Cost of providing inpatient burn care in a tertiary, teaching, hospital of North India.

There is an extreme paucity of studies examining cost of burn care in the developing world when over 85% of burns take place in low and middle income countries. Modern burn care is perceived as an expensive, resource intensive endeavour, requiring specialized equipment, personnel and facilities to provide optimum care. If 'burn burden' of low and middle income countries (LMICs) is to be tackled deftly then besides prevention and education we need to have burn centres where 'reasonable' burn care can be delivered in face of resource constraints. This manuscript calculates the cost of providing inpatient burn management at a large, high volume, tertiary burn care facility of North India by estimating all cost drivers. In this one year study (1st February to 31st January 2012), in a 50 bedded burn unit, demographic parameters like age, gender, burn aetiology, % TBSA burns, duration of hospital stay and mortality were recorded for all patients. Cost drivers included in estimation were all medications and consumables, dressing material, investigations, blood products, dietary costs, and salaries of all personnel. Capital costs, utility costs and maintenance expenditure were excluded. The burn unit is constrained to provide conservative management, by and large, and is serviced by a large team of doctors and nurses. Entire treatment cost is borne by the hospital for all patients. 797 patients (208 <12 years old) with acute burn were admitted with a mean age of 23.04 years (range 18 days to 83 years). The mean BSA burn was 42.26% (ranging from 2% to 100%). 378/797 patients (47.43%) sustained up to 30% BSA burns, 216 patients (27.1%) had between 31 and 60% BSA and 203 patients (25.47%) had >60% BSA burns. 258/797 patients died (32.37%). Of these deaths 16, 68 and 174 patients were from 0 to 30%, 31 to 60% and >60% BSA groups, respectively. The mean length of hospitalization for all admissions was 7.86 days (ranging from 1 to 62 days) and for survivors it was 8.9 days. There were 299 operations carried out in the dedicated burns theatre. The total expenditure for the study period was Indian Rupees (Rs) 46,488,067 or US$ 845,237. At 1 US$=Rs 55 it makes the cost per patient to be US$ 1060.5. Almost 70% of cost of burn management resulted from salaries, followed by investigations (11.56%) and dressings (8.24%). The mean cost of investigations per patient was Rs 6742.46 (US$ 122.59). Only 147/797 patients received 322 units of blood. Thus, the average cost of blood transfusion for all admissions was Rs 521.17 (US$ 9.47). Our study is evidence to direct costs of providing burn care in a tertiary centre of a low income country, and the large number of patients in our study while averaging the costs also validates the estimates. The 'reasonability' of care being delivered is defined by adequate resuscitation, daily topical dressings, appropriate surgery (escharotomy, debridement, and skin grafting), adequate nutrition and physical therapy. The 'reasonability' of outcomes can be measured by mortality figures. The bottom line of management is strict observation by burn staff. The low mean hospital stay also reflects our admission and discharge policy which is to benefit the maximum number of patients who require resuscitative/intensive care, and who have extensive and deep wounds, or injury of critical nature. We conclude that providing burn care based on our model can be emulated in other LICs as the costing is driven by 'necessity of expense' rather than 'ability to spend'.