Introduction:
In rural areas of the US, most healthcare facilities do not have the resources or expertise to deal with moderate to severe burns. Regional burn centers are often situated several hundred miles away from these facilities. Due to this reason, the transfer of a burn patient to these specialized centers may require air transportation — regardless of the condition of the patient. However, data indicates many patients transferred to burn centers are discharged within 48 hours. Although a majority of these patients fulfill at least one of the ABA referral criteria, the large number of early discharges suggests that these patients could have been referred for treatment at an outpatient clinic rather than being transferred to a burn center. Previous research has found that a major reason for unnecessary patient transfers (referred to as overtriage) is the inaccurate estimation of burns by referring physicians. It has also been shown that a significant portion of overtriaged patients were transported by air, which represents a large and avoidable expenditure to the healthcare system. In this context, it is critical to conduct outreach activities for educating rural healthcare facilities about the management of minor to moderate burns and the adverse impact of unnecessary transfers.

To make outreach programs more effective, it’s important to identify 1) common injury characteristics of overtriaged patients, and 2) referring facilities that contribute most to overtriage. This will help design targeted and more efficient interventions to reduce overtriage. In this study, our primary objective is to analyze the group of overtriaged burn patients and classify them according to injury characteristics to see if there is a predominant sub-group that could be targeted for interventions. For this purpose, we analyzed data of burn patients transferred over a five-year period to a regional burn center serving a large rural geographical area. It was found that a significant percentage of these patients were discharged within 48 hours, forming the overtriaged group. We further classified the overtriaged group according to burn etiology, degree of burn, presence of inhalation injury and burn area. A unique contribution of this research was the identification of a sub-group of patients with minor burns — defined as patients with thermal burns, no inhalation injuries, no third-degree burns, and total body surface area (TBSA) burned less than or equal to 5% — that comprised the majority of the overtriaged group. About 20% of these minor burn patients were discharged alive directly from the ED, without even requiring admission at the burn center. More than a third of these minor burn patients were flown to the burn center, representing an opportunity for significant potential savings in healthcare costs. Identification of this cohort allows the burn center to prioritize the type of burn injuries their outreach training activities should focus on.

Methods:
A retrospective review was performed of all burn patients transferred to a selected ABA-verified regional burn center over a five-year period between January 1, 2015 and December 31, 2019. This single-center review was approved by the institutional review board. Inclusion criteria were patients with thermal, electrical, and chemical burn injuries. Patients admitted with blunt or penetrating traumatic injuries, complications due to prior burns, and those with Steven Johnson’s syndrome, frostbite, and other non-burn related complex wounds were excluded. Overtriage was defined as being discharged alive from the burn center within 48 hours of transfer from a referring facility. Burn patient data retrieved from the institutional burn registry included age, date of injury, referring facility, date/time of admission, transfer mode, mechanism of injury, percentage TBSA burned for second and third degree burns, presence of inhalation injury, ICD-9 diagnosis, discharge disposition, and length of stay. Verification of missing/inconsistent data was performed by referencing the individual medical records. Statistical analysis was conducted in R (R Core team, 2020). Chi-Squared tests and Fisher’s exact tests were used for comparing proportions. The Shapiro-Wilk test was used to test the normality of probability distributions. The two samples Wilcoxon test was used for comparing distributions that were non-normal. A significance level of P < 0.05 was used in all cases.

Results:
Out of 1981 patients transferred to the selected burn center during the study period, 1763 met the inclusion criteria. 873 of these patients (49.5%) were discharged alive within 48 hours of admission and comprised the overtriaged cohort. A majority of the overtriaged patients (771, 88.3%) were thermal burn patients. The average percentage TBSA burned of the overtriaged cohort was 2.3%, which was significantly lower than that of the properly triaged group (11.6%). Almost 90% of the overtriaged cohort had TBSA burned ≤ 5%. The overtriaged patients also had a significantly lower number of third-degree burns (10.1% as opposed to 50.0%) and inhalation injuries (2.3% as opposed to 11.9%) compared to the properly triaged group. In-depth analysis of the overtriaged cohort revealed that patients in the minor burns category comprised the majority (609, 69.8%). This percentage was significantly higher than the proportion of minor burn patients in the properly triaged group (19.9%) with an odds ratio of 9.3 (95% confidence interval 7.5-11.6). Of these 609 overtriaged minor burn patients, approximately 35% were transferred by air. In addition, 117 (19.2%) were directly discharged alive from the ED affiliated with the burn center. This comprised 82% of the 143 total burn patients discharged alive directly from the ED.

Conclusions:
This study analyzed burn patient overtriage at a regional burn center using a 5-year dataset of burn patient transfers. The results showed that overtriage may be as high as 50%, indicating tremendous potential to improve the patient transfer process. A detailed analysis of injury characteristics of overtriaged patients helped to identify a primary sub-group of patients (minor burns) having only thermal second-degree burns, TBSA burned less than 5%, and no inhalation injuries. Minor burn patients were shown to have very high odds of rapid discharge. More importantly, almost a third of the overtriaged minor burn patients were flown to the burn center, while approximately 20% were directly discharged from the ED, representing significant and unwarranted healthcare costs.

In retrospect, it is better to refer many overtriaged patients to outpatient burn clinics, rather than transferring them to specialized burn centers. Doing this would result in considerable cost savings for patients, especially those who are unnecessarily airtransferred from distant rural areas. Inaccurate estimation of minor burns and the lack of expertise at rural healthcare facilities to treat such burns could be the primary reason for such transfers. By identifying the minor burns patient group, their significance and related injury characteristics, this study helps to design targeted intervention efforts to proactively reduce overtriage. For example, according to our results, it would be more impactful if training efforts gave priority to the proper estimation and treatment of second-degree thermal burns with small percentages of TBSA burned rather than inhalation injuries, intubation errors, and electrical, chemical or friction burns