Abstract | December 20, 2021
Development of an Integrative Model to Improve Access to Rehabilitative Services for Patients Following Burn Injury in the Outpatient Burn Clinic Setting: A Multidisciplinary Effort
- Recognize the important role therapy plays in community reintegration.
- Discuss the importance of a multidisciplinary partnership in achieving successful outcomes following burn injury.
- Identify barriers to outpatient follow up with rehabilitative services.
Specialized rehabilitative therapy is essential in assisting patients to achieve maximal range of motion, strength, and the ability to complete functional mobility tasks such as transfers, gait, and the ability to complete ADLs (activities of daily living) following burn injury. Over the past 10 years, the importance of early mobilization has been proven in the literature and is now part of the standard of care provided for this specialized population.
Most large burn centers have a designated interdisciplinary burn team including physical and occupational therapists who understand the unique needs of patients following burn injury (Holavanahalli et al, 2011). Some skills cited in the literature as necessary to be a specialized burn therapist include wound care assessment, edema control, management of pain and anxiety, positioning, splinting, range of motion, functional mobility and gait, ADLs, scar assessment and management, and endurance and muscular strength (Forbes et al, 2016). An understanding of the stages of wound healing is also integral to provide appropriate therapy as the patient progresses through the stages of care and transitions from an acute to an outpatient setting.
Treatment adherence plays a key role in patient success following discharge from the acute setting. With regards to burn care this includes completing dressing changes as needed, sun protection, stretching burn sites, strengthening exercises, gait training, completing ADLs and use of compression garments/silicone as indicated for the treatment of scarring. One study examined the burn survivor’s personal experiences with rehabilitation. It looked at several characteristics which influence a patient’s compliance with suggested care. One common characteristic identified was support which was further divided into support from family and friends, professional and peer support (Kornhaber et al, 2014). Professional support was defined as knowledge and education provided to burn survivors by healthcare professionals concerning therapy and wound care. Many burn survivors felt they did not have a good understanding of the importance of continued stretching or the use of compression garments which led to poor compliance. The study suggested that improved integration between the burn unit and the rehabilitation/community setting could improve the patent’s experience and provide a smoother transition during an often-challenging time (Kornhaber et al, 2014). Additional challenges during the transition to a community setting include limited funding, transportation, and lack of burn expertise in the general rehab community. Our urban based burn center addressed these issues by incorporating rehabilitation into follow up medical care at our outpatient burn clinic allowing patients to easily access therapy services regardless of payor source.
Burn-injured patients may face challenges to participating in formal rehabilitative services as an outpatient, potentially delaying or preventing full reintegration into their home life and community. Several barriers were identified including funding, available rehab therapy staff and lack of records when therapy services were provided at the burn clinic. Even when services were available patients were noted to receive less than adequate therapy due to a lack of burn-specific knowledge among local providers. During the early years, occupational and physical therapists would staff the outpatient clinic on a case-by-case basis, primarily facilitating compression therapy, and only for patients with some funding source. In 2018, leadership from acute rehabilitative services met with the outpatient and inpatient care administrators, the burn director, and the burn APRN and funding was secured from the outpatient cost center to allow physical and occupational therapy providers from the acute care hospital to offer services in burn clinic 8 hours per week. Therapists covering the clinic hours were a part of the inpatient interdisciplinary burn team, promoting continuity of care between settings. These particular therapists possess advanced skills and training in scar assessment and interventions for scar management including scar massage, measuring for custom compression garments and the use of silicone as indicated.
Starting in 2018, a physical or an occupational burn therapist is present during burn clinic for 4 hours twice per week. Therapists can provide therapy to assess progress in patients receiving outpatient services elsewhere, assist with stretching, ADLs, gait and assess patients for the need for custom compression garments. In 2019, further funds were obtained through our burn foundation to purchase ready to wear light compression gloves to provide to all patients in need regardless of funding. In 2019, 59 ready to wear gloves were distributed and in 2020, 67 gloves were distributed. Most recently, we were able to obtain basic therapy supplies including theraputty, theraband and rolling walkers to further expand the services we can provide. The charts below highlight the large volume of patients coming through the outpatient burn center particularly over the past 3 years as well as the significant increase in the number of patients measured for custom compression garments over that same period.
Overall, successful recovery and reintegration into society following burn injury requires a multidisciplinary approach given the complexity of burn injury. Consistent messaging from providers specializing in burn care is important to help patients transition from acute care to the outpatient setting as their physical wounds begin to close and the remodeling phase begins. This novel approach of having a rehab therapist specializing in burn care present to see patients during their follow up appointment with the burn physician or burn APRN has helped improve access to quality rehabilitative care regardless of payor source.