Study of factors associated with outcome of burn patients attending tertiary care hospital

Vinay Sridhar Tapare¹, Nandkumar Manikrao Salunke^2*

¹Associate Professor, ²Assistant Professor, Department of Community Medicine, B. J. Government Medical College, Pune-411001, Maharashtra, INDIA.

Email: vinay_tapare@yahoo.co.in, drnandusalunke1285@gmail.com

Abstract               Background: Burn injuries rank among the most severe types of injuries suffered by the human body. Goldman describes burns as “the silent epidemic” because since long years, fatal burns have continued to be a major public health problem in all over world. Burn injuries represent one of the most important public health problems faced by both developing and developed nations today. Aim: The aim of present hospital based descriptive study is to discover attributes associated with the outcome of burn cases admitted in tertiary care hospital which may lead to a better understanding of the cause and prevention of these conditions. Objectives: To assess the outcome of burn cases. To identify the factors associated with burn outcome. To provide necessary information to develop prevention program to reduce the problems of burn. Material and Methods: This observational cross sectional study was conducted for period of one year started from Jan 2013 to Dec 2013 in burn ward of Govt. Medical College, attached to tertiary care Hospital. Result: Mortality was highest (75%) in middle age group (46 to 60 years). Females had significantly higher mortality than males. Married patients report higher mortality (62.1%).Mortality in patients of three generation family (68.2%) was higher. Patients belonging to rural area had high (62.3%) mortality. Mortality was higher in middle level class patients (63.5%).Patients wearing polyester cloths had significantly higher (P<0.01) mortality. Mortality in patients during summer (64.8%) was higher. Burn injury occurring at home had significantly higher mortality (64.6%).Burns occurring during day time i.e. during 12 pm to 6 pm had highest mortality (67.6%). Flame burn had highest mortality (69.7%). Similarly suicidal burn had highest mortality (90.9%). Increase in TBSA significantly increased mortality. Conclusions: Mortality in patients reported to tertiary care hospital is high. In the present study overall mortality was 59.5% (125/217). Mortality was lowest (31.3%) in children under 6 years of age and highest (75%) in middle age group (46 to 60 years). Females had significantly higher (68%) mortality than males (47.8%). Increase in TBSA significantly increased mortality. Mortality was independent of marital status, type of family, residence, education, occupation, socio-economic status, season and time interval of hospitalization.

Key Words: Burn deaths, demographic, socio-cultural, clinico-social, burn mortality.

INTRODUCTION

Burn injuries rank among the most severe types of injuries suffered by the human body. Goldman describes burns as “the silent epidemic” because since long years, fatal burns have continued to be a major public health problem in all over world.¹ Burn injuries represent one of the most important public health problems faced by both developing and developed nations today. Burn injuries are major problem in the low-income and middle-income countries. Developing countries have a high incidence of burn injuries, creating a formidable public health problem. High population density, illiteracy, and poverty are the main demographic factors associated with a high risk of burn injury. Social, economic, and cultural factors interact to complicate the management, reporting, and prevention of burns. In India, approximately, there are 6 million burn cases occur annually, of which around 0.7 million cases require hospitalization, of which approximately 0.12 million die annually. Survival rate for burn patients in developing countries like India is around 50% for burn less than 40% while those in developed countries it is around 75-90% for 50% burn. Females suffer burns more frequently than males. Women in South-East Asia Region have the highest rate of burns, accounting for 27% of global burn deaths and nearly 70% of burn deaths in the region. The high risk for female is associated with open fire cooking or inherently unsafe cooking stove which can ignite loose clothing.² Open flames used for heating, lightening or for warming water for bath also pose risk of burn. Self directed or interpersonal violence are also important risk factors in studying the burn cases. Despite many medical advances, burns continue to remain a challenging problem due to the lack of infrastructure, inadequate number of trained professionals as well as the increased cost of treatment, all of which have a significant impact on the outcome. The best treatment is burn prevention. It is said that burns is a preventable injury and more than 80% burns injuries can be prevented.

MATERIALAND METHODS

Sample size: For the present study, level of significance was set at 5% with 95% confidence interval. The sample size (N) is calculated by the formula,

N=Z²_(1-α/2) (1-P)/∑²P

Where Z represent the measure of standard error of population proportion. Thus, for the present study the minimum sample worked out was 216. Considering the correction for lost to follow up patients (10%), it was proposed to study 240 burn patients.

Selection of sample: Systematic sampling technique was employed for selection of study sample. As the study period was extended for 12 consecutive months, every month total 20 patients were selected. Every 2^nd patient of burn eligible for admission was selected till total 20 patients selected per month. Patients with only minor superficial burn, treated as out-patients were not included. Altogether 240 burn patients admitted during the study duration were selected for the study. Of these, 3 patients did not give consent for the study and hence were not included. Also 20 patients lost to follow up due to DAMA (discharge against medical advice) were not included in the study. Thus, the total effective sample size was 217.

Data Collection: Data was collected over the period of one year started from Jan 2013 to Dec 2013 using pretested questionnaire which includes information like demographic, socio-cultural, clinico-social characteristic of patients. Data was then analysed using SPSS version 17 software.

RESULTS

Table 1: Demographic characteristics of burn deaths

Figure 1: Describes demographic characteristics of burn deaths

Mortality was lowest (31.3%) in children under 6 years of age and highest (75%) in middle age group (46 to 60 years). Though mortality was more in young children of 6-15 years (43.8%)) and old age above 60 years (57.1%) as compared to children below 6 years, it was not statistically significant (P>0.05). But mortality was significantly higher (OR=3.69, 95% CI =1.22- 11.12) in adults (16-45 years) and middle age of 45-60 years (OR= 6.6, 95% CI=1.23- 35.44). Overall, no significant difference (P>0.05) was observed between deaths among different age groups.

Table 2: Socio-cultural characteristics of burn deaths

Table 2 describes Socio-cultural characteristics of burn deaths. Although mortality in patients having different level of education vary widely from 33.3% in graduates to 68.2% in higher secondary education, overall, mortality was not significantly different in different level of education (P>0.05) Similarly mortality in patients having different type of occupation varies widely from 47.8% in business class to 71% in housewives. Overall, mortality was not significantly different in different types of occupation (P>0.05) Though mortality was higher in middle level class patients (63.5%) as compared to lower class patients (57.3%), it was not statistically significant (OR=1.29, 95% CI=0.72- 2.3). Patients wearing polyester cloths had significantly higher (P<0.01) mortality as compared to patients wearing cotton cloths. Mortality in patients reported during summer (64.8%) was higher as compared to rainy (51.4%) and winter (61.6%) season, the difference was not statistically significant (P>0.05). Burn injury occurring at home had significantly higher mortality (64.6%) and were more likely to succumb to burn injury (OR=3.35, 95% CI=1.54-7.26).

Table 3: Clinico-social characteristics of burn deaths

Table 3 describes clinico-social characteristics of burn deaths. Burns occurring during day time i.e. during 12 pm to 6 pm had highest mortality (67.6%) and most often resulted in patient death (OR=3.39, 95% CI=1.28-8.95) followed by 57.7% in cases occurring during 6 am to 12 pm. Mortality of burn injury occurring during night time was low, 38.1% in cases occurring during 6 pm to 12 Midnight and 38.5% in cases occurring during 12 Midnight to 6 am. Mortality significantly differs (P<0.05) according to occurrence time of burn injury. Mortality vary widely according to time interval of reporting to hospital after burn injury. Mortality was lowest (58.1%) in patients reporting to hospital within 4 hours of burn, while it was highest (77.8%) in patients reporting to hospital after 6 hours. Overall, mortality was not significantly different in patients reporting at different time interval after burn injury (P>0.05). Flame burn had highest mortality (69.7%) and was most likely to result in death (OR=23.79, 95% CI=6.97-81.24). Similarly suicidal burn had highest mortality (90.9%) and was most likely to result in death (OR=8.75, 95% CI=2.58-29.71). Increase in TBSA significantly increased mortality; thus, lowest mortality of 3.4% was observed in patients with 1-20% TBSA while highest mortality (100%) was observed in patients with >80% TBSA.

DISCUSSION

Outcome of burn patients may be either survival or death. If patient survived, he may have some kind of deformity depending upon the severity of burn injury. Multiple factors decide the outcome of patient. Comparing and interpreting burn mortality data’s are very difficult, because, study population, management protocol and statistical analysis differ widely among different studies. In the present study overall mortality was 59.5% (125/217). Of the remaining 40.5% survived patients, 6% had some kind of deformity. High mortality is consistent with other studies. Haralkar S J et al (2011)³ reported 65.8% case fatality. Zopate P R et al (2011)⁴found overall case fatality of 60%. In his study, mortality was directly proportional to TBSA. It was more with flame burn injury. The mortality rate in male was 31.2% and in females it was 68.8%. In contrast, mortality was comparatively less in studies reported by Shankar G et al⁵ (reported overall mortality of 41.6%), Shrivastava P S et al (2012)⁶ (reported overall case fatality of 35%), Chakraborty S et al (2013)⁷ reported mortality of 23.5% and Bharadwaj S D et al (2013)⁸ reported only 0.64% overall mortality. In the present study, mortality was lowest (31.3%) in children under 6 years of age and highest (75%) in middle age group (46 to 60 years). Females had significantly higher (68%, P<0.01) mortality than males (47.8%). Increase in TBSA significantly increased mortality; thus, lowest mortality of 3.4% was observed in patients with 1-20% TBSA while highest mortality (100%) was observed in patients with >80% TBSA. Mortality was independent of marital status, type of family, residence, education, occupation, socio-economic status, season and time interval of hospitalization. Out of 217 burn patients admitted, 129(59.4%) patients died within a period extending from 1 day to 42 days. Overall, the mean survival time was 13 days (95% CI=10-16 days). The risk of death is more during the first 10 days of admission especially after the age of 40 years. The mean survival time decreases as the total burn surface area increases. Overall, the mean survival time was significantly associated with nature of burn. Also the mean survival time in different mode of burn cases is significantly different. But the mean survival was independent of age groups, time and place of occurrence, and sex of patient.

CONCLUSIONS

To describe the epidemiological and clinical profile and also to determine the outcome and its contributing factors in burn patients admitted in tertiary care hospital, the present hospital based descriptive type of observational study was undertaken. Following conclusions are drawn based on the observations of the study.

Burn injuries are a serious public health problem with alarmingly high morbidity and mortality. Preventing burn injury will be a major challenge as its occurrences closely linked to living standards and cultural practices. The epidemiological factors of burn injuries vary in different parts of a country. Person at any age is susceptible for burn injury. Present study reported burn cases from age 1 to 85 years. Majority of cases, i.e.166 (76.5%) were in the young adult age group between 16 to 45 years. The mean age of patients suffering from burn injuries was 26.9 (median 25) years, indicating proportion of cases predominantly in young population. Females are more prone to burn injury. We found significantly higher cases in females (57.6%) than males. (42.4%). Married persons are more at risk for burn. Present study revealed 57.1% married cases as compared to 42.9% unmarried cases. People living in joint families are more prone to burn injury. Maximum cases (72.8%) were reported from joint family. The risk of burn injury was more in the literates having lower educational qualification. Housewives are at greater risk for burn. Maximum number of cases i.e. 35% was found in the house-wives. Families of lower socio-economic status sustain more burn injury. In the present study maximum number of cases 143 i.e. 65.9% were from lower socio-economic group. In the present study we could not found any seasonal pattern. In all seasons (summer, winter and rainy) reported burn cases was nearly equal. Occurrence of burn injury was similar in urban and rural area. The domestic burn was common. Present study reports maximum cases (74.2%) at home. Occurrence of burn injury was maximum during day time. In the present study maximum number of cases i.e. 84.3% (183/217) found in day time between 6 am to 6 pm. The response to seek medical care in burns was good. In the present study maximum cases (80.1%) were admitted within 4 hours after burn injury. Flame (80.6%) was most common mode of burn in present study. Accidental burns are more common. In the present study maximum number of cases 180 i.e.82.9% occurred are accidental. Duration of stay in hospital after burn injury was ranging from 1 to 42 days. In majority of cases, i.e. 165 (76%) cases, the range of duration was 1 to 7 days (median 4 days). Total body surface area (TBSA) burn ranged from 1% to 100% (mean 53.6%, median 54%). The mean TBSA observed in female (60.5%) was significantly higher as compared to males (44.2%). Mortality in patients reported to tertiary care hospital is high. In the present study overall mortality was 59.5% (125/217). Mortality was lowest (31.3%) in children under 6 years of age and highest (75%) in middle age group (46 to 60 years). Females had significantly higher (68%) mortality than males (47.8%). Increase in TBSA significantly increased mortality. Mortality was independent of marital status, type of family, residence, education, occupation, socio-economic status, season and time interval of hospitalization. Overall, the mean survival time was 13 days (95% CI=10-16 days). The risk of death was more during the first 10 days of admission especially after the age of 40 years. The mean survival time decreases as the total burn surface area increases. the mean survival time was significantly associated with nature of burn and mode of burn But the mean survival was independent of age groups, time and place of occurrence, and sex of patient.