, and therefore emergency education is urgently needed at present. Network education and unit education are two main channels affecting the overall level of pre-hospital emergency management in the contemporary
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burns 38 (2012) 1174–1180
period. The channel of education should vary with age groups: education via Internet and workplace should be the main channels of education for young adults, while community education should be intensified in elderly people.
Conflict of interest There is no competing interests or conflicts in the present paper.
Acknowledgements This project was supported by the National Natural Science Foundation of China (C30600646, 81071555, 81120108015).
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