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Timely access to care for patients with critical burns in India: a prehospital prospective observational study
  1. Jennifer A Newberry1,
  2. Corey B Bills2,
  3. Elizabeth A Pirrotta1,
  4. Michele Barry3,
  5. Govindaraju Venkata Ramana Rao4,
  6. Swaminatha V Mahadevan1,
  7. Matthew C Strehlow1
  1. 1 Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
  2. 2 Emergency Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
  3. 3 Internal Medicine, Stanford University School of Medicine, Stanford, California, USA
  4. 4 GVK Emergency Management and Research Institute, Hyderabad, India
  1. Correspondence to Dr. Jennifer A Newberry, Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA 94034, USA; newberry{at}


Background Low/middle-income countries carry a disproportionate burden of the morbidity and mortality from thermal burns. Nearly 70% of burn deaths worldwide are from thermal burns in India. Delays to medical care are commonplace and an important predictor of outcomes. We sought to understand the role of emergency medical services (EMS) as part of the healthcare infrastructure for thermal burns in India.

Methods We conducted a prospective observational study of patients using EMS for thermal burns across five Indian states from May to August 2015. Our primary outcome was mortality at 2, 7 and 30 days. We compared observed mortality with expected mortality using the revised Baux score. We used Χ2 analysis for categorical variables and Wilcoxon two-sample test for continuous variables. ORs and 95% CIs are reported for all modelled predictor variables.

Results We enrolled 439 patients. The 30-day follow-up rate was 85.9% (n=377). The median age was 30 years; 56.7% (n=249) lived in poverty; and 65.6% (n=288) were women. EMS transported 94.3% of patients (n=399) to the hospital within 2 hours of their call. Median total body surface area (TBSA) burned was 60% overall, and 80% in non-accidental burns. Sixty-eight per cent of patients had revised Baux scores greater than 80. Overall 30-day mortality was 64.5%, and highest (90.2%) in women with non-accidental burns. Predictors of mortality by multivariate regression were TBSA (OR 7.9), inhalation injury (OR 5.5), intentionality (OR 4.7) and gender (OR 2.2).

Discussion Although EMS rapidly connects critically burned patients to care in India, mortality remains high, with women disproportionally suffering self-inflicted burns. To combat the burn epidemic in India, efforts must focus on rapid medical care and critical care services, and on a burn prevention strategy that includes mental health and gender-based violence support services.

  • access to care
  • burns
  • emergency ambulance systems
  • global health

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  • Contributors JAN and MCS wrote the first draft of the article. JAN and EAP conducted the statistical analysis. JAN, CBB, EAP, GVRR, SVM and MCS contributed to study design. All authors assisted in interpretation of findings and revision of the manuscript. All authors read and approved the final manuscript.

  • Funding The work was funded jointly by Stanford University and GVK EMRI as part of collaborative agreement. No external funding supported this project.

  • Competing interests GVRR is the Director of Research and the Emergency Management Learning Centre at GVK EMRI.

  • Patient consent Not required.

  • Ethics approval The Institutional Review Board at Stanford deemed the study exempt because data were collected as part of routine quality improvement processes. The Ethics and Research Committee at GVK EMRI approved the publication of these findings.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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