Pa Patient Saf Advis 2018 Mar;15(1).
Hot Topic: Nonsurgical, Healthcare-Associated Burn Injuries
Critical Care, Gerontology, Nursing, Pediatrics, Physical/Occupational Therapy
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​Author

Cynthia Field, BSN, RN, NE-BC, CPHQ
Senior Patient Safety Analyst
Pennsylvania Patient Safety Authority

Abstract

Visual Abstract - Hot Topic: Nonsurgical Healthcare-Associated Burn Injuries


Burns are preventable injuries. Although most burns occur in the home, a recent review of events reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) found reports of patient burns occurring in the healthcare environment. These healthcare-associated burns may be related to the patient's medical treatments or to components of the healthcare environment. In addition, the risk of burns may be increased in patients with certain underlying medical conditions.

An analysis of reports submitted in 2016 through PA-PSRS identified 230 events of burns, of which 61.3% (n = 141) occurred in nonsurgical healthcare settings. Of the 141 nonsurgical burns 75.9% (n = 107) were considered thermal in nature (caused by direct contact with heat sources such as hot metals, scalding liquids, steam, and flame1). The most frequent thermal burns involved dietary spills of heated drinks or food (49.5%; n = 53 of 107) and heating devices (30.8%; n = 33), including powered devices such as circulating water or air blankets, warm compresses, and instant hot packs.

Implementing processes to assess and identify patients at risk for burns and developing risk reduction strategies are key to decreasing nonsurgical, healthcare-associated burns. Highlighting the relationship of temperature and time to development of a serious burn is essential in burn risk education; an object that feels only warm to the touch can cause serious injury if left on the skin over time.

Introduction

Burns are preventable injuries, and 73% of reported burns occur in the home.2 But a recent review of events reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) from January through December 2016 found reports of patient burns occurring in the healthcare environment. Burns are defined as injury to tissues caused by contact with heat therapy devices (dry, moist, or radiant), hot liquids, chemicals (e.g., corrosive substances), electricity, friction, or radiant and electromagnetic energy (e.g., x-rays).3

Healthcare-associated burns are caused either directly by therapies related to a patient's care (e.g., hot compresses, magnetic resonance imaging [MRI] studies) or indirectly from the effects of therapy or components of the healthcare environment (e.g., scald burns from spills of hot dietary items). The risk of a healthcare-associated burn may be increased in patients with certain underlying medical conditions. The majority of burn events reported through PA-PSRS in 2016 occurred in areas outside of the operating room (OR), including critical care, obstetrical, postanesthesia, rehabilitation, behavioral health, medical/surgical specialty, and outpatient units.

A literature search revealed that patient burns in nonsurgical areas have received less attention than burns occurring in the OR and that there is often a lack of burn risk assessment and prevention strategies in the nonsurgical healthcare setting.4,5 This issue may be related, in part, to a perception that objects used outside of the OR have less associated risk than electrocautery or electrosurgical devices used in the surgical setting. However, even objects such as warm compresses and hot drinks that may not feel hot to the touch can cause a significant injury if left in contact with skin over time.5-7

For historical context, a data snapshot of iatrogenic burn injuries (those caused inadvertently by medical treatments8) reported through PA-PSRS during 2007 revealed 224 reports of burns, two-thirds of which were thermal in nature.9  A review of 2016 events shows that healthcare-associated* burn events continue to occur in the commonwealth. This article analyzes healthcare-associated burns occurring in nonsurgical healthcare settings reported through PA-PSRS during 2016, identifies specific types of events that highlight the need for burn-risk assessment, and provides risk reduction strategies.

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* For this article, the term healthcare-associated is used instead of iatrogenic, but criteria for identifying and analyzing burns occurring in the healthcare setting for the 2016 query were similar to the criteria for the 2007 query.

Methods

Analysts queried the PA-PSRS database for events of patient burns submitted from January 1 through December 31, 2016. The following terms describing skin integrity were used to identify reports of burn injury: burn, welt, first degree, second degree, third degree, heat, hot pack, blister, skin lesion, and induration. Key words describing temperature and etiologies of burns were also included, as follows: thermal, scald, hot pack, heat water, very hot, coffee, tea, broth, soup, popcorn, and steam. Reports with the following terms were excluded: rug burn, razor burn, brush burn, c/o burn, cigar, scratch pad, bovie, denies burn, fired, match, evaporate, tape burn, burn net, go smoke, allow to smoke, stapler, sparkle, and did not fire.

The query identified 976 events; analysts' review of free-text narratives in the event details found 230 events that met criteria for healthcare-associated burns. Exclusions included patients admitted for the treatment of burns, burns caused by devices or incendiaries not typically found in the healthcare setting (e.g., straightening or curling irons and lighters), and surgical fires. Also excluded were events of patient use of the term "burning" to describe symptoms of other disease processes such as epigastric or chest pain, or sensations related to intravenous catheter infiltration, flushing, or infusion of fluids. Of the 230 reports of burns that met criteria for healthcare-associated burns, a further 89 were excluded because they occurred in an OR (n = 81), or labor and delivery room setting (n = 5), or when the surgical procedure occurred in a care area outside the OR (e.g., interventional radiology and neonatal intensive care unit; n = 3).

Analysts evaluated care areas, objects involved, and burn severity. Degree of injury was based on event detail descriptors including red or blistering, and/or when the level of burn injury was specifically identified as first, second, or third degree. Burn injuries are typically categorized by their etiology (cause); a common classification system was used for this analysis of the PA-PSRS data, as follows:

  • Thermal: caused by direct contact with heat sources such as hot metals, scalding liquids, steam, and flame.1 Thermal burns from radiant energy are also possible, such as from warming lamps and examination lamps.10
  • Electrical: from electrical current, either alternating current (AC) or direct current (DC).1
  • Radiation: due to prolonged exposure to ultraviolet rays of the sun or to other sources of radiation, such as x-ray.1
  • Chemical: due to contact with strong acids, alkalies, detergents, or solvents.1

Results

Analyst identified 141 nonsurgical, healthcare-associated burn events. Patient care areas are shown in Figure 1.

Figure 1. Nonsurgical Burns Reported by Location Where Event Occured (N = 141)

Burns injuries ranged from superficial first degree (involving only the epidermis), to full thickness third degree (involving the epidermis and dermis).1 Table 1 shows the number of nonsurgical, healthcare-associated burns based on the severity of dermal injury.

Table 1. Degree of Injury of Healthcare-Associated Burns Reported (n = 101 of 141*)

Degree of Burn Injury Number of Injuries Percentage of Injuries
First degree 6059.4%
Second degree 3837.6%
Third degree 33.0%
* There were 40 reports of burns with no symptoms described.  ​ ​

 

The most common burns (75.9%; n = 107) were considered thermal in nature. Figure 2 demonstrates the incidence of burn events reported based on the etiology of the burn.

Figure 2. Number of Burns of Etiology (n = 139 of 141)

Of the thermal burns, the majority involved dietary spills of heated drinks or food (49.5%; n = 53 of 107) and heating devices (30.8%; n = 33), including powered devices such as circulating water or air blankets and nonpowered devices such as heated compresses, packs, or water bags.

Although not as common, thermal burns associated with MRI studies and patient monitoring devices, chemical burns from contact with caustic solutions, and electrical burns from electrical nerve stimulation devices were among some of the other nonsurgical, healthcare-associated burn injuries reported. Refer to Figure 3 for objects resulting in burn injuries.

Figure 3. Objects Associated with Nonsurgical, Healthcare-Associated Burn Injuries Reported in Event Descriptions (N = 141)

Examples of healthcare-associated burn events from the PA-PSRS database are as follows:*

Thermal burns from hot dietary drinks:

A stroke patient was found with hot soup spilled on to chest. The patient examined by the MD and noted to have small blisters on anterior chest where soup had spilled. Second degree burns were identified and wound team consulted for management of injury.

My patient was sitting in bed with the head of bed up and said, "I spilled my tea." The patient stated he was unsure what happened. He was cleaned up, gown and linens changed. The MD was notified and examined the patient, identified a large reddened area on left inner thigh and groin measuring 12cm x 5cm with multiple small fluid filled blisters.

Thermal burns from heating devices:

Patient complained of left hip pain and asked for a warm compress. An ice bag was filled with water from the instant hot water dispenser and the bag was then placed on the patient's hip. A few minutes later, the patient was placed on the bedpan and the compress was removed. The following morning during rounds, the patient was examined by her physician and a thermal burn was found on her hip. The patient was readmitted at a later date for debridement of the burn and received follow-up care with the wound team.

The patient, who has no lower body sensation, had a warming pad placed on his left lower back, hip, and buttock, which was left in place for over 12 hours. The right buttock area is reddened and there are 3 blisters in the shape of the pattern on the pad.

Thermal MRI burn:

Patient had an MRI of the thoracic spine earlier in the day and came into the ED with two small burns thought to be related to the MRI. There was one small first degree burn and one small second degree burn. The patient was discharged with antibiotic cream for treatment of affected areas.

Chemical burn:

A newborn needed a frenulectomy before being discharged. The procedure was completed and the area treated with an application of silver nitrate to control bleeding. Contact with silver nitrate caused an unintended superficial chemical burn to oral mucosa and lips.

Electrical burn:

This patient received electrical stimulation treatment two days ago. He stated at this visit that he had burns where the electrodes had been located on his lower back. The patient stated that the area had blistered and opened so he had placed a dry gauze over the site. Area was assessed by this therapist and noted to have mild erythema and appearance of dried blister on left lower back. The site was cleansed with saline and covered with gauze, the patient was referred to PCP for further treatment of wound, and electrical stimulation treatment was conducted at a different site.

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* The details of the PA-PSRS event narratives in this article have been modified to preserve confidentiality.

Discussion

Review of recent event report data shows that the number of reported healthcare-associated burn events has not decreased compared with such burn events in the data snapshot completed 10 years ago in Pennsylvania.9 Review of the 2016 data found that the majority of healthcare-associated burns occurring in nonsurgical areas were thermal burns caused by commonly used objects, such as hot dietary items and heated devices or therapies.  

Development of burn prevention strategies begins with the awareness by healthcare providers that patients are at risk of burns from common and frequently used care items. Exposure, temperature, and time as well as patient risk factors are important considerations when developing burn prevention strategies.6,7,11,12 Table 2 highlights the relationship of temperature and time to the development of a serious burn injury.

Table 2. Relationship of Temperature and Time to Serious Burn Injury

Temperature ​                                         Time to Burn ​                            
°C °F First Degree Second and Third Degree
451132 hours3 hours
491212 minutes4 minutes
5513120 seconds30 seconds
601403 seconds5 seconds
Reference: Moritz AR, Henriques FC. Studies of thermal injury: II. The relative importance of time and surface temperature in the causation of cutaneous burns. Am J Pathol. 1947 Sep;23(5):695-720. PMID: 19970955 ​ ​ ​

 

Attention to the risks associated with medical device and current technology is another element to consider when developing burn prevention practices. Although occurring less frequently, electric, radiation and thermal burns from medical devices were also reported. More than one-third (n = 45 of 141) of the burn injuries reported involved the use of medical devices, including pulse oximeters, electrical nerve stimulators, defibrillators, ultraviolet light (phototherapy) equipment, and MRI scanners.

Patient factors can also increase the risk and severity of burn injury. The elderly and very young are at higher risk because they have thinner skin.6,10,11,13,14 Patients with impaired dexterity are prone to spills and at risk for scald burns, particularly in the healthcare setting where hot meals are served on free-moving patient tables and drinks are served in containers that may tip or be hard to grasp.12,14 Patients who have sensory deficits, including peripheral neuropathy related to a medical condition such as diabetes or spinal cord injury, may be unable to recognize when a heated object is causing injury to the skin.6,12,15 Difficulties with communication skills adds to burn risk; for example, patients who have difficulty communicating because of developmental delays, loss of cognition, or dysphasia (e.g., patients with stroke or brain injury) may be unable to express that they are having pain related to contact with a heated object.5,6 Patients receiving general anesthesia, sedation, neuromuscular blocking agents, or nerve blocks are also at risk for burns because of their temporary inability to sense or communicate pain associated with a burn injury.13

Risk Reduction Strategies

To decrease the risk of healthcare-associated burns, determine whether there are current strategies and policies for assessing and recognizing patient and environmental factors that add risk for burns.5,12

Ensure that environmental burn prevention strategies are in place, such as the following:

  • Maintain hot tap water at appropriate temperatures to prevent scald burns.12
  • Maintain warming and solution cabinets at recommended temperatures.13
  • Implement policies for use of instant hot water dispensers and microwave ovens, based on the patient population and specifications of the devices.16
  • Implement policies for serving food and beverages at safe temperatures.
  • Provide tableware designed to prevent spillage.
  • Educate dietary services staff on the safe preparation and delivery of heated beverages and food.16,17

Develop and implement policies, resources, and education for risk assessment and prevention of burns specific to the following:

  • Patient population and needs (e.g., infants, elderly, neurologically impaired).12,15,17
  • Manufacturer guidelines and recommendations for safe use of all powered warming, monitoring, and therapy devices.4,6,13,15,18
  • Use and risks of hot compresses, pads, and water bags.6
  • MRI safety.19-22

All education should include assessment of the skin under any warming or monitoring device at recommended intervals with particular attention to understanding the relationship of time to temperature and the risk of serious burn (i.e., objects that feel only warm to the touch, if left on the skin over time can lead to serious burn injury).5-7

Conclusion

Implementing assessment and identification of patients at risk for burns (e.g., elderly, young children, insensate, and cognitively or physically impaired) and developing burn risk reduction strategies is key to decreasing nonsurgical, healthcare-associated burns. Ensuring that healthcare providers understand the impact of the relationship of temperature and time to development of a serious burn injury may prevent painful injuries from healthcare-associated burns. Always assume that any "warmed" object has the capacity to cause a burn.

Acknowledgments

Mark E. Bruley, CCE, FACCE, Vice President, Accident and Forensic Investigation, ECRI Institute, was consulted for his expertise and knowledge of healthcare-associated burns during the development of this article.

Notes

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  2. National burn awareness week 2017: fact sheet. [internet]. Chicago (IL): American Burn Association; 2017 [accessed 2017 Dec 11]. [1 p]. Available: http://ameriburn.org/wp-content/uploads/2017/04/nbaw-fact-sheet-rev.pdf.
  3. Newman WA, Dorland D, editor. Dorland's illustrated medical dictionary. 32nd ed. Philadelphia (PA): Saunders; 2007.
  4. Feil M. Warming blankets and patient harm. Pa Patient Saf Advis. 2017 Dec;14(4). Also available: http://patientsafety.pa.gov/ADVISORIES/Pages/201712_warmingdevices.aspx.
  5. Patient safety tip of the week: iatrogenic burns. [internet]. Grantham (NH): Truax Group, Healthcare Consulting Services; 2010 Jun 1 [accessed 2017 Dec 08]. Available: www.patientsafetysolutions.com/docs/June_1_2010_Iatrogenic_Burns.htm.
  6. Cleland H, Wasiak J. Too hot for comfort. [internet]. Rockville (MD): PSNet, Patient Safety Netowrk (AHRQ); 2007 Dec [accessed 2017 Dec 08]. Available: https://psnet.ahrq.gov/webmm/case/166/too-hot-for-comfort.
  7. Moritz AR, Henriques FC. Studies of thermal injury: II. The relative importance of time and surface temperature in the causation of cutaneous burns. Am J Pathol. 1947 Sep;23(5):695-720. PMID: 19970955.
  8. Iatrogenic. [internet]. Merriam-Webster.com; [accessed 2017 Dec 11]. Available: https://www.merriam-webster.com/dictionary/iatrogenic#medicalDictionary.
  9. Data Snapshot: iatrogenic burn injuries. Pa Patient Saf Advis. 2009 Mar;6(1):36. Also available: http://patientsafety.pa.gov/ADVISORIES/Pages/200903_36.aspx.
  10. Guidance article: investigating device-related "burns." Health Devices. 2005 Dec;34(12):393-413. Also available: http://www.ecri.org.
  11. Möhrenschlager M, Weigl LB, Haug S, Schnopp C, Cremer H, Ring J, Abeck D. Iatrogenic burns by warming bottles in the neonatal period: report of two cases and review of the literature. J Burn Care Rehabil. 2003 Jan-Feb;24(1):52-5; discussion 49. Also available: http://dx.doi.org/10.1097/01.BCR.0000045660.50162.FE. PMID: 12543993.
  12. Surveyor guidance for excessive hot water temperatures. Tallahassee (FL): Florida Agency for Health Care Administration; 2011 Oct. 17 p. Also available: https://ahca.myflorida.com/MCHQ/Field_Ops/Protocols/General/Files/Hot_Water_Protocol.pdf.
  13. Bruley ME. Challenges in preventing electrical, thermal, and radiation injuries. In: Sanchez J, Barach P, Johnson J, Jacobs J, editors. Surgical Patient Care. Springer, Cham; 2017. p. 519-53. Also available: https://link.springer.com/chapter/10.1007/978-3-319-44010-1_31.
  14. Redlick F, Cooke A, Gomez M, Banfield J, Cartotto RC, Fish JS. A survey of risk factors for burns in the elderly and prevention strategies. J Burn Care Rehabil. 2002 Sep-Oct;23(5):351-6; discussion 341. Also available: http://dx.doi.org/10.1097/01.BCR.0000028568.13443.27. PMID: 12352138.
  15. Khan MA, Jamnadas-Khoda B, Gorman M, West E, Jay S, Zafeiris K, Ghosh SJ. Iatrogenic burns from the use of hot packs in paraplegic insensate patients. Injury Extra. 2011 Jun;42(6):64-5. Also available: http://www.sciencedirect.com/science/article/pii/S1572346111000171.
  16. Hot liquids: avoiding patient injury. Reducing Risk. 2011 Oct;1-3. Also available: http://www.princetoninsurance.com/downloads/Risk_Review_Downloads/12.2011/RRO_Dec2011_hotliquids_riskalert.pdf.
  17. Thacker T, Parke J. Departmental safety guidance - prevention of burns and scalds due to hot beverages. Version: 2. Derbyshire (UK): Derbyshire County Council; 2015 Sep. 2 p. Also available: https://www.derbyshire.gov.uk/images/DSG%20Prevention%20of%20Burns%20and%20Scalds%20due%20to%20Hot%20Beverages%20v2_tcm44-250268.pdf.
  18. Skin burns and fires during electroconvulsive therapy treatments. PA Patient Saf Advis. 2007;4(1):1-4. Also available: http://patientsafety.pa.gov/ADVISORIES/documents/200703_25.pdf.
  19. ECRI. Thermal injuries and patient monitoring during MRI studies. Health Devices. 1991 Sep;20(9):362-3.
  20. ECRI. Safety concerns in the MR environment: unique environment, unique risks. Health Devices. 2001 Dec;30(12).
  21. ECRI Institute. Hazard report. Antimicrobial dressings containing silver may cause pain and burns during MR scans. Health Devices. 2007 Jul;36(7):232-3.
  22. Hardy PT, Weil KM. A review of thermal MR injuries. Radiol Technol. 2010 Jul-Aug;81(6):606-9. Also available: http://www.radiologictechnology.org/content/81/6/606.long PMID: 20606054.
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