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7. Burn Care Teams
Keywords
Burn teamMultidisciplinary teamOutcomesTeam building7.1 Background
Teamwork is paramount in the delivery of healthcare. The burn care team, in particular, has always been an excellent model for a truly multidisciplinary and interdisciplinary team, as burn care providers must collaborate to maximize the success of patient care. The team is multidisciplinary because it utilizes the expertise of individuals from different disciplines but transcends to interdisciplinary by integrating the various approaches towards a shared goal. In a burn center, the set of goals is specific to the survival and quality of life of a burn patient.
7.1.1 Characteristics of an Effective Team
An effective burn team requires adequate team size, individuals with complementary backgrounds and skills, a balance of autonomy and authority, cohesion, open and inclusive, communication, and clearly defined measurable goals. This is essential for having the team being successful and working towards a common goal.
7.1.2 Burn Team Members
The special needs of burn patients are many and therefore the team has to be made out of multiple team players. There are numerous questions and issues that need to be addressed not only at hospital admission but also during hospitalization. These questions are contributors to burn patient outcomes and can only be addressed by a group of highly skilled healthcare professionals including burn surgeons, nurses, respiratory therapists, dietitians, physiotherapists, occupational therapists, social workers, pharmacists, speech-language pathologists, other support staff, and physicians such as physiatrists (rehabilitation physicians), psychiatrists, critical care physicians, anesthesiologists, and geriatric physicians.
7.1.3 Burn Surgeons
Historically, the attending surgeon was viewed as the “captain of the ship.”. However, this rigid hierarchy in healthcare and, particularly in burns, has undergone a redesign to support team-based care. The burn surgeon is a general or plastic surgeon with expertise in critical care, operative, and reconstructive management of burn patients, complex wound patients, as well as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) or other complex dermatologic patients.
7.1.4 Nurses
Nurses make up the largest portion of the burn care team and are responsible for providing continuous care of the patient. Burn nurses possess unique skills to provide for not only the critical care requirements of each patient but also the important wound care needs. Due to the complex nature of burn injuries where patients can also be mechanically ventilated and receive renal support, nurses provide intensive physical care, administer medications, conduct dressing changes, maintain patient comfort, and communicate with patients and families. Nursing acts as a liaison among the various multidisciplinary team members required to care for those with burn injuries ensuring a comprehensive holistic and supportive approach to care. Importantly, nurses are typically the first to observe any clinical changes in the patient and start any required intervention [1]. Therefore, nurses are central to the clinical course and assessment in clinical changes imperative for optimal patient outcomes. Care is provided using various assessments and critical thinking to identify slight changes in clinical condition.
7.1.5 Respiratory Therapists
Respiratory therapists are responsible for the management of the patient’s airway including intubation and assisting in insertion, management, and weaning of the tracheostomy. They perform the institution, management, and discontinuing of ventilation with the use of arterial blood gas values. If required, they take patients on scans for the optimization of their care. Respiratory therapists give medication to help treat inhalation injuries and pulmonary disease. They participate during dressings with the team to ensure that the patients are breathing adequately and comfortably while being given sedation. We also perform indirect calorimetry to help optimize the patient nutritional status.
7.1.6 Dietitians
The registered dietitian’s role in the burn unit is to monitor the dietary needs of the patients and provide nutritional recommendations and feeding regimens. Nutritional recommendations are adjusted to meet changing metabolic demands. The dietitian assesses multiple parameters including results of metabolic cart studies, laboratory markers in blood work, feeding tolerance, weight changes, and progression of wound healing and adjusts enteral feeds accordingly [2]. The dietitian is indispensable, especially for patients with pre-existing medical conditions, a complex social history associated with malnutrition, or a history of drug or alcohol misuse.
7.1.7 Occupational Therapists and Physiotherapists
Rehabilitation of the burn-injured patient is a continuum that commences from when the patient is admitted to hospital. The area and size of the burn and the patient’s pre-existing comorbidities heavily influence the stages of rehabilitation. Therapists regularly assess the injury and progress of wound healing to implement treatment modalities in order to meet goals such as function, strength, and range of movement. Rehabilitation is essential to minimize the development of contractures and reduce scarring and can continue on an out-patient basis [3].
7.1.8 Physiatrists
The physiatrist has an important role in guidance and education around a patient’s recovery, and short- and long-term functional goals. They work to increase both the patient’s and family’s understanding of the injury, medical management of burn-specific complications, and its impact on daily life. A vital part of the impact of burn injury includes quality of life, adjustment or coping skills, and managing changes in societal roles. Physiatrists also have a role in helping manage transitions of care from the acute care setting to discharge to rehabilitation, ambulatory, community, and return to work settings. As aforementioned, others and we suggest that it is important to have rehab team members attend to the patient even during acute hospitalization and not only when the patient left for rehab. Early integration of rehabilitation will improve outcomes and shorten length of stay.
7.1.9 Social Workers
The social worker is a crucial member of the burn center team who provides support and education for patients and families. The social worker conducts a comprehensive psycho-social assessment. Many aspects are included in the psycho-social assessment such as past medical history, including mental health, domestic violence and past trauma history, financial, employment, and housing considerations. Counseling is provided throughout hospitalization, discharge, and community reintegration phases to address practical needs and provide support to patients as they cope with the psychological and emotional issues that arise after injury including the risk of depression and PTSD. Social workers coordinate and advance an individualized discharge plan. The social worker also plays an important role in advance care planning and in end-of-life discussions.
7.1.10 Pharmacists
Pharmacists review and monitor all medications ordered for burn patients in hospital. They check to identify any allergies, drug interactions, and other potential safety concerns.
7.1.11 Physicians
Physicians from different specialties that are essential to the burn care team include anesthesiologists, critical care physicians, geriatric physicians, and psychiatrists. In addition to team members that are of different specialties, it is essential to have collaborations with other specialties, such as trauma, infectious disease, tissue bank, general surgery, internal medicine, and so on. When an issue occurs, these subspecialties are crucial to involve to help the patient to survive.
7.1.12 Students and Trainees
At teaching hospitals team members also include, students and trainees who are at burn centres for training and co-op palcements. Students come from a variety of professions and are integral to interprofessional teams.
7.1.13 Research Coordinator
The research coordinator’s works under the direction of the principal investigator. The research coordinator facilitates, supports, and coordinates daily clinical trial activities. They work with the rest of the burn care team and the institutional review board or research ethics board to help ensure research activities are performed in accordance with any regulations.
7.2 Burn Centers and the Team
An aspect that has allowed burn care teams to flourish is of course burn centers or the dedication of units to burn patients. A joint program of the American Burn Association (ABA) and the American College of Surgeons (ACS) is Burn Center Verification. Achieving verification means that a burn center meets rigorous standards and indicates that the center provides high-quality patient care to burn patients [4].
Burn centers have led to the increased use of protocolized care and improved outcomes. The implementation of standardized protocols and guidelines for management during the resuscitation period and for complications like sepsis and pneumonia that can occur after burn injury are beneficial. Evidenced-based care is imperative for good patient outcomes and for a team to function because there is little margin for error in these critically ill patients.
Despite efforts to increase the quality of care through evidence-based medicine, medical errors still occur. A recent study estimated that deaths due to medical error surpassed respiratory disease as the third leading cause of death in the United States [5]. The Canadian Adverse Events Study found that of the approximately 2.5 million annual hospital admissions 7.5% of all patients suffered an adverse event because of healthcare management that resulted in death, disability, or a longer hospital stay [6]. While the cause of medical errors can be multifactorial, a common denominator relates to communication. Successful teams require effective communication, which is challenging. Part of the solution comes from quality improvement, engaging patient safety teams, documentation of performance, and setting goals for performance indicators. Quality improvement is most successful when executed by a multidisciplinary team.
7.3 Education
While each burn care provider completes their respective education and training, a vital aspect for a successful burn care team is education as a team. There are many different approaches to interprofessional learning like exchange-based learning (seminars, workshop discussions, and case studies), problem-based learning, and simulations [7]. Feedback from students showed that interprofessional education forged a mutual respect and a better understanding of the healthcare team [7]. Weekly education rounds should be attended by all members of the team and, importantly, taught by all members of the team.
7.4 Summary
In summary, a successful burn care team depends on various components; it needs to be open and inviting, dynamic, have a strong communication, trusting, and truly multidisciplinary. Only then the burn team can provide high-quality care for patients.
Summary Box
In summary, teamwork is paramount for the effective delivery of burn care. The team has to be multidisciplinary with every team member having an important impact and insight on patients care. It is in our opinion extremely crucial to build a safe and open environment for rounds and patients-related meetings, in fact to invite all team care providers to actively participate and contribute. As recently indicated by several studies, a certain aspect of continuity, as well as open invitations for contribution, are a key to achieve a better outcome.
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