Archives of Academic Emergency Medicine. 2022; 10(1): e43 REV I EW ART I C L E Adherence to Referral Criteria for Burn Patients; a System- atic Review Ali Bazzi1,2, Mohammad Javad Ghazanfari2,3, Masoumeh Norouzi1∗, Mohammadreza Mobayen2, Fateme Jafaraghaee4, Amir Emami Zeydi5, Joseph Osuji6, Samad Karkhah1,2,7 † 1. Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran. 2. Burn and Regenerative Medicine Research Center, Guilan University of Medical Sciences, Rasht, Iran. 3. Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran. 4. School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran. 5. Department of Medical-Surgical Nursing, Nasibeh School of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran. 6. School of Nursing and Midwifery, Faculty of Health, Community, and Education, Mount Royal University, Calgary, Ab, Canada. 7. Quchan School of Nursing, Mashhad University of Medical Sciences, Mashhad, Iran. Received: March 2022; Accepted: April 2022; Published online: 2 June 2022 Abstract: Introduction: Burn injuries are under-appreciated trauma, associated with substantial morbidity and mortality. It is necessary to refer patients in need of specialized care to more specialized centers for treatment and rehabili- tation of burn injuries. This systematic review aimed to assess the adherence to referral criteria for burn patients. Methods: An extensive search was conducted on Scopus, PubMed, and Web of Science online databases using the relevant keywords from the earliest to October 7, 2021. The quality of the included studies was assessed using the appraisal tool for cross-sectional studies (AXIS tool). Results: Among a total of 7,455 burn patients included in the nine studies, 60.95% were male. The most frequently burned areas were the hands (n=3) and the face (n=2). The most and least common burn mechanisms were scalds (62.76%) and electrical or chemical (2.88%), respectively. 51.88% of burn patients had met ≥ 1 referral criteria. The overall adherence to the referral criteria for burn patients was 58.28% (17.37 to 93.39%). The highest and lowest adherence rates were related to Western Cape Provincial (WCP) (26.70%) and National Burn Care Review (NBCR) (4.97%) criteria, respectively. Conclusion: The overall adherence to the referral criteria for burn patients was relatively desirable. Therefore, well-designed future studies are suggested in order to uncover approaches to improve adherence to referral cri- teria for burn patients. Keywords: Burns; Guideline adherence; Referral and consultation; Systematic review Cite this article as: Bazzi A, Ghazanfari MJ, Norouzi M, Mobayen M, Jafaraghaee F, Emami Zeydi A, Osuji J, Karkhah S. Adherence to Referral Criteria for Burn Patients; a Systematic Review. Arch Acad Emerg Med. 2022; 10(1): e43. https://doi.org/10.22037/aaem.v10i1.1534. 1. Introduction Burn injuries are under-appreciated trauma associated with substantial morbidity and mortality (1-9). Based on the re- ∗Corresponding Author: Masoumeh Norouzi; Nursing and Midwifery School of Shahid Dr. Beheshti, Hamidyan Shahrak, Shahid Dr. Beheshti Ave., Rasht, Iran. Postal code: 41469-39841. Fax: +98-13-33550097, Tel: +98-13-33552088, Email: contact1995@yahoo.com, ORCID: http://orcid.org/0000-0002-2892- 944X. † Corresponding Author: Samad Karkhah; Nursing and Midwifery School of Shahid Dr. Beheshti, Hamidyan Shahrak, Shahid Dr. Beheshti Ave., Rasht, Iran. Postal code: 41469-39841. Fax: +98-13-33550097, Tel: +98-9032598167; , Email: sami.karkhah@yahoo.com, ORCID: http://orcid.org/0000-0001-9193-9176. port by World Health Organization, 11 million burns occur annually worldwide, 180,000 are fatal (10). Therefore, it is necessary to refer patients in need of specialized care to more specialized centers for treatment and rehabilitation of burn injuries (11). Meanwhile, referral criteria for transferring burn patients to burn specialty centers have been proposed by various burn associations in the USA, the United Kingdom, and Australia and New Zealand (11). However, despite using referral cri- teria for burn patients for more than two decades, there is still limited information on adherence to these criteria. In the Netherlands, adherence to the Emergency Management of Severe Burns (EMSB) criteria in patients primarily present- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Bazzi et al. 2 ing to a non-burn center was 70.03% (11) Two studies in the USA showed that adherence to the American Burn Associa- tion (ABA) and EMSB criteria in patients primarily present- ing to a non-burn center was 48.00% and 54%, respectively (12, 13). However, a study in the United Kingdom found that adherence to the British Burns Association (BBA) criteria in burn patients was 25.31% (14). The need to adhere to these criteria worldwide and the possible improved outcomes for burn patients cannot be overemphasized, hence the need to conduct this systematic review. Limited and contradictory studies have been published on adherence to referral criteria for burn patients. This system- atic review aimed to assess the adherence to referral criteria for burn patients. 2. Methods This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines (15). 2.1. Search strategy An extensive search was conducted on Scopus, PubMed, and Web of Science online databases using keywords such as "Burns", "Guideline adherence", “Patients”, and "Refer- ral criteria" from the earliest to October 7, 2021. For ex- ample, the search strategy in PubMed/MEDLINE database was ((“Guideline Adherence”) OR (“Policy Compliance”) OR (“Protocol Compliance”) OR (“Institutional Adherence”) OR (“Adherence, Institutional”)) AND ((“Referral Criteria”) OR (“Hospital Referral”) OR (“Guidelines”) OR (“Standards”) OR (“Reference Standards”) OR (“Criteria”) OR (“Referral”) OR (“Consultation”) OR (“Consultation and Referral”)) AND ((“Burns”) OR (“Patients”) OR (“Clients”)). Keywords were extracted from the medical subject headings and combined using Boolean operators (AND/OR). Two researchers per- formed the search steps, independently. In the present sys- tematic review, the gray literature such as conference pre- sentations, expert opinion, dissertations, research and com- mittee reports, and ongoing research were not seriously searched because they did not fully depict the results, and the results may completely change when they are not published. Gray literature is defined as papers that are produced in print and electronic formats but are not controlled by commercial publishers (16). 2.2. Inclusion and exclusion criteria In this review, studies published in English, focusing on ad- herence to referral criteria for burn patients were included (Table 1). The corresponding authors were contacted in cases of lack of access to articles or where relevant data was missing. 2.3. Study selection EndNote X8 software was used to manage the data. Dupli- cate articles were removed, first electronically and then man- ually. Title, abstract, and full text of articles were assessed based on inclusion/exclusion criteria. The reference list of eligible studies was reviewed to prevent missing relevant in- formation. In case of disagreement between researchers, the articles were evaluated by a third researcher. 2.4. Data extraction and quality assessment Assessment of the quality of included studies was performed by two researchers. The researchers extracted information from the included studies. The information included the name of the first author, year of publication, location, sam- ple size, male/female ratio, age, source of data collection, length of stay, burn mechanism, number of referral criteria met, the most frequently burned area, rate of adherence to referral criteria, the highest and lowest rates of adherence to referral criteria, instrument, and key results. The quality of the included studies was assessed using the appraisal tool for cross-sectional studies (AXIS tool). This tool evaluates the quality of the included studies using 20 items (17). 3. Results 3.1. Study selection A total of 822 studies (PubMed=268, Web of Science=135, and Scopus=419) were obtained via an initial database search, and three studies were obtained using the assessment of the reference list of eligible studies. Also, 216 and 123 duplicate records were removed electronically and manually, respec- tively. In the screening stage of the title and abstract of stud- ies, out of 483 studies, 425 articles were removed due to the obvious irrelevance of their topics with this research and 33 studies were excluded due to the type of the studies (animal studies, experimental studies, case reports, editorial letters, conferences papers and dissertations, reviews, etc). After as- sessment of the full-text of 17 studies, six articles were ex- cluded due to inappropriate study design or outcomes and two articles were excluded due to lack of desired information. Finally, nine studies (11-14, 18-22) were included in this sys- tematic review (Figure 1). 3.2. Study characteristics Among the 7,455 burn patients included in the nine studies (11-14, 18-22), 60.95% were male. All studies had a retrospec- tive design. Of the studies included, two were in the USA (12, 13), two were in the United Kingdom (14, 22), two were in the Netherlands (11, 18), one was in Canada (20), one was in Denmark (21), and one was in South Africa (19) (Table 2). Of the included studies, three studies assessed the ABA crite- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2022; 10(1): e43 Table 1: Eligibility Criteria Criteria Inclusion Exclusion Participants Burn patients Patients of all age groups Animal studies Outcomes Rate of adherence to referral criteria for burn patients The highest and lowest rate of adherence to referral criteria - Study Design Cross-Sectional Retrospective Case reports Experimental studies Letters to editors Conferences Reviews Time Frame The earliest to October 5, 2021 - Table 2: Basic characteristics of the studies included in this systematic review First Author/year Study period Design Source of data collection Sample Size M/F ratio Age* (years) Chipp et al., 2008 (14) United Kingdom 2004 Retrospective West Midlands Regional Burns Unit 561 53.00/47.00 N/A Carter et al., 2010 (12) USA 2006 to 2007 Retrospective North Carolina Hospital Association Patient Data System 2,036 66.80/33.20 48.05 (SD=17.75) Rose et al., 2010 (22) United Kingdom 2010 (6-month period) Retrospective Administrative database 190 55.26/44.74 0 to 15 Baartmans et al., 2012 (18) Netherlands 2002 to 2004 & 2007 to 2008 Retrospective Dutch National Trauma Registry 622 63.51/36.49 > 15 Davis et al., 2012 (13) USA 2008 Retrospective ICD-9 750 N/A 39.00 (SD=23.00) Reiband et al., 2014 (21) Denmark 2011 (3-months period) Retrospective ICD-10 97 70.10/29.90 10 months to 71 years Boissin et al., 2017 (19) South Africa 2011 to 2015 Retrospective Administrative database 1,165 55.71/44.29 0 to 12 Chambers et al., 2021 (20) Canada 2018 to 2019 Retrospective Administrative database 244 62.30/37.70 0.50 to 87 Van Yperen et al., 2021 (11) Netherlands 2014 to 2018 Retrospective Dutch National Trauma Registry 1,790 N/A N/A * at time of injury; ICD-9: International Classification of Diseases-9th revision; ICD-10: International Classification of Diseases-10th revision; SD: Standard Deviation; N/A: not available. ria (12, 13, 20), two studies evaluated the EMSB criteria (11, 18), one study assessed the BBA criteria (14), one study evalu- ated the National Burn Care Review (NBCR) criteria (22), one study assessed the National Burn Center (NBC) criteria (21), and one study evaluated the Western Cape Provincial (WCP) criteria (19) (Table 3). 3.3. Methodological Quality of included study As presented in Figure 2, all included studies had justifi- cations for sample size. Two studies did not define statis- tical significance. Six studies did not identify limitations. Four studies did not report funding sources or conflicts of interest, while four studies did not indicate the ethical ap- proval/informed consent protocols used. 3.4. Characteristics of burn patients As shown in Table 3, the average length of stay in the hos- pital for burn patients was seven days. The most frequently burned areas were the hands (n=3) (12, 20, 22) and the face (n=2) (14, 19). The most and least common burn mechanisms were scalds (62.76%) and electrical or chemical (2.88%), respectively (Figure 3). 51.88% of burn patients had met ≥ 1 referral criteria (Table 3). 3.5. Adherence to referral criteria for burn pa- tients The overall adherence to the referral criteria for burn pa- tients was 58.28% (17.37 to 93.39%) (Table 4). The highest and lowest rates of adherence were related to WCP (26.70%) and NBCR (4.97%) criteria, respectively (Figure 4). 4. Discussion This systematic review showed that most frequently burned areas were the hands and the face. The most and least com- mon burn mechanisms were scalds (62.76%) and electrical or chemical (2.88%), respectively. 51.88% of burn patients had met ≥ 1 referral criteria. The overall adherence to the referral criteria for burn patients was 58.28%. The highest and low- est adherence rates were related to WCP (26.70%) and NBCR This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Bazzi et al. 4 Figure 1: Flow diagram of the study selection process. (4.97%) criteria, respectively. As presented in this study, most commonly burned areas were the hands and the face. The greater prevalence of burns on the hands and face can be expected because these body parts are not usually covered. However, differences in burn areas may be due to differences in variables such as culture, customs, habits, geopolitical and climatic location in differ- ent societies. For example, in wars such as the Iraq and Viet- nam wars, most of the injured areas were the face and hands due to explosions (23). Sunburn on the hands and the face is more common in parts of Spain and on cyclists (24). There- fore, although most burns occur on the hands and face, fur- ther studies are needed to assess the factors associated with it. Based on the present study’s findings, the most and least common burn mechanisms were scalds (62.76%) and electri- cal or chemical (2.88%), respectively. Scalds are more com- mon in children (under 14 years old) and are caused by hot liquids. This finding was supported by a study in Iraq (25). Children are more prone to scalds at home due to their mo- bility. On the other hand, electrical and chemical burns are less common due to lower exposure of people. However, it is suggested that future studies pay more attention to different age groups in different types of burns. As presented in the present study, 51.88% of burn patients had met ≥ 1 referral criteria. There were differences in the number of referral criteria met in the studies, which can be explained by different referral criteria, family preferences, distance to the burn center, and insurance status (11). The overall adherence to the referral criteria for burn patients was 58.28%. Also, the highest and lowest adherence rates were related to WCP (26.70%) and NBCR (4.97%) criteria, re- spectively. However, there were many differences in stud- ies in terms of adherence to referral criteria. For example, a study in South Africa found that adherence to the referral cri- terion is 93.4% (19). In contrast, another study in the United Kingdom found that this adherence was 25.31% (14). This discrepancy may be due to differences in study design, ap- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2022; 10(1): e43 Figure 2: Assessment of the quality of the included articles. Figure 3: Burn mechanisms. plicable referral criteria, outcome criteria, and definition of adherence between different studies (11, 14, 19). Figure 4: Adherence to referral criteria for burn patients. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Bazzi et al. 6 4.1. Implications for education, practice, and management Adherence to referral criteria for burn patients will improve patient outcomes and ensure that burn patients are managed according to the latest evidence-based approaches. Findings of this systematic review indicate that much improvement is needed in educating hospital staff regarding making the necessary and timely referrals of burn patients based on laid down criteria. This calls for strategies that can improve ad- herence to referral criteria and reduce burn complications. The creation of a comprehensive burn system under the su- pervision of a burn specialist and the development of stan- dards and evidence-based protocols for burn control, alloca- tion of sufficient resources to burn systems and units, the hir- ing of adequate human resources, appropriate burn dressing and care, development of appropriate programs for regular visits to patients by burn specialists, and holding appropri- ate workshops for patients and health care providers can help manage burn patients. 4.2. Implications for future research The findings of this systematic review can help improve refer- ral patterns in burn patients admitted to non-burn centers. However, not all referral criteria are appropriate for manag- ing burn patients, and some require serious revision. There is also a need for further research on whether modifying some referral criteria or training physicians in non-burn centers can increase adherence to referral criteria. 4.3. Limitations This systematic review had several limitations. Although this systematic review was conducted based on the PRISMA checklist, it was not registered in the international prospec- tive register of systematic reviews (PROSPERO) database, and a public protocol does not exist. Despite a comprehensive systematic search in this review, researchers may not have found all studies published in this area. Also, language bias cannot be ignored because only English language studies were included in the present study. 5. Conclusion Although the overall adherence to the referral criteria for burn patients was relatively desirable, there is room for im- provement. The highest and lowest adherence rates were re- lated to WCP (26.70%) and NBCR (4.97%) criteria, respec- tively. Therefore, it is suggested to perform well-designed studies that will focus on interventions to improve adherence to referral criteria for burn patients in the future. 6. Declarations 6.1. Acknowledgments None. 6.2. Data availability The datasets generated and analyzed during the current study are available from the corresponding author on reason- able request. 6.3. Authors’ contributions Study concept and design by all authors; Data acquisition by all authors; Data interpretation by all authors; drafting the manuscript by all authors; Revision of the manuscript by all authors; the final version of the manuscript is approved by all authors. 6.4. Funding and supports None. 6.5. Conflict of interest The authors declare no conflict of interest. References 1. Miri S, Mobayen M, Aboutaleb E, Ezzati K, Feizkhah A, Karkhah S. Exercise as a rehabilitation intervention for severe burn survivors: Benefits & barriers. Burns. 2022. 2. Mobayen M, Ch MH, Ghazanfari MJ, Sadeghi M, Mirma- soudi SS, Feizkhah A, et al. Antibiotics as a two-edged sword: The probability of endotoxemia during burned wound treatment. Burns. 2022;48(3):730-1. 3. 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Bazzi et al. 8 Table 3: Referral criteria for the management of burn patients (continues) Author/year Cri- teria Description Criteria for Complex Bum ◦ Extremes of age (<5 or >60) ◦ Involvement of face/hands/perineum/feet ◦ Involvement of neck/axilla ◦ Circumferential deep dermal/full-thickness burns/limbs, torso/neck ◦ Inhalation injury ◦ Chemical injury (>5% TBSA) ◦ Ionizing radiation injury ◦ High-pressure steam injury ◦ High-tension electrical injury ◦ Hydrofluoric acid injury (>1% TBSA) ◦ Suspicion of non-accidental burn injury Chipp et al., Area involved 2008 (14) BBA Superficial >10 % children <16 years’ old >15 % adults ◦ Deep dermal or full-thickness >5% adult or child ◦ Small full-thickness burns should be discussed with a plastic surgeon Co-morbid conditions ◦ Cardiac limitation/myocardial infarction within 5 years ◦ Respiratory limitation of exercise ◦ Diabetes ◦ Pregnancy ◦ Immunosuppression ◦ Hepatic impairment ◦ Associated injuries (crush injuries, fractures, head injury) ◦ Partial-thickness burns greater than 10% TBSA ◦ Burns that involve the face, hands, feet, genitalia, perineum, or major joints Carter et al., ◦ Third-degree burns in any age group 2010 (12); ◦ Electrical burns, including lightning injury Davis et al., 2012 (13) ◦ Chemical burns Chambers et al., ◦ Inhalation injury 2021 (20) ABA ◦ Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality ◦ Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses a greatest risk of morbidity or mortality. In such cases, if the trauma poses a greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in line with the regional medical control plan and triage protocols ◦ Burned children in hospitals without qualified personnel or equipment for the care of children ◦ Burn injury in patients who will require special social, emotional, or long-term rehabilitative intervention Age Under 5yrs and over 60yrs Site Involvement Face, Hands, Feet, Perineum, Flexures particularly neck or axilla, circumferential or full-thickness burns of limbs, torso, or neck Inhalation Injury Excluding pure carbon monoxide poisoning Rose et al., Mechanism of Injury 2010 (22) NBCR ◦ Chemical Injury (>5% TBSA) ◦ Exposure to ionizing radiation ◦ High-pressure steam injury ◦ High-tension electrical injury ◦ Hydrofluoric Acid injury (>1% TBSA) ◦ Suspicion of Non-Accidental Injury (NAI) Size of Skin Injury ◦ Pediatrics >5% TBSA; Adult >10% TBSA This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 9 Archives of Academic Emergency Medicine. 2022; 10(1): e43 Table 3: Referral criteria for the management of burn patients Author/year Cri- teria Description ◦Existing Conditions ◦ Cardiac limitation or MI in last 5yrs ◦ Respiratory limitation of exercise ◦ Diabetes ◦ Pregnancy ◦ Immuno-suppression ◦ Hepatic disease Associated Injuries ◦ Crush injuries ◦ Fractures ◦ Head injuries ◦ Penetrating injuries ◦ Burns 10% or more TBSA in adults ◦ Burns 5% or more TBSA in children (<16 year) Baartmans et al., ◦ Full Thickness burns 5% or more TBSA 2012 (18) ◦ Burns of functional areas (face, hands, feet, genitals, perineum, or large joints (i.e., shoulder, elbow, knee, and ankle)) Van Yperen et al., ◦ Circumferential burns of the neck, chest, or extremities 2021 (11) EMSB ◦ Electrical burns (high voltage) including lightning strikes ◦ Chemical burns ◦ Burns with suspected associated inhalation injury ◦ Any burn patient with associated trauma or (pre-existing) medical condition that may affect treatment and recovery, or could increase mortality ◦ Burns at the extremes of age — young children (<1 year) and the elderly (75 years) ◦ Non-accidental burns ◦ Burns for which the burn mechanism is uncertain in combination with uncertainty about the compe- tence/equipment of the hospital for these types of injuries ◦ Burn wound that shows insufficient signs of healing within two weeks ◦ Partial thickness burn exceeding 3% ◦ Full thickness burn exceeding 1% ◦ Suspicion of inhalation injury Reiband et al., ◦ High-voltage burns 2014 (21) NBC ◦ Circular full-thickness burns ◦ Burn to the face ◦ Burn over the major joint ◦ Burn in the urogenital area ◦ Suspicion of non-accidental injury ◦ Cases of doubt ◦ Age: Under 2 years. ◦ Severity: Partial thickness burns with TBSA >15%, or full thickness burns with TBSA >15%. ◦ Anatomical site: Face, hands, feet, genitalia, perineum, major joints, or circumferential burns (These burns could also be dealt with at level 1 or 2 but discretion must be used). Boissin et al., ◦ Inhalation injury: Requiring ventilation for more than 48 h. 2017 (19) WCP ◦ Mechanism of injury: Exposure to ionizing radiation, high pressure steam, high tension electrical injury, hydroflu- oric acid injury >1% TBSA, or suspicion of a non-accidental burn injury. ◦ Existing co-morbidity: Cardiac limitation and/or myocardial infarction within five years, respiratory limitation of exercise, uncontrolled type 1 diabetes, medically or disease-induced immune suppression for any reason, existing psychiatric or suicidal tendencies. ◦ Other severe associated injuries: For example, polytrauma or crush syndrome. TBSA: Total Body Surface Area; MI: Myocardial Infarction; BBA: British Burns Association; ABA: American Burn Association; NBCR: National Burn Care Review; EMSB: Emergency Management of Severe Burns; NBC: National Burn Center; WCP: Western Cape Provincial. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Bazzi et al. 10 Table 4: Adherence to referral criteria for the management of burn patients (continues) First Au- thor/year Length of stay in hospital (day) Most burned area Burn mechanism Number of referral criteria met Adherence to referral criteria Chipp et al., 2008 (14) N/A Face ◦ Flames (N=253) ≥1 (N=378) 1. The rate of adherence to the BBA criteria in burn patients was 25.31% (N=142 out of 561). ◦ Scalds (N=112) ◦ Inappropriate referral: 156 (27.81%) ◦ Contact (N=79) ◦ Appropriate referral: 142 (25.31%) ◦ Chemical burns (N=34) ◦ Over-transferred: 17 (3.03%) ◦ Other (N=83) ◦ Under-transferred: 246 (43.85%) 2. The highest and lowest adherence to the BBA criteria were in TBSA burned and perineum (100%) and axilla (0%) burns, respectively. Carter et al., 2010 (12) 9.00 (SD=10.85) Wrist & Hand N/A ≥1 (N=1,416) 1. The rate of adherence to the ABA criteria in patients primarily presented to a non-burn center was 48.00% (N=457 out of 952). 2. The rate of adherence to the ABA criteria in a burn center was 79.98% (N=867 out of 1,084). Rose et al., 2010 (22) N/A Hands ◦ Flames (N=9) 1. The rate of adherence to the NBCR criteria in burn patients was 17.37% (N=33 out of 190). ◦ Scalds (N=89) ◦0 (N=64) ◦ Inappropriate referral: 61 (32.11%) ◦ Contact (N=66) ◦ 1 (N=46) ◦ Appropriate referral: 33 (17.37%) ◦ Electrical or Chemical (N=13) ◦ 2 (N=75) ◦ 3 (N=4) ◦ Over-transferred: 2 (1.05%) ◦ Other (N=13) ◦ 4 (N=1) ◦ Under-transferred: 94 (49.47%) Baartmans et al., 2012 (18) 6.5 N/A ◦ Scalds (N=472) N/A The rate of adherence to the EMSB criteria in burn patients was 80.22% (N=499 out of 622). ◦ Flames (N=101) ◦ Contact (N=10) ◦ Other (N=39) Davis et al., 2012 (13) 10.50 (SD=18.50) N/A N/A N/A The rate of adherence to the EMSB criteria in patients primarily presented to a non-burn center was 46.00% (N=345 out of 750). Reiband et al., 2014 (21) N/A Partial thickness burns exceeding 3% ◦ Flames (N=37) N/A The rate of adherence to the NBC criteria in burn patients was 70.10% (N=68 out of 97). ◦ Scalds (N=35) ◦ Contact (N=8) ◦ Other (N=17) This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 11 Archives of Academic Emergency Medicine. 2022; 10(1): e43 Table 5: Adherence to referral criteria for the management of burn patients First Au- thor/year Length of stay in hospital (day) Most burned area Burn mechanism Number of referral criteria met Adherence to referral criteria Boissin et al., 2017 (19) 7 Face ◦ Scalds (N=1,031) ≥1 (N=471) The rate of adherence to the WCP criteria in burn patients was 93.39% (CI: 91.8 to 94.7%). ◦ Flames (N=108) ◦ ≥2 (N=606) ◦ Electrical or Chemical (N=23) ◦ ≥3 or more (N=88) ◦ Other (N=3) ◦ Chambers et al., 2021 (20) N/A Hands ◦ Flames (N=68) N/A The rate of adherence to the ABA criteria in burn patients was 72.95% (N=178 out of 244). ◦ Scalds (N=68) ◦ Contact (N=77) ◦ Electrical or Chemical (N=13) ◦ Other (N=18) Van Yperen et al., 2021 (11) 2 Burns of functional areas N/A ◦ ≥1 (N=668) 1. The rate of adherence to the EMSB criteria in patients primarily presented to a non-burn center was 70.03% (N=666 out of 951). ◦ ≥2 (N=309) ◦ Inappropriate referral: 263 (27.65%) ◦ ≥3 (N=89) ◦ Appropriate referral: 403 (42.38%) ◦ ≥4 (N=26) ◦ Over-transferred: 20 (2.10%) ◦ ≥5 (N=11) ◦ Under-transferred: 265 (27.87%) ◦ ≥6 (N=3) 2. The rate of adherence to the EMSB criteria in a burn center was 92.25% (N=1,119 out of 1,213). ◦ ≥7 (N=1) 3. The highest and lowest adherence to the EMSB criteria were in children with ≥5% TBSA: Total Body Surface Area; BBA: British Burns Association; ABA: American Burn Association; NBCR: National Burn Care Review; EMSB: Emergency Management of Severe Burns; NBC: National Burn Center; WCP: Western Cape Provincial; SD: Standard Deviation. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Conclusion Declarations References