Who Pays the Bill? Appendix A
LITERATURE REVIEW OF BURN INCIDENCE AND TREATMENT
Before World War II, those who survived fires and other burn incidents with major injuries received virtually no care before reaching a hospital. If they reached the hospital alive, they would receive largely palliative care. If they escaped the constant threat of death from burn would sepsis and its complications while their wounds remained open, they generally faced a cosmetically and functionally compromised future, and the unappealing choice of dealing with or hiding from a generally uncomprehending and unsympathetic populace.
Treatment of patients with severe fire and burn injuries has shown remarkable progress in the past 50 years, at a rate that has accelerated in the past 25 years (Alexander, 1985; Dimick et al, 1993). During the same period, death and injuries from fires and burns have declined to current levels of approximately 4500 civilian fire deaths (Karte,r 1992) and 52,000 hospitalized primary ICD-code burn injuries per year (National Center for Health Statistics, 1993; Dimick et al., 1993). Counts of additional burn deaths and hospitalized fire injuries, while considerably lower, remain locked in unanalyzed data. Less severe injuries are more frequent. Total burn injuries, defined as contact with medical care and/or reduced activity for at least a day, were estimated at 1.75 million per year, or about .75 per year per 100 population (National Safety Council, 1992, tabulation of National Health Interview Survey, 1985-1987).
According to the most recent annual tabulation by the National Fire Protection Association, about 1200 of the nation's 4500 annual fire deaths result from fires started by dropped cigarettes (Miller A, 1993). There is no national system in place which counts all fire and burn injuries by type and ignition source. The National Fire Incident Reporting System (NFIRS), estimates the incidence of fatal and nonfatal fire injuries attended by fire departments. Data from the National Electronic Injury Surveillance System (NEISS) of the U.S. Consumer Product Safety Commission (CPSC) cover many burn injury sources comprehensively. Scattered burn center reviews place dropped cigarette fire injuries at between 3% of admissions (Burn Foundation, unpublished data, 1993) and 6% (Cleon Goodwin, unpublished data, 1993). Projected against the national total of 23,000 specialized burn facility admissions per year (Dimick et al, 1993), these reports suggest that the number of such cigarette fire injuries receiving specialized burn treatment is between 700 and 1400. This does not include additional injuries related to smoking, such as the accidental ignition of an accelerant (gasoline, kerosene, etc.) or the intentional ignition of combustibles by a cigarette, or the misuse of matches or cigarette lighters by children or compromised adults with ready access to smoking paraphernalia.
Overview of Recent Advances
Five landmark articles documenting major advances in burn treatment in recent decades have been cited by Cohen et al (1989). They include:
* a comprehensive approach to fluid and electrolyte needs (Baxter, 1974)
* prevention and control of infection (Heggers and Robson, 1986)
* early debridement and coverage (Janzekovic, 1970; Hunt et al, 1979)
* prevention of contractures with splints and early mobilization (Petros, 1986)
* prevention of hypertrophic scars and keloids with pressure garments (Larsen, 1971)
Additional important areas of recent advances and continuing concern are reflected in the topic headings in the report of the most NIH consensus conference on trauma and burn injury (Maddox et al, 1990). These include nutrition and metabolism, pulmonary injury, wound healing, and immunological consequences.
For those who survive a fire or burn injury incident to enter the medical care system, the standard for care is now a mature system extending from prehospital care and transportation through inpatient care and rehabilitation (American Burn Association, 1990; Bayley et al, 1989). Rehabilitation both during and after hospitalization is receiving increased attention (Cromes & Helm, 1992) although the overall societal approach to rehabilitation remains deficient (Salisbury, 1992).
Advances affecting the acute treatment of the most severely injured have particular relevance for the survivors of fire started by dropped cigarettes. Classed by ignition source, injuries caused by cigarettes have the longest hospital course, the most extensive respiratory and other complications, and the highest average hospitalization costs (Jones & Feller, 1988, Burn Foundation, 1990). Cigarette fires typically do not produce substantial quantities of CO and other toxic products while smoldering in a mattress or upholstered furniture before erupting into flame. Many National Institute of Standards and Technology (NIST) studies attest to this. However, those caught in the ensuing conflagrations suffer as a group the most severe mix of respiratory and burn injury of any fire injury scenario.
The literature on the treatment of fire and burn injury is growing by several hundred references each year. There are some 150 new references alone in the two major periodicals dedicated to burn injury, the Journal of Burn Care and Rehabilitation, inaugurated in 1981, and Burns, published in England since 1974. Dozens of articles addressing burn injury appear in other medical publications. Upwards of 250 papers and poster sessions, many remaining unpublished, are also presented each year at the annual meetings of the American Burn Association.
The recent literature documents continuing progress and further promise in advancing the frontier of survival and shortening the hospital stay through improved surgical and nursing technique in the areas of wound coverage and healing (Munster et al, 1992; Carrougher et al, 1991). There is increasing attention to diagnosing and treating inhalation injury, (Clark & Nieman, 1987) which remains the last major challenge to surviving the acute state of injury (Sobel, 1992). There is also increasing attention to how burn care can most effectively be administered in an era of changing payment mechanisms and reduced burn center occupancy. (Jordan, 1991; Fortune, 1992; Rees, 1992; Silverstein, 1992; Brigham, 1993.)
The following review assesses advances in more specific areas of burn care and research with particular reference to literature published within the past five years, and with special attention to respiratory injury. The review is intended to serve as a guide to recent trends, to aid in determining what effect they have had and are likely to have on outcomes of care and medical costs.
Rescue and Transportation
Fire suppression and rescue techniques have become so refined that the prospect of surviving a conflagration has increased significantly (Chiles, 1992). Investigation of fire fatalities has improved the abilities of architects and builders to prevent fires from occurring and to enhance rescue and escape efforts if a fire breaks out. With advances in air transport and the nationwide spread of emergency medical systems (Dimick et al, 1993), care in the prehospital state has substantially improved and transportation of the patient directly from the scene to a burn center has become standard practice (Chiles, 1992; Sharar et al, 1988). The widespread use of helicopters has even reached the point of stimulating recommendations for more precise criteria for their use (Baack et al, 1991). Both land and air transport have benefitted from the improvement in monitoring equipment, which is increasingly compact, user friendly and non-invasive, making the monitoring of hemodynamic stability more accurate and precise and enabling corrective action during transit.
Burn mortality continues to be associated with advanced age and higher percent of total body surface area burned (Thompson et al, 1986). In addition, mortality remains greater (40%) in any burn combined with an inhalation injury (Herndon, 1986). Those who present to the burn center are frequently more complex due to increased age, advanced disease or complicated medical history. Substance abuse and intoxication also contribute both to the severity of burn injury and to ensuing complications (Kelly & Lynch, 1992; Haponik & Munster, 1990; Clark & Neiman, 1988).
Advanced technology has created an array of new techniques in debridement and skin replacement, such that wound size is reduced more quickly and with fewer complications (Burke, 1990). Better equipment and technique during surgery have improved the control of the patient's wound bed and facilitated healing. Complications associated with prolonged anesthesia have accordingly declined. The contribution of strengthened nutritional status and other supports to the patient's immunological defenses are increasingly well documented (Heimbach, 1990; Garrel, 1991).
Early wound excision and closure have reduced the complications of burn wound sepsis and shortened hospital stays without increasing mortality (Heimbach, 1988). Now that burn care has "come of age", refined skin grafting techniques have enabled surgeons to treat patients quickly and efficiently. Today, burn wounds are frequently excised and autografted on an outpatient basis. Healing time is spent at home, rather in a high-priced hospital room. This reduced costs and potentially promotes early rehabilitation, if family and professional support is forthcoming.
These improvements have enabled the focus of grafting to expand at an earlier stage from wound coverage to cosmetic and functional restoration. In the most recent Presidential address to the American Burn Association, Warden (1993) communicated the need to establish early cosmesis and return to functional capacity as major goals of contemporary burn treatment.
Respiratory injury, and/or the ingestion of toxic gases, is the leading cause of death identified in data sources identifying fire victims (Harwood & Hall, 1989) and patients admitted to burn centers (Thompson, 1986; Tredget et al, 1990). Thompson reported mortality rates of 4% for patients without inhalation injury and 56% where such injury was present. Since inexperienced emergency room personnel may be distracted by the sensational external appearance of a large body surface wound, the emphasis in education is on securing an accurate history and performing a complete examination of the patient. These are crucial first steps in acquiring evidence of inhalation injury and implementing timely treatment (Herndon, 1986). Patients with smoke exposure but no thermal injury are also at risk for ominous complications if the emergency department practitioner does not implement appropriate treatment at the time of the initial examination (Haponik, 1990).
Jones and Feller (1988) reported that patients with a respiratory injury were hospitalized twice as long (46 days) as those without pulmonary involvement (18 days) based on average lengths of stay of patients documented in the National Burn Information Exchange from 1979 through 1986.
The patient who survives a thermal injury accompanied by a pulmonary injury faces a long recovery with multiple complications. Besides the physiologically damaging effects of smoke and heat, particles of smoke can cause toxic consequences that lead to delayed neurological problems (Sharar, 1990; Choi, 1983; Ellenhorn and Barcelous, 1988). Long-term pulmonary complications continue to involve all areas of the pulmonary tree causing restriction, stenosis or obstruction from the larynx and trachea to the bronchioles and parenchyma. Problems such as chronic obstructive pulmonary disease (COPD) can plague the survivor long after their initial hospitalization, complicating their rehabilitation and raising the costs to both patient and society (Colice, 1990).
Bronchoscopy examination is widely used and accepted for quick and effective determination of airway involvement and severity of injury (Herndon, 1986; Clark & Nieman, 1988; Haponik & Munster, 1990) yet it cannot predict the chance of respiratory failure (Shimozu, 1987). The xenon scan is a precise diagnostic tool for identifying a pulmonary injury, but is very expensive and not generally used if bronchoscopy is readily available (Herndon, 1986).
Increasing knowledge of the physical composition of smoke and its chemical properties has broadened the understanding of the causes of asphyxiation. Cyanide poisoning is now understood to be a major cause of death in addition to carbon monoxide (Jones 1987), accompanying the increased use of synthetic materials in building and decorating and the proliferation of plastics in home and industry (Decker and Garcia-Cantu, 1986). In 1991, Baud reported that plasma lactate concentration at the time of admission correlated more closely with blood cyanide intoxication than with blood carbon monoxide concentration.
The use of hyperbaric oxygenation in treating patients with thermal injury has become popular and at the same time controversial. Those who believe that hyperbaric treatment enhances removal of carboxyhemoglobin and promotes tissue oxygenation advocate its use with burn patients. Others feel that the cost and clinical risk is too great to justify transporting a thermally injured patient back and forth from the treatment chamber (Ellenhorn and Barcelous, 1988). In the report of a comparative study of recipients and non-recipients of hyperbaric oxygen in burn treatment, investigators reported a 39% decrease in surgical procedures, a 34% reduction in hospitalization and a 34% reduction in patient costs in the cohort receiving such treatment (Cianci et al, 1990). The study did not resolve whether the risk of transporting a patient to and from a hyperbaric chamber was justified.
Recent research has focused on pathophysiological changes in the lung as a consequence of smoke and heat, singly or in combination (Thom, 1989; Demling et al, 1992; Hales et al, 1991; Isago et al, 1991; Kramer et al, 1989). Researchers continue to explore the effect of inhalation injury on microvasculature permeability at the cellular level. It is still difficult to predict the fluid requirements of patients with inhalation injury. More recent work suggests that such injury requires additional fluid administration in the early post-injury phase (Thom, 1989). Further research to identify such fluid requirements is crucial, since contemporary resuscitation formulas do not meet the needs of those experiencing respiratory compromise (Navar et al, 1985; Herndon, 1986; Clark & Nieman, 1988; Haponik & Munster, 1990).
The burn treatment community's growing consensus is that the frontier of survival in burn care has been pushed close to its extreme, with the exception of respiratory injury, and that attention must increasingly be devoted to burn rehabilitation. (Helm, 1992; Salisbury, 1992) Controlling contracture and hypertrophic tissue formation, restoring psychological balance and regaining functional capacity are major clinical goals in the rehabilitation of the burn patient. Helm (1992) has identified the major components of rehabilitation services and listed ten broad educational, research and public policy goals related to burn rehabilitation. The psychosocial aspect of rehabilitation has long been and continues to be a major concern (Bowden et al, 1979; Blakeney, 1988). Current goals extend beyond getting the patient out of the hospital, to embrace the return of the patient to work or school through work hardening, or school reentry programs, provided directly by burn team members or through work consultation with community agencies. Obtaining disability insurance for disabled burn patients has been a vexing problem (Salisbury, 1992). Miller et al (1993) estimate 15% of hospitalized burn patients and 1% of those treated in emergency departments experience permanent decreases in earning power.
Recent advances in scar control include the use of silicone and elastomer inserts and conformers in areas where it is difficult to maintain pressure over hypertrophic tissue (Cohen et al, 1989; Pegg, 1989; Ward, 1991). Splinting material, used to reduce contracture formation and allow better control of the treated area, is now available in a reusable fashion that can be customized as a patient's needs change with reduced edema and changing skin coverage. The newer material is easier to clean and has a longer shelf life, thus reducing costs (Roberts et al, 1991).
The past ten years have brought advances in burn care including the identification of toxic substances at the scene of the injury, improved transportation of patients, early respiratory treatment and support, aggressive wound coverage, and more comprehensive rehabilitation services.
Today, those who survive serious injury do so because of knowledge gained from the unfortunate incidents of the past, technological advance, improved health care education, the maturing functioning of multi-disciplinary burn teams and society's ever-expanding demand for quality care. These improvements have a two-way impact on costs, the net effect of which is not clear. As those who ultimately expire from their injuries without recovering survive for longer periods, treatment costs increase. As the caliber and speed of recovery increases for those who do survive, the total hospitalization costs may go down, although more resources are concentrated on each day of care. Fire and burn deaths have decreased significantly in the past two decades. Now that well over 90% of burn center admissions survive to be discharged from the hospital, hopefully, the balance is shifting toward reducing costs. Better knowledge of this balance is needed to provide substance to the increasing ethical debate over the provision of extensive, intensive care to those who are massively burned (Kliever, 1989; Fratianne, 1992).