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. 2019 Sep 30;32(3):216–221.

Factors affecting length of stay among pediatric and adult patients admitted to the Lebanese Burn Centre: a retrospective study

J Bourgi 1,∗, E Yaacoob 1, M Berberi 1, M Chedid 1, P Sfeir 1, C Yaacoub 1, G Ghanime 1
PMCID: PMC7155401  PMID: 32313536

Summary

Burn injuries are serious lesions requiring specialized medical care, and are associated with prolonged length of hospital stay (LOS). This study aims to elucidate the epidemiological and clinical factors affecting the LOS of pediatric and adult patients with burn wounds. A single-centre retrospective study was conducted at the Hopital Libanais Geitawi Burn Centre in Lebanon. Medical records of patients admitted to the centre between January 2014 and December 2018 were retrieved. Epidemiological and clinical data, such as age, gender, LOS, co-morbidities, and clinical burn and operative characteristics were collected and subjected to statistical analysis. A total of 321 adult and 154 pediatric patients met the inclusion criteria. Mean LOS in the total population was 23.58 days. Univariate analysis revealed inconsistent correlations between the studied factors and the LOS of pediatric and adult patients. Factors positively affecting both populations were: undergoing an operation, number of operations, burn degree, infection, blood transfusion, and need for burn excision and grafting. Additionally, among pediatric patients LOS significantly increased with age, total body surface area (TBSA) burn wound, cause of burn, sepsis, wound dressing under anaesthesia, and escharotomy. On the other hand, female gender and fever were significant additional positive influencers of adult LOS. Multivariate analysis showed that both pediatric and adult LOS was significantly associated to number of operations, need for burn excision and skin grafting, and receiving a blood transfusion. Adult LOS was further affected by mechanical ventilation, infection and age. Our study demonstrated the differential influence of epidemiological and clinical factors among adult and pediatric populations, which allows better prediction of LOS and management of patients with burn injuries.

Keywords: burn, length of hospital stay, pediatric, adult

Introduction

Burn injuries constitute a major global health problem and are a leading cause of morbidity and mortality among their victims. The World Health Organization (WHO) estimates that annually 180 thousand deaths are burn-related, the majority of which occur in low-to-middle income countries.1 The damage induced by burns to the skin and organs and the subsequent disability carry a significant physical, emotional and economic burden. Burn victims require multidisciplinary medical care for the immediate treatment of their wounds as well as the rehabilitation and reconstruction of damaged tissue. As such, repeated hospital admissions ensue, along with significant costs, especially in developing countries.2

Both severe and minor burns contribute to long-term patient mortality, albeit at different rates where age groups are considered. Older burn patients exhibited approximately 1.4 times higher all-cause mortality when compared to a non-injured cohort,3 while higher mortality risk was reported in pediatric burn victims.4 This variation persisted when considering Length of Stay (LOS), which is often investigated as a predictor of patient health outcomes as well as treatment-associated financial cost.

Clear variations in LOS can be detected between different countries, regions or hospitals within the same country.5 Moreover, established predictors of the duration of hospitalization, such as inhalation injury, burn degree and TBSA, were reflected with variable degrees in studies conducted among adult and pediatric burn patients.6 The elucidation of factors affecting patient outcomes across different age groups therefore emerges as critical for the formulation of efficient prevention and treatment strategies.

In order to address the paucity of data reflecting burn injuries in Lebanon, the factors affecting LOS in this patient cohort were determined through a retrospective analysis of burn cases admitted to the HLG Burn Centre. The epidemiological and clinical characteristics of burn patients and their variation across two age groups, namely children and adults, were also taken, and could provide valuable insights for clinicians and policy makers alike, while updating available local burn data.

Materials and methods

The medical records of all patients admitted to the Burn Centre at HLG between January 2014 and December 2018 were reviewed retrospectively. A database was generated through an electronic data collection sheet, and included demographical and clinical burn variables. HLG’s Burn Centre is the first and only specialized burn centre in Lebanon equipped to handle all burn injuries, hence the absence of an age restriction and the inclusion of pediatric as well as adult patients in the study. All patients admitted to the burn centre were included in the study with the exception of patients with no recorded hospital LOS. Measured variables consisted of gender, age and co-morbidities. Percentage TBSA of burn, grade of burn, depth of burn, cause of burn, presence of infection and/or sepsis, smoke inhalation injury, number of visits to the operating theatre, blood transfusion and need for burn excision and skin grafting represented the collected clinical burn and operative characteristics.

Data analysis was completed using SPSS version 22. Descriptive statistics served to reflect the frequency, mean and standard deviation (SD) of all variables. LOS was statistically compared to study variables using Pearson Correlation Test and ANOVA where applicable. Factors associated with hospital length of stay were then subjected to multivariate analysis through a linear regression model. Two-sided p-values were calculated in all tests, with statistical significance set at p < 0.05.

Results

Patient characteristics

Between 2014 and 2018, 475 patients with recorded LOS were admitted to the burn centre at the HLG. Overall, approximately 70% of patients were male and mean age was 30.34 years. Smoke inhalation injury accounted for 13.3% of total burn cases: 70.32% of total cases had more than 20% TBSA burned (Table I). The majority of patients presented with 3rd degree burns, with flames most frequently reported as the cause of injury. More than half of the patients developed fever, contracted an infection and underwent a surgical intervention.

Seeing as both adults and children were included in the study, further analysis was undertaken in order to detect the potential difference in baseline and clinical characteristics. It was consequently found that adult burn patients were more likely to be female, present with co-morbidities, have foley or central line insertion, have a smoke inhalation or flame-related burn, as well as be intubated and receive an escharotomy. On the other hand, pediatric patients presented more often with burns less than 20% TBSA and scald-related burns, and were also more likely to develop a fever (Table I).

Table I. Characteristics of adult and pediatric patients admitted to the burn centre.

Table I

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Predictors of LOS

Bivariate analysis. Mean LOS was comparable between patient populations and was approximately 23 days across both groups (Table I). Bivariate analysis of the factors associated with hospital LOS was equally divided into two subgroups, namely adult and pediatric patients.

Demographic and burn characteristics. Firstly, the LOS of children was found to be significantly associated with increasing age and %TBSA burned. Moreover, children with superficial second-degree burns, flame or chemical-related injury, infection and sepsis had the longest LOS. On the other hand, gender was a significant predictor of LOS in adult patients, with women exhibiting longer LOS than men. Interestingly, adult patients included in this study presenting with smoke inhalation injury had significantly lower length of stay than patients who did not. Third- and fourth-degree burns were associated with the highest LOS among adults (approximately 30 days), while contracting fever or an infection significantly predicted increased LOS among adult patients (Table II).

Operations. Both pediatric and adult LOS was positively and significantly associated with having undergone an operation, as well as the number of operations. Need for burn excision and skin grafting significantly predicted increased LOS, which reached approximately 45 and 50 days in pediatric and adult patients, respectively. Receiving blood transfusions was similarly correlated with prolonged LOS in both populations, while mechanical ventilation reached statistical significance in adult patients only. Children’s LOS was further positively associated with escharotomy and wound dressing under anaesthesia (Table II).

Table II. Bivariate predictors of LOS in pediatric and adult patients admitted to the burn centre.

Table II

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Multiple regression model Linear regression model showed that three variables persisted as signifi cant positive predictors of LOS among children and adults, namely number of operations, need for either blood transfusion or burn excision, and skin grafting (Tables III and IV). Adult LOS was additionally associated with mechanical ventilation, infection and age.

Table III. Multivariate regression analysis of factors associated with LOS among pediatric patients admitted to the burn centre.

Table III

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Table IV. Multivariate regression analysis of factors associated with LOS among adult patients admitted to the burn centre.

Table IV

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Discussion

This study provides relevant insights as well as an update into the epidemiology of burn injuries in Lebanon, in addition to the risk factors of prolonged LOS. The comparability of our data to international registries could be subsequently determined, in addition to the elucidation of clinical and demographic trends among Lebanese burn patients.

Overall, mean LOS was consistent across both age groups in our patient population at approximately 23 and a half days, which marks a notable decrease compared to previous data published by the HLG burn centre, which reported an average LOS of 36.5 days between 1992 to 2012.7 The mean LOS determined in our study was similar to others in extant literature8,9 albeit also in direct contrast with local evidence from a tertiary hospital setting,10 as well as the ABA’s 2019 National Burn Repository report,11 both of which demonstrated an average LOS of less than 10 days. While similarities with US data do not include gender and TBSA-dependent distribution of burn injuries, the two most common burn etiologies in our study, namely flame and scalds, were consistent with the ABA analysis across both age groups.11 The majority of burn cases handled in our centre affected >20% TBSA compared to less than 10% TBSA in US hospitals11 and less than 5% TBSA in a Lebanese tertiary hospital.10 This could be attributed to the specialized, comprehensive and multidisciplinary care provided in the HLG burn centre, which includes treatment, rehabilitation and plastic surgery, thus attracting severely burned patients. Considering the non-negligible number of pediatric patients admitted to the burn centre (154 patients), further data analysis was undertaken to examine potential differences both in burn patient characteristics as well as LOS risk factors according to age group. This could help improve national burn prevention and treatment strategies, which should be adapted to specific patient populations to account for different behaviour patterns and consequently, risk variations. For example, children, most frequently those below 6 years of age, are widely reported to be at higher risk of burn injuries than adults.10,12,13 A study examining more than 6000 burn patients in Southwest China demonstrated that preschool children (less than 6 years of age) had the highest risk of burn, accounting for 34.7% of all burn cases.12 The high prevalence of burns among children could be attributed to their inquisitive and explorative nature, in conjunction with their lack of danger awareness. More importantly, pediatric burn victims had increased (1.6 times higher) rates of long-term all-cause mortality when compared to their non-burned counterparts.4

Initial analysis actually revealed clear distinctions and infrequent consistency of significant associations across the studied age groups. However, no discernible pattern could be extricated, with gender emerging as significantly associated with adult but not pediatric LOS in our study, for example, as opposed to that of Wang et al., where it did not reach statistical significance in either age group.6 The elucidation of the predictors of Lebanese burn patient LOS and its variation between children and adults could thus guide clinical practice and improve patient outcomes.

The number of operations, need for blood transfusion or for burn excision and grafting were significant predictors of LOS in both children and adults in our study, as demonstrated by multivariate regression analysis. Burn patients receiving surgical interventions were previously reported to have significantly increased LOS when compared to those treated medically.8

Longer than expected hospital stays could be further expounded by the number of procedures to which adult patients are subjected.14 A positive association was thus naturally evidenced between these two variables in our study as well as extant literature, which also report a significant increase in LOS concomitantly with that of the number of operations in pediatric patients.15

Blood transfusions were reported to significantly prolong hospital stay by approximately 60% in adult patients undergoing surgical interventions,16 with a similar positive correlation noted in children.17 This relationship was reflected in our study in both age groups, consistently with the report of increased LOS, mortality and infection rates in burn patients who had received transfusions compared to those who had not.18 On the other hand, when examining the number of blood transfusions received by burn patients, researchers could not establish a significant correlation with mortality or LOS.19 Moreover, evidence suggests that clinicians could consider ICU stay but not overall LOS when formulating red blood cell transfusion strategies in surviving, severely burned patients.20

Our study demonstrated an increase in the LOS of pediatric and adult burn patients receiving burn excision and skin grafting. These procedures are often required for more severe burns and could entail complications such as loss of skin graft, which lead to longer-than-expected LOS among burn patients.14 Con Strary to our findings, LOS was actually found to be reduced among burn patients who had received a skin graft,6 possibly due to the protective effect of covering a burn wound through the grafting process, thereby boosting healing and allowing early patient discharge. Moreover, early excision of burns significantly reduced mortality and LOS through the reduction of bacteremia, sepsis as well as the hastening of wound coverage and hospital discharge.21

Mechanical ventilation and infection are examples of complications that could arise in the treatment of burn patients, and lead to prolonged duration of hospitalization.22 Burn patients exceeding expected LOS in the hospital were more likely to have received ventilation and developed an infection,14 especially with a resistant micro-organism.23 Infections of various etiologies and locations remain the most common complication reported in burn patients,11 with a notable effect on mortality and morbidity.24 As such, mechanical ventilation and infection were significant risk factors of prolonged length of stay in our study, but only among adult patients. Pediatric patients presenting with scalds were previously shown to have longer LOS as well as an increased mortality risk when requiring mechanical ventilation,25 which was not reflected in our study. While unexpected, the absence of a significant correlation was not unprecedented, with increased burn hospital stay in a tertiary care hospital reportedly independent of wound infection.26

Age was a significant positive predictor of LOS in adult but not pediatric patients in our study. Previous international and national studies have reported increased length of stay with increased age, both among adults and children alike.8,9,15,26,27

This could be explained by the higher degree and severity of burns exhibited by older children, in addition to the increase in recovery time expected concomitantly with that of age. Moreover, older burn patients were associated with a higher degree of in-hospital mortality and were less likely to be discharged, as opposed to young patients.28 That being said, demonstrated influencers of burn patient LOS did not invariably include age,14,22 as was the case in the pediatric subgroup analysis in our study.

Interestingly and contrary to previous research, inhalation injury, as well as burn characteristics such as TBSA, burn degree and burn etiology, did not reach statistical significance in our study’s multivariate analysis across both patient populations. Prolonged length of stay was widely established in more severely burned patients (higher %TBSA or degree),15,27-29 with those presenting with 2nd degree burns 1.8 times more likely to be discharged from the hospital compared to patients with 3rd degree burns.27 Larger and deeper burns require increased surgical and medical interventions, such as dressing changes and reconstructive surgery, which ultimately are expected to prolong the duration of hospitalization. Inhalation injuries for their part have traditionally been considered among the main factors influencing burn patient outcomes. Despite their relative infrequency among burn patients, inhalation injuries significantly increase both mortality11,22,29 and length of stay.15,22,26,29 An unusual finding of the present study thus consists of the insignificance of inhalational injury as a predictor of LOS in the multivariate analysis, despite its univariate correlation with LOS among adults.

Conclusion

Our study provided valuable insights into the epidemiological and clinical factors affecting hospital LOS among adult and pediatric burn patients admitted to a specialized burn centre in Lebanon. Number of operations, blood transfusions and need for burn excision and skin grafting were identified as significant predictors of prolonged LOS in both patient cohorts, while adult LOS was additionally positively associated with age, mechanical ventilation and infection. More importantly, this study allowed the evaluation of burn outcomes and characteristics between a given country (Lebanon) and international data from other populations, in addition to previous local data from the same and other burn care facilities. As a result, the efficacy of current treatment and prevention strategies could be elucidated both on a national and hospital level, and improvements in burn patient care could be formulated.

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