What are the criteria to transfer a patient to a burn center?

Criteria for Transfer to a Burn Center

Patients with deep partial-thickness or full-thickness burns ≥10% TBSA, full-thickness burns ≥5% TBSA, burns involving critical anatomical areas (face, hands, feet, genitals, perineum, flexure lines), inhalation injury, electrical or chemical burns, or those requiring specialized care should be transferred to a burn center, with direct admission strongly preferred to reduce morbidity and mortality. 1, 2

Burn Severity Criteria Requiring Transfer

Total Body Surface Area (TBSA) Thresholds

• Deep partial-thickness or deeper burns ≥10% TBSA require burn center consultation 1
• Full-thickness burns ≥5% TBSA mandate burn center referral 1
• For children and older adults, lower thresholds apply due to specific dressing and medical needs 1
• Burns >20% TBSA require ICU-level burn center admission 3

Anatomical Location Criteria

Burns involving these critical areas require specialist consultation and likely transfer 2:

• Face (risk of airway compromise and disfigurement)
• Hands (functional disability risk)
• Feet (mobility impairment)
• Genitals or perineum (infection risk and functional complications)
• Flexure lines (contracture risk)
• Circumferential burns of limbs or torso (compartment syndrome risk) 2

Special Burn Types Requiring Transfer

• Electrical burns (high-voltage or low-voltage with significant tissue damage) 1, 4
• Chemical burns 1
• Radiation injuries 1
• Inhalation injury (suspected or confirmed smoke inhalation) 2, 3
• Frostbite 1
• Stevens-Johnson syndrome/TENS 1

Patient-Specific Factors

Age and Comorbidity Considerations

• Age >75 years with severe comorbidities and TBSA <20% still warrants burn center evaluation 3
• Children with TBSA ≥5% require formal resuscitation and burn center care 3
• Patients with diabetes mellitus are at increased risk of complications and should have early burn center referral 5

Clinical Instability Indicators

• Hemodynamic or respiratory instability may require stabilization at a nearby institution before transfer if transport time is long 2
• Cardiac arrest in the field with significant comorbidities suggests poor prognosis; telemedicine consultation should guide transfer decisions 6

Transfer Logistics and Timing

Direct vs. Secondary Transfer

Direct admission to a burn center is strongly preferred over secondary transfer because it: 2, 7

• Reduces time to surgical excision
• Decreases duration of mechanical ventilation
• Shortens ICU and hospital length of stay
• Improves overall survival and reduces long-term morbidity

Secondary transfers are associated with increased mortality risk and delayed definitive care 2, 7

Role of Telemedicine

When burn specialists are not readily available, telemedicine consultation should be used immediately to: 2, 1

• Accurately measure TBSA (prevents overtriage in 70-94% of cases)
• Determine burn depth and severity
• Guide initial fluid resuscitation
• Make appropriate transfer decisions
• Prevent unnecessary transfers that increase mortality risk

Common Pitfalls to Avoid

Assessment Errors

• TBSA overestimation occurs in 70-94% of cases by referring providers, leading to excessive fluid administration and complications 3, 1
• Use the Lund-Browder chart for accurate TBSA measurement, not the rule of nines 3, 1
• The patient's palm and fingers represent approximately 1% TBSA for quick field estimation 8, 3

Inappropriate Transfers

• Transferring expectant patients (revised-Baux score indicating futility) may not serve patient/family interests; telemedicine consultation can help identify these cases 6
• Delaying transfer for procedures that can be performed at the burn center (like bronchoscopy) increases morbidity 2
• Unnecessary intubation before transfer occurs in one-third of patients and increases complications 2, 3

Pre-Transfer Management Errors

• Failure to establish specialist consultation early increases morbidity and mortality 2
• Inadequate initial fluid resuscitation before transfer (should receive 20 mL/kg balanced crystalloid in first hour for adults >15% TBSA, children >10% TBSA) 8
• Delaying escharotomy when compartment syndrome is present; if transfer is not immediately feasible, obtain specialist advice before performing 3, 2

Specific Clinical Scenarios

Facial/Neck Burns

Intubation is not routinely required unless: 2, 3

• Deep circular neck burn present
• Symptoms of airway obstruction (voice change, stridor, laryngeal dyspnea)
• Very extensive burns (TBSA ≥40%)
• Exposure to vapors or smoke inhalation with risk of glottic edema

Electrical Burns

• All high-voltage electrical burns require burn center transfer 1
• Cardiac monitoring is essential due to arrhythmia risk 4
• Tissue damage is often deeper than surface appearance suggests 3

Smaller Burns Requiring Outpatient Follow-up

• Burns <10% TBSA that don't meet other criteria should be followed in burn center outpatient settings as soon as possible, preferably without delays of a week or more 1
• This ensures appropriate wound care and prevents complications like hypertrophic scarring 5