TY - JOUR
AU - MD, Adam J. Singer,
AB - Abstract The incidence of burn injury has decreased over the past several decades. Although this has been largely attributed to increased prevention awareness, few studies evaluate the effectiveness of implementing standard burn prevention strategies in preventing burn injury. The authors hypothesized that patients who sustain burns use burn prevention strategies less frequently than those who do not. This was a case-control study composed of a prospective survey questionnaire and retrospective burn registry query, which was performed in a suburban academic medical center with a burn unit. All burn patients seen by the burn service in the year 2008 and a nonrandom sample of nonburned emergency department patients and visitors during the same time period were enrolled. Demographics included age, gender, income, education, house type, insurance status, and prevention strategy usage including smoke alarms, carbon monoxide detectors, fire extinguishers, and escape plans. The primary outcome of interest in this study was burn injury. Chi-square tests were used to compare rates, Student's t-tests were used to compare mean values of continuous variables between burn patients and others, and multivariate logistic regression was used to determine the strongest predictors of sustaining burn injury. One hundred ninety-four burn patients and 348 nonburned emergency department patients and visitors were surveyed. Burn patients reported the same rates of smoke alarm usage (96.9 vs 96.3%, P = .692), carbon monoxide detectors (75.3 vs 67.2%, P = .05), and higher rates of fire extinguisher ownership (80.4 vs 72.7%, P = .045) when compared with others. In multivariable analysis, the strongest predictor of sustaining burn injury was less than high school education (odds ratio [OR] 3.61, 95% confidence interval [CI] 1.27–10.27), whereas English as a primary language (OR 0.48, 95% CI 0.26–0.89), a graduate degree (OR 0.10, 95% CI 0.02–0.42), income >$50,000 (OR 0.46, 95% CI 0.29–0.72), and keeping flammable liquids in a locked place (OR 0.59, 95% CI 0.44–0.80) were protective against burn injury. Smoke alarms (OR 0.75, 95% CI 0.22–2.61), fire extinguishers (OR 1.34, 95% CI 0.80–2.32), and having an escape plan (OR 0.85, 95% CI 0.56–1.29) were not protective. Patients who sustain burn injury use burn prevention strategies at similar rates when compared with those who do not. When holding demographic characteristics constant, utilization of most burn prevention strategies is not protective of sustaining burn injury. Those with lower levels of education and income remain more susceptible to burn injury. Each year in the United States, an estimated 500,000 people seek medical attention for burn injury.1 The incidence of burn injury, however, has decreased over the past several decades.2 Prevention programs have been largely credited with the decrease.3 Prevention is crucial in that many fire fatalities do not survive long enough to receive hospital care.4 It is commonly believed that burn prevention programs lead to increased rates of implementation of burn prevention strategies (such as smoke alarm installation). Implementation of these strategies subsequently is believed to decrease the likelihood of sustaining burn injury. Prevention strategies, however, are rarely evaluated for efficacy. Previous reports indicate that lower socioeconomic status is a strong predictor of burn injury.5 Whether this stems from the lack of exposure to burn prevention programs and subsequent lack of prevention strategy utilization or something further that increases the susceptibility of this population is unknown. To explore this relationship, we sought to quantify the relative importance of prevention strategy implementation when compared with socioeconomic status in the prediction of burn injury. METHODS Study Design This was a case-control study composed of a prospective survey questionnaire and retrospective burn registry query. The burn registry is a single-institution registry established in 2008 and enrolls all burn victims seen by the burn service. Burn registries have been previously described as useful in studying injury prevention.6 Our registry records demographic information and a variety of characteristics about the patient's usage of burn and fire prevention strategies. The survey questionnaire was designed to administer identical demographic and prevention questions to nonburned patients and others. Both the registry and survey questionnaire are approved by the institutions' committee on research involving human subjects. Setting The research was completed in the Emergency Department (ED) of a suburban tertiary academic medical center with an annual ED census of 70,000 visits. As this is the only large academic hospital and regional trauma center, data collected in this ED reflect the county's diverse population. The medical center has a specialized burn unit with approximately 150 to 200 admissions per year and is the only burn center in a county of approximately 1.5 million people.7 Subjects All burn patients, both adult and pediatric, who were enrolled in the registry in the year 2008 were included in the study. The controls were a nonrandom sample of 300 English-speaking nonburned ED patients and visitors and 48 Spanish-speaking nonburned ED patients and visitors during the same time period who answered questions identical to those found in the registry. Measures Measures evaluated included age as a continuous variable, gender, income coded as a four group categorical variable (<$25,000, $25,000–$49,999, $50,000–$100,000, and >$100,000), education (less than high school, high school, college, and graduate school), the number and age of children in the house, house type (apartment, one story house, and two story house), and insurance status (commercial insurance, medicare, Medicaid, and none). In burn patients, the mechanism of injury was also recorded (thermal, chemical, or electrical). The thermal group was further divided into scald, flame, contact, vapor, or frostbite. Prevention strategy usage was assessed, including the use of smoke alarms, carbon monoxide detectors, fire extinguisher ownership, escape plans, and safe storage of flammable liquids. The presence of child safety devices aimed to prevent burns or fire was also assessed. All of the prevention strategies were coded as dichotomous variables (yes/no). Outcomes The primary outcome of interest in this study was burn injury. Data Analysis Data from the registry query and survey questionnaire were combined to compare rates of implementation of burn prevention strategies in burn patients and others. SAS software version 9.1 (SAS Institute, Cary, NC) was used for analysis. Chi-square tests were used to compare rates of usage of prevention strategies in burn patients and others. Where groups became too small to support the assumptions of a χ2 test, a Fisher's exact test was used instead. For those strategies most applicable to households with children, a subset analysis of households with children younger than 10 years was completed. Student's t-tests were used to compare mean values of the continuous variables, age and the number of people in the household. Multivariate logistic regression was then used to determine whether prevention strategies were protective of sustaining burn injury when holding demographic factors constant. The socioeconomic variables initially chosen for logistic regression were based on previous literature. Prevention variables chosen were those considered to be the most widely established burn prevention strategies. Various models were then compared, and the final model was chosen based on its predictive ability as evaluated with a c statistic. P < .05 was considered significant for all tests. RESULTS The burn registry included 194 burn patients seen during the year 2008, 41.8% of which were pediatric (<18 years old). The majority of the burns were thermal injuries (95.2%). Of these, scalds were the most common (49.7%; Figures 1 and 2). The comparison group was composed of 348 nonburned ED patients and visitors. The percentage of survey respondents using the Spanish language version was higher than the percentage of burn patients who enrolled using the Spanish language forms (13.8 vs 4.6%, P > .001). The burn patients were younger on average (26.9 vs 37.6 years, P < .001) and had a lower percentage of females (42.9 vs 53%, P = .025; (Table 1). The burn group had a higher percentage of respondents with less than high school education (11.5 vs 2.7%) and fewer with graduate education (1.8 vs 15.9%, P < .001). The percentage of subjects born outside the United States (18.5 vs 22%, P = .339) and the percentage with a non-English primary language (13.8 vs 20.4%, P = .057) were similar. The house type (house vs apartment) and the mean number of inhabitants were similar (P = .082 and .586, respectively). Finally, the annual household income and insurance status were also similar (P = .267 and .055, respectively). Figure 1. View largeDownload slide Mechanism of burn injury. Figure 1. View largeDownload slide Mechanism of burn injury. Figure 2. View largeDownload slide Thermal injury type. Figure 2. View largeDownload slide Thermal injury type. Table 1. Demographic characteristics View Large Table 1. Demographic characteristics View Large Burn patients reported the same rates of smoke alarm usage (96.9 vs 96.3%, P = .692), carbon monoxide detectors (75.3 vs 67.2%, P = .05), and higher rates of fire extinguisher ownership (80.4 vs 72.7%, P = .045) when compared with others (Table 2). The maximum temperature of the home's hot water, however, was known by fewer burn patients (76.6 vs 86.1%, P = .007). Next, a subset analysis of the 92 burn patients and 108 others who reported having children younger than 10 years in their households was performed (Table 3). For this group, those with burn injury reported higher rates of several prevention strategies, including stove safety devices (31.5 vs 16.3%, P = .014), outlet covers (81.5 vs 63.2%, P = .005), and bath thermometers (37 vs 23.3%, P = .037). Furthermore, burn patients reported a higher rate of safe storage of flammable liquids, that is, cool and dry storage area (61.6 vs 47.9%, P = .002). Fireplace guards, however, were used by fewer burn patients (13.8 vs 37.7%, P = .003). Finally, we found no differences in the rates of faucet guards (20.7 vs 16%, P = .401) or the percentage of people aware of the maximum temperature of hot water (76.5 vs 83.5%, P = .242). Table 2. Burn prevention strategy usage View Large Table 2. Burn prevention strategy usage View Large Table 3. Prevention strategy usage in households with children <10-yr old View Large Table 3. Prevention strategy usage in households with children <10-yr old View Large In multivariable analysis, the strongest predictor of sustaining burn injury was less than high school education (odds ratio [OR] 3.61, 95% confidence interval [CI] 1.27–10.27; Table 4). English as a primary language (OR 0.48, 95% CI 0.26–0.89), a graduate degree (OR 0.10, 95% CI 0.02–0.42), annual income greater than $50,000 (OR 0.46, 95% CI 0.29–0.72), and locking up flammable liquids (OR 0.59, 95% CI 0.44–0.80) were protective against burn injury. Smoke alarms (OR 0.75, 95% CI 0.22–2.61), fire extinguishers (OR 1.34, 95% CI 0.80–2.32), and having an escape plan (OR 0.85, 95% CI 0.56–1.29) were not associated with the outcome of burn injury. Table 4. Multivariable logistic regression predictive of sustaining burn injury View Large Table 4. Multivariable logistic regression predictive of sustaining burn injury View Large In light of this finding, the data were reanalyzed by collapsing the education variable into less educated (those with high school diploma or less) and more educated (college or graduate degrees) groups regardless of injury status. A comparison of all burn prevention strategies by education was performed, but no statistically significant differences were found (data not shown). DISCUSSION Recent decreases in incidence and severity of burn injury in the United States have been attributed to prevention programs and legislation aimed at burn prevention.8 A 2009 study of pediatric burns treated in EDs found a 31% decrease in incidence during their 17-year study period.9 Rates of use of common burn prevention strategies have been studied previously and are similar to the rates we found.10 More widely promoted strategies such as smoke alarms are in use in high numbers.10 A 2002 report from Dallas, however, suggested that in some instances such as fires started by children's fire play, the presence of a smoke alarm was not necessarily protective against burn fatality.11 This illustrates the importance of looking beyond rates of smoke alarm usage to more complex behaviors aimed at preventing burn injury. More complex strategies such as escape plans were not as commonly reported by our subjects. This is consistent with a 2007 national random digit dial telephone survey that reported only 52% of households had an escape plan and 16% practiced it every 6 months.10 The efficacy of most of the more complex strategies has not been evaluated previously. Households with children need particular attention because children not only constitute a large portion of burn victims12 but also are at an increased risk of fatal burns when compared with adults.5 Numerous burn prevention strategies are recommended specifically for parents, including a reduction in the maximum temperature of the water heater to 120°F.13 Lowell et al14 presented a review of 140 pediatric burn cases and found that current prevention strategies did not adequately address the circumstances of injury that were most common. These included removing hot contents from microwaves and supervision of small children by older siblings.14 In addition, carrying an infant and hot liquid simultaneously is also a common mechanism not necessarily covered by burn prevention programs.15 Previous reports have stated that socioeconomic status is correlated to risk of burn injury.5 We found that education was the single strongest predictor of any burn injury, regardless of burn prevention strategy use. However, others have written that income was most strongly correlated to burn injury.11 Residents of low-income census tracts were found to be at much higher risk of death from house fire when compared with others in a 2001 analysis of factors related to injury from house fire.16 It is possible that income in other studies may be a proxy for education or vice versa. Regardless, socioeconomic status outweighs self-reported prevention strategy utilization as the strongest predictor of sustaining burn injury in our data. The most effective public health initiatives are targeted to those at highest risk.17 We have identified those at risk in our community; however, the data call into question the utility of interventions promoting the traditional burn prevention strategies such as smoke alarms and fire extinguishers. The combination of our data and recent work on common burn mechanisms suggests that future initiatives not only need to target those with less education but also need to educate beyond common prevention strategies. Future initiatives might focus on behaviors that lead to an increased risk, such as supervision of young children by older siblings,14 cooking and food-related dangers,6 and fire play.11 LIMITATIONS As in all research, this study has many limitations. The comparison group was a nonrandom sample and therefore may not represent the true rates of burn prevention strategy usage in the population. The choice of comparison group (nonburned ED patients and visitors) may also introduce sampling bias, as they may not accurately represent the prevention technique usage of the population as a whole. In addition, survey research is subject to recall bias, and in this study, in particular, those with burn injury may be more keenly aware of their usage of burn prevention strategies and subsequently overreport their rates of usage. As the rates of implementation varied in burn patients in a similar way to those without injury, we can infer that the representation is reasonable despite recall bias. Education in this study was used as a means to evaluate socioeconomic status. The potential responses to level of education included less than high school, high school, college, or graduate school. Because a large percentage of the burn patients were children, the education level was indicated as N/A. In future studies, recording the education level of parents would likely be more valuable. Finally, it is wise not to overinterpret the results of the study and extrapolate that there is no need for smoke alarms, as previous studies have shown a protective effect of smoke alarms.16 CONCLUSION Patients who sustain burn injury use burn prevention strategies at similar rates to those who do not sustain burn injury. When holding demographic characteristics constant, utilization of common burn prevention strategies is not protective of sustaining burn injury. Those with lower levels of education and income remain more susceptible to burn injury. The association of education and income with burn injury is stronger than the association of prevention strategy utilization. Those of lower income and education should, therefore, be targeted in future educational initiatives. Future initiatives, however, are more likely to be efficacious if focused on recently reported risk behaviors rather than traditional prevention strategies. Our plans include partnerships with the local organizations who provide burn prevention education to not only address those risks that may not be traditionally taught in burn prevention programs but also to assure that those groups of seemingly higher risk have access to the programs. REFERENCES 1. Fact Sheet. American Burn Association, 2007; available from http://www.ameriburn.org/resources_factsheet.php; Internet; accessed February 17, 2009. 2. Taira BR, Singer AJ, Thode HC Jr, Lee C Burns in the emergency department: a national perspective. J Emerg Med  2010; 39: 1– 5. Google Scholar CrossRef Search ADS PubMed  3. Forjuoh SN Burns in low- and middle-income countries: a review of available literature on descriptive epidemiology, risk factors, treatment, and prevention. Burns  2006; 32: 529– 37. Google Scholar CrossRef Search ADS PubMed  4. Weesner CL, Hargarten SW, Aprahamian C, Nelson DR Fatal childhood injury patterns in an urban setting. Ann Emerg Med  1994; 23: 231– 6. 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Google Scholar CrossRef Search ADS PubMed  10. Ballesteros MF, Kresnow MJ Prevalence of residential smoke alarms and fire escape plans in the U.S.: results from the Second Injury Control and Risk Survey (ICARIS-2). Public Health Rep  2007; 122: 224– 31. Google Scholar CrossRef Search ADS PubMed  11. Istre GR, McCoy M, Carlin DK, McClain J Residential fire related deaths and injuries among children: fireplay, smoke alarms, and prevention. Inj Prev  2002; 8: 128– 32. Google Scholar CrossRef Search ADS PubMed  12. Peleg K, Goldman S, Sikron F Burn prevention programs for children: do they reduce burn-related hospitalizations? Burns  2005; 31: 347– 50. Google Scholar CrossRef Search ADS PubMed  13. Feldman KW, Schaller RT, Feldman JA, McMillon M Tap water scald burns in children. Pediatrics  1978; 62: 1– 7. Google Scholar PubMed  14. Lowell G, Quinlan K, Gottlieb LJ Preventing unintentional scald burns: moving beyond tap water. Pediatrics  2008; 122: 799– 804. Google Scholar CrossRef Search ADS PubMed  15. http://www.aap.org/family/1to2yrs.htm; Internet; accessed February 25, 2009. 16. Istre GR, McCoy MA, Osborn L, Barnard JJ, Bolton A Deaths and injuries from house fires. N Engl J Med  2001; 344: 1911– 6. Google Scholar CrossRef Search ADS PubMed  17. Gorman RL, Charney E, Holtzman NA, Roberts KB A successful city-wide smoke detector giveaway program. Pediatrics  1985; 75: 14– 8. Google Scholar PubMed  Copyright © 2011 by the American Burn Association
TI - Predictors of Sustaining Burn Injury: Does the Use of Common Prevention Strategies Matter?
JF - Journal of Burn Care & Research
DO - 10.1097/BCR.0b013e318204b2eb
DA - 2011-01-01
UR - https://www.deepdyve.com/lp/oxford-university-press/predictors-of-sustaining-burn-injury-does-the-use-of-common-prevention-i0LceN3FBI
SP - 20
EP - 25
VL - 32
IS - 1
DP - DeepDyve
ER -