368 Bums (1992) 18, (5), 368-372 Printed in Great Brifuin
Predicting survival in burned patients
A. S. Bhatia’ and B. N. MukherjeeZ
‘Central JALMA Institute (Indian Council of Medical Research), Agra and ‘Indian Statistical Institute, Calcutta, India
Data pertaining to 562 consecutiveadmissions for bum treatment were
analysed to identify factors related to suroival. Besides socioeconomic,
demographic and bum-related variables, three indices to measure bum
sever@, were proposed and evaluated with the help of multiple regression
and disrriminant analyses. The results of multiple regression analysis
showed that one of the proposed indices, total burned surface (TBSJ, based
on presence or absence of bum injury on I I different body sites, fumed out
to be the best single predictor of survival. TBS alone accounted for64.5 per
cent of the total variance in survival variable. Combined use of TBS with
type and severity of bum, age, sex, etc. did not appreciably raise the value of
RZ. The results of the dism’minanf analysis yieMed a cut-off point of 20
TBS score which provided maximum separation bebeen surviuors and
fatalities. Using this cut-offpoint (20 per cent) the TBS indexprovided the
correct predictionof the eventual survival status in about 93 per cent of 562
patients. This cut-off point score of 20 was cross-validated on an
independent sample of 924 cases. The prediction in 79 per cent of patients
could be made correctly.
Introduction
The medical staff of most bum units may be asked to give an
opinion on the probability of survival of a patient and
his/her average duration of stay in the hospital. A number of
studies (Bull and Squire, 194% Bull and Fisher, 1954;
Rittenbury et al. 1965; McCoy et al., 1968; Bull, 1971;
Barnes, 1957; Moores et al., 1975; Clark et al., 1978) have
identified the factors related to the mortality of bum
patients. Most of these studies concentrated on the extent of
tofal body surface area burned and the patients’ age and
their relationship with survival. In spite of many reported
studies, the obtained results were not consistent. The
present study aimed to develop simple indices which may
help to forecast the chances of survival of burned patients.
Materials and methods
Retrospective data were collected from 562 consecutive
bum patients who were admitted to the bum ward of
Lucknow Medical College during fhe period April 1970 fo
April 1976. On each patient, at the time of initial admission
to hospital, data pertaining to various socioeconomic and
demographic variables, nature of injury (bums or scalds),
type of bums (minor or major), depth of bums (superficial or
deep), side and part of the body involved, were collected.
For the present purpose, bums or scalds covering up to 10
‘per cent body surface area (BSA) were classed as minor,
those with a BSA of more than 10 per cent were classed as
0 1992 Butteworth-Heinemann Ltd
0305-4179/92/050368-05
major. The bums with viable epithelial cells persisting in
deeper layers of the skin, sweat glands and hair follicles were
classed as superficial and those with the full thickness of the
skin destroyed and involving fat and muscles were classed as
deep bums. Additional follow-up information included
survival status and period in hospital.
Most patients in this data set had external thermal bums
and patients without external bums were excluded. Patients
below the age of 1 year and those patients without
follow-up information were also excluded. After deleting
such patients, a total of 562 patients were available for
analysis. Among these, a total of 133 patients (24 per cent)
succumbed to their injuries. The males and females were in
approximately equal numbers (M = 292, F = 270). The
median age was 22 years (range 1-90 years).
Three indices were proposed and evaluated. These
indices were developed because there was no data on the
extents of partial and full skin thickness bum nor an estimate
of the percentage of the total body surface burned following
the procedure used by Berkow (1924). The first index, total
burned surface (TBS), was developed on the basis of total
number of body parts affected by bum injuries. For the
purpose of developing the TBS index, the available informa-
tion on the presence of injury on II body parts, namely (a)
face, (b) neck, (c) front trunk, (d) rear trunk, (e) arm, (f)
forearm, (g) hand, (h) thigh, (i) leg, (j) foot and (k) perineum,
was used. For all body parts except the perineum a score of 3
was assigned if both right and left sides were affected. If only
one side was affected, a score of 2 was assigned. If there was
no lesion on any side, a score of 1 was assigned. For perineal
bums a score of 2 was assigned if this area was affected and 1
if not affected. For each of the 11 body parts a patient
received a score of either 3 or 2 or 1. The simple sum of these
scores for II body parts constituted the TBS index for the
patient. The possible score on the TBS index ranges from 12
to 32. This index may be regarded as a crude measure of the
extent of body surface burned.
SEVI-1 for a patient was defined as the sum of his/her
score for the type of bum (minor = 1, major = 2) and the
depth of the bum (superficial = 1, deep = 2); SEVI-2 was
calculated as the sum of scores of SEVI-1 and the period in
hospital in days. Besides these three indices, on each patient
the number of wound toilets and wound graftings were
recorded and analysed. Cross-classification tables, and, vari-
ous measures of central tendencies, variability, product-
moment intercorrelations and point-biserial correlations,
were obtained using the SPSS package (Nie et al., 1975).
After examining each variable separately for its relationship
Bhatia and Mukherjee: Prediding survival in burned patients 369

Table I. Mean and standard deviations of selected measures based on survivors and fatality groups

survivors * Fatalitiest t value

Mean s. d. Mean s. d.

TBS 16.36 2.69 25.63 3.67 31.701:

Depth of burn (superficial = 1, deep= 2) 1.19 0.39 1.21 0.41 0.51
Age 22.67 13.24 24.34 12.67 - 1.37
Sex (male= 1, female= 2) 1.42 0.49 1.68 0.47 5.35t
Nature of injury (burn = 1, scald = 2) 1.17 0.38 1.08 0.28 - 2.42:
Marital status (unmarried = 1, married = 2) 1.54 0.50 1.78 0.41 5.013
Age2 684.54 819.54 751.88 953.92 - 0.72
TBS’ 274.84 91.13 670.14 181.41 - 23.851
Age x TBS 375.04 234.18 628.69 327.68 -8.18f

‘n=430.
tn=l23.
$ tstatistics (one-tailed) is statistically significant at 0.05 level.

with the survival variable, the variables with significant
correlations were further analysed with the help of the
multiple regression program in the SPSS software package.
The variables in various multiple linear regression equations
were entered in a stepwise manner by entering one variable
at a time from the list of potential predictors (forward
stepping). A few multiple regression equations were also
derived with certain variables of interest inserted into the
equation. This was done to facilitate comparison of pre-
dicting power, as measured by percentage of variance
explained, between different subsets of predictors.
Similar to the studies of McCoy et al. (1968) and Clark et
al. (1978), the classical discriminant function analysis was
also applied. This technique attempts to distinguish between
two or more groups of patients using a collection of
discriminating variables measured on subjects with known
group membership. The groups of interest in the present
study are those patients which survive and those who do
not. The analysis produces a discriminant function or index,
which is a linear combination of the subset of discriminatory
variables. A patient with unknown group membership is
classified into one of the groups based on the magnitude of
the index. The stepwise Multiple Discriminant program of
the BMDP (Dixon and Brown, 1987) was used to perform
stepwise selection of discriminatory variables and to com-
pute linear discriminant function based on the selected
subset. The details of this methodology are provided by
Lachenbruch (1975).
For the purpose of cross-validation of the regression and
other statistical results, prospective data from 924
(alive = 621, dead = 303) patients were collected from five
different bum centres (Bombay, Calcutta, Delhi, Madras and
Lucknow) during the period May 1976 to October 1977.
The composition of the cross-validation sample in respect
of patients from different centres is Bombay= 24,
Calcutta = 79, Delhi = 484, Lucknow (independent sample)
= 98 and Madras = 239.
The major interest in the present study was to estimate
survival probabilities on the basis of clinical data on p
variables of interest e.g. xl, x2.. xp. The application of
multiple logistic function provides these estimates of risk
which are calculated by the following relationship:
pr(alive/xl, x2 . xp) = l/l + e - (bo+ ,Clbi “)
The quantity I= bO+ ibi Xi is called the prognostic
i= 1 about 64.5 per cent of the variance. Thus, the summation of
index because it allows both the assessment
condition and forecasts his or her outcome. Positive values
of I are signs of poor prognosis, while negative scores
correspond to lower risk patients. The quality of the
prognostic index can be tested by comparing the predicted
outcome with actual outcome. The details of this methodo-
logy are provided by Albert and Harris (1987).
Results
Mean difference between survivors and fatalities
The patients were divided into two groups: (a) those who
survived and (b) those who did not. The means and standard
deviations of the variables of interest are given in Table I. All
variables except age, age2 and depth of bum differed
significantly (one sided t-test) between the two groups. For
four of the six variables of interest, the mean scores for two
subpopulations (survivors and deaths) show statistically
significant differences. Age and depth of bum did not show
any significant difference between the means.
Multiple regression analysis
Nine records had missing data for one or more variable(s)
and hence these were excluded for the purpose of deriving
regression and discriminant equations. The equations to
predict survival were derived using classical multiple regres-
sion techniques. Initially, using all the variables, the stepwise
selection of variables resulted in the following equation to
predict survival:
Survival = - 0.42 (no. of wound toilets) -t- 0.62 (no. of
wound graftings) + 0.07 (TBS) - 6.12
The X2 from the above regression equation accounted for
about 89 per cent of the variance of the criterion survival
variable. Because of an additional interest in determining
how accurately a prediction might result from conjoint use
of demographic variables like sex, marital status and bum
severity variables, many possible sets of regression equa-
tions were derived.
Table II shows the obtained squared multiple correlations
between survival on the one hand and a number of
predictors. It is seen that survivorship is best predicted from:
(i) the knowledge of bums from 11 body parts (R2 = 0.68),
and (ii) information on age, agez, marital status, nature of
injury, depth, TBS and TBS (RZ= 0.69).
It is interesting to note that the TBS index alone explains
of patient 11 body parts with uniform weights of unity for each part
 370
Bums (1992) Vol. lS/No. 5

Table II. Square of the coefficient of multiple correlation (R’) for predicting survival from different sets of predictors

Name of variables for predicting survival R2

1. Total burn severity index (TBS) 0.645

2. SEW-I 0.069
3. SEW-2 0.054
4. Sex, marital status, nature of injury by burn or scald, TBS 0.650
5. Sex, marital status, nature of injury by burn or scald, SEVI-1 0.113
6. Sex, marital status, nature of injury by burn or scald, SEVI-2 0.138
7. Sex, marital status, TBS 0.647
8. Sex, marital status, SEVI-1 0.129
9. Sex, marital status, SEVI-2 0.134
10. Sex, marital status, minor or major burn, superficial or deep burn 0.138
11. Sex, marital status, minor or major burn, deeper or superficial burn, TBS 0.677
12. TBS, depth of burn, age, sex, nature of injury, marital status 0.645
13. Minor or major burn, deep or superficial burn, and TBS 0.674
14. Age 0.003
15. Age2 0.001
16. Age, marital status, minor or major burn, superficial or deep burn, age*, TBS, TBS 0.689
17. 11 body parts 0.684

Table III. Number of bum injury patients in cross-validation sample predicted alive or died on the basis of TBS index

Predicted survival status on the Actually Actually

basis of TBS index survived died Total

Predicted died 116 (18.7%) 226 (74.6%) 342

(TBS>20)
Predicted alive 505 (81.3%) 77 (25.4%) 582
(TBS ~20)
Total 621 303 924

Percentages to the column totals are shown in parenthesis.

shows virtually as much predictive efficiency as the equation
with different weights for all the I I body parts (Table 10. The
combined use of TBS, types of bum and its severity did not
appreciably raise the value of R’. As SEVI-I is a crude index
and the SEVI-2 score is mainly based on the period in
hospital, which in turn has a low correlation with survival
status (short hospital stays are associated with either very
severe bums who die or small bums), both of these indices
failed to show a substantial role in predicting survival after
bums. The conjoint use of demographic variables with TBS
also did not prove to be very useful. Little is gained by using
a complicated relationship involving quadratic functions of
age and TBS along with other variables. Thus, our findings
suggest that the simple sum of scores on 11 body parts is not
only a quick way of estimating percentage of body surface
burned, similar to the rule of the nines (Von Prince and
Yeakel, 1974), but it may also help predict the survivors
among bum injury cases.
Discriminant analysis
The coefficients of the linear functions which could discrim-
inate best between survivors and deaths in the Lucknow
sample were computed using the six variables of interest,
namely age, sex, marital status, depth of bums, nature of
injuries and TBS. The resulting discriminant function yielded
about 96 per cent of con-e&identification of survivors and
about 92 per cent of correct identification of the bum-injury
cases who died. The overall misclassification rate was 5 per
cent.
Applying the above discriminant function to cross-
valdiation data, it was found that the percentage of
misclassification was about 17 per cent. The percentage of
correct classification in the survivor group was 88 per cent,
whereas for the fatalities group it was 72.5 per cent.
The cut-off point of 20 TBS index score provided the
maximum separation between the two groups, namely
survivors and deaths in the Lucknow sample. The same
cut-off point was used for the purpose of classification of
patients in the original Lucknow and cross-validation
samples. For the Lucknow sample (n = 562), we found that
out of 149 patients who scored 20 or above in the TBS
index, only 26 survived. Similarly, out of 413 patients
scoring below 20 in the TBS index, only 10 died. Thus, the
percentage of overall misclassification on the basis of the
TBS index for the Lucknow sample is about 6 per cent.
The results of predictions based on the TBS index, with a
20 cut-off point score, for the cross-validation sample are
shown in TablelIZ. Among the 924 cases 582 would be
predicted to survive since they were scoring less than 20 on
the TBS index. Of these 582 patients, only 77 (13 per cent)
actually died, whereas the decisions for 505 patients or 87
per cent of these screened out would be correct. A total of
342 patients had a TBS score of 20 or more. Among these
226 actually died (66 per cent). A total of 731 (79 per cent)
predictions could be correctly made.
Using the cut-off point of 20 on the TBS index, the errors
of misclassifications were calculated for three of the cross-
validational subsamples, namely, Madras, Delhi and Luck-
now (new) where the sample sizes were not very small. The
classification matrices for the different centres are reported
in Table IV, from which it is seen that in each subsample, the
analysis predicted eventual survivors better than eventual
fatalities, as in the case of the original Lucknow sample.
Thus, the results of prediction based on the single TBS index
appear to be satisfactorily cross-validated.
Bhatia and Mukherjee: Predicting survival in burned patients 371

Table IV. Classification matrix for different subsamples from the Table V. Comparison between observed proportion of alive and
cross-validational sample on the basis of TBS index predicted proportion of alive

Predicted Observed
Actual % correct Pred.
status Alive Dead decision No. No. Prop. prop.
TBS alive dead alive alive
Delhi
Survivors 252 18 93.3 12 25 0 1 .oo 1.000
Fatalities 72 142 66.4 13 56 0 1 .oo 0.999
Total 324 160 81.4 14 34 0 1 .oo 0.998
Madras 15 64 1 0.985 0.996
Survivors 165 10 94.3 16 27 0 1 .oo 0.992
Fatalities 10 41 80.4 17 93 3 0.969 0.982
Total 175 51 91.2 18 32 0 1 .oo 0.960
Lucknow 19 43 4 0.915 0.917
Survivors 75 7 91.5 20 27 1 0.964 0.834
Fatalities 2 14 87.5 21 13 6 0.684 0.685
Total 77 21 91.8 22 5 4 0.556 0.508
23 4 15 0.210 0.319
24 2 7 0.222 0.176
25 2 17 0.105 0.088
26 0 11 0.000 0.042
27 0 24 0.000 0.020
Multiple logistic function analysis 28 0 8 0.000 0.009
Given a value of TBS index, survival probabilities were 29 0 8 0.000 0.004
30 0 7 0.000 0.002
derived using the LR program of BMDP software (Dixon
31 0 6 0.000 0.001
and Brown, 1987). The resulting equation is given below. 32 0 6 0.000 0.000
pr(‘live/TBS) = l/l + e- (‘7.4’- 0.79 X TBS)
Pred., predicted; prop., proportion.
The estimated chances of survival for all possible values
of TBS index along with the actual proportion of survivors
are given in Table V. It may be seen that for each value of In the present study, TBS alone could correctly predict
TBS, the proportion of actual survivors is very close to the the survival status of about 94 per cent of patients
predicted proportions. (fatalities=92 per cent, survivors= 94 per cent). In the
absence of a precise value for the percentage of body surface
area burned, it was not possible to test the validity of the
Discussion TBS index. However, its performance for the purpose of
An attempt has been made in the present study to examine prediction of survival status of burned patients is quite
the potential predictor variables in order to find the subset comparable with that of percentage of total body surface
which can best predict the survivals of burned patients. area burned.
Simple TBS index based on the presence or absence of bum The predictive efficiency of the TBS index was further
injury in II different parts of the body turned out to be the evaluated on a cross-validational sample (n= 924) by
best single predictor of survival. The TBS index alone calculating the errors of misclassification. It was found that in
accounted for 64.5 per cent of the variance of the sur- the cross-validation sample, 81 per cent of the burned
vivorship variable. The conjoint use of sex, marital status patients who actually survived had a TBS score below 20.
and TBS in predicting the survival of bum patients in the Among those who finally succumbed to their bum injuries,
present data was found to be almost as efficient as the use of only 25 per cent had a TBS score below 20. The TBS index
the single predictor based on TBS index. The inclusion of (a) appears to have the potential as a simple screening device to
nature of injury (bum or scald), (b) depth of bum or scald, differentiate between bum-injury patients with a high
and (c) quadratic functions of age and TBS in the predictor chance of survival and those with a low chance of survival.
set did not appreciably raise the value of R’. This finding In recent years, because of the availability of improved
justifies, indirectly, the ‘rule of nines’ for estimating percent- medical facilities and newer antibiotics, the prognosis of
age of body surface burned which in turn could be used as a burned patients may be better in comparison with the period
reliable measure for predicting survival of bum-injury 1970-77 to which the data pertains. This may appear to be a
patients. constraint in the direct usefulness of the proposed TBS
Using the discriminant function approach, Clark et al. index. However, this may not be so, as the index has been
(1978) found that actual fatalities could be correctly pre- developed on the information of involvement of different
dicted about 79 per cent of the time on the basis of body parts and any of the above improvements could
information on age, sex and percentage of total body surface possibly amount to a change in value of the ‘cut-off point’ of
area burned. The corresponding figure for survivals was 90 the TBS index (presently 20), which could best discriminate
per cent (total=87.6 per cent). A little gain in terms of between groups of patients with high chances of survival
percentage of correct classification was observed when and those with low chances. Hence the use of old data does
additional information on patient’s weight, percentage of not seem to affect the usefulness of the TBS index for newly
full skin thickness and partial skin thickness bums was used burned patients. The present data pertains to patients who
besides age, sex and percentage of total surface area burned received inpatient hospital care, the applicability of the
(survivals = 92 per cent, death = 82.8 per cent and over- results may be limited to these populations. Furthermore,
all = 90.4 per cent). In each case, the prediction of eventual the high mortality rate among patients studied may be
survivors was better than eventual fatalities, as was found in related to the type of patients who are admitted to hospital.
the present study. This is because patients with severe injuries are admitted to
372
hospital, whereas the less severe injuries are treated as
outpatients. Also the present data consisted of approxi-
mately equal proportions of males and females. This is
appropriate, since a recent survey of 3500 hospital admis-
sions in different hospitals in India (Davies, 1990) also
observed approximately equal numbers of males and
females (taking all age groups together) among thermally
injured patients who received inpatient hospital care.
The subjectivity in observing some of the variables
considered in the present study, i.e. depth of bum, type of
bum, nature of bum, etc., may not limit generalization of the
results since these variables were not found to be very
helpful in the development or improvement of this TBS
index (Table II).
The information on the involvement of some of the body
parts may not contribute significantly to survival probabili-
ties, e.g. perineum, and hence there is further scope for the
simplification of the TBS index. However, to maintain an
analogy between TBS and the rule of nines’ such an attempt
was not made.
Acknowledgements
The authors are grateful to The Director General, Indian
Council of Medical Research, New Delhi for granting
permission to use data pertaining to ‘Collaborative Study on
Bum Injuries’ and also for providing computing facilities.
Thanks are also due to Professor J. L. Gupta, formerly Head
of Bums and Plastic Surgery, S. J. Hospital, New Delhi, for
his valuable discussions. The authors are greatly indebted to
the anonymous referees of the submitted manuscript for
their useful comments.
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Paper accepted 19 March 1992.
Correspondence should be uai&essed to: Dr A. S. Bhatia, Central Jalma
Institute, Taj Gang, Agra-282001, India.