Sunday, October 10, 2004

Hospital Volume Outcome and Discharge Distribution of Burn Patients

Salvatore J. Pacella, MD, Paul A. Taheri, MD, MBA, David A. Butz, PhD, Deborah R. Harkins, RN, Matthew C. Comstock, BBA, and William M. Kuzon, Jr., MD, PhD.

Purpose: The American Burn Association has well established guidelines for transfer of the burn patient. However, little is known about the distribution of burn patients or the clinical outcome of patients referred to burn centers. It is a widely held belief that burn care, like other forms of tertiary care, should be focused at high volume centers to optimize patient outcome. The purpose of this study was to examine the distribution of burn patients and the clinical outcomes associated with burn injuries treated at high and low-volume centers.

Methods: Diagnostic related group (DRG) classifications and discharge data from the National Inpatient Sample (NIS) was analyzed for 1998-1999. Most severe burns are codified in the lower numbered DRGs 504-505, whereas less severe burns are codified in 510-511. Data included discharge disposition (routine, home health care, transfer to another facility, death) for DRGs 504-511. A total of 8924 burn patients from 975 hospitals in 24 states were analyzed. Hospitals were segregated into either high volume hospitals treating 100 or more patients/year (HVH) or low volume hospitals treating 99 or fewer patients per year (LVH). Discharge disposition was then compared across hospital classification.

Results: Of the 975 hospitals in the sample, 20 were classified as HVH and 955 as LVH, which included 697 hospitals with fewer than 5 admissions per year. Patients admitted in DRGs 504-505 (extensive third degree burns) had a mortality rate of 34.4% (121/352). Only 29 patients in these two DRGs were admitted to LVHs. Within the more severe DRG 506, 63.1% (n=385) of patients admitted to HVHs were discharged home without home care compared to 54.5% (n=225) of patients admitted to LVH. Accross all DRG classifications, patients admitted to HVH had significantly higher percentages of discharges home without requiring home care and underwent fewer transfers to short term or nursing facilities than patients admitted to LVHs.

Conclusion: Life-threatening burns are typically admitted to high volume hospitals. Regardless of the severity of burn injury, patient discharge status is enhanced at high volume burn centers. Established infrastructure, discharge networks, surgical experience and vaster resources found at high volume hospitals may be important factors for determining routine discharges. Consideration for transfer to a high volume center should be given to all patients regardless of the size of the burn or the intensity of the care required.

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