Advanced practice providers (APPs), such as physician assistants (PAs), advanced practice registered nurses (APRNs), and certified registered nurse anesthetists (CRNAs), are force multipliers for the physician to provide care and reach a broader patient population, especially in subspecialties such as burn reconstruction. The focus of this chapter is an overview of burn reconstruction from the perspective of the APP and practice considerations for the approach and organization of outpatient burn reconstruction that can be useful for any member of multidisciplinary reconstruction teams. APPs facilitate collaboration among a physician-directed multidisciplinary team, allowing for a more comprehensive and patient-focused approach. A brief overview of acute burn management is provided, during which stage the APP may also play an integral role. Any provider participating in acute burn care should strongly consider obtaining Advanced Burn Life Support (ABLS) certification, a targeted educational resource for first responders and other medical personnel focusing on the emergency care of the burn patient in the first 24 hours after burn injury.

Burn reconstruction is an essential component of the overall recovery of adult and pediatric burn patients. Burn care should focus on survival and quality of life with optimized restoration of function. The burn reconstruction and recovery process can take up to several years after the initial injury, depending on the depth and severity of the damage. Access to reconstructive care with a dedicated multidisciplinary team is valuable as surgical methods evolve and advance. Some of the reconstruction needs of the burn patient may include, but are not limited to, scar contracture release, unstable scarring, nonhealing wounds, dyspigmentation, pruritus management, anatomic/functional deformities, alopecia, syndactyly, heterotopic ossification (HO) or osteomyelitis, ectropion, complex tendon repair, and laser procedures.

The acutely burned patient undergoes multiple transitions in the recovery timeline, each of which may have reconstruction considerations.

The outpatient setting allows for more control over reconstruction’s nuances and multidisciplinary aspects, facilitating positive outcomes and a patient-centered approach. However, under some circumstances, reconstruction and acute burn closure coincide. Patient education begins as early as in the emergency or prehospital setting to help the patient and family understand the trajectory of acute burn care and that burns may become a lifelong diagnosis. They can result in chronic problems requiring ongoing specialized care. In the inpatient setting, the closure of functional and cosmetic areas should be approached with the prevention of poor outcomes in mind.

Reconstruction principles should be incorporated into every patient’s journey to reduce future reconstruction needs. The transition from acute inpatient care to outpatient care is an important step in the patient’s transition to independence, and they may become more empowered to participate in their care with aggressive therapy and start the rehabilitation process from burn-related critical illness. The transition from the acute care setting to inpatient rehabilitation and/or discharge is one of the most critical because this is a time when many of the final closure efforts are maturing. Losing continuity of care during this time can have devastating consequences for outcomes, especially regarding therapy goals, wound care, and specialist follow-up needs. The APPs can assist during this transition to ensure continuity of care and follow-up and provide oversight. Particular focus should be placed on educating patients and their family members about the standards of care and what to expect, as well as empowering them to participate in the care to promote good outcomes. Nursing and other support staff education and instructions should be provided in detail, especially when transitioning to home health, inpatient rehabilitation, skilled nursing facilities, correctional facilities, or any other entity that is not a specialized burn or reconstruction center.

Many patients find that the frequency of surgery during acute burn management is overwhelming and takes a significant emotional and physical toll over time. For this reason, the first outpatient appointments should be focused on achieving initial burn closure, education on scar management, and preventative measures for developing healthy, mature burn scars. Reconstruction surgery should not be pursued at this time unless there are unstable scars, autoreleased contractures, acute infection concerns, exposure of the cornea, or neurovascular bundles or if the patient is insistent upon and clinically ready to begin reconstruction efforts. Often, a burned patient’s critical and acute care is primarily physician directed from a skin closure and medical perspective. The transition to reconstruction allows patients to regain control over their lives, especially regarding surgery scheduling and priorities.

Upon referral to reconstructive care, the reconstruction patient will likely have symptomatic, functional, and cosmetic concerns. Surgical staging is usually necessary for patients with multiple areas of concern and major reconstruction needs. Some patients may tolerate multiple interventions simultaneously, but mobility and self-care considerations should be weighed with urgency to continue reconstruction efforts. In many cases, laser therapy can be effectively incorporated intraoperatively with other procedures to reduce the frequency of surgery. Generally, functional deficits will be prioritized, especially with hand reconstruction and major joint contractures. Oral commissure contractures and periorbital and oral aperture corrections are also prioritized for functional outcomes. Unstable or autoreleased areas should be given special priority and may drive more urgent surgical intervention to promote achieving and maintaining wound closure. Ultimately, prioritizing surgery is a joint effort between the surgical team and the patient, with the assistance of the multidisciplinary team. Physical and occupational therapy provides critical insight into the patient’s functional progress. ^,

Reconstruction may take several years and even necessitate intermittent interventions throughout the patient’s life. Managing expectations for cosmetic and functional results should be measured with quality of life and frequency of surgery. Thorough patient education, especially at the onset of reconstruction efforts, will help increase patient compliance and improve functional and cosmetic outcomes.

The reconstruction patient can have a complicated hospital stay, and a reconstruction center should have access to a robust multidisciplinary team. The patient-centered approach allows patients to take an active role in their care and decision-making, and the surgeon, with each patient, will set the tone for priorities and reconstruction timelines. APPs work with the surgeon to evaluate and treat patients, including assisting in surgery and performing routine bedside procedures in outpatient, inpatient, and intraoperative settings. Especially in nonacademic settings, APPs are pivotal in extending physicians’ capacity to provide their surgical expertise to more patients without sacrificing quality of care. APPs also facilitate communication among the multidisciplinary team, following up on consults, referrals, and continuity of treatment plans. A multidisciplinary approach to burn care has benefitted patients, families, and systems in achieving outcomes.

Provider support positions in the reconstruction outpatient setting can also be beneficial for extending care. A medical scribe is an adjunct to the team, allowing providers to spend more time facilitating care and providing patient support and education. Medical scribes also promote consistency, standardization, and increased recordkeeping accuracy, ultimately promoting efficiency among the care team. Medical photography is also essential to the reconstruction process, providing a benchmark for patients’ progression toward their care goals, documentation of complications, and giving insight for research. Any care team member can be designated to perform photography, but a dedicated professional medical photographer is ideal for the best quality documentation. According to individual institutional policies and available technology platforms, many applications are available for privacy-compliant photo repositories.

Rehabilitation and therapy services, including physical, occupational, and speech therapy, are nonnegotiable as reconstruction multidisciplinary team members. Therapy interacts with the patient at each visit to provide additional treatment modalities and recommendations for scar management, range of motion (ROM), and mobility. They will evaluate the patient postoperatively for splinting and compression needs and sometimes perform splinting intraoperatively for pediatric and complex splints. They are critical for appropriate splinting, stretching, and compression for complex scar areas. Patient education by therapy reinforces the importance of compliance, and they can identify and closely monitor functional efficacy and outcomes during reconstruction. Having in-house therapy resources does not negate the need for outpatient or in-home rehabilitation and therapy, and most reconstruction patients will benefit from continued referrals to these services several times a week when undergoing or recovering from reconstruction surgeries. Certified hand therapy especially should be maintained during hand reconstruction, per evidence-based guidelines, and at the surgeon’s discretion. ^,

Nursing staff facilitate the execution of care in all patient settings and are the first line of defense in identifying new and unresolved issues. According to the Burn Nursing Scope of Practice and Competency, the burn nurse facilitates coordination of care to facilitate outcomes. Nursing staff spend much time at the bedside with the patient between routine nursing assessments and time-consuming wound care in both inpatient and outpatient settings. Nurses are the gatekeepers for the patient flow in the perioperative and outpatient settings and facilitate many administrative support functions associated with referrals and follow-up care.

Certified child life specialists (CCLS) are an essential adjunct to the reconstruction team for pediatric patients. Their goal is to minimize the trauma to the patient and provide age-appropriate interventions and behavioral tools to promote coping mechanisms and positive outcomes. The pediatric burn patient can have complex psychological and behavioral responses to health care settings that require a specialized approach to care. The CCLS is trained to help manage fear and anxiety for the patient and family members, creating a less stressful healing environment in inpatient, outpatient, and perioperative settings.

Social workers and advocacy resources are necessary because of the multidisciplinary nature of reconstruction treatment. Social support, such as assistance with lodging, transportation, prescriptions, and primary care resources, is sometimes needed for patients who may travel long distances for treatment, are underinsured, or have complicated social situations. Additional support functions may be required to facilitate completion of work, school, or leave-related documents. Disability and workman’s compensation forms, as well as other related record requests may be needed. The reconstruction provider will provide referrals to other specialists in the absence of or in conjunction with the primary care provider, and many patients require assistance with identification and scheduling with specialists familiar with the complexities of burn reconstruction care. Social workers and nurse navigators are essential advocates for patient follow-up needs and for addressing social issues that may hinder the progress of reconstruction efforts.

Multidisciplinary consultants may be needed to facilitate the reconstruction process, especially if the patient’s acute burn course is complicated. The patient’s primary care provider should ensure adequate specialist follow-up after discharge. Still, frequently, it falls to the reconstruction team to make these referrals to optimize the patient for future surgeries medically. Other specialties may be needed if the patient had a prolonged hospital stay or sustained other trauma, such as general surgery, otolaryngology, and orthopedic surgery. Genital reconstruction may be a joint effort with urology or gynecology for especially complicated cases. If amputations were performed acutely or revised as part of the reconstruction plan, a prosthetist referral would be needed once wound healing and scar maturation are achieved. Each patient’s unique needs should be considered thoroughly for specialist referral.

All new patients begin with an initial evaluation in the clinic by a multidisciplinary reconstructive team, including a surgeon, APP, occupational and/or physical therapist, and nursing. The patient may be self-referred to the burn reconstructive clinic or referred by an acute burn provider based on established referral criteria, which include overall TBSA of 20% or greater in adults or 5% in pediatrics and required autografts for closure or autografts over specific anatomy (hands, feet, face, neck, breast, perineum, or any contracture-prone joints), burn scars that are hypertrophic or symptomatic, and alopecia. The referral should be made once the patient has achieved closure of most acute burn wounds.

During this initial evaluation in our reconstructive center, the patient is first welcomed to an exam room by nursing staff, who obtain vital signs and an initial assessment. Next, the patient completes self-reporting questionnaires utilizing validated screening tools on overall health, life satisfaction, mobility, functionality, pruritus, depression, and posttraumatic stress disorder. The physical and occupational therapy team then evaluates the patient’s functional and mobility status. Modified scar goniometric measurements are obtained of affected joints. Education and treatment are provided on scar management (sun protection, moisturization, scar massage, scar gel products, interim and custom compression), desensitization, custom orthotic fabrication, serial casting, task modification with adaptive equipment, hydrotherapy, and home exercise program. ^,

The provider then sits with the patient for a complete history and physical examination. The details and treatment of the acute burn injury and any previous reconstructive treatment are discussed. The patient’s personal goals, including cosmetic and functional, are also discussed during this time. After obtaining informed consent, medical photography of all burn scars and joint mobility is obtained at the initial visit and future follow-up. Plain film data persist for studies to identify HO, although microcomputed tomography may be considered if a physical exam warrants.

The surgeon subsequently evaluates the patient with the multidisciplinary team. A focused physical exam is performed, and the patient’s goals and limitations are reiterated. Potential options for surgical intervention are discussed. Patient priorities are considered with stages of operative planning and which individual procedures are best to pair together to limit surgeries without compromising patient rehabilitative success and satisfaction. The plan is staged working proximal to distal (e.g., axilla before hands). Most often, functional surgical goals are scheduled before cosmetic goals; however, the patient’s mental health and view of self are always considered.

During the discussion with the patient, several needs are systematically approached. An emphasis is placed on the importance of the social support system, which is the framework for assistance with activities of daily living (ADLs), wound care, and transportation, among others. Their mental health is also evaluated through evaluation during history, overall demeanor, and as self-reported by patients on questionnaires. If a patient’s acute injury was work related, special consideration is needed, including additional communication with the case manager and further orders for specific treatment options, equipment, or others as indicated.

At the conclusion of the visit, the provider reaffirms the plan with the patient, including expectations, and ample time is given to review the surgical and recovery processes and to answer the patient’s questions and those of their accompanying support person. After stages of the surgical reconstructive plan are created and the patient is agreeable, surgeries are submitted to insurance for the precertification process. If a patient is unfunded, self-pay options may be provided based on institutional guidelines. With written patient consent, external records are requested if the patient was treated acutely or had prior reconstructive treatment at an outside facility; if the patient has any additional comorbidities, especially those increasing the operative risk, records from those treating specialists are requested. In these circumstances, preoperative clearance is often required. Referrals are made to appropriate outside providers, including outpatient therapy (physical, occupational, certified hand, speech), neurology (nerve conduction velocity studies), orthotist, orthopedic surgery, cardiology, pulmonology, home health, prosthetist, among others. Lastly, nursing staff may apply wound care according to orders, providing the patient with a written discharge plan.

The amount and frequency of follow-up are very patient dependent. The patient may return to the clinic for necessary reevaluation (after progressing in a home exercise program or outpatient therapy, completing outside nerve or functional studies, or evaluating other providers as needed) before scheduling a surgical intervention. If outside medical records were requested, these are reviewed once received. Recommended surgery is scheduled by stage once the patient is clinically ready and agreeable to the plan. Patients quickly become familiar with their care team for their burn reconstructive journey by using a dedicated multidisciplinary approach in the clinic. As this is often a lengthy process with multiple surgeries and many clinic visits, having a good rapport with the team benefits the patient’s continuity of care.

The surgical plan for the burn reconstructive patient is an initial guide to the operative stages. The plan is fluid, and the order of operative stages may be altered during the surgical course per the patient and surgeon. Regardless of stage, there are several considerations for all patients at each aspect of the course, including preoperative, intraoperative, and postoperative. The next sections have some guidelines and considerations to bear in mind by stage.