Increased Incidence of Heater-Related Burn Injury During a Power Crisis Increased Incidence of Heater-Related Burn Injury During a Power Crisis Tina L. Palmieri, MD; David G. Greenhalgh, MD Hypothesis: Recent power shortages in California re- sulted in rolling blackouts and increased utility prices. Residents turned to alternative heating devices, such as space heaters, to decrease utility bills. Our hypothesis is that the incidence of heater-related injuries increased ow- ing to the use of alternative heating methods during the power crisis. Design: Retrospective case-series database and medi- cal record review of all burn admissions for the 4 months of November through February for the period 1998- 2002. Setting: Regional pediatric and adult burn unit in north- ern California. Patients: Patients admitted during the study interval with burn injury. Main Outcome Measures: Parameters recorded in- cluded patient demographics, cause of burn, total body surface area burn, number of operative procedures, and hospital length of stay during each of the 4 months in the interval. Results: A total of 512 patients were admitted during all 4-month intervals. During the power crisis there were significant increases in the number of hospital admis- sions (151 in 2000-2001 vs 117 in 1998-1999, 124 in 1999-2000, and 152 in 2001-2002) and heater-related burn admissions (36 in 2000-2001 vs 25 in 1998-1999, 26 in 1999-2000, and 29 in 2001-2002). The percentage total body surface area burn (mean ± SEM, 24.0% ± 4.6% in 2000-2001 vs 16.5% in 1998-1999, 12.3% in 1999- 2000, and 12.0% in 2001-2002), hospital length of stay (15.0 days in 2000-2001 vs 9.9 days in 1998-1999, 12.3 days in 1999-2000, and 7.0 days 2001-2002), and the number of operations (55 in 2000-2001 vs 7 in 1998- 1999, 18 in 1999-2000, and 19 in 2001-2002) also in- creased during the crisis. Conclusions: The number of heater-related burn ad- missions, as well as their magnitude, increased during the energy crisis, resulting in increased resource use and health care costs. The economic stresses of the power shortage had societal costs that extended far beyond the price of electricity. Arch Surg. 2002;137:1106-1108 T HE POWER shortage in north- ern California from Novem- ber 2000 through February 2001 resulted in a substan- tial increase in the price of natural gas and electricity throughout the state. As a result many residents, in an at- tempt to lower their utility bills, took a va- riety of measures to decrease these costs, ranging from lowering the temperature on the thermostat to the use of alternative heat- ing sources such as space heaters, wood- burning stoves, and fireplaces. Improper or inadequate use, installation, or supervision of these devices can result in house fires or direct burn injury from the heating source. Each year more than 100 000 per- sons are admitted to burn units with se- vere burns.1 The incidence of burn in- jury, owing to a variety of reasons, has been decreasing over the last 20 years.2 How- ever, the number of admissions to the Uni- versity of California Davis Regional Burn Center and Shriners Hospitals for Chil- dren Northern California Burn Center in- creased markedly during the winter months of 2000-2001, coinciding with the peak of the energy crisis. Although the financial and eco- nomic consequences of the energy short- age have been widely publicized, the po- tential increase in burn injury and its socioeconomic effect have not been ex- plored. The purpose of this study is to de- termine if the incidence in heater-related injuries in northern California increased during the power crisis. PATIENTS, MATERIALS, AND METHODS The study was approved by the University of Cali- fornia at Davis institutional review board. The University of California at Davis Regional Burn Center and Shriners Hospitals for Children Northern California Burn Center admit pa- tients from northern California, the central val- ley, and the adjacent states. Analysis of the Trauma Registry of the American College of Sur- geons burn database and retrospective patient ORIGINAL ARTICLE From the Shriners Hospitals for Children Northern California Burn Center and Department of Surgery, University of California at Davis Regional Burn Center, Sacramento. (REPRINTED) ARCH SURG/ VOL 137, OCT 2002 WWW.ARCHSURG.COM 1106 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 medical record review was completed for all burn admissions in the 4 months from November through February in years 1998 through 2002. Medical records were reviewed for patient demo- graphics, cause of burn, percentage total body surface area (TBSA) burn, survival, number of operative procedures required, and hos- pital length of stay (LOS). The mean monthly temperature for each of the study months was obtained from the Western Re- gional Climate Center.3 Differences between the total number of burns, heater-related burns, and the number of heater-related burns by month during the power shortage months (November 2000- February 2001) were compared with each of the 2 periods im- mediately prior (November 1999-February 2000 and November 1998-February 1999) as well as to the ensuing year (November 2001-February 2002) using the �2 test. Mean hosptial LOS and TBSA burn percentage differences between the power shortage months and each of the other 3 intervals were compared using the t test. Results are given as the mean (SEM). RESULTS A total of 512 patients were admitted in the 4 months from November through February in 1998-2002. There was a sig- nificant increase (P�.006) in the incidence of heater-related burn injuries between the 2000-2001 period and each of the 2 previous years as well as in the subsequent year (Table, Figure 1, and Figure 2). There was a significant increase in the TBSA burn, with mean burn size greater than 20% in the 2000-2001 period vs the previous and subsequent years (Figure 3). The number of operations also increased markedly, with 7 operations performed in 1998-1999, 18 in 1999-2000, 55 in 2000-2001, and 19 in 2001-2002. The male-female ratio of patients with burn injury was 2.2 in 2001-2002, 2.4 in 2000-2001, 3.3 in 1999-2000, and 1.9 in 1998-1999. The most common causes of the burn are house fires, lighting a heater, and direct contact with a heater (Figure 4). To control for the potential effect of tempera- ture on the incidence of heater burns, the mean California temperature for each of the study months was obtained from the Western Regional Climate Center.3 The mean tempera- ture in each of the study months did not differ significantly between any of the study intervals (Figure 5). The greatest increase in heater-related burn injuries occurred in January 2001. Coincidentally, on January 1, 2001, Pacific Gas and Electric increased rates by 16.5%, and South- ern California Edison raised rates by 9.9%. As the shortage became more severe, stage 3 alerts (declared when an op- erating reserve shortfall of 1.5% is unavoidable or when the operating reserve is forecast to be �1.5% after using all avail- able resources) were instituted. On January 17 and 18, 2001, rolling blackouts were ordered statewide. A statewide stage 3 alert continued for 24 consecutive days. The rate of ro- tating blackouts increased from 1 in 2000 to 38 in the pe- riod from January to May 22, 2001. During this same in- terval, stages 1 and 2 notifications increased from 91 to 127.4-8 140 160 180 120 100 80 60 40 20 0 November 1998- February 1999 November 1999- February 2000 November 2000- February 2001 November 2001- February 2002 N o. o f A dm is si on s Total Admissions Heater-Related Admissions ∗ Figure 1. Total number of burn admissions and heater-related burn admissions during the winter months (November-February) for 1998-2002. The percentages of heater-related burns increased significantly during November 2000 through February 2001 compared with November 1998 through February 1999, and November 2001 through February 2002 (P�.05, �2 test). Asterisk indicates significant differences. 12 14 16 18 10 8 6 4 2 0 November December January February N o. o f A dm is si on s 1998-1999 1999-2000 2000-2001 2001-2002 ∗ ∗ Figure 2. Distribution of heater-related burn injuries by month. A significant increase (P�.05, �2 test) in burn injuries occurred in the period 2000-2001 compared with the 1998-1999, 1999-2000, and 2001-2002 periods. Asterisks indicate significant differences. Demographic Data of Burn Admissions During Study Period* Interval Total No. of Admissions Total No. of Heater-Related Injury Admissions Age, Mean (SEM), y TBSA Burn, Mean (SEM), % Hospital LOS, Mean (SEM), d No. of OR November 1998-February 1999 117 25 33.2 (4.6) 16.5 (4.5) 9.9 (2.3) 7 November 1999-February 2000 124 26 45.7 (5.5)† 12.3 (2.7) 12.3 (2.7) 18 November 2000-February 2001 151 36‡ 32.4 (3.8) 24.0 (4.6)§ 15.0 (3.5)§ 55 November 2001-February 2002 152 29 42.0 (3.7)† 12.0 (2.9) 7.0 (1.5) 19 *TBSA indicates total body surface area; LOS, length of stay; and OR, operations. †P�.006 by t test compared with 1998-1999 totals. ‡P�.001 by �2 test compared with November 1998 through February 1999, November 1999 through February 2000, and November 2001 through February 2002 totals. §P�.001 by t test compared with November 1998 through February 1999, November 1999 through February 2000, and November 2001 through February 2002 totals. (REPRINTED) ARCH SURG/ VOL 137, OCT 2002 WWW.ARCHSURG.COM 1107 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 COMMENT The fiscal impact of the California energy crisis has been the focal point of published reports. The financial ef- fects of the shortage on California power companies, the state, and consumers have been well documented. Cali- fornia residents were encouraged to conserve electricity and gas during times of severe shortages, and the high cost of electricity further reinforced this request. Mea- sures taken to conserve energy ranged from decreasing the set point on the thermostat to using alternative de- vices such as space heaters, wood-burning stoves, and fireplaces. Cost restraints frequently lead people to use unsafe heating sources. These alternative heating sources have the potential to cause serious injury if not used prop- erly. To our knowledge, to date the potential effect of the shortage on consumer health has not been addressed. This article is the first to document an increase in con- sumer-related burns after the implementation of rolling blackouts and increased energy costs. The greatest in- crease in the incidence of heater-related burns occurred in January 2001, coinciding with the electricity rate increase and the institution of blackouts. The increased number and severity of burn injuries, as indicated by a significantly greater number of operative procedures performed dur- ing this period, had a detrimental effect on consumer physi- cal and financial health. This will likely result in long- term morbidity for the affected consumers. Prevention of these injuries could result in lower financial and con- sumer health costs. Implementation of preventive strate- gies, such as installation of smoke detectors in homes, have been successful in decreasing the incidence of burn in- jury.9-11 A similar strategy may well be of benefit in pre- venting heater-related burn injuries in the future. Al- though economic or societal events may increase the risk of this type of burn injury, education regarding appropri- ate behaviors in response to the power shortage may help to ameliorate these effects. The full impact of the California energy crisis re- mains unclear. Although current studies have centered on the financial impact of the crisis, further investigation into the effects on consumer health needs to be undertaken. This study was presented as a poster at the Pacific Coast Sur- gical Association Meeting, Las Vegas, Nev, February 16, 2002. Corresponding author: Tina L. Palmieri, MD, Depart- ment of Surgery, University of California, Davis, 2425 Stock- ton Blvd, Suite 718, Sacramento, CA 95817 (e-mail: tina.palmieri@ucdmc.ucdavis.edu). REFERENCES 1. American Burn Association. Initial assessment and management. In: Sheridan RL ed. Advanced Burn Life Support Course Instructor’s Manual. Chicago, Ill: Ameri- can Burn Association; 2001:9-11. 2. Brigham PA, McLoughlin E. Burn incidence and medical care use in the United States: estimates, trends, and data sources. J Burn Care Rehabil. 1996;17:95-107. 3. Western Regional Climate Center. Available at: http://www.wrcc.dri.edu/cgi-bin. Accessed February 10, 2002. 4. National Energy Information Center. Available at: http://www.eia.doe.gov/cneaf /electricity/california. Accessed February 10, 2002. 5. California Power Exchange. Available at: http://www.calpx.com. Accessed Feb- ruary 10, 2002. 6. Federal Energy Regulatory Commission. Order Directing Remedies for Califor- nia Wholesale Electric Markets. December 15, 2000. 7. California Public Utilities Commission and Electricity Oversite Board. California’s Electricity Options and Challenges. Report to Governor Gray Davis. August 2, 2000. 8. Sheffrin Anjali. California Independent System Operatory: What Went Wrong with California Electric Utility Deregulation? April 19, 2001. 9. Hall JR Jr. The US experience with smoke detectors: who has them? how well do they work? when don’t they work? Natl Fire Protection Agency J. 1994;88: 36-39, 41-46. 10. McKnight RH, Struttmann TW, Mays JR. Finding homes without smoke detec- tors: one step in planning burn prevention programs. J Burn Care Rehabil. 1995; 16:548-556. 11. Gorman RL, Charney E, Holtzman NA, Roberts KB. A successful city-wide smoke detector giveaway program. Pediatrics. 1985;75:14-18. 30 25 20 15 10 5 0 November 1998- February 1999 November 1999- February 2000 November 2000- February 2001 November 2001- February 2002 Interval N o. o f P at ie nt s % TBSA Burn Length of Stay, d ∗ ∗ Figure 3. Mean percentage of total body surface area (TBSA) involvement and hospital length of stay increased significantly in the interval from November 2001 through February 2002 compared with November 1999 through February 1999, November 1999 through February 2000, and November 2001 through February 2002 (P�.05, t test). Asterisks indicate significant differences. 12 10 8 6 4 2 0 Stove Heater Contact Lighting Heater House Fire Campfire Fireplace N o. o f E ve nt s 1998-1999 1999-2000 2000-2001 2001-2002 Figure 4. Causes of heater-related burns included contact burns with stoves, house fires, fireplaces, and campfires. 60 (33.4) 50 (27.8) 40 (22.2) 30 (16.7) 20 (11.1) 10 (5.6) 0 November December January February Te m pe ra tu re , ° F (° C) 1998-1999 1999-2000 2000-2001 2001-2002 Figure 5. Average ambient temperature in northern California during the interval from November through February 1998-2001. (REPRINTED) ARCH SURG/ VOL 137, OCT 2002 WWW.ARCHSURG.COM 1108 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021