Process Evaluation of Software Using the ...

2013 NBR Best Paper—Physician

Process Evaluation of Software Using the International Classification of External Causes of Injuries for Collecting Burn Injury Data at Burn Centers in the United States Andrés Villaveces, MD, PhD,*† Michael Peck, MD, ScD,‡ Iris Faraklas, BSN,§ Naiwei Hsu-Chang, RN, CCRN,║ Victor Joe, MD,¶ Lucy Wibbenmeyer, MD#

Detailed information on the cause of burns is necessary to construct effective prevention programs. The International Classification of External Causes of Injury (ICECI) is a data collection tool that allows comprehensive categorization of multiple facets of injury events. The objective of this study was to conduct a process evaluation of software designed to improve the ease of use of the ICECI so as to identify key additional variables useful for understanding the occurrence of burn injuries, and compare this software with existing data-collection practices conducted for burn injuries. The authors completed a process evaluation of the implementation and ease of use of the software in six U.S. burn centers. They also collected preliminary burn injury data and compared them with existing variables reported to the American Burn Association’s National Burn Repository (NBR). The authors accomplished their goals of 1) creating a data-collection tool for the ICECI, which can be linked to existing operational programs of the NBR, 2) training registrars in the use of this tool, 3) establishing quality-control mechanisms for ensuring accuracy and reliability, 4) incorporating ICECI data entry into the weekly routine of the burn registrar, and 5) demonstrating the quality differences between data collected using this tool and the NBR. Using this or similar tools with the ICECI structure or key selected variables can improve the quantity and quality of data on burn injuries in the United States and elsewhere and thus can be more useful in informing prevention strategies. (J Burn Care Res 2014;35:28–40)

Burn injuries kill more than 300,000 people every year across the globe.1 In the United States in 2008, there were 3,382 burn-related fatalities2 and in 2009 there were 381,012 nonfatal burn injuries.3 From the *University of North Carolina Injury Prevention Research Center, Chapel Hill; †Cisalva Institute, University of El Valle, Cali, Colombia; ‡AArizona Burn Center, Maricopa Medical Center, Phoenix; §Department of Surgery, University of Utah, Salt Lake City; ‖Torrance Memorial Medical Center Burn Center, Torrance, California; ¶Department of Surgery, University of California, Irvine; and #Department of Surgery, University of Iowa Carver College of Medicine, Iowa City. This study was funded by a grant from the International Association of Fire Fighters Burn Foundation. Grant R149 CE000196 from the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention to the UNC Injury Prevention Research Center partially funded time for completing the analyses by Dr. Villaveces. The other authors declare no conflict of interest. Address correspondence to Andrés Villaveces, MD, PhD, 626 Regent Place NE, Washington, DC, 20017. Copyright © 2013 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0b013e3182a3aaaa

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The costs of these injuries are extremely high. In 2005, of the 408,806 reported burn-related emergency department visits, the combined medical and work-loss costs were US$1,648,545,000.4 There are clearly benefits to designing and implementing prevention programs that reduce the incidence of burns and fire injuries. Such programs require a solid epidemiologic foundation. With the goal of gathering both epidemiologic and clinical data, burn centers in the United States collect information on burn injuries and report it on a voluntary basis to the National Burn Repository (NBR).5 Despite this system, the information collected by hospitals and uploaded to the NBR is insufficient for several reasons. The system does not include the key contextual variables of where and how burn injury events occur,6 has few data elements related to the context in which and place where injuries occurred, and is frequently limited to reporting a few characteristics of the mechanisms of injury.

Journal of Burn Care & Research Volume 35, Number 1

Moreover, the principal reason that data in the NBR describing the injury event are insufficient is that the structure for epidemiologic data is based solely on the International Classification of Disease 9 External Cause Codes (ICD-9 E-codes). To provide a more solid evidence base for effective primary prevention efforts, the context and circumstances in which injuries occur need to be clearly understood. The International Classification of External Causes of Injuries (ICECI)7 is based on best practices of injury surveillance and is a classification system of the World Health Organization. The granularity of detail provided by the ICECI is vastly superior to that provided by ICD-9 E-codes. The specific aim of our research was to evaluate the ICECI as a surveillance tool used for the ongoing systematic collection, analysis, interpretation, and dissemination of data regarding burns to thus enhance prevention activities designed to reduce burn-related morbidity and mortality. To this end, we developed software to make the ICECI scoring system user-friendly. The hypothesis tested in this project was that the ICECI software can be used easily, efficiently, and accurately by burn centers that are already engaged in gathering data for the American Burn Association’s NBR.5 With this process evaluation we aimed to assess linkage of the ICECI software to existing operational programs of the NBR, train registrars in the use of this software, establish quality-control mechanisms for ensuring accuracy and reliability, incorporate ICECI data entry into the weekly

Villaveces et al 29

routines of the burn registrars, and compare these preliminary burn injury outcomes with the standard reporting variables used currently by the NBR.

METHODS Data-Collection Tool The ICECI has a multiaxial and hierarchical structure with a core module and five additional modules (Figure 1), and as a whole has direct correspondence with the ICD (Figure 2). The core module includes the variables: mechanism of injury, objects and substances producing injury, place of occurrence, activity in progress when an individual was injured, intent to cause injury, and involvement of alcohol or other psychoactive drugs. The five additional modules are used to collect more detailed information on violence, transportation, place of occurrence of injury, sports-relatedness, and occupational-relatedness.7 With the help of a consultant, G. Price, we created a mechanism for electronic data entry using readily accessible software for database management (MSAccess® 2010; Microsoft Corp., Redmond, WA), replicating module by module the structure of the ICECI. We also consulted with the ICECI development group to ensure the accuracy of our database. Although this tool could be used for data entry of any type of injury, for this evaluation we focused exclusively on entering data regarding burn-related injuries. We created a version of ICECI that allowed us to record data fields for all modules, using dropdown boxes to choose from eligible ICECI codes.

Figure 1. Structure of International Classification of External Causes of Injury (ICECI) modules.

30 Villaveces et al

Journal of Burn Care & Research January/February 2014

Figure 2. Correspondence between International Classification of External Causes of Injury (ICECI) coding and International Classification of Disease (ICD) coding.

We used the entire module available for burn injuries as it appears in the World Health Organization ICECI data set structure. We also linked to the NBR files created locally at each burn center to load selected demographic and clinical information, help select the proper ICECI codes, and produce reports on injury data. This software also has specific modules including a core module documenting injury intent, mechanism, place of occurrence, object causing injury, activity when injury happened, and substance abuse relatedness. In addition it has modules documenting whether or not events were related to violence (interpersonal or self-inflicted), transport-related, or sports-related. Two additional modules document in detail the characteristics of places where injuries occurred and the occupational classification of victims. The software also produces prompts reminding registrars that for each choice made in the core module, there are related choices in other modules.

Data Collection Participation of burn centers contributing to the NBR was elicited for this project by announcements made at the annual meeting of the American Burn Association. Each site obtained approval from their local Institutional Review Boards for the Protection of Human Subjects. All data were deidentified so that patient privacy was protected. Of the 11 centers we invited to participate, not all accepted. The main reason for this was that invited hospitals at the time

of this study were renewing the software they use for integration with the NBR, and the software renewal progress was lengthy and interfered with their datacollection activities. The number of patients entered into the data set was not based on data availability but rather on specific segments of time selected by hospital personnel to test the tool independent of the number of patients at the time when the data were being collected. For the process evaluation we collected quality measures including description of registrar-training activities and delineation of measures related to the use of the ICECI in real time. Data were collected between July 2007 and September 2009. Data related to the implementation of the tool included the following: •• dates when data were collected by each of six participating burn centers •• total number of cases entered, using the tool within each center and for the whole sample •• most frequent time ranges when burn injuries occurred (divided into quarters of the day) •• mean and median time required to complete each record (in minutes) •• range of attempts by each registrar to complete data entry for each case. We also collected data on burn injury outcomes from the six participating hospitals and reported descriptive statistics on these data disaggregated by hospital and for the total sample. Specifically, we


Villaveces et al 31

collected information on the following variables within the core module: •• age and sex of subjects •• injury intent •• characteristics of intentional injury •• mechanism of burn injury •• object or substance producing the injury •• activities by individual at time of injury •• economic activity and occupation of victim •• place of occurrence of burn injury (ie, specific buildings and locations in buildings where injuries occurred). We also coded information for additional modules including the following: •• details about events that occurred in healthcare or educational facilities •• whether the event occurred in an urban or rural area •• details about sports-related incidents •• details about transport-related injuries We subsequently compared these data with information currently collected for the 2011 report of the NBR5 to evaluate the differences in surveillance capabilities achieved by this simple electronic tool.

RESULTS The six burn centers participating in this study were located in Arizona, California, Iowa, and Utah. In 2009, annual admissions among the six centers totaled 2316 and ranged from 132 to 952 patients per center per year. However, actual numbers of patients included in this report are smaller than the numbers of admissions (Table 1); the 909 patients entered into the ICECI database represent roughly 39% of all patients admitted during this time period.

Full-time registrars were employed at these centers, and spent 24 to 32 hours each week coding for the NBR. Registrar-training activities involving the ICECI software included familiarization with the software, testing the software capabilities and limitations, and understanding the definitions included in each of the data entry points. These tasks were conducted directly by teleconference with each of the registrars under the supervision of G. Price, who designed the software. Data entry time requirements for ICECI-specific variables are detailed in Table 1. Four observations were made. First, given the small amount of time that registrars spent entering the majority of these data, the use of this tool did not increase workload unreasonably. Second, registrars tackled a distinct learning curve to become more familiar with the tool. Third, ease of use with the ICECI software increased significantly, typically after coding 10 charts, and dropped by a factor of 2 to 3. And fourth, missing information was the most common cause of delays in data entry, forcing the registrars to return to the charts up to five times as the missing information became available. Review of the data profiles created by the ICECI led to several additional observations. The majority of burn injuries occurred in afternoons or evenings. With the exception of one contributing hospital that specializes in the care of burned children and has a high rate of admissions for child abuse and selfharm, the majority of injuries were unintentional (Figure 3). Among intentional injuries the majority (44%; 11 of 25) were linked to self-harm. Assaults were responsible for 36% (9 of 25) of the intentional burns (Table 2). The most common mechanism of injury was energy transfer through fire and flames, followed by scalds (liquid or gas) and contact with hot, solid

Table 1. Description of data processed by six burn centers using the International Classification of External Causes of Injury electronic data entry tool, 2007–2009, United States Measured Characteristics Burn Center location

Hospitals and Burn Centers That Reported Data Hospital 1

Hospital 2

Hospital 3

Hospital 4

Hospital 5

Hospital 6

Total

Annual admissions (2009) 952 409 222 312 132 289 2316 Date range of data collection 12/07–5/08 9/08–9/09 5/09–6/09 10/07–1/08 1/08–5/08 11/08–5/09 10/07–9/09 Number of burn cases entered 290 395 19 12 69 124 909 Most frequent time range of 12:00–17:59 18:00–23:59 18:00–23:59 Not collected Not collected 00:00–05:59 12:00–17:59 event occurrence Mean (median) data entry time 4.18 (3.29) 6.95 (4.67) 5.96 (4.66) 9.23 (5.48) 4.10 (3.32) 2.84 (2.66) 5.35 (3.63) in minutes Range of attempts to complete 1–5 1–4 1–2 1–2 1–4 1–3 1–5 data entry


32 Villaveces et al

Figure 3. Percent distribution of burn injuries by injury intent among 909 patients admitted to six burn centers, using the International Classification of External Causes of Injury (ICECI) classification of injuries, United States, 2008–2010.

objects (Figure 4). After fire, flames, or smoke, the specific objects or substances causing burns were food or drinks, hot objects, liquids or gases, and home appliances; a similar proportion of injuries were transport-related burns (Figure 5). When injuries occurred, most people were involved in leisure activities or vital activities such as eating or sleeping (Table 3). About 20% of reported events were linked to work-related activities (Table 4). The most commonly reported employment-related activities were electricity, gas or water-supply work, and construction work. Approximately 43% of reported burns occurred to individuals who worked as technicians, service workers, or workers of trades and crafts. About 65% of injuries occurred indoors (Table 5). A similar percentage of reported events occurred in the home, followed by places of work (ie, industries, streets, commercial and agricultural areas). The sections of buildings where injuries had occurred included kitchens (32%), gardens or yards (9%), and bedrooms or bathrooms (9%). Almost 40% of reported burn injuries occurred in detached homes and 13% in apartments. In 90% of cases, reports identified the injured party as the person responsible for the home. Alcohol use was suspected or confirmed in about 8% of patients, and use of another substance was suspected or confirmed in 9% of cases (Table 6). Sections of the report addressing healthcare facilities, type of educational facility, whether or not an event occurred in urban or rural area, sports-relatedness, mode of transport used, and information about other persons involved in the event were not tabulated because the percentage of missing values for these modules was above 90%. For the sportrelatedness category only two individuals were burned while performing these activities and these

were related to wheeled-motor sports occurring in school-related recreational activities. We also compared our reported percentage distributions with similar data reported by the NBR, which collects data from 76 burn centers in 33 states. Among the injuries reported we found that the two characteristics of intent and mechanism were similar between the two data sources (Table 7).

DISCUSSION Our study aimed to use an enhanced data-collection tool to improve the quality and quantity of information on burn-related injuries. The study provided useful information about burn patients who receive care in burn centers. The richness of these epidemiologic data far exceeds that of the currently used variables, without adding substantial burden to burn center registrars’ workloads. This means that with a simple readily available tool, very few person-hours would be needed to collect invaluable data about the context in which burn injuries occur. Moreover, this electronic tool was integrated into existing reporting registries and hence can feed data into the NBR through the currently used mechanisms. The use of this tool provided more detailed information on data that are useful for public health activities. Although not all of the variables contained in ICECI are applicable in emergency department settings, a few contextual variables related to injuries’ place of occurrence and activities conducted when injuries happened can better inform primary prevention activities in the wider population. Accordingly, although we considered ICECI as a whole when applying this new tool, we do not intend to promote its use in documenting full ICECI details on burn


Villaveces et al 33

Table 2. Characteristics of population that received care for burn-related injuries in six burn centers where the International Classification of External Causes of Injury burn injuries electronic tool was tested, United States, 2008–2010 Demographic and Injury Characteristics

Burn Centers Hospital 1

Hospital 2

Hospital 3

Mean (median) age of cases 31.8 (30.5) 27.4 (25) 28.7 (26) entered Percentage distribution of injuries by selected characteristics, n (%) Females (27.9) (33.9) (31.6) Injury intent Unintentional 280 (96.6) 366 (92.7) 19 (100.0) Self-harm 3 (1.03) 5 (1.27) — Assault 1 (0.34) 7 (1.77) — Iatrogenic — 4 (1.01) — Other/undetermined/ 6 (2.06) 13 (3.29) — unspecified Violence relatedness Self-harm risk factors Conflict with partner/ 1 (33.33) 2 (40.0) — relative Psychological/ — 3 (60.0) — psychiatric condition Other/undetermined/ 2 (66.67) — — unspecified Previous self-harm attempts Yes — 2 (40.0) — No 3 (100) 3 (60.0) — Other/undetermined/ — — — unspecified Interpersonal violence Context of assault Altercation — 2 (28.57) — Other crime — 2 (28.57) — Undetermined/ 1 (100) 3 (42.86) — unspecified Relation to perpetrator Spouse/partner — 2 (28.57) — Parent — 3 (42.86) — Acquaintance or friend — 1 (14.29) — Stranger — 1 (14.29) — Other/undetermined/ 1 (100) — — unspecified

Hospital 4

Hospital 5

Hospital 6

7.2 (6.5)

27.4 (18)

34.8 (36)

(33.3) 11 (91.67) — 1 (8.33) — —

(31.2) 69 (100.0) — — — —

(26.6) 114 (91.94) 3 (2.42) — 1 (0.81) 6 (4.84)

Total 29.6 (27.4) 30.2 (28.7)* (30.8) 859 (94.5) 11 (1.21) 9 (0.99) 5 (0.55) 24 (2.75)

—

—

2 (66.67)

5 (21.74)

—

—

1 (33.33)

4 (17.39)

12 (100)

—

— 1 (8.33) 11 (91.67)

— — —

— — 1 (8.33)

— — —

— — —

2 (10.0) 2 (10.0) 5 (25.0)

2 (8.33) — — — 11 (91.67)

— — — — —

— — — — —

3 (15.0) 3 (15.0) 1 (5.0) 1 (5.0) 12 (60.0)

—

1 (33.33) 2 (66.67) —

14 (60.87)

3 (13.04) 9 (39.13) 11 (47.83)

Percentages might not amount to 100 because of missing values. Hospital 4 serves only younger populations. *Value without Hospital 4.

injury events. Rather, the tool highlights the better quality of information that is useful for public health and can inform prevention activities in a more meaningful way. As such, this initial step assists in identifying some of those key variables that are not currently collected. Next steps should focus on a more refined assessment of the variables that should be but are not currently collected, with the objective of creating minimum data requirements. Overall, these data confirm that nonfatal injuries reported in U.S. burn centers are more frequently

unintentional, occur in the home, and are associated with normal living activities. Most injuries occur among young populations and a higher proportion of males are affected. A prominent proportion of injuries occur during work-related activities, many of which include technical-, service-, or trade-related work. Our approach had some limitations. We strived to include a larger number of burn centers but because of technical, personnel, or timing issues we could not engage all of the 11 centers we initially contacted. The main reason for nonparticipation was

34 Villaveces et al


Figure 4. Percent distribution of burn injuries by mechanism among 909 patients admitted to six burn centers, using the International Classification of External Causes of Injury (ICECI) classification of injuries, United States, 2008–2010.

that several centers were renewing their software to link with the NBR. Although this led to a smaller sample, comparison of our data with NBR-reported data reassured us that the characteristics of the information here reported do not differ appreciably from those of national data. We did not collect data on the time it took for registrars to collect the information entered in the tool. The ascertainment of additional detailed data may require more registrar time and it is possible that time constraints might have made it more difficult for registrars to collect some of the variables that have higher proportions of missing data. We did not conduct an economic-related evaluation of this system. Although this would have

provided useful data regarding sustainability and implementation costs, insufficient funding did not accommodate gathering this information. Our funding was also insufficient to create an online tool for data entry. Implementation in other settings using an online approach is both desirable and feasible. Some of the categories comprised in the ICECI modules were missing a large proportion of values. The individuals filling in the forms might have perceived these variables as less important; this missing information may also have been much harder to collect in this context. This is precisely one of the advantages of having tested this tool. The tool was useful in identifying key variables that are currently


Villaveces et al 35

Figure 5. Percent distribution of burn injuries by object or substance producing injury among 909 patients admitted to six burn centers, using the International Classification of External Causes of Injury (ICECI) classification of injuries, United States, 2008–2010.

missing in the NBR but are valuable for improving burns-related data quality. A high proportion of missing data included information on whether burn injuries were sports-related or occurred in educational institutions. When injuries occur in these types of places, other, more efficient, information systems might be put into place. Burn centers are typically where injuries of greater severity are detected and reported. Reports to burn centers of burn injuries occurring in sports settings and educational settings were rare. Research on the evaluation of registries has shown that time burden and technical issues can seriously hamper the sustainability of data-collection procedures.8–10 The creation of a simple, easily

accessible, user-friendly, and affordable tool is thus essential to ensure procedural sustainability. Burn centers can further use this information to conduct research and design preventive approaches for burn injuries. Additionally, trauma registries could incorporate these enhanced tools to gather more accurate information about other injuries. This tool can also work as a stand-alone program in settings where linkage to NBR is not viable or applicable. Feeding this information into the NBR allowed us to obtain a clearer picture of the context, location, and characteristics of burn injuries in the United States. Furthermore, the structure of this tool can easily be adapted for any global setting as it relies on a publicly known data system (ICECI) and uses


36 Villaveces et al

Table 3. Characteristics of population that received care for burn-related injuries in six burn centers where the International Classification of External Causes of Injury burn injuries electronic tool was tested, United States, 2008–2010 Demographic and Injury Characteristics Mechanism of injury Blunt force Transportation-related Falling, stumbling, jumping, pushing Other mechanical Thermal Scalding (liquid or gas) Contact with solid object Fire/flame


Hospital 2

Hospital 3

Hospital 4

Hospital 5

Hospital 6

Total

— —

2 (0.51) 1 (0.25)

— —

— —

— —

2 (1.61) —

4 (0.44) 1 (0.11)

—

6 (1.52)

1 (5.26)

—

1 (1.45)

1 (0.81)

8 (0.88)

84 (28.97) 31 (10.69) 125 (43.10)

136 (34.43) 59 (14.94) 134 (33.92)

4 (21.05) 1 (5.26) 7 (36.84)

— — 1 (33.33)

— — —

32 (25.81) 8 (6.45) 31 (25.0)

256 (28.44) 100 (11.11) 298 (33.11)

— 8 (2.02)

— —

— —

— 2 (2.90)

2 (1.61) 17 (13.71)

3 (0.33) 37 (4.10)

— — — —

— 65 (94.2) — —

1 (0.81) 8 (6.45) 7 (5.64) 6 (4.84)

1 (0.11) 104 (11.55) 29 (3.22) 8 (0.89)

Heat stroke 1 (0.34) Other heat source 10 (3.44) (ie, smoke) Cooling — Undefined 19 (6.55) Exposure to chemicals 12 (3.78) Exposure to weather or — natural force Complications of — health care Other/undetermined/ 8 (2.75) unspecified Object/substance producing injury Transport-related 16 (5.52) Mobile machinery 1 (0.34) Watercraft transport 1 (0.34) Furniture/furnishing 1 (0.34) Infant or child product 1 (0.34) Household appliance 30 (10.34) Cooking/cleaning utensil 6 (2.07) Personal-use item 10 (3.45) (including tobacco) Sports/recreational 1 (0.34) equipment Work-related tool 5 (1.72) Weapon — Animal, plant, or person — Building or building 21 (7.24) component Ground surface 2 (0.69) Other materials 9 (3.10) Flame, fire, or smoke 88 (30.34) Hot object, liquid, or gas 33 (11.38) Food or drink 37 (12.76) Pharmaceutical substance — Other substance 6 (2.07) Medical/surgical device 1 (0.34) Other/unspecified 21 (7.24)

— 12 (3.03) 9 (2.28) 2 (0.51)

— — 1 (5.26) —

4 (1.01)

—

—

—

—

4 (0.44)

22 (5.57)

5 (26.31)

2 (66.67)

1 (1.45)

9 (7.27)

47 (5.21)

41 (10.38) 1 (0.25) 2 (0.51) 7 (1.77) — 28 (7.09) 8 (2.03) 11 (2.78)

1 (5.26) — — — — 1 (5.26) — —

1 (8.33) — — — — — — —

2 (2.90) 2 (2.90) 1 (1.45) — — 9 (13.04) 33 (47.83) 5 (7.25)

11 (8.87) 2 (1.61) — 7 (5.65) — 10 (8.06) 4 (3.23) 4 (3.23)

72 (7.92) 6 (0.66) 4 (0.44) 15 (1.65) 1 (0.11) 78 (8.58) 51 (5.61) 30 (3.30)

9 (2.28)

—

—

2 (2.90)

—

12 (1.32)

10 (2.53) 1 (0.25) — 10 (2.53)

2 (10.53) — — 3 (15.79)

— — — —

4 (5.80) — — 2 (2.90)

7 (5.65) — 2 (1.61) 4 (3.23)

28 (3.08) 1 (0.11) 2 (0.22) 40 (4.40)

18 (4.56) 3 (0.76) 96 (24.30) 65 (16.46) 64 (16.20) 1 (0.25) 1 (0.25) 1 (0.25) 18 (4.55)

— — 5 (26.32) 3 (15.79) 2 (10.53) — 1 (5.26) — 1 (5.26)

— — 5 (41.67) 1 (8.33) 2 (16.67) — — — 1 (8.33)

— — 5 (7.25) 1 (1.45) 1 (1.45) — — — 2 (2.90)

1 (0.81) 2 (1.61) 13 (10.48) — 15 (12.10) 2 (1.61) 3 (2.42) 2 (1.61) 35 (28.22)

21 (2.31) 14 (1.54) 212 (23.32) 103 (11.33) 121 (13.31) 3 (0.33) 11 (1.21) 4 (0.44) 78 (8.58)

Percentages might not amount to 100 because of missing values. Hospital 4 serves only younger populations.


Villaveces et al 37

Table 4. Characteristics of population that received care for burn-related injuries in six burn centers where the International Classification of External Causes of Injury burn injuries electronic tool was tested, United States, 2008–2010 Demographic and Injury Characteristics Activity when injured Paid work Unpaid work Education Sports/exercise Leisure or play Vital activity Under care Travelling Other/undetermined/ unspecified Economic activity Agriculture/hunting/ forestry Mining/quarrying/ extraction Manufacturing Electricity/gas/ water supply Construction Wholesale or retail trade Hotels and restaurants Transport/storage/ communications Other community/ social service activity Other/undetermined/ unspecified Occupation Legislator/senior official/manager Professionals Technicians or associate professionals Service workers/ shops/market sales Craft or related trades workers Plant machine operators/ assemblers Other/undetermined/ unspecified


Hospital 2

Hospital 3

Hospital 4

Hospital 5

Hospital 6

Total

42 (14.48) 52 (17.93) 3 (1.03) 1 (0.34) 54 (18.62) 71 (24.48) 15 (5.17) 2 (0.69) 50 (17.24)

36 (9.11) 12 (3.04) 1 (0.25) 4 (1.01) 114 (28.86) 117 (29.62) 15 (3.80) 12 (3.04) 84 (21.27)

6 (31.58) 2 (10.53) — — 6 (31.58) 1 (5.26) 2 (10.53) — 2 (10.53)

— — — — — — 7 (8.33) — 11 (91.67)

8 (11.59) 1 (1.45) — — 25 (36.23) 32 (46.38) 2 (2.90) — 1 (1.45)

14 (11.29) 19 (15.32) — — 33 (26.61) 14 (11.29) 1 (0.81) 1 (0.81) 42 (33.87)

106 (11.66) 86 (9.46) 4 (0.44) 5 (0.55) 232 (25.52) 235 (25.85) 36 (3.96) 15 (1.65) 190 (20.9)

—

—

1 (16.67)

—

—

1 (7.14)

2 (1.68)

1 (2.33)

—

—

—

—

—

1 (0.84)

— 14 (32.56)

3 (8.33) 8 (22.22)

1 (16.67) 1 (16.67)

— —

— 1 (12.50)

— 4 (28.57)

4 (3.36) 28 (23.53)

3 (6.98) 1 (2.33) 4 (9.30) —

6 (16.67) 3 (8.33) 2 (5.56) 5 (13.89)

1 (16.67) 1 (16.67) — 1 (16.67)

— — — —

2 (25.0) — 2 (25.0) 2 (25.0)

— 2 (14.29) 1 (7.14) —

12 (10.08) 7 (5.88) 9 (7.56) 8 (6.72)

—

1 (2.78)

—

—

1 (12.50)

1 (7.14)

3 (2.52)

20 (46.51)

8 (22.22)

—

—

5 (35.72)

45 (37.81)

—

1 (2.78)

—

—

—

—

1 (0.84)

1 (2.33) 12 (27.91)

— 3 (8.33)

— 5 (83.33)

— —

— 2 (25.0)

— —

1 (0.84) 22 (18.49)

5 (11.63)

4 (11.11)

—

—

2 (25.0)

1 (7.14)

12 (10.08)

2 (4.65)

13 (36.11)

—

—

1 (12.50)

1 (7.14)

17 (14.29)

1 (2.33)

3 (8.33)

1 (16.67)

—

1 (12.50)

—

6 (5.04)

22 (51.16)

12 (33.34)

—

2 (25.0)

12 (85.72)

60 (50.42)

12 (100)

12 (100)


readily available software (MS-Access). The process evaluation of our investigations allowed us to demonstrate that the tool can be easily used in emergency department settings, but the evaluation also identified a set of superiorly relevant variables and consequently improves the quality of data on burn injuries.

CONCLUSIONS We accomplished our goals of 1) creating a data-collection tool for the ICECI, which can be linked to existing operational programs of the NBR, 2) training registrars in the use of this tool, 3) establishing quality-control mechanisms for ensuring accuracy


38 Villaveces et al

Table 5. Characteristics of population that received care for burn-related injuries in six burn centers where the International Classification of External Causes of Injury burn injuries electronic tool was tested, United States, 2008–2010 Demographic and Injury Characteristics


Place of occurrence Indoor 161 (60.30) Outdoor 87 (32.58) Unspecified 19 (7.12) Place of occurrence (building type) Home 184 (63.45) Residential institution 2 (0.69) Medical service area — School or educational area 3 (1.03) Sports or athletic area 2 (0.69) Street/roads or transport area 3 (1.03) Industrial/construction area 33 (11.38) Farm or agricultural area 1 (0.34) Recreational/public/ 31 (10.69) cultural area Commercial area 6 (2.07) Countryside 1 (0.34) Other/undetermined/ 24 (8.28) unspecified Part of building or grounds Bathroom 6 (2.25) Kitchen 61 (22.85) Living room 5 (1.87) Bedroom 4 (1.50) Playroom/family room — Classroom 3 (1.12) Balcony — Stairs — Garden/yard — Garage — Driveway — Sports facility — Private road — Parking area — Other/undetermined/ 166 (62.17) unspecified Type of home Detached house 6 (3.26) Row house — Apartment 7 (3.80) Farmhouse — Mobile home — Other/undetermined/ 171 (92.93) unspecified Person responsible for home Injured person 170 (92.39) Perpetrator — Another person 1 (0.54) Undetermined/unspecified 13 (7.07)

Hospital 2

Hospital 3

Hospital 4

Hospital 5

Hospital 6

Total

199 (63.99) 95 (30.55) 17 (5.47)

10 (71.43) 4 (28.57) —

6 (50.0) 1 (8.33) 5 (41.67)

55 (82.09) 12 (17.39) —

67 (75.28) 18 (20.22) 4 (4.49)

498 (65.53) 217 (28.55) 45 (5.92)

253 (64.05) 1 (0.25) — — — 29 (7.35) 15 (3.80) — 19 (4.81)

11 (57.89) — — — — — 2 (10.53) — 1 (5.26)

7 (58.33) — — — — — — — —

54 (78.26) 2 (2.90) 1 (1.45) — — 4 (5.80) 3 (4.35) — —

75 (61.29) — 1 (0.81) — — 4 (3.23) 1 (0.81) 2 (1.61) 2 (1.61)

585 (64.36) 5 (0.55) 2 (0.22) 3 (0.33) 2 (0.22) 40 (4.40) 84 (9.24) 3 (0.33) 54 (5.94)

4 (1.01) 1 (0.25) 73 (18.48)

— 3 (15.79) 2 (10.53)

— — 5 (41.67)

— — 3 (4.35)

2 (1.61) 23 (2.42) 33 (26.61)

13 (1.43) 8 (0.88) 140 (15.40)

18 (5.79) 116 (37.30) 15 (4.82) 25 (8.04) — — — 1 (0.32) 39 (12.54) 3 (0.96) 13 (4.18) 1 (0.32) 2 (0.64) 1 77 (24.76)

1 (7.14) 5 (35.71) — — — — — — — — — — — — 8 (57.14)

2 (16.67) 3 (25.0) — — — — — — — — — — — — 7 (58.33)

1 (1.49) 40 (59.70) 5 (7.46) 6 (8.96) 1 (1.49) — 1 (1.49) — 2 (2.99) — — — — 2 (2.99) 9 (13.43)

6 (6.74) 14 (15.73) — 2 (2.25) — — — — 9 (10.11) 3 (3.37) — — — — 55 (61.79)

34 (4.47) 239 (31.45) 25 (3.29) 37 (4.87) 1 (0.13) 3 (0.39) 1 (0.13) 1 (0.13) 66 (8.68) 10 (1.32) 14 (1.84) 2 (0.26) 2 (0.26) 3 (0.39) 322 (42.38)

6 (50.0) — — — — 6 (50.0)

22 (40.74) 1 (1.85) 30 (55.56) — — 8 (1.85)

1 (1.32) — 7 (9.21) 3 (3.95) 1 (1.32) 64 (84.21)

233 (39.49) 8 (1.36) 78 (13.22) 4 (0.68) 3 (0.51) 264 (44.75)

4 (33.33) — — 8 (66.67)

53 (98.15) — — 1 (1.85)

71 (93.42) 2 (2.63) 1 (1.32) 2 (2.63)

535 (90.68) 12 (2.03) 16 (2.71) 19 (3.22)

198 (50.13) 7 (1.77) 34 (13.44) 1 (0.40) 2 (0.79) 11 (4.35)

231 (91.30) 10 (3.95) 9 (3.56) 3 (1.19)

— — — — — 11 (100)

6 (54.55) — 5 (45.45) 3 (1.19)



Villaveces et al 39

Table 6. Characteristics of population that received care for burn-related injuries in six burn centers where the International Classification of External Causes of Injury burn injuries electronic tool was tested, United States, 2008–2010 Demographic and Injury Characteristics Alcohol use No available information No use Suspected/confirmed use Other substance use No available information No use Suspected/confirmed use in event


Hospital 2

Hospital 3

Hospital 4

Hospital 5

Hospital 6

Total

109 (37.59) 155 (53.45) 26 (8.96)

13 (3.29) 353 (89.37) 29 (7.34)

1 (5.46) 18 (94.74) —

3 (25.0) 9 (75.0) —

2 (2.90) 66 (95.65) 1 (1.45)

3 (2.42) 100 (80.65) 21 (16.94)

131 (14.41) 701 (77.12) 77 (8.47)

105 (36.21) 152 (52.41) 33 (11.38)

9 (2.28) 351 (88.86) 35 (8.86)

— 19 (100) —

3 (25.0) 9 (75.0) —

— 67 (97.1) 2 (2.90)

2 (1.61) 109 (87.90) 13 (10.49)

119 (13.09) 707 (77.78) 83 (9.13)


and reliability, 4) incorporating ICECI data entry into the weekly routine of the burn registrar, 5) demonstrating the quality differences between data collected using this tool and that of the NBR, and 6) identifying important variables that should be collected and are currently not included by the NBR. Using this or similar tools with the ICECI structure

Table 7. Comparison of selected National Burn Repository injury characteristics obtained from the 2010 U.S. Burn Data Repository with findings from 909 records collected from burn units at six U.S. hospitals, 2008–2010 Injury Classification

ICECI Data

Circumstance of injury (injury intent) Unintentional 859 (94.5) Self-harm 11 (1.21) Assault 9 (0.99) Iatrogenic† 5 (0.55) Other/undetermined/ 24 (2.75) unspecified Cause (injury mechanism) Fire/flame 298 (33.11) Scald 256 (28.44) Contact with hot object 100 (11.11) Other nonburn 13 (1.51) Electrical — Chemical 29 (3.22) Burn unspecified 104 (11.55) Inhalation only 37 (4.10) Other (skin disease, 25 (2.90) radiation)

US NBR* 98,286 (90.68) 1,272 (1.17) 3,111 (2.87) — 5,724 (5.28)

48,843 (41.64) 36,328 (30.97) 10,381 (8.85) 9,000 (7.67) 4,466 (3.81) 3,490 (2.96) 2,895 (2.47) 947 (0.81) 953 (0.81)

ICECI, International Classification of External Causes of Injury; NBR, National Burn Repository. Data from U.S. NBR only for 2010 represents data collected from 76 burn centers in 33 states. †Category does not appear in U.S. NBR.

and information can considerably improve the quantity and quality of data on burn injuries in the United States and elsewhere and thus would be more useful in informing the development of prevention strategies.

ACKNOWLEDGMENTS We thank Mr. Gary Price of RDB Programming and Consulting Services, Durham, NC, for the development of the electronic surveillance data entry tool and for training hospital personnel in its use. We are especially thankful to the following burn centers for their participation in this study or for collaborating with us, including the Arizona Burn Center, Maricopa Medical Center, Phoenix, AZ; Arrowhead Regional Medical Center, Colton, CA; Utah Health Sciences Center, Salt Lake City, UT; Shriners Hospitals for Children, Northern California, Sacramento, CA; Torrance Memorial Medical Center, Torrance CA; and the University of Iowa Hospitals & Clinics, Iowa City, IA. We additionally thank the Timothy J. Harnar Burn Center, UMC Health Center, Lubbock, TX; Paul and Carol David Foundation Burn Institute, Akron Children’s Hospital, Akron, OH; New York Presbyterian Hospital (Cornell Medical Center) New York, NY; and Wake Forest University Baptist Medical Center Medical Center, Winston-Salem, NC for considering participation in the study. We would also like to thank Dr. Carol W Runyan for her helpful comments and review in earlier versions of this project. Finally, we express our gratitude for the editorial skills of Ms. Andrea Sattinger. REFERENCES 1. Kramer CB, Rivara FP, Klein MB. Variations in U.S. pediatric burn injury hospitalizations using the national burn repository data. J Burn Care Res 2010;31:734–9. 2. Centers for Disease Control and Prevention. WISQARS Fatal Injury Reports 2008, United States. [World Wide Web]. 2008; available from http://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html; accessed November 2011.

40 Villaveces et al

3. Centers for Disease Control and Prevention. WISQARS Non-Fatal Injury Reports 2009, United States. [World Wide Web]. 2009; available from http://www.cdc.gov/injury/ wisqars/nonfatal.html; accessed November 2011. 4. Centers for Disease Control and Prevention. WISQARS Cost of Injury Reports 2005, United States. [World Wide Web]. 2005; available from http://wisqars.cdc.gov:8080/ costT/; accessed November 2011. 5. American Burn Association. National Burn Repository Report. Chicago, IL: American Burn Association; 2011. p. 125. 6. Bowman SM, Aitken ME, Maham SA, Sharar SR. Trends in hospitalisations associated with paediatric burns. Inj Prev 2011;17:166–70.


7. World Health Organization. International Classification of External Causes of Injuries (ICECI). 2004; available from http://www.rivm.nl/who-fic/ICECIeng.htm; accessed May 2011. 8. Bray F, Parkin DM. Evaluation of data quality in the cancer registry: principles and methods. Part I: comparability, validity and timeliness. Eur J Cancer 2009;45:747–55. 9. Parkin DM, Bray F. Evaluation of data quality in the cancer registry: principles and methods Part II. Completeness. Eur J Cancer 2009;45:756–64. 10. Wynn A, Wise M, Wright MJ, et al. Accuracy of ad ministrative and trauma registry databases. J Trauma 2001;51:464–8.