Abstract
Burn injuries are one of the leading causes of morbidity worldwide. Although the overall incidence of burns and burn-related mortality is declining, these factors have not been analysed in our population for 25 years. The aim of this study has been to determine whether the epidemiological profile of patients hospitalized for burns has changed over the past 25 years. We performed a retrospective cohort study of patients hospitalised between 1 January 2011 and 31 December 2018 with a primary diagnosis of burns. The incidence of burns in our setting was 3.68/105 population. Most patients admitted for burns were men (61%), aged between 35 and 45 years (16.8%), followed by children aged between 0 and 4 years (12.4%). Scalding was the most prevalent mechanism of injury, and the region most frequently affected was the hands. The mean burned total body surface (TBSA) area was 8.3%, and the proportion of severely burned patients was 9.7%. Obesity was the most prevalent comorbidity (39.5%). The median length of stay was 1.8 days. The most frequent in-hospital complications were sepsis (16.6%), acute kidney injury (7.9%), and cardiovascular complications (5.9%). Risk factors for mortality were advanced age, high abbreviated burn severity index score, smoke inhalation, existing cardiovascular disease full-thickness burn, and high percentage of burned TBSA. Overall mortality was 4.3%. Multi-organ failure was the most frequent cause of death, with an incidence of 49.5%. The population has aged over the 25 years since the previous study, and the number of comorbidities has increased. The incidence and severity of burns, and the percentage of burned TBSA have all decreased, with scalding being the most prevalent mechanism of injury. The clinical presentation and evolution of burns differs between children and adults. Risk factors for mortality were advanced age, smoke inhalation, existing cardiovascular disease, full-thickness burn, and high percentage of burned TBSA.
Similar content being viewed by others
Introduction
Burns are a common problem in people of all age groups, from all walks of life, all over the world.
Nonfatal burns, the most prevalent type, are one of the leading causes of morbidity, including prolonged hospitalization, disfigurement, and disability.
Recent years have seen a significant decrease in both burn incidence and burn-related mortality, although figures continue to be very high. In 2017, burns accounted for 9 million injuries and 120,000 deaths worldwide1.
In addition to the decrease in incidence and mortality, a systematic review published by Smolle2 reported a downward trend in burn-related length of hospital stay (LOS) between 2001 and 2016. The length of stay/percentage of burned total body surface area (LOS/%TBSA) ratio has decreased from 1.5–3 days to 0.5–1.4 days2,3,4.
A multitude of epidemiological studies published in Europe over the past 10 years have reported a decrease in incidence, mortality, and severity of burns (a major burn is defined as > 20% TBSA5) and LOS6,7,8,9,10,11,12,13,14,15,16. However, few studies describe comorbidities in relation to burned patients and their effect on morbidity and mortality17,18,19,20.
The last epidemiological study performed in Catalonia was published in 199921, and showed that comorbidity and female sex were not associated with higher mortality.
The healthcare system in Catalonia and in Spain is public system. The Hospital Universitario Vall d'Hebron (HUVH) is a tertiary hospital and there is only this burn unit that receives patients not only from the local Barcelona area but also from other provinces, with a catchment area of 9 million inhabitants. It is also one of the leading burn units in Spain. The Hospital has been awarded the CSUR certificate of clinical quality in Spain, is a member of the European network of burns disasters, and is certified by the EBA (European Burns Association).
The aim of this study has been to describe the epidemiological profile of the hospitalised burned patient, the complications occurring during their hospital stay, and the burn-related mortality rate, and to compare these variables with data published 25 years ago.
Material and method
Study design and patient selection
The study was approved by the Hospital Universitario Vall d’ Hebron ethics committee (PR[ATR]385/2016). The requirement for informed consent from the study subjects was waived by the IRB of Hospital Universitario Vall d’ Hebron due to the retrospective study. The study follows the recommendations of the STROBE statement for reporting observational studies and all research was performed in accordance with the Declaration of Helsinki.
This is a retrospective cohort study of patients admitted to the HUVH from 1 January 2011 to 31 December 2018.
Inclusion criteria were: all patients admitted to the HUVH with a primary diagnosis of burns. The primary diagnosis was coded according to the criteria of the International Classification of Diseases (the ICD-9 was used from 2011 to 2016 and the ICD-10 from 2017 to 2018).
Patients diagnosed with burns who died within the first 12 h of admission were excluded.
Data were taken from the patient’s digital clinical history and supplemented with data from their primary care records. The cost was calculated using data from the annual budget of the burn unit. Patients were monitored at 30 and 90 days after hospital discharge by the follow-up specialist.
Study variables were (see Appendix 1): Age, sex, burned TBSA, burn location, burn degree, mechanism of injury, work accident, Abbreviated Burn Score Index (ABSI), and smoke inhalation. Comorbidities were: toxic habits, cardiovascular or respiratory disease, diabetes mellitus, chronic kidney failure, liver disease, clotting disorder, use of antiplatelet agents or oral anticoagulants, chronic anaemia, neuromuscular disorders, active neoplasia, and obesity. Variables collected during hospitalisation were: LOS, ICULOS, surgical intervention and reintervention. Complications during admission included compartment syndrome, cardiovascular complications, acute respiratory distress syndrome, need for tracheostomy and time from admission to tracheostomy, days on mechanical ventilation, acute kidney injury (AKI), stroke, and sepsis. Outcomes variables were: In-hospital mortality 12 h after admission, cause of death, and 30- and 90-day mortality.
Smoke inhalation was defined either by clinical suspicion or diagnosed through fibro-bronchoscopy. MOF (Multiple Organs Failure) was defined as the failure of two or more of the following organs or systems: cardiovascular, respiratory, neurological, renal, hematological, gastrointestinal, hepatic, and neurological. We followed the recommendations of the ABA (American Burn Association) for definition of sepsis22. AKI (Acute Kidney Injury) diagnosis was based on the RIFLE clinical criteria23.The diagnosis of ARDS (Acute Respiratory Distress Syndrome) adhered to the diagnostic criteria outlined in the Berlin definition24.
Data were extracted from the Redcap project database (Tennessee, USA).
Statistical analysis
The Redcap project (https://www.project-redcap.org/) database was used for this study. Statistical analysis was performed on R (version 4.1.1, R Core Team, Vienna, Austria) by the Statistics and Bioinformatics Unit (UEB) of the Vall d'Hebrón Hospital Research Institute.
For categorical variables, the frequency and 95% confidence interval were calculated. For continuous variables, the mean and standard deviation were calculated together with the mean 95% confidence interval and the median and interquartile range (IQR).
A group comparison test was performed to compare the different categories of the variable of interest. The Kruskall–Wallis test was used for quantitative variables. The chi-square test or Fisher's exact test was used for categorical variables when the expected count was less than 5. Kaplan–Meier curves were used to analyse the factors associated with an increase in mortality. A univariate Cox regression model was fitted to quantitative variables. The Hazard Ratio was calculated with a 95% confidence interval. Variables were selected attending at clinical reasons from those related at the univariate analysis in order to avoid overfitting”. For variable selection in automatic model, Lasso technique has been used. This technique penalized the función of maximization of the coeficients. This penalization is lead by a lamda parameter that is maximized to obtain the optimal value and select all the variables over the lambda value.
Ethics approval and consent to participate
This study was approved by the HUVH ethics committee (PR(ATR)385/2016). The recommendations of the STROBE statement for reporting observational studies were followed.
Results
A total of 2744 patients were included in the study (Fig. 1). Of these, 34 were misdiagnosed or patients died within 12 h of admission, and therefore eliminated. Two separate admissions (discharged and re-admitted for surgery or burn-related complications) were recorded for 59 patients. These double admissions with their corresponding hospital stays were merged into a single variable. The date of the first admission was taken as the date of admission to simplify the calculation of other time-related variables, such as the time from admission to various procedures.
Study flow chart.
Demographics
The incidence of hospital admission was 3.68/100,000 inhabitants (Table 1). Of the 2651 study patients, 2169 were adults (81.8%) and 482 were aged under 16 years (children). Male patients accounted for 61.9% of admissions. Mean age was 41.4 ± 24.7 years. The most numerous age group was 35–45 years in adults (16.8%) and 0–4 years (12.4%) in children.
Burn characteristics
The mean burned TBSA was 8.3% (Table 1) full-thickness burns were diagnosed in 23.4% of adults and 7.3% of children. In 75.1% of patients, less than 10% of TBSA was affected. In 9.7% of patients, > 20% of TBSA was affected; in adults, this incidence (10.6%) was double that of children (p < 0.001). In all age group, burns in the arms (64.8%) were most frequent, followed by the legs (51.8%), and the head and neck (35.3%).
Scalding (37.7%) was the most prevalent mechanism of injury overall; however, after adjusting for age and sex, the most prevalent mechanism of injury in adult males was flame (39%), and scalding in adult females and in children (45.9% and76.6%, respectively); 14.1% of burns occurred in the workplace. Summer was the season with the highest number of admissions (28%).
Comorbidities
In adults, 31.5% of patients were smokers and 8.4% reported alcohol dependence. Obesity was the most prevalent comorbidity (39.5%), along with cardiovascular disease (29.9%) and dyslipidaemia (21.1%). In children, respiratory disease (asthma) was the most prevalent comorbidity (7.3%) (Table 2).
Treatment
Table 3 summarizes the treatments administered. Over half (63.8%) of the sample underwent surgery; the difference between children (41.4%) and adults (68.9%) was statistically significant (p < 0.001). Of the surgical patients, 19.5% required a median of 1 (IQR 1.2) reintervention. Median time from the burn event to surgery was 16 [IQR 12–21.8] days in children and 14 [IQR 9–20] days in adults (p < 0.001). In contrast, Table 4 shows that the median waiting time for surgery is 10 days [IQR 7–15] days, compared to patients with minor burns, with a median of 15 days (p < 0.001).
Complications/Outcomes
Some (13%) patients required admission to the ICU; this percentage was significantly higher in children (25.9%) than in adults (10.7%) (p < 0.001), although children remained in the unit for a median of 1 (IQR 1.4) day and adults for a median of 13 [IQR 3.30] days (Table 5).
Mechanical ventilation was required in 3.9% of children and 9.4% of adults (p < 0.001). Median time on mechanical ventilation was significantly lower in children (6 days [IQR 3.15.5]) compared to adults (10 days [IQR 2.25]).
In adults, the most prevalent complications during hospital stay were sepsis (16.6%), AKI (7.9%), and cardiovascular complications (5.9%). Among children, the most frequent complication was sepsis (14.9%). The most frequent foci of infection in our sample were burns (50.7%), following by respiratory (35.2%), and urine (27.9%) infections.
Blood transfusion was required in 13.7% of patients; the rate of transfusion was significantly higher in adults vs. children (p < 0.001).
Overall mortality in the study period was 3.5%; the age-adjusted the mortality rate in children was 0% vs. 4.3% in adults. Table 6 describes the clinical differences between survivors and deceased.
The most frequent cause of death was multiple organ failure (MOF) (49.5%); 9.5% of deaths were due to sepsis. Mortality at 30 and 90 days was 2% in the group of adults, while no children died during post-discharge follow-up. At 30 days, 148 patients had been lost to follow-up, and 235 at 90 days. The mean age of patients who died was 68.6 years. The mean LOS in our population was 14.6 (± 20.4) days; this was significantly lower in children (11.8 [± 14.8] days). The median LOS/TBSA ratio was 1.9 for adults and 1.5 for children. In the univariate analysis, the Kaplan–Meier survival curve was calculated (Figs. 2, 3, 4, 5, 6, 7, 8, 9 and 10) for each qualitative variable (Table 7).
Kaplan–Meier survival curve for ABSI score.
Kaplan–Meier survival curve for Age.
Kaplan–Meier survival curve for ARDS.
Kaplan–Meier survival curve for Cardiovascular comorbidity.
Kaplan–Meier survival curve for Enolism.
Kaplan–Meier survival curve for Gender.
Kaplan–Meier survival curve for Smoke Inhalation.
Kaplan–Meier survival curve for TBSA (%).
Kaplan–Meier survival curve for delay time for admission.
In the clinical adjusted multivariate analysis (Table 8), the factors that increased mortality were ABSI ≥ 7 (HR 15.55 [95% CI 6.62–36.54]; p < 0.001), age over 80 years (HR 23.52 [95% CI 10.10–54.77] p < 0.001), smoke inhalation (HR 3.30 [95% CI 2.15–5.07]; p < 0.001), burned TBSA (1.02 [95% CI 1.02–1.03]; p < 0.001), cardiovascular comorbidity (HR 2.12 [95% CI 1.34–3.34]; p < 0.001), and full-thickness burn (1.69 [95% CI 1.06–2.68]; p = 0.027). Table 9 shows the multivariate analysis of factors associated with mortality (unadjusted). The observed mortality correlated with the ABSI-predicted mortality, with no statistically significant differences (Table 10).
Economic factors
In our study, mean annual expenditure was €5,030,043.85, with a mean cost per patient of €15,179.31.
Discussion
This is the first study to describe the epidemiological profile of children and adults presenting with burns in Catalonia. It is also the first to describe the overall in-hospital complications presented by patients admitted for burns, since these complications are usually analysed in a subgroup, such as major burn patients.
Demographics
Burns were more frequent among men (61.6%)—a global trend due to the predominance of men working in metallurgy or agriculture. In our review, this incidence was somewhat lower than that reported in 1998 (64%), 2008 (65%), and 2018 (66%)21,25,26, and is consistent with the trend observed in other developed countries6,7,8,15,27,28,29,30. In Palacios31, however, 51% of burn patients were men.
The mean age in our study was 41.4 years (49.7 years in adults). This is similar to Palacios 31 and higher than the earlier study published by Barrett21, and reflects a global trend due to worldwide population ageing.
The proportion of burns in children (18.1%) is lower than in other developed countries7,28,32,33 and far lower than that reported in developing countries11,34. One of the reasons for this low incidence is the consistently low birth rate in Spain over the past few decades and compulsory school education. Interestingly, the age range with the highest incidence of burns is usually 0–4 years, in some cases accounting for up to 50% of all admissions32,35,36,37,38. In our study, the incidence in this age group was 68%. This percentage, though similar to that reported in other studies, is still very high, and suggests that the authorities should promote health education and implement preventive measures in this age group (including their parents). A relatively simply measure would be to introduce legislation to lower the maximum permitted temperature of household water, an approach that has proven effective in other countries39,40.
Characteristic of burns
Scalding was the most frequent mechanism of injury (37.7%) in our review, whereas flame was the most prevalent cause of burns in the 1990s. After adjusting for age and sex, flame was the most prevalent mechanism in adult men, and scalding was the most prevalent mechanism in adult women and in children. These results are in line with studies published in other countries, such as Portugal41, Israel29, China42,43,44, Switzerland9, and Holland7. In Europe, flame was the most prevalent mechanism of injury, although scalding was more prevalent in children27.
The mean burned TBSA was 8.3%, significantly lower than previous studies, such as 16% in Barrett21 and 18% in Sánchez25. This reduction in burned TBSA may be due to a lower incidence of flame burns, which are usually severe, extensive, and accompanied by smoke inhalation45.
The proportion of patients with burns covering less than 10% of total body surface has increased from 60% in 1995 to 75% today. This is a global trend that has also been reported in other studies7,16,43,46,47, and could be due to the decline of flame as the main cause of burns in our setting. For the same reason, the number of patients with 20% of TBSA affected has decreased to 9.7%. According to figures from the ABA (American Burn Association), 22.5% of burn patients in 2013 presented major burns48. In children, 77% of patients presented burns affecting less than 10% TBSA, in line with other studies28,35,36,41,49.
Comorbidities
Our study provides an overview of comorbidities in burn patients and their effect on mortality. Smoking is the most prevalent comorbidity (25.8%), while the rate of cardiovascular disease (24%) is similar to Barret et al. 21, and significantly higher than that reported by other authors, such as 8% in Knowlin50. The percentage of in-hospital cardiovascular complications was also higher in our series compared with Knowlin (5.9% vs. 3%), while cardiovascular comorbidity increased mortality at a rate similar to that observe by Knowlin50 (HR 2.12 [95% CI 1.34–3.34], p = 0.001).
Alcohol abuse was reported in 6.9% of patients in our study, a high rate compared to the average of 4.2% in the Spanish population in 201951. These figures are consistent with those reported by Eiroa-Orosa, who showed that a higher proportion of burn patients had a history of substance abuse compared with the general population52.
In Spain, according to the ENPE study, 22% of the population is obese, and obesity is more prevalent in men aged over 65 years from low-income groups53 . In Catalonia, the percentage of obesity (16%) is lower than the Spanish average. In our series, 34.5% of adult patients were obese, a proportion that contrasts with most reports in the literature; however, according to the Center for Disease Control, 42.4% of the US population was obese in 201754, while Jeschke reported a prevalence of 29%55. In our population, obesity was not associated with increased mortality.
Treatment
Surgery was required in 64% of our patients, a percentage that is higher than other studies, such as Dokter7. The significant difference in the rate of surgery observed between adults and children is consistent with other studies, in which burns in children are usually less severe and respond well to conservative treatment, particularly high protein intake.
Complications
None of the studies identified in our database search summarise the most common complications during hospital admission.
Several authors have described AKI as an independent risk factor for mortality56,57,58,59,60. This complication arose in 8% of patients in our study, whereas an incidence of 30% has been reported in other studies60 with an 80% mortality rate56,61. However, it is important to bear in mind that nearly all these studies were performed in critically ill patients17,62, so the findings cannot be extrapolated to the general population. Burn patients are at increased risk of suffering potentially fatal infection of any cause in the first 5 years after the burn63, and sepsis increases LOS and ICULOS64. In our study, 16.3% of patients were diagnosed with sepsis, somewhat higher than the figures published in Belgium65.
Outcomes
Mortality remained at 3.5% (0% in children under 16 years of age and 4.3% in adults). This rate is somewhat higher than that reported in most developed European countries6,10,15,65,66.
We compared observed vs. predicted mortality based on the ABSI to determine the accuracy of this score in our population67. The ABSI correlated with observed mortality, except in mild injury patients (ABSI < 6) and very severe injury patients (ABSI ≥ 12), in which mortality was lower than predicted.
A factor that has changed substantially over the years is cause of death. In Barrett et al., the main causes were acute respiratory distress syndrome (ARDS) (34%), MOF (26.8%) and sepsis (13.2%). The decrease in ARDS (13.7%) is striking, and may be due to improvements in critical care, a decrease in flame burns, and advances in mechanical ventilation. The incidence of sepsis-related deaths has also declined, and it is now the cause of death in 9.5% of patients, 50% lower than the figure reported by Barret et al.21 and in line with the findings of a Belgian study65. The decrease in mortality due to sepsis is a promising development, and may be due to the implementation of strict care protocols in critically ill patients68, together with improvements in the use of antibiotics and in the management of septic shock.
In our study, the main cause of death was MOF (49.5%). According to the American Burn Association, MOF is the cause in 27.5% of fatalities48,69 . In other studies, this percentage increases to 40%.17,70.
The main predictors of in-hospital mortality identified in this study are age over 80 years, ABSI ≥ 7, smoke inhalation, cardiovascular comorbidity, full-thickness burn, and burned TBSA. These factors have also been described as predictors elsewhere8,27,33,43,46,50,71,72. Interestingly, there is scant evidence elsewhere of the association between cardiovascular comorbidity and increased mortality; however, in our series, this comorbidity increased the probability of dying by 112%. We, like some other authors, did not find gender to be associated with increased mortality8,73,74, although this contrasts with the findings of other studies67.
The number of admissions for burns has decreased dramatically from 6.6/105 population/year to 3.68/105 population/year This is a global trend1,2,15,33,75, despite significantly higher rates of admission reported in some of our European neighbours, such as 18.9/10541 in Portugal, and 36.9/105 in Romania.11 Both LOS and LOS/TBSA in Catalonia are above the average in developed countries2,4,6,11,13,71, possibly due to 2 factors: first, the average waiting time from burn event to surgery is 18 days, far higher than the average 14.7 days in the Netherlands7; second, home care in our region is underdeveloped, a situation that places an additional burden on in-hospital care.
In total, 14% of adults were admitted for burns occurring in the workplace, similar to the percentage reported by Barrett, and midway between the 5.9% reported by Palacios31 and 20.9% by Sánchez25. Other countries that have published statistics relating to burns in the workplace include Germany, with an incidence that ranges from 18%-33.7%12,76, Switzerland with 31%9, the USA with 18%77, China with 78%72, Australia with 17% 74,78, and Austria with 14.9%8.
Economic factors
Care costs are currently one of the main problems in the healthcare sector. The economic downturn followed by the SARS-CoV-2 pandemic has brought public health systems in Spain to the brink of collapse, and it is now more important than ever to optimise resource management. As mentioned above, mean annual expenditure was €5,030,043.85, with a mean cost per patient of €15,179.31; these cost estimates were not TBSA-weighted. In Portugal, meanwhile, the cost per patient is €8,03041, in Holland it is €26,54030 and in Finland, €25,0003.
This study has several limitations.
As our study was performed in a single hospital, our findings cannot be assumed to reflect the situation in other regions; however, this single-centre design ensures that both the study population and the treatment of burns is homogeneous.
Selection bias cannot be ruled out, since patients with non-severe burns are not initially treated at or transferred to the HUVH, so we were unable to include these data in our analysis. Another potential source of selection bias stems from our retrospective design, insofar as some patients were lost because doctors did not always strictly adhere to the 90-day follow-up schedule.
In the study of comorbidities, patients were not assessed using the gold-standard Charlson index, and the presence of psychiatric disorders was not recorded.
Conclusions
This study shows that changes have occurred in the pattern of burn injuries, their extent, and their severity, and burns are now predominantly less extensive and deep in our setting. The pattern of clinical presentation differed been children and adults. In our series, children ages between 0 and 4 years of age account for 68% of all children admitted for burns. This means that they are still most important risk group and should be the target of preventive measures and health education campaigns. The factors associated with a higher risk of mortality were age, %TBSA, full-thickness burns, smoke inhalation, and cardiovascular comorbidity. Unlike other studies, in our series female sex was not a risk factor for mortality. Prospective, multicentre studies are needed to obtain a more accurate picture of the situation of burn patients in Spain.
Data availability
The data collected in this study is available upon reasonable request. Please, contact with Luis Abarca Vilchez; labarcavilchez@gmail.com.
Abbreviations
- TBSA:
-
Total body surface area
- LOS:
-
Length of stay
- AKI:
-
Acute kidney injury
- ABSI:
-
Abbreviated Burn Severity Index
- MOF:
-
Multiple Organ Failure
- HUVH:
-
Hospital Universitario Vall d’ Hebrón
References
James, S. L. et al. Epidemiology of injuries from fire, heat and hot substances: Global, regional and national morbidity and mortality estimates from the Global Burden of Disease 2017 study. Inj. Prev. https://doi.org/10.1136/injuryprev-2019-043299 (2019).
Smolle, C. et al. Recent trends in burn epidemiology worldwide: A systematic review. Burns https://doi.org/10.1016/j.burns.2016.08.013 (2017).
Haikonen, K., Lillsunde, P. M. & Vuola, J. Inpatient costs of fire-related injuries in Finland. Burns https://doi.org/10.1016/j.burns.2014.03.016 (2014).
Kruger, E., Kowal, S., Pinar Bilir, S., Han, E. & Foster, K. Relationship between patient characteristics and number of procedures as well as length of stay for patients surviving severe burn injuries: Analysis of the american burn association national burn repository. J. Burn Care Res. 41, 1037–1044. https://doi.org/10.1093/jbcr/iraa040 (2020).
Guilabert, P. et al. Fluid resuscitation management in patients with burns: Update. Br. J. Anaesth. 117, 284–296. https://doi.org/10.1093/bja/aew266 (2016).
Åkerlund, E., Huss, F. R. M. & Sjöberg, F. Burns in Sweden: An analysis of 24 538 cases during the period 1987–2004. Burns 33, 31–36. https://doi.org/10.1016/j.burns.2006.10.002 (2007).
Dokter, J. et al. Epidemiology and trends in severe burns in the Netherlands. Burns 40, 1406–1414. https://doi.org/10.1016/j.burns.2014.03.003 (2014).
Ederer, I. A. et al. Gender has no influence on mortality after burn injuries: A 20-year single center study with 839 patients. Burns 45, 205–212. https://doi.org/10.1016/j.burns.2018.08.012 (2019).
Müller, M. et al. Aetiology of adult burns treated from 2000 to 2012 in a Swiss University Hospital. Burns 42, 919–925. https://doi.org/10.1016/j.burns.2016.03.005 (2016).
Onarheim, H., Jensen, S. A., Rosenberg, B. E. & Guttormsen, A. B. The epidemiology of patients with burn injuries admitted to Norwegian hospitals in 2007. Burns https://doi.org/10.1016/j.burns.2009.06.191 (2009).
Pieptu, V. et al. Epidemiology of hospitalized burns in Romania: A 10-year study on 92,333 patients. Burns https://doi.org/10.1016/j.burns.2021.05.020 (2021).
Schiefer, J. L. et al. Etiology, incidence and gender-specific patterns of severe burns in a German Burn Center—Insights of 25 years. Burns 42, 687–696. https://doi.org/10.1016/j.burns.2015.10.031 (2016).
Tanttula, K., Haikonen, K. & Vuola, J. Hospitalized burns in Finland: 36 305 cases from 1980–2010. Burns 44, 651–657. https://doi.org/10.1016/j.burns.2017.09.001 (2018).
Theodorou, P. et al. Incidence and treatment of burns: A twenty-year experience from a single center in Germany. Burns 39, 49–54. https://doi.org/10.1016/j.burns.2012.05.003 (2013).
van Yperen, D. T., van Lieshout, E. M. M., Verhofstad, M. H. J. & van der Vlies, C. H. Epidemiology of burn patients admitted in the Netherlands: A nationwide registry study investigating incidence rates and hospital admission from 2014 to 2018. Eur. J. Trauma Emerg. Surg. https://doi.org/10.1007/s00068-021-01777-y (2021).
Zayakova, Y., Vajarov, I., Stanev, A., Nenkova, N. & Hristov, H. Epidemiological analysis of burn patients in East Bulgaria. Burns 40, 683–688. https://doi.org/10.1016/j.burns.2013.08.016 (2014).
Jeschke, M. G. et al. Morbidity and survival probability in burn patients in modern burn care. Crit. Care Med. 43, 808–815. https://doi.org/10.1097/CCM.0000000000000790 (2015).
Knowlin, L., Stanford, L., Moore, D., Cairns, B. & Charles, A. The measured effect magnitude of co-morbidities on burn injury mortality. Burns 42, 1433–1438. https://doi.org/10.1016/j.burns.2016.03.007 (2016).
Low, Z. K. et al. Comparison of clinical outcomes in diabetic and non-diabetic burns patients in a national burns referral centre in southeast Asia: A 3-year retrospective review. Burns 43, 436–444. https://doi.org/10.1016/j.burns.2016.06.004 (2017).
Sayampanathan, A. A. Systematic review and meta-analysis of complications and outcomes of obese patients with burns. Burns 42, 1634–1643. https://doi.org/10.1016/j.burns.2016.05.008 (2016).
Barret, J. P., Gomez, P., Solano, I., Gonzalez-Dorrego, M. & Crisol, F. J. Epidemiology and mortality of adult burns in Catalonia. Burns 25, 325–329 (1999).
Greenhalgh, D. G. et al. American burn association consensus conference to define sepsis and infection in burns. J. Burn Care Res. 28, 776–790. https://doi.org/10.1097/BCR.0b013e3181599bc9 (2007).
Putra, O. N., Saputro, I. D. & Diana, D. Rifle criteria for acute kidney injury in burn patients: prevalence and risk factors. Ann. Burns Fire Disasters 34, 252 (2021).
Cartotto, R. et al. The Acute Respiratory Distress Syndrome (ARDS) in mechanically ventilated burn patients: An analysis of risk factors, clinical features, and outcomes using the Berlin ARDS definition. Burns 42, 1423–1432. https://doi.org/10.1016/j.burns.2016.01.031 (2016).
Sanchez, J. L. A., Bastida, J. L., Martínez, M. M., Moreno, J. M. M. & Chamorro, J. J. Socio-economic cost and health-related quality of life of burn victims in Spain. Burns 34, 975–981. https://doi.org/10.1016/j.burns.2007.12.011 (2008).
Sousa, D. et al. Microbiology in burns patients with blood stream infections: Trends over time and during the course of hospitalization. Infect. Dis. 50, 289–296. https://doi.org/10.1080/23744235.2017.1397738 (2018).
Brusselaers, N., Monstrey, S., Vogelaers, D., Hoste, E. & Blot, S. Severe burn injury in Europe: A systematic review of the incidence, etiology, morbidity, and mortality. Crit. Care https://doi.org/10.1186/cc9300 (2010).
Duke, J. et al. A study of burn hospitalizations for children younger than 5 years of age: 1983–2008. Pediatrics https://doi.org/10.1542/peds.2010-3136 (2011).
Harats, M. et al. Burns in Israel, comparative study: Demographic, etiologic and clinical trends 1997–2003 versus 2004–2010. Burns 42, 500–507. https://doi.org/10.1016/j.burns.2015.05.023 (2016).
Hop, M. J. et al. Economic burden of burn injuries in the Netherlands: A 3 months follow-up study. Injury 47, 203–210. https://doi.org/10.1016/j.injury.2015.09.009 (2016).
Palacios García, P. et al. Trends in burn injuries in Galicia (Spain): An epidemiological study. Int. Wound J. 17, 1717–1724. https://doi.org/10.1111/iwj.13456 (2020).
Duke, J. M., Rea, S., Boyd, J. H., Randall, S. M. & Wood, F. M. Mortality after burn injury in children: A 33-year population-based study. Pediatrics 135, e903–e910. https://doi.org/10.1542/peds.2014-3140 (2015).
Zavlin, D. et al. Multi-institutional analysis of independent predictors for burn mortality in the United States. Burns Trauma https://doi.org/10.1186/s41038-018-0127-y (2018).
Li, H. et al. Epidemiology of pediatric burns in southwest China from 2011 to 2015. Burns 43, 1306–1317. https://doi.org/10.1016/j.burns.2017.03.004 (2017).
Armstrong, M. et al. Epidemiology and trend of US pediatric burn hospitalizations, 2003–2016. Burns 47, 551–559. https://doi.org/10.1016/j.burns.2020.05.021 (2021).
Johnson, E. L. et al. Agents, mechanisms and clinical features of non-scald burns in children: A prospective UK study. Burns 43, 1218–1226. https://doi.org/10.1016/j.burns.2017.01.036 (2017).
Sanyaolu, L., Javed, M. U., Eales, M. & Hemington-Gorse, S. A 10 year epidemiological study of paediatric burns at the Welsh Centre for burns and plastic surgery. Burns 43, 632–637. https://doi.org/10.1016/j.burns.2016.10.004 (2017).
Wang, S. et al. Epidemiology of burns in pediatric patients of Beijing City. BMC Pediatr. https://doi.org/10.1186/s12887-016-0686-7 (2016).
Kendrick, D. et al. Home safety education and provision of safety equipment for injury prevention. Cochrane Database of Syst. Rev. https://doi.org/10.1002/14651858.CD005014.pub3 (2012).
Prokopenko, M., Reed, A. J. M., Chicco, M. & Issa, F. Preventable burns from domestic tap water. Eur. Burn J. 3, 362–369. https://doi.org/10.3390/ebj3020031 (2022).
Santos, J. V. et al. Hospitalisations with burns in children younger than five years in Portugal, 2011–2015. Burns 45, 1223–1230. https://doi.org/10.1016/j.burns.2019.01.003 (2019).
Chen, S. H., Chen, Y. C., Chen, T. J. & Ma, H. Epidemiology of burns in Taiwan: A nationwide report including inpatients and outpatients. Burns 40, 1397–1405. https://doi.org/10.1016/j.burns.2014.01.014 (2014).
Cheng, W. et al. Epidemiology of hospitalized burn patients in China: A systematic review. Burns Open 2, 8–16. https://doi.org/10.1016/j.burnso.2017.10.003 (2018).
Fan, X. et al. Burns in a major burns center in East China from 2005 to 2014: Incidence and outcome. Burns 43, 1586–1595. https://doi.org/10.1016/j.burns.2017.01.033 (2017).
Wasiak, J. et al. The epidemiology of burn injuries in an Australian setting, 2000–2006. Burns 35, 1124–1132. https://doi.org/10.1016/j.burns.2009.04.016 (2009).
Chen, L. et al. Development of a framework for managing severe burns through a 17-year retrospective analysis of burn epidemiology and outcomes. Sci. Rep. https://doi.org/10.1038/s41598-021-88507-x (2021).
Cleland, H., Fernando, D. T. & Gabbe, B. J. Trends in Victorian burn injuries 2008–2017. Burns https://doi.org/10.1016/j.burns.2021.06.007 (2021).
Ogura, A. et al. Associations between clinical characteristics and the development of multiple organ failure after severe burns in adult patients. Burns 45, 1775–1782. https://doi.org/10.1016/j.burns.2019.02.014 (2019).
Brink, C. et al. Infant burns: A single institution retrospective review. Burns 45, 1518–1527. https://doi.org/10.1016/j.burns.2018.11.005 (2019).
Knowlin, L., Reid, T., Williams, F., Cairns, B. & Charles, A. Burn mortality in patients with preexisting cardiovascular disease. Burns 43, 949–955. https://doi.org/10.1016/j.burns.2017.01.026 (2017).
Observatorio Español de las Drogas y las Adicciones. Informe 2021. Alcohol, tabaco y drogas ilegales en España. Madrid: Ministerio de Sanidad. Delegación del Gobierno para el Plan Nacional sobre Drogas. 243 p. (2021).
Eiroa-Orosa, F. J., Giannoni-Pastor, A., Fidel-Kinori, S. G. & Argüello, J. M. Substance use and misuse in burn patients: Testing the classical hypotheses of the interaction between post-traumatic symptomatology and substance use. J. Addict. Dis. 35, 194–204. https://doi.org/10.1080/10550887.2015.1127717 (2016).
Pérez-Rodrigo, C., Hervás Bárbara, G., Gianzo Citores, M. & Aranceta-Bartrina, J. Prevalence of obesity and associated cardiovascular risk factors in the Spanish population: The ENPE study. Revista Española de Cardiología (English Edition) https://doi.org/10.1016/j.rec.2020.12.020 (2021).
Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017-2018 Key findings Data from the National Health and Nutrition Examination Survey. 2017.
Mild Obesity Is Protective After Severe Burn Injury n.d.
Clark, A. et al. Acute kidney injury after burn. Burns 43, 898–908. https://doi.org/10.1016/j.burns.2017.01.023 (2017).
Demsey, D., Mordhorst, A., Griesdale, D. E. G. & Papp, A. Improved outcomes of renal injury following burn trauma. Burns 45, 1024–1030. https://doi.org/10.1016/j.burns.2019.04.001 (2019).
Folkestad, T. et al. Acute kidney injury in burn patients admitted to the intensive care unit: A systematic review and meta-analysis. Crit. Care https://doi.org/10.1186/s13054-019-2710-4 (2020).
Witkowski, W. et al. Early and late acute kidney injury in severely burned patients. Med. Sci. Monit. 22, 3755–3763. https://doi.org/10.12659/MSM.895875 (2016).
Wu, G. et al. Risk factors for acute kidney injury in patients with burn injury: A meta-analysis and systematic review. J. Burn Care Res. 38, 271–282. https://doi.org/10.1097/BCR.0000000000000438 (2017).
Kuo, G. et al. Using acute kidney injury severity and scoring systems to predict outcome in patients with burn injury. J. Formos. Med. Assoc. 115, 1046–1052. https://doi.org/10.1016/j.jfma.2016.10.012 (2016).
Tan Chor Lip, H., Tan, J. H., Thomas, M., Imran, F. H. & Azmah Tuan Mat, T. N. Survival analysis and mortality predictors of hospitalized severe burn victims in a Malaysian burns intensive care unit. Burns Trauma https://doi.org/10.1186/s41038-018-0140-1 (2019).
Duke, J. M., Randall, S. M., Wood, F. M., Boyd, J. H. & Fear, M. W. Burns and long-term infectious disease morbidity: A population-based study. Burns 43, 273–281. https://doi.org/10.1016/j.burns.2016.10.020 (2017).
Raz-Pasteur, A., Hussein, K., Finkelstein, R., Ullmann, Y. & Egozi, D. Blood stream infections (BSI) in severe burn patients-early and late BSI: A 9-year study. Burns https://doi.org/10.1016/j.burns.2012.09.015 (2013).
Costescu Strachinaru, D. I. et al. Epidemiology and etiology of blood stream infections in a Belgian burn wound center. Acta Clin. Belg. Int. J. Clin. Lab. Med. https://doi.org/10.1080/17843286.2021.1872309 (2021).
Brandão, C. The role of comorbidities on outcome prediction in acute burn patients place des comorbidités dans les critères pronostiques des patients brûlés. Ann. Burns Fire Disasters 34, 323 (2021).
Forster, N. A. et al. 30 years later—Does the ABSI need revision?. Burns 37, 958–963. https://doi.org/10.1016/j.burns.2011.03.009 (2011).
Palomar, M. et al. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. Crit. Care Med. 41, 2364–2372. https://doi.org/10.1097/CCM.0b013e3182923622 (2013).
Miller, S. F. et al. National burn repository 2005: A ten-year review. J. Burn Care Res. 27, 411–436. https://doi.org/10.1097/01.BCR.0000226260.17523.22 (2006).
Kallinen, O., Maisniemi, K., Böhling, T., Tukiainen, E. & Koljonen, V. Multiple organ failure as a cause of death in patients with severe burns. J. Burn Care Res. 33, 206–211. https://doi.org/10.1097/BCR.0b013e3182331e73 (2012).
Nickel, K. J., Omeis, T. & Papp, A. Demographics and clinical outcomes of adult burn patients admitted to a single provincial burn centre: A 40-year review. Burns 46, 1958–1967. https://doi.org/10.1016/j.burns.2020.06.020 (2020).
Wang, T. et al. Epidemiological characteristics and factors affecting length of hospital stay for children and adults with burns in Zunyi, China: A retrospective study. PeerJ https://doi.org/10.7717/peerj.5740 (2018).
Blom, L., Klingberg, A., Laflamme, L., Wallis, L. & Hasselberg, M. Gender differences in burns: A study from emergency centres in the Western Cape, South Africa. Burns 42, 1600–1608. https://doi.org/10.1016/j.burns.2016.05.003 (2016).
Toppi, J., Cleland, H. & Gabbe, B. Severe burns in Australian and New Zealand adults: Epidemiology and burn centre care. Burns 45, 1456–1461. https://doi.org/10.1016/j.burns.2019.04.006 (2019).
Mehta, K. et al. Gender-based disparities in burn injuries, care and outcomes: A World Health Organization (WHO) Global Burn Registry cohort study. Am. J. Surg. https://doi.org/10.1016/j.amjsurg.2021.07.041 (2021).
Obed, D. et al. Epidemiology and outcome analysis of 1359 intensive care burn patients: A 13-year retrospective study in a major burn center in Germany. Burns https://doi.org/10.1016/j.burns.2022.08.022 (2022).
Nurczyk, K. et al. Work-Related burn injuries in a tertiary care burn center, 2013 to 2018. J. Burn Care Res. 41, 1009–1014. https://doi.org/10.1093/jbcr/iraa105 (2020).
McInnes, J. A. et al. Epidemiology of work-related burn injuries presenting to burn centres in Australia and New Zealand. Burns 45, 484–493. https://doi.org/10.1016/j.burns.2018.09.011 (2019).
Acknowledgements
To María Guisasola, Berta Sola and Laura Butler, for their help in data collection. To the Burn Unit for their daily work with burn patients.
Author information
Authors and Affiliations
Contributions
Study design: L.A., M.J.C. Study conduct: L.A., M.J.C. Data analysis: L.A., P.G.,M.J.C Final approval of the contents: J.P.B. Wrote the manuscript and approved the final manuscript: L.A., P.G., G.U., N.M., M.J.C. Reviewed the final version: L.A., M.J.C.
Corresponding author
Ethics declarations
Competing interests
PG honorary for lectures from Baxter Spain. MJC fees for lectures from Baxter Spain.
Additional information
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Abarca, L., Guilabert, P., Martin, N. et al. Epidemiology and mortality in patients hospitalized for burns in Catalonia, Spain. Sci Rep 13, 14364 (2023). https://doi.org/10.1038/s41598-023-40198-2
Received:
Accepted:
Published:
DOI: https://doi.org/10.1038/s41598-023-40198-2
- Springer Nature Limited