The cost of a major paediatric burn

Abstract

There is little written on the financial cost of burns care. This project examined three major paediatric burns of 30–40% total body surface area (%TBSA) admitted to the South West Paediatric Burns Service in Bristol, and calculated the cost per patient of acute inpatient treatment. A list of costs was established for theatre time, bed time, medications and fluids, dressings, invasive procedures, therapy services and investigations. The time period was the initial inpatient stay, from admission to the burns service, to first discharge. Staff in the relevant managerial and purchasing departments provided additional information about charging. We calculated a mean cost per patient of £63,157.22 (range £55,354.79–£74,494.24).

Our results suggest that current income achieved for a major paediatric burn underestimates the actual financial burden of treatment. The North Bristol NHS Trust tariff cost for a “major burn, third degree of more than 19% TBSA, or affecting multiple body regions with significant graft” is £17,797 (2009). The fact that our costs are almost certainly an underestimate in themselves serves to reinforce this view. We hope that the data presented here can provide some guidance and understanding in the funding of burns care, a complex and difficult area to cost.

Introduction

A major paediatric burn is considered to be one that requires formal burns resuscitation, which according to national guidelines is defined as a full or partial thickness burn of over 10% total body surface area (TBSA) [1]. The newly agreed England and Wales guidelines for transfer to a burns centre for children include burns with a TBSA of >20% full thickness or 30% partial thickness. The management of a major paediatric burn involves an extensive inpatient hospital stay, with care on a High Dependency Unit (HDU) or Intensive Care Unit (PICU), operating theatre episodes under general anaesthesia for assessment, application of biological dressings, debridement, skin grafting and dressing of wounds, as well as medications including antibiotic treatment.

There is little written on the cost of burns care, although there is a widely held view that it is expensive [2]. At Frenchay hospital, Bristol, Griffiths et al. estimated an average cost of £1850 per case for a paediatric minor scald (<10% TBSA). In 2003, 144 children were admitted to the hospital with minor scalds, a total cost of £266,400. The total length of hospital stay was <48 h and involved only one theatre trip [3]. The study ignored more complicated (and expensive) cases that would involve further surgical procedures, and potential complications such as wound infection.

The cost of caring for a burns patient is known to be higher than for non-burns patients. Dimick et al estimate that care for burns patients is at least twice as expensive that for other hospitalised patients [4]. The tariff for a “major burn, third degree of more than 19% TBSA, or affecting multiple body regions with significant graft” is £17,797 in the North Bristol NHS Trust.

A recent study in Wales estimated costs for burns patients using Healthcare Resource Groups (HRGs). They estimated a cost of €37,704 (£32,466) for a burn of 18–50% TBSA involving multiple graft procedures. However, this costing was not undertaken on an individual level, as such a task was acknowledged to be “a huge undertaking [involving] many hours of work” [5].

Most UK NHS Trusts do not have tariffs for major burn care. The lack of information on burns costing has lead to the publication of some potentially misleading figures. For example, a paper by Mashreky et al. [6] analysing the economic and social impact of burns injuries used H.R. Griffiths’ scald costing as an estimate for the cost of all burns inpatient stays in the United Kingdom [6]. The National Burn Care Review (2001) also found the current methods for estimating the cost of burns care to be “grossly inaccurate” [7].

The National Burn Care Review states that ‘approximately 1000 patients are admitted with severe burns requiring fluid resuscitation each year, half of whom are children of <16 years of age [8]. Between 2003 and 2006, an average of 2547 children were admitted to burns services submitting data to the international burn database with a further 1540 admitted to other hospitals (iBID data 2009) [9]. At the South West Paediatric Burns Service, 27 children were admitted with burns over 10% in 2007, eight with burns of more than 20% TBSA. In 2008, a further eight cases were admitted with burns of >20% TBSA [9]. These numbers mean that even small mismatches of income to actual cost of care will significantly affect a UK NHS Trust's financial balance.

The nature of burns makes it difficult to generalise regarding specific treatment. Two children with similar major burns will have different management plans for a number of reasons; the mechanism of injury (scald or direct flame burn), the depth and site of the burn, infective complications during treatment and the success of grafting procedures. The cost of caring for patients with the same percentage burns is therefore likely to vary significantly from case to case. The aim of this project was to examine three major paediatric burns without major complications, in as much detail as possible, to determine where the majority of resources were used, and to highlight specific costs that might be overlooked in a larger study. We hoped to achieve accurate hospital costs for a major paediatric burn between 30% and 40% TBSA during an inpatient stay at a burns service and to compare this to the current England tariff cost. By costing from the “ground up”, we hoped to provide figures that could be transferred to other regions and countries.