No Change in Fireworks-Related Burn Center Admissions: A 10-Year Analysis of the Admission Rates, Treatment, and Costs

Round 1

Reviewer 1 Report

Dear authors, I got to review your manuscript "No change in fireworks-related burn center admissions: a 10- 2 year analysis of the admission rates, treatment, and costs", in which you present the outcome of fireworks-associated injuries in the Netherlands. While in general, I think your manuscript is worthwhile of reading and quite entertaining, there are some aspects, that need improvement: 1.) In the abstract you conclude with "In contrast to the hypothesis..." yet you did not introduce a hypothesis in the abstract - so please adapt it accordingly. 2.) In the introduction you hypothesize that the number of admissions decrease since the introduction of several means that have been implemented to decrease these numbers, yet you do not provide a timeframe in which these means have been established. Therefore, a direct correlation is impossible to observe. Please introduce these numbers (year) and also provide references therefore. 3.) You seem to be surprised to have most of the patients admitted to a burn centre despite the small TBSA burnt - yet according to most guidelines, burns to the face or hands require the treatment in a specialized burn centre and even propose admission for stationary treatment. Since, most of the burns in your study population were located in the face or on the hands, I am not surprised by that, at all (ultimately, not only to rule out an inhalation injury or for surgery, but maybe also because of the mere locations). Please discuss these guidelines as well. 4.) What do you mean by "...on average €9,040 could be saved..." - as far as I understood, this amount is what the treatment cost roundabout. Therefore, either the sentence, or the grammatical tense should be corrected. 5.) According to my experience, one of the most dangerous injuries after handling fireworks are traumatic amputations. These are not necessarily included when analyzing the diagnosis "burns". In my opinion, it would be of high interest how many traumatic amputations have been admitted to the units/centres - especially on December 31st and January 1st. Since a traumatic amputation weighs more than "just" a superficial burn of 1% TBSA, it might be, that these patients have been excluded, ultimately alleviating your study population. If you cannot provide these numbers, this should at least been discussed and listed as a limitation. 6.) Please have a native speaker double-check the manuscript as there are some grammatical and orthographical inconsistencies. Thank you & Kind Regards

Author Response

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Reviewer 2 Report

This is a retrospective study about healthcare cost of patients with fireworks-related burns admitted to a Dutch burn center during 10 years.  They included 133 patients, most of them between  december 29 and Janury 3 The patients were young and suffered minor burns although the health care they needed was not negligible. The authors found no differences over the years.

The authors collect data well and display it appropriately, but it does not provide data of great interest

Mayor

I have some doubts about whether this study can draw conclusions about the effectiveness of preventive measures and there may be other factors

Author Response

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Reviewer 3 Report

Dear authors,

 

thank you for submitting this article.

I believe that this topic is very interesting and is would be interesting if firework restrictions in 2020 have an influence in the number of admitted patients.

I am not sure if there were any firework restrictions in the Netherlands. If yes, it would be interesting to include this data in the manuscript.

 

I do have a few questions.

1. Why is the methods section not behind the background section?
2. How many burn centers include patients in the national burn database?
3. What are the criteria for inclusion in the national burn database? Solely the burn wound treatment? It seems that the patients do not have to stay overnight in hospital to be included.
4. In the abstract you write that since there are firework free areas a decrease of patients admitted to the emergency department was observed. Nevertheless, you describe that there was no decrease of patients injured through fireworks in the study period. Please explain
5. How can the costs for a patients treated in daycare be over 5000€? It seems that every patients had costs of at least 5000€, even the 35% of patients solely treated in day care setting. Please explain and calculate the costs more precisely
6. In the results section you write “patients admitted to a burn center” This is a little confusing. Please rephrase. ( maybe… admitted to one of the participating burn centers)
7. How many patients were included in Dutch the burn registry altogether in the study period
8. What makes this article special compared to the article “Injuries, treatment, and impairment caused by different types of fireworks; results of a 10 year multicenter retrospective cohort study”- This article deals with the same topic. Here over 250 patients from solely 2 hospitals were included between 2007 and 2017 with injuries caused by fireworks. How come this number is so much higher? Are explosion injuries also included in the burn registry, usually injuries though explosions involve burn injuries, don’t they?  Normally the number of patients included in the burn registry should be higher, because more hospitals are included. Please explain.

 

Thank you again for this interesting work.

Author Response

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Reviewer 4 Report

Thank you for the chance to review the manuscript, “No change in fireworks-related burn center admissions: a 10 year analysis of the admission rates, treatment, and costs” submitted by  Daan T. Van Yperena et al. The manuscript presents an interesting outline of the trend in burn center admissions due to fireworks injuries over a 10 year period to a Dutch burn center. Treatments and costs are also reported. No significant differences in the number of admissions over the period were noted. The authors concluded that governmental restrictions placed on fireworks during this period were ineffective. Within the text the authors suggested several policy changes.

 

This is an outstanding and specific gathering of data that supports a change in policy. My main suggestions for this well written manuscript would be to emphasize the needed policy changes further by 1. Elaborating more on the specific laws that were set in place by the Government during this period that were either ineffective or not enforced.

2. Expand the section on the suggested policy change and provide further references and stories on situations where and when these changes were implemented and the documentation of the magnitude of effectiveness of the intervention.

 

Author Response

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Reviewer 5 Report

The authors present a very important preventable cause of burn centre admission that has a life-changing outcome with avoidable high burden on the tax-payer.

As burn clinicians, all of us wish to avoid burn injuries to our patients as much as possible and fireworks are certainly a leading cause particularly around celebrations of events. The manuscript is generally well written and presented.

My queries and suggestions:

The overall emphasis of the manuscript is to identify the burden of the firework related injury on the burn centres in order to educate the public and have sound debate with the policy makers.  In that regard, the authors do not do justice to the data: 

1. It would be prudent to show the actual numbers from year to year so the reader gets a feel for actual numbers overall and then hone down to the time period of maximum ie Dec-Jan. 
2. There is a wide range of TBSA involved. It would help to identify the number of patients who had more than/equal to 15%TBSA so we know how many serious injuries have occurred; identify why 13 patients required ICU admission as this is serious; highlight all additional injuries as this can increase the morbidity. As written, the manuscript DOES NOT give justice to the severity of the injury. By averaging out, the manuscript reads as if the fireworks cause minor injuries and patients are just kept for observation overnight increasing the cost.  Whilst majority of the injuries are minor, the serious ones need to be highlighted to increase the impact.
3. Finally, the statement that there was no change in the burn centre admission parallel to reduction in A&E attendances is questionable. The trend fluctuates (albeit yearly data not shown, just December and January). We need to see the total number and if possible alongside the A&E data.  Question is do the burn centres admit patients from their own A&E or do they get transferred from elsewhere with smaller injuries as there are only 3 burn centres and more A&Es so is the data skewed?

This manuscript will be enhanced by addressing the above

Author Response

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Round 2

Reviewer 2 Report

The modifications made have improved the mansubscript

 

   

Reviewer 3 Report

Thank you for answering all of my questions.

I have no further questions.