burns 34 (2008) 965974

available at www.sciencedirect.com

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

Mortality and morbidity among elderly people

with burnsEvaluation of data on admission
D.B. Lumenta a,b,*, A. Hautier a, C. Desouches a, J. Gouvernet c,
R. Giorgi c, J.-C. Manelli a, G. Magalon a
a

Regional Burns Centre, La Conception, Public University Hospital, F-13385 Marseille, France
Division for Plastic and Reconstructive Surgery, Medical University Vienna, Vienna, Austria
c
LERTIM, Medical Faculty, University Aix-Marseille, F-13385 Marseille, France
b

article info

abstract

Article history:

People aged 65 years represent a growing population within burns units in the Western

Accepted 5 December 2007

world. In 2001, this group was reported to rise to 20% of such admissions. We reviewed the
records of 265 burn cases with complete admission and discharge histories, from January

Keywords:

1990 to December 2003 in an A-level regional burns centre.

The predictive value of age, gender, total body surface area burned (TBSA), inhalation

Burns
Comorbidity

trauma (IT), premorbid conditions and currently used burn scores (Baux, ABSI, Ryan) for

Aged, 80 and above

haemodynamic or respiratory complications, mortality and morbidity were analysed.

Mortality

Additionally a subset of patients with diabetes mellitus and >30% total body surface area

Morbidity

burned were reviewed.

Diabetes

About 16% of all admissions with burns were 65 years of age, with a mortality rate of

Inhalation Injury

30.6% (81/265). Only gender and premorbid conditions did not influence mortality. Haemo-

Length of Stay

dynamic and respiratory complications were significantly related to TBSA, presence of I and
any of the three scores (all p < 0.001). Among survivors (184/265), the median duration of
hospital stay was 26.0 days. Factors contributing to a significantly increased length of stay
were, in decreasing order, total body surface area burned, high levels of burn scores,
inhalation trauma, flame injury and certain premorbid conditions (cardiovascular disease,
alcoholism). About 77.7% of all patients were discharged either to a rehabilitation centre or
back to their previous form of housing.
This study showed that among burned people aged 65 years a good outcome as
evaluated on discharge can be achieved. Studies pooling different centres results are
needed to improve the significance of conclusions drawn from these data.
# 2007 Elsevier Ltd and ISBI. All rights reserved.

1.

Introduction

The age group of 65 years and older represents the fastest

growing segment of populations in the USA and Europe.
The age distribution pattern, formerly building a triangular

pyramid, will become a cylinder-like structure in 20 years.

People aged 65 years will make up about one-third of the
population in the Western world by 2025 [1]. This development
must be taken into account; it is reported that this cohort is
more prone to burns [2], and burns units should prepare for the

* Corresponding author at: Division for Plastic and Reconstructive Surgery, Medical University Vienna, Vienna, Austria. Tel.: +43 1 404000.
E-mail address: david.lumenta@meduniwien.ac.at (D.B. Lumenta).
0305-4179/$34.00 # 2007 Elsevier Ltd and ISBI. All rights reserved.
doi:10.1016/j.burns.2007.12.004

966

burns 34 (2008) 965974

admission of a growing number of elderly people in the future.

Therefore it is not surprising that studies dealing with this
group have become popular, with particular regard to cost
analysis [3,4], outcome prediction [5] and premorbid conditions [69]. However, the most relevant factors increasing the
risks among this group for mortality and length of stay (LoS)
remain age, total body surface area burned (TBSA) [9], and
sometimes inhalation trauma [1012]. The main hypotheses
for an increased risk among older individuals commonly
invoke comorbidities, slower reactions, bedridden conditions
and decreased mental status [6,13,14].
Age is an accepted parameter that has readily been
integrated into current burn scores such as the Baux,
Abbreviated Burn Severity Index (ABSI) and Ryan scores,
and is known to contribute to increased mortality [1518]. In
order to examine the influence of the above factors on
outcome among burned people aged 65 years, it is necessary
for this entity to be examined separately. The present study
aims to evaluate the contribution of these parameters on
admission to mortality and morbidity (e.g. LoS, modes of
discharge), analyse the power of existing burn scores and
examine possible associations of premorbid conditions with
commonly encountered respiratory or haemodynamic complications.

2.

Materials and methods

2.1.

Patient selection

A total of 265 burned people aged 65 years, were admitted to

our burns centre from January 1990 to December 2003.
Parameters from each case were collected prospectively on
a standardised institutional patient record database. Incomplete datasets and individuals who developed toxic epidermal
necrolysis were excluded from the study.

2.2.

Treatment

During the study period, the standard treatment regimen was

not subjected to major changes. Resuscitation protocol
consisted of oxygen supply via a nasal cannula, intubation
or tracheotomy (as appropriate); rapid fluid administration
with crystalloid solutions during the first 24 h, using central
and/or peripheral lines, according to urinary output and
haematocrit; and, if needed, albumin infusions after the first
day, according to plasma albumin levels. Arterial lines, urinary
and gastric tubes were placed as required.
Burns were initially covered with silver sulfadiazine and
were evaluated immediately on admission, at 24 and 48 h
thereafter. Immediate incisional decompression via eschariotomy or fasciectomy was performed for deep circular burns
involving neck, extremities or trunk. No prophylactic
antibiotic therapy was administered. Further surgery was
not performed until haemodynamic stability was established, and patients usually underwent operation between
days 5 and 7 after burn (data not shown). After necrosectomy, areas were either covered primarily with homologous
skin grafts and secondarily with autologous meshed skin
grafts, or were primarily covered with autologous meshed

skin grafts. Operated body surface area did not exceed 20%
per session.
Inhalation trauma (IT) was suspected in the presence of
deep second- and third-degree burns of the head and neck as
well as in particular circumstances (e.g. fire in enclosed
environment), and was confirmed using fibre-optic bronchoscopy if necessary.
For control of severe acidosis, bicarbonate solution was
infused until pH was normal. Burn victims with myolysis or
haemolysis received standard bicarbonate for urine alkalisation. Individuals with haemoglobin levels below 8 mg/dl
received erythrocyte concentrate transfusions.
As soon as the patients condition allowed (respiratory
support, graft take, bathing frequency, monitoring requirements), transfer to the minor burns sector of the same centre
was arranged in order to improve the psychological context
and to provide additional social support.
Treatment was not withheld from any of the patients on
account of burn severity or premorbid conditions.

2.3.

Grouping and definitions

Patients were divided into four age groups: 6569, 7079, 8089
and 90 years-of-age. We analysed criteria influencing overall
survival, taking a closer look at premorbid conditions as well
as the occurrence of haemodynamic and respiratory complications. We then evaluated among survivors the same
parameters and their contribution to LoS.
The following parameters were examined: age, gender,
burn type, circumstances of burn, TBSA, IT, pre-existing
comorbidities, complications during in-hospital stay, mortality and LoS among survivors. We determined the burn scores
adapted from Ryan, Tobiasen (ABSI) and Baux to compare their
predictions for our patient collective [15,17,20].
Premorbid conditions were divided into the following
subgroups (Table 1): hypertension (HTN), cardiovascular
disease (CVD), cardiac disease (CARDIAC), diabetes mellitus
(DIAB), respiratory (RESP), neurological (NEURO), digestive
tract (DIG), renal (RENAL), psychiatric (PSY), chronic alcohol
abuse-related (ALC) disorders, allergic (ALLERG), neoplastic
(TUMOUR) and all other conditions (OTHER) not listed above.
Heart-related diseases were split into three subgroups:
hypertension, cardiovascular disease and other cardiac illnesses. Chronic alcohol abuse was defined as daily alcohol
intake of 60 g and above, and people in this group required
additional therapy in order to overcome alcohol withdrawal
symptoms [20].
Criteria for a haemodynamic complication was met, if one
of the following conditions applied:
septic shock, defined as recommended by the ACCP/SCCM
[21];
severe arrhythmia, implying persistent bradycardic or
tachycardic irregularity without fever or other septic signs
despite adequate electric and/or drug therapy;
severe hypertension, if on constant readings systolic blood
pressure remained >160 mmHg or diastolic blood pressure was
consistently >100 mmHg despite adequate drug treatment;
other therapy-resistant hypotensive states, defined as other
shock states.

967

burns 34 (2008) 965974

Table 1 Premorbid conditions: subgroups and definitions

Subgroup

Abbreviation

Hypertension
Cardiovascular
Cardiac

HTN
CVD
CARDIAC

Diabetes
Respiratory
Neurological
Digestive tract

DIAB
RESP
NEURO
DIG

Renal
Psychiatric
Alcoholism
Allergies
Neoplastic

RENAL
PSY
ALC
ALLERG
TUMOUR

Other

OTHER

Description
High blood pressure
Coronary heart disease, diseases of the arteries
Congestive heart failure, chronic arrhythmias, ventricular dysfunction,
heart valve and other myocardial diseases
Diabetes mellitus types I and II
Bronchial, pulmonary and pleural diseases
Central/peripheral nerve system and neuromuscular disorders
Illnesses of the upper and lower digestive tract including pancreatic and
liver diseases
Renal and urinary output-related diseases
Mental/psychiatric disease
Chronic alcohol abuse
Allergic diseases
Cancer and other neoplastic diseases regardless of origin or histological
grading
All others not classified above

Respiratory complications were classified according to the

mode of ventilation; the first group had no additional treatment
(NONE), the second underwent oral or nasal intubation with or
without later tracheotomy and artificial ventilation (WITH), and
the third group additionally required a positive end-expiratory
pressure (PEEP) >10 cmH2O and an inspiratory fraction of
oxygen (FiO2) > 0.6 (PLUS).

tory complications. We used a logistic regression approach to

evaluate mortality, haemodynamic and respiratory complications, and a linear regression model to analyse LoS with a
forward stepwise approach ( p < 0.25 as threshold for entering
or removing variables). Analyses were performed with SPSS
software (Version 11.0 SPSS, Chicago, IL).

2.4.

3.

Results

3.1.

General epidemiology

Statistical analysis

To compare death and survival we used for quantitative values

(age, TBSA, etc.) the MannWhitney test, and for qualitative
variables (gender, type of burn, etc.) chi-squared or Fishers
exact testing. For analysis of the correlation of age, TBSA, the
different scores and the LoS, the MannWhitney or the
KruskalWallis test were used. For univariate analysis, pvalues below 0.05 were considered significant. Multivariate
analysis was performed in order to identify independent
variables for mortality, defined as death in hospital, LoS (using
a logarithmic transformation), haemodynamic and respira-

People aged 65 years and over accounted for 16% of all

admissions in our burns centre between January 1990 and
December 2003. Most thermal injuries among the elderly
occurred in a domestic environment (78.1%, 207/265); this was
followed by 6.8% (18/265) occurring during leisure activities
(e.g. barbecue), 6.0% (16/265) with suicidal implications and
3.4% (9/265) in road traffic accidents. Other burns occurred in
occupational (0.4%, 1/265), homicidal (1.5%, 4/265) and other

Fig. 1 Aetiology and circumstances of burn admissions of people aged I65 years between January 1990 and December
2003.

968

burns 34 (2008) 965974

Fig. 2 The influence of age on in-hospital mortality. With

increasing age, mortality significantly (yp = 0.01)
increased.

(2.6%, 7/265) contexts. In two cases the circumstances were

unclear. The noxious agent in most burns was either hot water
(30.9%, 82/265) or flame (65.3%, 173/265). Other agents included
electric current (3/265), lightning (2/265), chemical compounds
(1/265), frost bite (1/265) and combined accident patterns (3/
265, see Fig. 1).
The average age of our patient collective was 76.5 (65100
years) and Fig. 2 shows the distribution pattern according to
the four age groups. Of the 265 patients, 160 (60.4%) were
women and 105 (39.6%) were men. The mean TBSA was 17.1%,
where the median represented 10.0% (520%, interquartile
range).

3.2.

Mortality

Of the 265 cases, 81 (30.6%) were fatalities; IT was confirmed in

17.7% of the population (47/265). Statistically, gender had no
significant influence on mortality ( p = 0.34), and nor did the
aetiology of the injury. The presence of IT correlated
significantly with death ( p < 0.001); 70.2% (33/47) of patients
with IT died. Without IT, mortality was 22.0% (48/218).
Age and TBSA (total, deep or third-degree burns) significantly influenced mortality ( p < 0.001). Splitting of age groups
clearly revealed the age-dependence; mortality rose to 61.5%
among burn victims aged 90 years and older (Figs. 2 and 3).
All three scores (Ryan, ABSI and Baux) had a significant
predictive value, with p < 0.001 for mortality, as shown in
Tables 2a2c [15,17,21]. Premorbid conditions had no statistically significant influence on mortality (Table 3).

3.3.

Fig. 3 Mortality by total body surface area burned (TBSA):

(A) total area (TBSAtot); (B) deep burns of 2B and 3rd degree
(TBSAdeep); (C) third-degree burns alone (TBSA3). With
increasing extent of TBSAtot, non-survival becomes more
likely. This is also reflected in TBSAdeep and TBSA3, with
their shrinking share of total burn size, but rising
mortality (yall p < 0.0001).

Haemodynamic and respiratory complications

To identify whether a given parameter on admission had an

impact on the occurrence of haemodynamic (Tables 4a and 4b)
or respiratory complications (Tables 5a and 5b), we analysed
the same set of data.
The occurrence of haemodynamic complications was not
significantly influenced by age or gender, but was significantly
related to TBSA (total, deep or third-degree), presence of IT,
and any of the three scores (all p < 0.001). The only premorbid
disease which was significantly linked to the development of
haemodynamic complications was CARDIAC ( p = 0.001).

The development of respiratory complications was not

significantly linked to gender. However, age was significantly
associated with an increased number of intubations and
mechanical ventilation (NONE versus WITH/PLUS, p = 0.04).
The occurrence of a flame injury ( p = 0.04), the TBSA (total,
deep or third-degree), IT and the three scores (all p < 0.001)
were significantly linked to the development of respiratory
complications. The following premorbid conditions were also
subject to intensified respiratory management: CARDIAC
( p = 0.004), ALC and PSY (both p = 0.01).

969

burns 34 (2008) 965974

Table 2a Mortality related to Ryan scorea

Score

Mortality (%)

0
1
2
3

0 (0/0)
21 (45/214)
50 (15/30)
100 (21/21)

Since the Ryan score includes age 60 years as single factor,
there was no score below 1 in our population. Mortality rose
significantly with higher score values in all scoring methods
( p < 0.001).

Table 2b Mortality related to abbreviated severity of

burn index (ASBI) scorea
Score

Mortality (%)
11.1
15.7
24.5
72.7

11
1213
1415
16
a

(7/63)
(13/83)
(13/53)
(48/66)

At an ABSI score 16 mortality jumped to 72.7%.

Neither of the two groups of complications, haemodynamic

( p = 0.08) or respiratory ( p = 0.054), had a significant impact on
LoS among either non-survivors or survivors.

3.4.

Length of stay

Among the 184 survivors, the median LoS was 26.0 (1152),
interquartile range days and correlated significantly with
TBSA ( p < 0.001), the Baux, ABSI (both p < 0.001) and Ryan
( p = 0.006) scores, and presence of combustion injury (117/184;
p = 0.02) and IT (14/184; p = 0.001). Premorbid conditions
significantly linked to an increased LoS were CVD (25/184;
p = 0.003) and ALC (13/184; p = 0.02) with a median LoS of 21.5
(1475) and 54 (32109) days, respectively. In our study
population, neither age nor gender influenced the LoS.

3.5.

Subset analysis

3.5.1.

Diabetic group

When comparing the diabetic (12.1%, 32/265) with the nondiabetic (87.9%, 233/265) patients, there was no statistically
significant difference for age (77.7 years versus 76.3 years,
respectively) or TBSA (15.0  19.3% versus 17.4  19.1%,
respectively). Furthermore, no significant factor predisposing
people with DIAB to increased haemodynamic or respiratory
complications, mortality or LoS could be found. Of the
premorbid conditions, only RENAL showed a tendency to be

Table 2c Mortality related to Baux scorea

Score
<80
8089
9099
100
a

Mortality (%)
7.0 (4/57)
14.8 (12/81)
24.6 (16/65)
79.0 (49/62)

Mortality rose steeply to 79.0% with Baux values 100.

Table 3 Premorbid conditions and mortality: no

significant correlation
Condition

Number of
deaths with
condition

Percentage
dead with
condition

20
8
22
11
2
12
6
1
20
9
3
6
20

24.1
24.2
40.0
34.4
9.1
33.3
18.8
25.0
37.7
40.9
20.0
33.3
24.1

Hypertension
Cardiovascular
Cardiac
Diabetes
Respiratory
Neurological
Digestive tract
Renal
Psychiatric
Alcoholism
Allergies
Neoplastic
Other

Significance

N.S.
N.S.
N.S.
N.S.
N.S.
N.S.
N.S.
N.S.
N.S.
N.S.
N.S.
N.S.
N.S.

N.S., not significant.

more prevalent among the diabetic than in non-diabetic group

(6.3% versus 0.9%, p = 0.07), without reaching statistical
significance.

3.5.2. Total body surface area burned (>30%): high vs.

other
Of the 265 patients, 9.9% (high group, 36/365) had a TBSA total
>30% and >20% TBSA with 2B and third degree. When this
group was compared with the remaining patients, referred to
as the other group (229/365), mortality was significantly
increased in the high group (91.7% versus 21.0%, p < 0.0001), as
was the prevalence of IT (72.2% versus 9.2%, p < 0.001). Of the
three survivors in the high group (3/36), none had IT. Among
premorbid conditions, only PSY was significantly more
prevalent among the high group (33.3% versus 17.9%,
p = 0.03). Diabetes was diagnosed in five patients of the high
group (5/35, 13.9%), which eventually died. However, statistically DIAB was not a significant risk factor for mortality.
The presence of any haemodynamic complication was
significantly more common in the high group (69.4% versus
29.7%, p < 0.001). After grouping according to specific
complications, a statistically significant difference was
confirmed for severe arrhythmia (25.0% of the high group
versus 10.9% of the other, p = 0.03) and other shock states
(44.4% versus 12.2%, p < 0.001). However, septic shock
showed a non-significant positive correlation (30.6% versus
13.3%, p = 0.09) and severe HTN did not reach statistical
significance. The demand for ventilator-assisted support
(respiratory complications) was significantly more prevalent
in the high group (WITH 30.6% versus 17.9% and PLUS 55.6%
versus 14.4%, both p < 0.001). It is also to be noted that people
in the high group had a significantly greater demand for renal
replacement therapy than those in the other group (25.0%
versus 7.9%, p < 0.005).

3.6.

Regression analysis and predictive value

In the multiple logistic regression analysis, all the scores had a

significant predictive value for mortality. We also found that,
from a statistical point of view, the Baux score was the most

970

burns 34 (2008) 965974

Table 4a Haemodynamic complications among 265 burned people: statistics itemised by premorbid conditiona
Condition

Number with condition developing

a haemodynamic complication

Percentage with condition developing

a haemodynamic complication

29
15
30
12
8
15
12
1
24
11
3
9
29

34.9
45.5
54.5
37.5
36.4
41.7
37.5
25.0
45.3
50.0
20.0
50.0
34.9

Hypertension
Cardiovascular
Cardiac
Diabetes
Respiratory
Neurological
Digestive tract
Renal
Psychiatric
Alcoholism
Allergies
Neoplastic
Other

p-Value
N.S.
N.S.
0.001
N.S.
N.S.
N.S.
N.S.
N.S.
N.S.
N.S.
N.S.
N.S.
N.S.

N.S., not significant.

Only cardiac diseases were significantly associated with the development of haemodynamic complications.

accurate in estimating the risk for mortality in the study

population. As the regression analysis of this isolated collective
(65 years) suggested, adding the deep TBSA (odds ratio: 4.62;
95% confidence interval: 1.6013.38) to the Baux score (odds
ratio: 1.09; 95% confidence interval: 1.061.12) improved its
predictive power (HosmerLemeshow, p = 0.50).
The results for haemodynamic complications were comparable with those for mortality; the Baux score in combination with deep surface burns rendered most accurate results
and proved to be a relevant predictive factor.
The regression analysis yielded statistically convincing
results for neither LoS nor the development of respiratory
complications.

4.

3.7.

Most burns treated at our centre resulted from domestic

incidents; hot water scalds represented about one-third of
these (mostly typical bathing accident patterns), which stands
for a rather high fraction compared with the literature. In
France, the local public service providers deliver boiling hot
water via the taps, and the high percentage of scalds is
therefore not surprising. As one prevention strategy among
injury-prone persons, this is certainly an area for improvement [22,23]. Mandatory retirement age in France is 65 years,
and work-related injuries were therefore almost not observed
in our study (one case only).

Modes of discharge

Of the 265 burn victims, 81 died. The 184 survivors were either
discharged to a rehabilitation centre (46.2%, 85/184), or sent
home (31.5%, 58/184), transferred to another hospital (8.7%, 16/
184) or within our hospital (7.6%, 14/184). The remaining 11
patients did not fit into any of these discharge groups. Since
77.7% of survivors were not transferred within the same or to
another hospital (see Fig. 4), this relatively high share best
reflects our hospital LoS (HOS).

The aim of the current study was to verify among a population

of burned people aged 65 years, in a single burn centre,
adequate prediction markers and relevant premorbid conditions on admission leading to an increased complication rate,
mortality or HOS. This study was not intended to be an
instrument of decision making, but rather a tool for developing a more refined burn score, indicating factors probably
requiring more attention and leading to an improvement of
therapeutic strategies in burn patients.

4.1.

4.2.
Table 4b Haemodynamic complications among 265
burned people: statistics according to haemodynamic
eventa
Event

None
Septic shock
Severe arrythmia
Severe hypertension
Other shock states
a

Total number of
patients with
haemodynamic
complication
172
53
34
12
60

Percentage with
haemodynamic
complication
64.9
20.0
12.8
4.5
22.6

In decreasing order septic shock, severe arrythmia and severe

hypertensive states were the predominant haemodynamic events.

Discussion

General considerations

Mortality and morbidity

In the population analysed, gender did not influence mortality

or LoS at any step of the analysis [5]. Age, TBSA and the Baux,
Ryan and ABSI scores were among the significant parameters
found to influence mortality, in agreement with other reports
[14,17,24]. The simplistic Baux score, adding age to TBSA,
yielded the most accurate results from a statistical point of
view, in this as in previous studies [7].
We divided patients into four age groups oriented on the
Medical Subject Headings (MeSH) database definition of aged
and 80 and above, splitting these again into two subgroups.
This allowed for better comparison and demonstration of age
dependence. Studies comparing younger with older populations [22] or all age groups [14] revealed a significant risk for

971

burns 34 (2008) 965974

Table 5a Respiratory complications among 265 people with burns: statistics according to treatmenta
Treatment
NONE
WITH
PLUS

Therapy

Number of patients
receiving therapy

Percentage of patients
receiving therapy

Oxygen delivery
+Intubation or tracheotomy
with artificial ventilation
+PEEP > 10 and FiO2 > 0.6

160
52

60.4
19.6

53

20.0

NONE, no additional treatment; WITH, oral or nasal intubation, with or without later tracheotomy, and artificial ventilation; PLUS, same as
WITH additionally requiring a positive end-expiratory pressure and >10 cmH2O; inspiratory fraction of oxygen (FiO2) > 0.6.
a
A total of 105 patients (39.6%) received mechanical ventilation, and 53 (50.5%) of these required a positive end-expiratory pressure (PEEP)
above 10 cmH2O and an inspiratory fraction of oxygen (FiO2) above 0.6.

Table 5b Respiratory complications among 265 people with burns: statistics itemised by premorbid conditiona
Condition
Hypertension
Cardiovascular
Cardiac
Diabetes
Respiratory
Neurological
Digestive tract
Renal
Psychiatric
Alcoholism
Allergies
Neoplastic
Other

Number of patients with condition,

developing a respiratory complication

Percentage of patients with condition,

developing a respiratory complication

56
21
24
21
13
23
21
3
24
6
10
9
56

67.5
63.6
43.6
65.6
59.1
63.9
65.6
75.0
45.3
27.3
66.7
50.0
67.5

p-Value
N.S.
N.S.
0.004
N.S.
N.S.
N.S.
N.S.
N.S.
0.01
0.01
N.S.
N.S.
N.S.

N.S., not significant.

Other cardiac, psychiatric diseases and alcoholism were significantly associated with the development of respiratory complications.

mortality with increasing age; one paper showed that among

people aged 80 years, HOS depended on presence of IT and
number of surgical operations [2]. We found similar results,
but did not include the number of operations in our statistics.
Focusing on IT, this is on the one hand an important factor
related to the development of complications or death [12]. On
the other hand, IT does not correlate with mortality in all
available studies [2]. Since this factor has been integrated in
most burn scores, it merits special attention as a therapeutic
guideline for risk assessment of associated complications, but
its value as a selective prediction marker is inconsistent [9,10].

4.3.

Fig. 4 Modes of discharge of 184 survivors; 77.7% of all

patients were discharged to a rehabilitation centre or back
home.

The mortality rate in our high group agrees with the literature,
which is either comparable [7,17,25,26] or excluded for further
analysis because of the high death toll [27]. The exact causes of
death cannot be defined from the data available and postmortems were not performed routinely. The most likely causes
of death, however, can be found in the significantly higher rates
of haemodynamic and respiratory complications. Furthermore,
renal replacement therapy (an indicator for acute renal
insufficiency, for example due to multiple organ failure or
rhabdomyolysis) was significantly more prevalent among a
quarter of the high group. The fact that septic shock showed
only a positive correlating trend in the high group can be
explained by the considerable number of individuals succumbing within 10 days after admission. Koller et al. found in a group
aged >65 years, with a smaller mean TBSA of 22%, that 78% of
the patients died from an infectious complication, but almost all

In our study, IT was significantly associated with respiratory

and haemodynamic complications, as well as mortality and
LoS.
Age was significantly associated with intensified respiratory
management. It is hypothesized that intubation was more
freely performed in older patients before, on or after admission.
From the data available we could not decide whether this was
due to the treating clinicians judgment or was an agedependent phenomenon.

Total body surface area burned >30% (high group)

972

burns 34 (2008) 965974

were tested positive for mulit-resistant bacteria in period of

more than 14 days after admission. It seems that deaths in our
high group during the first 10 days were more probably due to
haemodynamic, respiratory and renal instability than to septic
shock with defined bacterial infection, which was more likely to
occur after 14 days following admission [28].

4.4.

Premorbid conditions

4.4.1.

Comparative data

Since all data were collected prospectively, the subset

classification of diseases was rather accurate. Some
studies included the number of different premorbid conditions to account for a higher mortality, which resulted in
inconclusive findings. In particular, older age groups have
been excluded in separate analyses of burned people, because
the predominance of premorbid conditions and their presumed impact on outcome might have biased the actual focus
of a given study, as in protein energy malnutrition [27] or
diabetes [29].
Wibbenmeyer et al., in an investigation of 308 burned
people aged >60 years, found only age, TBSA and IT to be
significantly related to mortality. As in our study, there was no
significant difference in the presence of comorbidities among
either those surviving or those succumbing to their injuries [7].
Covington et al. confirmed this in an evaluation of 252 burned
people aged >55 years, and suggested that the number of
premorbid conditions explained prolonged HOS and lower
survival rate. Among the predictors found to be significantly
associated with more than one pre-burn health problem were
lower respiratory tract infections and sepsis [13]. Other studies
also concentrated on the number of premorbid conditions, but
not on specific subcategories; Lionelli et al., assessing 201
burned people aged >75 years, showed that age adjusted for
TBSA and IT (both significant) was again significantly
correlated to mortality. Although the cause of death was
separated into cardiac, pulmonary or renal organ failure, there
was no significant correlation between number of comorbidities and death [12]. In contrast, Rao et al. identified in a group
of 63 burned people aged >65 years a significant positive
correlation of TBSA and the number of pre-existing comorbidities to mortality, but not to age [6]. Still et al. observed among
236 burned people aged >60 years that more than one
premorbid condition (70.3%) versus no premorbid condition
(29.7%) was linked to increased LoS but not to mortality. Most
other such studies that are available do not focus on
premorbid conditions and their correlation to mortality or
LoS [3035].
All these data, as ours, have in common that they rely on a
single centres experience; some differ in the age groups
analysed and study endpoints, which renders comparative
interpretation difficult. We hypothesised that the contribution
of a single condition had an overall greater impact on
mortality and morbidity (e.g. cardiac versus allergic conditions) and that summing the number of conditions was not an
accurate method for evaluation.
However, most authors examining premorbid conditions
among people with burns could not identify a specific disease
entity which led to poorer prognosis [8,9,28]. A recent study of
comorbidities among a national sample in the United States of

over 30,000 burned people in all age groups revealed that

various illnesses were associated with increased mortality or
LoS, including ALC, CARDIAC and CVD [25]. We tried to find
premorbid conditions which led to haemodynamic or respiratory complications, and observed that CARDIAC yielded
positive correlating results with both. Although the prevalence
of CARDIAC or CVD is quite high in this age group in general,
the percentage was rather low in our population compared
with the literature [36,37]. However, whether this was due to
under-diagnosis, or to the fact that most patients did not
require a specific cardiological work-up, cannot be determined
retrospectively.
The contributions of ALC and PSY to respiratory complications are closely linked to IT, since the majority of the injuries
occurred in closed environments (data not shown). In our
group, PSY were significantly linked to high TBSA (>30%) and
thus increased mortality. Additionally, the impact of PSY
associated with delayed wound healing, extended time to
mobilisation and decreased compliance is not negligible [38].

4.4.2.

The diabetic context

Although we had expected DIAB to have a greater impact, e.g.

increasing LoS due to poorer wound healing and diabetesassociated cardiovascular, renal or immunocompromising
conditions, we did not find a significant influence on mortality
or morbidity. In comparison with the literature, the percentage of patients with DIAB in our study population seemed
relatively low; possibly under-diagnosis affected this result.
McCampbell et al. showed that mortality (2%) did not differ
significantly between diabetic and non-diabetic cohorts in all
age groups. The rates for different infections among burned
people aged 1865 years were significantly higher among those
with DIAB, among whom the number of full-thickness burns
was also significantly higher [29]. In a national review, DIAB
was not significantly associated with in-hospital mortality, but
was significantly associated with increased HOS after controlling for demographic and burn characteristics [25].
Our patients did not receive tight glucose control until 2002,
but whether this had an overall impact remains unclear. Since
the introduction of intensive insulin therapy for individuals in
intensive care units [39], glucose control has gained considerable attention. However, studies covering this topic among
burned people are scarce and concern mainly children [40];
there was no significant difference in LoS, but burned children
with DIAB who received intensive insulin therapy were four
times more likely to survive than those receiving conventional
insulin therapy and, when adjusted for LoS, the incidence of
urinary tract infections was significantly lower among the
intensive therapy group [41]. In another report, burned
children with poor glucose control had a significantly greater
incidence of positive bacterial blood cultures, when corrected
for LoS, and significantly reduced skin graft take compared
with normoglycaemic children [42]. However, as the authors
also noted, a definite correlation between the intensive insulin
therapy regimen and outcome could not be established, and
failure to control blood sugar levels despite intensive insulin
therapy could be independently associated with mortality
within intensive care units [43]. To the best of our knowledge,
there do not exist any studies examining the effects of DIAB or
intensive insulin therapy among elderly people with burns,

burns 34 (2008) 965974

but we do not consider our study population appropriate for

relevant interpretation. Age and DIAB both act as independent
risk factors for mortality or morbidity. In burn patients, factors
like hypermetabolism, weight loss and protein malnutrition
render distinction of relevant factors for outcome forecast
more difficult.

4.4.3.

Clinical indicators

In sum, premorbid conditions are good clinical indicators for

possible complications during treatment, but they do not aid
in predicting mortality or morbidity. The total number of
comorbidities in a case may eventually lead to an increased
HOS, e.g. if additional therapy is needed after completed burn
therapeutic work-up. However, this was not analysed in our
study. It seems that burns and their directly associated
problems are intrinsically responsible for mortality and
morbidity. In this context, all three scores, with the Baux
score, being from a statistical point of view the most relevant
in our series, proved to be indicative of mortality.

4.5.

Selected parameters

Our burns centre has two different units; the first has eight
single-bed en-suite intensive care rooms, and the second
consists of six general ward style rooms with single beds. As
soon as intensive monitoring or care is no longer needed,
patients are transferred to the second unit and are then
discharged as soon as wound healing permits. Thus the LoS
presented in this study closely reflected the HOS, and patients
usually remained longer in hospital than in acute-unit only
settings. Another consequence of the two-unit policy is the
overall decreased burn size among our patients compared
with the literature, since even minor burns are treated in the
second unit. However, LoS is still a controversial parameter.
On the one hand, it is a good continuous quantitative value,
readily available in all units, but the complication rate might
be better reflected in the HOS. Some authors argue that this
parameter aids in indicating areas for treatment performance,
but HOS or LoS incorporate institutional policies. For example,
discharge of patients can depend on cost pressure, but can also
be influenced by a retention of patients, in order to preserve a
current bed status and therefore the overall unit size [11,44].
We argue that the additional use of therapeutic interventions
needed for any given complication (e.g. modes of ventilation,
number of surgical operations, duration of antibiotic therapy),
data which are readily available in all units, might better
reflect the medical impact of a condition encountered during
hospital stay. LoS or HOS both depend on numerous factors,
some of them not primarily of medical nature, which lowers
their interpretive value.
We used the modes of discharge to further examine
morbidity. All burned patients aged 65 years were included
in this study, and about 31.5% could return to their previous
domestic environment; 46.2% were transferred to a rehabilitation centre. Altogether, these results seem promising for
burned people aged 65 years, since more than 75% may be
discharged without further need of in-hospital care. However, the functional outcome of these individuals cannot
be estimated from our data and studies of this type are
scarce [45].

4.6.

973

Care approach

In this study surgery was usually performed on days 57 after

injury, when most patients aged 65 years would have reached
a stable condition. In the literature the concept of early excision
and grafting as opposed to later operative (>7 days) or
conservative management is still controversially discussed
[46]. According to Kirn there does not seem to exist an advantage
of early surgical intervention for individuals aged 65 years [47].
It was also found that this age group undergoing surgery
had a significantly longer HOS, but with the timing of surgery
having no effect on HOS or outcome [6]. Since all patients
scheduled for operations needed excision and grafting because
of third-degree burns, and were therefore treated with the
corresponding delay, we cannot rule out possible positive or
negative effects of a different surgical strategy.

4.7.

Perspectives

This study was limited to one centres experience. Even within

one healthcare system, it remains difficult to match and
carefully compare data, mostly because of different treatment
approaches and selection of outcome parameters.
In the age of evidence-based medicine, physicians and
surgeons are facing difficulties when it comes to treatment of
burns, particularly among aged individuals. Economic, financial
or institutional restrictions augment the pressure on doctors to
encourage a sensible distribution of limited resources. The
danger of prognostic indices consists in the linking of financial
to medical decisions [48]. However, it would be helpful for us to
identify areas of possible improvement in diagnosis or therapy.
Survival as a single outcome parameter does not suffice for
evaluating burn treatment; adding LoS/HOS and factors
complicating hospital stay based on therapeutic management,
as already proposed by Dindo et al. for the evaluation of surgical
complications [44], can improve the explanatory power of a
study and facilitate meta-analysis of pooled results from
various burns centres. It would also be helpful to analyse
long-term results extending beyond the mode of discharge, a
parameter we selected for this report.
We suggest that standardized parameters for future studies,
should be set, at least, to provide easily available analysis factors
for a possible later pooling of data; that complications should be
evaluated according to therapeutic actions (e.g. number of
operations, modes of ventilation, duration of antibiotic therapy);
and that objective (e.g. modes of discharge) and qualitative
morbidity parameters (e.g. from standardised patient questionnaires) should be selected to evaluate long-term outcome.

Conflict of interest statement

None.

references

[1] Department of Economic and Social Affairs. World population

ageing: 19502050. New York: United Nations; 2002.

974

burns 34 (2008) 965974

[2] Pomahac B, Matros E, Semel M, Chan RK, Rogers SO,

Demling R, et al. Predictors of survival and length of stay in
burn patients older than 80 years of age: does age really
matter? J Burn Care Res 2006;27:2659.
[3] Sanchez JL, Pereperez SB, Bastida JL, Martinez MM. Costutility analysis applied to the treatment of burn patients in
a specialized center. Arch Surg 2007;142:507.
[4] Aylin P, Bottle A, Majeed A. Use of administrative data or
clinical databases as predictors of risk of death in hospital:
comparison of models. BMJ 2007;334:1044.
[5] Chang EJ, Edelman LS, Morris SE, Saffle JR. Gender
influences on burn outcomes in the elderly. Burns
2005;31:315.
[6] Rao K, Ali SN, Moiemen NS. Aetiology and outcome of
burns in the elderly. Burns 2006;32:8025.
[7] Wibbenmeyer LA, Amelon MJ, Morgan LJ, Robinson BK,
Chang PX, Lewis 2nd R, et al. Predicting survival in an
elderly burn patient population. Burns 2001;27:58390.
[8] Germann G, Barthold U, Lefering R, Raff T, Hartmann B. The
impact of risk factors and pre-existing conditions on the
mortality of burn patients and the precision of predictive
admission-scoring systems. Burns 1997;23:195203.
[9] Horbrand F, Schrank C, Henckel-Donnersmarck G,
Muhlbauer W. Integration of preexisting diseases and risk
factors in the abbreviated burn severity index (ABSI).
Anasthesiol Intensivmed Notfallmed Schmerzther
2003;38:1517.
[10] Edelman DA, White MT, Tyburski JG, Wilson RF. Factors
affecting prognosis of inhalation injury. J Burn Care Res
2006;27:84853.
[11] Andel D, Kamolz LP, Niedermayr M, Hoerauf K, Schramm
W, Andel H. Which of the abbreviated burn severity index
variables are having impact on the hospital length of stay? J
Burn Care Res 2007;28:1636.
[12] Lionelli GT, Pickus EJ, Beckum OK, Decoursey RL,
Korentager RA. A three decade analysis of factors affecting
burn mortality in the elderly. Burns 2005;31:95863.
[13] Covington DS, Wainwright DJ, Parks DH. Prognostic
indicators in the elderly patient with burns. J Burn Care
Rehabil 1996;17:22230.
[14] Pereira CT, Barrow RE, Sterns AM, Hawkins HK, Kimbrough
CW, Jeschke MG, et al. Age-dependent differences in
survival after severe burns: a unicentric review of 1,674
patients and 179 autopsies over 15 years. J Am Coll Surg
2006;202:53648.
[15] Baux S. Contribution a` letude du traitement local des
brulures thermiques etendues. Paris; 1961.
[16] Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE
II: a severity of disease classification system. Crit Care Med
1985;13:81829.
[17] 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;338:3626.
[18] Tobiasen J, Hiebert JH, Edlich RF. Prediction of burn
mortality. Surg Gynecol Obstet 1982;154:7114.
[20] Hasin D. Classification of alcohol use disorders. Alcohol Res
Health 2003;27:517.
[21] Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D,
et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis
Definitions Conference. Crit Care Med 2003;31:12506.
[22] Bessey PQ, Arons RR, Dimaggio CJ, Yurt RW. The
vulnerabilities of age: burns in children and older adults.
Surgery 2006;140:70517.
[23] Grant EJ. Burn prevention. Crit Care Nurs Clin North Am
2004;16:12738.
[24] Baux S, Mimoun M, Saade H, Lioret N, Esteve M, Nolland XB,
et al. Burns in the elderly. Burns 1989;15:23940.
[25] Thombs BD, Singh VA, Halonen J, Diallo A, Milner SM. The
effects of preexisting medical comorbidities on mortality

[26]
[27]

[28]

[29]

[30]

[31]
[32]
[33]
[34]

[35]

[36]

[37]
[38]

[39]

[40]
[41]

[42]

[43]

[44]

[45]

[46]

[47]

[48]

and length of hospital stay in acute burn injury: evidence

from a national sample of 31,338 adult patients. Ann Surg
2007;245:62934.
Zoch G, Meissl G, Bayer S, Kyral E. Reduction of the
mortality rate in aged burn patients. Burns 1992;18:1536.
Demling RH. The incidence and impact of pre-existing
protein energy malnutrition on outcome in the elderly burn
patient population. J Burn Care Rehabil 2005;26:94100.
Koller R, Zoch G, Bayer GS, Agstner I, Andel H, Frey M, et al.
The influence of different therapeutic approaches on the
survival of elderly burn patients. Chirurg 1999;70:91522.
McCampbell B, Wasif N, Rabbitts A, Staiano-Coico L, Yurt
RW, Schwartz S. Diabetes and burns: retrospective cohort
study. J Burn Care Rehabil 2002;23:15766.
Sarhadi NS, Kincaid R, McGregor JC, Watson JD. Burns in
the elderly in the south east of Scotland: review of 176
patients treated in the Bangour Burns Unit (198291) and
burn inpatients in the region (197591). Burns 1995;21:915.
Ho WS, Ying SY, Chan HH. A study of burn injuries in the
elderly in a regional burn centre. Burns 2001;27:3825.
Lewandowski R, Pegg S, Fortier K, Skimmings A. Burn
injuries in the elderly. Burns 1993;19:5135.
Hunt JL, Purdue GF. The elderly burn patient. Am J Surg
1992;164:4726.
Mabrouk A, Maher A, Nasser S. An epidemiologic study of
elderly burn patients in Ain Shams University Burn Unit,
Cairo, Egypt. Burns 2003;29:68790.
Cutillas M, Sesay M, Perro G, Bourdarias B, Castede JC,
Sanchez R. Epidemiology of elderly patients burns in the
South West of France. Burns 1998;24:1348.
Heart disease and stroke statistics2004 update, American
Heart Association, vol. 2004. American Heart Association,
Dallas, TX; 2003. p. 5.
Eco-Sante France 2007. Institut de Recherche et
Documentation en Economie de la Sante; 2007.
Kamolz LP, Andel H, Schmidtke A, Valentini D, Meissl G,
Frey M. Treatment of patients with severe burn injuries: the
impact of schizophrenia. Burns 2003;29:4953.
van den Berghe G, Wouters F, Verwaest C, Bruyninckx F,
Schetz M, et al. Intensive insulin therapy in the critically ill
patient. N Engl J Med 2001;345:135967.
Pidcoke HF, Wade CE, Wolf SE. Insulin and the burned
patient. Crit Care Med 2007;35:52430.
Pham TN, Warren AJ, Phan HH, Molitor F, Greenhalgh DG,
Palmieri TL. Impact of tight glycemic control in severely
burned children. J Trauma 2005;59:114854.
Gore DC, Chinkes D, Heggers J, Herndon DN, Wolf SE, Desai
M. Association of hyperglycemia with increased mortality
after severe burn injury. J Trauma 2001;51:5404.
Lacherade JC, Jabre P, Bastuji-Garin S, Grimaldi D, Fangio P,
Theron V, et al. Failure to achieve glycemic control despite
intensive insulin therapy in a medical ICU: incidence and
influence on ICU mortality. Intensive Care Med
2007;33:81421.
Dindo D, Demartines N, Clavien PA. Classification of
surgical complications: a new proposal with evaluation in a
cohort of 6336 patients and results of a survey. Ann Surg
2004;240:20513.
van Baar ME, Essink-Bot ML, Oen IM, Dokter J, Boxma H,
van Beeck EF. Functional outcome after burns: a review.
Burns 2006;32:19.
Kara M, Peters WJ, Douglas LG, Morris SF. An early surgical
approach to burns in the elderly. J Trauma 1990;30:
4302.
Kirn DS, Luce EA. Early excision and grafting versus
conservative management of burns in the elderly. Plast
Reconstr Surg 1998;102:10137.
Andel H, Kamolz LP. Scoring in burned patients: our
opinion. Burns 2003;29:2978.