- Email: [email protected]
Paediatric burns patients: Reasons for admission at a tertiary centre
burns 41 (2015) 708–713
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Paediatric burns patients: Reasons for admission at a tertiary centre M.J. Marino a,1, R.M. Kimble a,2,*, K.A. Stockton b,3 a
Stuart Pegg Paediatric Burns Centre, Royal Children’s Hospital, Brisbane, Australia Centre for Burns and Trauma Research, Queensland Children’s Medical Research Institute, University of Queensland, Australia b
article info
abstract
Article history:
Aim and method: The aim of this study was to determine the reasons why children with
Accepted 19 December 2014
burns are admitted upon primary presentation to a tertiary burns centre. The study was a
Keywords:
with a burns injury over an 18 month period.
Paediatric
Results: A total of 159 children with an overall median age of 25 months were included in the
retrospective chart review of all children admitted to the Stuart Pegg Paediatric Burns Centre
Burns
study. The reason for admission was able to be determined in all but two of these patients,
Reasons for admission
and categorised into either severity, region of body burnt, social reasons, timing of presentation, geographical reasons, age and other. The majority of children (45%) were admitted for severity, followed by region of body burnt (24%) and social reasons (11%). One third of children were admitted because of reasons other than the biology of the burn itself (severity or body region). Conclusion: The findings of this study demonstrate that it is not just children with severe burns who are admitted. One third of children are admitted because of the impact of the burn injury on the family, not because of a need for immediate management of the burns injury itself. The full impact of paediatric burns on our healthcare system is not solely determined by the physical characteristics of the burn itself. # 2015 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Burns are one of the most common causes of injury with presentation to hospital in children and adults globally [1]. Burns in children are associated with significant physical and psychological morbidity, often utilising long term management by both medical and allied health staff [2,3]. Medical management is
often initiated in hospital emergency departments (DEM) and is continued either with admission to hospital and/or in a dedicated burns outpatient department. The majority of paediatric patients with burns injury that attend hospital emergency departments are managed as outpatients and do not get admitted [4–6]. Most centres in middle to high income countries have admission rates of 10–20% [1,7]. In another study only 10% of those that presented to DEM with burns were admitted [8], whilst up to a quarter of
* Corresponding author at: Level 7 Lady Cilento Children’s Hospital, Raymond Tce, South Brisbane, Queensland 4029, Australia. Tel.: +61 7 3636 1278. E-mail addresses: [email protected] (M.J. Marino), [email protected] (R.M. Kimble), [email protected] (K.A. Stockton). 1 Mater Children’s Hospital, Brisbane, Australia. 2 Paediatric Surgery UQ, Lady Cilento Children’s Hospital, Brisbane, Australia. 3 CCBTR, Australia. http://dx.doi.org/10.1016/j.burns.2014.12.020 0305-4179/# 2015 Elsevier Ltd and ISBI. All rights reserved.
709
burns 41 (2015) 708–713
those treated as an outpatient were admitted at a later stage [9]. Burns in children are also a significant cost to the healthcare system [10]. Whilst it is intuitive that admission following a presentation to an emergency department for a burn would be based principally on the severity of the burn, clinical experience shows that there are many other factors which lead to admission. Rates of admission are well published in the literature but what is yet to be reported is why exactly children are admitted. The aim of this study was to determine the reasons for admission of all children with burns, who presented to The Stuart Pegg Paediatric Burns Centre (SPPBC), a tertiary level paediatric burns centre based at the Royal Children’s Hospital (RCH) Brisbane, over an 18 month period.
2.
Methods
The study utilised data from The Queensland Paediatric Burns Registry (QPBR), a database containing information on all patients less than sixteen years of age who attended the Royal Children’s Hospital (RCH) Brisbane with a burn. Ethics approval was obtained prior to commencement of this study from the Queensland Children’s Health Services Human Research Ethics Committee, based at the RCH (HREC 14/ QRCH/156). With parental/guardian consent, data was prospectively obtained by completion of a detailed pro forma completed at the time of presentation to the RCH DEM. The pro forma includes information on:
Patient demographics Events preceding the burn injury First aid given at the scene and in hospital Characteristics of the burn such as depth, site and body surface
Further information including length of admission and operation details is also recorded. The SPPBC uses the Shakespeare classification for burn depth which classifies burns as superficial (erythema only), superficial partial thickness, deep dermal partial thickness and full thickness [11].
Charts were reviewed in order to ascertain the reason for admission. Relevant data were initially identified on the database to facilitate chart review. The dataset was password protected and access was available only from within the Centre for Children’s Burns and Trauma Research (CCBTR). Once the reason for admission was obtained, it was recorded on the dataset which was de-identified for subsequent analysis. All patients admitted upon first presentation between January 1st 2013 and June 30th 2014 inclusive, were included in the study. Children were considered admitted if treated as an inpatient for greater than four hours.
2.1.
Data analysis
Statistical analysis was performed using SPSS software (version 22). Due to the non-normal distribution of age and length of stay, data is presented as median and interquartile range (IQR). Mann Whitney U test was utilised to compare length of stay between groups. Two tailed p values of <0.05 were considered to be statistically significant.
3.
Results
The total number of paediatric patients admitted in the 18 month period was 164. Of these, all consented to having their information recorded in the QPBR. Five patients consented only to having their data stored de-identified, and their chart was therefore unable to be reviewed to determine reason for admission. As such, they were excluded from analysis, leaving 159 patients. Ninety-six children (60%) were males and 63 (40%) were female, with an overall median age of 25 (IQR 15,75) months at the time of injury (see Table 1). One hundred and fifteen patients (72%) were admitted for over 24 h with the median duration of admission of these children being 3 (IQR 1, 10) days. The reason for admission was able to be ascertained by chart review in all but two of the 159 patients. Documentation in these charts was either absent or did not clearly identify a reason for admission. Upon reviewing individual charts, the underlying reason for admission was able to be categorised into seven different groups:
Table 1 – Characteristics of paediatric burns patients based on reason for admission. Category
n
Overall %
Severity Region of body Social Geographical Timing Age Other Indeterminableb
72 38 18 13 8 4 4 2
45.3 23.9 11.3 8.2 5.0 2.5 2.5 1.3
Overall a b c
159
100
Median age months (IQR) 30 22 24 45 30 3 71 – 25
(16, 92) (15, 48) (15, 67) (15, 98) (10, 84) (1, 4) (24, 139)
n ATSI
% ATSI
9 4a 5 2 0 1 0 1
13 11 28 15 0 25 0 –
9 1 2 1
22
14
Two people from this group did not know, or identify ATSI status. Only demographics and contribution to totals are included. Median stay less than 12 h.
Median length of stay (days)
% Deep
Median % TBSA
% with operation
2 (1, 3) 2 (0.3, 4) –
69 40 39 46 13 25 25 –
10 2 1 2 1 3 3 –
82 18 28 38 0 0 25 –
2
51
3
49
(2, (1, (1, (1,
17) 4) 4) 3)
c
710
burns 41 (2015) 708–713
1. Severity: patients needing resuscitation, total body surface area (TBSA) >10%, deep burns undergoing theatre immediately (for debridement, escharotomy etc.). 2. Region of body: patients that underwent admission not because of how deep or extensive their burn, but instead because of the area burnt. This included: Upper limb: receiving neurovascular observation for circumferential burns Lower limb: as for above but may also have needed assistance with mobilising Perineum: receiving monitoring to ensure urine able to be passed, or urinary catheter passed to allow for this Eyes: received periodic observation and ophthalmology review Mouth: received respiratory monitoring for airway burns, and/or monitoring of oral intake. A proportion of these patients temporarily received nasogastric feeds 3. Social: the child was admitted not because of characteristics of the burn itself, but because of the social situation of the patient. Reasons include concern about available care in the home environment, an inability to attend outpatient follow up once discharged, issues related to whose care the child should be discharged into and children in whom the possibility of intentional injury needed to be investigated. 4. Geographical: where the child was admitted after transfer from a distant hospital for assessment, although if the
patient lived locally, the characteristics of the burn would not have led to admission. 5. Timing: patients that presented to emergency late at night and were admitted for parental convenience sake, or to await review by the surgical registrar the next morning. 6. Age: children under twelve months of age with burns not considered severe but underwent observation due to their young age. 7. Other: admission was due to the mechanism of burn injury which necessitated observation and those with concomitant medical problems or injuries. Severity was the most common reason for admission accounting for 45% of all admissions (see Fig. 1). This group had the highest rate of deep burns with 69% of patients having a deep burn as well as the highest per cent TBSA (median of 10%). This group also had the longest duration of stay with a median of 9 (IQR 2, 17) days, p < 0.001 as well as the highest operation rate at 82%. Thirty eight children (24%) of patients were admitted because of the area of body affected by the burn. Of this group, upper limb burns were the most common accounting for 7.5% of overall admissions (Fig. 2). This was followed by burns affecting the mouth (6.3%), lower limb and perineum (4.4%) and eyes (1.3%). Those with mouth burns were mostly admitted to monitor oral intake and a smaller proportion received temporary nasogastric feeds. Several of these
Fig. 1 – Reasons for admission.
burns 41 (2015) 708–713
711
Fig. 2 – Admissions due to region of body affected. Total equal to the 24% admitted for region of body burnt.
patients were also admitted for airway monitoring. Four children (2.5% overall) were admitted for observation due to their age, with a median age of 3 (IQR 1, 4) months. Eleven per cent of children were admitted for social reasons. This group had the highest proportion of Aboriginal and Torres Strait Islander (ATSI) people at 28%. Eight per cent of admissions were due to the distance travelled to hospital. The median distance travelled to hospital from home was 276 km. This group had a median duration of stay of one day. Timing of injury accounted for 5% of all admissions, with 75% of admissions occurring between 23:30 and 02:30 (range 19:21– 02:21). The median per cent TBSA from this group was 1% and no patients underwent an operation, indicating that these were relatively minor burns. Four children were admitted for other reasons. One child had superficial electrical burns that did not undergo surgery but was admitted for cardiac monitoring. Another child had superficial burns after a multi-trauma and was admitted for associated injuries. Similarly, two children were admitted for treatment or management of concomitant medical conditions.
4.
Discussion
This study was the first to look at the reasons why children are admitted following burn injury upon first presentation to hospital. It is important to emphasise that only children admitted upon first presentation were incorporated in this
study. A number of children initially treated as outpatients go on to have inpatient admissions, usually for surgery [7]. A vast majority of all inpatients were admitted due to severity of their burn. This group incorporates all those with burns over 10% TBSA which meets criteria for automatic admission. As would be expected, most of these patients underwent an operation either during their first admission or upon subsequent admissions, a greater proportion than any other group. Patients admitted for severity also had the longest duration of stay. A third of all admissions were of less severe burns affecting a particular region of body. Half of this group were admitted due to limb burns, 32% for upper limb and 18% for lower limb. Many lower limb burns, particularly those affecting the feet, underwent inpatient admission to ensure mobility prior to discharge. Burns around joints were not directly a reason for admission at our centre as these are managed in the outpatient setting. Combining children admitted for severity and region of body burnt, two thirds (69%) of all burns patients were admitted for immediate treatment of, or observation due to the burn injury itself. This leaves one third of all paediatric burns admissions secondary to reasons which are not directly related to the biology of the burn itself. This is not to say that these patients did not warrant admission, but highlights that gathering just inpatient data does not necessarily mean that only information regarding the most severe or significant burns are captured.
712
burns 41 (2015) 708–713
It could be argued that some of these inpatients did not require an admission. Of the group of patients admitted for geographical reasons, median stay was only one day and median TBSA only 1%. These patients were transferred from rural hospitals for assessment in accordance with wellestablished tertiary referral guidelines. Whilst they would not have been admitted if they lived local, they travelled a median distance of 276 km from home, a reflection of the vast size of Queensland, and it would be unreasonable to discharge these patients straight home having travelled so far. Perhaps the only group of patients in whom the decision to admit must be questioned is the 5% of children who were admitted solely because of the timing of presentation. These burns were minor with a median TBSA of 5%, 12.5% being deep and none underwent an operation. They all had a short admission of less than 12 h. Most were admitted after 23:30, either to see the burns registrar the morning after or for the comfort of the parent as it was too late to safely drive home. These children would not have been admitted if they had presented to hospital earlier. Social reasons accounted for a large proportion of overall admissions at 11%. Amongst this group were children whose parent or guardian would struggle to offer the appropriate care or support at home following their burn, and children in whom intentional injury had to be investigated. Various socioeconomic burns risk factors have been identified, including low household income and home value and maternal education [1,12–14]. Similarly, children of mothers with more than three children have been shown to be at greater risk of harm from burns [13]. Many paediatric burns patients therefore already come from difficult social environments. On top of this, burns are amongst the most traumatic of injuries and impose significant psychological, educational and social limitations on the young child which the parent must bear [15,16]. It is therefore not surprising that some children undergo admission to ease the excessive burden a burn injury places on the child’s already challenging home environment. These children and their families benefit from the multidisciplinary care provided from an inpatient stay. This study is limited in that reason for admission was determined retrospectively. This to a certain degree relies on interpretation and presumed accuracy of admission documentation. Whilst the reason was clear in a majority of cases, inferences had to be made on occasion. To improve accuracy, the reason for admission was cross-checked with staff of the burns centre who more often than could not recall the inpatient. Of course there are often many reasons which influence the decision to admit a child with a burn and where this was apparent upon chart review, the most likely reason was chosen. The reason for admission was able to be determined in all but two charts; one which had no documentation at all, and another whereby the admission note did not offer any clues as to why the patient was admitted. The study could be improved by prospectively recording the reason for admission upon presentation. As a result of this study, the QPBR now includes prospective data collection regarding reason for admission. A major strength of the study was that it encompasses almost all children (minus the five deidentified children) who were admitted to our tertiary burns centre over the whole 18 month period, giving a holistic picture.
5.
Conclusion
Most paediatric burns research is based solely on inpatient data, despite recent studies highlighting significant differences exist between the characteristics of inpatient and outpatient burns [7,9,17]. The findings of this study demonstrate that it is not just children with severe burns who are admitted. One third of children are admitted because of the impact of the burn injury on the family, not because of a need for immediate management of the burns injury itself. A wide variety of arguably less significant burns also contribute to inpatient hospital burden. The full impact of paediatric burns on our healthcare system is not solely determined by the physical characteristics of the burn itself.
Conflict of interest statement The authors have no financial or other relationships that could lead to conflicts of interest.
references
[1] Peck MD. Epidemiology of burns throughout the world. Part I: Distribution and risk factors. Burns 2011;37:1087–100. [2] Blakeney P, Meyer 3rd W, Robert R, Desai M, Wolf S, Herndon D. Long-term psychosocial adaptation of children who survive burns involving 80% or greater total body surface area. J Trauma 1998;44:625–32 [discussion 633–624]. [3] Spinks A, Wasiak J, Cleland H, Beben N, Macpherson AK. Ten-year epidemiological study of pediatric burns in Canada. J Burn Care Res: Off Publ Am Burn Assoc 2008;29:482–8. [4] Kilburn N, Dheansa B. Socioeconomic impact of children’s burns – a pilot study. Burns 2014. [5] Taghavi M, Rasouli MR, Boddouhi N, Zarei MR, Khaji A, Abdollahi M. Epidemiology of outpatient burns in Tehran: an analysis of 4813 cases. Burns 2010;36:109–13. [6] Han TH, Kim JH, Yang MS, Han KW, Han SH, Jung JA, et al. A retrospective analysis of 19,157 burns patients: 18-year experience from Hallym Burn Center in Seoul, Korea. Burns 2005;31:465–70. [7] Stockton K, Harvey J, Kimble R. A prospective observational study investigating all children presenting to a specialty paediatric burns centre. Burns 2014. [8] Ansari-Lari M, Askarian M. Epidemiology of burns presenting to an emergency department in Shiraz, South Iran. Burns 2003;29:579–81. [9] Kahn SA, Bell DE, Hutchins P, Lentz CW. Outpatient burn data: an untapped resource. Burns 2013;39:1351–4. [10] Shields BJ, Comstock RD, Fernandez SA, Xiang H, Smith GA. Healthcare resource utilization and epidemiology of pediatric burn-associated hospitalizations, United States, 2000. J Burn Care Res: Off Publ Am Burn Assoc 2007;28:811–26. [11] Shakespeare PG. Standards and quality in burn treatment. Burns 2001;27:791–2. [12] Park JO, Shin SD, Kim J, Song KJ, Peck MD. Association between socioeconomic status and burn injury severity. Burns 2009;35:482–90. [13] Scholer SJ, Hickson GB, Mitchel Jr EF, Ray WA. Predictors of mortality from fires in young children. Pediatrics 1998;101:E12.
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[14] Istre GR, McCoy MA, Osborn L, Barnard JJ, Bolton A. Deaths and injuries from house fires. N Engl J Med 2001;344:1911–6. [15] Mathers C, Fat DM, Boerma JT, Organization WH. The Global Burden of Disease: 2004 Update. World Health Organization; 2008.
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[16] Weedon M, Potterton J. Socio-economic and clinical factors predictive of paediatric quality of life post burn. Burns 2011;37:572–9. [17] Brown M, Coffee T, Adenuga P, Yowler CJ. Outcomes of outpatient management of pediatric burns. J Burn Care Res: Off Publ Am Burn Assoc 2014;35:388–94.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Paediatric burns patients: Reasons for admission at a tertiary centre M.J. Marino a,1, R.M. Kimble a,2,*, K.A. Stockton b,3 a
Stuart Pegg Paediatric Burns Centre, Royal Children’s Hospital, Brisbane, Australia Centre for Burns and Trauma Research, Queensland Children’s Medical Research Institute, University of Queensland, Australia b
article info
abstract
Article history:
Aim and method: The aim of this study was to determine the reasons why children with
Accepted 19 December 2014
burns are admitted upon primary presentation to a tertiary burns centre. The study was a
Keywords:
with a burns injury over an 18 month period.
Paediatric
Results: A total of 159 children with an overall median age of 25 months were included in the
retrospective chart review of all children admitted to the Stuart Pegg Paediatric Burns Centre
Burns
study. The reason for admission was able to be determined in all but two of these patients,
Reasons for admission
and categorised into either severity, region of body burnt, social reasons, timing of presentation, geographical reasons, age and other. The majority of children (45%) were admitted for severity, followed by region of body burnt (24%) and social reasons (11%). One third of children were admitted because of reasons other than the biology of the burn itself (severity or body region). Conclusion: The findings of this study demonstrate that it is not just children with severe burns who are admitted. One third of children are admitted because of the impact of the burn injury on the family, not because of a need for immediate management of the burns injury itself. The full impact of paediatric burns on our healthcare system is not solely determined by the physical characteristics of the burn itself. # 2015 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Burns are one of the most common causes of injury with presentation to hospital in children and adults globally [1]. Burns in children are associated with significant physical and psychological morbidity, often utilising long term management by both medical and allied health staff [2,3]. Medical management is
often initiated in hospital emergency departments (DEM) and is continued either with admission to hospital and/or in a dedicated burns outpatient department. The majority of paediatric patients with burns injury that attend hospital emergency departments are managed as outpatients and do not get admitted [4–6]. Most centres in middle to high income countries have admission rates of 10–20% [1,7]. In another study only 10% of those that presented to DEM with burns were admitted [8], whilst up to a quarter of
* Corresponding author at: Level 7 Lady Cilento Children’s Hospital, Raymond Tce, South Brisbane, Queensland 4029, Australia. Tel.: +61 7 3636 1278. E-mail addresses: [email protected] (M.J. Marino), [email protected] (R.M. Kimble), [email protected] (K.A. Stockton). 1 Mater Children’s Hospital, Brisbane, Australia. 2 Paediatric Surgery UQ, Lady Cilento Children’s Hospital, Brisbane, Australia. 3 CCBTR, Australia. http://dx.doi.org/10.1016/j.burns.2014.12.020 0305-4179/# 2015 Elsevier Ltd and ISBI. All rights reserved.
709
burns 41 (2015) 708–713
those treated as an outpatient were admitted at a later stage [9]. Burns in children are also a significant cost to the healthcare system [10]. Whilst it is intuitive that admission following a presentation to an emergency department for a burn would be based principally on the severity of the burn, clinical experience shows that there are many other factors which lead to admission. Rates of admission are well published in the literature but what is yet to be reported is why exactly children are admitted. The aim of this study was to determine the reasons for admission of all children with burns, who presented to The Stuart Pegg Paediatric Burns Centre (SPPBC), a tertiary level paediatric burns centre based at the Royal Children’s Hospital (RCH) Brisbane, over an 18 month period.
2.
Methods
The study utilised data from The Queensland Paediatric Burns Registry (QPBR), a database containing information on all patients less than sixteen years of age who attended the Royal Children’s Hospital (RCH) Brisbane with a burn. Ethics approval was obtained prior to commencement of this study from the Queensland Children’s Health Services Human Research Ethics Committee, based at the RCH (HREC 14/ QRCH/156). With parental/guardian consent, data was prospectively obtained by completion of a detailed pro forma completed at the time of presentation to the RCH DEM. The pro forma includes information on:
Patient demographics Events preceding the burn injury First aid given at the scene and in hospital Characteristics of the burn such as depth, site and body surface
Further information including length of admission and operation details is also recorded. The SPPBC uses the Shakespeare classification for burn depth which classifies burns as superficial (erythema only), superficial partial thickness, deep dermal partial thickness and full thickness [11].
Charts were reviewed in order to ascertain the reason for admission. Relevant data were initially identified on the database to facilitate chart review. The dataset was password protected and access was available only from within the Centre for Children’s Burns and Trauma Research (CCBTR). Once the reason for admission was obtained, it was recorded on the dataset which was de-identified for subsequent analysis. All patients admitted upon first presentation between January 1st 2013 and June 30th 2014 inclusive, were included in the study. Children were considered admitted if treated as an inpatient for greater than four hours.
2.1.
Data analysis
Statistical analysis was performed using SPSS software (version 22). Due to the non-normal distribution of age and length of stay, data is presented as median and interquartile range (IQR). Mann Whitney U test was utilised to compare length of stay between groups. Two tailed p values of <0.05 were considered to be statistically significant.
3.
Results
The total number of paediatric patients admitted in the 18 month period was 164. Of these, all consented to having their information recorded in the QPBR. Five patients consented only to having their data stored de-identified, and their chart was therefore unable to be reviewed to determine reason for admission. As such, they were excluded from analysis, leaving 159 patients. Ninety-six children (60%) were males and 63 (40%) were female, with an overall median age of 25 (IQR 15,75) months at the time of injury (see Table 1). One hundred and fifteen patients (72%) were admitted for over 24 h with the median duration of admission of these children being 3 (IQR 1, 10) days. The reason for admission was able to be ascertained by chart review in all but two of the 159 patients. Documentation in these charts was either absent or did not clearly identify a reason for admission. Upon reviewing individual charts, the underlying reason for admission was able to be categorised into seven different groups:
Table 1 – Characteristics of paediatric burns patients based on reason for admission. Category
n
Overall %
Severity Region of body Social Geographical Timing Age Other Indeterminableb
72 38 18 13 8 4 4 2
45.3 23.9 11.3 8.2 5.0 2.5 2.5 1.3
Overall a b c
159
100
Median age months (IQR) 30 22 24 45 30 3 71 – 25
(16, 92) (15, 48) (15, 67) (15, 98) (10, 84) (1, 4) (24, 139)
n ATSI
% ATSI
9 4a 5 2 0 1 0 1
13 11 28 15 0 25 0 –
9 1 2 1
22
14
Two people from this group did not know, or identify ATSI status. Only demographics and contribution to totals are included. Median stay less than 12 h.
Median length of stay (days)
% Deep
Median % TBSA
% with operation
2 (1, 3) 2 (0.3, 4) –
69 40 39 46 13 25 25 –
10 2 1 2 1 3 3 –
82 18 28 38 0 0 25 –
2
51
3
49
(2, (1, (1, (1,
17) 4) 4) 3)
c
710
burns 41 (2015) 708–713
1. Severity: patients needing resuscitation, total body surface area (TBSA) >10%, deep burns undergoing theatre immediately (for debridement, escharotomy etc.). 2. Region of body: patients that underwent admission not because of how deep or extensive their burn, but instead because of the area burnt. This included: Upper limb: receiving neurovascular observation for circumferential burns Lower limb: as for above but may also have needed assistance with mobilising Perineum: receiving monitoring to ensure urine able to be passed, or urinary catheter passed to allow for this Eyes: received periodic observation and ophthalmology review Mouth: received respiratory monitoring for airway burns, and/or monitoring of oral intake. A proportion of these patients temporarily received nasogastric feeds 3. Social: the child was admitted not because of characteristics of the burn itself, but because of the social situation of the patient. Reasons include concern about available care in the home environment, an inability to attend outpatient follow up once discharged, issues related to whose care the child should be discharged into and children in whom the possibility of intentional injury needed to be investigated. 4. Geographical: where the child was admitted after transfer from a distant hospital for assessment, although if the
patient lived locally, the characteristics of the burn would not have led to admission. 5. Timing: patients that presented to emergency late at night and were admitted for parental convenience sake, or to await review by the surgical registrar the next morning. 6. Age: children under twelve months of age with burns not considered severe but underwent observation due to their young age. 7. Other: admission was due to the mechanism of burn injury which necessitated observation and those with concomitant medical problems or injuries. Severity was the most common reason for admission accounting for 45% of all admissions (see Fig. 1). This group had the highest rate of deep burns with 69% of patients having a deep burn as well as the highest per cent TBSA (median of 10%). This group also had the longest duration of stay with a median of 9 (IQR 2, 17) days, p < 0.001 as well as the highest operation rate at 82%. Thirty eight children (24%) of patients were admitted because of the area of body affected by the burn. Of this group, upper limb burns were the most common accounting for 7.5% of overall admissions (Fig. 2). This was followed by burns affecting the mouth (6.3%), lower limb and perineum (4.4%) and eyes (1.3%). Those with mouth burns were mostly admitted to monitor oral intake and a smaller proportion received temporary nasogastric feeds. Several of these
Fig. 1 – Reasons for admission.
burns 41 (2015) 708–713
711
Fig. 2 – Admissions due to region of body affected. Total equal to the 24% admitted for region of body burnt.
patients were also admitted for airway monitoring. Four children (2.5% overall) were admitted for observation due to their age, with a median age of 3 (IQR 1, 4) months. Eleven per cent of children were admitted for social reasons. This group had the highest proportion of Aboriginal and Torres Strait Islander (ATSI) people at 28%. Eight per cent of admissions were due to the distance travelled to hospital. The median distance travelled to hospital from home was 276 km. This group had a median duration of stay of one day. Timing of injury accounted for 5% of all admissions, with 75% of admissions occurring between 23:30 and 02:30 (range 19:21– 02:21). The median per cent TBSA from this group was 1% and no patients underwent an operation, indicating that these were relatively minor burns. Four children were admitted for other reasons. One child had superficial electrical burns that did not undergo surgery but was admitted for cardiac monitoring. Another child had superficial burns after a multi-trauma and was admitted for associated injuries. Similarly, two children were admitted for treatment or management of concomitant medical conditions.
4.
Discussion
This study was the first to look at the reasons why children are admitted following burn injury upon first presentation to hospital. It is important to emphasise that only children admitted upon first presentation were incorporated in this
study. A number of children initially treated as outpatients go on to have inpatient admissions, usually for surgery [7]. A vast majority of all inpatients were admitted due to severity of their burn. This group incorporates all those with burns over 10% TBSA which meets criteria for automatic admission. As would be expected, most of these patients underwent an operation either during their first admission or upon subsequent admissions, a greater proportion than any other group. Patients admitted for severity also had the longest duration of stay. A third of all admissions were of less severe burns affecting a particular region of body. Half of this group were admitted due to limb burns, 32% for upper limb and 18% for lower limb. Many lower limb burns, particularly those affecting the feet, underwent inpatient admission to ensure mobility prior to discharge. Burns around joints were not directly a reason for admission at our centre as these are managed in the outpatient setting. Combining children admitted for severity and region of body burnt, two thirds (69%) of all burns patients were admitted for immediate treatment of, or observation due to the burn injury itself. This leaves one third of all paediatric burns admissions secondary to reasons which are not directly related to the biology of the burn itself. This is not to say that these patients did not warrant admission, but highlights that gathering just inpatient data does not necessarily mean that only information regarding the most severe or significant burns are captured.
712
burns 41 (2015) 708–713
It could be argued that some of these inpatients did not require an admission. Of the group of patients admitted for geographical reasons, median stay was only one day and median TBSA only 1%. These patients were transferred from rural hospitals for assessment in accordance with wellestablished tertiary referral guidelines. Whilst they would not have been admitted if they lived local, they travelled a median distance of 276 km from home, a reflection of the vast size of Queensland, and it would be unreasonable to discharge these patients straight home having travelled so far. Perhaps the only group of patients in whom the decision to admit must be questioned is the 5% of children who were admitted solely because of the timing of presentation. These burns were minor with a median TBSA of 5%, 12.5% being deep and none underwent an operation. They all had a short admission of less than 12 h. Most were admitted after 23:30, either to see the burns registrar the morning after or for the comfort of the parent as it was too late to safely drive home. These children would not have been admitted if they had presented to hospital earlier. Social reasons accounted for a large proportion of overall admissions at 11%. Amongst this group were children whose parent or guardian would struggle to offer the appropriate care or support at home following their burn, and children in whom intentional injury had to be investigated. Various socioeconomic burns risk factors have been identified, including low household income and home value and maternal education [1,12–14]. Similarly, children of mothers with more than three children have been shown to be at greater risk of harm from burns [13]. Many paediatric burns patients therefore already come from difficult social environments. On top of this, burns are amongst the most traumatic of injuries and impose significant psychological, educational and social limitations on the young child which the parent must bear [15,16]. It is therefore not surprising that some children undergo admission to ease the excessive burden a burn injury places on the child’s already challenging home environment. These children and their families benefit from the multidisciplinary care provided from an inpatient stay. This study is limited in that reason for admission was determined retrospectively. This to a certain degree relies on interpretation and presumed accuracy of admission documentation. Whilst the reason was clear in a majority of cases, inferences had to be made on occasion. To improve accuracy, the reason for admission was cross-checked with staff of the burns centre who more often than could not recall the inpatient. Of course there are often many reasons which influence the decision to admit a child with a burn and where this was apparent upon chart review, the most likely reason was chosen. The reason for admission was able to be determined in all but two charts; one which had no documentation at all, and another whereby the admission note did not offer any clues as to why the patient was admitted. The study could be improved by prospectively recording the reason for admission upon presentation. As a result of this study, the QPBR now includes prospective data collection regarding reason for admission. A major strength of the study was that it encompasses almost all children (minus the five deidentified children) who were admitted to our tertiary burns centre over the whole 18 month period, giving a holistic picture.
5.
Conclusion
Most paediatric burns research is based solely on inpatient data, despite recent studies highlighting significant differences exist between the characteristics of inpatient and outpatient burns [7,9,17]. The findings of this study demonstrate that it is not just children with severe burns who are admitted. One third of children are admitted because of the impact of the burn injury on the family, not because of a need for immediate management of the burns injury itself. A wide variety of arguably less significant burns also contribute to inpatient hospital burden. The full impact of paediatric burns on our healthcare system is not solely determined by the physical characteristics of the burn itself.
Conflict of interest statement The authors have no financial or other relationships that could lead to conflicts of interest.
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