Elsevier

Burns

Volume 44, Issue 2, March 2018, Pages 335-343
Burns

Raising suspicion of maltreatment from burns: Derivation and validation of the BuRN-Tool

https://doi.org/10.1016/j.burns.2017.08.018Get rights and content

Highlights

  • The BuRN-Tool; a validated clinical prediction to identify children with suspected maltreatment.

  • The score is simple and easy to complete in an emergency department setting.

  • It has a sensitivity of 84% (71.5–91.6) and specificity of 80% (77.0–82.9).

  • The BuRN-Tool is an adjunct to decision-making, to predict children at risk for maltreatment.

Abstract

Background

10–25% of childhood burns arise from maltreatment.

Aim

To derive and validate a clinical prediction tool to assist the recognition of suspected maltreatment.

Methods

Prospectively collected data from 1327 children with burns were analyzed using logistic regression. Regression coefficients for variables associated with ‘referral for child maltreatment investigation’ (112 cases) in multivariable analyses were converted to integers to derive the BuRN-Tool, scoring each child on a continuous scale. A cut-off score for referral was established from receiver operating curve analysis and optimal sensitivity and specificity values. We validated the BuRN-Tool on 787 prospectively collected novel cases.

Results

Variables associated with referral were: age <5 years, known to social care, concerning explanation, full thickness burn, uncommon body location, bilateral pattern and supervision concern. We established 3 as cut-off score, resulting in a sensitivity and specificity for scalds of 87.5% (95% CI:61.7–98.4) and 81.5% (95% CI:77.1–85.4) respectively and for non-scalds sensitivity was 82.4% (95%CI:65.5–93.2) and specificity 78.7% (95% CI:73.9–82.9) when applied to validation data. Area under the curve was 0.87 (95% CI:0.83–0.90) for scalds and 0.85 (95% CI:0.81–0.88) for non-scalds.

Conclusion

The BuRN-Tool is a potential adjunct to clinical decision-making, predicting which children warrant investigation for child maltreatment. The score is simple and easy to complete in an emergency department setting.

Section snippets

Table of contents summary

The BuRN-Tool: a novel clinical prediction tool for the emergency room to identify cases of maltreatment in children who have sustained a burn.

What’s known on this subject

A proportion of children with medically attended burns will have sustained their injuries from child neglect or physical abuse. These children are assessed by clinicians with varying pediatric experience and underlying maltreatment may go unrecognized.

What this study adds

A clinical prediction tool, derived from research evidence and primary epidemiologic data, and validated prospectively on a novel dataset, has the potential to raise suspicion of maltreatment associated with pediatric burns and be an adjunct to clinical decision-making.

Derivation

To derive the CPT we used data from a prospective multicenter study of children presenting with a burn to two pediatric EDs, three general EDs and three burns units in the UK and Ireland during 2008–2010 [16]. Children less than 16 years old were included; victims of household fires were excluded. A standardized data collection proforma, the Burns and Scalds Assessment Template (Supplementary Fig. S1), was completed by the treating clinician, recording: age, gender, gross motor developmental

Ascertainment and demographics

A total of 1484 cases were identified, 157 were excluded due to double counting or failure to fulfil the inclusion criteria, leaving 1327 cases; 768 (58%) were scalds (median age; 1 year [IQR 1–3]) and 559 (42%) non-scalds (median age; 2 years [IQR 1–8]). Gender ratio (Male:Female) was 3:2. A total of 8.4% (112/1327; 7.7% for scalds and 9.5% for non-scalds) cases were referred to a children’s social care team. Data completeness for scald cases included in the analyses was 99.6% (765/768) and

Discussion

The BuRN-Tool is an easily completed CPT with the potential to identify which children with burns warrant further child abuse evaluation. The performance of the BuRN-Tool was prospectively validated against a novel dataset to that used for derivation. Although not perfect, the performance of the BuRN-Tool was satisfactory in both derivation and validation and performed slightly better in the validation study with a sensitivity and specificity around 80%.

The strengths of this study are that a

Conclusion

The BuRN-Tool is a prospectively derived level 3 (highest evidence-based standard of validation) CPT [11], [25], with satisfactory accuracy, that has been developed from research evidence and validated prospectively. The items are basic clinical features and the scoring is straight forward; together with the BaSAT it has the potential to act as an ‘aide memoire’ to standardize the assessment of children with burns across multiple professionals in busy emergency settings, and identify those who

Contributors’ statement

Alison Kemp and Sabine Maguire conceptualized, designed, managed and supervised the derivation and validation phase of the study, designed the data collection instruments, and coordinated and supervised data collection at the validation sites, wrote the study manuscript final versions.

Linda Hollén completed the statistical analyses, drafted the initial manuscript and coordinated the final version.

Alan Emond directed the research network, chaired and advised research team meetings, co- ordinated

Funding source

This study was supported by the Scar Free Foundation, and the Health and Care Research Wales. The Children’s Burns Research Centre is part of the Burns Collective, a Scar Free Foundation initiative with additional funding from Vocational Training Charitable Trust and Health and Care Research Wales.

Financial disclosure

The authors have indicated they have no financial relationships relevant to this article to disclose.

Conflict of interest

The authors have no potential conflicts of interest to disclose.

Acknowledgements

The authors wish to thank everyone who contributed data to this study. The participating EDs and units and lead clinicians were:

Derivation study: Cardiff University/Cardiff and Vale University Hospital Board, Wales (Z Lawson, H Dowd, D Farrell), Birmingham Childrens Hospital, England (G DeBelle, C Thomas), Royal Gwent Hospital, Newport, Wales (A Rawlinson, S Jones, J Probert), Morriston Hospital, Swansea, Wales (T Potokar, P Thompson, A McNab), Our Lady’s Hospital for Sick Children, Crumlin,

References (32)

  • B. Thombs

    Patient and injury characteristics, mortality risk, and length of stay related to child abuse by burning: evidence from a national sample of 15,802 pediatric admissions

    Ann Surg

    (2008)
  • L. Wibbenmeyer et al.

    Factors related to child maltreatment in children presenting with burn injuries

    J Burn Care Res

    (2014)
  • J. Woodman et al.

    Performance of screening tests for child physical abuse in accident and emergency departments

    Health Technol Assess

    (2008)
  • Great Britain

    Children Act 2004 (c.31)

    (2004)
  • E. Wallace et al.

    Framework for the impact analysis and implementation of Clinical Prediction Rules (CPRs)

    BMC Med Inform Decis Mak

    (2011)
  • I. Stiell et al.

    Implementation of clinical decision rules in the emergency department

    Acad Emerg Med

    (2007)
  • Cited by (0)

    The research team are all members of the Scar Free Foundation Centre for Children’s Burns Research.

    View full text