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The BuRN-Tool could help staff in emergency departments identify children with burns who are at high risk of abuse or neglect. In a study, the tool was widely used and accurate. It increased referrals to safeguarding services among children less than 5 years, who are least able to explain how they sustained their injuries.

Burns are common in children, especially those under 5. But estimates suggest that up to 1 in 4 children’s burns are caused by abuse or neglect (maltreatment). Staff in busy emergency departments may lack the time or the experience to identify children who need to be protected.

Researchers developed an assessment (the Burns and Scalds assessment template, BaSAT) to prompt staff to collect standardised information about children with burns. They then introduced their risk assessment tool (BuRN-Tool). Healthcare professionals were asked to input information about the injury and the explanation given by parents.

A scoring system indicated the likelihood that abuse or neglect contributed to or caused the injury. This gave staff an objective way of knowing when to discuss a child with a more senior colleague, or to refer the child to safeguarding services.

A score of 3+ for children under 5 was associated with increased referrals to safeguarding services. The tool was less effective in older children.

The researchers suggest emergency departments should use the assessment template BaSAT, and the BuRN-Tool when young children come to emergency departments because of burns.

Further information about burns and scalds can be found on the NHS website.

What’s the issue?

Every year, more than 4000 children with burns attend emergency departments in the UK. Estimates vary but suggest that up to 1 in 4 (10 - 24%) are thought to result from neglect or deliberate injury.

Staff working in busy emergency departments struggle to identify neglect and abuse. They are under pressure to treat and discharge many patients quickly. There is high turnover of staff, and they are not all experienced in treating children. Most maltreatment of children with burns is through neglect, which is difficult to recognise.

Professionals use a range of tools to reveal maltreatment. Some general tools (used to predict maltreatment related to a range of injuries) are not as accurate as those developed for specific injuries. The BuRN-Tool was designed to assess the risk of abuse or neglect in children with burns.

It asks, for example, about the severity of the burn, whether it is on both sides of the body, and whether the professional has concerns about a lack of supervision or insufficient explanation. Each answer is assigned a score. The researchers recommended that a child is referred when the total score is 3 or more.

Researchers wanted to find out if the BuRN-Tool helps emergency staff recognise maltreatment. They looked at whether the tool triggered further discussion with senior colleagues and increased the number of children referred to the hospital safeguarding team or children’s social care. They also wanted to check whether their recommended cut-off score (3 or more) was appropriate.

What’s new?

The study, in England and Wales, was carried out in 3 paediatric emergency departments and one general emergency department. It included all children under 16 who attended with a burn.

The researchers created a standard form (Burns and Scalds assessment template, BaSAT) for professionals to complete for each child, to ensure information was collected routinely. In each emergency department, once 200 forms had been completed, the researchers asked clinicians to use the BuRN-Tool as well as the form for at least 200 more children. The research team provided online training for professionals at each stage, first to complete the BaSAT, and then the BuRN-Tool.

Researchers compared referral rates before and after the BuRN-Tool was introduced. They analysed data from a total of 2443 children, with an average age of 2 years. They found that more than 1 in 4 (28%) children had a score of 3+ on the BuRN-Tool.

The study found that the BuRN-Tool:

  • was widely used, mainly by nurses and junior doctors, and more than 9 in 10 children in the emergency department with burns, were assessed with the tool
  • was accurate and the training appropriate since scores given by healthcare professionals generally agreed with those given by researchers.

Among children who scored 3+ with the BuRN-Tool:

  • far more (65%) were discussed with senior colleagues, compared to fewer (13%) who scored less than 3
  • more were referred for safeguarding concerns in all centres in the study, compared to those who scored less than 3.

The introduction of the BuRN-Tool made no difference to overall referral rates to social services. Nor did it alter referrals of older children. But children under 5 years old who scored 3+ were more likely to be referred.

The researchers concluded that the BuRN-Tool helps clinicians to take appropriate safeguarding actions. It may be especially useful for less experienced clinicians who are assessing safeguarding risks in young children with burns.

Why is this important?

Researchers and clinicians gave similar scores to children, which shows that the tool was accurate and the training appropriate.

Children under 5 are least likely to be able to explain what happened for themselves. The BuRN-Tool was effective in these young children. Its use increased referrals for safeguarding concerns, and led to more discussions with senior colleagues.

After the study, the researchers followed up with social services to find out what had happened after a referral had been made. Social services were more likely to have taken action for children whose score was 3+. The researchers say that the cut-off score of 3 was therefore appropriate.

Simplicity is essential in an assessment that needs to be completed in busy wards dealing with emergencies. The study found that the BuRN-Tool was convenient to complete since most cases were given a score. The researchers say the tool provides an objective assessment that can be helpful, especially for less experienced clinicians.

What’s next?

Further research has explored the action taken by social services after a referral in more detail. This will be published soon. The team would like to find out if the BuRN-Tool changes the child protection measures taken by children’s social workers.

Two of the hospitals that took part in the research have started using the BuRN-Tool in their emergency departments. The researchers hope that other busy emergency departments will start using the tool to help staff recognise potential abuse or neglect in children presenting with burns.

You may be interested to read

This NIHR Alert was based on: Hollen L, and others. Evaluation of the efficacy and impact of a clinical prediction tool to identify maltreatment associated with children’s burns. BMJ Paediatrics Open 2021;5:e000796

The Scar Free Foundation funds and oversees research on scar free healing.

A study on the BaSAT form: Hepburn K, and others. Burns and Scalds Assessment Template: standardising clinical assessment of childhood burns in the emergency department. Emergency Medical Journal 2020;37:351-354

How to differentiate accidental burns from those related to maltreatment: Mullen S, and others. Fifteen-minute consultation: Childhood burns: inflicted, neglect or accidental. Archives of Disease in Childhood - Education and Practice 2019;104:74–78

The accuracy of the BuRN-Tool: Kemp A, and others. Raising suspicion of maltreatment from burns: Derivation and validation of the BuRN-Tool. Burns 2018;44:2

Clinicians’ views: Johnson EL, and others. Exploring the acceptability of a clinical decision rule to identify paediatric burns due to child abuse or neglect. Emergency Medicine Journal 2016;33:465-470

Funding: This research was supported by Health Care Research Wales, with thanks to The Scar Free Foundation.

Conflicts of Interest: None declared.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

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Study author

Identifying neglect and abuse in young children presenting to busy emergency departments is challenging. Staff are under pressure to manage and discharge high numbers of patients quickly. In addition, there is high turnover of staff and they are not all experienced in treating children.

We were delighted that the BuRN-Tool could help staff refer children at risk to children’s social care. The tool will be useful for clinicians of all grades who see children in emergency departments.

Children’s social care workers and health visitors see children in the age group at risk of child abuse or neglect when they sustain a burn. These professionals need to know about the BuRN-Tool in order to identify more children who are at risk of child abuse or neglect. Improved family support will help prevent future injury or neglect.

The tool is being used now in 2 children’s emergency departments that took part in this study.

Alison Kemp, Emeritus Professor of Child Health, Cardiff University 

Member of the public

If this tool can alert children’s social care to potential abuse or neglect, particularly in children under 5, and therefore prevent future maltreatment, it will be well worth implementing as standard practice. I hope it will improve vigilance of under 5s who have suffered burns.

The public need to know that this prediction scoring could take place when a child presents at an emergency department with a burn. They need to know that higher scores will be discussed and possibly referred to children’s services. It is also important for them to know that lower scores will likely mean the burn is accepted as a one-off accident and they will not be referred. Otherwise the fear of being referred might put some people off from seeking help.

About 40 000 children every year attend busy and pressurised emergency departments in the UK. This tool will standardise and increase the focus on the background to accidents and how burns were received.

Making the BuRN-Tool electronic and building it into healthcare records that automatically generate a score would improve effectiveness. It would prevent inaccurate or incomplete forms from being submitted. Risk factors would be included in a child’s electronic medical records for other clinicians to be aware of.

Victoria Hamer, Public Contributor, Lewes, East Sussex

Nurse Scientist

We miss far too many children who have been injured due to abuse or neglect. Where we have cause for concern, we do not always have the confidence to escalate these to senior colleagues. The BuRN-Tool eliminates uncertainty on whether to have this conversation and provides evidence that can be presented to children’s social care.

Incorporating the BuRN-Tool score as standard in the emergency department will increase confidence in safeguarding decisions. It will make discussions with senior colleagues more likely, resulting in appropriate referrals for children under 5 to social care.

The tool should be widely rolled out across the UK and indeed internationally. A series of briefings to emergency department clinicians may encourage them to use it. Most hospitals should have baseline data on current referrals and it should be straightforward to compare data before and after the tool is introduced.

Julie Taylor, Professor of Child Protection, University of Birmingham

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