19 Epidemiology of Acute Burn Admissions at a Referral Center in Nepal: A Comparison Between Direct Admissions and External Referrals

Abstract

Abstract Introduction Nepal is a low-income country where burn injury is a leading cause of preventable deaths and disabilities. A major burn center was established in 2013 to care for patients with acute injuries and reconstruction needs from local and from distant communities. We aimed to characterize the epidemiology of admissions and patterns of referral to guide health system planning and efforts. Methods We described prospectively collected data from patients with acute burns from January 2016 to July 2019. Sociodemographic and injury data included age, sex, hospital of provenance or direct admission status, total burn surface area (TBSA), and presence of complications on admission (e.g., wound infection, sepsis). Outcomes included length of stay and mortality. Differences in proportions and medians were compared with Chi square and Wilcoxon Rank Sum tests, respectively. Results There were 1,813 patients admitted with acute burns over the study period. Median patient age was 26 years (IQR 12–45). More than half of patients were female (55%). Median TBSA was 15% (IQR 7–30%) with a median Baux score of 48 (IQR 27–75). Most patients were transferred from another facility (65% of admissions). Referrals came from over 300 facilities across the country. Referred patients had larger TBSA (median 16%, IQR 9–30%) compared to directly admitted patients (median 12%, IQR 5–30% (p=0.0001). Although median day post-burn day of presentation was 1 day for both groups, referrals had significant admission delays (IQR 0–7) compared to direct admissions (IQR 0–4, p=0.0001). An infection was present on admission in 5% of referrals compared to 2.4% of direct admissions (p=0.01). Median length of stay (among survivors) was longer for referrals (10 days, IQR 5–17) compared to 6 days (IQR 2–12) for direct admissions [p=0.001]). Mortality rate was relatively unchanged across the study period (23% in 2016, 21% in 2019, p=0.82). For patients with burn TBSA >40%, inpatient mortality decreased from 76% in 2016 to 51% in 2019 (p=0.05), however there were few instances of hospital discharges with a palliative intent. There was no difference in mortality rate for referrals compared to direct admissions (21 vs 22%, p=0.63]. Conclusions Despite significant delays in presentation and higher rates of infection on admission, mortality for referral patients was similar to directly admitted patients. Additionally, improvements in care quality have led to significant decreases in the mortality rate for large burns. These data suggest that regionalization of care in Nepal may successfully rescue and manage severe burns in a specialized center. Applicability of Research to Practice These data support regionalization of care for patients with burn injuries in Nepal. Further work to understand the epidemiology and care of patients who do not get referred is required to address system gaps.