Carter Jeffrey E, Neff Lucas P, Holmes James H
Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC 27106, USA.
J Burn Care Res. 2010 Jan-Feb;31(1):26-30. doi: 10.1097/BCR.0b013e3181cb8efb.
The American Burn Association (ABA) has an established set of criteria for burn center referral to guide healthcare providers and improve patient outcomes. As U.S. healthcare becomes increasingly focused on improving quality of care (ie, pay-for-performance initiatives), assessing and monitoring the referral patterns to burn centers is critical in providing optimal burn care. Few studies have compared admission, treatment, and discharge patterns at burn centers and nonburn centers. Our goal was to compare practice and referral guidelines for patients with burn injuries by reviewing every discharge record in our state over a 2-year period. The study was conducted in a retrospective fashion using our state's hospital association patient database of International Classification of Diseases, 9th revision (ICD-9) discharge codes, querying 940.00 to 948.99, over the period of October 1, 2005, to September 30, 2007. Additional variables abstracted included the discharging hospital, outcome, race, gender, payor status, length of stay, procedures, and age. Adherence to referral criteria was established by comparing the discharge ICD-9 codes with the burn center referral criteria established by the ABA and American College of Surgeons Committee on Trauma in Guidelines for the Operation of Burn Centers. Injury patterns were analyzed using the 2 burn centers in our state and the remaining 107 nonburn centers providing care to burn patients. A total of 2036 adult patients aged 18 to 106 years sustained burn injuries requiring hospital admission, and 1416 (70%) met ABA referral criteria based on ICD-9 codes. Of the 1084 patients treated at burn centers, 88% met referral criteria. Of the 952 burns treated entirely at nonburn centers, 48% met referral criteria but were not transferred. The most common burns treated at nonburn centers included injuries to the hand, wrist, face, neck, and lower extremity. The mean number of criteria met by patients treated at nonburn centers was 1.5, and all deaths occurring at nonburn centers met referral criteria. A significantly higher percentage of patients with Medicare were not transferred from nonburn centers (P < or = .00001), and a significantly higher percentage of patients were discharged to nursing homes as opposed to home (P = .01) from nonburn centers. Forty-seven percent of the patients sustaining burn injuries in our state receive all of their acute inpatient care at nonburn centers, and almost half of these met ABA burn center referral criteria. Given the disparity in discharge placement and immediate availability of burn specialists in our state, all patients meeting ABA referral criteria should be referred to burn centers. More focused outreach and education for initial providers may help improve access and referral to burn centers.
美国烧伤协会（ABA）制定了一套烧伤中心转诊标准，以指导医疗服务提供者并改善患者治疗效果。随着美国医疗保健越来越注重提高医疗质量（如按绩效付费计划），评估和监测烧伤中心的转诊模式对于提供最佳烧伤护理至关重要。很少有研究比较烧伤中心和非烧伤中心的入院、治疗及出院模式。我们的目标是通过回顾本州两年期间的每份出院记录，比较烧伤患者的治疗实践和转诊指南。该研究采用回顾性方式，利用本州医院协会的国际疾病分类第九版（ICD - 9）出院编码患者数据库，查询2005年10月1日至2007年9月30日期间的940.00至948.99编码。提取的其他变量包括出院医院、治疗结果、种族、性别、付款人状态、住院时间、治疗程序和年龄。通过将出院ICD - 9编码与ABA及美国外科医师学会创伤委员会在《烧伤中心运营指南》中制定的烧伤中心转诊标准进行比较，确定是否符合转诊标准。利用本州的2家烧伤中心和其余107家为烧伤患者提供护理的非烧伤中心分析损伤模式。共有2036名年龄在18至106岁的成年患者因烧伤需要住院治疗，其中1416名（70%）根据ICD - 9编码符合ABA转诊标准。在烧伤中心接受治疗的1084名患者中，88%符合转诊标准。在完全由非烧伤中心治疗的952例烧伤患者中，48%符合转诊标准但未被转诊。非烧伤中心治疗的最常见烧伤包括手部、腕部、面部、颈部和下肢损伤。在非烧伤中心接受治疗的患者平均符合的标准数量为1.5项，且所有在非烧伤中心发生的死亡病例均符合转诊标准。医疗保险患者未从非烧伤中心转诊的比例显著更高（P≤0.00001），且与出院回家相比，从非烧伤中心出院到疗养院的患者比例显著更高（P = 0.01）。本州发生烧伤的患者中有47%在非烧伤中心接受了所有急性住院治疗，其中近一半符合ABA烧伤中心转诊标准。鉴于本州出院安置情况以及烧伤专科医生可及性的差异，所有符合ABA转诊标准的患者均应转诊至烧伤中心。对初始医疗服务提供者开展更有针对性的宣传和教育可能有助于改善烧伤中心的就医机会和转诊情况。
