Geriatric Burn Injuries Presenting to the Emergency Department of a Major Burn Center: Clinical Characteristics and Outcomes

Abstract

Background:

Burn injuries in geriatric patients are common and may have significant associated morbidity and mortality. Most research has focused on the care of hospitalized patients after admission to burn units. Little is known about the clinical characteristics of geriatric burn victims who present to the emergency department (ED) and their ED assessment and management.

Objective:

to describe the clinical characteristics and outcomes of geriatric patients presenting to the ED with burn injuries

Methods:

We performed a comprehensive retrospective chart review on all patients aged ≥60 with a burn injury presenting from January 2011 – Sept 2015 to a large, urban, academic ED in a hospital with a 20-bed burn center.

Results:

A total of 459 patients aged ≥60 were treated for burn injuries during the study period. Median age of burn patients was 71 years, with 23.7% aged ≥80. 56.6% were female. The most common burn types were hot water scalds (43.6%) and flame burns (23.1%). Median burn size was 3% total body surface area (TBSA), with 17.1% having burns >10% TBSA. 7.8% of patients suffered inhalation injury. After initial evaluation, 46.4% of patients were discharged from the ED. Among patients discharged from the ED, only 1.9% were re-admitted for any reason within 30 days. Of the patients intubated in the ED, 7.1% were extubated during the first 2 days of admission, and 64.3% contracted ventilator-associated pneumonia.

Conclusion:

Better understanding of ED care for geriatric burn injuries may identify areas in which to improve emergency care for these vulnerable patients.

INTRODUCTION

Burn injuries in geriatric patients are common (1). Older adults are particularly susceptible to burn injury (2) due to increasing dementing illness (3), sensory impairment, poor mobility, slow reaction times, and medication side effects. Adults aged ≥60 represent more than 14% of patients admitted to U.S. burn centers (4). The population of older adults is projected to double by 2050 (5), and, as a result, the incidence of burn injuries will also rise (5,6).

Burns can have higher morbidity and mortality for older adults compared with younger patients, partially due to co-morbidities, thin and fragile skin, and reduced immunologic response (2,3). According to the Centers for Disease Control and Prevention, these injuries are currently the fourth leading cause of unintentional injury mortality among people aged ≥65 (7). The importance of age in predicting mortality from burn injury has been long recognized, with all published prediction formulas including age as a factor (2, 8–14), beginning with Bull and Fisher’s graphical mortality risk assessment method in 1954 (15) and the Baux score in 1961 (8). Recent research suggests that older adults are twice as likely to die from their burn injuries as younger adults (16), and have increased morbidity (2, 17, 18), including long-term disability and loss of independence (19). After inhalational injury, older adults are particularly susceptible to pneumonia and their morbidity and mortality rises significantly (4). Though outcomes in burn treatments in younger patients have improved dramatically in the last 50 years, these improvements are less dramatic in older adults (2, 20, 21).

Much research to-date has focused exclusively on the treatment of elderly patients with severe burns who are hospitalized in burn centers (2, 4, 6, 22–27). There is limited information available regarding the clinical characteristics of all geriatric burn victims who present to the emergency department (ED), including those with less severe injuries who may be discharged from the ED and followed up in an outpatient setting. Furthermore, the assessment and management of geriatric burn patients in the ED has not been well-studied. Our objective with the present study was to describe the clinical characteristics and outcomes of geriatric patients presenting to the ED with burn injuries.

Materials and Methods

We performed retrospective chart review on all patients aged ≥60 with a burn injury presenting to New York-Presbyterian Hospital from January 2011 – Sept 2015. Weill Cornell Medical Cente is a large, urban, academic ED that treated over 90,000 patients each year, 30% of whom were ≥60 years old during the period under study. The hospital is both an American College of Surgeons-verified Level 1 trauma center and an American College of Surgeons / American Burn Association-verified burn center. The burn center has 20 burn beds and admitted nearly 800 patients annually during a similar period, including accepting more than 330 via transfer from outside institutions. 15% of burn admissions were aged ≥60.

We defined older adults for this research as patients aged ≥60. No consensus exists in the epidemiologic burn literature about the appropriate age cut-off for older adulthood. Previous burn research has used age cut-offs from ≥45 (28) to ≥80 (29), with most using ≥60 (4, 17, 21, 30) or ≥65 (1, 3, 6, 11, 16, 20, 31). We chose ≥60, as this is the cutoff used in the National Burn Repository (4), which is maintained by the American Burn Association and represents the largest resource on epidemiology of thermal injury for patients admitted to burn centers in North America. We utilized the National Burn Repository as an important comparator for our findings. To ensure that patients aged 60–64 did not represent a population with substantially different characteristics or outcomes than older adults, we compared them to patients aged 65–69 and found no significant differences. For our analysis, we also divided patients into sub-categories by age: 60–69, 70–79, and 80+. These are the same categories used in the National Burn Repository.

Cases were identified using International Classification of Diseases 9^th (ICD-9) and 10^th (ICD10) Revisions. Coding switched from ICD-9 to ICD-10 during this period, so both systems were used. Codes 940–949 in ICD-9 and T20-T32 in ICD-10 were used. To ensure that all cases were captured, we also reviewed all records for patients aged ≥60 where a specialty consultation by the Burn service was requested by the ED clinical team. For patients who presented to the ED multiple times for the same burn injury, we only analyzed for their initial visit. We did not include patients who were transferred into the burn center from another hospital without ED evaluation. This study was reviewed and approved by the Weill Cornell Medicine Institutional Review Board.

Data Collection

We used a standardized data abstraction protocol and collected from the medical record: demographics, baseline clinical information, burn injury characteristics, ED assessment and management, burn unit management for admitted patients, and outcomes. The presence of concern for potential inhalation injury was determined based on clinical documentation from the ED or in-patient provider and did not require a threshold CO level or a confirmatory bronchoscopy. This is different from previous studies of burn-related inhalational injury which examined only cases confirmed with additional invasive testing (32). We tracked the occurrence of ventilator-associated pneumonia, an important complication for critically-ill burn patients. We did not track the occurrence of sepsis or other infections. We collected information about burn depth, however we do not report it in this manuscript, partially because accurate assessment of the differences between 2^nd and 3^rd degree burns may be challenging in the ED. We did not examine the use of escharotomy specifically because, in our hospital, that procedure is done in the operating room or on the burn unit. We did not calculate or use in our analysis the revised Baux score (33). Though commonly used in admitted burn patients, it is not easily calculable in the ED and is not typically a factor in determining the suitability of admission versus out-patient management.

Our data abstraction protocol was developed to optimize accuracy and minimize the potential for bias (34). We created a coding manual for abstractors and investigators with a data dictionary and clear criteria about how to handle ambiguously-recorded medical chart data, and we designed and used a standardized data collection instrument. We developed a customized Research Electronic Data Capture (REDCap, Nashville, Tennessee) database to facilitate data collection. Data abstractors were trained extensively and were blinded to the study’s goals while conducting abstraction. A subset of charts was reviewed by the investigators to ensure the abstraction was done accurately.

Evaluation of Burn Size

Burn size was typically recorded by providers as a percentage of Total Body Surface Area (TBSA), with superficial burns (historically described as 1^st degree) excluded. For cases where burn size was not recorded by any providers using TBSA for the patient but only using standard measurements (e.g, centimeters), we used the following estimates: ≤9 cm² = 1%, >9cm² and ≤18cm² = 2%. We developed this approach specifically for this research based on our extensive expertise with burn management.

Data Analysis

We conducted data analysis using Stata v14.0 (Stata Corp, College Station, TX). Results are presented as percentages or medians and means with standard deviations. Comparisons were made using Chi Square tests, Wilcoxon Rank-Sum tests or t-tests, as appropriate. All p values were 2 tailed, with P<0.05 considered statistically significant. No corrections for multiple comparisons were made because all analyses were pre-planned and all comparisons are reported.

Results

From January, 2011 – September, 2015, 459 patients aged ≥60 were treated for burn injuries in the New York Presbyterian Hospital / Weill Cornell Medical Center ED. Patients treated for burn injuries were more commonly female (56.6% vs. 43.4%). The median age of burn patients was 71 years old, and 45.1% were aged 60–69, 31.1% were aged 70–79, and 23.7% were aged ≥80. Characteristics of these patients, their injuries, and their ED treatment categorized by sex and age group are shown in Table 1.

Table 1:

Characteristics of Emergency Department visits for patients aged ≥60 (n=459) with burn injuries, 2011–2015

	Total (%) (n=459)		Male (%) (n=199)	Female (%) (n=260)	p-value		Age 60 – 69 (n=207)	Age 70 – 79 (n=143)	Age 80+ (n=109)	p-value
Age (median, mean ± SD)	71, 72.9 ± 9.3		69, 72.0 ± 9.0	72, 73.6 ± 9.5	0.0643		65, 64.8 ± 2.5	74, 74.1 ± 2.9	86, 86.8 ± 4.6
Female gender	56.6						51.7	62.9	57.8	0.109
Arrived by ambulance (n=431)	47.6		49.2	46.3	0.546		42.3	48.8	55.8	0.081
Diabetes	24.6		23.6	25.4	0.663		25.1	25.9	22.0	0.761
Degenerative Musculoskeletal disorder	8.5		4.5	11.5	0.008		1.9	11.9	16.5	<0.001
Dementing Illness	7.8		6.5	8.8	0.361		2.4	7.0	19.3	<0.001
Type of burn					0.047					0.007
Scald (water)	43.6		41.2	45.4	0.371		42.5	40.6	49.5	0.333
Flame	23.1		23.1	23.1	0.992		19.3	23.8	29.4	0.129
Contact	16.1		15.1	16.9	0.594		13.5	21.0	14.7	0.158
Scald (oil)	8.3		6.5	9.6	0.235		13.5	4.9	2.7	0.001
Chemical	4.8		7.0	3.1	0.049		6.8	4.9	0.9	0.049
Flash	3.0		5.0	1.5	0.052		2.9	3.5	2.7	0.941
Electrical	1.1		2.0	0.4	0.171		1.4	1.4	0	0.613
Contributing causes
Cooking	43.4		33.7	50.8	<0.001		49.8	39.9	35.8	0.035
Eating/drinking	12.8		12.1	13.5	0.657		8.7	16.1	16.5	0.054
House Fire	8.9		11.1	7.3	0.163		6.8	10.5	11.0	0.333
Bathing	7.0		9.0	5.4	0.127		3.9	5.6	14.7	0.001
Occupational	6.5		12.1	2.3	<0.001		8.7	7.7	0.9	0.010
Applying heat therapy	4.6		4.5	4.6	0.962		4.3	4.9	4.6	0.959
Radiator/steam pipe/space heater	4.4		5.5	3.5	0.283		4.3	3.5	5.5	0.766
Smoking	3.3		2.5	3.8	0.598		2.4	4.9	2.7	0.435
Candle/wax	2.6		1.5	3.5	0.246		1.4	2.8	4.6	0.222
Intoxication	1.7		3.5	0.4	0.024		2.9	0.7	0.9	0.336
Electrical	1.3		2.0	0.8	0.410		1.4	2.1	0	0.432
Cosmetics	1.1		1.0	1.1	1.000		1.4	0	1.8	0.260
Other*	5.7		6.5	5.0	0.481		7.2	5.6	2.7	0.281
Total body surface area burned (median, mean ± SD) (n=170)	3, 9.2 ± 16.7		3, 9.9 ± 18.4	3, 8.4 ± 15.1	0.661		2, 6.2 ± 13.9	3, 10.3 ± 16.4	4.7, 13.5 ± 20.6	0.004
≤1%	26.5		25.3	27.6	0.937		34.5	22.5	15.2	0.109
>1%−5%	45.9		45.8	46.0			46.4	47.5	43.5
>5%−10%	10.6		12.0	9.2			7.1	10.0	17.4
>10%	17.1		16.9	17.2			11.9	20.0	23.9
Body region(s) of burn injury
Upper extremities	53.2		53.8	52.7	0.819		57.0	50.3	49.5	0.324
Lower extremities	40.7		43.2	38.8	0.345		34.3	43.4	49.5	0.024
Trunk	27.2		26.6	27.7	0.801		23.7	26.6	34.9	0.102
Head / Neck	21.4		21.1	21.5	0.911		19.3	23.1	22.9	0.630
Burns on ≥2 body regions	28.1		29.6	26.9	0.520		24.6	26.6	36.7	0.068
Concern for potential inhalational injury	7.8		7.0	8.5	0.573		4.3	11.9	9.2	0.030
Given/documented tetanus vaccination	64.9		64.8	65.0	0.969		68.1	64.3	59.6	0.319
Admitted from Emergency Department	53.6		57.8	50.4	0.115		45.9	54.5	67.0	0.002

^*Other: Ironing, Assault, Using cleaning chemicals, Applying cold therapy, Home repairs, Radiation therapy, Steam room/ sauna, Sun, Outdoor fire, Heated clothing, Automobile care

The most common burn types among these patients were hot water scalds (43.6%) and flame burns (23.1%). The most frequent contributing cause was cooking, particularly among female patients and those aged 60–69. Occupational burns occurred more commonly among male patients, as did burns sustained while intoxicated with alcohol. Hot oil (scald burns) were more common in younger age groups. Bathing contributed more frequently to burns among patients aged ≥80.

Median burn size was 3% TBSA, with 17.1% of patients having burns >10% TBSA. Larger burns were more common among patients aged ≥80. Burns were most commonly on the upper extremities, but patients aged ≥80 also very commonly (49.5%) had injuries on the lower extremities.

After initial evaluation, 46.4% of patients were discharged from the ED. Characteristics of these patients and their treatment outcomes are shown in Table 2. The median age of discharged patients was 69 years old and 60.6% were female. No patients with burns >5% TBSA were discharged. Only 7 patients with concern for potential inhalational injury were discharged from the ED. In these patients, while there was initial concern for potential smoke inhalation, with associated coughing or minimal soot around nares or mouth, ED evaluation including carboxyhemoglobin level and clinical observation lowered the concern for significant inhalation injury enough for providers to feel that discharge was safe. Among discharged patients, only 59.1% received a tetanus shot or documentation that it was up-to-date.

Table 2:

Characteristics of Emergency Department visits for patients aged ≥60 (n=213) with burn injuries seen and discharged from the ED, 2011–2015

	Total (%) (n=213)		Male (%) (n=84)	Female (%) (n=129)	p-value		Age 60 – 69 (n=112)	Age 70 – 79 (n=65)	Age 80+ (n=36)	p-value
Age (median, mean ± SD)	69, 71.0 ± 8.2		68, 70.4 ± 8.1	70, 71.4 ± 8.3	0.357		65, 64.7 ± 2.5	73, 73.7 ± 2.9	84, 85.5 ± 4.5
Female gender	60.6						56.2	69.2	58.3	0.224
Arrived by ambulance (n=201)	28.9		27.5	29.8	0.730		26.4	27.1	38.9	0.340
Diabetes	19.2		17.9	20.2	0.678		21.4	18.5	13.9	0.670
Degenerative Musculoskeletal disorder	5.2		1.2	7.7	0.053		1.8	9.2	8.3	0.044
Dementing Illness	2.8		2.4	3.1	1.000		0	1.5	13.9	<0.001
Type of burn					0.002					0.454
Scald (water)	48.8		40.5	54.3	0.049		49.1	44.6	55.6	0.572
Flame	10.3		13.1	8.5	0.284		8.9	10.8	13.9	0.653
Contact	19.2		15.5	21.7	0.260		17.0	24.6	16.7	0.420
Scald (oil)	10.3		8.3	11.6	0.440		14.3	4.6	8.3	0.120
Chemical	7.0		13.1	3.1	0.011		8.0	7.7	2.8	0.670
Flash	3.3		7.1	0.8	0.016		2.7	4.6	2.8	0.870
Electrical	0.9		2.4	0	0.154		0	3.1	0	0.120
Contributing causes
Cooking	45.1		34.5	51.9	0.013		50.9	40.0	36.1	0. 185
Eating/drinking	18.3		16.7	19.4	0.617		11.6	23.1	30.6	0.019
House Fire	2.3		2.4	2.3	1.000		1.8	1.5	5.6	0.384
Bathing	4.7		3.6	5.4	0.743		2.7	4.6	11.1	0.117
Occupational	8.9		19.0	2.3	<0.001		10.7	9.2	2.8	0.372
Applying heat therapy	6.1		5.9	6.2	1.000		4.5	6.1	11.1	0.331
Radiator/steam pipe/space heater	2.3		3.6	1.5	0.385		3.6	1.5	0	0.577
Smoking	1.9		2.4	1.5	0.648		2.7	1.5	0	1.000
Candle/wax	1.4		2.4	0.8	0.563		0.9	1.5	2.8	0. 746
Intoxication	0.5		1.2	0	0.394		0.9	0	0	1.000
Electrical	2.3		3.6	1.5	0.385		1.8	4.6	0	0.462
Cosmetics	0.9		2.4	0	0.154		1.8	0	0	0.678
Other*	6.6		7.1	6.2	0.784		8.9	6.1	0	0.171
Total body surface area burned (median, mean ± SD) (n=48)	1, 1.6 ± 1.2		1, 1.6 ± 1.0	1, 1.6 ± 1.4	0.690		1, 1.5 ± 1.1	1, 1.5 ± 0.7	1, 1.9 ± 1.9	0.952
≤1%	60.4		57.1	63.0	0.683		57.6	66.7	66.7	0.906
>1%−5%	39.6		42.9	37.0			42.4	33.3	33.3
Body region(s) of burn injury
Upper extremities	52.6		51.2	53.5	0.743		54.5	49.2	52.8	0.798
Lower extremities	29.1		30.9	27.9	0.633		30.4	30.8	22.2	0.607
Head / Neck	16.9		19.0	15.5	0.500		17.0	13.8	22.2	0.560
Trunk	15.0		9.5	18.6	0.070		12.5	20.0	13.9	0.374
Burns on ≥2 body regions	12.2		10.7	13.2	0.591		12.5	12.3	11.1	1.000
Concern for potential inhalational injury	3.3		2.4	3.9	0.706		0.9	6.1	5.6	0.078
Given/documented tetanus vaccination	59.1		53.6	62.8	0.181		60.7	60.0	52.8	0.691
Re-admitted to hospital for any reason within 30 days	1.9		2.4	1.5	0.648		2.7	1.5	0	1.000

Among all patients that were discharged from the ED, only 1.9% were re-admitted to our hospital for any reason within 30 days. Each of these 4 cases is described in Table 3.

Table 3:

Characteristics of Patients Who Were Discharged from the ED After Burn and then Re-Admitted

Age	Gender	TBSA Burned	Body Part(s)	# of days post discharge	Re-presentation burn-related?	Details	Length of Stay
67	Female	0.5	Leg	2	Yes	Was offered admission during initial ED visit but refused. Seen in clinic in two days, was having difficulty with proper wound care due to pain and depth of wound, so agreed to admission.	8 days
69	Male	0	Nose (inside)	8	No	Reported dyspnea for 3 days with history of COPD; Presented to ED and was admitted with dyspnea (for 9 days) 17 days prior to burn	6 days
63	Female	2.5%	Arm, axilla	3	Yes	Placed in Mepilex and discharged with plan for close burn clinic follow-up. No appointments available, so advised by burn team to re-present to ED. When burn re-examined, judged to be extensive enough to require admission for daily wound care and operative therapy	7 days
71	Male	1%	Ankle, dorsum of foot	7 (from 2nd ED visit)	Yes	Was seen in ED for burn, treated with bacitracin with plan for close burn follow-up. Re-presented to ED in 7 days because unable to get follow-up appointment, and same-day follow-up appointment facilitated. Seen again 7 days later in burn clinic, with concern for deep wound requiring operative management, so admitted.	9 days

Two hundred forty-six patients (53.6%) were admitted to the hospital, with patients aged ≥80 having the highest admission rate (67.0%). Characteristics of in-hospital treatment and outcomes are shown in Table 4. The median length of hospitalization across all older age groups was 12 days. Nearly half of admitted patients (49.2%) required skin graft surgery. Women admitted to the hospital were more likely than men to be discharged to the community with a home health aide. Almost a quarter (24.9%) of admitted patients who presented from the community were discharged to institutional / long-term care settings, including half of patients aged ≥80. Among these admitted patients, median burn size was 6% TBSA, with burns most commonly on the lower extremities (59.3%) and nearly half (48.1%) with burns on ≥2 body regions. Among admitted patients, 11.8% died during hospitalization. Characteristics of these patients are shown in Table 5. Among patients who died, the median age was 79 and median burn size was 40%TBSA. Of these patients, 96.5% had burns on ≥2 body regions, and 41.4% had potential inhalational injury. The most common cause of death identified was septic shock / pneumonia (41.4%).

Table 4:

Characteristics of in-hospital treatment and outcomes for patients aged ≥60 with burn injuries (n=246), 2011–2015

	All (%) (n=246)		Male (%) (n=115)	Female (%) (n=131)	p-value		Age 60 – 69 (n=95)	Age 70 – 79 (n=78)	Age 80+ (n=73)	p-value
Age (median, mean ± SD)	73, 74.6 ± 9.8		71, 73.2 ± 9.4	74, 75.8 ± 10.0	0.040		65, 64.9 ± 2.5	74, 74.4 ± 2.9	88, 87.4±4.6
Female gender	53.2						46.3	57.7	57.5	0.224
Total body surface area burned (median, mean ± SD) (n=122)	4, 12.1±18.9		4, 12.6±20.4	4, 11.5±17.3	0.922		3.5, 9.2±17.2	3.5, 11.6±17.2	5.5, 16.4±22.1	0.075
≤1%	13.1		14.5	11.7	0.921		19.6	14.7	2.7	0.248
>1%−5%	48.4		46.8	50.0			49.0	50.0	45.9
>5%−10%	14.7		16.1	13.3			11.8	11.8	21.6
>10%	23.8		22.6	25.0			19.6	23.5	29.7
Body region(s) of burn injury
Upper extremities	53.7		55.6	51.9	0.557		60.0	51.3	47.9	0.263
Lower extremities	50.8		52.2	49.6	0.689		38.9	53.8	63.0	0.007
Trunk	37.8		39.1	36.6	0.688		36.8	32.0	45.2	0.242
Head / Neck	25.2		22.6	27.5	0.38		22.1	30.8	23.3	0.385
Burns on ≥2 body regions	41.9		43.5	40.5	0.632		38.9	38.5	49.3	0.306
Concern for potential inhalational injury	11.8		10.4	13.0	0.537		8.4	16.7	11.0	0.238
Length of hospitalization (median, mean ± SD) (n=217)	12, 18.6±24.9		12, 20.1±26.8	11.5, 17.3±23.3	0.651		11, 14.2 ± 18.7	11, 18.5 ±25.2	13, 25.3±31.1	0.055
Required skin graft surgery	49.2		45.2	52.7	0.243		51.6	47.4	47.9	0.836
Given/documented tetanus vaccination	69.9		73.0	67.2	0.317		76.8	67.9	63.0	0.138
Discharge to location (n=217)					0.059					<0.001
Community	45.6		53.5	39.0	0.032		63.3	47.8	16.7	<0.001
Community with Home Health Aide	28.1		21.2	33.9	0.038		22.2	31.3	33.3	0.259
Institution/long-term care	26.3		25.2	27.1	0.756		14.4	20.9	50.0	<0.001
Presented from community but discharged to institution/long-term care (n=217)	24.9		25.4	24.2	0.841		13.3	17.9	50.0	<0.001
Died during hospitalization	11.8		13.9	9.9	0.333		5.3	14.1	17.8	0.025

Table 5:

Characteristics of patients who died after admission (n=29), 2011–2015

	All (%) (n=29)
Age (median, mean ± SD)	79, 80.5 ± 10.5
Total body surface area burned (median, mean ±SD) (n=23)	40, 41.8 ± 25.9
>1%−5%	8.7
>5%−10%	8.7
>10%	82.6
Body region(s) of burn injury
Trunk	89.7
Upper extremities	86.2
Lower extremities	82.8
Head / Neck	69.0
Burns on ≥2 body regions	96.5
Inhalational injury	41.4

Characteristics of ED, in-hospital treatment, and outcomes for the 11.8% of patients who suffered potential inhalation injury and were admitted to the hospital are shown in Table 6. More than 48% of these patients were intubated in the ED. Seven of these patients received an ENT consultation / fiberoptic airway evaluation prior to intubation while 7 did not. No patients required cricothyroidotomy due to inability to intubate. Among patients not intubated in the ED, 11 received an ENT consultation / fiberoptic evaluation. Of the patients who were intubated in the ED, 7.1% were extubated during the first day of admission and no additional patients were extubated on the second day. Ventilator-associated pneumonia was found to be contracted by 64.3% of patients intubated in the ED. More than 41% of the patients admitted with potential inhalational injury died during hospitalization.

Table 6:

Characteristics of Emergency Department and in-hospital treatment and outcomes for geriatric patients admitted with concern for potential inhalational burn injuries (n=29), 2011–2015

	All (%) (n=29)
Intubated in ED	48.3
After ENT consult / fiberoptic airway eval	24.1
Without ENT consult / fiberoptic airway eval	24.1
Not intubated in ED	51.7
ENT consultation / fiberoptic eval performed	38.0
ENT consultation / fiberoptic eval not performed	13.7
Intubated in burn unit after admission	10.3
Among all patients intubated in the ED (n=14), % extubated during:
First day of admission	7.1
Second day of admission	0.0
Among all patients intubated in the ED (n=14), % who contracted ventilator-associated pneumonia	64.3
Received hyperbaric therapy	11.1
Discharge to location (n = 17)
Community	47.1
Institution/long-term care	41.2
Community with Home Health Aide	11.7
Died during hospitalization	41.3

Discussion

To our knowledge, this is the first study to describe the clinical characteristics and outcomes of geriatric patients presenting to the ED with burn injuries. Though substantial literature exists about management of geriatric patients who are admitted to burn centers (6, 35–37), including analysis of the ABA registry (2, 4, 38), our work adds important new insight into both the initial assessment and management of burns in older adults who present to the ED as well as their ultimate disposition after this ED management.

Our work shows patterns of burn injuries that may be common in different sub-groups of older adults. In geriatric women in younger age groups (aged 60–69 and 70–79), upper extremity burns from cooking injuries were most common. This pattern has been previously described, often called “granny gown burns,” (39) when clothing catches fire while cooking. Notably, these burns pose operative challenges when they extend to the axilla and back. This was common, as 26% of upper extremity burns also included the trunk. In geriatric men in younger age groups (aged 60–69 and 70–79) burns occurred frequently from occupational injuries. Though these injuries also occur in men aged <60, (40–42) it is possible that, with age, reaction times slow, dexterity is decreased, and sensation is dulled, making older adults more susceptible (43). Intoxication contributes to burns more commonly in older men than women. In the older aged sub-group (aged ≥80), burns are more commonly associated with bathing, and these patients have larger injuries, including, more commonly, burns involving the lower extremities. Older adults, whether bathing on their own or with the help of a caregiver, are susceptible to burns from scalding water and are less able to remove themselves from an inappropriately hot shower or bath, making these burns sometimes large and severe. These patterns suggest opportunities for current and future prevention and educational efforts about the particular risk of this mechanism for older adults. In fact, outreach coordinators from our burn unit have developed and delivered educational programs to older adults and home health care workers to raise awareness on bathing-related scald burns in older adults.

A large percentage of burn victims were discharged from the ED, even many patients aged ≥80. This suggests that older adult burn victims do not always require hospital admission. Notably, even a small percentage of patients suffering potential inhalation injury were discharged directly after ED evaluation. Among patients that were discharged, only 0.9% were re-admitted for any reason within 30 days, suggesting that the decision to discharge was neither unsafe nor unreasonable. Among the few patients who re-presented to the ED and were admitted to the hospital for burn-related reasons, issues with access to care, difficulty managing wound care themselves, and progression of injury were the causes for these admissions rather than issues with the assessment and care provided initially in the ED. The rate of tetanus vaccination at our institution was low, particularly for discharged patients (59.1%), even though ensuring protection against tetanus was at that time and still is the standard of care in treating burn injuries nationally and at our institution as burns are tetanus-prone wounds. Tetanus vaccination should be routinely confirmed and updated if the last dose was greater than 5 years prior. We have subsequently re-educated our ED providers, and our current policy is that tetanus status should be confirmed and updated if necessary for all burn injuries.

Our institution’s criteria for discharging older adult patients with substantial burn injuries include: 1. an established domicile, 2. the ability to manage any necessary wound care themselves or another person who can provide this care, 3. adequate nutrition, and 4. the ability to return for a scheduled burn clinic follow up visit, whether in person or virtually if appropriate. Ability of patients to secure follow-up appointments to the outpatient burn clinic is an important part of disposition decision-making. Our burn surgeons have clinic on multiple weekday afternoons, and, typically, the outpatient burn clinic in our hospital has availability within 1–2 weeks for follow-up as appropriate. One important strategy to facilitate discharge in appropriate patients is the use of multi-day silver sulfate-foam bandage dressings (Mepilex Ag) rather than traditional dressings, including silver sulfadiazine and bacitracin, which must be changed twice daily and are modified as the quantity and quality of burn eschar and exudate evolve. The advantages of silver sulfate-foam bandages, which are placed by an expert burn practitioner and not manipulated by the patient or their agent, mitigate the pain and supplies associated with traditional serial dressing changes. Notably, silver sulfate-foam bandages are contraindicated for use on dry eschar, third-degree burns, or wounds with heavy bleeding.

Our criteria for admission or referral to a burn center are consistent with the recommendations of the American Burn Association (44), which include: 1. partial thickness burns greater than 10% TBSA, 2. burns that involve the face, hands, feet, genitalia, perineum, or major joints, 3. third degree burns in any age group, 4. electrical burns, including lightning injury, 5. chemical burns, 6. inhalation injury, 7. burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality, 8. any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality, 9. burned children in hospitals without qualified personnel or equipment for the care of children, 10. burn injury in patients who will require special social, emotional, or rehabilitative intervention. For older adults, categories #7 (pre-existing medical disorders) and #10 (need for social, emotional, or rehabilitative intervention) are particularly relevant and should be thoroughly considered. Notably, in this series, all older adults with partial thickness burns greater than 5% were admitted, suggesting that actual practice for older adults in our institution is more conservative than the admission criteria used. This suggests that, for older adults, ED providers should be cautious, and 5% may be more appropriate as a threshold for transfer or admission.

Our work expands on the large body of existing literature about the characteristics, inpatient management, and outcomes of older adult burn patients admitted to and treated in burn units of hospitals with burn centers. The most comprehensive available data on geriatric burns treated in U.S. burn centers is the American Burn Association National Burn Repository (4). Our burn center participates in this registry. This database has been a key source for many existing evaluations, and extensive age-based analysis is conducted annually. Comparison of our findings for geriatric patients admitted to New York Presbyterian Hospital / Weill Cornell Medical Center to the national registry data identifies potential differences in patient populations and burn treatment strategies between our center and others.

Geriatric burn patients admitted to our institution were older than in the nationally reported data in the ABA registry (4). There were fewer patients in the youngest age category (age 60–69) at our institution than were reported nationally (45.1% vs. 53.8%) (4). The oldest age category (age 80+) included 23.7% of our patients vs. 18.1% of patients nationally (4). A much higher percentage of our patients were women than in the national ABA registry (56.6% vs. 37.8%) (4). This difference likely results primarily from the fact that our population is older. These demographic differences from national statistics should be taken into account when interpreting our results (4). As compared to the national data, a smaller percentage of patients in our population had large burns (>10% TBSA) (17.1% vs. 27.5%) (4). And in our population, a much higher percentage of older adult burn victims required skin graft surgery (49.2% vs. 35.3%) (4). This suggests either that our admitted patients had much more severe skin burns or that grafting practices are more aggressive in our institution as compared to others. Another possible likely cause for observed differences are the exclusion of patients who were evaluated at another hospital and then transferred directly to our burn unit without an ED visit. Rate of death during hospitalization was slightly lower for our institution than the burn registry (11.8% vs 12.6%) (4) but mean length of hospitalization among admitted patients was longer (18.6 days vs. 17.8 days) (4). Notably, as might be anticipated, younger admitted patients (ages 20–59) in the ABA registry had lower mortality (2.3%) and lower mean length of hospitalization (9.0 days).

Determining whether to intubate patients in the ED for airway protection after inhalational injury can be challenging. Progressive edema may make successful intubation increasingly difficult as time elapses, and, though not in this series, cricothyroidotomy is necessary in some cases (42, 45). As a result, aggressive early airway control is a common approach for ED providers, particularly in a busy ED (46–48). Our approach to airway management of geriatric burn patients involves presuming that all burn airways will be difficult. Therefore, to maximize first pass success, the most experienced clinician in the ED conducts the procedure, typically with a bougie or other adjuncts available and used. While fiberoptic tools are available for emergency providers and may be useful to inform the intubation decision and conduct the procedure, we do not currently have access to either a shorter fiberoptic naso-pharyngoscope or longer fiberoptic laryngoscope in our ED. Rather, our ENT and Anesthesia colleagues have access to these and can bring them down to the ED in the context of a consultation. Therefore, if we are unsure about the degree of swelling or soot at the level of the vocal cords and this knowledge will impact the decision about whether to intubate, we will consult ENT to provide a naso-pharyngoscopic assessment. If we believe that a patient needs fiberoptic intubation, we will consult Anesthesia.

Burn surgeons typically have a different perspective than ED providers on aggressive airway control. Recognizing the high frequency of ventilator-associated pneumonia and other complications associated with intubation and ventilation, they typically prefer to avoid intubation unless absolutely necessary (49–51). In geriatric patients, challenges associated with airway management after inhalational injury are magnified (52). Due to decreased lung reserve and earlier fatigue, early ventilatory support is more commonly required, underscoring the importance of close monitoring and early airway control (53). Unfortunately, however, this decreased reserve also makes geriatric patients at higher risk for contracting ventilator-associated pneumonia and for having a more severe course of the disease if intubated (54, 55).

Given that only 7.1% were extubated during the first day of admission and no additional patients were extubated on the second day, our findings suggest that ED management of airway was appropriate. Notably, despite aggressive airway control, the inpatient mortality for these admitted potential inhalation injury patients was high (41.3%), underscoring the challenges of effectively managing these injuries. Mortality in our institution is higher than in the ABA registry (31.3%), likely because of our patients’ increased age.

Burn Intensive Care Units (ICUs) have the highest rates of ventilator-associated pneumonia of any ICUs (56, 57). The impact of inhalation injuries contributes to this, impairing mucociliary clearance and injuring the alveolar macrophages which protect the respiratory tract from infection (57, 58). Patients intubated in the ED after traumatic injuries have been shown to have higher rates of ventilator-associated pneumonia than patients intubated later in the hospitalization (57–59). Critically-ill older adults are not necessarily at greater risk for ventilator-associated pneumonia than intubated younger adults, but the associated mortality is much higher (60). Our burn unit has extensive protocols to minimize ventilator-associated pneumonia, including: head of bed elevation, robust mouth care, chest physical therapy, spontaneous breathing trials, early mobilization, and early removal of mechanical ventilation (61). Despite this, rates remain persistently high among older adult patients, underscoring the importance of and risks associated with the decision to intubate.

Research has suggested that any ED visit for a previously healthy older adult, irrespective of the patient’s acute complaint, may represent a “sentinel event,” (62, 63) signifying a reduction in their functional or cognitive status that is important for providers to recognize. Even if discharged from the ED, older adults have an immediately higher risk of loss of independence, an increased rate of hospital admission or death, and a higher rate of ED re-presentation (63–67). This may be particularly true for a burn injury. Future research is needed to explore this further and to assess the potential for comprehensive geriatric assessments and targeted interventions for older adult ED burn patients. The potential of telemedicine to provide burn care (68, 69) and to provide / supplement acute and follow up care for older adults (70, 71) has already been explored. This platform, the use of which has grown dramatically recently during the COVID-19 pandemic, may become an important tool in optimizing care. Possibilities include both acute burn assessment in the home (perhaps obviating the need for an ED visit) as well as follow–up burn care after an ED evaluation and subsequent discharge.

Limitations

This study has several limitations. Our findings are from the ED of a single, busy urban burn center in the northeastern US and may not be generalizable to other clinical settings. As well, patients included in this analysis may have received care at another ED before coming to ours for additional treatment for their burn injuries. Our findings are derived from retrospective analysis, which relies on the accuracy and completeness of medical records not originally compiled for the purpose of research. In addition, though rigorous, our case-finding strategy may have missed older adults presenting to the ED with burn injuries, which would impact our results. It is possible that some patients may have died without our knowledge, as we did not conduct active follow-up beyond medical chart review. Also, patients may have presented to other health care facilities rather than re-presenting to our ED. As our ED/hospital is a locally and nationally-recognized burn center, though, presentations to other EDs might be anticipated to be less than for other conditions. Also, many other local hospitals would likely re-direct patients with burn-related complaints, complications, or follow-up issues back to our ED/hospital for evaluation. We did not track how many patients arrived to the ED with an advanced directive or were made DNR or comfort care during the hospitalization. This certainly may have impacted care-related decision-making and mortality. The cases about which we report here are also several years old. Notably, though, while burn care continues to evolve, there have not been substantial changes in the management protocols for burn patients during the last 5 years in our institution, and we believe analysis of this data provides important insights on this phenomenon. Also, given that our analysis was conducted before the beginning of the COVID-19 pandemic, which has had and likely will continue to have an important impact on management of older adults with acute conditions presenting to the ED as well as on their health-care seeking behaviors (72, 73), our results may not accurately reflect future burn care practice or resource utilization.

Conclusions

Our work describes in detail geriatric patients with burn injuries treated in the ED, offering insight and improving understanding of this common problem that may be challenging to manage. Common patterns of burn injuries presenting to the ED change with increasing age, with cooking a common associated cause in older adults in the youngest age category and bathing more common in the oldest age category. Many older adults, even aged ≥80, with burn injuries may be safely discharged from the ED. ED providers should be cautious about discharging patients with greater than 5% partial thickness burns, though. Decisions about intubating older adults in the ED for airway protection after inhalation injury can be particularly challenging. Burn injuries in older patients may represent a sentinel event, even in those who are discharged directly from the ED, and therefore may provide an opportunity to recognize functional or cognitive decline and to immediately intervene. More research is needed to better understand burn injuries in geriatric patients in order to improve emergency care for this vulnerable population.

ARTICLE SUMMARY.

1. Why is this topic important?

Burn injuries in geriatric patients are common and may have significant associated morbidity and mortality, but little is known about the clinical characteristics of geriatric burn victims who present to the emergency department and their ED assessment and management.

2. What does this study attempt to show?

This study’s objective is to describe the clinical characteristics and outcomes of geriatric patients presenting to the ED with burn injuries

3. What are the key findings?

Nearly half (46.4%) of patients were discharged from the ED after initial evaluation, and only 1.9% of these re-admitted for any reason within 30 days. Among inhalation injury patients intubated in the ED, 7.1% were extubated during the first 2 days of admission, and 64.3% contracted ventilator-associated pneumonia.

4. How is patient care impacted?

Better understanding of ED care for geriatric burn injuries may identify areas in which to improve emergency care for these vulnerable patients.