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Available online at www.sciencedirect.com

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

Validation of the burn intervention score in a

National Burn Centre ,
$ $$

Islam Abdelrahman a,b,c, * , Moustafa Elmasry a,b,c , Mats Fredrikson c ,

Ingrid Steinvall b,c
a
Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt
b
Department of Hand Surgery, Plastic Surgery and Burns, Linköping University, Linköping, Sweden
c
Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden

article info abstract

Article history: The Linköping burn score has been used for two decades to calculate the cost to the hospital
Accepted 2 February 2018 of each burned patient. Our aim was to validate the Burn Score in a dedicated Burn Centre by
Available online xxx analysing the associations with burn-specific factors: percentage of total body surface area
burned (TBSA%), cause of injury, patients referred from other (non-specialist) centres, and
survival, to find out which of these factors resulted in higher scores. Our second aim was to
Keywords:
analyse the variation in scores of each category of care (surveillance, respiration, circulation,
Burn intervention score
wound care, mobilisation, laboratory tests, infusions, and operation).
Validation
We made a retrospective analysis of all burned patients admitted during the period 2000–15.
Workload
Multivariable regression models were used to analyse predictive factors for an increased daily
burn score, the cumulative burn score (the sum of the daily burn scores for each patient) and the
total burn score (total sum of burn scores for the whole group throughout the study period) in
addition to sub-analysis of the different categories of care that make up the burn score.
We retrieved 22301 daily recordings for inpatients. Mobilisation and care of the wound
accounted for more than half of the total burn score during the study. Increased TBSA% and
age over 45 years were associated with increased cumulative (model R2 0.43, p< 0.001) and
daily (model R2 0.61, p<0.001) burn scores. Patients who died had higher daily burn scores,
while the cumulative burn score decreased with shorter duration of hospital stay (p< 0.001).
To our knowledge this is the first long term analysis and validation of a system for scoring
burn interventions in patients with burns that explores its association with the factors
important for outcome. Calculations of costs are based on the score, and it provides an
indicator of the nurses’ workload. It also gives important information about the different
dimensions of the care provided from thorough investigation of the scores for each category.
© 2018 Elsevier Ltd and ISBI. All rights reserved.

$
The study was done and financed by the Department of Hand Surgery, Plastic Surgery and Burns, Linköping University Hospital, and the
Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
$$
The paper has not been presented at any conferences yet.
* Corresponding author at: The Burn Centre Dept. of Hand and Plastic Surgery, Linköping University Hospital, 58185 Linköping, Sweden.
E-mail address: islam.abdelrahman@liu.se (I. Abdelrahman).
https://doi.org/10.1016/j.burns.2018.02.001
0305-4179/© 2018 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: I. Abdelrahman, et al., Validation of the burn intervention score in a National Burn Centre, Burns
(2018), https://doi.org/10.1016/j.burns.2018.02.001
JBUR 5480 No. of Pages 8
2 burns xxx (2018) xxx –xxx
1. Introduction
The implementation of a computerised registry and therapeu-
tic intervention scoring system adapted specifically for burn
care has been described by many authors [1–3]. The scoring
systems designed for general intensive care do not reflect burn
care accurately [4], however, and the management of the
wound in particular is specific to the care of burns, and must be
incorporated into the measurement of the workload [3,5–7]. In
2000 we published the intervention scoring system (burn
score) used in our centre, [1] which was designed to include
burn-specific items in a widely-used score [8], and was
validated against the Therapeutic Intervention Scoring Sys-
tem (TISS) [1]. Every patient at the Linköping Burn Centre has
been daily scored by a nurse, and the daily scores have been
used to calculate the cost of care.
During past decades attention has been directed to the
measurement of the workload in general intensive care, and
numerous systems have been developed [9–19] to improve the
quality of care and optimise the use of resources [16,20–22].
Initially the workload was scored according to therapeutic
interventions, and was mainly related to the patient’s illness
[9–11], but over time the focus has moved from the patient to
the nurse, and taken into account other aspects, such as the
time spent on nursing activities [12,13,15]. Even human factors
have been considered [14,20]. The Burn Score gathers both the
nurses’ activities and the patients’ severity of injury and illness
together to give a more accurate balance for the overall burn
care provided.
Our aim was to validate the Burn Score by analysing the
associations with burn-specific factors such as percentage of
total body surface area burned (TBSA%), cause of injury,
whether the patient was local or referred from outside that
region, and survival. We analysed the factors that resulted in
higher scores and consequently increased the workload and
resources used. Our second aim was to analyse the variation in
scores of each category of care measured by the burn score
(surveillance, respiration, circulation, wound care, mobilisa-
tion, laboratory tests, infusions, and operation).
2. Methods
All admissions during the period 2000–2015 were included. We
analysed data from the prospectively-maintained burn regis-
try that is recorded daily by the nursing staff [1]. The study was
approved by the Regional Ethics Review Board in Linköping
(2013/341-31).
The study was done in the national burn centre in
Linkoping, Sweden which serves about 5 million inhabitants.
The burn centre serves the southern region of Sweden and the
Uppsala university hospital burn centre serves northern
Sweden. Patients could be local residents or referrals, and
the severity of burns varied accordingly. Referrals were
admitted in line with the national guidelines for burn care
in Sweden.
The protocol in our Burn Centre includes early excision and
grafting [1,23–25], revision of the wound every second day,
standard ventilation [26,27], fluid management [28], and early
Please cite this article in press as: I. Abdelrahman, et al., Validation of the burn intervention score in a National Burn Centre, Burns
(2018), https://doi.org/10.1016/j.burns.2018.02.001
enteral nutrition, and we recorded the variables: TBSA%, cause
of injury, age, sex, patients who were referred from outside the
region, duration of hospital stay, and survival. The patient’s
burn score covered surveillance (patients’ vital signs monitor-
ing, physical status including urine output, ECG monitoring,
oxygen saturation and invasive cardiac function monitoring),
respiration, circulation, wound care, mobilisation, laboratory
tests, infusions, and operation (Supplementary Table S1). Each
category is given a score from 0 to 4 except for the operation,
which is calculated based on the operating time and type of
dressing material (1h=2 points in the score).
Standard ventilation is defined as:
Pressure-controlled ventilation with positive end expirato-
ry pressure (PEEP) of at least 5cm H2O. For recruitment
maneuvers we used opening pressures of up to 55cm H2O
and PEEP levels were adjusted thereafter accordingly. The aim
was <30cm H2O for ventilatory plateau pressures and 6–8ml/
(kgmin) for expiratory tidal volumes to reduce any risk of
ventilator-induced lung injury.
The daily burn score refers to the score recorded for each
patient every 24h; the cumulative burn score refers to the sum
of the daily scores for each patient; and the total score is the
sum of scores for the whole group throughout the study period.
Our definition of “intensive care days” is when at least one
of the following criteria was fulfilled: mechanical ventilation,
inotropic support, or surveillance round the clock (a recorded
score of 3 or 4 in the categories surveillance, respiration, and
circulation). We defined mortality as death from any cause
while an inpatient on the burn centre.
2.1. Data analysis and statistics
Data were analysed with the help of STATA (STATA v12.0,
Stata Corp. LP, TX, USA), and presented as median (10–
90 centiles) unless otherwise stated. The significance of
differences between characteristics were examined with the
help of the Mann Whitney U test and the chi square test, as
appropriate, and multivariable regression was used to analyse
the significance of factors associated with cumulative burn
scores, and multivariable panel regression (panel variable by
patient) was used for the analysis of the significance of
differences in daily burn scores. Probabilities of less than
0.05 were accepted as significant.
3. Results
The scores of 1363 patients were analysed based on 22301 daily
inpatient recordings of burn scores. Table 1 shows personal
and clinical data and median cumulative burn scores by the
groups of those who survived and those who died. The highest
score was in the category “wound care” (Table 1) which,
together with mobilisation, made up more than half the total
burn score during the study (Supplementary Fig. S1). The
distribution of parts played by different categories of care
while patients were in intensive care differed from those
recorded for patients who were not in intensive care (Fig. 1).
The mean cumulative burn scores/TBSA% for patients who
died among the TBSA%<10% were nearly five times that of
survivors. In groups that ranged from 10% to 50% TBSA% the
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Table 1 – Descriptive details of the patients and cumulative burn scores by the groups of survivors and those who died.
All groups (n=1363) Alive (n=1293, 95%) Deaths (n=70, 5%) p Value Test of significance
Sex (male) 960 (70) 915 (71) 45 (64) 0.25 Chi square
Age (years) 32.9 (1.3–72.2) 31.2 (1.2–69.2) 71.4 (46.1–85.8) <0.001 M
TBSA% 6.5 (1–31) 6 (1–25.5) 39.3 (13.6–85.3) <0.001 M
Superficial dermal burns BSA% 2 (0–12) 2 (0–12) 0 (0–11.8) 0.002 M
Deep dermal burns BSA% 0.5 (0–9.5) 0.5 (0–8.5) 4.8 (0–20.8)) <0.001 M
Full thickness burn BSA% 0 (0–14) 0 (0–9) 26.1 (2–71.5) <0.001 M
Duration of hospital stay (days) 8 (2–36) 8 (2–35) 8 (2–63.5) 0.35 M
Duration of stay/TBSA% 1.4 (0.3–5.3) 1.5 (0.4–5.7) 0.3 (0–2.5) <0.001 M
Referred from outside the region, n (%) 621 (46) 580 (45) 41 (59) 0.02 Chi square
Mechanical ventilation, n (%) 278 (20) 218 (17) 60 (86) <0.001 Chi square
Intensive care patients, n (%) 373 (27) 305 (24) 68 (97) <0.001 Chi square
No who required operation, n (%) 976 (72) 929 (72) 47 (67) 0.40 Chi square
Sedation dressing patients, n (%) 841 (62) 787 (61) 54 (77) 0.006 Chi square

Scores for categories:

Surveillance 3 (0–57) 3 (0–47) 19 (6–208.5) <0.001 M
Respiration 1 (0–41) 0 (0–32) 16.5 (4.5–189) <0.001 M
Circulation 0 (0–8) 0 (0–3) 10 (0–115.5) <0.001 M
Wound care 11 (1–62) 11 (1–60) 12.5 (1.5–132.5) 0.11 M
Mobilisation 9 (2–62) 8 (2–58) 18 (3–177) <0.001 M
Laboratory tests 2 (0–28) 1 (0–24) 11.5 (1–88.5) <0.001 M
Infusions 3 (0–61) 3 (0–52) 18.5 (4–186.5) <0.001 M
Operation 4 (0–30) 4 (0–25) 12.5 (0–82.5) <0.001 M
Cumulative score 34 (7–348) 32 (7–312) 133.5 (22.5–1128) <0.001 M

Data are median (10–90 centiles) or no (%). M=Mann Whitney U test. BSA =body surface area.

Fig. 1 – The percentage of the contribution of each category of care to the recorded total burn score during the study period,
grouped by days when intensive care (red) was required. (For interpretation of the references to colour in this figure legend, the
reader is referred to the web version of this article.).

mean cumulative burn scores/TBSA% were similar among
those who survived and those who died, while among those in
whom TBSA% was greater than 50%, the mean cumulative
score/TBSA% was considerably reduced among those who
died compared with those who recovered (Fig. 2).
Flame was the cause of the burn in almost half the patients
admitted while scalds accounted for 30%; the highest total
burn scores, which reflected the impact on the Burn Centre,
were noticed among patients with flame burns, followed by
those with scalds. The total burn score ratio between flame
burns and scalds was 10:1. The chemical group had the
smallest total score (Supplementary Table S2).
The highest daily burn scores were in the group with flame
burns in all categories of care. That group showed the highest
operating scores while scalds and chemical burns showed the
smallest scores. The overall trend was for both mobilisation
and wound care to give the highest scores whatever the cause,
with a mean daily score around 1.5 in all groups (Supplemen-
tary Fig. S2).
We noticed a linear increase in the pattern of cumulative
burn score coefficients (in the categories wound care,
respiration, and operation) when the TBSA% was larger,
compared with those coefficients for daily burn scores.
“Wound care” was strongly associated with larger TBSA% in
the cumulative burn score, which reflected the need for
repeated procedures for wound care over a longer period in
hospital for patients with bigger TBSA%. However, in the daily
burn score, the category “respiration” showed higher

Please cite this article in press as: I. Abdelrahman, et al., Validation of the burn intervention score in a National Burn Centre, Burns
(2018), https://doi.org/10.1016/j.burns.2018.02.001
JBUR 5480 No. of Pages 8

4 burns xxx (2018) xxx –xxx

Fig. 2 – Shows the mean cumulative burn score required for each TBSA% among different TBSA% groups in both those who
survived and those who died.

coefficient values than “wound care” in the different TBSA%
groups (Fig. 3).
The R2 for different regression models of categories of care
using cumulative burn score as the dependent variable seems
to be in the same range (0.42), except for the category
“circulation” (0.22), (Supplementary Table S3) probably
because fewer patients required the highest level of this care
(Supplementary Fig. S1). The cumulative burn score model
shows that mortality was associated with lower scores for care
categories except for “circulation”. Patients over 45 years old
required more care, which was reflected in higher scores for
that age group. Neither sex nor referrals from other centres
was associated with higher cumulative burn scores. Compared
with patients with TBSA% of less than 10%, there was a directly
proportional increase in the burn score with increased TBSA%
in all categories of care (Supplementary Table S3).
Unlike the cumulative burn score, mortality was associated
with increased daily burn scores in all categories of care, with
particularly high values in “surveillance”, “respiration”, and
“circulation”. There was a direct proportional relation between
increased age and increasing scores in all the categories of
care, but sex had no impact on the daily burn score. The R2 for
different models were stronger when they were calculated on
daily burn scores (rather than models based on the cumulative
burn score) except for the R2 in the category “wound care”.
Compared with the patients with TBSA% of less than 10%,
those with a TBSA% of more than 60% had daily burn scores
that increased by 7.8 points for each day of care (Table 2).
4. Discussion
We propose a validated intervention scoring system that could
be applied worldwide in burn centres. We have analysed 16
years’ data of daily recorded burn scores from our Burn Centre,
and as far as we know this is the first long-term analysis of an
intervention scoring system for burns that has been validated.
We found TBSA% to be the strongest factor in the increase in
both daily and cumulative burn scores, which confirms our
initial presumption. Not only does it provide an indicator of the

Fig. 3 – Compares the relation between the coefficients of three categories of care; respiration, wound care, and operation which
showed a different order in the cumulative burn score compared to the daily burn score. See all coefficients in Table 2 and
Supplementary Table S3.

Please cite this article in press as: I. Abdelrahman, et al., Validation of the burn intervention score in a National Burn Centre, Burns
(2018), https://doi.org/10.1016/j.burns.2018.02.001
 JBUR 5480 No. of Pages 8
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Table 2 – Daily burn score, regression model for the association with each category of care.
Surveillance Respiratory Circulatory Wound care Mobilisation Lab tests Infusions Operation Total

Coef. p Value Coef. p Value Coef. p Value Coef. p Value Coef. p Value Coef. p Value Coef. p Value Coef. p Value Coef. p Value
TBSA%:
0–9.9
10–19.9 0.3 <0.001 0.2 <0.001 0.0 0.04 0.2 <0.001 0.2 <0.001 0.2 <0.001 0.4 <0.001 0.1 0.28 1.7 <0.001
20–29.9 1.0 <0.001 0.8 <0.001 0.2 <0.001 0.4 <0.001 0.6 <0.001 0.4 <0.001 1.0 <0.001 0.3 <0.001 4.5 <0.001
30–39.9 1.1 <0.001 1.0 <0.001 0.3 <0.001 0.4 <0.001 0.7 <0.001 0.5 <0.001 1.2 <0.001 0.3 <0.001 5.7 <0.001

burns xxx (2018) xxx –xxx

40–49.9 1.2 <0.001 1.0 <0.001 0.3 <0.001 0.4 <0.001 0.8 <0.001 0.5 <0.001 1.3 <0.001 0.3 <0.001 6.3 <0.001
50–59.9 1.3 <0.001 1.1 <0.001 0.2 <0.001 0.5 <0.001 0.8 <0.001 0.5 <0.001 1.4 <0.001 0.4 <0.001 6.0 <0.001
60 and more 1.5 <0.001 1.3 <0.001 0.8 <0.001 0.6 <0.001 1.0 <0.001 0.7 <0.001 1.5 <0.001 0.4 <0.001 7.8 <0.001

Male sex 0.0 0.38 0.0 0.89 0.0 0.87 0.0 0.37 0.0 0.20 0.0 0.06 0.0 0.16 0.0 0.34 0.2 0.17
Patients from elsewhere 0.2 <0.001 0.2 <0.001 0.1 0.005 0.1 <0.001 0.1 <0.001 0.1 <0.001 0.2 <0.001 0.1 0.003 1.3 <0.001

Age (years):
0–4.9
5–17.9 0.1 0.36 0.1 0.35 0.1 0.09 0.0 0.75 0.1 0.14 0.0 0.73 0.1 0.05 0.0 0.85 0.3 0.16
18–45.9 0.1 0.20 0.1 0.002 0.0 0.90 0.1 0.03 0.2 <0.001 0.2 <0.001 0.4 <0.001 0.2 0.03 1.3 <0.001
46–65.9 0.2 <0.001 0.3 <0.001 0.1 <0.001 0.1 0.004 0.2 <0.001 0.2 <0.001 0.4 <0.001 0.2 0.002 2.1 <0.001
66 and older 0.5 <0.001 0.5 <0.001 0.2 <0.001 0.1 0.23 0.5 <0.001 0.3 <0.001 0.6 <0.001 0.2 0.04 3.2 <0.001

Mortality 1.2 <0.001 1.3 <0.001 1.2 <0.001 0.3 <0.001 0.6 <0.001 0.6 <0.001 0.9 <0.001 0.5 <0.001 6.6 <0.001
Constant 0.3 <0.001 0.1 0.03 0.0 0.07 1.2 <0.001 0.9 <0.001 0.0 0.75 0.1 0.001 0.3 <0.001 2.4 <0.001

R2 0.58 0.59 0.45 0.08 0.61 0.51 0.61 0.05 0.61

2
n= 1363, days =22301, multivariable panel regression, the “between” R is presented in the table. The table shows nine regression models, the first eight for each category of care, and the last for the sum of
the daily burn score.

5
JBUR 5480 No. of Pages 8
6 burns xxx (2018) xxx –xxx
nurses’ workload, but more importantly it gives essential data
about the care provided including the progress of care of each
inpatient, and the basis of calculations of costs.
The computerised system has been the source of data for
several previous publications [29–33] and for local auditing,
but we have not made a comprehensive analysis of the burn
score until now. There have been many studies published
about different intervention scores and ways of measuring
workload, [3,7,9,16,22,34], but we know of no studies that
have described accurate data about different interventions
collected over a long period in a dedicated Burn Centre. Even
when we searched in other fields where intervention scores
have been used, such as intensive care [7], we found no such
publications.
There was a steep rise in both the cumulative and daily burn
scores between the groups TBSA% 10%–19.9% and 20%–29.9%,
contrary to the gradual rise among the groups with larger TBSA
%. The category “circulation” showed the biggest proportional
increase in this TBSA% group, followed by “respiratory care”,
but the effective increase in the total score was the result of the
increases in the categories “respiratory” and “surveillance”.
We have previously used the 20% TBSA% as a cut off point for
severe burns [35,36] as most of those patients require more
care [37], and this is confirmed by the present results of the
need for more interventions.
The longer hospital stay for patients with larger TBSA%
resulted in a higher cumulative burn score, and the daily
analysis confirmed an increase in the groups with bigger
TBSA%. A study from Finland showed the direct relation
between increasing TBSA% and costs of a burn [38], which is
in line with our results as increasing cumulative burn scores
indicates higher costs/patient. Patients less than 18 years old
required less daily burn care than older patients, and there
was a steady increase as patients got older. This is in line
with previous studies [38] that showed increasing costs in
elderly patients.
Patients referred from elsewhere had increased daily burn
score coefficients, and increased scores in all the categories
of care as well. This could be explained by the fact that local
patients are kept in the burn centre for a period that includes
both the acute phase of the injury and the healing phase,
while those from elsewhere are usually sent back to their
referring hospital when they are well enough to finalise their
treatment [31]. Duration of hospital stay was the major
contributing factor to the results among patients who died,
probably because patients with the smallest TBSA% were
likely to live longer and required a higher cumulative burn
score than the group with a bigger TBSA%, which is usually
associated with high mortality after a short hospital stay.
Few studies have presented the results of an intervention
scoring system for burns [7,39] that covered nursing time or
prediction of mortality. There are more studies of interven-
tion scores in general intensive care settings, although they
differ from those in burn care in factors such as duration of
stay, age, and the nature of the disease [4]. The relation
between workload and mortality has been assessed in some
intensive care studies from the number of staff [40,41], and a
few studies have shown that patients who died required
more interventions, as measured by TISS [4]. Collins et al. [42]
reported a correlation between the number of nurses’
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(2018), https://doi.org/10.1016/j.burns.2018.02.001
recordings (surveillance), and mortality, which was similar
to our finding.
The pattern of increased operations and scores for the
category “wound dressing” with increased TBSA% that we
found is in line with findings from other studies that have
focussed on analysis of costs [43]. Contrary to our finding that
scores were higher with increased TBSA% in all categories,
those that focussed on costs showed relatively less increase in
costs with increased TBSA% [38], which can be explained by
the different methods of measurement.
In a previous publication [32] we have compared mortality
in two different time periods (2000–2007 and 2008–2015) and we
have shown a decrease in mortality with the same levels of
resources consumption, workload assessed by the burn score.
The previous publication mentioned that the two compared
periods were similar regarding medical interventions, no
introduction of revolutionary techniques was introduced in
the field of wound care and on the technical aspect of the
intensive care the ventilators and the monitors are upgraded
but they require the same amount of work. However, the staff
probably became more experienced over time. This could raise
the prospect of investing more in upgrading knowledge and
developing skills among the staff.
4.1. Limitations of the study
We could not compare the recorded workload with the actual
number of staff who provided the service as we did not have
precise records of nurse:patient ratios. On the other hand, the
Burn Score has been used during the last two decades to
convert the recorded points to a final daily cost, which
increases the reliability of the score. The intervention scoring
system currently in use in general intensive care units in
Sweden [44] and the Burn Score [1] are both modified versions
of the original nursing care recording system [8].
4.2. Conclusion
This is to our knowledge the first long-term analysis and
validation of a burn intervention score that explores its
association with the factors important for the outcome of
care in burns. The different scores for category of care were
consistently distributed among different groups of TBSA%,
age, mortality, and patients referred from elsewhere. The Burn
Score also gives important information about the different
dimensions of the care provided by thorough investigation of
the score/category of care.
Conflict of interest statement
The authors declare that there is no conflict of interest.
Appendix A. Supplementary data
Supplementary data associated with this article can be found,
in the online version, at https://doi.org/10.1016/j.
burns.2018.02.001.
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Please cite this article in press as: I. Abdelrahman, et al., Validation of the burn intervention score in a National Burn Centre, Burns
(2018), https://doi.org/10.1016/j.burns.2018.02.001
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Please cite this article in press as: I. Abdelrahman, et al., Validation of the burn intervention score in a National Burn Centre, Burns
(2018), https://doi.org/10.1016/j.burns.2018.02.001