Feb. 4, 1998 A research team from the Massachusetts General Hospital (MGH) and Shriners Burns Hospital has developed a system for objectively estimating the probability of death in patients with severe burn injuries. The formula, based on three risk factors, can help physicians, patients and family members make decisions about the care of critically burned people. In addition, researchers testing new treatment approaches can target therapies to those patients who need them most.
"The availability of an objective system for estimating a patient's chance of survival can be invaluable in helping physicians, patients and family members make decisions about resuscitation or other care-related issues," says Colleen Ryan, MD, first author of the report appearing in the Feb. 5 issue of The New England Journal of Medicine.
The researchers reviewed records of the more than 1,600 burn patients admitted to the MGH and Shriners from 1990 to 1994 and examined whether the risk of death appeared to be associated with several factors: age, sex, extent of burn (the percentage of body surface involved), depth of severe burn, type of burn (such as flame, scald, chemical or electrical), and whether the patient also suffered injury to the respiratory tract (smoke inhalation injury).
They found that 96 percent of the patients admitted during those years survived to be released from the hospital, and they identified three factors associated with increased risk of death: an age of 60 or older, serious injury to more than 40 percent of body surface and the presence of inhalation injury. Based on this information, the researchers developed a simple model for predicting the risk of death. Patients with none of the identified risk factors have a 0.3 chance of death; patients with one risk factor have a 3 percent chance of death; patients with two risk factors have a 33 percent chance of death; and patients with all three risk factors have an almost 90 percent chance of death. Each of the three risk factors had a similar impact on risk.
"One of the most important messages to be taken from this study is how many seriously burned patients are surviving today," says Ronald Tompkins, MD, ScD, director of the MGH Burn Service and chief of staff at Shriners and the study's senior author. "Advances in treatment available at our institutions and other burn centers have made a huge difference. Survival rates are so good that we can now concentrate much of our research on improving patients' quality of life."
Ryan, who is a burn surgeon at both the MGH and Shriners, adds that being able to identify those patients with the poorest prognosis can allow them to receive some of the experimental treatment programs that might improve their survival. She cautions that factors not evaluated in this study — such as any delay in transferring patients from local hospitals to a burn center — could further affect an individual's risk of death.
"Patients and their loved ones faced with requesting a do-not-resuscitate order should have as much information as possible in making such a difficult decision," Ryan says. "But no one should look at the results of this study as writing off patients with three risk factors. We are hopeful that new advances in therapy will improve the prognosis for this very small group of patients at highest risk."
The paper's coauthors are William Thorpe, PhD, and Robert Sheridan, MD, of both the MGH and Shriners; David Schoenfeld, PhD, of the MGH Biostatistics Center; and Edwin Cassem, MD, chief of Psychiatry at the MGH.
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