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Teamwork for Total Burn Care: Burn Centers and Multidisciplinary Burn Teams
Introduction
Severe burn injuries evoke strong emotional responses in most people including health professionals who are confronted by the specter of pain, deformity, and potential death. Intense pain and repeated episodes of sepsis, followed by either death or survival encumbered by pronounced disfigurement and disability, have been the expected sequelae to serious burns for most of mankind's history. However, these dire consequences have been ameliorated so that, although burn injury is still intensely painful and tragic, the probability of death has been significantly diminished. During the decade prior to 1951, young adults (15–43 years of age) with total body surface area (TBSA) burns of 45% or greater had a 49% mortality rate ( Table 2.1 ). Forty years later, statistics from the pediatric and adult burn units in Galveston, Texas, show that a 49% mortality rate is associated with TBSA burns of 70% or greater in the same age group. Over the past decade, these mortality figures have improved even more dramatically, so that almost all infants and children can be expected to survive when resuscitated adequately and quickly. Although improved survival has been the primary focus of burn treatment advancement for many decades, today the major goal—since survival rates have highly increased—is rehabilitation of burn survivors to maximize quality of life and reduce morbidity.
Table 2.1
Percent total body surface area (TBSA) burn producing an expected mortality of 50% in 1952, 1993, and 2006
| Age (years) | 1953 † (% TBSA) |
1993 * (% TBSA) |
2006 ° (% TBSA) |
|---|---|---|---|
| 0–14 | 49 | 98 | 99 |
| 15–44 | 46 | 72 | 88 |
| 45–65 | 27 | 51 | 75 |
| 65 | 10 | 25 | 33 |
† Bull, JP, Fisher, AJ. Annals of Surgery 1954;139.
* Shriners Hospital for Children and University of Texas Medical Branch, Galveston, Texas.
° Pereira CT et al. J Am Coll Surg 2006; 202(3): 536–548 and unpublished data. PP. 1138–1140 (PC65).
Such improvement in forestalling death is a direct result of the maturation of burn care science. Scientifically sound analyses of patient data have led to the development of formulas for fluid resuscitation and nutritional support. Clinical research has demonstrated the utility of topical antimicrobials in delaying onset of sepsis, thereby contributing to decreased mortality of burn patients. Prospective randomized clinical trials have shown that early surgical therapy is efficacious in improving survival for many burned patients by decreasing blood loss and diminishing the occurrence of sepsis. Basic science and clinical research have helped decrease mortality by characterizing the pathophysiological changes related to inhalation injury and suggesting treatment methods that have decreased the incidence of pulmonary edema and pneumonia. Scientific investigations of the hypermetabolic response to major burn injury have led to improved management of this life-threatening phenomenon, not only enhancing survival, but also promising an improved quality of life.
Optimal treatment of severely burned patients requires significant healthcare resources and has led to the development of highly specialized burn centers over the past decades. Centralizing services to regional burn centers has made implementation of multidisciplinary acute critical care and long-term rehabilitation possible. It has also enhanced opportunities for study and research over the past several decades. This has led to great advances both in our knowledge and in clinical outcomes, with further advancements being expected.
Implementation of a wide range of medical discoveries and innovations has improved patient outcomes following severe burns over the past half century. Key areas of advancements in recent decades include fluid resuscitation protocols; early burn wound excision and closure with grafts or skin substitutes, nutritional support regimens, topical antimicrobials and treatment of sepsis, thermally neutral ambient temperatures, and pharmacological modulation of hypermetabolic and catabolic responses. These factors have helped to decrease morbidity and mortality following severe burns by improving wound healing, reducing inflammation and energy demands, and attenuating hypermetabolism and muscle catabolism.
Melding scientific research with clinical care has been promoted in recent burn care history largely because of the aggregation of burn patients into single-purpose units staffed by dedicated healthcare personnel. Dedicated burn units were first established in Great Britain to facilitate nursing care. The first U.S. burn center was established at the Medical College of Virginia in 1946. The same year, the U.S. Army Surgical Research Unit (later renamed the U.S. Army Institute of Surgical Research) was established. Directors of both centers and later, the founders of the burn centers at University of Texas Medical Branch in 1947 and Shriners Hospitals for Children–Galveston in 1963 emphasized the importance of collaboration between clinical care and basic scientific disciplines to improve the patient's outcome.
The organizational design of these centers engendered a self-perpetuating feedback loop of clinical and basic scientific inquiry. In this system, scientists receive first-hand information about clinical problems, while clinicians receive provocative ideas about patient responses to injury from experts in other disciplines. Advances in burn care attest to the value of a dedicated burn unit organized around a collegial group of basic scientists, clinical researchers, and clinical caregivers, all asking questions of each other, sharing observations and information, and seeking solutions to improve patient welfare.
Findings from the group at the Army Surgical Research Institute point to the necessity of involving many disciplines in the treatment of patients with major burn injuries and emphasize the utility of a team concept. For this reason the International Society of Burn Injuries and its journal, Burns , as well as the American Burn Association and its publication, Journal of Burn Care and Research , have publicized the notion of successful multidisciplinary work by burn teams to widespread audiences.
Members of a Burn Team
The management of severe burn injuries benefits from concentrated integration of health services and professionals, with care being significantly enhanced by a true multidisciplinary approach. The complex nature of burn injuries necessitates a diverse range of skills for optimal care. A single specialist cannot be expected to possess all skills, knowledge, and energy required for the comprehensive care of severely injured patients. For this reason, reliance is placed on a group of specialists to provide integrated care through innovative organization and collaboration.
In addition to including burn-specific providers, the burn team consists of epidemiologists, molecular biologists, microbiologists, physiologists, biochemists, pharmacists, pathologists, endocrinologists, and numerous other scientific as well as medical specialists. Because burn injury is a complex systemic injury, the search for improved treatments leads to inquiry from many approaches. Each scientific finding stimulates new questions and the potential involvement of additional specialists.
At times, the burn team can be thought of as including the environmental service workers responsible for cleaning the unit, the volunteers who may assist in a variety of ways to provide comfort for patients and families, the hospital administrator, and many others who support the day-to-day operations of a burn center and significantly impact the well-being of patients and staff. However, the traditional burn team consists of a multidisciplinary group of direct-care providers. Although burn surgeons, plastic surgeons, nurses, nutritionists, and physical and occupational therapists form the skeletal core; most burn units also include anesthesiologists, respiratory therapists, pharmacists, spiritual therapists, and music therapists. The increasing number of survivors has consequently also added psychologists, psychiatrists, and, more recently, exercise physiologists to the burn team. In pediatric units, child life specialists and school teachers are also significant members of the team of caregivers.
Patient satisfaction can be formally measured through questionnaires to provide positive feedback to caregivers and highlight potential areas of improvement. Allowing patients to feel as if they are part of decisions about their care, listening and responding to concerns, providing encouragement, and displaying empathy are all important for maintaining satisfaction in patients and their families. These approaches also reduce fear, apprehension, and misunderstandings.
Healing relies on a complex array of factors. These include individual factors such as motivation, pre-existing health status, obesity, malnutrition, comorbidities, family support, and social support. They also include wider societal factors such as reintegration, individual perception, and coping strategies as well as factors specific to the mechanism of injury such as trauma, bereavement, grief, and loss.
Patients and their families are infrequently mentioned as members of the team but are obviously important in influencing the outcome of treatment. Persons with major burn injuries contribute actively to their own recovery, and each brings individual needs and agendas into the hospital setting that may influence the way treatment is provided by the professional care team. The patient's family members often become active participants. This is even more important in the case of children, but is also true in the case of adult patients. Family members become conduits of information from the professional staff to the patient. At times, they act as spokespersons for the patient, and, at other times, they become advocates for the staff in encouraging the patient to cooperate with dreaded procedures.
With so many diverse personalities and specialists potentially involved, purporting to know what or who constitutes a burn team may seem absurd. Nevertheless, references to “burn teams” are plentiful, and there is agreement on the specialists and care providers whose expertise is required for the optimal care of patients with significant burn injuries ( Fig. 2.1 ).
Burn Surgeons
Ultimate responsibility and overall control for the care of a patient lies with the admitting burn surgeon, the key figure of the burn team. The burn surgeon is either a general surgeon or plastic surgeon with expertise in providing emergency and critical care, as well as in performing skin grafting and amputations. The burn surgeon provides leadership and guidance for the rest of the team, which may include several surgeons. The surgeon's leadership is particularly important during the early phase of patient care when moment-to-moment decisions must be made based on the surgeon's knowledge of physiologic responses to injury, current scientific evidence, and appropriate medical/surgical treatments. The surgeon must not only possess knowledge and skills in medicine, but also be able to clearly exchange information with a diverse staff of experts in other disciplines and lead the team. The surgeon alone cannot provide comprehensive care but must be wise enough to know when and how to seek counsel as well as how to clearly and firmly give directions to direct activities surrounding patient care. The senior surgeon of the team is accorded the most authority and control of any member of the team and thus bears the responsibility and receives accolades for the success of the team as a whole.
Plastic Surgeons
Next to burn surgeons, who are particularly involved in the immediate and acute phase of surgical treatment, are the plastic surgeons, who are typically involved instead in long-term surgical treatment. The plastic surgeons aim to deliver care that yields the best functional and aesthetic results for the burn survivor. The burn surgeon should always work in close collaboration with the plastic surgeon. Most burn surgeons are plastic surgeons, but in instances where this is not the case, the presence of plastic surgeons in the team is essential. Ideally, this collaboration should start during the initial phase of surgical treatment. The plastic surgeon's duty is primarily to care for the patient in terms of functional improvement through surgeries that aim to lessen scarring and decrease the functional limitations created by scarring. This surgical treatment often requires numerous operations that may take place for years after the burn injury.
Anesthesiologists
An anesthesiologist who is an expert in the altered physiologic parameters of burned patients is critical to the survival of the patient who usually undergoes multiple acute surgical procedures. Anesthesiologists on the burn team must be familiar with the phases of burn recovery and the physiologic changes to be anticipated as burn wounds heal. Anesthesiologists play significant roles in facilitating comfort for burned patients, not only in the operating room, but also during the painful ordeals of dressing changes, staple removal, and physical exercise.
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