Access to Operative Intervention Reduces Mortality in Adult Burn Patients in a Resource‐Limited Setting in Sub‐Saharan Africa

Abstract

Introduction Early excision and grafting remains the standard of care after burn injury. However, in a resourcelimited setting, operative capacity often limits patient access to surgical intervention. This study sought to describe access to excision and grafting for adult burn patients in a sub-Saharan African burn unit and its relationship with burn-associated mortality. Methods We analyzed patients recorded in the Kamuzu Central Hospital Burn Registry in Lilongwe, Malawi from 2011-2019. We examined patient characteristics, interventions, and outcomes for adults aged C16 years. Modified Poisson regression modeling was used to identify risk factors for mortality. Results Five hundred and seventy-three patients were included. Median age was 30 years (IQR 23-40) with a male preponderance (63%). Median percent total body surface area burned (%TBSA) was 15% (IQR 8-26) and 68% of burns were caused by flame. 27% (n = 154) had burn excision with skin grafting, with a median time to operation of 18 days (IQR 9-38). When adjusted for age, %TBSA, and time to presentation, operative intervention conferred a survival benefit for patients with flame burns with a RR 0.16 (95% CI 0.06, 0.42). Conclusions In a resource-limiting setting, access to the operating room is inadequate, and burn patients are not prioritized. While many scald burn patients may be managed with wound care alone, patients with flame burn require surgical intervention to improve clinical outcomes. Burn injury in this region continues to confer a high risk of mortality, and more investment in operative capacity is imperative.

A plastic and reconstructive surgery landscape assessment of Malawi: a scoping review of Malawian literature

“…Patient outcomes were reported in eleven studies [ 20 , 22 , 23 , 25 , 28 , 31 – 33 , 39 , 42 , 43 ]. Burn-related mortality was reported as high as 27% across all ages and as low as 11% for patients younger than 5 years [ 32 ].…”

“…Distribution and volume of surgical procedures were reported in nine studies [ 20 – 22 , 25 , 34 , 36 , 39 – 41 ]. The proportion of patients operated on varied between 19 and 30% of patients [ 20 , 21 , 25 , 39 , 40 ].…”

“…Distribution and volume of surgical procedures were reported in nine studies [ 20 – 22 , 25 , 34 , 36 , 39 – 41 ]. The proportion of patients operated on varied between 19 and 30% of patients [ 20 , 21 , 25 , 39 , 40 ]. Another study by Steinlechner et al found that skin grafting accounts for only 0.1% of the surgeries in district hospitals and only 0.6% in central hospitals in Malawi [ 41 ].…”

“…Several studies reported only one consultant plastic surgeon in each of the country's two burn units at Kamuzu Central Hospital (KCH) and Queen Elizabeth Central Hospital (QECH) [ 20 , 21 , 29 , 30 ]. QECH reported having one surgical trainee, while KCH reported having two COs [ 20 , 21 , 29 , 30 ]. One study reported that there was only one fellowship-trained pediatric surgeon in Malawi [ 43 ].…”

“…Four studies advocated for earlier treatment of burns and the use of surgical interventions rather than non-operative management alone [ 20 , 25 , 30 , 40 ]. These studies suggested that early excision of burn wounds significantly reduced bacterial colonization and subsequent infection [ 25 ], surgical interventions for burn wounds significantly increased the odds of survival [ 40 ], and that patients with deeper burns should be prioritized for surgery to prevent the mortality that often arises in resource-limited settings due to delayed treatment of severe injuries [ 20 ].…”