Elsevier

Burns

Volume 45, Issue 1, February 2019, Pages 165-172
Burns

Increasing ambulatory treatment of pediatric minor burns—The emerging paradigm for burn care in children

https://doi.org/10.1016/j.burns.2018.08.031Get rights and content

Highlights

  • Smaller and more superficial burns were more likely to be treated in outpatient setting.

  • Shorter travel distance from patient home to emergency department predicted outpatient treatment.

  • California data suggest a trend toward outpatient treatment of pediatric burns <20% total body surface area.

  • After adjustment, White and Asian patients may be more likely to discharge home than their Black and Hispanic peers.

Abstract

Introduction

Innovations in topical burn treatment along with a drive toward value-based care are steering burn care to the outpatient setting. Little is known regarding what characteristics predict outpatient treatment of pediatric minor burns and whether there is a temporal trend toward this treatment paradigm.

Methods

A retrospective cohort study was performed using California’s Office of Statewide Health Planning and Development linked emergency department and inpatient database (2005–2013). All patients under 18 years of age with a primary burn diagnosis were extracted. Using patient and facility level variables, we used regression modeling to evaluate predictors of outpatient burn treatment and temporal trends.

Results

There were 16,480 pediatric minor burn encounters during the period. 56.4% were male, 85.3% had <10% total body surface area (TBSA), 76.3% were scald or contact, and 77.3% were at deepest depth 2nd degree. Multiple variables predicted an increased likelihood of discharge home including older age(p < 0.001), smaller TBSA(p < 0.001), and superficial/partial thickness burns(< 0.001). Children of Hispanic and Black race were less likely to be discharged home compared to White and Asian peers(p = <0.001). On Poisson modeling, the incidence rate ratio over the 9-year period for home discharge was 1.004 (95% CI 1.001–1.008, p = 0.032).

Conclusion

Older patients and those with more superficial burns were more likely to be treated as outpatients. Black and non-white Hispanic race was associated with inpatient admission. There is a growing trend toward ambulatory treatment of minor burns in the pediatric population. Further research is needed to assess whether outpatient treatment of pediatric minor burns results in greater readmissions.

Introduction

Burns are a leading mechanism of injury among pediatric patients in the United States and are frequently cared for in emergency departments (ED). In 2015, the Center for Disease Control and Prevention reported 104,940 nonfatal burn injuries and 290 deaths among children aged 0–17 years [1]. ED providers are frontline in burn treatment, and are tasked with evaluation, triage, and treatment of these injuries. Guidance from the American Burn Association (ABA) recommends referral to burn centers for children presenting to facilities that do not have “qualified personnel and equipment for the care of children [2].” Appreciating the vague nature of this recommendation, some within the burn community recommend that any pediatric burn with >5% TBSA should be evaluated by a burn center [3].

For those burns for which inpatient resuscitation and monitoring are not indicated, (i.e. <15% total body surface area for <12 years old, and <20% TBSA for adolescents), the decision for inpatient admission depends on multiple factors including tolerance for wound care, treatment of concomitant injuries, suspicion of abuse/neglect with filing to child protective services, and social support at home. Emerging technologies in the past two decades in the form of occlusive silver dressings [4] have yielded products that can be safely and effectively used to treat partial and full-thickness thickness burns in an ambulatory setting [5], [6]. While some patients may eventually need surgical excision of deeper burns, these procedures can be scheduled as outpatients and the children do not have to be subjected to risks of inpatient admission.

Additionally, leaders within the international [7] and US [8] burn community advocate for ambulatory burn care when feasible to limit unnecessary hospitalization, decrease treatment costs, and improve patient experience [9]. We aim to (1) evaluate predictors of home discharge for pediatric burn patients presenting with <20% burns, and (2) determine the significance of the perceived trend toward ambulatory burn care for pediatric burns <20% TBSA. We hypothesize that ED discharge home has increased during the study period.

Section snippets

Data

The Office of Statewide Health Planning and Development (OSHPD) database captures all patient admissions and emergency department visits in the state of California. This repository creates unique identifiers for all patients, (OSHPD is not a sampled database). The following study utilized a merged non-publically available version that linked the emergency department and inpatient datasets from 2005 to 2013.

Cohort

Encounters were identified using International Classification of Disease (ICD) 9th

Results

There were 108,125 encounters for burn related injuries in the pediatric population (<18 years of age at time of injury) (Fig. 1). 53,621 were excluded for missing TBSA; 34,163 were excluded for missing depth. 2680 encounters were excluded for non-index visits (i.e. secondary ED visits), and 1181 were excluded for TBSA >20%. This yielded 16,480 unique index ED encounters with TBSA <20% and known depth.

The mean age was 4.5 years (SD 5.1), and 56.4% were male (Table 1). 85.3% of encounters were

Discussion

Our analysis documents the first evidence for a trend toward the ambulatory treatment of pediatric burns in California, mirroring findings from the international community [12]. This trend was significant after consideration of multiple factors including patient demographic, facility and burn characteristics. Not surprisingly, many variables predicted the outpatient treatment of minor burns in the pediatric population such as smaller %TBSA, more superficial depth, and patient residence near the

Conclusion

Independent predictors of outpatient treatment included older patients, more superficial burns, smaller total body surface area percentage, scald/contact mechanism, and hand burns. Non-accidental injury and greater travel distance to ED predicted inpatient treatment. Non-Hispanic white and Asian patients were treated as outpatients more frequently than Hispanic and Black patients. There was significant growth in the trend toward ambulatory treatment of minor burns in the pediatric population,

Conflicts of interest

No authors have any financial disclosures or conflicts of interest regarding the contents of this manuscript.

References (29)

  • D.A. Peters et al.

    Healing at home: comparing cohorts of children with medium-sized burns treated as outpatients with in-hospital applied Acticoat to those children treated as inpatients with silver sulfadiazine

    J Burn Care Res

    (2006)
  • C.C. Sheckter et al.

    Cost-effectiveness comparison between topical silver sulfadiazine and enclosed silver dressing for partial-thickness burn treatment

    J Burn Care Res

    (2014)
  • M. Brown et al.

    Outcomes of outpatient management of pediatric burns

    J Burn Care Res

    (2014)
  • P. Silverstein et al.

    An open, parallel, randomized, comparative, multicenter study to evaluate the cost-effectiveness, performance, tolerance, and safety of a silver-containing soft silicone foam dressing (intervention) vs silver sulfadiazine cream

    J Burn Care Res

    (2011)
  • Cited by (11)

    • Epidemiology and trend of US pediatric burn hospitalizations, 2003–2016

      2021, Burns
      Citation Excerpt :

      Due to advancements in burn care, burn patients are increasingly treated in an outpatient setting, where medical costs are also lower [1,2].

    • The association of burn patient volume with patient safety indicators and mortality in the US

      2020, Burns
      Citation Excerpt :

      Prior analyses have demonstrated that it is difficulty to accurately identify hospital-acquired infections using administrative data [25,26]. Trends suggest that many burn patients that historically would have admitted are now being treated as outpatient [27], which is not captured in this data. There may be some burn centers that have a greater tendency to manage burns on an outpatient basis, which could reduce their admission volume.

    • Update in Pediatric Burn Care

      2023, Current Trauma Reports
    • Burn Injuries Associated with At-Home Hair Braiding

      2022, Journal of Burn Care and Research
    View all citing articles on Scopus

    Presented at the 2018 American Burn Association 50th Annual Meeting Chicago, IL April 13th, 2018.

    View full text