Clinical outcome of patients with self-inflicted burns

doi:10.1016/j.burns.2016.11.005

Burns

Volume 43, Issue 4, June 2017, Pages 789-795

https://doi.org/10.1016/j.burns.2016.11.005 Get rights and content

Highlights

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If matched for burn severity, mortality was equal in patients attempting suicide and accidentally burned.
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If matched for burn severity, patients who attempted suicide were in hospital as long as those accidentally burned.
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Self-inflicted burns should be distinguished based on the patient’s intention.
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Outcome differs for suicide attempt and self-harm without the intention to die.

Abstract

Introduction

Patients with self-inflicted burns (SIB) are thought to have a longer length of stay compared to patients with accidental burns. However, other predictors for a longer length of stay are often not taken into account, e.g. percentage of the body surface area burned, age or comorbidities. Therefore, we wanted to study the outcome of patients with SIB at our burn center.

Methods

A retrospective, observational study was conducted. All adult patients with acute burns admitted to the burn center of the Martini Hospital Groningen, between January 1, 2009 and December 31, 2013 were included. Data on characteristics of the patient, injury, and outcome (LOS, mortality, discharge destination) were collected. In patients with SIB, suicide attempts (SA) were distinguished from self-harm without the intention to die (non-suicidal self-injury, NSSI). To evaluate differences in outcome, each patient with SIB was matched on variables and total score of the Abbreviated Burn Severity Index (ABSI) to a patient with accidental burns (AB).

Results

In total 29 admissions (21 SA and 8 NSSI) were due to SIB and 528 due to accidents. Overall, when compared to AB, there were significant differences with respect to mortality and LOS for SA and/or NSSI. Mortality was higher in the SA group, while the LOS was higher in both the SA and NSSI groups compared to the AB group. However, after matching on ABSI, no statistical significant differences between the SA and SA-match or the NSSI and NSSI-match group were found.

Conclusion

With the right and timely treatment, differences in mortality rate or length of stay in hospital could all be explained by the severity of the burn and the intention of the patient.

Introduction

Patients with self-inflicted burns (SIB) often have extensive burns and require a lot of care and attention of a multidisciplinary burn team. Overall, patients with SIB are thought to have a longer length of stay (LOS) compared to other patients with burns [1]. Although several research papers have been published, there is no consensus on the outcome of SIB patients in terms of LOS and their mortality [2].

SIB seem culturally determined and are more common in Eastern compared to Western countries [3]. For example, incidence is reported to be 36.6% in Iran [4] and 6.8% in Switzerland [5]. In 2004, Laloe clustered the motives for SIB in three broad groups: those burning themselves because of a psychiatric illness, e.g. depression or schizophrenia (Western and Middle East countries), those doing so for personal reasons (e.g. India, Sri Lanka, Papua-New Guinea, Zimbabwe), and a small group doing so for political reasons (e.g. India, South Korea) [6]. For burns that are not motivated ideologically or attempted during an altered mental state, such as delirium or “confusion”, two new psychiatric disorders are suggested by the American Psychiatric Association (APA) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5): Suicidal Behavior Disorder and non-suicidal self-injury (NSSI) [7]. The difference between the two disorders lies in the intention of the patient to inflict burns on himself. This distinction can elucidate the debate on outcome after SIB. In addition, a shift in thinking about self-inflicted injuries is reflected in DSM-5. Mental illnesses such as depressive disorder or schizophrenia are now considered to be independent conditions and risk factors for Suicidal Behavior Disorder or NSSI [7].

LOS in burn patients may depend on whether the burns are accidental or self-inflicted [8], and the intention of the burns as patients who inflict the burns themselves often have a higher %TBSA burned [9], [10]. A higher %TBSA burned and higher age are the most commonly identified significant prognostic factors for LOS [11]. In addition, % full thickness burn, female gender, inhalation injury, surgery and depth of burn are found to be predictors [11]. Furthermore, general effects of psychiatric illness/comorbidity might explain a longer LOS in SIB patients, as longer LOS is observed in general medical patients with psychiatric comorbidity [12]. Probable explanations for psychiatric patients to stay longer in hospital are sought in complications in care related to mental illness including differential diagnosis of medical disorders, treatment refusal or the need for additional psychiatric consultation or treatment [12]. Noteworthy, psychiatric illness may also trigger quicker referral or acceptance to a nursing home reducing the length of stay. Furthermore, part of these patients may have poorer hygienic habits which might influence length of stay and morbidity after burns.

Whether LOS is indeed prolonged in self-inflicted burns is not clear as many studies failed to adequately control for variables known to affect time needed for burn recovery. Thombs and Bresnick did control for several initial differences and showed no difference between psychiatric patients with self-inflicted burns compared with psychiatric patients with accidental burns in terms of mortality or length of stay [13]. Besides adjusting for a psychiatric diagnosis (yes/no), they controlled for 18 other variables. By taking a psychiatric diagnosis into their regression analyses, however, we feel they may have controlled for at least one variable too many, leaving no differences between the average group means. Overadjustment can obscure a true effect or create an apparent effect when none exists [14], [15]. In view of contradictory scientific information, we aim to compare the outcome of patients with SIB (suicide attempt and non-suicidal self-injury) treated at the burn center with patients admitted with accidental burns.

Section snippets

Material and methods

A retrospective, observational study was conducted. All patients aged 18 years and older with acute burns admitted to the burn center of the Martini Hospital Groningen between January 1, 2009 and December 31, 2013 were included. The Martini Hospital is a dedicated burn centre and serves children and adults primarily from the north-eastern part of the Netherlands. Data on individual patients were retrieved from the Dutch National Burn Repository R3 and if necessary supplemented from patient’s

Results

In this study, 557 acute burn admissions were included. In 29 cases (5%), psychiatric interview confirmed self-inflicted burns (21 SA and 8 NSSI). Two cases of SA involved the same person as did two cases due to NSSI.

Discussion and conclusion

The aim of this study was to find out how patients with self-inflicted burns fare. We found that the higher mortality in the SA group is due to a higher %TBSA burned, higher prevalence of full thickness burns and/or inhalation injuries compared to our total population. When matched for severity of the burns using the ABSI score, no significant differences in mortality and length of stay between the SA- or NSSI-group and their matched control groups were found. Thus, the outcome of those who

Conflicts of interest

None. All authors have approved the final article.

Acknowledgments

We wish to thank the Dutch Burn Repository Group of the burn centers of the Red Cross Hospital and the Maasstad Hospital for their contribution to the Dutch Burn Repository, and the Dutch Burns Foundation and Martini Hospital Groningen for their support.

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Those with self-inflicted burns are a small but consistent group among burn patients, with large injuries and conflicting findings regarding their in-hospital mortality. Overall, burn survivors have a shorter life expectancy, as compared with national controls, but long-term mortality after self-inflicted burns is understudied. The aim of this retrospective study was to investigate possible differences in long-term mortality among survivors after self-inflicted and accidental burns.
All adult patients with burns admitted at the Linköping Burn Centre and discharged alive between 2000 and 2017 were included, and end of follow up was April 26, 2021. Those with unknown survival status at that time were excluded. A Cox proportional hazards regression model, adjusted for age and sex, was used to analyse long term mortality.
Among the 930 patients included in this study, 37 had self-inflicted burns. Overall, median follow up period was 8.8 years and crude mortality was 24.7%. After adjustment for age and sex, self-inflicted burns were independently associated with long-term mortality, Hazard Ratio= 2.08 (95% CI 1.13–3.83). Post hoc analysis showed that the effect was most pronounced during the first years after discharge although it was noticeable over the whole study period.
Long-term risk of mortality after discharge from a burn centre was higher in patients with self-inflicted burns than in patients with accidental burns. The effect was noticeable over the whole study period although it was most pronounced during the first years after discharge.
The effect of self-inflicted burns on ABSI score prediction power: A four-year prospective multicenter study of the German Burn Registry
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Estimates in the literature show TBSA for SIB at on average 45% compared to 26% for other cases [13]. As the negative relation between TBSA and survival probability is well established in the literature it remains controverse whether the lower survival rates of attempted suicide patients is caused by higher TBSA or whether attempted suicide has an independent influence on survival rates [6,13–17]. Extensive burns usually involve long-term multidisciplinary treatments in specialized burn centers.
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Exploratory analysis of long-term physical and mental health morbidity and mortality: A comparison of individuals with self-inflicted versus non-self-inflicted burn injuries
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While burn patients in general receive a high level of care, SIB patients in particular may benefit from early and targeted interventions to improve outcomes [19] including prevention of recurrent self-inflicted injuries and enhanced long-term physical and psychological functioning. Though there are several retrospective studies, case reports, and literature reviews presenting the incidence, injury characteristics, basic demographics, and short-term outcomes of patients with SIB injuries [1,6,9,10,12,20–23], there is a shortage of literature reporting long-term functional and psychological outcomes, particularly in comparison to non-SIB injuries. Additionally, the majority of studies included <100 SIB patients, limiting generalizability, and yielded contradictory results regarding short-term increases in morbidity and mortality when accounting for injury severity.
Self-inflicted burn (SIB) injuries are relatively rare, but patients may experience complex biopsychosocial challenges. This study aimed to compare long-term physical and psychological outcomes for individuals with SIB and non-SIB injuries.
Records of adult SIB (n = 125) and non-SIB (n = 3604) injuries were collected from U.S. burn centers within the Burn Model System between 1993 and 2018. Assessments were administered at discharge, 6 months, 24 months, 5 years, and 10 years.
SIB patients were more often younger, unmarried, unemployed, male, struggling with pre-morbid psychiatric issues, and injured by fire/flame (all p < 0.001). SIB injury predicted prolonged mechanical ventilation, hospitalization, and rehabilitation (all p < 0.001). After injury, SIB patients had increased anxiety at 24 months (p = 0.0294), increased suicidal ideation at 5 years (p = 0.004), and clinically worse depression at 10 years (p = 0.0695). SIB patients had increased mortality across 24 months compared to non-SIB patients (OR = 4.706, p = 0.010).
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Intentional burn injury outcomes are usually more severe, have a high mortality and are seen more often in low and middle-income countries. This study will examine the epidemiological characteristics of intentional burn injury patients and mortality outcomes at a regional Burn Center.
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Self-inflicted injuries were associated with larger burns, a higher rate of mortality and increased rate of comorbid psychiatric diagnosis. Consistent with previous research, self-inflicted burns were significantly larger and were associated with a significantly increased risk of mortality during the admission [28]. Over half the patients admitted following a self-inflicted burn succumbed to their injury.
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Review the psychiatric history of patients treated in a statewide burn service following severe burn injury and determine whether psychiatric history, extent of burn and mortality are impacted by gender and whether the injury was self-inflicted.
A data linkage study was performed with psychiatric history and mental health service contact data matched to patients’ data collected via a previous retrospective file audit. Unadjusted and adjusted logistic regression modelling measured interactions between gender and self-inflicted burn status, and other study outcomes.
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¹: The Dutch Burn Repository Group of the Martini Hospital consists of G.I.J.M. Beerthuizen, J. Eshuis, J. Hiddingh, S.M.H.J. Scholten-Jaegers and M.K. Nieuwenhuis.

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Clinical outcome of patients with self-inflicted burns

Highlights

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Section snippets

Material and methods

Results

Discussion and conclusion

Conflicts of interest

Acknowledgments

Burns

Burns

Burns

Burns

Burns

J Psychosom Res

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Ann Emerg Med

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