# Adherence to Burn Center Referral Criteria for Pediatric Burns

## TL;DR

This study finds that many children with severe burns in Ontario don't receive specialized care, suggesting a need for better referral practices.

## Contribution

The study quantifies low adherence to burn center referral criteria in pediatric care and identifies factors influencing specialized treatment.

## Key findings

- 43.6% of children met referral criteria, but only 21.6% received specialized burn center care.
- Meeting more referral criteria increased the likelihood of burn center treatment.
- Inhalation and chemical injuries were most strongly associated with specialized care.

## Abstract

This cohort study investigates the association between pediatric burn characteristics, including referral criteria, and receipt of care at a specialized burn center.

Is the presence of pediatric burn center referral criteria associated with treatment at specialized burn centers in Ontario, Canada?

In this cohort study of 79 782 children and adolescents with burn injuries, 43.5% met at least 1 burn center referral criterion; however, only 21.6% of these individuals received specialized care. Youths meeting 1 or more referral criteria were significantly more likely to be treated at a burn center.

In this study, adherence to burn center referral criteria in Ontario was low, suggesting missed opportunities for specialized care and a need for improved referral practices.

Burn injuries are a leading cause of emergency department visits and hospitalizations among children and adolescents. Referral to specialized burn centers is recommended for severe injuries, but adherence to referral guidelines in pediatric care remains uncertain.

To evaluate the association between pediatric burn characteristics, including referral criteria, and the setting of care, burn center vs non–burn center.

This population-based cohort study used linked health and administrative databases among all children and adolescents aged 0 to 17 years with a hospital visit for burn injury residing in Ontario, Canada (population, approximately 16 million), from April 1, 2003, to March 31, 2023. Data were analyzed from November 2023 to September 2024.

Presence and number of 1 or more of 6 measurable burn center referral criteria: burns over more than 10% of the total body surface area, full-thickness burns, critical anatomical areas, and inhalation, chemical, or electrical injuries.

Receipt of care at a specialized burn center vs a non–burn center. Adjusted rate ratios (aRRs) were estimated using modified Poisson regression.

Among 79 782 youths with burn injuries (median [IQR] age, 4 [1-12] years; 44 191 male [55.4%]), 16 164 individuals (20.3%) were rural residents, 19 067 individuals (23.9%) lived in the lowest material resource quintile, and 1636 individuals (2.1%) were nonrefugee immigrants. There were 34 812 youths (43.6%) who met at least 1 referral criterion, but only 7533 of these (21.6%) were treated at a burn center. Youths meeting any referral criterion were more likely to be treated at a burn center compared with those who met no referral criteria (aRR, 1.50; 95% CI, 1.46-1.54). The likelihood of burn center treatment increased with the number of criteria (1 criterion: aRR, 1.27; 95% CI, 1.23-1.30; 2 criteria: aRR, 2.63; 95% CI, 2.51-2.75; ≥3 criteria: aRR, 4.71; 95% CI, 4.32-5.15). Inhalation (aRR, 1.88; 95% CI, 1.21-2.91) and chemical (aRR, 1.80; 95% CI, 1.65-1.97) injuries had the largest aRRs in the association with burn center care.

In this study, burn center referral criteria were associated with increased likelihood of specialized care, although the application of criteria was inconsistent. These findings suggest that enhancing adherence to referral guidelines and addressing geographic and systemic barriers are essential to improving equitable access to specialized pediatric burn care.