Increasing ambulatory treatment of pediatric minor burns—The emerging paradigm for burn care in children☆
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.
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Epidemiology and trend of US pediatric burn hospitalizations, 2003–2016
2021, BurnsCitation Excerpt :Due to advancements in burn care, burn patients are increasingly treated in an outpatient setting, where medical costs are also lower [1,2].
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2020, BurnsCitation 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 ReportsPediatric Fracture Epidemiology and US Emergency Department Resource Utilization
2022, Pediatric Emergency CareBurn Injuries Associated with At-Home Hair Braiding
2022, Journal of Burn Care and Research
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Presented at the 2018 American Burn Association 50th Annual Meeting Chicago, IL April 13th, 2018.