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ORIGINAL ARTICLE
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Survival analysis of burn patients attending a tertiary care hospital of western Maharashtra, India


1 Department of Community Medicine, B. J. Government Medical College, Pune, India
2 Department of Community Medicine, Government Medical College, Baramati, Maharashtra, India

Date of Submission07-Jun-2021
Date of Decision13-Jul-2021
Date of Acceptance13-Jul-2021

Correspondence Address:
Nandkumar Salunke,
Department of Community Medicine, B.J. Government Medical College, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_431_21

  Abstract 


Introduction: Burn injuries are a major problem in low-income and middle-income countries. High population density, illiteracy, and poverty are the main demographic factors associated with a high risk of burn injury. Social, economic, and cultural factors interact to complicate the management, reporting, and prevention of burns. Aim: The aim of this study was to discover attributes associated with the survival of burn cases. Objectives: The objective of this study was to assess the survival of burn cases. To identify the factors associated with the survival of burn cases. Materials and Methods: This observational, cross-sectional study was conducted for a period of 1 year started from January 2013 to December 2013, in the burn ward of Government Medical College, attached to the tertiary care hospital. Results: Overall, the mean survival time was 13 days (95% confidence interval = 10–16 days). Its time was significantly different (P = 0.000). The mean survival time was significantly associated (P = 0.007) with the nature of burn. It was a maximum (18 days) in patients having burn injury at workplace. It was 13 days in males as compared to 12 days in females. The mean survival time was maximum (20 days) in burn cases occurring between 6 pm and 12 midnight and minimum (10 days) in cases between 12 pm and 6 pm. Conclusions: The mean survival time was significantly associated with nature and mode of burn but was independent of age groups, time, place of occurrence, and sex of the patient.

Keywords: Burn deaths, burn mortality, survival time



How to cite this URL:
Salunke N, Tapare VS, Parande MA, Tambe MP. Survival analysis of burn patients attending a tertiary care hospital of western Maharashtra, India. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=337072




  Introduction Top


Burn injuries rank among the most severe types of injuries suffered by the human body. Goldman describes burns as “the silent epidemic” because for long years, fatal burns have continued to be a major public health problem in all over the world.[1] Burn injuries represent one of the most important public health problems faced by both developing and developed nations today.

Burn injuries are a major problem in low-income and middle-income countries. Developing countries have a high incidence of burn injuries, creating a formidable public health problem. High population density, illiteracy, and poverty are the main demographic factors associated with a high risk of burn injury. Social, economic, and cultural factors interact to complicate the management, reporting, and prevention of burns.

In India, approximately, there are 6 million burn cases occur annually, of which around 0.7 million cases require hospitalization, of which approximately 0.12 million die annually. The survival rate for burn patients in developing countries such as India is around 50% for burn <40%, whereas those in developed countries, it is around 75%–90% for 50% burn.

Females suffer burns more frequently than males. Females in South-East Asia Region have the highest rate of burns, accounting for 27% of global burn deaths and nearly 70% of burn deaths in the region. The high risk for female is associated with open fire cooking or inherently unsafe cooking stove which can ignite loose clothing.[2]

The high risk for female is associated with open fire cooking or inherently unsafe cooking stove which can ignite loose clothing.[3] At the same time, accidental burns in women also occur commonly, to which they are more vulnerable as most of the women (housewives) spend their time in the kitchen.[4] Open flames used for heating, lighting, or warming water for bath also pose a risk of burn. Self-directed or interpersonal violence are also important risk factors in studying the burn cases.

Despite many medical advances, burns continue to remain a challenging problem due to the lack of infrastructure, an inadequate number of trained professionals as well as the increased cost of treatment, all of which have a significant impact on the outcome. The best treatment is burn prevention. It is said that burns are preventable injury and more than 80% of burn injuries can be prevented. Hence, to discover the attributes associated with the survival of burn cases admitted in tertiary care hospital which may lead to a better understanding of the cause and prevention of these conditions, the study was undertaken.

Objectives

  1. To analyze the survival of burn cases
  2. To identify the factors associated with the survival of burn cases.



  Materials and Methods Top


Study design

This was a hospital-based descriptive type of observational study.

Setting

This study was conducted in a tertiary care hospital attached to government medical college. It has 1200 inpatient beds, and over 800 patients of different categories of burns are admitted annually in recent years. Separate burn wards are available for the management of burn patients. The study was conducted in burn units under the department of surgery of a tertiary care hospital.

Sample size

For the present study, the level of significance was set at 5% with 95% confidence interval (CI). The sample size (N) is calculated by the formula.[5]

N = Z2 (1−α/2) (1 − P)/∑2P

Where Z represents the measure of standard error of population proportion.

Thus, for the present study, the minimum sample worked out was 216. Considering the correction for lost to follow-up patients (10%), it was proposed to study 240 burn patients.

Selection of sample

Systematic sampling technique was employed for the selection of study sample. As the study period was extended for 12 consecutive months, every month total 20 patients were selected. Every 2nd patient of burn eligible for admission was selected till total 20 patients selected per month. Patients with only minor superficial burn, treated as outpatients were not included in this study. Altogether, 240 burn patients admitted during the study duration were selected for the study. Of these, three patients did not give consent for the study and hence were not included in this study. Furthermore, twenty patients lost to follow-up due to discharge against medical advice were not included in the study. Thus, the total effective sample size was 217.

Ethical consideration

For the present study, data were collected over a period of 1 year from May 2012 to April 2013. The written informed consent was obtained from the patients. Ethical clearance was obtained from the institutional ethical committee before the start of the study.

Statistical analysis

The data were entered into MS Excel. The analysis was performed using SPSS for Windows version 17.0 (SPSS Inc., Chicago, Illinois, USA). Survival analyses are a set of statistical approaches for data analyses where the outcome variable of interest is time until an event occurs.[6],[7] In the present study, the time of entry into the study is the day of admission in the hospital and the occurrence of the event (outcome variable) is the day of death of the patient. The time between entry into a study, and the occurrence of an event was measured in days. Patients who do not experience the event are called “censored” observations. The survival rate in different categories of patients was estimated using Kaplan–Meier survival analyses. The number of observed events is compared with the number of expected events using Breslow test for equality of survival distribution. Furthermore, survival curves (Kaplan–Meier curves) were plotted for each group. The sections of the curve where the slope is steep indicate the periods when patients are more at risk for experiencing the event.


  Results Top


Out of 217 burn patients admitted, 129 (59.4%) patients died within a period extending from 1 day to 42 days. Overall, the mean survival time was 13 days (95% CI = 10–16 days). The survival plots of different age groups indicate that the risk of death is maximum during the first 10 days of admission, especially after the age of 40 years [Table 1] and [Figure 1].
Figure 1: Survival plot of age group. Age group coding: 05 = 1, 6–15 = 2, 16–45 = 3, 46–60 = 4, >60 = 5)

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Table 1: Survival characteristics of burn patients according to age groups

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Out of 217 burn patients admitted, 88 (40.6%) patients survived. The mean survival time was maximum (24 days) in patients having total body surface area (TBSA) 0%–20%, whereas it was minimum (3 days) in patients having TBSA >80%. Overall, the mean survival time was significantly different (P = 0.000) in patients of different total burn surface area [Table 2] and [Figure 2].
Figure 2: Survival plot of burn per cent (total body surface area). TBSA coding: 0–20% =1, 21%–40% =2, 41%–60% =3, 61%–80% =4, >80% =5

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Table 2: Survival characteristic of burn patients according to burn per cent (total body surface area)

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The mean survival time of accidental burn and burns due to homicide was almost equal, i.e., 14–15 days. In suicidal burn cases, the mean survival time was very short, i.e., 5 days. Overall, the mean survival time was significantly associated (P = 0.007) with the nature of burn [Table 3] and [Figure 3].
Figure 3: Survival plot of nature of burn. Nature of burn coding: Accidental = 1, Suicidal = 2, and Homicidal = 3

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Table 3: Survival characteristic of patients according to nature of burn

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Survival analyses of burn cases according to the mode of burn indicate maximum survival time (24 days) in cases due to scald. Burn cases due to flame and electrical cause show the mean survival time of 10–13 days [Table 4] and [Figure 4].
Figure 4: Survival plot of mode of burn. Mode of burn coding: Flame = 1, Scald = 2, and Electrical = 3

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Table 4: Survival characteristic of patients according to mode of burn

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The mean survival time in males was 13 days as compared to 12 days in females [Table 5] and [Figure 5].
Figure 5: Survival plot of sex. Sex group coding, Male = 1, Female = 2

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Table 5: Survival characteristic of burn patients according to sex

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The mean survival time of burn cases reporting within 4 h (12–15 days) is little more than the cases reporting after 4 h (7–10 days) [Table 6] and [Figure 6].
Figure 6: Survival plot of time interval. Time interval coding: 0–2.0 = 1, 2.1–4.0 = 2, 4.1–6.0 = 3, 6.1–8.0 = 4

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Table 6: Survival characteristic of patients according time interval

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  Discussion Top


The overall mortality in this study was found to be 59.4%. A study conducted by Lal et al.[8] reported it to be 36.19%, whereas a study conducted by Ismaeil et al.[9] reported it to be 20%. The mean survival time was maximum (22 days) in school-age children (6–15 years) and minimum (7 days) in middle age group (46–60 years). In remaining age groups, i.e., under-six children, adults, and old age groups, the mean survival time was between 10 and 13 days. Overall, the mean survival time was not significantly different (P = 0.178) in different age groups.

The mean survival time decreases as the total burn surface area increases. The survival plots of different TBSA groups indicate that the risk of death is maximum during the 1st 5 days of admission with patients having TBSA is >60%. A similar type of study conducted in Malaysian burns intensive care unit also found that TBSA more than 20% was the important predictor of mortality among burn cases.[10]

The survival plots indicate that the risk of death is maximum during the first 10 days of admission in suicidal and homicidal cases.

The difference of mean survival time in different modes of burn cases is significantly different (P = 0.000). The survival plots of all modes of burn cases indicate that the risk of death is maximum during the 1st week of admission in burn cases due to flame and electrical cause.

The mean survival time is independent of sex of patient (P = 0.209). The survival plots of burn cases according to sex of patient indicate that the risk of death is maximum during the 1st week of admission in both sexes.

The mean survival time is not significantly different (P = 0.468) when the patient is reported at different time intervals during the first 8 h of burn. The survival plot shows that the risk of death is maximum during 1st week in cases reported after 4 h.


  Conclusions Top


Overall, the mean survival time was 13 days (95% CI = 10–16 days). The risk of death was more during the first 10 days of admission, especially after the age of 40 years. The mean survival time decreases as the total burn surface area increases. The mean survival time was significantly associated with nature of burn and mode of burn, but the mean survival was independent of age groups, time and place of occurrence, and sex of patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gupta AK, Uppal S, Garg R, Gupta A, Pal R. A clinico-epidemiologic study of 892 patients with burn injuries at a tertiary care hospital in Punjab, India. J Emerg Trauma Shock 2011;4:7-11.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Mukherjee GD. Management of burns in general practice. J Indian Med Assoc 1977;68:9-14.  Back to cited text no. 2
    
3.
Park K. Park's Textbook of Preventive and Social Medicine. 22nd ed. Jabalpur: M/S Banarsidas Bhanot Publishers; 2013.  Back to cited text no. 3
    
4.
Bhagora RV, Darji JA, Panchal DN, Kalele SD, Parmar DJ. Profile of burns cases brought for post- mortem examination at mortuary of Sir T. Hospital, Bhavnagar. NJIRM 2011;2:109-12.  Back to cited text no. 4
    
5.
Lwanga S, Lemeshow S. Sample Size Determination in Health Studies: A Practical Manual.1991.  Back to cited text no. 5
    
6.
George B, Seals S, Aban I. Survival analysis and regression models. J Nucl Cardiol 2014;21:686-94.  Back to cited text no. 6
    
7.
Barakat A, Mittal A, Ricketts D, Rogers BA. Understanding survival analysis: Actuarial life tables and the Kaplan-Meier plot. Br J Hosp Med (Lond) 2019;80:642-6.  Back to cited text no. 7
    
8.
Lal S, Yadav GK, Gupta R, Shrivastava GP, Singh S, Bain JS. Mortality pattern of burn patients admitted in S. G. M. Hospital Rewa: A teaching institute of central India. J Sci Soc 2012;39:130-5.  Back to cited text no. 8
    
9.
Ismaeil T, Alramahi G, Othman F, Mumenah N, Alotaibi L, Baazim H, et al. Survival analysis of mechanically ventilated patients in the burn unit at king abdulaziz medical city in Riyadh 2016-2019. Int J Burns Trauma 2020;10:169-73.  Back to cited text no. 9
    
10.
Tan Chor Lip H, Tan JH, Thomas M, Imran FH, Azmah Tuan Mat TN. Survival analysis and mortality predictors of hospitalized severe burn victims in a Malaysian burns intensive care unit. Burns Trauma 2019;7:3.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

 
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