Where should a patient with severe burns be admitted?

Where Should a Patient with Severe Burns Be Admitted?

Patients with severe burns (>10% body surface area epidermal loss) should be admitted directly to a specialized burn center without delay, as this approach significantly reduces mortality and morbidity compared to delayed transfer or admission to general intensive care units. 1

Admission Criteria and Destination

Direct Burn Center Admission (Preferred)

• Patients requiring specialized burn care should be admitted directly to a burn center rather than initially to a general hospital, as direct admission reduces time to surgical excision, duration of mechanical ventilation, and overall mortality 1
• Multiple studies demonstrate that burn centers provide superior survival outcomes due to their concentration of specialized expertise, dedicated facilities for managing extensive skin loss, and high patient volumes 1
• Early surgical excision and skin grafting performed at burn centers significantly reduce morbidity, mortality, and length of hospital stay 1
• Delayed transfer to burn centers is associated with increased mortality 1

Specific Admission Thresholds

Immediate burn center admission is indicated for: 1

• Adults with >10% body surface area (BSA) epidermal loss
• Circumferential third-degree burns causing compartment syndrome
• Burns involving critical anatomical areas (face, hands, feet, flexion lines, genitals, perineum) regardless of extent 2
• Severe cutaneous adverse reactions (Stevens-Johnson syndrome/toxic epidermal necrolysis) with >10% BSA involvement 1

Alternative ICU Admission

• If a burn center is not immediately accessible and the patient has hemodynamic or respiratory instability with long transport time, initial stabilization at a nearby ICU with burn experience may be considered 1
• The receiving ICU must have experience treating extensive skin loss, facilities for specialized wound care, and capability for multidisciplinary management 1

Essential Care Setting Requirements

Physical Environment 1

• Barrier nursing in a side room with controlled humidity
• Pressure-relieving mattress
• Ambient temperature maintained between 25°C and 28°C
• Facilities to manage logistics of extensive skin loss wound care

Multidisciplinary Team Coordination 1

The burn center team must be coordinated by a specialist in skin failure (dermatology and/or plastic surgery) and include:

• Intensive care physicians
• Ophthalmology
• Specialized burn nursing staff
• Additional consultants as needed: respiratory medicine, gastroenterology, gynecology, urology, oral medicine, microbiology, pain management, dietetics, physiotherapy, pharmacy

Critical Pitfalls to Avoid

• Never delay transfer to a burn center for patients meeting admission criteria, as delayed transfer directly increases mortality risk 1
• Do not perform escharotomy outside a burn center unless absolutely unavoidable, as poorly performed procedures increase morbidity; obtain specialist telemedicine consultation if transfer is impossible 1, 3
• Avoid admitting severe burn patients to general wards or non-specialized ICUs when burn center transfer is feasible, as this compromises access to early surgical intervention and specialized wound management 1

Role of Telemedicine

• Telemedicine consultation should be utilized when specialist burn surgeons are not immediately available to accurately assess burn severity, measure total BSA involvement, and determine appropriate triage 1, 2
• Telemedicine systems prevent both inappropriate transfers and dangerous delays in necessary transfers 1
• These systems must allow rapid image transfer and processing while meeting international telemedicine practice standards 1

Special Considerations for Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

• These patients require the same burn center admission criteria as thermal burns (>10% BSA epidermal loss) 1
• Calculate SCORTEN within the first 24 hours of admission to predict mortality risk 1
• Immune checkpoint inhibitor-induced severe cutaneous reactions (grade 3-4) require immediate burn unit or ICU admission with dermatology consultation 1