Adherence to burn center referral criteria for pediatric burns

Importance — Burn injuries are a leading cause of emergency department visits and hospitalizations among children and adolescents. Referral to specialized burn centers is recommended for severe injuries, but adherence to referral guidelines in pediatric care remains uncertain.

Objective — To evaluate the association between pediatric burn characteristics, including referral criteria, and the setting of care, burn center vs non–burn center.

Design, setting, and participants — This population-based cohort study used linked health and administrative databases among all children and adolescents aged 0 to 17 years with a hospital visit for burn injury residing in Ontario, Canada (population, approximately 16 million), from April 1, 2003, to March 31, 2023. Data were analyzed from November 2023 to September 2024.

Exposure — Presence and number of 1 or more of 6 measurable burn center referral criteria: burns over more than 10% of the total body surface area, full-thickness burns, critical anatomical areas, and inhalation, chemical, or electrical injuries.

Main outcome and measure — Receipt of care at a specialized burn center vs a non–burn center. Adjusted rate ratios (aRRs) were estimated using modified Poisson regression.

Results — Among 79 782 youths with burn injuries (median [IQR] age, 4 [1-12] years; 44 191 male [55.4%]), 16 164 individuals (20.3%) were rural residents, 19 067 individuals (23.9%) lived in the lowest material resource quintile, and 1636 individuals (2.1%) were nonrefugee immigrants. There were 34 812 youths (43.6%) who met at least 1 referral criterion, but only 7533 of these (21.6%) were treated at a burn center. Youths meeting any referral criterion were more likely to be treated at a burn center compared with those who met no referral criteria (aRR, 1.50; 95% CI, 1.46-1.54). The likelihood of burn center treatment increased with the number of criteria (1 criterion: aRR, 1.27; 95% CI, 1.23-1.30; 2 criteria: aRR, 2.63; 95% CI, 2.51-2.75; ≥3 criteria: aRR, 4.71; 95% CI, 4.32-5.15). Inhalation (aRR, 1.88; 95% CI, 1.21-2.91) and chemical (aRR, 1.80; 95% CI, 1.65-1.97) injuries had the largest aRRs in the association with burn center care.

Conclusions and relevance — In this study, burn center referral criteria were associated with increased likelihood of specialized care, although the application of criteria was inconsistent. These findings suggest that enhancing adherence to referral guidelines and addressing geographic and systemic barriers are essential to improving equitable access to specialized pediatric burn care.