Improvements in outcomes for older adults sustaining burn injuries have lagged far behind those of younger patients. As this segment of the population grows, there has been an increasing interest in better understanding the epidemiology and outcomes of injury in older adults. The National Burn Repository (NBR) provides a unique opportunity to examine burn injuries on a national level. We aimed to characterize specific injury and outcome trends in older adult with burns through analysis of the NBR. We examined the records of all patients in the NBR aged 55 and older. To characterize age effects on injury and outcomes, patients were stratified into three age categories: 55 to 64 years, 65 to 74 years, and 75 years and older. Baseline characteristics, details of hospital treatment, mortality, and disposition were compared among these three age groups using χ 2 or analysis of variance. Logistic regression analysis was performed to assess the impact of age on burn mortality. A total of 180,401 patient records were available from 1991 to 2005, of which 23,180 (14%) met age inclusion criteria. Mean burn size (9.6% TBSA) and percent with inhalation injury (11.3%) did not markedly differ by age. Men predominated overall (ratio 1.4:1), although women (4290) outnumbered men (3439) in the oldest age category. Length of stay per TBSA and median hospital charges increased with increasing age category, suggesting higher resource consumption with aging. Mean number of operations per patient, however, decreased with age. Mortality rates and discharge to nonindependent status increased with age. By logistic regression, the adjusted odds ratio for mortality was 2.3 (95% CI 2.1-2.7) in the 65 to 74 age group, and 5.4 (95% CI 4.8-6.1) in the oldest group when compared with the 55 to 64 age group. Mortality rates decreased significantly after 2001 across all age groups. This analysis demonstrates age-dependent differences in resource utilization and mortality risk within the older burn population and highlights the need for a national research agenda focused on management practices and outcomes in older adult with burns.
Despite advances in medical and surgical techniques, older adults tend to be at high risk for adverse outcomes following burn injury. The purpose of this study was to examine the relative impacts of age and medical comorbidities on outcome following injury in a cohort of older adults. This was a retrospective study of all patients age 55 and over admitted to the University of Washington Burn Center from 1999 to 2003. To examine the effect of baseline medical comorbidities on outcome, a Charlson Comorbidity Index score was calculated for each patient. Multivariate regression analyses were used to examine the impact of age and comorbidities on mortality and other complications. Patient records were also matched with the National Death Index to determine the effects of age and comorbidities on mortality within 1 year following hospital discharge. A total of 325 patients who were of 55 years and older were admitted to the burn center during the 5-year study period. The overall mortality rate was 18.5%. Mortality was independently associated with age, inhalation injury, and burn size. One-year mortality was significantly associated with those older than age 75 and the Charlson score. Longer length of stay was significantly associated with burn size, inhalation injury, and total number of in-hospital complications. This study demonstrates that patient age—independent of baseline medical comorbidities—and TBSA burn are the most significant factors impacting in-hospital mortality risk following burn injury. Higher number of medical comorbidities was associated with increased mortality risk within 1 year following discharge.
Despite many advances in modern burn care, deaths still occur in the burn intensive care unit. For patients with severe burns, providers may advocate to withdraw life support early during hospitalization when the extent of injury makes survival highly unlikely or when the patient's condition deteriorates during resuscitation. Our regional burn center has implemented a stepwise withdrawal protocol since 2001 in an effort to standardize symptoms palliation at the end of life. In this study, the authors evaluated the frequency of early withdrawal and the protocol impact on end-of-life processes of care in burn patients who died within 72 hours of hospitalization. A 13-year review of all burn patients aged ≥18 years admitted to our burn center to identify all patients who died within 72 hours of hospitalization was performed. Patients were dichotomized to the periods before (1995 to mid-2001) and after implementation of standardized withdrawal protocol (mid-2001 to 2007). Descriptive analyses were performed to compare end-of-life care processes between the two periods. A total of 4374 adult patients with acute burns were admitted during the 13-year study period, of which 252 (6%) died during hospitalization. Of the patients who died within 72 hours, 106 (84%) had withdrawal of life support compared with 20 (16%) who died with ongoing life support. Higher mean TBSA distinguished patients who died by withdrawal (61 vs 48%, P = .06). Since mid-2001, all 61 patients who had life support withdrawn were by protocol. Implementation of the protocol has led to more frequent use of opioid infusion (98 vs 87%, P = .07) and benzodiazepine infusion (95 vs 49%, P < .01), without hastening time to death (median 5.0 vs 5.5 hours, P = .70). The large majority of early burn deaths at our regional center occur via withdrawal of life support. Implementation of a protocolized withdrawal has resulted in more consistent provision of analgesia and sedation without hastening death. Burn centers should consider using a protocol for withdrawal of life support to improve consistency in end-of-life symptoms palliation.
Modern burn care is a resource intensive endeavor requiring specialized equipment, personnel, and facilities in order to provide optimum care. The costs associated with burn injury to both patients and society as a whole can be multifaceted and large. The purpose of this study was to evaluate the association between hospital costs, patient characteristics, and injury factors in a cohort of pediatric patients admitted to a regional burn center. We performed a review of the hospital charges accrued by pediatric patients (age <16 years) admitted to our burn center from 1994 to 2004 and explored the relationship between baseline patient, injury and hospital course characteristics and total costs. Hospital charges were converted to 2005 dollar costs using an inflation index and a cost to charge ratio. Univariate and multivariate regressions were performed to identify the factors most significantly associated with cost. In addition, we performed a subset cost analysis for patients with burns more than 20% TBSA. A total of 1443 pediatric patients (age <16) were admitted to our burn center during the study period. The overall mean hospital cost in 2005 dollars was $9026 (SD = $25,483; median = $2138). Area of full thickness burn was the only patient or injury factor significantly associated with greater hospital costs (P < .05) on multivariate analysis. No single anatomic area was associated with increased hospital costs when adjusted for total overall burn size. Injury severity was the most significant factor impacting index hospitalization costs following pediatric burn injury. Further studies defining the long-term societal costs impact of burn injury are needed as are studies that evaluate the impact of burn injury on quality of life.Modern burn care is a resource intensive endeavor requiring specialized equipment, multidisciplinary personnel, and facilities. The costs associated with burn injury to both patients and society can be multifaceted and large. Given that the sequelae of burn injury may require ongoing physical, occupational, and psychological therapy as well as repeated in-patient surgical procedures, the costs associated with burn care may persist for years after the initial injury.These long-term care and cost considerations are perhaps even more significant in the pediatric population. Children who sustain severe burn injury can typically expect medical and psychological care that extends years beyond their injury. In addition, pediatric injuries impact parents and/or other caregivers, as well as siblings in the family. During the, often lengthy, postinjury hospitalization, parents often miss prolonged periods of work in order to be at their children's bedside. Following discharge, arrangements for home care also need to be made which frequently result in more missed work days for parents.Although the costs associated with other illnesses, such as chronic pulmonary disease, spinal cord injury, and diabetes have been well studied, [1][2][3][4][5] little is known about the costs of either the in...
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