burns 43 (2017) 1070 1077

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Assessing guidelines for burn referrals in a resource-

constrained setting: Demographic and clinical
factors associated with inter-facility transfer

A. Klingberg a, * , L. Wallis b , H. Rode c , T. Stenberg a , L. Laflamme a,d ,

M. Hasselberg a
a
Department of Public Health Sciences, Karolinska Institutet, Widerstrmska Huset, Tomtebodavgen 18 A, 171 77
Stockholm, Sweden
b
Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Private Bag X24,
Bellville 7535, South Africa
c
Department of Paediatric Surgery, Red Cross War Memorial Childrens Hospital and Faculty of Health Sciences,
University of Cape Town, South Africa
d
University of South Africa, Preller Street, Pretoria 0002, South Africa

article info abstract

Article history: Aim: The aim was to assess demographic and clinical factors associated with inter-facility
Accepted 26 January 2017 referrals for patients with burns in a resource-constrained setting.
Methods: This was a cross-sectional case review of patients presenting with a burn at the
trauma unit at the Red Cross War Memorial Childrens Hospital (RXH) in Cape Town, South
Africa.
Keywords: Results: Six hundred and eleven(71%) children were referred to the burns or the intensive
Burns care unit and 253 children were treated and discharged from the trauma unit. Of those
Trauma care admitted as inpatients 94% fulfilled at least one of the criteria for referral and 80% of those
Emergency care treated and discharged fulfilled the criteria for referral.
Referral criteria Conclusions: Almost three out of four children evaluated at the trauma unit were referred to
Children the burns unit for further management. However, a large number of patients were treated
Sub-Saharan Africa and discharged from the trauma unit despite being eligible for referral.
2017 Elsevier Ltd and ISBI. All rights reserved.

South Africa has a high incidence of burns, with children

1. Introduction
Burn care has advanced in the past decades, resulting in
better outcomes in patients with major burns. Unfortunate-
ly, children in low and middle-income countries (LMIC) are
still disproportionally affected [1], and clinical outcomes
are often worse in resource-constrained health care systems
[2].
less than four years old at highest risk: their average annual
rate is 6.0/10,000 childyears, with boys affected to an extent
higher than girls [3]. While children with minor burns may
successfully be treated at primary care level, those with severe
or complex burns often require treatment at higher levels of
care to minimise physical and psychosocial consequences.
Trauma systems should aim to ensure timely and appro-
priate care within the financial and resource limitations of the

* Corresponding author.
E-mail address: anders.klingberg@ki.se (A. Klingberg).
http://dx.doi.org/10.1016/j.burns.2017.01.035
0305-4179/ 2017 Elsevier Ltd and ISBI. All rights reserved.
 burns 43 (2017) 1070 1077 1071

health systems; utilization of proper triage is an important part
of achieving this goal. Accurate triage is the match between
injury severity and the level of care. The care and referral paths
will also depend on the local context and available resources.
To support decision making, referral criteria are used to guide
health practitioners when deciding whether to transfer a
patient to a higher level of care.
While studies have previously assessed adherence to burn
referral criteria in high-income settings, indicating many
patients are not always referred according to the established
criteria [47], studies from LMICs are scarce. One recent study
from another part of South Africa found that many patients
were often inappropriately referred to the burns unit [8].
Another study from South Africa studying pathways to care
found that two of the most critical barriers to access to care
were clinical assessment and referrals of the patients [9]. The
underlying reasons for the over- and under-referrals within
burn care are multifaceted, but include insufficient knowledge
among emergency department (ED) staff on burn management
[10], errors in burn estimation [11], and lack of dressings and
topical solutions [10].
In the Western Cape of South Africa, the provincial
government has set up a network of services and facilities
to treat these large numbers of burns. These services were
established to de-escalate management of burns to the
appropriate levels of care comprising primary healthcare
facilities and clinics, regional and district hospital and tertiary
institutions [12]. To improve referral of patients, referral
criteria have been implemented [13]. However, the extent to
how these criteria are appropriate to the burden of burns in the
region and the local health system is unknown.
The aim of this study was to assess demographic and
clinical factors associated with inter-facility referrals for
patients with burns in a resource-constrained setting. Two
research questions were formulated: (1) What is the magni-
tude of over- and under-referral among children presenting to
the emergency department? (2) What are the clinical and
demographic differences between children referred to an in
hospital burn unit and children treated and discharged at the
emergency department?
2. Methods
2.1. Design and setting
This study was a cross-sectional case review of patients with a
burn presenting to the emergency department and reviewed at
the trauma unit (TU) at the Red Cross War Memorial Childrens
Hospital (RXH) in Cape Town. The RXH is the only health
institution dedicated to children within the Western Cape
Province, offering a wide-ranging set of services of specialist
paediatric care. The RXH is also a referral hospital for the entire
country of South Africa and neighbouring countries for
specialized care. The hospital serves approximately 260,000
patients annually and has 300 beds, with about 1300 burn
patients attending the TU during 2015. Patients are predomi-
nantly from impoverished areas. The Burns Unit at the RXH is

Referral criteria for transfer to burns centre in the Western Cape Province of South Africa.

1 Age under 2 years

2 Paral thickness burns >15 TBSA

3 Full thickness burns >15 TBSA

Anatomical site - Face, hands, genitalia, perineum, major joints, circumferenal burns. These
4
burns can also be dealt with at level 1 or 2, but discreon must be used.

5 Inhalaon injury requiring venlaon for over 48 hours

6 Mechanism of injury:
Exposure to ionising radiaon injury
High pressure steam injury
High tension electrical injury (>1000 volts)
Hydrouoric acid injury >1% TBSA
Suspicion of non-accidental burn injury

7 Exisng Co-morbidity:
Cardiac limitaon and/or MI within 5 years
Respiratory limitaon of exercise
Uncontrolled type 1 diabetes
Pregnancy
Medically or disease induced immune-suppression for any reason
Exisng psychiatric or suicidal tendencies
Suspected drug/alcohol abuse

8 Severe associated injuries, e.g., polytrauma and crush syndrome

Fig. 1 Western Cape Referral criteria for transfer to a burns centre [13].
1072 burns 43 (2017) 1070 1077

Table 1 Demographic and injury characteristics of children with burns at the RXH trauma unit, Cape Town South Africa
(n=870). Study period Feb 1st, 2015Sept 30th, 2015.

Boys (%) Girls (%) D% Total (%)

Age groups
Infants/toddlers (<2) 268 (55.5) 208 (53.7) 1.7 476 (54.7)
Late toddlers (23) 115 (23.8) 86 (22.2) 1.6 201 (23.1)
Preschool (46) 54 (11.2) 50 (12.9) 1.7 104 (12.0)
School-aged (712) 46 (9.5) 41 (10.6) 1.1 87 (10.0)
No information 0 (0.0) 2 (0.5) 0.5 2 (0.2)

Burn mechanism
Scalds 399 (82.6) 313 (80.9) 1.7 712 (81.8)
Contact burns 39 (8.1) 40 (10.3) 2.3 79 (9.1)
Fire/flame 32 (6.6) 25 (6.5) 0.2 57 (6.6)
Othersa 12 (2.5) 8 (2.1) 0.4 20 (2.3)
No information 1 (0.2) 1 (0.3) 0.1 2 (0.2)

TBSA
05% 219 (45.3) 176 (45.5) 0.1 395 (45.4)
610% 110 (22.8) 87 (22.5) 0.3 197 (22.6)
1115% 44 (9.1) 40 (10.3) 1.2 84 (9.7)
1625% 22 (4.6) 24 (6.2) 1.6 46 (5.3)
>25% 11 (2.3) 9 (2.3) 0.0 20 (2.3)
No information 77 (15.9) 51 (13.2) 2.7 128 (14.7)

Burn depth
Partial thickness 380 (78.7) 304 (78.6) 0.1 684 (78.6)
Partial/full thickness 12 (2.5) 5 (1.3) 1.2 17 (2.0)
Full thickness 8 (1.7) 4 (1.0) 0.6 12 (1.4)
No information 83 (17.2) 74 (19.1) 1.9 157 (18.0)

Abbreviated Injury Score (AIS)

12 412 (85.3) 335 (86.6) 1.3 747 (85.9)
3+ 23 (4.8) 16 (4.1) 0.6 39 (4.5)
No information 48 (9.9) 36 (9.3) 0.6 84 (9.7)

Time to presentation
Same day 287 (59.4) 223 (57.6) 1.8 510 (58.6)
Day after 123 (25.5) 110 (28.4) 3.0 233 (26.8)
26days later 50 (10.4) 47 (12.1) 1.8 97 (11.1)
7+ days later 7 (1.4) 3 (0.8) 0.7 10 (1.1)
No information 4 (0.8) 6 (1.6) 0.7 10 (1.1)

Disposition at trauma unit

Referred to burns unit 344 (71.2) 249 (64.3) 6.9 593 (68.2)
Referred to ICU 8 (1.7) 9 (2.3) 0.7 17 (2.0)
Treated at trauma unit 127 (26.3) 126 (32.6) 6.3 253 (29.1)
No information 4 (0.8) 3 (0.8) 0.1 7 (0.8)

Referral site
Clinics 160 (33.1) 131 (33.9) 0.8 291 (33.4)
Level 1 110 (22.8) 86 (22.2) 0.6 196 (22.5)
Level 2 30 (6.2) 20 (5.2) 1.0 50 (5.7)
Level 3 5 (1.0) 2 (0.5) 0.5 7 (0.8)
Private hospital/clinicsb 9 (1.9) 7 (1.8) 0.1 16 (1.8)
Self-referred 69 (14.3) 57 (14.7) 0.4 126 (14.5)
No information 100 (20.7) 84 (21.7) 1.0 184 (21.1)

Total 483 (55.5) 387 (44.5) 11 870c (100.0)

a
Others include: chemical burns and electrical burns.
b
Private hospital/clinics are not classified by level in this study.
c
One child had missing information on gender and was excluded from the table.
 burns 43 (2017) 1070 1077
the only specialised burns unit for children under the age of
thirteen in the Western Cape Province.
2.2. Study population and data collection
Children with a burn visiting the TU during the period February
1st, 2015 and September 30th, 2015 were identified from the
admission records at the TU. This eight-month period also
covers the winter months associated with a higher incidence
of burns [14,15]. In total, 907 children under the age of thirteen
were identified with a burn. Thirty-six were excluded due to
incomplete information, resulting in a final sample of 871
patients (16.8% of all patients seen at the TU during the study
period). The following information was collected on each case:
gender, age, body part burnt, date of attendance, date of injury,
original referral site, burn mechanism, total body surface area
(TBSA), burn depth, and co-morbidity, and the outcomes were
whether the patient was referred to the burns unit or treated at
the TU. This information was used to determine whether the
injury matched the Western Cape Guidelines for referral of
burns (Fig. 1). For descriptive purposes, Abbreviated Injury
Score (AIS) was subsequently calculated by an emergency
physician (AIS 1=minor, 2=moderate, 3=serious, 4=severe,
5=critical and 6=un-survivable), and distance to the RXH from
each referral site was estimated using Google Maps (Google,
Inc., Mountain View, CA, U.S.A).
2.3. Referral criteria
The current criteria for referral of children with burns in the
Western Cape were introduced in 2013 (see Fig. 1). In this study,
the clinical and demographic data of the referred patients were
evaluated to determine whether they fulfilled one or more
criteria for referral to the burns unit.
Fig. 2 Disposition of patients and fulfilment of referral criteria among 864 patients seen at the RXH trauma unit between Feb 1st
2015Sept 30th 2015.
1073
2.4. Statistical analyses
Mean and standard deviation (SD) were used for descriptive
purposes on age and TBSA. Continuous data on age, TBSA, and
travel distance were reported as a median. Comparative
analysis was carried out using MannWhitney U-test for
continuous variables (age, TBSA, travel distance), and Chi-
square test was used for nominal data (gender) and to analyse
differences between the outcomes, children meeting the
referral criteria and children not meeting the referral criteria.
A P-value0.05 was considered significant in all statistical
analyses. The software IBM SPSS Statistics version 23 was used
in the statistical analysis.
2.5. Ethical approval
The study was approved by the University of Cape Town
Faculty of Health Sciences Human Research Ethics Committee
(HREC REF 452/2015).
3. Results
3.1. Patient characteristics
Table 1 presents information on demographic and injury
characteristics of the patients. Out of the 871 children in the
study, 55.5% were boys, and 54.7% were under two years of age.
The mean age was 2.93 years (SD 2.73), the median 1.8 years
(IQR=1.173.52). The majority of the burns were scalds
(81.8%), followed by contact and flame burns. Other types
of burns (electrical, chemical and inhalational burns) were
seen in 20 children (2.3%). Children with burns due to scalds
tended to be younger than children with flame burns. In a little
less than half of the children, the burn had a TBSA of less than
1074 burns 43 (2017) 1070 1077

5%, and 22.6% of the children had a burn of a TBSA of 510%.
Larger burns, above 15% TBSA, were seen in about 7% of the
children. Partial thickness burns were identified clinically in
79% of the children, a mixture of partial/full thickness in 2%
and full thickness in 1% of the children. Among all age groups,
there were no differences in severity between boys and girls.
Fifty-nine percent of the children came to the TU on the day
sustaining the injury, another 27% the following day and about
15% attendance was delayed for two or more days after the
burn occurred.
Most patients were initially seen at another health facility
before presenting to RXH, and 15% were self-referred or
transported by ambulance from the site of injury. There were
69 referral sites identified, and these were located 4366km
away (median 16km). About 18% of the children were first seen
at a site less than 10km away, and 31 (3.5%) children were seen
at a site more than a 100km away. Around a third of the children
were referred from primary health centres (33.4%), followed by
district hospitals (22.5%), and 14.5% of children were self-
referred or came with an ambulance. Only a few children (1.8%)
were referred from a private clinic or hospital. Children referred
from more than a 100km away had a median TBSA twice as high
as those children referred from within 10km.
co-morbidity had a referral rate of 83.3%. All other criteria
had a referral rate of 100%.
3.3. Differences in demographic and clinical characteristics
between referred children and children treated and discharged
Table 3 presents data on demographic and injury character-
istics between referred patients and those treated and
discharged at the TU for all ages (Table 3) and separately for
children younger than two and children older than two in
Tables 3a and 3b. All ages aggregated, there were no differ-
ences in age between the referred children and those treated
and discharged at the TU. However, among patients under two
years, referred children were slightly younger and had larger
burns (Table 3a). In all age groups, there was a significant
difference in TBSA between the referred children and those
treated and discharged. Among the older children (Table 3b)
but not the younger ones there was a significant difference in
gender; boys were more likely to be referred compared to girls.
Among the referred children older than two, girls had TBSA
significantly higher than boys (mean 11.3%, median 8,
compared to 9.3%, median 7P 0.038).

3.2. Disposition and fulfilment of referral criteria 4. Discussion

Most children seen at the TU were referred for further in-
hospital care. Seven of the 871 children had no information on
referral and were excluded from analysis. Six hundred and
eleven (71%) children were referred to the burns or the
intensive care unit (see Fig. 2), and 253 children were treated
and discharged from the TU. Of those admitted as inpatients,
94% fulfilled at least one of the criteria for referral, and 80% of
those treated and discharged fulfilled the criteria for referral.
Table 2 describes the number of children fulfilling each
criterion and the referral rate per criterion. In both referred and
not referred patients, the referral criteria most often fulfilled
were anatomical site and age under two. However, these
criteria also had the lowest rate of referral. The referral
criterion anatomical site had a referral rate of 78% and age
under two a referral rate of 70%. The referral criterion
Almost three out of four children were referred for further in-
hospital care, and most fulfilled at least one of the criteria for
referral. However, under-referral was commonplace, since
most not referred also fulfilled the criteria for referral. Among
the children referred, the TBSA was larger compared to the
children treated and discharged at the TU.
Studies from HIC countries point in the same direction
where patients eligible for referral were not referred [47].
These studies report a rate of under-referral, ranging between
44 and 65%, while in our study, the potential under-referral
was 80%. One explanation for the high rate of under-referral
found in our study might be that patients who are eligible for
referral according to the criteria are often assessed and
managed at the trauma unit with support from staff at the
burns unit, furthermore, this immediate feedback may

Table 2 Number of children fulfilling one or more criteria and number of children subsequently referred to the burns unit
n=864.
Referral criteria for transfer to Number children fulfilling (%)b Number of children fulfilling at least one (%)c
burns centre each criteriona n=864 criterion and being referreda n=611
1 Age under 2 years 472 (54.6) 328 (69.5)
2 Partial thickness burns >15TBSA 52 (6.0) 52 (100.0)
3 Full thickness burns >15TBSA 8 (0.9) 8 (100.0)
4 Anatomical site 646 (74.8) 504 (78.0)
5 Inhalation injury requiring ventila- 4 (0.5) 4 (100.0)
tion for over 48h
6 Mechanism of injury 1 (0.1) 1 (100.0)
7 Existing co-morbidity 84 (9.7) 70 (83.3)
8 Severe associated injuries e.g. poly- 0 (0.0) 0 (0.0)
trauma and crush syndrome
a
Each child can fulfil more than one criteria.
b
Percentage of children fulfilling the criteria.
c
Percentage of children fulfilling the criteria and being referred.
 burns 43 (2017) 1070 1077 1075

Table 3 Gender, age, TBSA and criteria fulfilment of referred and treated and discharged children with burns presenting to
the trauma unit n=864a .

Referred n=611 (%) Treated and discharged n=253 (%) P

Sex
Boys n =479 352 (57.7) 127 (50.2) 0.026
Girls n =384 258 (42.3) 126 (49.8)
Age (median) n=862 1.84 1.76 0.600
TBSA (median) n =732 7 3 0.000
Fulfilled at least one referral criterion
Fulfilled n =775 573 (93.8) 202 (79.8) 0.000
Not fulfilled n =89 38 (6.2) 51 (20.2)
a
Two patients missing age.

Table 3a Gender, age (<2 years), TBSA and criteria fulfilment of referred and Treated and discharged children with burns
presenting to the trauma unit n=472.
Referred n=328 (%) Treated and discharged n=144 (%) P
Sex n=471
Boys n =265 187 (57.2) 78 (54.2) 0.547
Girls n =206 140 (42.8) 66 (45.8)
Age (median) n=472 1.2 1.26 0.039
TBSA (median) n =407 7 3 0.000
Fulfilled at least one referral criterion n= 471
Fulfilled n =471 327 (100.0) 144 (100.0)
Not fulfilled n =0 0 (0.0) 0 (0.0)

Table 3b Gender, age (2 years), TBSA and criteria fulfilment of referred and Treated and discharged children with burns
presenting to the trauma unit n=390.
Referred n=282 (%) Treated and discharged n=108 (%) p
Sex n= 390
Boys n =214 165 (58.5) 49 (43.4) 0.023
Girls n =176 117 (41.5) 59 (54.6)
Age (median) n=390 3.66 4.36 0.128
TBSA (median) n =325 8 2 0.001
Fulfilled at least one referral criterion n= 390
Fulfilled n =302 244 (86.5) 58 (53.7) 0.000
Not fulfilled n =88 38 (13.5) 50 (46.3)

strengthen the trauma staffs ability to assess and manage
burns compared to other trauma units.
There are no similar studies from LMICs; however, one
study from a burns unit in South Africa indicated many
patients were inappropriately referred or not referred. In that
study, 30% of the patients could have been dealt with at a
health facility without a burns unit They also expressed
concern about a large number of delayed referrals [8].
Many children treated and discharged at the TU fulfilled the
criteria based on age and anatomical site of the burn. While
these two criteria are important as, even minor burns in
children may require specialist care, most were small and were
probably well-managed at the TU. In high-income settings,
Brown et al. conclude that minor burns in children can be
successfully treated as out-patients if they are appropriately
selected for outpatient care [16]. However, this selection is not
always straightforward, highlighting the importance of clear
criteria for referral.
Similar to other findings from South Africa [15,17], there
were more boys with burns in this study. Interestingly, despite
no differences in severity among the older children, boys were
more likely to be referred compared to girls. However, while
fewer girls in our study were referred to the burns unit, the girls
referred had significantly higher TBSA compared to the
referred boys.
The small group of children referred, despite not meeting
any of the criteria, had the same median TBSA as the children
that fulfilled the criteria, indicating these burns were severe
and likely benefitted by being referred. This study did not
collect data on subsequent treatment of the children treated
and discharged at the TU, but they followed two pathways,
either referred to the burns outpatient services of the RXH for
follow up care or back to the primary referral site. There might
be other reasons to refer patients, such as social circumstances
or difficulties for the patient to leave the hospital. Since
referrals at the TU are usually discussed with a burns registrar,
1076 burns 43 (2017) 1070 1077
patients may be admitted for further treatment during later
hours, when the burns registrar is off duty, that otherwise
could have been administered in the TU, such as washing or
escharotomy. A study from Australia found that about a third
of all admissions among children were related to other reasons
than the biology of the burn [18].
A recent study from the Western Cape province assessed
adherence of initial burn management and found short-
comings in the initial care of patients and the decision to
transfer patients [19]. In our study, most children were referred
from other health facilities within the province and many had
minor burns. Twenty-nine percent were treated and dis-
charged from the TU. Of these, 89 children met none of the
criteria for referral. The majority of these burns were small and
did not require admission to the TU, highlighting the
importance of organization and capacity within the health
care system to ensure treatment is administered at the correct
level [8,2022]. Primary health care personnel, commonly the
first receivers of children with burns, are often unfamiliar or
uncertain about paediatric thermal injuries. Physical factors,
such as their young age, size, vascular access difficulties, and
confusion over fluid resuscitation calculation, altered ther-
moregulation, analgesia, and transport considerations are
factors creating uncertainty regarding further management.
Other reasons may be a lack of consumables, such as
dressings, that might hinder first-hand receivers from treating
the patients [12], or the referring doctors are over-estimating
the severity of the burn and believe the burn is eligible for
referral. Studies have found that the burn size in children is
often inaccurately estimated by the referring doctors
[11,23,24], which may lead to errors in fluid administration
and unnecessary transfer. All these factors, therefore, often
add to uncertainty, prompting health care personnel to
facilitate earlier transfer.
To understand the impact on morbidity and mortality
among patients with burns, future studies must track the
pathways of those discharged back to community centres or
the outpatients department for ongoing care. This would be a
crucial factor in assessing the credibility of the established
criteria and the functionality of community burn care.
5. Limitations
Every effort was made to capture all the information, but an
inherent problem with retrospective record studies is that
information may be lacking. Burn size (especially small
scattered burns) and depth and co-morbidity were often
missing and may reflect lack of experience assessing paediat-
ric burns or simply, because of time constraints in document-
ing the burn properly. If a patient had missing information, it
was assumed not to fulfil the criteria, meaning there were
likely more patients that fulfilled the criteria, had information
been available.
The referral criteria should not be seen as absolute, and
there is room for their interpretations. For example, the criteria
state that the referral criteria anatomical site can also be
dealt with at level 1 or 2 hospitals, but discretion must be used.
Finally, in this study, the clinical and the demographic data
was only retrospectively compared to the burns criteria to
determine whether they matched, and it is not possible to
know whether the criteria were used.
6. Conclusion
Almost three out of four children evaluated at the TU were
referred to the burns unit for further management. Common
criteria fulfilled among all children were age less than 2 years
and anatomical sites. Most of the referred children fulfilled at
least one criteria for referral. There were a few children
referred, despite not fulfilling any of the criteria, i.e., being
over-referred. The data suggest these burns were severe and
likely benefited from referral. Many patients were treated and
discharged from the trauma unit, despite being eligible for
referral. This under-referred group had mostly minor
burns and were probably well-managed at the trauma unit.
The potential consequences of especially under-referral are
still unknown. Longitudinal outcome studies are needed to
comprehend both short-term and long-term outcomes
of these patients, especially for those treated and discharged
at lower levels of care, despite fulfilling the criteria for
referral.
Conflict of interest
The authors declare no conflicts of interest.
Acknowledgements
The authors gratefully acknowledge financial support from
the Marianne and Marcus Wallenberg Foundation and the
Swedish Research Council. The authors would also like to
acknowledge the staff at the medical records department at
the Red Cross War Memorial Hospital for assisting in the
retrieval of patient folders.
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