burns 44 (2018) 57 –64

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Relationship between multidisciplinary critical care

and burn patients survival: A propensity-matched
national cohort analysis

Thet Su Win a, Metin Nizamoglu a, *, Ritesh Maharaj b, Sarah Smailes a,

Naguib El-Muttardi a, Peter Dziewulski a
a
St. Andrews Centre for Burns, Broomfield Hospital, Chelmsford CM1 7ET, UK
b
King’s Health Partners, King’s College Hospital, Denmark Hill, London SE5 9RS, UK

article info abstract

Article history: Objective: The aims of this study are: firstly, to investigate if admission to specialized burn
Accepted 6 November 2017 critical care units leads to better clinical outcomes; secondly, to elucidate if the
multidisciplinary critical care contributes to this superior outcome.
Methods: A multi-centre cohort analysis of a prospectively collected national database of
1759 adult burn patients admitted to 13 critical care units in England and Wales between
Keywords: 2005 and 2011. Units were contacted via telephone to establish frequency and constitution of
Specialized critical care services daily ward rounds. Critical care units were categorized into 3 settings: specialized burns
Burns critical care units, generalized critical care units and ‘visiting’ critical care units. Multivariate
Multidisciplinary care logistic regression analysis and propensity dose–response analysis were used to calculate
Health policy risk adjusted mortality.
Results: Multivariate logistic regression analysis shows that admission to a specialized burn
critical care service is independently associated with significant survival benefit compared to
generalized critical care unit (adjusted OR for in-hospital death 1.81, [95% CI, 1.24, 2.66]) and
‘visiting’ critical care services (adjusted OR for in-hospital death 2.24 [95% CI, 1.49, 3.38]).
Further analysis using propensity dose–response analysis demonstrates that risk-adjusted
in-hospital mortality rate decreased as the dose of multidisciplinary care increased, with an
adjusted odds ratio of 1 (specialized burn critical care units), 1.81 (generalized critical care
units) and 2.24 (‘visiting’ critical care units).
Conclusions: Admission to a specialized burn critical care service is independently associated
with significant survival benefit. This is, at least in part, due to care being provided by a fully
integrated multidisciplinary team.
© 2017 Elsevier Ltd and ISBI. All rights reserved.

designed to focus care for specific patient populations. The

1. Introduction relationship between management in specialized critical care
units and clinical outcomes have been examined for several
Critical care services have evolved over the last two decades, critical care services, ranging from paediatric critical care [1,2],
with the introduction of specialized critical care services neurocritical care [3–5] and cardiothoracic surgery [6], with the

* Corresponding author at: St. Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford CM1 7ET, UK.
E-mail address: mnizam@doctors.org.uk (M. Nizamoglu).
https://doi.org/10.1016/j.burns.2017.11.003
0305-4179/© 2017 Elsevier Ltd and ISBI. All rights reserved.
58 burns 44 (2018) 57 –64
general finding that management in specialized critical care
units results in superior clinical outcomes for selected patient
groups. The reasons for this are not yet clear, but purported
benefits of specialization include reduction of diagnosis and
treatment variability, and increasing staff expertise and
education [7].
Recently, it is increasingly being recognized that a well-
functioning critical care unit is defined not only by the
presence of multidisciplinary providers, but also by how well
those providers work together– the multidisciplinary care [8].
Specialized critical care units are typically based on multidis-
ciplinary approach, where tightly knit teams of providers with
varying domains of expertise are present on the same site to
provide critical care as a team. Although the multidisciplinary
care teams have been shown to improve critical care survival
[9], whether the multidisciplinary approach contributes to the
superior clinical outcomes previously reported in specialized
critical care units is unknown.
Patients with major burns are unique, representing the
most severe model of trauma. The complex nature of burn
injury necessitates the availability of diverse skills and
knowledge in a fully integrated manner. The UK National
Burn Care Review [10] recommended that if an adult burn
patient benefits from critical care, it should be provided within
one of the following three settings: first setting is a specialized
burns critical care unit within a burn centre. Second setting is
care provision within the burn unit where there is an adjacent
or conjoined critical care unit from which the intensivists
provide the critical care input. If, however, the burn unit and
critical care service are within the same hospital but not
adjacent (i.e. more than 50m away), it is recommended that
the burn patient is managed within the general critical care
unit with the burns team visiting to provide the burn care
input.
Since the publication of the UK National Burn Care Review
in 2001, there is no study that examine if any of the three
recommended critical care settings is associated with superior
clinical outcomes. Therefore, our objective was to determine
whether the settings within which critical care is provided for
burn patients has an independent effect on patient survival.
We hypothesized that, after adjusting for burn severity and
patient characteristics, admission to a specialized burn critical
care service would be associated with reduced in-hospital
mortality rate after severe burns.
We further hypothesized that, the multidisciplinary care –
the cornerstone of all specialized burn critical care units,
contributes to this superior clinical outcome.
2. Methods
2.1. Data source
We conducted a retrospective multi-centre cohort analysis of
patients admitted (between January 2005–January 2011) to all
13 critical care services in England and Wales that admit burn
patients. All 13 critical care services participate in the UK
National Burn Injury Database (NBID). NBID is the largest
inpatient burn care database in the United Kingdom that
collects detailed patient demographics, burn injury
characteristics, clinical and outcome data on adult burns
patients at participating hospitals for benchmarking and
quality improvement [11]. NBID data are prospectively
collected locally and uploaded monthly to a national server
after removing patient-identifiable information. Data from
NBID, blinded to hospital, critical care services and patients,
were requested and released for the present analysis.
Furthermore all aforementioned 13 critical care services
that admit burn patients were contacted via telephone. The
frequency and constituents of the daily ward round staff was
recorded. The units were then categorized into three doses of
treatment:
1. High dose: specialised burn critical care units – MDT ward
round led (assumption they have 3 whole-time equivalent
(WTE) of combined service).
2. Intermediate dose: visiting critical care unit – surgeon led
with visiting intensivist (assumption they have 2 WTE of
combined service).
3. Low dose: generalized critical care unit – intensivist led
with visiting surgeon (assumption they have 1 WTE of
combined service).
We considered that the ideal MDT burns team consisted of a
surgeon, intensivist, and allied health professionals. The units
with the most integration of MDT working together would
have all 3 WTE working together. Therefore this group was
assumed to have 3 WTE of combined service. The least
integrated generalized critical care unit may have similar
elements, however these function with visiting burns sur-
geons and visiting allied health professionals reviewing the
patient at different times. Effectively there is just 1 WTE
looking after the patient at any given time. The intermediate
group was assumed to be in the middle of these extremes, with
2 WTE of combined service, as there is burn surgeon and allied
health professional input on the burn unit with visiting
intensivist input. This provides some interaction in the MDT
but not complete overlap between the three components of
care.
2.2. Definition of critical care settings
In England and Wales, adult patients (age >16) with severe
burns are admitted to critical care services across the
National Network for Burn Care [12] depending on the
geographical location of burn incidence. While the compo-
nents of the clinical teams appear similar, the organizational
structures of critical care services within these networks vary
significantly. For the purpose of this study, critical care
services included both intensive care units and high
dependency units. A High dependency unit provides treat-
ment to patients needing single organ support (excluding
mechanical ventilation) such as renal haemofiltration or
ionotropic support with invasive blood pressure monitoring.
They are staffed with one nurse to two patients. Intensive
care provides care to patients with two or more organ support
(or needing mechanical ventilation alone). They are staffed
with one nurse per patient ratio and usually have a doctor
present in the unit 24 h per day.
 burns 44 (2018) 57 –64
2.2.1. High dose multidisciplinary care
Specialized burn critical care services are organized as
strictly closed services in which a dedicated burns multidis-
ciplinary team (MDT) assumes total control and decision-
making ability over all aspects of patient care. The burns
MDT consists of including plastic surgeons, intensivists,
paediatricians, microbiologists, pain team, dietetics, physio-
therapy, pharmacists, psychotherapists and specialist skin-
care nursing. They conduct daily MDT ward rounds and
provide 24-h critical care as a fully integrated team (high dose
multidisciplinary care).
2.2.2. Intermediate dose multidisciplinary care
A second model of critical care is where patients with severe
burns are admitted to burns units where the burns team
(which does not include an intensivist) coordinates daily
rounds, provides 24h care and implements admission and
discharge criteria. Intensivists from adjacent or conjoined
general critical care unit provide input via visiting daily rounds
and support the critical care management, in concert with the
burn team (intermediate dose multidisciplinary care).
2.2.3. Low dose multidisciplinary care
General critical care services for burns patients is defined as
patients being admitted to a generalized critical care unit,
which admits patients with a wide range of diagnoses and
procedures. The general critical care team coordinates daily
rounds, provides 24-h care and implements admission and
discharge criteria. Additionally, the burn team visit the general
critical care services daily to manage the burn aspect of
patient’s care (low dose multidisciplinary care).
2.3. Patient selection
Patients who were admitted to a critical care service with the
primary diagnosis of burns who had completed survey data
were eligible for inclusion in this study. We excluded
patients younger than 16 years of age and patients with
missing data. For patients with repeated critical care
admission for the same hospitalization, only the first
admission was included (Fig. 1).
Fig. 1 – Case selection pathway.
59
2.4. Variables
Our primary outcome was in-hospital mortality. The primary
exposure was the type of critical care services to which the
patient was admitted: specialized burns critical care (high dose
multidisciplinary care), general critical care with burns teams
visiting (low dose multidisciplinary care) or burns units with
visiting intensivists (intermediate dose multidisciplinary care).
The dose of multidisciplinary care did not change for any
critical care services throughout the study period.
2.5. Analysis
Characteristics of critical care services were summarized
with descriptive statistics. Patient-related characteristics
were evaluated with ANOVA for continuous variables and
the chi-square test for categorical variables. To evaluate the
independent effect of critical care settings on in-hospital
mortality, we performed a logistic regression analysis, which
used the type of critical care services as the exposure and in-
hospital mortality as the outcome variable. Covariates were
determined a priori based on previous studies [13,14].
Patient-level covariates included age, gender, percentage
total burn surface area (%TBSA), presence of inhalation
injury, use of mechanical ventilation on admission to critical
care unit and presence of full thickness burns. The results are
presented as adjusted odds ratio (OR) with 95% confidence
intervals (CI).
2.6. Propensity model
A propensity score is a statistical technique that attempts to
estimate the effect of a treatment, policy, or other intervention
by accounting for the covariates that predict receiving the
treatment. A propensity model was developed to account for
baseline differences at admission between patients admitted
to different critical care settings. Propensity score method is
widely used in medical research to adjust for baseline
differences that may occur in non-randomized studies [15].
In our propensity model, we considered the treatment (the
dose of multidisciplinary care) to be continuous (i.e. not binary
60 burns 44 (2018) 57 –64

or categorical) because all 3 critical care settings (specialized
burns critical care; generalized critical care; ‘visiting’ critical
care) have a degree of multidisciplinary care. In all three
settings, all individual members of multidisciplinary team
(including intensivists, burn surgeons, nurses, respiratory
therapists, occupational and physical therapist, dietician,
pharmacist) are available. The main difference, however, is
the time spent together by the members of the multidisciplin-
ary team to discuss and collaborate for an integrated patients
care plan. Hence, we elected to calculate the dose–response
function where the treatment takes on a continuum of values
[16]. Covariates were determined a priori based on previous
studies [13,14]. Covariates included in our propensity model
were age, gender, TBSA, presence of inhalation injury, use of
mechanical ventilation on admission to critical care unit and
presence of full thickness burn.
The algorithm used has three steps. Firstly the conditional
distribution of treatment given the co-variates was estimat-
ed (propensity score calculated). Secondly the conditional
expectation of the outcome given the co-variates was
modelled (expected outcome calculated given the treatment
and propensity score). Thirdly the estimated regression
function was averaged over the score function at the each
level of treatment (estimating average potential outcome at
each level of treatment). In our algorithm, we assigned the
value 1 to lowest dose of multidisciplinary care (generalized
critical care services), 2 to intermediate dose of multidisci-
plinary care (‘visiting’ critical care services) and 3 to the
highest dose of multidisciplinary care (specialized burns
critical care services). The dose response algorithm under-
takes bootstrapping procedure that encompasses the esti-
mation of the generalized propensity score and the alpha
parameters. The re-estimation of the generalized propensity
score and the alpha parameters at each replication of the
bootstrapping procedure aims to account for the uncertainty
of the estimation of the generalized propensity score and
alpha parameters. The algorithm establishes whether the
data fit the normality assumption and balancing property.
The user-specified algorithm dose–response (Stata 12.0;
StataCorp, College Station, Texas, USA) was used for this
analysis [17].
2.7. Statistical analysis
Multivariate logistic regression analysis and propensity
modeling were performed with Stata 12.0 (StataCrop, College
Station, Texas, USA). Other statistical analyses were
performed with GraphPad Prism 6 (GraphPad Software, La
Jolla California, USA).
3. Results
3.1. Characteristics of critical care services
We collected data from all 13 critical care services that treated
patients with severe burns in England and Wales, and
analyzed data from 1759 of 1964 critical care admissions
(89.6%) (Fig. 1). 3 specialized burns critical care services (high
dose multidisciplinary care) contributed data on 758 admissions
(43.1%), 7 generalized critical care units (low dose multidisciplin-
ary care) contributed data on 634 admissions (36%), and 3 burns
units with ‘visiting’ intensivists (intermediate dose multidisci-
plinary care) contributed data on 367 admissions (20.9%). The
hospitals within which the critical care services reside were
diverse with respect to the number of hospital beds, the
number of critical care beds and regional location across
England and Wales (Table 1).
3.2. Patient characteristics
The characteristics of burn patients admitted to different
critical care settings are shown in Table 2. There were
significant differences between patients admitted. Specialized
burns services admitted patients with significantly smaller
TBSA% burns (and significantly lower burn severity score as
measured by Belgium outcome in burn injury (BOBI) score [18])
to critical care services.
Unadjusted crude in-hospital mortality was significantly
lower in patients admitted to specialized burns critical care
units. Further analysis (Fig. 2) shows that there was a
significant survival benefit in patients with lower burn
severity score group (BOBI score 0–3) admitted to specialized

Table 1 – Care unit characteristics.

Specialized burns critical care Generalized critical care ‘Visiting’ critical care
units units units
Critical care units, no 3 7 3
Patients, no. (% of total) 758 (43.09%) 634 (36.04%) 367 (20.9%)
Average no. of critical care beds, median 5 (5–10) 15 (8–100) 2 (2–3)
(IQR)
Daily MDT ward round, no. (% of total) 3 (100%) 0 (0%) 1 (33.3%)
Type of hospital in which the critical care units resides – no. (%)
Teaching or specialist burns centre 3 (100%) 4 (57%) 2 (66.7%)
Large (Bed >500) 2 (66.7%) 5 (71.4%) 2 (66.7%)
Medium (Bed 250–500) 0 (0%) 2 (28.6%) 1 (33.3%)
Small (Bed <250) 1 (33.3%) 0 (0%) 0 (0%)
Region – no.
England 2 7 3
Wales 1 0 0
 burns 44 (2018) 57 –64 61

Table 2 – Patient demographics per care unit.

Specialized burn critical Generalized critical care ‘Visiting’ critical care P value
care units units units
Age, years [mean  SD (range)] 43.7 19.1 (16–101) 43.9 19.4 (16–96) 43.5 18.03 (16–89) 0.957
Female – no. (%) 190 (25.1%) 178 (28.1%) 126 (34.3%)
Mechanism of burn
Flame/flash 488 517 313
Scald 66 44 22
Contact 58 15 4
Electrical 89 30 9
Chemical 40 10 8
Friction 4 4 0
Cold 4 0 0
Radiation 2 1 3
Skin disease 2 5 2
Unknown 5 8 6
% TBSA (mean SD) 15.8 20.2 23.7 21.9 28.7 23.4 <0.0001*
Presence of inhalation injury – no. (%) 242 (31.9%) 377 (59.5%) 205 (55.9%)
Presence of full thickness burn – no (%) 381 (50.3%) 359 (56.6%) 244 (66.5%)
Mechanical ventilation on ICU admission – 318 (42%) 534 (84.2%) 326 (88.8%)
no (%)
Admission Belgium burn severity scoresa 2.02 2.15 3.14 2.1 3.2 2.2 <0.0001*
(Mean SD)
Unadjusted in-hospital death – no. (%) 85 (11.2%) 141 (22.2%) 106 (28.6%) <0.0001*
a
Belgium outcome in burn injury (BOBI) score is a measure of severity of burn injury ranging from 0 to 10, with higher score indicating more severe
injury and a higher risk of death.
*
Statistically significant.

burns critical care unit (unadjusted mortality 6.67% special-
ized burns critical care services versus 10.5% generalized
critical care services versus 14.5% ‘visiting’ critical care
services).
3.3. Critical care services and in-hospital mortality
Multiple logistic regression analysis found the following
variables to be independent predictors of in-hospital
mortality: age, gender, TBSA, presence of full thickness burn,
mechanical ventilation on admission. Table 3 shows the risk-
adjusted odds ratios (ORs) for in-hospital mortality comparing
patients admitted to the three critical care settings. Adjusting
for potential confounders, there was a significantly reduced
in-hospital mortality for patients admitted to fully integrated
multidisciplinary specialized burns critical care services,
compared to generalized critical care services (adjusted odds
ratio for death [OR] 1.81, 95% confidence interval [CI, 1.24, 2.66])

Fig. 2 – In-hospital mortality versus BOBI score.

62 burns 44 (2018) 57 –64

Table 3 – Risk adjusted odds ratios for in-hospital mortality.

Adjusteda odds ratio (95% CI) P value
Specialized burn critical care services 1
Generalized critical care services 1.81 (1.24–2.66) 0.002
‘Visiting’ critical care services 2.24 (1.49–3.38) <0.001
a
Values adjusted for age, gender, TBSA, presence of full thickness burns, presence of inhalation injury, mechanical ventilation on the day of
admission to critical care units.

and ‘visiting’ critical care services (adjusted OR for death 2.24
[1.49, 3.38]).
3.4. Propensity dose–response function
The propensity-matched cohort analysis demonstrated that
there is a dose–response relationship between the dose of
multidisciplinary care and patient survival, in that as the dose
of multidisciplinary care increased, in-hospital mortality rate
decreased (Fig. 3).
4. Discussion
The objective of this study was to explore the impact of
specialized burns critical care units on outcome of burns
patients. More specifically, our aim was to examine if
management in any of the three critical care settings
recommended by the UK National Burn Care Review [10]
results in superior clinical outcomes. The unadjusted in-
hospital mortality was significantly lower in specialized burn
critical care units. On average the %TBSA admitted to
specialized burn critical care units was lower compared to
the other units. This may be because care provision character-
istics have a greater impact on patient outcomes in smaller
injuries, whereas outcomes in larger burns are influenced by
the extent of the injury. However we found that admission to a
specialized burn critical care service was independently
associated with significantly reduced in-hospital mortality.
After adjusting for potential confounders, including TBSA, our
study found that the odds ratio of death in the specialized
burns critical care services versus generalized critical care
units was 1.81 (95% CI 1.24–2.66, p=0.002).
Specialized burn critical care services are typically based on
multidisciplinary approach, in which burn surgeons, inten-
sivists, nurses and other staff members provide critical care as
a team. This is evidenced by the fact that there is a dedicated
daily multi-disciplinary ward round in all specialized burns
critical care services in our study. We, therefore, further
investigated, using propensity-matched dose–response
modeling, if the multidisciplinary nature of care in specialized
burn critical care units that leads to survival benefit for the
patients. In this analysis, our finding remains consistent –
patients admitted to specialized burns critical care services
with highest dose of multidisciplinary care had the lowest in-
hospital mortality. Importantly, we demonstrated that the
mortality rate decreased as the dose of multidisciplinary care
increased. These findings suggest that the survival benefit
conferred by admission to a specialized burn critical care
service is explained, at least in part, by the care provided by a
fully integrated multidisciplinary team with daily multidisci-
plinary rounds.
The care of critically ill burn patient is extraordinarily
complex and multi-factorial, involving optimal wound care,
respiratory support, sedation, pain management, nutritional
support and nursing. In specialized burns critical care units,

Fig. 3 – In-hospital mortality versus dose of multidisciplinary care.

 burns 44 (2018) 57 –64
tightly knit teams of providers with varying domains of
expertise are present on the same site. They conduct daily
multidisciplinary ward rounds and provide 24-h critical care as
a team. In other critical care settings (generalized critical care
and ‘visiting’ critical care settings), although care is provided
by multiple disciplines, the level of multidisciplinary care (i.e.
the integration of multiple disciplines) is reduced. This is
reflected in the finding that only 33% (1 out of 3) of ‘visiting’
critical care units and 0% (0 out of 7) of generalized critical care
units conduct dedicated daily multidisciplinary ward rounds.
The effect of multidisciplinary care on improved critical
care survival has been previously demonstrated in a large
population-based study of critically ill medical patients
admitted to 112 acute care hospitals in the USA [9]. In this
study, 30-day mortality was significantly lower when
critically ill patients were managed by a multidisciplinary
team that rounded daily [9]. In addition, multiple smaller
studies have demonstrated how multidisciplinary collabora-
tion has improved both clinical [19–22] and financial [20]
outcomes in mechanically ventilated patients in critical care
services.
Several explanations exist for these findings. Multidisci-
plinary care may promote best clinical practices based on the
latest evidence for sepsis and prevention of ICU complications
[23–25]. Also pharmacist involvement in the MDT is associated
with fewer adverse drug events [26] and may be associated
with lower mortality among ICU patients [27]. Multidisciplin-
ary care may also contribute to improved communication
between health care providers [28]. Communication may
facilitate therapies and nurse-driven protocols for weaning
and sedation, which may result in reduced duration of
mechanical ventilation shortening ICU length of stay [29,30].
This study has important implications for organization of
critical care services for burns patients. First, our findings
provide empirical evidence to support a multidisciplinary
model of critical care, which is currently firmly established in
specialized burns critical care units. Our findings indicate that
approximately 60% of critically ill burn patients are admitted
to non-specialized burn critical care units. These non-
specialized critical care units, despite fulfilling the recom-
mendations of the UK National Burn Care Review (2001) [10]
has significantly higher in-hospital mortality rates compared
to specialized burns critical care units.
Centralization of specialist services, including single-
specialty critical care units, is heavily debated. Establishment
of centralized specialist burns critical care services will
undoubtedly require major service reconfiguration with
associated significant cost. Our study has provided insights
into ways to improve mortality in critical care units without
major service reconfiguration. We have demonstrated that
non-specialized critical care services may achieve significant
reduction in mortality in burns patients by implementing a
multidisciplinary, team-based approach with daily dedicated
multidisciplinary ward rounds. In the current era of maximiz-
ing efficiency with minimal additional costs, policy makers
and health system leaders can use these findings to optimally
organize critical care services and potentially improve clinical
outcomes.
Several limitations should be considered when interpreting
the results of this study. Although we used multivariate
63
regression and propensity analysis to limit the potential for
bias, residual confounding remains possible owing to unmea-
sured variables, such as co-morbidities and associated trauma,
which may influence outcomes. In addition, our study did not
consider annual case volume of critically ill burn patients for
each critical care service, which could be a confounder, or
could even be considered the causal pathway. Another
potential limitation is that this study used in-hospital
mortality as the primary outcome measure, but did not
considered functional outcomes and long-term quality of life.
Examination of such factors may shed more meaningful light
into the effect of critical care interventions on patient
outcomes [31]. Furthermore it is acknowledged for the
purposes of this study critical care units included both ICU
and HDU units, which have varying degrees of patient support
and monitoring. This variation of care provision found at
different units may have confounded patient outcomes.
In conclusion, our findings suggest that admission to a
specialized burn critical care service is independently
associated with significant survival benefit. In addition,
our study demonstrated that survival benefit conferred by
admission to a specialized burn critical care service may be
explained, at least in part, by the care provided by a fully
integrated multidisciplinary team with daily multidisciplin-
ary rounds.
Conflicts of interest
None.
Acknowledgement
The authors thank Mr. Ken Dunn, Chairman of the National
Burn Injury Database, for releasing the data for this study.
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