The American Burn Association (ABA) has an established set of criteria for burn center referral to guide healthcare providers and improve patient outcomes. As U.S. healthcare becomes increasingly focused on improving quality of care (ie, pay-for-performance initiatives), assessing and monitoring the referral patterns to burn centers is critical in providing optimal burn care. Few studies have compared admission, treatment, and discharge patterns at burn centers and nonburn centers. Our goal was to compare practice and referral guidelines for patients with burn injuries by reviewing every discharge record in our state over a 2-year period. The study was conducted in a retrospective fashion using our state's hospital association patient database of International Classification of Diseases, 9th revision (ICD-9) discharge codes, querying 940.00 to 948.99, over the period of October 1, 2005, to September 30, 2007. Additional variables abstracted included the discharging hospital, outcome, race, gender, payor status, length of stay, procedures, and age. Adherence to referral criteria was established by comparing the discharge ICD-9 codes with the burn center referral criteria established by the ABA and American College of Surgeons Committee on Trauma in Guidelines for the Operation of Burn Centers. Injury patterns were analyzed using the 2 burn centers in our state and the remaining 107 nonburn centers providing care to burn patients. A total of 2036 adult patients aged 18 to 106 years sustained burn injuries requiring hospital admission, and 1416 (70%) met ABA referral criteria based on ICD-9 codes. Of the 1084 patients treated at burn centers, 88% met referral criteria. Of the 952 burns treated entirely at nonburn centers, 48% met referral criteria but were not transferred. The most common burns treated at nonburn centers included injuries to the hand, wrist, face, neck, and lower extremity. The mean number of criteria met by patients treated at nonburn centers was 1.5, and all deaths occurring at nonburn centers met referral criteria. A significantly higher percentage of patients with Medicare were not transferred from nonburn centers (P < or = .00001), and a significantly higher percentage of patients were discharged to nursing homes as opposed to home (P = .01) from nonburn centers. Forty-seven percent of the patients sustaining burn injuries in our state receive all of their acute inpatient care at nonburn centers, and almost half of these met ABA burn center referral criteria. Given the disparity in discharge placement and immediate availability of burn specialists in our state, all patients meeting ABA referral criteria should be referred to burn centers. More focused outreach and education for initial providers may help improve access and referral to burn centers.