Section
9
TRANSFER
TO BURN FACILITY
Definition
of a Burn Center
The
burn center must be capable of delivering all
therapy required, including rehabilitation, and
must perform training of personnel and burn
research. Burn centers are generally found in
association with hospitals of 500 beds or more,
usually in university centers. No attempt has been
made to differentiate between the expertise
available and the severity of burns treated in
burn units as opposed to burn centers. Burn
centers do not provide treatment for only major
burns. In fact, the center should also treat minor
and moderate burns.
A burn
center must contain a minimum of six beds and must
have a designated director who is a board-certified
general or plastic surgeon with one additional year
of specialized training in burn therapy or
equivalent experience in burn patient care. The
intensive care unit training, or its equivalent,
plus a minimum of 6 months’ experience in burn
care. Fully trained and licensed or registered
physical therapists and registered occupational
therapists with a minimum of 3 months’ training or
6 months’ experience in burn treatment must be
assigned regularly. A licensed dietician must also
be assigned regularly.
Indications
for Patient Transfer
Using
these basic treatment settings, the American Burn
Association has identified three treatment
categories for burn patients: major, moderate, and
minor burn injuries.
Major
Burn Injuries
This
group includes second degree burns with a body
surface area greater than 25% in adults (20% in
children); all third degree burns with a body
surface area of 10% or greater; all burns involving
hands, face, eyes, ears, feet, and perineum; all
inhalation injuries; electrical burns; complicated
burn injuries involving fractures or other major
trauma; and all poor risk patients.
Major
burn patients would normally enter the system at the
site of injury and be transported to a hospital with
a burn center. The choice of a hospital depends on
distance and time, the patient’s burn
complications (respiratory condition, shock), and
bed availability.
The
American Burn Association emphasizes the importance
of direct communication and transfer agreements
among hospitals. If the seriousness of the
patient’s injury dictates transportation to the
closest emergency department of special expertise
hospital, than subsequent transfer to a hospital
with a burn center should be arranged after
establishing cardiopulmonary stabilization and
intravenous fluid therapy for shock. Rehabilitation,
including corrective surgery for cosmetic and
functional deficiencies, completes the therapeutic
circle.
Moderate,
Uncomplicated Burn Injuries
This
second group includes second degree burns with a
body surface area of 15 to 25% in adults (20 to 20%
in children), third degree burns with a body surface
of less than 10% and burns that do not involve eyes,
ears, face, hands, feet, or perineum. Excluded from
the group are electrical injuries, complicated
injuries (fractures), inhalation injuries, and all
poor risk patients (elderly patients and patients
with an intercurrent disease)
Most of
the patients in this group would receive emergency
care at the site of the injury and be transported
directly to either a special expertise hospital or
to an in-depth expertise hospital with a burn
center.
In
certain situations involving transfer difficulties,
a given hospital may have to assume the role of a
special expertise hospital temporarily.
Minor
Burn Injuries
The
third group includes second degree burns with a body
surface area of less than 15% in adults (10% in
children), third degree burns with a body surface
area of less than 2%, and burns not involving eyes,
ears, face, hands, feet or perineum. It excludes
electrical injuries, inhalation injuries
(fractures), and all poor risk patient.
The
patients in this group may be treated at the scene
of the accident by emergency medical technicians and
transported to a hospital emergency department where
definitive care begins. Definitive care includes
follow-up care and discharge of the patient after
complete recovery.
HOW
TO TRANSFER
The burn
patient, as opposed to the multiple trauma patient
with active blood loss, is unlikely to develop shock
or airway obstruction in the first 30 minutes
postburn. Therefore once oxygen is started at the
scene to treat carboxyhemoglobin, two options are
available:
To
transfer directly to burn facility if within 30
minutes
To
transfer to local emergency room to initiate
treatment, then to burn facility
The
objectives of the interim emergency room admission
are to : (1) secure an airway; (2) start fluid
therapy and completely neutralize the heat source.
These procedures should be performed before a long
transportation. Safety during transfer is more
important than speed. A warm environment with good
monitoring equipment, ventilator, if necessary, and,
of course, well-trained personnel. Within a 30 mile
radius, ground transportation is usually adequate.
Between 50 and 150 miles, the helicopter can save
considerable time and should be used if a safe
transportation can be provided.
