Burn center referral criteria linked to specialized care

Researchers have identified increased odds of receiving specialized care following burn center referral criteria, publishing their findings in JAMA Network Open.¹

Significant rates of emergency department visits linked to burn injuries have been reported for children and adolescents in Ontario, Canada.² Experts recommend patients with severe burns or those that involve functionally critical areas be referred to specialized burn centers, with referral guided by established clinical criteria.¹

“It is unknown how well clinicians adhere to burn center referral criteria in Ontario. This is important given that aligning burn care delivery to patient needs ensures system efficiency and optimal patient outcomes,” wrote investigators.

Burn care comparisons

The population-based cohort study was conducted to evaluate patient and clinical characteristics linked to receiving treatment at a burn center vs non–burn center facility. Data was obtained from health administrative and demographic data sets held at the Institute for Clinical Evaluative Sciences.

Participants included Ontario residents aged 0 to 17 years with a complete linkage to the Ontario provincial health care registry and a recorded burn injury between April 1, 2003, and March 31, 2023. Burn injuries were diagnosed using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes.

Exclusion criteria included burn injury not linked to an institution number and recurrent burn injuries. The presence of at least 1 of 6 identifiable burn center referral criteria was reported as the primary outcome, determined through health administrative data. The referral criteria included the following:

• More than 10% total body surface area (TBSA)
• Full-thickness burns
• Burns involving critical anatomical areas
• Inhalation injuries
• Chemical injuries
• Electrical injuries

The setting of definitive burn care was reported as the primary outcome and included either a burn center or a non–burn center. Patients with a recorded encounter at 1 of 6 designated burn care facilities in Ontario within 6 weeks of their first health care encounter for a burn injury were considered treated at a burn center.

Patient demographics and referral criteria

Demographic characteristics, indicators of social vulnerability, care accessibility factors, and the year of burn injury were reported as covariates. The study included 79,782 youths with burn injuries.

Participants were aged a median of 4 years, and 20.3% resided in rural regions. Of youths, 23.9% lived in neighborhoods in the most material resource–deprived quintile, and 2.1% were nonrefugee immigrants.

The presence of at least 1 burn center referral criterion was reported for 43.6% of burn injuries, with 34.5% being burns involving critical anatomical areas, 6.7% full-thickness burns, and 3.3% chemical burns. Treatment at a burn center was reported in 17% of pediatric patients with burns, with 55.6% of these youths having burn center referral criteria.

Treatment at non–burn centers was reported in the remaining 83% of patients, with 41.2% of these patients having burn center referral criteria. Infants and preschool-aged children, urban-dwelling youths, and youths living in regions with burn centers were more likely to be treated at burn centers.

Risk increases with additional referral criteria

Being treated at a burn center was reported among 13.3% of youths with no burn center referral criteria, vs 21.6% with at least 1 referral criterion, indicating an adjusted rate ratio (aRR) of 1.50. The aRR rose with an increase in the number of referral criteria, at 1.27 for 1 criterion, 2.63 for 2 criteria, and 4.71 for 3 or more criteria vs no criteria.

A treatment rate at burn centers of 22.5% was reported for burns involving more than 10% TBSA, vs 24.3% for full-thickness burns, 17.4% for burns involving critical anatomical areas, 25% for inhalation injuries, and 26.7% for chemical injuries. Youths with electrical injuries were not more likely to be treated at a burn center vs references.

Overall, these results indicated an association between burn center referral criteria and treatment at burn centers. However, inconsistent application in clinical practice was reported, indicating missed opportunities to provide guidance-based care.

“Improving alignment of clinical practice to referral guidelines and addressing systemic and geographic barriers are essential next steps,” wrote investigators.

References

1. Gus E, To T, Fish J, Diong C, Saunders N. Adherence to burn center referral criteria for pediatric burns. JAMA Netw Open. 2026;9(2):e2559159. doi:10.1001/jamanetworkopen.2025.59159
2. Spinks A, Wasiak J, Cleland H, Beben N, Macpherson AK. Ten-year epidemiological study of pediatric burns in Canada. J Burn Care Res. 2008;29(3):482-488. doi:10.1097/BCR.0b013e3181776ed9