Beruflich Dokumente
Kultur Dokumente
of Pages 8
ScienceDirect
Article history: The Linköping burn score has been used for two decades to calculate the cost to the hospital
Accepted 2 February 2018 of each burned patient. Our aim was to validate the Burn Score in a dedicated Burn Centre by
Available online xxx analysing the associations with burn-specific factors: percentage of total body surface area
burned (TBSA%), cause of injury, patients referred from other (non-specialist) centres, and
survival, to find out which of these factors resulted in higher scores. Our second aim was to
Keywords:
analyse the variation in scores of each category of care (surveillance, respiration, circulation,
Burn intervention score
wound care, mobilisation, laboratory tests, infusions, and operation).
Validation
We made a retrospective analysis of all burned patients admitted during the period 2000–15.
Workload
Multivariable regression models were used to analyse predictive factors for an increased daily
burn score, the cumulative burn score (the sum of the daily burn scores for each patient) and the
total burn score (total sum of burn scores for the whole group throughout the study period) in
addition to sub-analysis of the different categories of care that make up the burn score.
We retrieved 22301 daily recordings for inpatients. Mobilisation and care of the wound
accounted for more than half of the total burn score during the study. Increased TBSA% and
age over 45 years were associated with increased cumulative (model R2 0.43, p< 0.001) and
daily (model R2 0.61, p<0.001) burn scores. Patients who died had higher daily burn scores,
while the cumulative burn score decreased with shorter duration of hospital stay (p< 0.001).
To our knowledge this is the first long term analysis and validation of a system for scoring
burn interventions in patients with burns that explores its association with the factors
important for outcome. Calculations of costs are based on the score, and it provides an
indicator of the nurses’ workload. It also gives important information about the different
dimensions of the care provided from thorough investigation of the scores for each category.
© 2018 Elsevier Ltd and ISBI. All rights reserved.
$
The study was done and financed by the Department of Hand Surgery, Plastic Surgery and Burns, Linköping University Hospital, and the
Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
$$
The paper has not been presented at any conferences yet.
* Corresponding author at: The Burn Centre Dept. of Hand and Plastic Surgery, Linköping University Hospital, 58185 Linköping, Sweden.
E-mail address: islam.abdelrahman@liu.se (I. Abdelrahman).
https://doi.org/10.1016/j.burns.2018.02.001
0305-4179/© 2018 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: I. Abdelrahman, et al., Validation of the burn intervention score in a National Burn Centre, Burns
(2018), https://doi.org/10.1016/j.burns.2018.02.001
JBUR 5480 No. of Pages 8
Please cite this article in press as: I. Abdelrahman, et al., Validation of the burn intervention score in a National Burn Centre, Burns
(2018), https://doi.org/10.1016/j.burns.2018.02.001
JBUR 5480 No. of Pages 8
Table 1 – Descriptive details of the patients and cumulative burn scores by the groups of survivors and those who died.
All groups (n=1363) Alive (n=1293, 95%) Deaths (n=70, 5%) p Value Test of significance
Sex (male) 960 (70) 915 (71) 45 (64) 0.25 Chi square
Age (years) 32.9 (1.3–72.2) 31.2 (1.2–69.2) 71.4 (46.1–85.8) <0.001 M
TBSA% 6.5 (1–31) 6 (1–25.5) 39.3 (13.6–85.3) <0.001 M
Superficial dermal burns BSA% 2 (0–12) 2 (0–12) 0 (0–11.8) 0.002 M
Deep dermal burns BSA% 0.5 (0–9.5) 0.5 (0–8.5) 4.8 (0–20.8)) <0.001 M
Full thickness burn BSA% 0 (0–14) 0 (0–9) 26.1 (2–71.5) <0.001 M
Duration of hospital stay (days) 8 (2–36) 8 (2–35) 8 (2–63.5) 0.35 M
Duration of stay/TBSA% 1.4 (0.3–5.3) 1.5 (0.4–5.7) 0.3 (0–2.5) <0.001 M
Referred from outside the region, n (%) 621 (46) 580 (45) 41 (59) 0.02 Chi square
Mechanical ventilation, n (%) 278 (20) 218 (17) 60 (86) <0.001 Chi square
Intensive care patients, n (%) 373 (27) 305 (24) 68 (97) <0.001 Chi square
No who required operation, n (%) 976 (72) 929 (72) 47 (67) 0.40 Chi square
Sedation dressing patients, n (%) 841 (62) 787 (61) 54 (77) 0.006 Chi square
Data are median (10–90 centiles) or no (%). M=Mann Whitney U test. BSA =body surface area.
Fig. 1 – The percentage of the contribution of each category of care to the recorded total burn score during the study period,
grouped by days when intensive care (red) was required. (For interpretation of the references to colour in this figure legend, the
reader is referred to the web version of this article.).
mean cumulative burn scores/TBSA% were similar among operating scores while scalds and chemical burns showed the
those who survived and those who died, while among those in smallest scores. The overall trend was for both mobilisation
whom TBSA% was greater than 50%, the mean cumulative and wound care to give the highest scores whatever the cause,
score/TBSA% was considerably reduced among those who with a mean daily score around 1.5 in all groups (Supplemen-
died compared with those who recovered (Fig. 2). tary Fig. S2).
Flame was the cause of the burn in almost half the patients We noticed a linear increase in the pattern of cumulative
admitted while scalds accounted for 30%; the highest total burn score coefficients (in the categories wound care,
burn scores, which reflected the impact on the Burn Centre, respiration, and operation) when the TBSA% was larger,
were noticed among patients with flame burns, followed by compared with those coefficients for daily burn scores.
those with scalds. The total burn score ratio between flame “Wound care” was strongly associated with larger TBSA% in
burns and scalds was 10:1. The chemical group had the the cumulative burn score, which reflected the need for
smallest total score (Supplementary Table S2). repeated procedures for wound care over a longer period in
The highest daily burn scores were in the group with flame hospital for patients with bigger TBSA%. However, in the daily
burns in all categories of care. That group showed the highest burn score, the category “respiration” showed higher
Please cite this article in press as: I. Abdelrahman, et al., Validation of the burn intervention score in a National Burn Centre, Burns
(2018), https://doi.org/10.1016/j.burns.2018.02.001
JBUR 5480 No. of Pages 8
Fig. 2 – Shows the mean cumulative burn score required for each TBSA% among different TBSA% groups in both those who
survived and those who died.
coefficient values than “wound care” in the different TBSA% increased age and increasing scores in all the categories of
groups (Fig. 3). care, but sex had no impact on the daily burn score. The R2 for
The R2 for different regression models of categories of care different models were stronger when they were calculated on
using cumulative burn score as the dependent variable seems daily burn scores (rather than models based on the cumulative
to be in the same range (0.42), except for the category burn score) except for the R2 in the category “wound care”.
“circulation” (0.22), (Supplementary Table S3) probably Compared with the patients with TBSA% of less than 10%,
because fewer patients required the highest level of this care those with a TBSA% of more than 60% had daily burn scores
(Supplementary Fig. S1). The cumulative burn score model that increased by 7.8 points for each day of care (Table 2).
shows that mortality was associated with lower scores for care
categories except for “circulation”. Patients over 45 years old
required more care, which was reflected in higher scores for 4. Discussion
that age group. Neither sex nor referrals from other centres
was associated with higher cumulative burn scores. Compared We propose a validated intervention scoring system that could
with patients with TBSA% of less than 10%, there was a directly be applied worldwide in burn centres. We have analysed 16
proportional increase in the burn score with increased TBSA% years’ data of daily recorded burn scores from our Burn Centre,
in all categories of care (Supplementary Table S3). and as far as we know this is the first long-term analysis of an
Unlike the cumulative burn score, mortality was associated intervention scoring system for burns that has been validated.
with increased daily burn scores in all categories of care, with We found TBSA% to be the strongest factor in the increase in
particularly high values in “surveillance”, “respiration”, and both daily and cumulative burn scores, which confirms our
“circulation”. There was a direct proportional relation between initial presumption. Not only does it provide an indicator of the
Fig. 3 – Compares the relation between the coefficients of three categories of care; respiration, wound care, and operation which
showed a different order in the cumulative burn score compared to the daily burn score. See all coefficients in Table 2 and
Supplementary Table S3.
Please cite this article in press as: I. Abdelrahman, et al., Validation of the burn intervention score in a National Burn Centre, Burns
(2018), https://doi.org/10.1016/j.burns.2018.02.001
JBUR 5480 No. of Pages 8
(2018), https://doi.org/10.1016/j.burns.2018.02.001
Please cite this article in press as: I. Abdelrahman, et al., Validation of the burn intervention score in a National Burn Centre, Burns
Table 2 – Daily burn score, regression model for the association with each category of care.
Surveillance Respiratory Circulatory Wound care Mobilisation Lab tests Infusions Operation Total
Coef. p Value Coef. p Value Coef. p Value Coef. p Value Coef. p Value Coef. p Value Coef. p Value Coef. p Value Coef. p Value
TBSA%:
0–9.9
10–19.9 0.3 <0.001 0.2 <0.001 0.0 0.04 0.2 <0.001 0.2 <0.001 0.2 <0.001 0.4 <0.001 0.1 0.28 1.7 <0.001
20–29.9 1.0 <0.001 0.8 <0.001 0.2 <0.001 0.4 <0.001 0.6 <0.001 0.4 <0.001 1.0 <0.001 0.3 <0.001 4.5 <0.001
30–39.9 1.1 <0.001 1.0 <0.001 0.3 <0.001 0.4 <0.001 0.7 <0.001 0.5 <0.001 1.2 <0.001 0.3 <0.001 5.7 <0.001
Male sex 0.0 0.38 0.0 0.89 0.0 0.87 0.0 0.37 0.0 0.20 0.0 0.06 0.0 0.16 0.0 0.34 0.2 0.17
Patients from elsewhere 0.2 <0.001 0.2 <0.001 0.1 0.005 0.1 <0.001 0.1 <0.001 0.1 <0.001 0.2 <0.001 0.1 0.003 1.3 <0.001
Age (years):
0–4.9
5–17.9 0.1 0.36 0.1 0.35 0.1 0.09 0.0 0.75 0.1 0.14 0.0 0.73 0.1 0.05 0.0 0.85 0.3 0.16
18–45.9 0.1 0.20 0.1 0.002 0.0 0.90 0.1 0.03 0.2 <0.001 0.2 <0.001 0.4 <0.001 0.2 0.03 1.3 <0.001
46–65.9 0.2 <0.001 0.3 <0.001 0.1 <0.001 0.1 0.004 0.2 <0.001 0.2 <0.001 0.4 <0.001 0.2 0.002 2.1 <0.001
66 and older 0.5 <0.001 0.5 <0.001 0.2 <0.001 0.1 0.23 0.5 <0.001 0.3 <0.001 0.6 <0.001 0.2 0.04 3.2 <0.001
Mortality 1.2 <0.001 1.3 <0.001 1.2 <0.001 0.3 <0.001 0.6 <0.001 0.6 <0.001 0.9 <0.001 0.5 <0.001 6.6 <0.001
Constant 0.3 <0.001 0.1 0.03 0.0 0.07 1.2 <0.001 0.9 <0.001 0.0 0.75 0.1 0.001 0.3 <0.001 2.4 <0.001
5
JBUR 5480 No. of Pages 8
nurses’ workload, but more importantly it gives essential data recordings (surveillance), and mortality, which was similar
about the care provided including the progress of care of each to our finding.
inpatient, and the basis of calculations of costs. The pattern of increased operations and scores for the
The computerised system has been the source of data for category “wound dressing” with increased TBSA% that we
several previous publications [29–33] and for local auditing, found is in line with findings from other studies that have
but we have not made a comprehensive analysis of the burn focussed on analysis of costs [43]. Contrary to our finding that
score until now. There have been many studies published scores were higher with increased TBSA% in all categories,
about different intervention scores and ways of measuring those that focussed on costs showed relatively less increase in
workload, [3,7,9,16,22,34], but we know of no studies that costs with increased TBSA% [38], which can be explained by
have described accurate data about different interventions the different methods of measurement.
collected over a long period in a dedicated Burn Centre. Even In a previous publication [32] we have compared mortality
when we searched in other fields where intervention scores in two different time periods (2000–2007 and 2008–2015) and we
have been used, such as intensive care [7], we found no such have shown a decrease in mortality with the same levels of
publications. resources consumption, workload assessed by the burn score.
There was a steep rise in both the cumulative and daily burn The previous publication mentioned that the two compared
scores between the groups TBSA% 10%–19.9% and 20%–29.9%, periods were similar regarding medical interventions, no
contrary to the gradual rise among the groups with larger TBSA introduction of revolutionary techniques was introduced in
%. The category “circulation” showed the biggest proportional the field of wound care and on the technical aspect of the
increase in this TBSA% group, followed by “respiratory care”, intensive care the ventilators and the monitors are upgraded
but the effective increase in the total score was the result of the but they require the same amount of work. However, the staff
increases in the categories “respiratory” and “surveillance”. probably became more experienced over time. This could raise
We have previously used the 20% TBSA% as a cut off point for the prospect of investing more in upgrading knowledge and
severe burns [35,36] as most of those patients require more developing skills among the staff.
care [37], and this is confirmed by the present results of the
need for more interventions.
The longer hospital stay for patients with larger TBSA% 4.1. Limitations of the study
resulted in a higher cumulative burn score, and the daily
analysis confirmed an increase in the groups with bigger We could not compare the recorded workload with the actual
TBSA%. A study from Finland showed the direct relation number of staff who provided the service as we did not have
between increasing TBSA% and costs of a burn [38], which is precise records of nurse:patient ratios. On the other hand, the
in line with our results as increasing cumulative burn scores Burn Score has been used during the last two decades to
indicates higher costs/patient. Patients less than 18 years old convert the recorded points to a final daily cost, which
required less daily burn care than older patients, and there increases the reliability of the score. The intervention scoring
was a steady increase as patients got older. This is in line system currently in use in general intensive care units in
with previous studies [38] that showed increasing costs in Sweden [44] and the Burn Score [1] are both modified versions
elderly patients. of the original nursing care recording system [8].
Patients referred from elsewhere had increased daily burn
score coefficients, and increased scores in all the categories 4.2. Conclusion
of care as well. This could be explained by the fact that local
patients are kept in the burn centre for a period that includes This is to our knowledge the first long-term analysis and
both the acute phase of the injury and the healing phase, validation of a burn intervention score that explores its
while those from elsewhere are usually sent back to their association with the factors important for the outcome of
referring hospital when they are well enough to finalise their care in burns. The different scores for category of care were
treatment [31]. Duration of hospital stay was the major consistently distributed among different groups of TBSA%,
contributing factor to the results among patients who died, age, mortality, and patients referred from elsewhere. The Burn
probably because patients with the smallest TBSA% were Score also gives important information about the different
likely to live longer and required a higher cumulative burn dimensions of the care provided by thorough investigation of
score than the group with a bigger TBSA%, which is usually the score/category of care.
associated with high mortality after a short hospital stay.
Few studies have presented the results of an intervention
scoring system for burns [7,39] that covered nursing time or Conflict of interest statement
prediction of mortality. There are more studies of interven-
tion scores in general intensive care settings, although they The authors declare that there is no conflict of interest.
differ from those in burn care in factors such as duration of
stay, age, and the nature of the disease [4]. The relation
between workload and mortality has been assessed in some Appendix A. Supplementary data
intensive care studies from the number of staff [40,41], and a
few studies have shown that patients who died required Supplementary data associated with this article can be found,
more interventions, as measured by TISS [4]. Collins et al. [42] in the online version, at https://doi.org/10.1016/j.
reported a correlation between the number of nurses’ burns.2018.02.001.
Please cite this article in press as: I. Abdelrahman, et al., Validation of the burn intervention score in a National Burn Centre, Burns
(2018), https://doi.org/10.1016/j.burns.2018.02.001
JBUR 5480 No. of Pages 8
Please cite this article in press as: I. Abdelrahman, et al., Validation of the burn intervention score in a National Burn Centre, Burns
(2018), https://doi.org/10.1016/j.burns.2018.02.001
JBUR 5480 No. of Pages 8
[42] Collins SA, Cato K, Albers D, Scott K, Stetson PD, Bakken S, et al. [44] Samuelsson C, Sjoberg F, Karlstrom G, Nolin T, Walther SM.
Relationship between nursing documentation and patients’ Gender differences in outcome and use of resources do exist in
mortality. Am J Crit Care 2013;22:306–13. Swedish intensive care, but to no advantage for women of
[43] Ahn CS, Maitz PKM. The true cost of burn. Burns 2012;38:967–74. premenopausal age. Crit Care 2015;19:129.
Please cite this article in press as: I. Abdelrahman, et al., Validation of the burn intervention score in a National Burn Centre, Burns
(2018), https://doi.org/10.1016/j.burns.2018.02.001