Associations between burn care services and impairment at discharge after burn injury: Analysis of the Global Burn Registry.

BACKGROUND: Throughout the world, burn injury is a major cause of death and disability. In resource-limited countries, burn injury is one of the leading causes of permanent disability among children who survive traumatic injuries, and burn injury is the fourth leading cause of disability worldwide. This study applied Andersen's model of health care access to evaluate if patient characteristics (predisposing factors), burn care service availability (enabling factors) and injury characteristics (need) are associated with physical impairment at hospital discharge for patients surviving burn injuries globally. Specifically, access to rehabilitation, nutrition, operating theatre, specialized burn unit services, and critical care were investigated as enabling factors. The secondary aim was to determine whether associations between burn care service availability and impairment differed by country income level. METHODS: This is a cross-sectional secondary analysis of prospectively collected data from the World Health Organization, Global Burn Registry. The outcome of interest was physical impairment at discharge. Simple and multivariable logistic regressions were used to test the unadjusted and adjusted associations between the availability of burn care services and impairment at hospital discharge, controlling for patient and injury characteristics. Effect modification was analyzed with service by country income level interaction terms added to the models and, if significant, the models were stratified by income. RESULTS: The sample included 6622 patients from 20 countries, with 11.2% classified with physical impairment at discharge. In the fully adjusted model, patients had 89% lower odds impairment at discharge if the treatment facility provided reliable rehabilitation services compared to providing limited or no rehabilitation services (OR.11, 95%CI.08,.16, p < .01). However, this effect was modified by county income with the strong and significant association only present in high/upper middle-income countries. Sophisticated nutritional services were also significantly associated with less impairment in high/upper middle-income countries (OR=.04, 95% CI 0.203, 0.05, p < .01), but significantly more impairment in lower middle/low-income countries (OR=2.01, 95% CI 1.50, 2.69, p < .01). Patients had 444% greater odds of impairment if treated at a center with specialty burn unit services (OR 5.44, 95%CI 3.71, 7.99, p < .01), possibly due to a selection effect. DISCUSSION: Access to reliable rehabilitation services and sophisticated nutritional services were strongly associated with less physical impairment at discharge, but only in resource-rich countries. Although these findings support the importance of rehabilitation and nutrition after burn injury, they also highlight potential disparities in the quantity or quality of services available to burn survivors in poorer countries.

Gender-based disparities in burn injuries, care and outcomes: A World Health Organization (WHO) Global Burn Registry cohort study.

BACKGROUND: We aimed to describe the gender-based disparities in burn injury patterns, care received, and mortality across national income levels. METHODS: In the WHO Global Burn Registry (GBR), we compared patient demographics, injury characteristics, care and outcomes by sex using Chi-square statistics. Logistic regression was used to identify the associations of patient sex with surgical treatment and in-hospital mortality. RESULTS: Among 6431 burn patients (38 % female; 62 % male), females less frequently received surgical treatment during index hospitalization (49 % vs 56 %, p < 0.001), and more frequently died in-hospital (26 % vs 16 %, p < 0.001) than males. Odds of in in-hospital death was 2.16 (95 % CI: 1.73-2.71) times higher among females compared to males in middle-income countries. CONCLUSIONS: Across national income levels, there appears to be important gender-based disparities among burn injury epidemiology, treatment received and outcomes that require redress. Multinational registries can be utilized to track and to evaluate initiatives to reduce gender disparities at national, regional and global levels.

Epidemiological trends of severe burns, 2009-2019: A study in the service of burns in Albania.

INTRODUCTION: Statistical and epidemiological data taken throughout decades show trends of the pathology of burns and its treatment. The aim of this study is to analyze the summarized epidemiological and clinical data of severe burn patients during the period 2009-2019 in order to acquire an accurate and recent picture of this pathology. This can create a basis for improving community health outcomes. MATERIAL AND METHOD: The study retrospectively analyzes the data of severe burn patients admitted in the Intensive Care Unit (ICU) of the Service of Burns and Plastic Surgery of the University Hospital Center in Tirana, Albania, from 2009 to 2019. SPSS 23 software is used for the conduction of the Descriptive and Inferential Statistics. Statistical significance is defined as p<0.05. RESULTS: Incidence rate of burn admissions which need ICU treatment in our data was 5.2 patients/100,000population/year. The mean age of our population was 24.9±25.5 years. The most frequent causes of burns in all patients were scalds (49.6%) followed by flame (39.5%), electrical (5.1%), chemical (5%) and with unknown cause (0.7%). Death rate from fire and burns for the period 2009-2019 was 0.3 patients per 100,000population/year. Overall mortality was 6.8%. The ABSI, Baux and R Baux scoring system remain accurate and valuable tools in the prediction of burn patient mortality. A probability of death chart for our service has been developed based on age and BSA (%) burned which needs to validate in the future. CONCLUSIONS: Etiology of burns have changed toward an increase in proportion of flame burns especially in adults and elderly population. Survival following severe burns has improved over the past 11 years even in patients with three risk factors (age ≥60, BSA (%) burned ≥40% and presence of inhalation burn). LA 50 for all patients was 80%. LOS/BSA (%) ratio is a more valuable indicator than LOS alone. Improvement in the treatment of severe burns is a combination of preventive health care, appropriate treatment protocols and improvements in equipment and infrastructure.

Cross-Sectional Assessment of Burn Center and Nonburn Center Patient Care: A Multi-Database Comparison.

The practice of burn care is complex and continues to be a rapidly evolving field. To assess how differences in management affect hospital stay characteristics and outcomes, the authors sought to compare outcomes data from two sources, such as burn center and nonburn center data. The National Burn Repository (NBR, version 8) and the 2014 Nationwide Readmission Database (NRD) were compared based on ICD-9 948-series burn-related diagnosis codes, generating a total of 83,068 and 14,131 burn patients from the NBR and NRD, respectively. Patients were stratified by burn size and compared based on demographic factors and hospital stay characteristics. t-Test and chi-squared statistics were performed with SAS, version 9.4. Burn patient populations from the NBR and NRD databases, when stratified by patient demographic factors, were found to have similar sex distributions, 68% and 64% male, respectively. The average age was significantly higher in the NRD data at 39.5 ± 23.6 compared with 30.9 ± 22.3 years. Hospital stay characteristics, including length of stay and mortality, were not found to differ significantly. Differences were identified in the number of trips to the OR, which was significantly greater in the NBR population as well as the total cost of care, which was significantly less in the NBR population at $92k compared with $125k. This study has shown through the interpretation of multiple databases that not only do demographics differ between burn and nonburn center populations, but also do management strategies, particularly in operative intervention and cost.

The Effect of Surgical Intervention on Pediatric Burn Injury Survival in a Resource-Poor Setting.

INTRODUCTION: Burns are one of the most common injuries sustained globally. Low- and middle-income countries (LMICs) are disproportionately affected by burn injury morbidity and mortality; African children have the highest burn mortality globally. In high-income countries, early surgical intervention has shown to improve survival. However, when applied to burn victims in LMICs, improved survival in the early excision cohort (≤5 d) was not seen. Therefore, we aimed to determine the magnitude of the effect of surgical intervention on burn injury survival. METHODS: A retrospective analysis of a prospectively collected data, utilizing the Kamuzu Central Hospital Burn Database from May 2011 to July 2019, was performed. Pediatric patients (≤12 y) were included. Patients were excluded if they underwent surgical intervention for nonacute burn care management. Bivariate analyses stratifying by type of surgical intervention was performed, comparing demographics, burn characteristics, surgical intervention, and patient mortality. Standardized estimates were adjusted using the inverse-probability of treatment weights to account for confounding. Weighted logistic regression modeling was performed to determine the odds of mortality based on if a patient underwent surgical intervention. RESULTS: During the study, 2364 patients were seen at the Kamuzu Central Hospital, 1785 (75.5%) were children ≤12 y who met inclusion criteria. In the overall cohort, 342 (19.2%) underwent operations, including split-thickness skin graft (n = 196, 57.3%), debridement (n = 116, 33.9%), escharotomy (n = 19, 5.6%), and amputation (n = 1, 0.3%). The surgery cohort was older (4.2 ± 3.1 versus 3.1 ± 2.6 y, P < 0.001) with larger percent total body surface area burns (16%, interquartile range: 10-24 versus 13%, interquartile range: 8-20, P < 0.001) than those who did not have surgery. In the propensity score-weighted logistic regression predicting survival, patients undergoing surgery after burn injury had an increased odds of survival (odds ratio: 5.24, 95% confidence interval: 2.40-11.44, P = 0.003) when compared with patients not undergoing surgery. CONCLUSIONS: In this propensity-weighted analysis, surgical intervention following burn injury increases the odds of survival by a factor of 5.24 when compared with patients not undergoing surgical intervention. Efforts to enhance burn infrastructure to deliver surgical care is imperative to attenuate burn mortality in resource-poor settings.

Effect of the Affordable Care Act on a Safety-Net Burn Center.

We hypothesized that the Patient Protection and Affordable Care Act (ACA) would have beneficial financial effects on our burn center at a safety-net hospital. We performed a retrospective chart review of all burn patients admitted to our center from 2008-2016. These were further divided into three time periods: 2008-2010 (pre-ACA), 2011-2013 (transitional), and 2014-2016 (post-ACA). Cost and reimbursement dollars were adjusted to health personal consumption expenditures price index. Total charges increased from the pre-ACA group ($69,400) to the transitional group ($85,600) and increased again in the post-ACA group ($100,100) (p<.001). When looking at reimbursements relative to charges, actual reimbursement by percentage dropped over each time period. Despite an increase in insured patients, our burn center actually saw a decrease in reimbursements relative to billing.

Regional disparities in access to verified burn center care in the United States.

BACKGROUND: Burn injuries result in 50,000 annual admissions. Despite joint referral criteria from the American College of Surgeons (ACS) and American Burn Association (ABA), many severely injured patients are not treated at verified centers with specialized care. Only one prior study explores regional variation in access to burn centers, focusing on flight or driving distance without considering the size of the population accessing that center. We hypothesize that disparities exist in access to verified centers, measured at a population level. We aim to identify a subset of nonverified centers that, if verified, would most impact access to the highest level of burn care. METHODS: We collected ABA data for all verified and nonverified adult burn centers and geocoded their locations. We used county-level population data and a two-step floating catchment method to determine weighted access in terms of total beds available locally per population. We compared regions, as defined by the ABA, in terms of overall access. Low access was calculated to be less than 0.3 beds per 100,000 people using a conservative estimate. RESULTS: We identified 113 centers, 59 verified and 54 nonverified. Only 2.9% of the population lives in areas with no verified center in 300 miles; however, 24.7% live in areas with low access. Significant regional disparities exist, with 37.3% of the population in the Southern Region having low access as compared with just 10.5% in the Northeastern Region. We identified 8 nonverified centers that would most impact access in areas with no or low access. CONCLUSION: We found significant disparities in access to verified center burn care and determined nonverified centers with the greatest potential to increase access, if verified. Our future directions include identifying barriers to verification, such as lack of fellowship-trained burn surgeons or lack of hospital commitment. LEVEL OF EVIDENCE: Epidemiological, level III.

Epidemiologic Investigation of Chemical Burns in Southwestern China from 2005 to 2016.

The epidemiological characteristics of chemical burns vary in different regions of the world. This study aims to survey the epidemiology, outcomes, and costs of chemical burns in southwest China, to determine associated risk factors and to obtain data for developing an effective approach to prevent and treat chemical burns. This retrospective study includes 410 cases with chemical burns admitted to the Institute of Burn Research of Southwest Hospital from 2005 to 2016. Data, including demographic, etiology, outcomes, and costs, were collected and analyzed. A total of 410 cases admitted to our burn center were included. The average age of the burn patients was 38.58 ± 14.66 years. The incidence of chemical burns peaked in autumn. The most common etiology were acids. Limbs were the most common burn sites (59.51%). Average total body surface area (TBSA) was 12.37 ± 18.67%. The percentage of patients who underwent procedures and the number of procedures were significantly greater for TBSA and full-thickness burns. The mortality of chemical burns was 1.22%. The median length of stay (LOS) and cost were 21 days and 65,852 CNY, respectively. The major risk factors for cost were the number of procedures, TBSA and full-thickness burns, the major risk factors for LOS were the number of procedures and outcome. Chemical burns mainly occurred in adult males with occupational exposures to chemical agents due to inappropriate operation. Emphasis on safety education for the public and professional pre-employment training for workers should become key preventive targets to reduce the incidence of chemical burns.

Building the Burn Physician Workforce for the 21st Century: Report From February 2014 Burns Workforce Conference.

American Burn Association Past President Palmer Q. Bessey, MD, orchestrated a Burn Workforce Conference in Washington, DC in February, 2014, with the goal of evaluating the workforce needs for doctors, nurses, and occupational/physical therapists. This report summarizes the issues related to the need for training future surgeons to manage burn patients. General surgery and plastic surgery residents currently have minimal requirements for burn experience during their training. The respective Boards, however, do require knowledge in the management of burn care. The number of surgeons entering burn fellowships is limited to approximately 10 per year and there are only a handful of burn fellowship programs to train future burn surgeons. A survey sent to burn surgeons revealed that the current workforce is aging and needs to a constant supply of new physicians. It is clear that there is a need to formalize burn fellowships and it was felt that the American Burn Association should be responsible for accreditation of those fellowships.

The organisation of critical care for burn patients in the UK: epidemiology and comparison of mortality prediction models.

In the UK, a network of specialist centres has been set up to provide critical care for burn patients. However, some burn patients are admitted to general intensive care units. Little is known about the casemix of these patients and how it compares with patients in specialist burn centres. It is not known whether burn-specific or generic risk prediction models perform better when applied to patients managed in intensive care units. We examined admissions for burns in the Case Mix Programme Database from April 2010 to March 2016. The casemix, activity and outcome in general and specialist burn intensive care units were compared and the fit of two burn-specific risk prediction models (revised Baux and Belgian Outcome in Burn Injury models) and one generic model (Intensive Care National Audit and Research Centre model) were compared. Patients in burn intensive care units had more extensive injuries compared with patients in general intensive care units (median (IQR [range]) burn surface area 16 (7-32 [0-98])% vs. 8 (1-18 [0-100])%, respectively) but in-hospital mortality was similar (22.8% vs. 19.0%, respectively). The discrimination and calibration of the generic Intensive Care National Audit and Research Centre model was superior to the revised Baux and Belgian Outcome in Burn Injury burn-specific models for patients managed on both specialist burn and general intensive care units.

Prospective Evaluation of Operating Room Inefficiency.

Previously, they identified that 60 per cent of their facility's total operative time is nonoperative. They performed a review of their operating room to determine where inefficiencies exist in nonoperative time. Live video of operations performed in a burn operating room from June 23, 2017 to August 16, 2017 was prospectively reviewed. Preparation (end of induction to procedure start) and turnover (patient out of room to next patient in room) were divided into the following activities: 1) Preparation: remove dressing, position patient, clean patient, drape patient, and 2) Turnover: clean operating room, scrub tray setup, anesthesia setup. Ideal preparation time was calculated as the sum of time needed to perform preparation activities consecutively. Ideal turnover time was calculated as the sum of time needed to clean the operating room and to set up either the scrub tray or anesthesia (the larger of the two times as these can be done in parallel). They reviewed 101 consecutive operations. An average of 2.4 ± 0.8 cases per day were performed. Ideal preparation and turnover time were 16.6 and 30.1 minutes, a 38.3 and 32.5 per cent reduction compared with actual times. Attending surgeon presence in the operating room within 10 minutes of a patient's arrival was found to significantly decrease time to incision by 33 per cent (52.7 ± 14.3 minutes down to 35.7 ± 20.4, P < .0001). A reduction in preparation and turnover time could save $1.02 million and generate $1.76 million in additional revenue annually. Reducing preparation and turnover to ideal times could increase caseload to 4 per day, leading to millions of dollars of savings annually.

Consistency of total body surface area assessment in severe burns: Implications for practice.

BACKGROUND: Paediatric burn injury is common and often serious. Injuries occur across New South Wales (NSW), with specialised treatment provided in a centralised burns unit. Early management prior to transfer is essential but variation is seen. OBJECTIVES: To determine if differences exist between referring hospital estimates of the total body surface area (TBSA) of burns, and estimates for the same burns by the Burns Unit. To consider if differences in estimations influence initial and ongoing management, and decisions regarding transfer/retrieval. METHODS: A retrospective record review of all patients referred to NSW Newborn and Paediatric Emergency Transport Service (NETS) with burn injury between January 2009 and January 2011. Both NETS and NSW Burns Unit records were analysed. RESULTS: A total of 123 patients were referred to NETS with burn injury. Approximately half (55/123 = 45%) were referred with a TBSA >10% and transferred to the NSW Burns Unit, where just over half (33/55 = 60%) were assessed as >10%. This means 40% of cases received an initial overestimation of TBSA by referring hospitals. NETS medical teams transferred 34 patients to the Burns Unit, eight (24%) of which on retrospective review did not meet the NSW Burn Transfer Guidelines criteria for a medical team transfer. CONCLUSIONS: Our review demonstrated significant differences between the TBSA assessment of referring hospitals and the NSW Burns Unit. These inconsistencies may have resulted in children receiving treatment and transport not indicated based on accurate TBSA assessment. Potentially unnecessary transfers have implications for the displacement of children and families but also impact overall health costs and resource availability.

Improvement in mortality at a National Burn Centre since 2000: Was it the result of increased resources?

The aim of this study was to find out whether the charging costs (calculated using interventional burn score) increased as mortality decreased.During the last 2 decades, mortality has declined significantly in the Linköping Burn Centre. The burn score that we use has been validated as a measure of workload and is used to calculate the charging costs of each burned patient.We compared the charging costs and mortality in 2 time periods (2000-2007 and 2008-2015). A total of 1363 admissions were included. We investigated the change in the burn score, as a surrogate for total costs per patient. Multivariable regression was used to analyze risk-adjusted mortality and burn score.The median total body surface area % (TBSA%) was 6.5% (10-90 centile 1.0-31.0), age 33 years (1.3-72.2), duration of stay/ TBSA% was 1.4 days (0.3-5.3), and 960 (70%) were males. Crude mortality declined from 7.5% in 2000-2007 to 3.4% in 2008-2015, whereas the cumulative burn score was not increased (P  =  .08). Regression analysis showed that risk-adjusted mortality decreased (odds ratio 0.42, P  =  .02), whereas the adjusted burn score did not change (P  =  .14, model R 0.86).Mortality decreased but there was no increase in the daily use of resources as measured by the interventional burn score. The data suggest that the improvements in quality obtained have been achieved within present routines for care of patients (multidisciplinary/orientated to patients' safety).

Burden of burns in Portugal, 2000-2013: A clinical and economic analysis of 26,447 hospitalisations.

INTRODUCTION: There is a lack of recent and nation-wide epidemiological studies of burns in Europe, mainly in southern Europe. There are no recent studies describing the clinical and economic burden of burns in this European area. Hence, this research aimed to describe the clinical and economic burden of burn hospitalisations in Portugal. METHODS: A retrospective observational study was performed and the Portuguese hospitalisation database of public hospitals was used; all inpatients, discharged between 2000 and 2013, with a main or secondary diagnosis of burns (ICD-9-CM: 940.xx-949.xx) were taken into account. Furthermore, admissions to hospitals with and without burn centres were compared. RESULTS: A total of 26,447 burn hospitalisations were registered (mean of 1889burn admissions/year). The total hospitalisation rate was of 18.9hospitalisations/100,000inhabitants/year, and there was a higher incidence of male patients. Burn hospitalisations and hospitalisation rates are significantly decreasing - mostly in 0-14-year-old patients - and children below the age of 5 years represented a fifth of all admissions. Besides the important morbidity, the in-hospital mortality rate was of 4.4%. With a total annual charge of almost 13million Euros, the average cost per burn admission is increasing, and reached 8032Euros in 2013. Additionally, more than half of the patients admitted to hospitals without burn centres were not transferred to hospitals with burn centres, not following the European Burns Association transferral criteria. CONCLUSIONS: As the largest southern European nation-wide epidemiological study of burn patients, this research highlights that burn admissions, as well as hospitalisation rates, are decreasing significantly. This was particularly obvious among the youngest patients despite the fact that the numbers still remain very high. Moreover, the in-hospital mortality rate is still excessively high and the burn transferral criteria are not being followed. Thus, it is important to improve preventive measures, reach out to and educate providers about the burn transferral criteria, and develop specific health care strategies for children with these injuries.

The speech-language pathologist's role in multidisciplinary burn care: An international perspective.

PURPOSE: To explore international practices of speech-language pathology (SLP) within burn care in order to provide direction for education, training and clinical practice of the burns multidisciplinary team (MDT). METHOD(S): A 17-item online survey was designed by two SLPs experienced in burn care with a range of dichotomous, multiple choice and open-ended response questions investigating the availability and scope of practice for SLPs associated with burn units. The survey was distributed via professional burn association gatekeepers. All quantitative data gathered were analysed using descriptive statistics and qualitative data were analysed using content analysis. RESULT(S): A total of 240 health professionals, from 6 different continents (37 countries) participated within the study. All continents reported access to SLP services. Referral criteria for SLP were largely uniform across continents. The most dominant area of SLP practice was assessment and management of dysphagia, which was conducted in concert with other members of the MDT. CONCLUSION: SLP has an international presence within burn care that is currently still emerging.

Economic burden of burn injuries in the Netherlands: A 3 months follow-up study.

INTRODUCTION: Burn care has rapidly improved in the past decades. However, healthcare innovations can be expensive, demanding careful choices on their implementation. Obtaining knowledge on the extent of the costs of burn injuries is an essential first step for economic evaluations within burn care. The objective of this study was to determine the economic burden of patients with burns admitted to a burn centre and to identify important cost categories until 3 months post-burn. PATIENTS AND METHODS: A prospective cohort study was conducted in the burn centre of Maasstad Hospital Rotterdam, the Netherlands, including all patients with acute burn related injuries from August 2011 until July 2012. Total costs were calculated from a societal perspective, until 3 months post injury. Subgroup analyses were performed to examine whether the mean total costs per patient differed by age, aetiology or percentage total body surface area (TBSA) burned. RESULTS: In our population, with a mean burn size of 8%, mean total costs were €26,540 per patient varying from €742 to €235,557. Most important cost categories were burn centre days (62%), surgical interventions (5%) and work absence (20%). Flame burns were significantly more costly than other types of burns, adult patients were significantly more costly than children and adolescents and a higher percentage TBSA burned also corresponded to significantly higher costs. DISCUSSION AND CONCLUSION: Mean total costs of burn care in the first 3 months post injury were estimated at €26,540 and depended on age, aetiology and TBSA. Mean total costs in our population probably apply to other high-income countries as well, although we should realise that patients with burn injuries are diverse and represent a broad range of total costs. To reduce costs of burn care, future intervention studies should focus on a timely wound healing, reducing length of stay and enabling an early return to work.

Burns ITU admissions: length of stay in specific levels of care for adult and paediatric patients.

Prediction of total length of stay (LOS) for burns patients based on the total burn surface area (TBSA) is well accepted. Total LOS is a poor measure of resource consumption. Our aim was to determine the LOS in specific levels of care to better inform resource allocation. We performed a retrospective review of LOS in intensive treatment unit (ITU), burns high dependency unit (HDU) and burns low dependency unit (LDU) for all patients requiring ITU admission in a regional burns service from 2003 to 2011. During this period, our unit has admitted 1312 paediatric and 1445 adult patients to our Burns ITU. In both groups, ITU comprised 20% of the total LOS (mean 0.23±0.02 [adult] and 0.22±0.02 [paediatric] days per %burn). In adults, 33% of LOS was in HDU (0.52±0.06 days per %burn) and 48% (0.68±0.06 days per %burn) in LDU, while in children, 15% of LOS was in HDU (0.19±0.03 days per %burn) and 65% in LDU (0.70±0.06 days per %burn). When considering Burns ITU admissions, resource allocation ought to be planned according to expected LOS in specific levels of care rather than total LOS. The largest proportion of stay is in low dependency, likely due to social issues.

Burn management in sub-Saharan Africa: opportunities for implementation of dedicated training and development of specialty centers.

BACKGROUND: In low- and middle-income countries burn injuries remain responsible for a large burden of death and disability. Given an annual worldwide incidence of almost 11 million new individuals affected per year, major burn injuries have a higher annual incidence than HIV and tuberculosis combined. METHODS: A survey instrument was adapted for use as an international assessment tool and then used to measure the availability of personnel, materials, equipment, medicines, and facility resources in nine Rwandan hospitals, including three referral centers. RESULTS: Forty-four percent of surveyed hospitals had a dedicated acute-care burn ward, while two-thirds had intensive care options. Relevant wound-care supplies were widely available, but gaps in the availability of critical pieces of equipment such as monitors, ventilators, infusion pumps, electrocautery, and dermatomes were discovered in many of the surveyed institutions, including referral hospitals. Early excision and grafting were not performed in any of the hospitals and there were no physicians with specialty training in burn care. CONCLUSIONS: Whereas all surveyed hospitals were theoretically equipped to handle the initial resuscitation of burn patients, none of the hospitals were capable of delivering comprehensive care due to gaps in equipment, personnel, protocols, and training. Accordingly, steps to improve capacity to care for those with thermal injury should include training of physicians specialized in critical care and trauma surgery, as well as plastic and reconstructive surgery. Consideration should be given to creation of national referral centers specializing in burn care.