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Fires and Burns
Interventions to Prevent Scald Burns
Background
Toddlers, particularly children under
2 years of age are most at risk for scald burns. Scald burns are usually caused
by hot liquids; tap water in the bath or spilling of hot drinks or liquids from
large containers on the stove. The data from the Harstad Injury Prevention Study33 indicate that 64.3% of hospitalized burn injuries
resulted from scalds, 31.4% were contact burns and 4.3% due to open flames.
Two-thirds of the patients were under 2 years of age and 66% were male. The
United States Consumer Product Safety Commission in 1978 reported 2,600 scald
burns, 25% of these were serious enough to require hospitalization.34 The studies reviewed here have used educational,
legislative regulations and environmental interventions to reduce scald burns.
Review of scald burn interventions:
Author | Ytterstad, 1995 |
Study design and target population | Non-equivalent control group design.
Children under age 5.
Intervention community: Harstad,
Norway
Control community: Trondheim, Norway
|
Intervention | Burn prevention component of Harstad Injury Prevention
Study, a multi-faceted community campaign with active and passive interventions
including promotion of stove cooker guards and setting of 55¡ C tap water temperature. |
Outcomes | Hospital and ED treated injuries
Short-term hospitalization costs
|
Results | 52.9% decrease in injuries (52.4 to 24.7 per 10,000
person years, p<0.05).
Non-significant increase in injuries in
control city (RR=0.43, 0.23-0.82).
Reduction in hospitalization from
103.4 per 10,000 person years to 48.6 (rate ratio=0.47).
Scalds predominant injury; hot
coffee and hot water most common cause (2/3 of all injured under 2 years
old).
|
Study quality and conclusions | Multi-faceted community campaign based on known
risk factors a success. Public participation and feedback of local burn
data considered important in achieving success.
Use of multi-disciplinary approaches, active and
passive interventions important.
Complete databases in intervention
& control communities; minimal effect of registration loss.
|
Author | Waller, 1993 |
Study design and target population | Nonequivalent control group design.
Random sample of households with
children under 3 in Dunedin, NZ, July-November 1990.
Intervention group: n=54
Control group: n=56.
Excluded households with baseline
water temperature under 60¡ C (n=33, 23%)
|
Intervention | Half-hour educational home visit included measuring
water temperature, discussing how to lower temperature and offering free
plumber’s advice.
National media campaign ("Hot
water burns like fire") conducted by Accident Compensation Corporation
(ACC) at same time.
|
Outcomes | Recognition of ACC campaign.
Mean water temperature.
Proportion of homes with temperature
under 60¡ C
|
Results | Identification of ACC campaign 73% vs. 16% at baseline.
Significant decrease in mean hot water temperature
61.2¡ C vs. 64.2¡ at baseline, p=0.001.
Proportion of homes with water
temperature under 60¡ C increased to 41.9% from 9.3% (intervention group)
and 30% vs. 10% (control group). OR=1.6, 0.34-7.6.
Majority of households still had
temperatures above 55¡ C.
|
Study quality and conclusions | Educational campaign too time intensive and not
effective.
Media campaign, particularly TV messages, most
successful way to reach public.
Water heated by electric water
heater and/or "wetback" heating system. Latter is an ancillary
water heating device that can heat water to 100¡ C and override the electric heater thermostat.
Present thermostats are ineffective.
Small study with 50% response rate.
|
Author | Erdman, 1991 |
Study design and target population | Non-equivalent control group design
Home visit and measurement of temperature
for a random sample of Seattle, WA, households with post-law heaters (cases:
n=50) and pre-law heaters (controls: n=50).
|
Intervention | Statewide legislation requiring preset temperature
of 49¡ C (120F) for all new water heaters, 1983.
Law requires all utility customers to receive an
annual warning of hazards of hot water and energy savings of lower temperatures;
concomitant educational campaign.
|
Outcomes | Proportion of homes with tap water temperature
less than 54¡ C
Mean tap water temperature change
Hospital admission rate for scald
burns
|
Results | 77% homes (84% of home with post-law and 70% of
homes with pre-law water heaters) had tap water temperatures less than 54¡ C vs. 80% of homes with temperatures above 54¡ C in 1977. No statistically significant
difference in safe temperature between case and control groups. OR for safe
temperature was 2.25, 0.78-6.63.
Mean water temperature 50¡ C in 1988 vs. 60¡ C in 1977.
56% reduction in hospital admission
rate, from 5.5 children per year to 2.4 per year. Rate ratio=0.44. Severity
of burns reduced.
|
Study quality and conclusions | Classic study
Educational programs aimed at reducing
temperature settings of water heaters were effective.
Legislation increased number of
homes with tap water lower than 54¡ C.
Excellent consumer acceptance.
|
Author | Katcher et al., 1989 |
Study design and target population | Randomized control trial, single-blinded
Patients at pediatric ambulatory clinic, University
of Wisconsin at Madison
(n=697 ).
|
Intervention | Cases: Received liquid crystal thermometer and
counseling (hot tap water safety pamphlet)
Controls: counseling only.
Safe water temperature 54.4¡ C (130F)
|
Outcomes | Baseline and post intervention questionnaire to
measure changes in knowledge, hot water temperature, and thermostat lowering.
Validated a subsample with home visits
at 1 year. (Response rate: 76.5% cases, 70.2% controls).
|
Results | Group that received thermometer and read
pamphlet more likely to test water temperature need OR
No difference between groups for non-readers of
pamphlet.
|
Study quality and conclusions | Home visit to validated, self-reported water temperatures
done on small subsample (n=40).
Data not given for intervention
and control groups separately. These groups demographically similar.
Knowledge of safe water temperature
associated with testing.
Anticipatory guidance more successful
when thermometer provided.
|
Author | Webne, 1989 |
Study design and target population | Randomized controlled trial, single blinded
Referred by community-based pediatricians Calgary,
Alberta, Canada.
Restricted to families with 1 child
under 3 and 1 over 3 years with high baseline tap water temperatures.
|
Intervention | Educational pamphlet and liquid crystal thermometer.
Intervention introduced to each participant at
different points in time in random order.
4 home visits:
baseline, intervention, follow-up
plus telephone report of measured temperatures, 1 month follow-up.
|
Outcomes | Measured tap water temperatures for 3 time periods:
mean baseline to post intervention, post intervention
to follow-up, and mean baseline to follow up.
Analyzed using 50 C and 54 C as
safe temperature cut-off.
|
Results | No effect of intervention.
No statistically significant decrease
in hot water temperature; proportion of heaters with safe temperature
not statistically different pre- and post- intervention.
|
Study quality and conclusions | Very small study (n=12), and time-intensive.
Conclude that compliance is a significant problem
even after education and personal demonstration.
Recommend legislation to require
pre-set water heater temperature.
|
Author | Williams, 1988 |
Study design and target population | Randomized controlled trial, single blinded
Parents enrolled in pre-natal classes at Urban
hospital, Kansas City, Kansas (n=75).
|
Intervention | Education plus "accident prevention"
information vs. usual prenatal curriculum |
Outcomes | Tap water temperature, use of smoke detectors and
car seats evaluated during home visit. |
Results | 58% of experimental group had tap water temperature
below 130F (n=23) vs. 31% of controls (n=11).
No significant differences between
groups for car seat or smoke detector use.
|
Study quality and conclusions | Higher proportion of households with safe water
temperature in intervention group.
Study weaknesses: post-test evaluation
only; no adjustment for confounding; experimental group had more highly-educated
parents and higher proportion of owner-occupied homes.
|
Author | Elberg, 1987 |
Study design and target population | Interrupted time series
Patients admitted to Burns Unit, Odense
University Hospital, Denmark (1968-77 vs. 1978-84), n=1391.
46% of study sample under 16 years.
|
Intervention | 10-year intensive information campaign: press,
radio, TV.
Household product modification
|
Outcomes | Deaths and hospitalization in burn unit; mean annual
incidence of burn injuries
Burns not separated by type.
|
Results | Scalds accounted for 80% of all burns (366/457)
in children under 6.
Greatest success in reducing scald and
contact burns in children under 6 years, with 50% reduction in all burn
injuries, p<0.05.
|
Study quality and conclusions | Complete case ascertainment.
Campaign effective for younger children.
Small number of burn injuries:
1391 over 17-year period; 33% of burns in children under 6; 13% to 6-15
year olds.
|
Author | Katcher, 1987 |
Study design and target population | Non-equivalent control group design
750,000 subscribers of Wisconsin
Electric Power Company, Madison, WI.
|
Intervention | Multi-faceted community campaign; educational pamphlet
sent with electric bill with offer of free liquid-crystal thermometer upon
request.
Newspaper, TV and radio publicity, coupons
in hospitals and doctor’s offices.
|
Outcomes | Self-reported knowledge, testing tap water temperature
and lowering water heater thermostat. Three telephone surveys (n=337, 318,
325). |
Results | 140,000 thermometers requested. Pre-and post-program
general population random surveys found increased awareness of the danger
of hot tap water, from 72 % to 89%, but no increase in testing or lowering
of water heater temperatures.
Random sample survey of thermometer requesters
had a higher rate of testing (a difference of 58.1% (55.3% to 60.9%) than
in general population.
43% of testers reported temperatures
above 54.4¡ C and 52% of this group lowered their water heater
thermostat.
|
Study quality and conclusions | Increasing awareness of hazard via education doesn’t
necessarily result in behavior change.
Motivated consumers (those requesting
thermometer) more likely to change.
Radio and TV messages found to
be more effective than pamphlet.
Data is self-report and was not
validated by actual temperature measurements.
|
Author | Barone, 1984 |
Study design and target population | Randomized controlled trial, single blinded
Enrollees in "Parenting the Toddler"
classes; middle and upper-middle class parents, suburban Kansas city (n=79).
|
Intervention | Education plus specific burn prevention information
and thermometer to measure water temperature |
Outcomes | Tap water reduction |
Results | Knowledge of safe tap water temperature 90% in
experimental group vs. 32% in controls.
No difference in mean water temperature
measured at post-intervention home visit (41.5% experimental group with
safe temperatures vs. 39.5% of controls).
|
Study quality and conclusions | Educational intervention not effective in this
population.
Post-test evaluation only; smoke detector use over
90% and car seat use 100%.
|
Author | Thomas, 1984 |
Study design and target population | Randomized controlled trial, single blinded.
Members of HMO in Kansas City, Kansas who selected
90 min. "well baby" classes.
Randomized to experimental or control
group; children under 1 year.
|
Intervention | Module on burn prevention including coupon for
reduced price smoke alarm added to usual well baby class curriculum.
Home visit after 4-6 weeks for both groups
|
Outcomes | Scores on Fire Safety Knowledge Test
Home tap water temperature
Smoke alarm installation
|
Results | Mean score on Knowledge test 20.3 (experimental
group) vs. 18.9 (control group), p=0.0001.
76% of experimental group had safe water
temperature vs. 23% of controls; 66% of experimental group lowered temperature
setting vs. none of the controls, p=0.01.
No significant difference in smoke
alarm installation.
|
Study quality and conclusions | Single education session effective.
However, the study was small and
had the following weaknesses:
selection bias-volunteers for classes;
population employed, married and in late 20’s; post-test measures
only for water temperature and smoke detector installation.
|
Summary of scald burn interventions
Legislation requiring a safe pre-set temperature for all
water heaters has proved a more effective method of reducing scald burns than
education to encourage parents to turn down water heaters. Educational approaches
are effective in some populations when they are accompanied by a tangible product
such as a thermometer to measure tap water temperature. Legislation is necessary
to insure safe temperatures in multi-family dwellings served by a central water
heater. Safe temperatures can be maintained by building code inspection. Product
modification, that is, environmental interventions offer the most effective
methods for reducing scald burns from hot coffee and soups and other hot liquids
on the stove. Wide based ("no spill") cups and rails around kitchen
stoves are good examples of well designed safer products.33
Recommendations on scald burn
interventions
Tap water scalds can best be prevented by lowering the water temperature at
the source. Legislation which outlines manufacturers specifications appears
to be the most effective method. Temperatures should be checked as part of Building
Code inspections of multi-family dwellings and apartments. Potential dangers
of high tap water temperatures can be successfully addressed by providing educational
material and a free liquid crystal thermometer to use in testing home tap water
temperatures. Scald burns from hot liquids can be prevented by modifying coffee
cups and kitchen stoves to prevent hot liquid spills.
Recommendations for future
research
Engineering approaches should be employed to design safer products and
prevent hot liquid spills.
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