Referral Guidelines
NBCR Report Appendix 2: National Burn Injury Referral Guidelines
It has been traditional to use the size of skin injury following a burn injury as the single criterion to guide referral. This approach has often been criticised as overly simplistic. Consideration of other important factors has proved difficult as quantification of these is unclear or impossible. It has been recognised that practical clarification is needed and the British Burn Association by way of the Committee of the National Burn Care Review wish to propose the following guidance. Such guidance is not to be viewed as rigid instruction but used to help highlight some of the important features of burn injury that are known to predict a complex clinical course. It is proposed that burn injuries be referred to appropriate burn care hospitals based on the injury complexity for assessment and management.
COMPLEX A burn injury is more likely to be complex if associated with the following criteria:
| Age | under 5yrs or over 60yrs |
| Site involvement (with dermal or full thickness loss) |
face or hands or perineum or feet or any flexure particularly the neck or axilla or any circumferential dermal or full thickness burn of the limbs, torso or neck |
| Inhalation injury | any significant such injury, excluding pure carbon monoxide poisoning |
| Mechanism of injury |
chemical injury (>5% TBSA) exposure to ionizing radiation injury high pressure steam injury high tension electrical injury hydrofluoric acid injury (>1% TBSA) suspicion of non-accidental burn injury; adult or paediatric |
A complex burn injury is also suggested by one involving:
| Size of skin injury with dermal or full thickness loss) | (paediatric (under 16yrs old) >5% TBSA or adult (16yrs or over) >10% TBSA |
A burn injury may also be deemed complex if it occurs alongside:
Existing conditions eg cardiac limitation &/or MI within 5yrs respiratory limitation of exercise diabetes pregnancy immuno-suppression for any reason hepatic impairment; cirrhosis
Associated injuries crush injuries
fractures
head injury
penetrating injuries
Associated injuries, such as those listed, complicate any burn injury and may make it complex. However the range of presenting problems must be carefully considered and the most compelling injury dealt with first, according to clinical need. This may, in some circumstances, delay any referral for the burn injury to be dealt with. In such instances advice as regards burn management should always be sought.
A complex non-burn would include:
Inhalation injury any significant such injury with no cutaneous burn, excluding pure carbon monoxide poisoning
Vesicullobullous
disorders eg any over 5% TBSA
epidermolysis bullosa staphylococcal scalded skin syndrome (Ritter’s) Stevens-Johnson syndrome toxic epidermal necrolysis (Lyell’s)
All injuries deemed to be complex need referral to the local Burn Centre or Burn Unit.
The criteria listed above put the patient at risk of a complex injury. While some are absolute others such as age
60 years, co-existing medical problems, associated head injury, fractures, burns to the face, hand feet are open to interpretation if the burn is not more than 5% TBSA and has no area of deep burn. Under these circumstances the burn may be treated locally in an A&E Department provided it is reviewed within 24 hours by an experienced A&E clinician, and referred to the burns service if there is doubt about the extent or severity of the injury. A&E Departments are advised to discuss these type of cases with their local burns service on initial presentation, if there is any uncertainty about the nature, severity or the significance of each of the criteria.
NON-COMPLEX All burn injuries felt not to be complex may be referred for assessment and admission according to the skin surface area involved.
Size of skin injury paediatric (under 16yrs old) 2% to 5% TBSA if dermal or any smaller injury if full thickness loss. adult (16yrs or over) 5% to 10% TBSA if dermal or any smaller injury if full thickness loss.
All non-complex injuries referrals should be made to a local Plastic Surgery Unit (Burn Facility).
Other injuries, not meeting the criteria laid out above, are often suitable for care in an A&E Department or in the community.
NON-ACUTE REFERRALS Injuries that may require referral from A&E, GP, Practice Nurse or District Nurse in the post acute phase include:
Wound healing any wound unhealed at 14 days post injury
Complications any significant infection, septic episode or suggestion of a Toxic Shock-like illness
Rehabilitation
Any healed wound where the scarring suggests there will be:
a significant aesthetic impact &/or psychological disturbance
the need to consider skin camouflage
a significant functional limitation
the need to consider pressure therapy or other forms of scar modification
the need to consider surgical reconstruction
In the opinion of the National Burn Care Review Committee and the British Burn Association, there is no justification for injuries requiring hospital admission to be dealt with outside this system.
British Burn Association published date: February, 2001
review date: 1st March, 2003