TY - JOUR
AU1 - BHSc, Jay Toor,
AU2 - MA, Jennifer Crain,
AU3 - RN, Charis Kelly,
AU4 - FRCS(C), Cindy Verchere,
AU5 - FRCS(C), Joel Fish,
AB - Abstract There is an alarming lack of public awareness surrounding the safety of glass-fronted fireplaces. This has resulted in an active campaign from the American Burn Association Prevention Committee. One issue encountered while advocating for prevention among manufacturers is the lack of corroborating and accurate data. The purpose of this study was to examine the annual trends and epidemiology of glass-fronted fireplace-related burn injuries to children less than 15 years old, who presented to Canadian emergency departments between 1990 and 2010. Records of pediatric burn injuries related to glass-fronted fireplaces were extracted from the Canadian Hospitals Injury Reporting and Prevention Program database for the study period (1990–2010). Cases were analyzed in terms of anatomic area affected, demographics, seasonality, safety device use, and injury severity. A total of 616 cases of burns from glass-fronted fireplaces were identified. The incidence increased at an average of 2.7 cases per year. This is a greater than 20-fold increase over 20 years. Seventy-five percentage of the cases occurred in children less than 2 years, and 95% occurred in children less than 5 years. The study demonstrated a growing risk from glass-fronted fireplace burns, likely due to the increasing popularity of household gas fireplace units. These units are a particular risk to children less than 2 years, attributable to their developing mobility and reduced reaction time. This is a preventable injury that should be addressed through changes to legislation and manufacturing. Glass-fronted fireplace (GFFP) units are becoming increasingly popular alternatives to wood-burning fireplaces. Burns from these units are a preventable public health issue causing substantial morbidity.1 Becker and Cartotto2 investigated surface temperatures of the glass enclosures of common models, and found that they reached temperatures hot enough to cause deep partial thickness burns with less than 1 second of contact even after they have been shut-off for 5 minutes.3 Combining this with delayed reaction time in toddlers creates a risk for causing significant burn injuries from contact with hot glass that encloses these units.4,5 The Consumer Product Safety Commission reports that over 2000 American children less than 5 years sustained burn injuries from these GFFP units between 1999 and 2009.6 A retrospective chart review by Dunst et al1 demonstrated a 15-fold rise in the incidence of burns due to GFFPs between 1996 and 2002 at an American regional burn center. Another retrospective data analysis by Naqui et al4 found 35 cases of GFFP burns from 1994 to 2001 in Manchester, England. It was found that most injuries involved the hand, palm, or fingers, and that all cases were accidental. Zettel et al5 identified 27 cases of GFFP burns at a single Canadian pediatric hospital from 1999 to 2002, and found that the etiology was most often loss of balance (37%) and touching out of curiosity (30%). At present, there is no large-scale report on the incidence of GFFP burns. Aside from the aforementioned studies, current statistics cite very low and incorrect rates. These data are collected from nonburn-specialized hospitals using personal communication. Currently, the American Burn Association is planning a campaign through a prevention committee aimed at GFFPs, and there is a strong need for an accurate and large-scale report on this issue. Accordingly, the purpose of this study was to describe epidemiology and trends of pediatric GFFP burns presenting to Canadian emergency departments over a 20-year period. METHODS Data Source The Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) database was analyzed retrospectively (data years 1990–20101) to determine incidence as well as relationships between burn and patient characteristics.7 CHIRPP is an injury and poisoning surveillance system currently operating in the emergency departments of 11 pediatric and six general hospitals across Canada (at the time of the study period, only 15 hospitals were participating). Details of injury and poisoning cases presenting to the emergency department at these hospitals are collected using the CHIRPP Injuries and Poisonings Reporting Form, a one-page questionnaire. Capture rates vary across sites. While CHIRPP captures people who are dead on arrival at the hospital, those who died at the scene or later in hospital are not included. Patients who bypass the ED registration desk for immediate treatment may not be captured as well as those who do not complete an Injury/Poisoning Reporting form. As such, fatal injuries are under-represented in CHIRPP data. The injury or poisoning event details are filled out by the presenting patient or parent/caregiver in conjunction with hospital staff, who provide the clinical details. Information on over 30 variables is collected, including a free-text narrative describing the injury event, what the patient was doing at the time of injury, etiology of injury, patient demographics, time and place the injury occurred, whether or not a safety device was used, injury type, body part, whether or not admission was required, and other details surrounding the injury incident. Total burn surface area and depth of burn are not captured. All forms filled out at participating hospitals are collected and sent to the Public Health Agency of Canada, where they are entered into an electronic database and coded for analysis. Additional details about the CHIRPP database and its composition can be found at http://www.phac-aspc.gc.ca/injury-bles/chirpp/.7 Case Identification Methodology A subset of 26,878 records of burn cases among children aged 0 to 14 years for the study period of 1990 to 2010 was created. This subset was extracted from the full CHIRPP database containing approximately 2.2 million records (from 1990 to 2010; all ages and injury types), using the year, age, and nature of injury variables. Burns from all types of fireplaces were then identified by analysis of the free text narrative; cases in which description of the injury event mentioned “fireplace, fire place, or its French equivalent “foyer” were included in this subset; cases of woodstoves were excluded. Finally, the narratives of identified fireplace cases were further analyzed for presence of the words “glass,” “window,” or their French equivalents “fenetre,” “verre,” or “vitre.” These cases with confirmed involvement of hot fireplace glass were used as the study population of GFFP burns. Data Analyses The data were analyzed using the statistical package Statistical Analysis Software Analytics Pro with regards to trends over time, patient demographics, case details, and burn characteristics. RESULTS During the 20-year study period (1990–2010), 616 cases of burns from GFFPs presented to the 15 hospitals included in the study. Patient Demographics and Burn Characteristics Demographics of patients and characteristics of burns are presented in Tables 1 and 2, respectively. Mean age of children with GFFP burns was 20 months old with 75% (n = 462) occurring in children less than 2 years and 95% (n = 585) occurring in children less than 5 years. Table 1. Patient demographics View Large Table 1. Patient demographics View Large Table 2. Patients' burn characteristics View Large Table 2. Patients' burn characteristics View Large Incidence and Annual Trends An average of 29 fireplace burns occurred per year from 1990 to 2010, with a maximum of 61 GFFP burns in 2007. Over the study period, annual incidence increased at an average of 2.7 cases per year. This is demonstrated in the scatter plot in Figure 1. In contrast, 26,878 burns occurred from all causes, and there was a decrease in incidence of burns from all causes, as demonstrated in Figure 2. The slope of incidence of fireplace burns was 0.9 (P < .0001) compared with burns from all causes being −0.3 (P = .27). The relative increase of GFFP burns to burns from all sources from 1990 to 2010 was found to be statistically significant (Fisher's test [P < .0001]). Figure 1. View largeDownload slide GFFP injuries between 1990 and 2010. Number of GFFP burns is plotted on vertical axis. Year is plotted on horizontal axis. GFFP, glass-fronted fireplace. Figure 1. View largeDownload slide GFFP injuries between 1990 and 2010. Number of GFFP burns is plotted on vertical axis. Year is plotted on horizontal axis. GFFP, glass-fronted fireplace. Figure 2. View largeDownload slide Burn injuries from all sources between 1990 and 2010. Number of burns from any source is plotted on vertical axis. Year is plotted on horizontal axis. Figure 2. View largeDownload slide Burn injuries from all sources between 1990 and 2010. Number of burns from any source is plotted on vertical axis. Year is plotted on horizontal axis. Seasonality As anticipated, most burns occurred in fall and winter months, with 40% (n = 249) occurring between December and February, 20% (n = 130) between March and May, 6% (n = 33) between June and August, and 33% (n = 204) between September and November. The month with the highest number of burns was December (20%, n = 110), while the fewest reported burns occurred in July (1%, n = 8). Safety Measures and Severity A safety device was reported to be used in 8% (n = 52) of cases. Zero percentage of none (n = 0) of these cases required admission to hospital, in contrast to the 3% (n = 17) that were admitted to hospital when no safety device was used. However, this was not a statistically significant difference (P = .649). It is notable that the use of a safety device is often under-reported in CHIRPP, and the type of device was not specified in any of the 52 cases above. DISCUSSION This study demonstrated a consistent rise in the incidence of GFFP burns, over 20-fold over the 20 years. In contrast, the number of burns from all sources decreased over the same time period. Most GFFP burns occurred in children less than two (75%), attributable to their restricted mobility and reduced reaction time. Almost all GFFP burns were on the upper extremity (94%), and the highest proportion of burns occurred during winter (40% in December to February). In addition, the rise in incidence of GFFP burns according to our study is consistent with smaller-scale studies conducted by Dunst et al1 and Naqui et al.4 The demographics of patients, typically less than 4 years old, as well as the upper limb being the most common body region affected is consistent with the findings of Naqui et al4 and Zettel et al.5 This study had two major strengths: 1 This is was the largest study conducted on Canadian GFFP burns in terms of both time period and sample size. 2) It also utilized detailed and accurate emergency department presentation data collected by the Public Health Agency of Canada. The limitations of the study included: 1) The CHIRPP population itself had some inherent limitations: most of the data comes from pediatric hospitals, often located in major cities, and as such, certain demographics are under-represented in the dataset, including Aboriginal persons and rural inhabitants. 2) Furthermore, many severely injured patients requiring immediate attention bypass the emergency room and completion of a CHIRPP form. As such, although 3% of the pediatric GFFP burn cases examine in this study, were admitted to hospital, actual rates of admission may be higher. 3) Moreover, patients seen elsewhere, including but not limited to urgent care centers and walk-in clinics, are not captured in CHIRPP. 4) Another limitation was that although a safety device was reported to be used in 8% of cases, the use of a safety device is often under-reported in CHIRPP, and the type of device was not specified in any of the 52 cases above. 5) In addition, TBSA and depth of burn were not reported. 6) Notably, at the time of data analysis, the data entry for the year 2010 was not complete. As such, the reported incidence for that year would likely have been higher. Notwithstanding limitations, earlier research provides evidence that CHIRPP data represent general injury patterns among some children in Canada (11–15 years old).8 Implications for Policy, Practice, and Research This study describes a growing risk from an increasingly common household appliance that is often overlooked as a major hazard. However, this is incongruent with a recent review by advocacy groups representing GFFP manufacturers. That report suggested that very few injuries have occurred from GFFPS, and has been presented to influential political parties. In addition, the Hearth Patio and Barbecue Association (HPBA), the main advocacy group supporting GFFP manufacturers, has published on their information guide for consumers that “while very rare, injuries (from GFFPs) have been reported.”9 In addition, they take the stance that “there are no exceptional burn risks presented to young children by glass-fronted gas fireplaces, and that there are only a handful of serious burns treated each year from these devices,” and “we believe these incidents are few and rare.”9,10 While our study finds that the overall incidence is not overwhelming, GFFP burns are not rare and cannot be dismissed. More importantly, these burns are increasing at a statistically significant rate, and are therefore causing unnecessary and easily avoidable morbidity to an increasing number of children. Our study supports the need for more injury prevention efforts. The American Burn Association's Prevention Committee and the American Academy of Pediatrics are carrying out a campaign for legislation changes that will mandate manufacturers to conform to more stringent safety standards. GFFP burns occur because of a combination of dangerously high exterior surface temperatures in conjunction with susceptibility of the affected demographic (age 0–4). Along with decreased mobility affecting their reaction time, toddlers are in a stage of development characterized by sensorimotor exploration, and this leads them to contact GFFPs out of curiosity of the flame in addition to accidental contact. As such, potential interventions aimed at reducing GFFPs must address these issues, and include the following: 1) GFFP design can be altered to either prevent contact, such as by raising the unit four or more feet above the ground, or by using materials that cause the exterior of the glass to be a poor heat conductor. 2) Also, more numerous and clear labeling on the units and in the instruction and operators manual can aid in educating consumers about an often overlooked danger. Clear language on this material is necessary, as opposed to the common misleading wording currently used by GFFP manufacturers, such as description of a glass-front as “heat resistant.”11 3) In addition, an illuminated visual warning system on the unit can indicate dangerous temperatures. Such a dynamic warning system more effectively attracts attention than static labeling, which leads to habituation with long-term exposure. It would aid in keeping parents cognizant of a danger to their children, and would also warn of hot glass for the period of time immediately after the unit has been shut off. 4) Furthermore, better education of consumers on a large-scale is necessary, because GFFP hazards are frequently overlooked due to consumers' passive awareness of their danger. Currently, the only attempt toward consumer education is informing interested parties through labeling and warnings on manufacturer websites. Active campaigns such as broadly distributed informative announcements through media are necessary. According to the CPSC Injury Cost Model, an estimated 1754 GFFP burns occurring between 1999 and 2009 have had associated injury costs of $91 million.12 Manufacturers have a responsibility to financially support advertising and awareness efforts. 5) Finally, an integrated safety device would be the most effective intervention. By creating a protective airspace between contact and hot parts, it prevents nonreversible injury, including that from inadvertent contact. Although the HPBA attempted to appease regulatory standards by offering to include removable protective grills with future products by 2015, these are required to be attached by the consumers themselves. Manufacturers need to directly integrate safety measures into their devices to avoid issues of consumer awareness, compliance and system failure from poor installation, intentional removal, or accidental damage. This HPBA offer also does not mitigate the risks associated with existing GFFP units. Currently, protective grills are expensive optional accessories that can be purchased between $66.96 and $189.95.11,12 This issue can be addressed by free safety grills and installations. In 2011, Petition CP11-1 supporting the above safety measures was provided to the CPSC, and incorporated comments from burn doctors, technical entities, safety advocacy groups, and private citizens related to GFFP burn victims. All comments filed against the petition were made by members of the gas appliance industry. The vast majority of support and evidence supports the application of legislation forcing better safety standards. Our study now adds further statistical data confirming the breadth of this issue. Further research should aim to present additional accurate and large-scale data such as that provided by our study to further support advocacy for changes in legislation and manufacturing of GFFPs. The American Burn Association's Prevention Committee has initiated a retrospective study over a 3-year period involving 17 North American burn centers. Data collection will include precise incidence, type of burn, severity, and demographics including age and ethnicity. It is based out of the University of Iowa under the direction of Dr. Lucy Wibbenmeyer, and is estimated to be completed in 2014. Hopefully accurate and comprehensive data provides strong evidence contradicting claims by GFFP manufacturers, and aids in advocating toward a permanent and comprehensive solution to this constant hazard. REFERENCES 1. CM Dunst, EC Scott, JJ Kraatz, PM Anderson, JA Twomey, GL Peltier Contact palm burns in toddlers from glass enclosed fireplaces. J Burn Care Rehabil  2004; 25: 67– 70. Google Scholar CrossRef Search ADS PubMed  2. L Becker, R Cartotto The gas fireplace: a new burn hazard in the home. J Burn Care Rehabil  1999; 20: 86– 9; discussion 85. Google Scholar CrossRef Search ADS PubMed  3. AR Moritz, FC Henriques Studies of thermal injury: II. The relative importance of time and surface temperature in the causation of cutaneous burns. Am J Pathol  1947; 23: 695– 720. Google Scholar PubMed  4. Z Naqui, S Enoch, M Shah Glass front of gas fire places: a clear and present danger. Burns  2005; 31: 72– 5. Google Scholar CrossRef Search ADS PubMed  5. JC Zettel, A Khambalia, W Barden, T Murthy, C Macarthur Gas fireplace contact burns in young children. J Burn Care Rehabil  2004; 25: 510– 2. Google Scholar CrossRef Search ADS PubMed  6. Taylor LC. Fireplace safety rules to change thanks to Canadian pediatrician. The Toronto Star; January 23 2012. Retrieved on June 19 2013 from: http://www.thestar.com/article/1119856--fireplace-safety-rules-to-change-thanks-to-canadian-pediatrician. 7. Canadian Ministry of National Health and Welfare, Public Health Agency of Canada, Injury and Child Maltreatment Section, Health Surveillance & Epidemiology Division. Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP). (2012). Available from Public Health Agency of Canada website: http://www.phac-aspc.gc.ca/injury-bles/chirpp/; accessed 19 June 2013. 8. W Pickett, RJ Brison, SG Mackenzie Youth injury data in the Canadian hospitals injury reporting and prevention program: do they represent the Canadian experience? Inj Prev  2000; 6: 9– 15. Google Scholar CrossRef Search ADS PubMed  9. Hearth, Patio and Barbecue Association. Gas Fireplace, Stove and Insert Safety FAQs. Available from http://www.hpbacontario.ca/ca/wp-content/uploads/2013/03/2012-Glass-Safety-FAQ.pdf; accessed 15 Sept 2013. 10. Perkins B. Industry moves ahead of gas-fired fireplace safety standards to prevent burns. Realty Times; December 06 2012. Available from http://realtytimes.com/homeimprovement1/item/633-20121207_gasfireplacesafety; accessed 19 June, 2013. 11. Consumer Product Safety Comission. Ballot Vote Sheet for Petition CP 11-1, Request for Standard for Gas Fireplaces with Glass Fronts; March 21 2012. Available from http://www.cpsc.gov/PageFiles/91429/fireplace.pdf; Retrieved 15 Sept 2013. 12. Heart, Patio and Barbecue Association of Canada. Safety Mandate for New Glass Front Fireplaces. Available from http://www.hpbacontario.ca/ca/news/hotglass/; accessed 15 September, 2013. Copyright © 2016 by the American Burn Association
TI - Pediatric Burns from Glass-Fronted Fireplaces in Canada: A Growing Issue Over the Past 20 Years
JF - Journal of Burn Care & Research
DO - 10.1097/BCR.0000000000000331
DA - 2016-09-01
UR - https://www.deepdyve.com/lp/oxford-university-press/pediatric-burns-from-glass-fronted-fireplaces-in-canada-a-growing-AiYw5q1s7R
SP - e483
EP - e488
VL - 37
IS - 5
DP - DeepDyve
ER -