ORIGINAL CONTRIBUTION

Modification of the American Burn Association Injury Severity Grading System Richard F. Edlich, MD, PhD* Nancy Larkham, RN* J. Treacy O'Hanlan, MDt Robert Berry, MDt John Hiebert, MD* George T. Rodeheaver, MD* Milton 7". Edgerton, MD* Charlottesville, Virginia

This study evaluated the regional bum health care system of the Commonwealth of Virginia using the criteria for optimal care of the burn patient designated by the American Burn Association. The data base for this evaluation was hospital records of seven hospitals in Virginia. The major shortcoming of the designated criteria was the g.rading system for the severity of bum injury. Using the criteria designated by the American Burn Association, a large number of minor burn injuries were judged erroneously to be major burn injuries. A modification of the American Bum Association's injury severity grading system is proposed which more precisely identifies the minor burn injury. Ediich RF, Larkharn N, O'Hanlan JT, Berry R, Hiebert J, Rodeheaver GT, Edgerton MT: Modification of the American Burn Association injury severity grading system. JACEP 7:226-228, June 1978.

American Burn Association, injury severity grading system; burns, injury severity grading system. INTRODUCTION B u r n c a r e m u s t b e g i n a t t h e scene of i n j u r y a n d c o n t i n u e t h r o u g h e m e r g e n c y care and t r a n s p o r t a t i o n to an e m e r g e n c y d e p a r t m e n t w i t h a d v a n c e d life support c a p a b i l i t y and, subsequently, to specialized b u r n t r e a t m e n t centers. Because of the s e v e r i t y of b u r n injury, and the h i g h l y specialized n a t u r e of its medical t r e a t m e n t , the a v a i l a b i l i t y of specialized burn t r e a t m e n t facilities is an e s s e n t i a l e l e m e n t of a burn care system. However, m a n y p a t i e n t s w i t h lesser b u r n injuries do not require care in a specialized b u r n care t r e a t m e n t center, and m a y be t r e a t e d in a hospital where special expertise in b u r n care is not available. The A m e r i c a n Burn Association 1 r e c e n t l y e s t a b l i s h e d guidelines for b u r n t r e a t m e n t facilities as well as a g r a d i n g s y s t e m for j u d g i n g the severity of b u r n injury. Burn care was considered in four t r e a t m e n t settings: a hospital w i t h i n d e p t h expertise and o p t i m u m facilities for b u r n care (burn unit, b u r n center), a h o s p i t a l w i t h s p e c i a l e x p e r t i s e in b u r n c a r e ( b u r n p r o g r a m ) , a h o s p i t a l From the University of Virginia Burn Center* and Departments of SurgerYt and Orthopedics,$ University of Virginia Medical Center, Charlottesville, Virginia. Dr. Edlich is a Junior Clinical Faculty Fellow of the American Cancer Society. Address for reprints: Richard F. Edlich, MD, University of Virginia Medical Center, Burn Center, Charlottesville, Virginia 22901.

7:6 (Ju ne) 1978

JACEP

226/13

Table 1 ABA INJURY SEVERITY GRADING SYSTEM

Depth Magnitude of burn injury

Complications

Second Degree Burn Adult Children (% BSA) (% BSA)

Third Degree (% BSA)

Major

> 25%

> 20%

Moderate

15-25%

10-20%

< 10%

Minor

< 15%

< 10%

< 2%

emergency d e p a r t m e n t , and emergency care at the site of accident. Using these four t r e a t m e n t settings, three t r e a t m e n t modules were identified (Table 1). Major burn injury is d e f i n e d as second d e g r e e burns, greater than 25% body surface area (BSA) in adults (20% in children); all t h i r d degree b u r n s 10% BSA or greater; all burns involving hands, face, eyes, ears, feet, perineum; all inhalation injury, electrical burns, and complicated burn injury involving fractures; or other major t r a u m a and all poor risk patients. The second module, moderate uncomplicated burn injury, is identified as second degree burn of 15% to 25% BSA in adults (10% to 20% in children) with less t h a n 10% third degree burn which does not involve either eyes, ears, face, hands, feet, or perineum. The t h i r d module, minor burn injury is a second degree burn of less t h a n 15% BSA in a d u l t s (10% in children) w i t h less t h a n 2% t h i r d degree, not involving eyes, ears, face, hands, feet or perineum. The moderate and minor burn modules exclude electrical injury, i n h a l a t i o n injury, complicated injury, ,complicated injury (fractures), and all poor risk patients (extremes of age, intercurrent disease, etc). The American Burn Association1 has recommended t h a t patients with a major burn injury be treated in a hospital with optimum facilities (burn unit, b u r n center). For the moderate uncomplicated burn injury, t h e p a t i e n t s s h o u l d be c a r e d for either in a special expertise hospital (burn program) or in the h o s p i t a l with o p t i m u m f a c i l i t i e s . P a t i e n t s with minor burn i n j u r y should be transported to a hospital emergency d e p a r t m e n t where definitive treatment is initiated, including follow-up

14/227

10% or >

MECHANISM OF HEAT TRANSFER No. Flash

21

Flame

41

Scald

47 7

Chemical

10

Electrical

11

Unknown

6

TOTAL

143

care to complete recovery and discharge from the system. This c o n c e p t u a l i z a t i o n of the b u r n h e a l t h c a r e s y s t e m by t h e American Burn Association has obvious benefits for physicians. It provides a description of a s y s t e m in which the patient can receive care. By complying with these recommendations, physicians can assume that their patients will receive the most appropriate care at a reasonable cost. Furthermore, these criteria form the basis for a structural, process and outcome a n a l y s i s of care a l l o w i n g physicians to audit their burn health care system. During the past year, we evaluated our regional burn health care system using the American Burn Association's specific criteria for optimal care as a measure of compliance. Our report points out the shortcomings of the American Burn Association's guidelines and suggests methodology by which these problems can be minimized.

JACEP

+

Poor Risk, Trauma, Fx +

--

Table 2

Contact

Special Location

METHODS Seven hospitals in V i r g i n i a located in our catchment area with a total 2,300 beds agreed to participate in the study with the understanding that their hospitals and patients remain anonymous. Using the strict American Burn Association criteria, these h o s p i t a l s were c l a s s i f i e d as hospital emergency departments even though some were staffed by p h y s i c i a n s who have c o n s i d e r a b l e e x p e r i e n c e and e x p e r t i s e in burn care. There were 143 burn patients involved in this study. The severity of burn injury of each patient treated in these hospitals was judged by the t h r e e t r e a t m e n t m o d u l e s . These levels of burn injury were related to specific outcome m e a s u r e s of care which included m o r t a l i t y and morbidity (duration of hospitalization). RESULTS In the 143 burn patients treated in these seven hospitals over a 21month period, there was a remarkably low mortality rate (0.7%). Over h a l f s u s t a i n e d b u r n i n j u r i e s from h e a t sources in which the contact time with the skin was short (Table 2). The flash (15%), chemical (7%), and scald burns (32%) are cases in point. These burns, which are almost e x c l u s i v e l y second d e g r e e , are localized to the peripheral portions of the body (hands, feet, and face) and involve a r e l a t i v e l y s m a l l surface area (less than 5% BSA). Only one of the 143 patients died as a result of a t h e r m a l injury. This victim, a 70year-old woman, sustained a thermal injury to 70% of her body surface and died one day after hospital admission. Her transfer to a specialty care burn center was delayed since the three specialty burn centers had no a v a i l a b l e beds. These e x e m p l a r y s u r v i v a l s t a t i s t i c s are a s s o c i a t e d

7:6 (June) 1978

.

with a short duration of hospital stay (Figure). Approximately 40% of the patients were discharged from the hospital within six days after thermal injury and 22% within ten days. Using the criteria established by the American Burn Association, the burn patients treated in these hospitals were classified according to the severity of injury. The majority of patients, 70%, were judged to have major thermal injury, 8% a moderate uncomplicated injury, and 22% a minor injury. The l e n g t h of hospitalization of the patient groups did not correlate with the designated severity of injury. The majority of burn patients judged to have major burn injuries had very short hospital stays (less than 15 days). Consequently, it is our contention that this latter group of patients were victims of minor burn injuries that were j u d g e d e r r o n e o u s l y to have major burn injuries.

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DISCUSSION The potential benefits of such a burn severity grading system as the American Burn Association's have been discussed by Fisher et al. ~ Most importantly, these criteria for optimal care establish a basis for treatment standards along broad categories as required by professional medical auditing agencies. Yet, if such practices of care were to be im stituted in our burn health region, the consequences would be disturbing. The specialty burn treatment center would be deluged with patients (76 from our study) with minor injuries judged to be major. This influx of patients to specialty care facilities, some of which are close to 100% occupancy rate, would fill beds re-

Fig. This figure relates the duration o f hospitalization to the severity of burn injury as designated by the American B u r n Association criteria as well as by the proposed modified criteria. served for the c r i t i c a l l y ill burn victim. In addition, the unnecessary transfer of these patients with minor burn injuries to the burn center would obviously contribute to the rising costs of medical care. The potential problems in this burn grading system can be obviated by modifying the definition of the minor burn injury treatment module.

We propose that minor burn be redefined as 1) a second degree burn of less than 5% BSA, with less than 1% third degree involving the eyes, ears, hands, feet, perineum, resulting from heat (flash, scald) or chemical sources in which the skin contact time is extremely short; or 2) a second degree burn of less than 15% BSA in adults (10% in children) with less than 2% third degree, but not involvi n g t h e specially designated anatomic areas. Electrical injury, complicated injury (fractures), inhalation injury and all poor risk patients (extremes of age, intercurrent disease, etc.) are still excluded from this treatment module (Table 3). This proposed modification correctly identified 76 patients as minor burn injuries which were viewed erroneously as major burn injuries by the American Burn Association criteria (Figure). These minor burn injuries heal rapidly with no discernible scarring under the care of physicians without special training in burn Care. The setting in which the treatment is initiated will depend greatly upon socioeconomic and psychological considerations. Before this proposed change in criteria is approved, it must be carefully evaluated in both retrospective and prospective reviews Of hospital records to ensure that the burn patients receive optimal care at reasonable costs. REFERENCES 1. Specific Optimal Criteria fo'r Hospital Resources for Care of Patients with Burn Injury. American Burn Association. April, 1976. 2. Fisher JC, Wells JA, Fulwider BA, et al: Do we need a burn severity grading system? J Trauma 253:252, 1977.

Table 3 MODIFIED ABA INJURY SEVERITY GRADING SYSTEM Depth Magnitude of bum Injury

Complications

Second Degree Burn Adult Children (% BSA) (% BSA)

Third Degree , Special Location

(% BSA)

Major

> 25%

> 20%

Moderate

15-25%

10-20%

Minor

Modification of the American Burn Association injury severity grading system.

ORIGINAL CONTRIBUTION Modification of the American Burn Association Injury Severity Grading System Richard F. Edlich, MD, PhD* Nancy Larkham, RN* J...
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