Annals of Burns and Fire Disasters - vol. XXVII - n. 3 - September 2014

THE BURN REGISTRY PROGRAM IN IRAN - FIRST REPORT Karimi H.,1 Momeni M.,1* Motevalian A.,2 Bahar M.A.,1 Boddouhi N.,1 Alinejad F.3 Burn Research Center, Iran University of Medical Sciences, Tehran, Iran 1 Faculty of Medicine 2 Faculty of Health 3 Department of Infectious Diseases

SUMMArY. Burn injury is still a major problem in Iran, resulting in many reports which are usually dispersed, uncoordinated and probably unreliable. We created a burn registry comprised of a data entry program with 222 variables for each admitted burn patient. This program was established in August 2010 at the Iran University of Medical Sciences, Motahari Burn Hospital. We had 14,277 burn patients from August 2010 to August 2011, 877 of whom were admitted to the hospital. Of the patients, 65.9% were male and 34.1% were female. The age was 28.85 years (SD = 19.77). The most prevalent cause of burn was flame 78.5% (pipe propane gas 57.2; kerosene 19.9%). The mean total body surface area (TBSA) involvement was 23%. A total of 77.8% of patients were discharged with partial recovery, while mortality was 8.9%. The mean hospital stay was 14.63 days (SD =11.07). The program is designed to help understand the scope of burn injury in Iran, providing information on patients, etiology, and course of treatment. It also highlights differences between various parts of the country in terms of the causes and frequency of burn injuries. Moreover, the burn registry provides a basis for further research and surveys for treatment and preventive programs. Our results showed that, although Emergency Medical Services (EMS) staff are highly capable and well-trained, their coverage seems to be less than 50% and needs to be increased. Marriage status was shown to have no influence on the occurrence of burns, and among our patients, 57.0 % were poorly educated. Keywords: burn, epidemiology, mortality, risk factors, registry

Introduction

According to a 2003 study on the national burden of disease in Iran, burn injuries are 13th in terms of causing a burden among the general population, and 7th in terms of mortality in children aged 5-14 years old.1 Burn injury is a global public health issue, accounting for an estimated 195,000 deaths annually.2 Despite being preventable, these injuries still cause a significant amount of morbidity and mortality in Iran. Given that each patient needs special care, equipment and well-trained, educated staff, the various stages of burn treatment are sophisticated, expensive and time consuming. Therefore prevention of burn injuries is not only more efficient but also reduces costs. Prevention is far more rewarding than treatment and requires exploration of the epidemiological factors of the injury. Data from across the country show that there are prob2-8 ably about 100,000 burns in Iran each year. Unfortunately, these data are widespread and uncoordinated, and thus their reliability and validity cannot be guaranteed. There are 12 specialized Burn Hospitals in Iran (Tehran, Tabriz, Rasht, Sari, Mashhad, Esfahan, Kermanshah, Ah-

waz, Shiraz, Kerman, Zahedan, Azarshahr) (Fig. 1), and more than 45 burn care facilities that are located inside a General Hospital.9-15 There is no standardised admission cri-

Fig. 1 Map of Iran.

* Corresponding author: Mahnoush Momeni M.D., Motahari Burn Hospital, Tehran Burn Reasearch Center, Yasami Alley,Vali-Asr Ave., P.O. Box: 19395-4949, Tehran, Iran. Tel.: + 98 912-325-2387; fax: + 98 218-877-0048; e-mail: [email protected]

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teria, and treatment plans are equally likely to differ across the various facilities. There is no central body in Iran responsible for data collection from the burn centers. The reported data are gathered from each individual center within a small part of the country, and it is likely that many of these data overlap. Some patients may be admitted to 2-3 centers over the course of their treatment and thus their data would be counted up to 3 times in the reports. Even demographic data from the centers are not completely reliable.3-15 Length of hospitalization, treatment plans, ICU care, costs of treatment and patient outcomes are not reported in their entirety. For the reasons outlined above, we have developped a burn registry program in Iran (with the cooperation of the Iran Burn Research Center) which is intended for collecting exact and accurate data from all over the country. This will provide a database for clinicians, researchers, healthcare authorities, payers, insurance companies, the Ministry of Health, and the general public. At present, there is no registry program for burn injuries in Iran. There is also a lack of special information about these injuries. If we accept that the best form of treatment for burn injuries is to prevent them, the first step in planning the necessary preventive programs is to have complete and reliable data on burn patients.

cational booklets and written programs. Authorities will also be able to use this program when formulating post discharge treatment needs, such as physical, social and work therapy for disabled patients. Materials and methods

In the first step of this program, a literature review was conducted followed by a series of specialized meetings with expert physicians who work in burn centers and are familiar with burn care plans, treatment and problems associated with burn data. After an assessment of the literature and related papers,16-33 the data were categorized into 11 groups: 1. Demographic data 2. In-site questionnaires (accident questionnaire) 3. Cause of burn 4. Pre-hospital care data 5. Emergency departement treatment data 6. Co-existent illnesses 7. Diagnostic evaluation and treatments in emergency department (part A and B)

Burn registry program

The purpose of the burn registry program is to provide a centralised on-line repository allowing burn centers across Iran to upload, store and share their data. The program is complex, storing all relavant and important information that can be used by healthcare authorities and researchers as a basis for developing preventive programs to reduce the total number of burn victims in Iran. Thus, policy-makers will be helped to identify burn epidemiology in Iran through the data stored on burn patients. The second aim is to help authorities in the health ministry to ensure that there are enough adequate burn care facilities in those parts of the country that are in more need of burn care centers and hospitals. The burn registry program provides demographic data, etiological data, and basic criteria for evaluating each burn hospital and comparing their results and outcomes. It provides a basis for comparing different treatment plans and for evaluating the efficiency of treatments and of prehospital care. It helps to highlight the pitfalls in burn treatment, to evaluate new modalities of treatment, and to compare results among burn centers, as well as overall progress through the years. This registry calculates the treatment costs and its burden on the country’s economy, and also identifies where new burn center institutions are required within Iran. Our data will reveal training needs among the general population or specific groups within the population (e.g. children). This registry can be used for multimedia training programs and for producing specific edu-

Fig. 2 - Lund & Browder table for identifying burn percentage.

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8. In-ward diagnostic evaluation 9. Treatment in first 24 hours after admission 10. Treatment after 24 hours 11. Outcome of patients (including treatment cost)

A special questionnaire was developed and tested in a 4-month pilot study at Motahari Hospital, which is the largest burn center in Iran with more than 120 beds set aside for burn treatment. The results of the pilot were assembled and evaluated by an expert team. All missing and irrelevant data were identified and omitted from the questionnaire. A modified questonnaire was then prepared with 222 variables and was used for gathering the data from all admitted burn patients. In this questionnaire, a table is used to write the exact burn percentage on each body part (i.e., head, neck, upper arm, forearm, hand, anterior trunk, posterior trunk, thigh, leg, foot and genitalia) (Figs. 2-3). The program began in August 2010. A combined team of 5 general practioners, 8 trained nurses and 6 physicians completed the forms. Data were collected in 2 parts: the first part was completed at the time of admission by the general practioner and 6 trained nurses; the second part

was completed during hospitalization by the physician and 6 trained nurses. The completeness and validity of the data were level two checked by 3 external physicians. All of the data were analysed using SPSS V20. Our objective was to define all relevant data required for the epidemiological survey in terms of identifying problems associated with burn care. We sought to gather all comments and special guidelines from burn centers regarding the questionnaire, with the overall aim of developping a complete and reliable questionnaire. results

Over the course of one year, we treated 14,277 burn patients, 877 of whom were admitted to the hospital according to ABA admission criteria. Table I shows the frequency and percentage of our patients by age. Of our patients, 65.9% were male and 34.1% female. Table II shows the marriage status of the patients, while Table III shows Table I - Frequency of burn patients by age group Age group 85 years Total

Frequency 141 68 161 197 133 78 49 32 16 2 877

Percentage (%) 16.1 7.8 18.3 22.4 15.1 8.9 5.6 3.7 1.8 0.2 100

Table II - Distribution of patients according to marital status Marital status Single Married Divorced Death of spouse Re-marriage Total

Frequency 405 444 10 17 1 877

Percentage 46.2 50.6 1.1 2.0 0.11 100

Table III – Distribution of educational level among burn patients

Fig. 3 - Burn record sheet used in our center for a brief review of the burn areas over the body and a summary of the TBSA.

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Educational level Illiterate Minimal reading & writing High school Diploma University level Unknown Total

Frequency 288 213 328 47 1 877

Percentage (%) 32.8 24.3 37.4 5.33 0.12 100

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that 57.0% were poorly educated (less than high school level) and 5.3% had a higher level of education (above college level). The causes of burn were flame (53.5%), electrical (14.5%), chemical (2.2%), and contact burns (3.7%) (Table IV). Among patients with flame burn, the most frequent cause was gas flame (57.2%). It was revealed that 92.6% of the burns were accidental (Table V), and 19.1% occurred in the workplace. The mode of transfering the patients to the hospital is shown in Table VI. In 36.5% of cases, the pre-hospital triage was done effectively for the patients. 35.2% were referred to our hospital from other centers in the country and 64.8% of our patients were brought directly to our hospital. During the period of hospital stay, at least one session of wound debridement was done in 82.9 % of the patients. Escharotomy was carried out in 10.4% of patients. In 19.5% of admissions, early wound excision and grafting were carried out between days 2-5 of admission. The most prevalent topical antibiotics used were Nitrofurazone and Silver sulfadiazine. In 280 (31.9%) patients amniotic membrane as a temporary biologic dressing was used to cover the wounds. In 248 (28.2%) cases the wounds were covered by skin autografts. Table VII shows the ultimate results of the treatments, admission and the outcome of the patients.

Table IV – Frequency of the burn causes Burn cause Scalds Flame Contact Burn Electrical injury Chemical Total

Percentage (%) 30.6 53.5 3.7 10 2.2 100

Table V – Mode of trauma (burn) Mode of Burn Suicide Burning others Accidental Unknown Total

Frequency 44 10 812 11 877

Percentage (%) 5 1.1 92.6 1.3 100

Table VI – Distribution of modes used for transferring burn patients Mode of transfer With EMS ambulances Own vehicles Private ambulances Total

Discussion

Burns are one of the most prevalent causes of injury 1 in our country with a high percentage of mortality. Our data shows that more than 6.1% of burn patients need to be admitted to a burn hospital. Burns were more prevalent in males (1,634) in accordance with the findings in most of the literature. The mean TBSA of our patients was 23%, while Igbal et al.35 revealed a mean TBSA in their center of 38.04 ± 15.18%. The most frequent age group in our study was 25-35 years old. Igbal et al.35 reported a mean age for adults of 33.63 ± 10.76 years. This shows that it is most frequently the younger members of the general population who are affected by burns. It is this group, therefore, that would need to be targeted for preventive measures. About 57% of burn patients were poorly educated (less than high school level), so multimedia programs are likely to be more effective for burn prevention than written educative papers. Even so, a report from the US found that educational level had no influence on the occurance of burns.36 Scalds are the most frequent causes of burns, and these burns victims are generally treated in outpatient clinics. Flame burns were the most frequent cause of hospital admission (53.5% ), and thus preventive measures are required regarding use of “propane gas” and “kerosene”. The incidence of electrical burns is higher than in any developed country and in any other reports, and therefore requires special attention from authorities in terms of causes and treatment. In Pakistan, electrical injury was reported to be about 10%, while in Ontario it was 6.21%, in Bei-

Frequency 269 470 32 87 19 877

Frequency 304 467 106 877

Percentage (%) 34.7 53.2 12.1 100

Table VII – Distribution of patient outcomes Outcome Complete recovery Partial recovery Amputation Refer to other center Discharge on patient’s will Death Total

No. of Patients 85 682 1 1 30 78 877

Percent 9.7% 77.8% 0.1% 0.1% 3.4% 8.9% 100%

jing it was 16.1%, and in Tirana, Albania it was 4.5%.35,3792.6% of burns were accidental and more than 80% were non-work related. In a report from the USA National Burn Repository, flame burns accounted for about 40% of cases, and 69% were non work-related accidents.36 It seems that most burns in our country are accidental and could be prevented through the application of safety protocols. More than 53% of patients were transported to a burn center by their own vehicle and not by the Emergency Medical Services (EMS). It can be postulated that EMS coverage is less than 50% and therefore developing more EMS centers with trained staff is an urgent need. In 79.6% of the cases dealt with by EMS, pre-hospital care and treatment were effective and complete. This shows the high capabality of EMS staff in caring for burn patients, as well

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as the quality of their educational and training programs. Even so, training boosts and refresher courses would still be valuable and should be considered by the authorities. About one third of our patients were referred to us by other hospitals, and thus our data is a fair representation of the data from across the whole country. Although there were suggestions that marriage status may have role in the occurrence of burns, in our study and that by Tempereau,40 the reverse was shown to other studies.41-44 Early wound excision and skin grafting were done in 19.5% of the patients. These patients had low TBSA involvement and thus had a better chance of early discharge, and subsequently an early return-to-work. In this way, loss of earnings is very limited in this group of patients. In 31.9% of our patients, physicians used amniotic membrane as a temporary biologic dressing,which is cheap and readily available.This requires direct coopration with the companies to ensure that they prepare the proper amniotic membrane and that it is sterile. In 28.2% of cases, skin grafts were the final treatment for the patients, meaning that less than a third of our patients had deep burns. More than 85% of patients were discharged from hospital, whereas the mortality rate was about 8.9%. This latter figure is higher than the mortality rate found in developed countries.23,29 Still, high rates of mortality have also been reported, such as 17.5%.44 However, when com-

paring the mortality rate between two centers or two countries, it is also important to consider the TBSA and mean TBSA of the patients. Obviously the lower the TBSA involved, the lower the mortality rate. Even so, the data shows that preventive programs would have a positive impact in reducing mortality from 8.9% to 4-5%, as in developed countries.24,46-49 The mean length of hospital stay (LOS) was 14.64 +/- 11.07. Our data is comparable with those from other reports: in Pakistan the mean LOS was 12.16 ± 6.07 days (range 2-73 days), and in a report from Tirana it was 11.6+/- 10.35,39 The average length of stay in the Buttemeyer 45 report was from 6-24 days in ICU. LOS surely depends on age, sex, TBSA, cause of burn, presence or absence of inhalation injury, and co-exsiting diseases. Preventive programs, which aim to reduce TBSA and inhalation injury, and to encourage proper treatment of co-exsiting illnesses, may also have a positive effect on reducing the LOS. conclusion

The authors believe that the burn registry program will provide a basis for researchers to use in conducting their work and in developing programs. Based on one year’s experience of the burn registry, better coverage of EMS has been identified as an urgent need for pre-hospital care of burn patients.

rÉSUMÉ. Les blessures par brûlure sont toujours un problème majeur en Iran, résultant dans de nombreux rapports qui habituellement sont dispersés, mal coordonnés et probablement peu fiables. Nous avons créé un programme de saisie de données de registre de brûlure avec 222 variables pour chaque patient brûlé admis. Ce programme a été créé en Août 2010 à l'Université des sciences médicales de l'Iran, à l'hôpital Motahari. A partir d'Août 2010 jusqu'à Août 2011 nous avons eu 14,277 patients brûlés, dont 877 ont été hospitalisés. Parmi les patients, 65,9 % étaient des hommes et 34,1% étaient des femmes. L'âge moyen était de 28,85 années (SD = 19,77). La cause de brûlure la plus courante était la flamme (en 78,5% des cas, dont 57,2 % étaiaent causés par le gaz tuyau de propane et 19,9% par le kérosène). La moyenne de la surface corporelle totale (SCT) brulée était de 23%. 77,8 % des patients ont reçu leur congé avec récupération partielle, tandis que la mortalité était de 8,9%. La durée moyenne d'hospitalisation était de 14,63 jours (SD = 11:07). Ce programme a été conçu pour aider à comprendre la portée des brûlures en Iran, fournissant des informations sur les patients, l'étiologie et le traitement. En outre, il met en évidence les différences entre les diverses régions du pays en termes de la fréquence et les causes des brûlures. En plus, le registre fournit une base pour des recherches et des enquêtes sur le traitement et la prévention des brûlures. Nos résultats ont montré que, bien que le personnel EMS sont très capables et bien formés, la couverture des EMS semble être inférieure à 50% et doit être augmentée. Selon les résultats, le statut de mariage n'a aucune influence sur la survenue de brûlures. Enfin, parmi nos patients, 57,0% étaient peu instruits. Mots-clés: brûlure, épidémiologie, mortalité, facteurs de risque, registre BIBLIoGrAPHY

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The burn registry program in Iran - First report.

Les blessures par brûlure sont toujours un problème majeur en Iran, résultant dans de nombreux rapports qui habituellement sont dispersés, mal coordon...
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