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journal homepage: www.elsevier.com/locate/burns

t.c o m journal homepage: www.elsevier.com/locate/burns Review Prognostic scoring systems in burns: A review N.N.
t.c o m journal homepage: www.elsevier.com/locate/burns Review Prognostic scoring systems in burns: A review N.N.

Review

Prognostic scoring systems in burns: A review

N.N. Sheppard * , S. Hemington-Gorse, O.P. Shelley, B. Philp, P. Dziewulski

St. Andrew’s Centre for Burns and Reconstructive Surgery, Broomfield, Chelmsford, United Kingdom

a r t i c l e i n f o

Article history:

Accepted 19 July 2011

Keywords:

Burns

Prognosis

Scoring system

Mortality

Contents

a b s t r a c t

Survival after burn has steadily improved over the last few decades. Patient mortality is,

however, still the primary outcome measure for burn care. Scoring systems aim to use the

most predictive premorbid and injury factors to yield an expected likelihood of death for a

given patient. Age, burn surface area and inhalational injury remain the mainstays of burn

prognostication, but their relative weighting varies between scoring systems. Biochemical

markers may hold the key to predicting outcomes in burns. Alternatively, the incorporation

of global scales such as those used in the general intensive care unit may have relevance in

burn patients. Outcomes other than mortality are increasingly relevant, especially as

mortality after burns continues to improve.

The evolution of prognostic scoring in burns is reviewed with specific reference to the

more widely regarded measures. Alternative approaches to burn prognostication are

reviewed along with evidence for the use of outcomes other than mortality. The purpose

and utility of prognostic scoring in general is discussed with relevance to its potential uses in

audit, research and at the bedside.

# 2011 Elsevier Ltd and ISBI. All rights reserved.

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2.

Materials and methods

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2.1. Abbreviated burn severity index (ABSI) 1982

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2.2. Cape Town modified burns score 1998

 

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2.3.

Ryan

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2.4. Burd 2002

 

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2.5. Belgian outcome in burn injury (BOBI) 2009

 

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2.6. Laboratory-based prognostic scoring

 

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2.7. Non burn-specific measures

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2.8. Predicting other

 

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2.8.1.

Length of stay .

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2.8.2.

 

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3.

Quality of life .

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Discussion

3.1.

Designing a scoring

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* Corresponding author at : 34 Tithe Close, Gazeley, Newmarket, Suffolk, CB8 8RS, United Kingdom. Tel.: +44 1371830454; fax: +44 07980901395. E-mail address: nicknsheppard@hotmail.com (N.N. Sheppard). 0305-4179/$36.00 # 2011 Elsevier Ltd and ISBI. All rights reserved. doi: 10.1016/j.burns.2011.07.017

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3.1.1.

Mortality prediction in practice

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3.1.2.

Predicting death at the bedside

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3.1.3.

Predicting outcome for research

 

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3.1.4.

Internal audit

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4.

Conclusion

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References

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1.

Introduction

Survival after burn has steadily improved over the last few decades. With overall death rates in the range of 5–15%, patient mortality is still at the forefront of outcome measures for burn care. Numerous factors combine to form a clinical picture and dictate interventions and outcome. Scoring systems aim to use the most predictive of these factors to yield an expected likelihood of death for a given patient. This prediction has a number of potential uses. The standardised mortality ratio (SMR) is the ratio of observed to predicted deaths and can be used as an index of a units overall performance. A scoring system enables a plot of performance over time, which takes into account variations in case-mix. A standardized tool allows for improved research and comparison of therapeutic interventions. The SMR is used as the endpoint for trial of an intervention. The ideal scoring system would extend beyond research and audit. A robust schema should improve our ability to provide a bedside prognosis and even plan delivery of treatment, provision of services and identify the patients in whom a palliative approach should be taken over one of aggressive intervention [1]. Some, however, would argue that no score should determine medical interventions [2]. Any of the above may be possible for a system that is locally standardised, but the final step is for a scoring tool to retain accuracy and precision when applied to different patient populations in differing units with inevitably differing case- mixes. For this a multi-centre approach is required. The search for understanding of the factors contributing to mortality has been an integral part of burns research from early in its nascence as a specialized area of practice. Studies from Copenhagen [3] and Toronto [4] paved the way for an analysis by Bull and Fisher [5], which yielded a prognostic nomogram based on age and percentage area burned. It was Baux in 1961 who first described the oft quoted rule- of-thumb that:

Mortality rate ¼ age þ percentage area burned

This was only published in a thesis in French, but gained wide international acceptance [6]. A later modification was the prognostic burn index (PBI) below which takes account of the effects of differing burn thickness [7].

1

PBI ¼ TBSA full thickness þ 2 ðTBSA partial thicknessÞ þ age

Much of the work over the subsequent decades centred entirely around the two variables of age and burn surface area. During this time burn mortality fell with each step of progress in general intensive care and burns surgery [8]. Fluid

resuscitation, improved intensive care techniques and early surgical excision are just a few of many advances which have improved the prognosis for the burned patients. Inhalational injury was subsequently found to be highly predictive and yielded the equation by Clark [9] e z

p ¼

1 þ e z

where p = probability of mortality, z = 7 9 + 0.78(respiratory symptom score) + 0.094(TBSA) + 0.34(age). The need for a more refined approach to burns care analysis has prompted many attempts to generate predictive models and considerable debate as to the merits of this approach. We look in detail at the work undertaken to better elucidate the relationship between the patient, their injury and their risk of subsequent mortality.

2. Materials and methods

Pubmed and medline databases were searched using the terms burn, score, outcome, prediction and mortality. Sub- searches were performed for intensive care outcome, mortali- ty, quality and score and each resultant scoring systems name cross-referenced with the term burn. Numerous papers have looked at prognostic factors alone, but we have focussed on those which have generated a scoring system per se. All named burns scoring systems are included, or those general ITU systems for which there is evidence or opinion relating them to burns patients. The better-known, most recent and more widely evidenced systems are the subject of more detailed discussion.

2.1. Abbreviated burn severity index (ABSI) 1982

Published in 1982 the ABSI is in widespread use [10]. The system was based on analysis of over 1300 patient records. The system used multivariate logistic regression to determine the power of 5 variables (gender, age, inhalation injury, %TBSA and presence of FT burn) to predict mortality. Each variable was then assigned a numerical value which varies according to severity. The sum of these values is used to predict mortality ( Table 1). Tobiasen et al. applied the score to an estimation group and

found it to be accurate at predicting risk. It was then validated using data collected from a combination of community hospitals and burn centres and once again found to be accurate. This scoring system is easy to use and based upon simple clinical findings. It gives a range for survival which may be of benefit when discussing outcomes with family members.

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b u r n s 3 7 ( 2 0 1 1 ) 1 2 8 8 – 1 2 9 5

Table 1 – Abbreviated burn severity index.

Variable

Patient characteristic

Score

Sex

Female

1

Male

0

Age in years

0–20

1

21–40

2

41–60

3

61–80

4

81–100

5

Inhalation injury Full thickness burn TBSA %

1

1

1–10

1

 

11–20

2

21–30

3

31–40

4

41–50

5

51–60

6

61–70

7

71–80

8

81–90

9

91–100

10

Total burn score

Threat to life Very low Moderate Moderately severe Serious Severe Maximum

Survival probablity

2–3

> 99

4–5

98

6–7

80–90

8–9

50–70

10–11

20–40

12–13

< 10

Its accuracy has been confirmed by validation both internally and externally. It does however need to be charted and visible within a burns unit as it is difficult to remember the value of all components. Once again it acts only as a guide for outcome and is not an absolute predictor of mortality.

2.2. Cape Town modified burns score 1998

The main aim of the Cape Town system was to improve the Baux score and create a triage-type scoring system to ensure that burn injured patients are directed to the appropriate centre (i.e. intensive care or ward) for management [11] . The authors acknowledge that %TBSA and age have an equal effect on outcome but recognize the importance of the presence or absence of an inhalation injury. They attempt to refine the Baux score by assigning a numeric value to the degree of inhalation injury. As in the ABSI score multiple logistic regression is utilized to determine the impact of %TBSA, age and inhalation injury on mortality concentrating in particular on inhalation injury. The Cape Town group noted that they encountered 28 deaths which were not predicted by the Baux score. Of these 24 had an inhalation injury. Using multiple regression analysis it was determined that each grade of inhalation injury (mild, moderate, severe, score 1, 2, 3 respectively) had 20 the effect on mortality. The modified burn score thus created: age + %TBSA + (20 inhalation score) was found to markedly improve the predictive value from 43% with Baux to 84% in their patient group. The disadvantage of the modified score was a fall in specificity. Once again the score is easy to remember and apply however it is not accurate at predicting outcome. Its increased sensitivity is at the expense of a high rate of false predictions

of mortality. It is however a useful resource for triage when mass causalities may exceed capacity for treatment.

2.3. Ryan 1998

This study was based on a retrospective review of 1665 patients admitted to Massachusetts General Hospital and the Shriners burns institute between 1990 and 1994 [12]. It was published in 1998. Age greater than 60, TBSA greater than 40% and inhalational injury were identified as risk factors for mortality. Gender, admission and discharge dates, type of burn, and need for escharotomy were analysed and found not to be predictive. Their calculations led to a simple scoring system based on how many of the above three risk factors were present. Hence, no risk factors gave a mortality of 0.3%, 1 factor 3%, 2 risk factors 33% and all 3 risk factors had a mortality of 90%. This held for patients under the age of 90. The widely held criticism of this system is that the mortality rates for the higher-risk burns with scores of 2 or 3 were based on groups of 111 and 22 patients, respectively. It has also been noted that few authors have been able to report an overall mortality rate as low as in this cohort (4%) [10,11,13] and the scoring system has been found to under-predict mortality in severely burned patient groups [14]. All of this suggests that the system is based too heavily on lower risk burns and fails on accuracy with larger, high-risk burns in whom mortality is more likely.

2.4. Burd 2002

This study sought to isolate burns of greater than 10% from the broader burn population and yield a predictive model for major burns in Hong Kong [15] . 286 major burns were seen over a 7 year period with a median burn size of 18%. Stepwise logistical regression was used for the analysis. Independent risk factors for death were inhalational injury, age and TBSA. LOS was, in addition to these, predicted by gender. The formulas are given below.

Probability of death ¼ ð1 þ eyÞ 1 where e ¼ 2 : 718;

y ¼ 3 : 6 1 : 7ðinhalation injuryÞ þ 0: 001ð ageÞ 2

þ 0 : 001ðTBSA of burnÞ 2 ; ¼ inhalation injury ðno ¼ 1; yes ¼ 0 Þ

LOS ¼ 8: 7 þ 2 :1 ðTBSA of burnÞ 0: 0018ðTBSA of burnÞ2

þ

16: 7ðinhalation injuryÞ 9 : 4ðSexÞ y ;

¼ inhalation injuryðno ¼ 0 ; yes ¼ 1 Þ;

y

¼ sexðfemale ¼ 1; male ¼ 2Þ

In essence, the mortality component of this study is very similar to the much earlier Clark formula [9] . It demonstrates the usefulness of multivariate analysis in yielding a manageable ‘line-of-best fit’, the equation for which can be put into practice as a unit-specific predictive measure. In this case their formula proved 93% positively predictive although it is not clear whether this was carried out on a separate study population or on the population from which it was derived. In this study, it is of note that length of stay is not predicted by age but by gender; they do not go on to elucidate exactly how predictive this formula subsequently proved to be.

b u r n s 3 7 ( 2 0 1 1 ) 1 2 8 8 – 1 2 9 5

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Table 2 – Belgian outcome in burn injury scale. 0 1 2 3 4 Age
Table 2 – Belgian outcome in burn injury scale.
0
1
2
3
4
Age (years)
< 50
50–64
65–79
> 80
TBSA (%)
< 20
20–39
40–59
60–79
> 80
Inhalation injury
No
Yes
Total score
0
1
2
3
4
5
6
7
8
9
10
Predicted mortality (%)
0.1
1.5
5
10
20
30
50
75
85
95
99

2.5. Belgian outcome in burn injury (BOBI) 2009

The BOBI scoring system is the most recent addition to the severity scores [16]. The group attempted to develop a model that accurately predicted the probability of mortality based upon the clinical parameters set out by Ryan et al. in essence this scoring system attempts to increase the predictive value of Ryan’s scoring system by subdividing patients according to age and TBSA ( Table 2). The model was derived using data from prospectively recorded databases for more than 5000 patients between 1999 and 2003. As expected the majority of patients fell into the low risk mortality groups with 270 patients scoring 5 and above. This might lead one to believe that as with Ryan the scoring system is flawed however this does not appear to be the case. Prior to initial publication the scoring system was validated in a further 981 patients and was found to accurate predicting 40 of 42 deaths. To add weight to its value the model has been tested with a different population for external validation [17]. The system once again demonstrated a high predictive value. As with all scoring systems there are drawbacks and limitations. A major criticism levelled at all such systems is that the impact of complications and co-morbidities is often ignored. The Belgian group acknowledged this but rightly point out that the impact of co-morbidities is too small to sway the prediction score. They also point out that many of the complications which adversely affect survival occur in the most severe injuries who would score highly on mortality prediction. It is also therefore assumed that this does not further impact outcome. The Belgian scoring system has clear advantages over the Ryan and ABSI. It refines the Ryan score hence increasing predictive value [14,17] and is more simple and easier to remember than ABSI for bedside use. Its place however in prospective prediction of poor outcome is yet to be determined.

2.6. Laboratory-based prognostic scoring

Taking the process a step further from the bedside are the studies which examine biochemical and inflammatory mar- kers and their correlation with burn mortality. The unique burn inflammatory response may combine with variables such as age and inhalation injury to yield a specific change in biochemical constitution which can readily be assessed by simple laboratory assays. The prognostic inflammatory and nutritional index (PINI) is one such system [18] . Plasma levels of albumin, prealbumin, orosomucoid and C-reactive protein (CRP) were found to correlate with burn severity. Subsequent work showed the

PINI to correlate with mortality [19] in 60 patients with burns of mean 44.7% TBSA. Early changes in renal function have been shown to independently predict mortality [20]. This readily measurable parameter may reflect much of the systemic effect of the inflammatory response and hypoperfusion which goes on to bring about death after a burn. In a similar vein, base deficit and lactate changes over the first 24 h correlate with mortality [21]. Tumour necrosis factor (TNF) has been found to correlate with mortality and to be independent of burn area and age. It was more common in, but not limited to those with sepsis [22]. The study results include unexplained anomalies and lacked the statistical power to definitively confirm predictive merit in the assay, but the correlation has been borne out since. It was shown that admission TNF level did not correlate with burn surface area or mortality rates, but the maximum level attained during the admission did [23] . Other circulating inflammatory factors released after burn have been the subject of intense research. IL-6, IL-8 and IL-10 have all been demonstrated to increase following burns, but there are conflicting studies as to their correlation with subsequent mortality [24,25].

2.7. Non burn-specific measures

The APACHE or ‘acute physiology and chronic health evalua- tion’ score was developed in the early 1980s by Knaus et al. [26]. His initial 34 variables were narrowed down to 12 in 1985 with the development of APACHE II [27] . This system assigns points for aberrant variables occurring within the first 24 h of ITU admission. As such it goes further than any of the existing burn-specific systems in using the patients response to initial goal-directed therapy as part of their prognostic determina- tion. It was updated to APACHE III in 1991 and is a highly regarded tool used throughout the literature [28]. Apache II score on admission was found to be associated with subsequent mortality in burns [29]. Apache III has been formally tested on a burn population and found to correlate with mortality and PBI [30]. The correlation coefficient for APACHE III score plotted against PBI was .74. However, with a sample size of just 74 with completed APACHE scores of which 14 died the study does not allow us to draw conclusions as to whether this proved to be the better predictor of mortality than the burn-specific models. These findings yielded the appropriately titled FLAMES score (fatality by longevity, APACHE II score, measured extent of burn, and gender). In 1439 patients attending a single unit, this achieved areas under the receiver operating characteristic (ROC) curve of 0.97 in the population from which it was

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developed and 0.93 in a validation population [31] . Thus, it performed better than APACHE or burn indexes alone. APACHE III score and burn severity (in terms of full thickness area) have been shown to provide more reliable prediction of mortality in burn patients when combined than can either score alone [32] . The study lacks the numbers required to fully validate a scoring system, but it demonstrates integration of burn-specific factors with the APACHE score and paves the way for a larger investigation of this combination. APACHE IV is the most recent incarnation [33] . The Sepsis-Related Organ Failure Assessment tool specifi- cally looks at organ-failure in the ITU population [34]. SOFA scores were investigated in 439 burns intensive care patients. The SOFA score on days 0–4 and the rate-of-change of this score are predictive of mortality and this is independent of age, sex, TBSA or inhalational injury [35]. Organ failure has been investigated in a burns population. The ‘Thermal Injury Organ Failure Score’ was developed in a study looking at organ failure and performed better than APACHE II in predicting mortality [36]. SAPS (simplified acute physiology score) was developed as an offshoot of APACHE I and was updated in 1993 to SAPS II [37]. Both SOFA and SAPS scores were used as part of a study looking at mortality and quality-of-life (QoL) correlates. Both scoring systems were found to correlate with mortality [38] , but with numbers of just 50 and with only 19 QoL 1-year follow-ups, again, lasting conclusions with respect to these scoring systems cannot yet be made. The paediatric intensive care population was addressed specifically by the PRISM (paediatric risk of mortality) score. This was first developed in 1988 [39] and has subsequently been revised to PRISM III-APS (Acute Physiology Score). It was originally a condensation of the physiologic stability index to 14 routine physiologic variables based on 116 deaths in 1415 patients across 4 units. PRISM scores were combined with operative status and age to provide a good predictive performance. The revision to PRISM III was performed on a larger data set and takes into account readings at 12 and 24 h following admission [40] . It performs better than its predeces- sor for a general ITU population. The system has not been looked at for a burn-specific paediatric population. While the use of non-burn specific measures may prove valid in a general ITU population, none take into account the profound physiological effects of the burn itself. In isolation, they cannot compare to measures that do take into account the burn. However, the rigor with which they have been formulated and the number of variables that have proved worthy of inclusion through thorough statistical analysis, may provide a standard to which we should be striving in the development of a robust burns scoring system.

2.8. Predicting other outcomes

It has long been argued that mortality should no longer be the only yardstick against which burn care is measured. In the short term mortality may be valid. However, consideration should be given to medium-term measures of persistent hypermetabolic response and length of stay. In the long term, quality of life and exercise tolerance may be relevant endpoints for consideration [41].

2.8.1. Length of stay

Length of stay has been looked at in some of the studies in which mortality was the primary burn outcome [12,15,16] . There is a rule-of-thumb for which a reference could not be found that length of stay in days is roughly equal to value for TBSA. Ryan found that patients could be subdivided by burn size to give predictions of a probable range in which the length of stay would fall. These ranges are broad, but loosely correspond to the crude rule above. If this relationship is expressed as the ratio of length of stay in days/TBSA, we can aim for a value of 1 [42] . The Hong Kong study discussed earlier [12] yielded an equation for prediction of length of stay and crucially found that sex was more predictive than age. The equation has not been the subject of subsequent prospective analysis. Further study of these parameters with larger data sets and stratifica- tion rather than a simple line of best fit analysis may give a clearer picture of this relationship.

2.8.2. Quality of life

While the predictive factors for quality of life after burns have been examined in a number of studies, no predictive scoring system has yet been developed. The burn specific health scale (BSHS) is the current standard measure for quality of life outcomes after burns [43,44]. It is a laborious questionnaire which considers 114 items divided into 8 sub-scales. Many variations, including abbreviated versions have been developed, each with their merits and were reviewed in detail by Yoder et al. [45]. This paper also summarizes the data from numerous studies which identified factors affecting eventual quality of life scores on this scale. BSHS scores have been shown to correlate with extent of burn and burn location (particularly hand and face) along with length of stay and eventual mobility [46,47]. Furthermore, it was shown that psychosocial support, both existing pre burn and that offered by friends, family and professionals post burn is a key predictive factor for subsequent rehabilitation [48]. The Short-Form 36 survey has been used in one study which found two factors in addition to the established variables for mortality prediction. In the physical section of the survey, hand function at follow up correlated strongly with overall QOL score. For the mental section, pre-existing social support was found to be predictive of outcome [43]. Psychological well-being has been found to be independent of burn severity [49]. In the same study of 34 burn patients, subsequent psychopathology was found to correlate with pre-injury psychological state, coping mecha- nisms and a threat of death at the time of the injury. An all-encompassing approach to prediction modelling for the burn patient should consider these factors in its analysis, but as yet none has gone this far and until quality of life endpoints can be reliably assessed, scoring systems for their prediction will lag some way behind.

3.

Discussion

3.1. Designing a scoring system

Certain parameters clearly have a place in any prognostic index. The inclusion of age and burn area are widely agreed,

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but there remains disagreement in the literature as to the relative merits of total burn area versus the area of full thickness burn. In an Australian cohort of 228 patients, full thickness area was found to correlate with mortality where partial thickness area did not [32] . The ‘Smith score’ adds considerable weight to the presence of absence of inhalational injury [50] and the relevance of this parameter in prognostic scoring is now widely accepted. However, it has been suggested that the need for invasive ventilation may be more predictive than inhalational injury alone [51]. There is also the question of how inhalational injury is defined as it can be diagnosed on clinical examination or by bronchoscopy. Parameters which remain contentious are those of gender, mechanism of injury and the physiological variables which come in when burn factors are combined with any of the established ITU prognostic models. The principal disagreement between many of the proposed scoring systems is the relative weighting of the basic components. The continued findings of each unit that a new model best predicts performance in their patient group may simply reflect the heterogeneity of burns patient groups and practice and be evidence for the futility of attempts to develop an all-encompassing prognostic tool.

3.1.1. Mortality prediction in practice

The margin for error of any scoring system depends entirely on its intended use. Of the potential uses covered earlier some are beyond the scope of any of the existing scoring measures. Developing new measures or selecting from existing scoring systems must be done in the context of the intended application. All of the published scoring systems show validity for the patient groups on which they were developed, but care must be taken when planning to broaden their scope.

3.1.2. Predicting death at the bedside

It has been described as a ‘nightmare scenario’ that bedside decisions may be made on the basis of a score [2]. Ryan et al. found that in 37 similar patients with an intermediate risk for death according to his scoring system, 11 had ‘‘do no attempt to resuscitate’’ (DNAR) orders and 26 did not. Only 5 of the 26 patients who were expected to die went on to do so. There were no differences between the resuscitated or DNAR groups in terms of Ryan score or any of the other factors examined in the paper [12]. The scoring system did not provide useful information during the decision-making process and the eventual outcomes show that had it have been used for decision-making, more of the 26 for whom DNAR orders were not issued may have died unnecessarily. Such a retrospective analysis, albeit at risk of selection and observer bias would be a worthy test of any score being put forward for clinical application. Ryan’s findings are a salutary warning against the clinical application of such measures. The alternative to an objective scoring system is the subjective view of the clinician, in combination with those of the whole clinical team. Sensitivity and specificity for APACHE II versus clinical opinion were compared and subjective appraisal was found to perform better in the mixed intensive care population studied [52]. ‘Clinical sense’ has subsequently been shown not to differ in accuracy from the APACHE III score [53]. Such similarity can be argued to validate the scoring system

against the current accepted standard. Moreover, however, it demonstrates a lack of need for it at the bedside. If the rigmarole of collating scores offers no meaningful benefit over the opinion of an experienced team, they have no clinical merit. The exception to this may been where experience is limited and a useful mortality prediction provides something of an alternative. In Western medicine in the modern era with centralized burn services and considerable specialist exper- tise, this is rarely a requirement. However, in parts of the world where access to specialist burns services are more limited, this kind of prognostic evaluation may be invaluable. For this to work, however, the scoring system in use must been one validated on an equivalent population with a similar lack of access to facilities. Such a situation may be best served by the simplest Baux calculation, but the work is yet to be done to demonstrate this. Medicine in the developed world is under increasing financial pressure and here there are further warnings for the implementation of mortality prediction. In uncertain economic times there is a concern that scoring patients may provide opportunities for bureaucrats to limit therapeutic options [2].

3.1.3. Predicting outcome for research purposes

There is a clear requirement to risk-stratify patient groups in order to properly assess outcomes following the introduction of novel therapies. With so many scoring systems to choose from, how does the researcher make a selection to best analyse their units outcomes or the efficacy of a new intervention? One approach may be to retrospectively compare the existing systems within their unit and ascertain which proves to be the most applicable to use prospectively in their research population. The most rigorous approach may be to use more than one or as many as possible. Since most of the burns systems are based on similar information, scores could be included from numerous models with little extra effort. This would have the double benefit of adding rigor to the findings of an individual study, but will also provide much-needed information for a later reviewer to conclude which is the most reliable of the existing prognostic prediction measures.

3.1.4. Internal audit

Sound clinical practice and the ongoing assessment of its quality includes the need for audit. Internal audit of mortality is the most basic means of assessing trends in a unit’s performance. Dose–response data such as burn area to mortality require probit analysis to determine meaningful statistics. This renders dose–response data – in this case e.g. TBSA and mortality – into a linear relationship from which an LD 50 can be calculated. That is, in this example, the percentage burn at which that unit has a mortality rate of 50%. It can also be used independently for age and other continuous variables. It is useful as an audit tool for its simplicity, but does not attempt to provide multivariate information. A more complex scoring system provides a basis for local audit of mortality with a correction for case-mix. Internal audit is the most robust circumstance in which scoring systems are useful as many of the criticisms applied thus far apply when their remit is thus reduced.

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In the evolving climate of transparency there may be merit in the compulsory publication of a unit’s figures for agreed outcome parameters including mortality. This could be corrected for case-mix using one of the above systems. While comparisons between units may be unfair or problematic, trends with time within a unit will be a good guide to its ongoing performance and may allow timely intervention should standards show evidence of falling. Cumulative SUMmation (CUSUM) charts have been de- scribed as a method of continuous monitoring and have been extensively used in industry for quality control purposes. CUSUM charts for prospective surveillance of mortality have been proposed and utilized in many clinical fields including Cardiac Surgery, Anaesthesia and General Practice [54,55] to enable early detection of substandard outcomes. We are in the process of assessing this methodology to continuously monitor our own burn service to see if this is a valid tool in the burn setting. To perform a CUSUM analysis the data for each patient is continuously plotted as a cumulative sum of the observed (Xo) minus the expected (Xe) outcome or Xn = Xn(1) + (Xo Xe). Expected outcomes can be generated by using the scoring systems described. CUSUM charts can be generated for burn service providers to continuously monitor outcome data. Deviation below the expected outcome could be used to trigger review of clinical practice within a burn service. This system could be used within one service or across many burn care providers as a method of quality control and improvement.

4.

Conclusion

Numerous burns prognostic scoring systems exist of which no one can claim to be the most accurate across the entire burn population. An ideal prognostic system should include information about quality of life. There is no evidence to support their use at the bedside for decision-making. The subjective view of the clinical team is as valid and is more likely to take into account the gamut of factors which underpin the decision-making required in the severely injured patient. As a research tool they are, however, invaluable. It is necessary to be able to compare outcomes to an expected or control value and a single value from an established scoring system would facilitate this greatly. Intuition may suggest that a scoring system which comprises more components would prove more accurate. However, for mortality in burns, TBSA, age and inhalation injury appear to outweigh other factors significantly enough to be the only components used to give a prediction. It would be very interesting to see further efforts to combine APACHE or SOFA-based system with these three burn parameters to provide a complex, but robust burn scoring system for research purposes. As it stands the achievements so far in this area have provided a choice of schemes to control for case-mix in a burn population, but their value in prediction for a given patient is limited. As such, they are best used for internal audit and research though not yet for the planning of services and less still bedside decision-making.

Conflict of interest statement

None declared.

r e f e r e n c e s

[1] Knaus WA, Wagner DP, Lynn J. Short-term mortality predictions for critically ill hospitalized adults: science and ethics. Science 1991;254(5030):389–94. [2] Andel, Kamolz. Scoring in burned patients. Our opinion. Burns 2003;29(4):297–8. [3] Lutken. Mortality from burns. Ugesk Laeger 1937;99:409. [4] Farmer. Experience with burns at the hospital for sick

children. Am J Surg 1943;59:195. [5] Bull, Fisher. A study of mortality in a burns unit: a revised estimate. Ann Surg 1954;139(3):269–74. [6] Baux. Contribution a l’etude du traitement local des brulures thermiques etendues. These, Paris; 1961. [7] Nakae, Wada. Characteristics of burn patients transported by ambulance to treatment facilities in Akita Prefecture. Jpn Burns 2002;28(1):73–9. [8] Barnes BA, Constable JD, Burke AF. Mortality of burns at the Massachusetts General Hospital 1955–1969: transactions of the 3rd International Congress on Research in Burns. Res Burns 1971;430. [9] Clark CJ, Reid WH, Gilmour WH, Campbell D. Mortality probability in victims of fire trauma: revised equation to include inhalation injury. Br Med J (Clin Res Ed)

1986;292(6531):1303–5.

[10] Tobiasen J, Hiebert JM, Edlich RF. The abbreviated burn severity index. Ann Emerg Med 1982;11(5):260–2. [11] Godwin, Wood. Major burns in Cape Town: a modified burns score for patient triage. Burns 1998;24(1):58–63. [12] Ryan CM, Schoenfeld DA, Thorpe WP, Sheridan RL, Cassem EH, Tompkins RG. Objective estimates of the probability of death from burn injuries. N Engl J Med 1998;338(6):362–6. [13] O’Keefe GE, Hunt JL, Purdue GF. An evaluation of risk factors for mortality after burn trauma and the identification of gender-dependent differences in outcomes. J Am Coll Surg 2001;192(2):153–60. [14] Sheppard NN, Hemington-Gorse S, Ghanem A, Philp B, Dziewulski P, Shelley OP. The Belgian severity prediction model compared to other scoring systems in a burn intensive care population. Burns 2010;36:1320–1. [15] Ho WS, Ying SY, Burd A. Outcome analysis of 286 severely burned patients: retrospective study. Hong Kong Med J

2002;8(4):235–9.

[16] Belgian Outcome in Burn Injury Study Group. Development and validation of a model for prediction of mortality in patients with acute burn injury. Br J Surg 2009;96(1):

111–7.

[17] Brusselaers N, Juha´ sz I, Erdei I, Monstrey S, Blot S. Evaluation of mortality following severe burns injury in Hungary: external validation of a prediction model developed on Belgian burn data. Burns 2009;35(7):1009–14.

[18]

Kudla´ ckova´ M, Ande˘l M, Ha´ jkova´ H, Nova´ kova´ J. Acute phase proteins and prognostic inflammatory and nutritional index (PINI) in moderately burned children aged up to 3 years. Burns 1990;16(1):53–6.

[19] Gottschlich MM, Baumer T, Jenkins M, Khoury J, Warden GD. The prognostic value of nutritional and inflammatory indices in patients with burns. J Burn Care Rehabil

1992;13(1):105–13.

[20] Steinvall I, Bak Z, Sjoberg F. Acute kidney injury is common, parallels organ dysfunction or failure, and carries

b u r n s 3 7 ( 2 0 1 1 ) 1 2 8 8 – 1 2 9 5

1295

appreciable mortality in patients with major burns: a prospective exploratory cohort study. Crit Care

2008;12(5):R124.

[21] Andel D, Kamolz L-P, Roka J, Schramm W, Zimpfer M, Frey M, et al. Base deficit and lactate: early predictors of morbidity and mortality in patients with burns. Burns

2007;33(8):973–8.

[22] Marano MA, Fong Y, Moldawer LL, Wei H, Calvano SE, Tracey KJ, et al. Serum cachectin/tumor necrosis factor in critically ill patients with burns correlates with infection and mortality. Surg Gynecol Obstet 1990;170(1):32–8. [23] Endo S, Inada K, Yamada Y, Kasai T, Takakuwa T, Nakae H, et al. Plasma tumour necrosis factor-alpha (TNF-alpha) levels in patients with burns. Burns 1993;19(2):124–7. [24] Yeh FL, Shen HD, Fang RH. Deficient transforming growth factor beta and interleukin-10 responses contribute to the septic death of burn patients. Burns 2002;28:631–7. [25] Csontos C, Foldi V, Pa´ linkas L, Bogar L, Ro¨ th E, Weber G, et al. Time course of pro- and anti-inflammatory cytokine levels in patients with burns – prognostic value of interleukin-10. Burns 2010;36(4):483–94. [26] Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE – acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 1981;9(8):591–7. [27] Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med

1985;13(10):818–29.

[28] Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastos PG, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991;100(6):1619–36. [29] Wong Ti H, Tan BH, Ling ML, Song C. Multi-resistant Acinetobacter baumannii on a burns unit – clinical risk factors and prognosis. Burns 2002;28(4):349–57. [30] Tanaka Y, Shimizu M, Hirabayashi H. Acute physiology, age, and chronic health evaluation (APACHE) III score is an alternative efficient predictor of mortality in burn patients. Burns 2007;33(3):316–20. [31] Gomez M, Wong DT, Stewart TE, Redelmeier DA, Fish JS. The FLAMES score accurately predicts mortality risk in burn patients. J Trauma 2008;65(3):636–45. [32] Moore EC, Pilcher DV, Bailey MJ, Cleland H, McNamee J. A simple tool for mortality prediction in burns patients:

APACHE III score and FTSA. Burns 2010;36(7):1086–91. [33] Zimmerman JE, Kramer AA, McNair DS, Malila FM. Acute Physiology and Chronic Health Evaluation (APACHE) IV:

hospital mortality assessment for today’s critically ill patients. Crit Care Med 2006;34(5):1297–310. [34] Vincent JL, Moreno R, Takala J, Willatts S, de Mendonc¸a A, Bruining H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 1996;22(7):707–10. [35] Lorente JA, Vallejo A, Galeiras R, To´ micic V, Zamora J, Cerda´ E. Organ dysfunction as estimated by the sequential organ failure assessment score is related to outcome in critically ill burn patients. Shock 2009;31(2):125–31. [36] Saffle JR. Multiple organ failure in patients with thermal injury. Crit Care Med 1993;21(11):1673–83.

[37] Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/ North American multicenter study. JAMA 1993;270(24):

2957–63.

[38] Pavoni V, Gianesello L, Paparella L, Buoninsegni LT, Barboni E. Outcome predictors and quality of life of severe burn patients admitted to intensive care unit. Scand J Trauma Resusc Emerg Med 2010;18:24. [39] Pollack MM, Ruttimann UE, Getson PR. Pediatric risk of mortality (PRISM) score. Crit Care Med 1988;16(11):1110–6. [40] Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated Pediatric Risk of Mortality score. Crit Care Med

1996;24(5):743–52.

[41] Pereira C, Murphy K, Herndon D. Outcome measures in burn care. Is mortality dead? Burns 2004;30(8):761–71. [42] Mossey, Shapiro. Self-rated health: a prediction of mortality among the elderly. Am J Public Health

1982;72:800–8.

[43] Anzarut A, Chen M, Shankowsky H, Tredget EE. Quality-of- life and outcome predictors following massive burn injury. Plast Reconstr Surg 2005;116(3):791–7. [44] Munster. Measurements of quality of life: then and now. Burns 1999;25(1):25–8. [45] Yoder LH, Nayback AM, Gaylord K. The evolution and utility

of the burn specific health scale: a systematic review. Burns

2010;36:1143–56.

[46] Baker RA, Jones S, Sanders C, Sadinski C, Martin-Duffy K, Berchin H, et al. Degree of burn, location of burn, and length of hospital stay as predictors of psychosocial status and physical functioning. J Burn Care Rehabil

1996;17(4):327–33.

[47] Kimmo T, Jyrki V, Sirpa AS. Health status after recovery from burn injury. Burns 1998;24(4):293–8. [48] Pruzinsky T, Rice L, Himel H, Morgan R, Edlich R. Psychometric assessment of psychologic factors influencing adult burn rehabilitation. J Burn Care Rehabil

1992;13:79–88.

[49] Willebrand M, Andersson G, Ekselius L. Prediction of psychological health after an accidental burn. J Trauma

2004;57(2):367–74.

[50] Smith DL, Cairns BA, Ramadan F, Dalston JS, Fakhry SM, Rutledge R, et al. Effect of inhalation injury, burn size, and age on mortality: a study of 1447 consecutive burn patients.

J Trauma 1994;37(4):655–9. [51] Galeiras R, Lorente JA, Pe´ rtega S, Vallejo A, Tomicic V, de La Cal MA, et al. A model for predicting mortality among critically ill burn victims. Burns 2009;35(2):201–9. [52] Marks RJ, Simons RS, Blizzard RA, Browne DR. Predicting outcome in intensive therapy units – a comparison of Apache II with subjective assessments. Intensive Care Med

1991;17(3):159–63.

[53] Atiyat B, Kloub A, Abu-Ali H, Massad I. Clinical Sense in the Prediction of Surgical/Trauma Intensive Care Mortality. Eur

J Sci Res 2009;30(2):265–71.

[54] Noyez. Control charts Cusum techniques and funnel plots.

A review of methods for monitoring performance in

healthcare. Interact Cardiovasc Thorac Surg 2009;9(3):p494. [55] Guthrie B, Love T, Kaye R, MacLeod M, Chalmers J. Routine

mortality monitoring for detecting mass murder in UK general practice: test of effectiveness using modelling. Br J Gen Pract 2008;58(550):311–7.