Demographic Comparison of Burn Emergency Only Visits and Admissions in an Urban Burn Center Areta Kowal-Vern, MD, FCAP, FASCP, CTBS,*† Faran Bokhari, MD, FACS, FCCM,*† Stathis Poulakidas, MD, FACS*†
There are few publications about demographics of Emergency Department (ED) burn patient visits. The purpose of this study was to compare ED only burn patients with admitted patients in an urban burn center. This was a retrospective review (1999 to 2014) of a burn unit patient registry. Patients were seen either in the Emergency Room or Trauma Bay (ED-TB) by staff, who determined whether the patient required admission or not. During this period, of the 5936 burn injury ED-TB encounters, there were 3754 (63%) admissions and 2182 (37%) ED-TB only (evaluation and discharge) visits. The median age was 30 years, and the %TBSA in the ED-TB only versus admitted patients was 1% vs 4% TBSA, P < .0001. Both groups had mainly scalding injuries in the kitchen. The majority of the ED-TB only patients presented with upper extremity burns (40%), whereas admitted patients had burns in multiple areas (49%). Most of the ED-TB only patients (73%) came to the hospital themselves, 23% were transferred from other hospitals, and 2% each, direct from the scene and clinic. In contrast, 53% of admitted patients were transferred from other hospitals, 29% came in on their own, and 11% were brought in direct from the scene, or from the burn clinic (7%), P = .0001. This review suggests that the main reason for non-admission of ED-TB only patients was the severity of injury; ED-TB only patients had a significantly less severe %TBSA (P < .0001), and fewer comorbidities compared to admitted patients. (J Burn Care Res 2016;37:181–190)
According to the American Burn Association 2013 Burn Fact Sheet, there are 450,000 burn injuries receiving medical treatment annually with 40,000 hospitalizations relating to burn injury, including 30,000 at hospital burn centers.1 Peck et al2 note that there has been a general decline in the number of burn injuries hospitalized or seen in the Emergency Department in the United States. Currently, of the burn injuries treated, 90% are seen in the Emergency Departments and discharged. There are few publications about the demographics of Emergency Department and Trauma Bay (ED-TB) burn patient visits compared to admitted patients. From the *Department of Trauma, Sumner L. Koch Burn Center, Stroger Cook County Hospital, Chicago, Illinois; and †Department of Surgery, Rush University Medical Center, Chicago, Illinois. Address correspondence to Areta Kowal-Vern, MD, Sumner K. Koch Burn Center, Room 3229, John Stroger Hospital of Cook County, 1901 West Harrison Street, Chicago, Illinois 60612. Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000197
Publications are usually based on the national, state, or individual hospital medical care surveys, probability studies, and product safety surveillances of ED patients only.3–7 Statistical variables depend on the information gathered and available for analysis. There was also variability in the treatment parameters in the emergency departments according to national, state, product surveillance, and local hospital databases. The purpose of this study was to compare ED-TB only burn patient demographics with those of patients admitted in an urban burn center.
METHODS Study Population This was a retrospective 15-year (184 months) review (March 1999 to June 2014) of an in-house burn center patient registry. The hospital mission is to provide treatment for all patients who come regardless of ability to pay. Study patients were seen by the burn staff, who determined whether the patients required admission or not. Patients seen in clinic visits or 181
Journal of Burn Care & Research May/June 2016
182 Kowal-Vern, Bokhari, and Poulakidas
in-house consultations were not included in this analysis. Unlike the published literature, this study registry has only patients with second and third-degree burns, and no first-degree burns. The Hospital Institutional Review Board approved this study.
Statistical Analysis Statistical analysis was performed using Statistica® (STATSOFT, Tulsa, OK) for descriptive and basic statistics. Summary descriptive statistics such as median, chi-squared 2 × 2 summary frequencies (Pearson, Maximum Likelihood), one way analysis of variance (ANOVA), with the Tukey test for unequal numbers, and the nonparametric Mann–Whitney U test were performed. Statistical analysis compared the ED-TB only with the admitted patients by age, %TBSA, ethnicity, wound age, season, location, mechanism, body part, and yearly distribution. A P value of 10% TBSA; 2) burns that involve the face, hands, feet, genitalia, perineum, or major joints; 3) third-degree burns in any age group; 4) electrical burns, including lightning injury; 5) chemical burns; 6) inhalation injury; 7) burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality: 8) any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality; 9) burned children in hospitals without qualified personnel or equipment for the care of children; and 10) burn injury in patients who require social, emotional, or rehabilitative intervention. Patients were admitted on the basis of the ABA Burn Center referral criteria recommendations and the clinical decision of the Burn Team. Patients who were mainly intoxicated or drug abusers were admitted depending on their burn or wound status meeting the ABA Burn Center referral recommendations and the discretion of the Burn Team. Consults seen in the ED-TB were sent home and given an appointment to be seen in the Burn Clinic. If they had any problems prior to their clinic visit appointment, they were to come back to the TB for evaluation.
ED-TB Patient Care All patients with burn injury, inhalation injury, wounds, or frostbite were evaluated in the ED-TB.
The Emergency Department was staffed by boardcertified Emergency Physicians, and all Emergency Department resident staff rotated through the Burn Center Units and Clinic as part of their residency training. Once a patient was seen by the Emergency Department physicians, he or she was seen by a Burn Resident/Fellow/Attending on-call and either admitted, treated, and sent home, or given a Burn Clinic appointment. When a patient arrived in the Trauma Bay area, he or she was evaluated by a Trauma Physician and Resident on-call and the Burn Team was called for treatment and disposition. The Burn Physician either admitted the patient, or treated and sent the patient home to return for follow-up in the Burn Clinic. If there was good family support, patients with >10% TBSA partial thickness burns were sent home with supplies and scheduled return Burn Clinic visits. Patients who missed their Burn Clinic appointment came to the Trauma Bay to be seen. Homeless individuals were usually admitted even with small burns, wounds, or frostbite injuries, especially in the winter. They frequently did not have the facilities for dressing changes, and if sent out too early, came back with cellulitis or gangrene. Most homeless stayed outside or in shelters during the winter months. Many preferred being outside and visiting shelters and soup kitchens for sustenance. The demographics of this homeless population (which constitutes 4.5% of this population) have been previously published.8
RESULTS All Burn, Wound, and Frostbite ED-TB Encounters and Admissions Of all the 7221 ED-TB encounters, there were 4696 (65%) admissions and 2525 (35%) ED-TB only visits (Table 1). Except for patients transferred from other services to the Burn Service, all other admissions direct from scene, hospital transfers, walk-in patients, or clinic patients were admitted through the ED-TB area. The median age and %TBSA in the admitted versus the ED-TB only patients was 31 vs 34 years, and 1% vs 4% TBSA, P < .0001. No population requiring a shorter length of stay (LOS) on admission to the Burn Center was identified. Patients coming from the clinic or the TB-ED area for admission had a median TBSA of 2% and an LOS of 5 days. Admissions brought in direct from scene had a median TBSA of 9% and an LOS of 7.5 days. Patients who were transferred from another hospital had a median 2% TBSA with an LOS of 6 days. There was a
Journal of Burn Care & Research Volume 37, Number 3
Kowal-Vern, Bokhari, and Poulakidas 183
Table 1. Demographics of all ED-TB and admitted patients Median Number Type (%) Burn Frostbite Other (wound, ulcer, etc.) Age (yrs) %TBSA Sex (male/ female) % Sex ratio Race (%) African–American Hispanic Caucasian Other
ED-TB 2525
Admissions
Table 2. Demographics of burn injury patients seen only in the ED-TB area and compared to admitted patients P
4696 0.0000
86 4 10
80 4 16
31 1 65/35
34 4 67/33
2:1
2:1
54 29 12 5
.7 .0001 .003 NS 0.052
56 27 14 3
ED-TB, Emergency Department-Trauma Bay; NS, not significant.
similar distribution among the admitted and ED-TB only patients in: type of injury, sex and sex ratio, ethnicity, wound age, grafting, and mechanism of injury.
Burn Injury ED-TB Only Encounters and Admissions During this period, of the 5936 burn injury ED-TB encounters, there were 3754 (63%) admissions and 2182 (37%) ED-TB only (evaluation and discharge) visits (Table 2). Since 1999, the ED-TB only visits have been increasing and the admission numbers have been decreasing (Figure 1). The median age was 30 years, and the %TBSA in the ED-TB only vs admitted patients was 1% vs 4% TBSA, P < .0001. Both ED-TB only and admitted patients had mainly
There are few publications about demographics of Emergency Department (ED) burn patient visits. The purpose of this study was to compare ED only burn patients with admitted patients in an urban burn center. This was a retrospective review (1999 to 2014) of a burn unit patient registry. Patients were seen either in the Emergency Room or Trauma Bay (ED-TB) by staff, who determined whether the patient required admission or not. During this period, of the 5936 burn injury ED-TB encounters, there were 3754 (63%) admissions and 2182 (37%) ED-TB only (evaluation and discharge) visits. The median age was 30 years, and the %TBSA in the ED-TB only versus admitted patients was 1% vs 4% TBSA, P < .0001. Both groups had mainly scalding injuries in the kitchen. The majority of the ED-TB only patients presented with upper extremity burns (40%), whereas admitted patients had burns in multiple areas (49%). Most of the ED-TB only patients (73%) came to the hospital themselves, 23% were transferred from other hospitals, and 2% each, direct from the scene and clinic. In contrast, 53% of admitted patients were transferred from other hospitals, 29% came in on their own, and 11% were brought in direct from the scene, or from the burn clinic (7%), P = .0001. This review suggests that the main reason for non-admission of ED-TB only patients was the severity of injury; ED-TB only patients had a significantly less severe %TBSA (P < .0001), and fewer comorbidities compared to admitted patients. (J Burn Care Res 2016;37:181–190)
According to the American Burn Association 2013 Burn Fact Sheet, there are 450,000 burn injuries receiving medical treatment annually with 40,000 hospitalizations relating to burn injury, including 30,000 at hospital burn centers.1 Peck et al2 note that there has been a general decline in the number of burn injuries hospitalized or seen in the Emergency Department in the United States. Currently, of the burn injuries treated, 90% are seen in the Emergency Departments and discharged. There are few publications about the demographics of Emergency Department and Trauma Bay (ED-TB) burn patient visits compared to admitted patients. From the *Department of Trauma, Sumner L. Koch Burn Center, Stroger Cook County Hospital, Chicago, Illinois; and †Department of Surgery, Rush University Medical Center, Chicago, Illinois. Address correspondence to Areta Kowal-Vern, MD, Sumner K. Koch Burn Center, Room 3229, John Stroger Hospital of Cook County, 1901 West Harrison Street, Chicago, Illinois 60612. Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000197
Publications are usually based on the national, state, or individual hospital medical care surveys, probability studies, and product safety surveillances of ED patients only.3–7 Statistical variables depend on the information gathered and available for analysis. There was also variability in the treatment parameters in the emergency departments according to national, state, product surveillance, and local hospital databases. The purpose of this study was to compare ED-TB only burn patient demographics with those of patients admitted in an urban burn center.
METHODS Study Population This was a retrospective 15-year (184 months) review (March 1999 to June 2014) of an in-house burn center patient registry. The hospital mission is to provide treatment for all patients who come regardless of ability to pay. Study patients were seen by the burn staff, who determined whether the patients required admission or not. Patients seen in clinic visits or 181
Journal of Burn Care & Research May/June 2016
182 Kowal-Vern, Bokhari, and Poulakidas
in-house consultations were not included in this analysis. Unlike the published literature, this study registry has only patients with second and third-degree burns, and no first-degree burns. The Hospital Institutional Review Board approved this study.
Statistical Analysis Statistical analysis was performed using Statistica® (STATSOFT, Tulsa, OK) for descriptive and basic statistics. Summary descriptive statistics such as median, chi-squared 2 × 2 summary frequencies (Pearson, Maximum Likelihood), one way analysis of variance (ANOVA), with the Tukey test for unequal numbers, and the nonparametric Mann–Whitney U test were performed. Statistical analysis compared the ED-TB only with the admitted patients by age, %TBSA, ethnicity, wound age, season, location, mechanism, body part, and yearly distribution. A P value of 10% TBSA; 2) burns that involve the face, hands, feet, genitalia, perineum, or major joints; 3) third-degree burns in any age group; 4) electrical burns, including lightning injury; 5) chemical burns; 6) inhalation injury; 7) burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality: 8) any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality; 9) burned children in hospitals without qualified personnel or equipment for the care of children; and 10) burn injury in patients who require social, emotional, or rehabilitative intervention. Patients were admitted on the basis of the ABA Burn Center referral criteria recommendations and the clinical decision of the Burn Team. Patients who were mainly intoxicated or drug abusers were admitted depending on their burn or wound status meeting the ABA Burn Center referral recommendations and the discretion of the Burn Team. Consults seen in the ED-TB were sent home and given an appointment to be seen in the Burn Clinic. If they had any problems prior to their clinic visit appointment, they were to come back to the TB for evaluation.
ED-TB Patient Care All patients with burn injury, inhalation injury, wounds, or frostbite were evaluated in the ED-TB.
The Emergency Department was staffed by boardcertified Emergency Physicians, and all Emergency Department resident staff rotated through the Burn Center Units and Clinic as part of their residency training. Once a patient was seen by the Emergency Department physicians, he or she was seen by a Burn Resident/Fellow/Attending on-call and either admitted, treated, and sent home, or given a Burn Clinic appointment. When a patient arrived in the Trauma Bay area, he or she was evaluated by a Trauma Physician and Resident on-call and the Burn Team was called for treatment and disposition. The Burn Physician either admitted the patient, or treated and sent the patient home to return for follow-up in the Burn Clinic. If there was good family support, patients with >10% TBSA partial thickness burns were sent home with supplies and scheduled return Burn Clinic visits. Patients who missed their Burn Clinic appointment came to the Trauma Bay to be seen. Homeless individuals were usually admitted even with small burns, wounds, or frostbite injuries, especially in the winter. They frequently did not have the facilities for dressing changes, and if sent out too early, came back with cellulitis or gangrene. Most homeless stayed outside or in shelters during the winter months. Many preferred being outside and visiting shelters and soup kitchens for sustenance. The demographics of this homeless population (which constitutes 4.5% of this population) have been previously published.8
RESULTS All Burn, Wound, and Frostbite ED-TB Encounters and Admissions Of all the 7221 ED-TB encounters, there were 4696 (65%) admissions and 2525 (35%) ED-TB only visits (Table 1). Except for patients transferred from other services to the Burn Service, all other admissions direct from scene, hospital transfers, walk-in patients, or clinic patients were admitted through the ED-TB area. The median age and %TBSA in the admitted versus the ED-TB only patients was 31 vs 34 years, and 1% vs 4% TBSA, P < .0001. No population requiring a shorter length of stay (LOS) on admission to the Burn Center was identified. Patients coming from the clinic or the TB-ED area for admission had a median TBSA of 2% and an LOS of 5 days. Admissions brought in direct from scene had a median TBSA of 9% and an LOS of 7.5 days. Patients who were transferred from another hospital had a median 2% TBSA with an LOS of 6 days. There was a
Journal of Burn Care & Research Volume 37, Number 3
Kowal-Vern, Bokhari, and Poulakidas 183
Table 1. Demographics of all ED-TB and admitted patients Median Number Type (%) Burn Frostbite Other (wound, ulcer, etc.) Age (yrs) %TBSA Sex (male/ female) % Sex ratio Race (%) African–American Hispanic Caucasian Other
ED-TB 2525
Admissions
Table 2. Demographics of burn injury patients seen only in the ED-TB area and compared to admitted patients P
4696 0.0000
86 4 10
80 4 16
31 1 65/35
34 4 67/33
2:1
2:1
54 29 12 5
.7 .0001 .003 NS 0.052
56 27 14 3
ED-TB, Emergency Department-Trauma Bay; NS, not significant.
similar distribution among the admitted and ED-TB only patients in: type of injury, sex and sex ratio, ethnicity, wound age, grafting, and mechanism of injury.
Burn Injury ED-TB Only Encounters and Admissions During this period, of the 5936 burn injury ED-TB encounters, there were 3754 (63%) admissions and 2182 (37%) ED-TB only (evaluation and discharge) visits (Table 2). Since 1999, the ED-TB only visits have been increasing and the admission numbers have been decreasing (Figure 1). The median age was 30 years, and the %TBSA in the ED-TB only vs admitted patients was 1% vs 4% TBSA, P < .0001. Both ED-TB only and admitted patients had mainly
