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342
B. T. Stewart and N. S. Gibran
be leaving the hospital and new or exacerbated acute stress
symptoms, fear, isolation, and anxiety [18]. Additionally, the
functional gains achieved during inpatient care must be consolidated in the days and weeks after hospital discharge.
Therefore, these patients are often best supported by close,
interdisciplinary follow-up with providers within a known
system.
Functions ofanOutpatient Burn Clinic
When possible, care of patients with burn injuries in the outpatient setting should be interdisciplinary with careful attention paid to patients’ physical, psychological, and social
well-being. Specifically, nursing and wound care, scar management, functional activities, psychosocial therapy, and
vocational rehabilitation services should be available for
patients when needed either in-person or via telemedicine.
Even small burns can have significant biopsychosocial
impacts.
Burn Surgery Services
Burn surgeons play important roles in outpatient burn care,
including clinical care, acute wound management, scar reconstruction, and long-term follow-up. Burn surgeons often
guide the overall care of burn injured patients. During an
outpatient encounter, the surgeon will assess the patient,
wound and their broader psychosocial context for
opportunities to reduce the risk of hypertrophic scar and
contracture formation with surgical care. Over the long term,
surgeons work with patients and the interdisciplinary team to
mitigate the impacts that scars, contractures, and other
sequelae of burn injury have on patients through a reconstruction plan. The array of specialist skills to manage acute
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burn injuries and burns as a chronic condition is extensive
[19]. Surgeons must be aware of their limitations and seek
consultation and co-management with other specialist colleagues when needed.
Wound Care andNursing Services
Wound care and education comprise a significant proportion
of burn clinic resources and nursing responsibilities. Successful
wound management facilitates timely healing, minimizes the
risk of infection, reduces pain, and prevents the need for
inpatient care (see Chap. 6). Burn clinics should offer a variety of dressing options to achieve these goals depending on
the patient and wound characteristics. As an example, some
patients prefer daily dressing changes so that they can shower
frequently, and others prefer longer term dressing options
that minimize pain and anxiety of wound care. Importantly,
wounds must be assessed during the first days and weeks
from injury to evaluate and predict wound closure. Patients
whose wounds are not anticipated to heal within 2–3weeks
should be evaluated for surgical wound closure to mitigate
the risk of hypertrophic scar formation. Wound assessments
should be timed such that decisions about benefits and risks
of early excision and grafting can be made with the patient
and their family. Concerns about wound infection, including
patient-reported change in wound appearance or increased
pain with wound care, should trigger expert wound
assessment.
The American Burn Association (ABA) published Burn
Nursing: Scope and Standards of Practice reflects a focused
effort to establish specific guidelines for the specialty of burn
nursing in both the inpatient and outpatient settings.
Consensus-based burn nursing competencies should be
applied to build nursing and wound care capacity in burn
centers and to support regional education outreach programs [20].
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B. T. Stewart and N. S. Gibran
Burn Therapy Services
Burn therapy is central to successful mobility, resumption of
activities of daily living, and range of motion and strength
(see Chap. 22). Burn therapists assess range of motion and
risk of contracture, prescribe stretching and exercise programs, create custom splints and casts, recommend assistive
devices and home and work adaptations, and coordinate care
for new amputees. Like nurses, therapists provide critical
educational services to patients and their families. In 2011,
the Rehabilitation Committee of the ABA published clinical
competencies for burn rehabilitation therapists [21]. These
guidelines provide recommended standards of performance
for therapists caring for burn patients. Given that many
patients require community-based outpatient therapy to
counteract contracture and improve range of motion and
independence, expansion of burn therapy competency training to non-specialists and development of teletherapy programs are potentially valuable opportunities for burn center
outreach and education to improve patient functional
outcomes.
Psychology andSocial Services
Burn injuries have a high prevalence of pain, pruritus, acute
and post-traumatic stress symptoms, anxiety, depression, opioid misuse and abuse, changes in sexuality and intimacy and
challenges with body image [22–28]. These symptoms constitute physical and mental function and often negatively
impact social connectedness, community integration, and
post-traumatic growth. Further, individual symptoms can be
difficult to identify and can amplify one another, which complicates their management. National consensus has concluded that outpatient screening for pain interference,
depression, and post-traumatic stress are critical for optimal
care of burn patients [29, 30]. Furthermore, access to psychology and social services is critical in the outpatient burn set-
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ting to directly address burn-related mental health issues.
Burn clinic psychologists commonly employ motivational
interviewing, cognitive behavioral therapy (CBT), and relaxation exercises. [31, 32] In particular, CBT is a psychological
intervention that improves people’s ability to manage pain,
acute stress symptoms, anxiety, and depression [33]. CBT
generally focuses on challenging and changing unhelpful cognitive distortions, such as catastrophizing. It also targets maladaptive behaviors, improves emotional regulation, and aides
in the development of personal coping strategies. The most
common treatment dose of CBT involves 6–10, 60-min outpatient sessions. However, 4 sessions have been shown to have
significant and similar benefits but with markedly less burden
on patients in the outpatient setting [34]. CBT delivered
through telemedicine has also been demonstrated to be safe
and effective [35].
Non-surgical Scar Management Services
In addition to the care and planning provided by a burn surgeon, clinics should provide scar management services or
referral opportunities for consultation and counseling about
scar and treatment options, clinic-based treatments (e.g.,
intralesional therapies such as steroid injection, microneedling), fitting for custom pressure garments, scar massage, and
coordination for surgical management. Management of scar
in the outpatient setting is beyond the scope of this chapter
(see Chap. 21).
Vocational Rehabilitation Services
Return to work has been identified as a core functional outcome for burn care and rehabilitation. Burn injury causes
significant interruption of work, with an average time away
from work of 17weeks and only 66% of patients working at
6 months post-injury [36]. A significant number of patients
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B. T. Stewart and N. S. Gibran
may never return to work, with reported rates of only 60 to
80% of previously employed patients working at 1year [37].
Vocational rehabilitation is essential for graduating patients
back to the work environment. A key member of the outpatient burn care team is a vocational counselor who coordinates return to work with both patients and employers,
including the need for duty modifications. Published evidencebased guidelines [37] for comprehensive return to work programs following burns include having a vocational counselor
who [38]:.
1. Advocates for workers’ rights and focuses on ability, not
disability
2. Liaises between patient, employer burn center, workers’
compensation, and labor and industry
3. Completes and updates the Activity Prescription Form
4. Encourages active patient participation in the return-to-
work process
5. Provides a toolkit of activities for recovering patients to
facilitate return to work
6. Distributes the Burn Model System Employment After
Burn Injury factsheet.
Child Life andScholastic Support Services
For children, return to school is an important goal for outpatient burn care and, on average, occurs 8–10days following
injury [39]. Despite a fast return, children may experience
difficulty with managing pain at school, integration due to
appearance, physical limitations, and the reactions of their
peers [40]. Efforts should be made to help children keep up
with schoolwork. School visits or videoconferences from the
clinic may help reintroduce children who have changes in
appearance or assistive devices to their teachers and peers. A
comprehensive return to school program with a child-life
specialist to educate peers and teachers and encourage acceptance represents best practice for burn centers that care for
children [41]. These services are well-suited for telemedicine,
particularly in virtual school settings.
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General Principles ofOutpatient Burn Care
The outpatient burn care plan for acute injuries should incorporate the following principles:
1. Screen for concerning signs, symptoms, and impairments
2. Perform patient and wound assessment
3. Cleanse the wound and develop a dressing plan
4. Manage pain, anxiety and acute stress symptoms
5. Assess range of motion and create a stretching and exer-
cise plan
6. Educate patients and their support system
7. Dene return conditions and schedule
8. Consider long-term follow-up to assess the patient and
their scars
Screen forConcerning Signs, Symptoms,
andImpairments
Identifying patients who need specific or additional services
is a core function of outpatient burn care. People living with
burn injuries experience a range of physical, psychological,
and social morbidity. Further, morbidities can manifest in
subtle ways that can go undetected if not systematically
assessed with objective and valid measures [42–44]. Burn
clinic staff can use brief measures to assess for overall physical and mental health and function and specific conditions
common among people living with burn injuries, such as poor
range of motion, significant pain interference, pruritus, anxiety, depression, isolation, and acute and post-traumatic stress
disorder (ASD/PTSD). As an example, the International
Society for Burn Injuries (ISBI) and other national burn
associations (e.g., ABA, Australian, and New Zealand Burns
Association [ANZBA]) recommend screening for ASD/
PTSD, anxiety, depression, and alcohol abuse [1, 30, 45].
Examples of measures currently used by burn clinics include
Patient-Reported Outcomes Measurement Information
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B. T. Stewart and N. S. Gibran
System® (PROMIS) Global-10, Patient Health
Questionnaire-2 (PHQ-2), CAGE Alcohol Questionnaire,
and PTSD Checklist 5-Civilian (PCL-C).
ASD/PTSD are particularly common following burn
injury. The presence of ASD early after injury predicts the
development of PTSD, indicating that early diagnosis and
treatment is beneficial [27, 46]. The prevalence of PTSD
ranges from 2 to 40% by 6months post-injury, 9 to 45% in the
year post-injury, and 7 to 25% more than 2years post-injury
[46]. This prevalence is more than twice that of the general
population. Symptoms including intrusive thoughts, nightmares, flashbacks, and hypervigilance are common among
people living with both conditions. Standardizing screening
and the use of validated tools can identify patients in need of
treatment early. The PCL-C has been used for this purpose,
although other tools are available [47, 48]. The Primary Care
PTSD screen is a short, four-item test designed for use in the
primary care setting [49]. Patients who screen positive should
either receive psychological treatment or be referred to a
mental health provider for evaluation and treatment.
Systematic use of PRO measures as screening tools allows for
efficient application of the intensive resources required to
manage severe physical and psychosocial comorbidities to
the patients who need them most.
Perform Patient andWound Assessment
In addition to performing a standard history and physical
examination, the outpatient provider should examine the
wound and consider its size, distribution, depth, and stage of
healing. Interpreting burn wounds, particularly early after
injury, can be challenging since the wound depth may progress or become more apparent 72–96h after injury. Photos
and videoconferencing can be used to support consultation
with an experienced burn care provider and/or track changes
in the wound appearance and healing over time, particularly
when incorporated into the medical record [3]. Burn wound
assessment is covered in detail elsewhere in Chap. 6.
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Cleanse theWound andDevelop aDressing Plan
Wounds should be washed with soap and water, and loose
blisters and non-viable skin remnants should be debrided.
Opinions about the optimal management of and dressing
plan for burn wounds vary. Numerous randomized controlled
trials and observational studies have demonstrated that no
single technique is superior [50]. It is important to consider
wound characteristics, patient / family ability to manage the
wound and execute the dressing plan, and the general dressing principles. A cross-sectional survey of 121 burn providers
from 39 countries provided insight into the ideal burn dressing qualities [51]. Respondents recommended that the ideal
dressing would establish an optimum micro-environment for
wound healing, maintain the wound temperature and moisture level, allow epithelial migration, exclude environmental
bacteria, minimize pain, not require daily changes, and be
affordable. Although there is no ideal dressing to date, many
of these qualities are satisfied by the use of non-stick gauze
and antibiotic ointment, silver-impregnated dressings, and
biological dressings [52]. All wounds should be supported
with gentle compression to minimize swelling and pain from
vascular engorgement and reduce the risk of infection [53].
Manage Pain, Anxiety, andAcute Stress Symptoms
Patients should undergo a systematic assessment to understand their pain, anxiety, and acute stress symptoms (see
Chap. 16). Most patients will require pain medication for
wound care. Acetaminophen and/or non steroidal antiinflammatory drugs (NSAIDs) are often sufficient, but low
doses of opioids may be needed in some cases. Pain medications with or without a low dose of anxiolytic medication can
be provided for patients to take ~30min prior to their outpatient visit to facilitate more comfortable and less traumatic
wound care in the outpatient setting, particularly for their
first dressing removal or when conservative debridement is
anticipated.
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B. T. Stewart and N. S. Gibran
Multimodal analgesia should be prescribed for patients
who have background and breakthrough pain despite use of
the medications above or who are living with significant pain
interference. Multimodal analgesia consists of targeted pharmacological therapies with varying mechanisms combined
with non-pharmacological techniques [54]. In addition to
acetaminophen, NSAIDs, and opioids, patients with more
complex pain needs may also be prescribed gabapentinoids,
α–adrenergic agonists, tricyclic antidepressants (TCA), and
serotonin-norepinephrine reuptake inhibitors (SNRI) (e.g.,
duloxetine) [29]. The goal of multimodal analgesia is to
reduce pain intensity and interference while minimizing side
effects from any one class of medication. Although theoretically useful and commonly employed, observational studies
of burn pain management have demonstrated that multimodal analgesia that includes gabapentin ± duloxetine did
not consistently reduce pain intensity [55].
Opioid misuse, abuse, and diversion can occur after burn
injury. However, the vast majority of patients do not use opioids 30 days after injury [56]. Therefore, efforts to identify
those at high risk of opioid misuse and abuse and provision
of supportive strategy for opioid tapering in the outpatient
setting are required [57]. Given the frequency of preinjury
substance use disorder, collaboration with addiction and pain
medicine specialists is often needed to achieve excellent outcomes for these vulnerable patients [29, 58].
Most patients will not have anxiety or acute stress symptoms that require pharmacological therapy. Instead, nonpharmacological techniques can be taught to patients and
used when needed (e.g., relaxation, distraction, cognitive
restructuring, time- or quota-based activity pacing, sleep
hygiene) [27, 31, 32, 59–61]. Patients with significant anxiety,
depression, and acute stress symptoms should be referred for
cognitive behavioral therapy at a burn center or with a mental health provider close to their home [31, 62].
Pruritus can occur after a burn injury during the wound
healing and scar remodeling phases [55, 63–65]. Postburn
pruritus may begin early after a burn injury and can persist
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afterward. Itch affects more than 40% of long-term burn survivors [64]. Despite this high prevalence, the pathophysiology
of pruritus following burn injury is poorly understood.
Although itch of cutaneous origin shares a common neural
pathway with pain, the afferent nerve fibers conducting itch
are a distinct subset: they respond to histamine, acetylcholine,
and other pruritogens, but are generally insensitive to
mechanical stimuli [66]. An elegant hypothesis proposes four
classes of itch: cutaneous (proprioceptive), neuropathic, neurogenic, and psychogenic [66]. Treatment of postburn itch,
like pain, should be approached in a systematic way that
acknowledges the aforementioned classes of itch using multimodal protocols [67]. Although numerous treatments are
prescribed for postburn pruritus (e.g., moisturizer, topical
lidocaine, anti-histamines, gabapentinoids, ondansetron, μ
opioid antagonists, κ opioid agonists, TCA, SSNRI, steroid
injection, laser therapy), there is no consensus on the best
protocol or biomarkers for use of specific agents. Some trial
and error and time are typically required to achieve satisfactory relief.
Assess Range ofMotion andCreate aStretching
andExercise Plan
Providers and/or therapists should assess the range of motion
of joints affected by a burn and develop a stretching and exercise plan that mitigates contractures. Regardless of whether a
wound heals on its own or is skin grafted, a scar is formed: all
scars contract. Although wound contraction is a normal
response to injury, a major goal of therapy is to prevent contracture formation, the complication of excessive contraction,
usually across joints or areas with lax skin. Contracture limits
range of motion by forming scar bands that span joints.
Stretching and exercise increase or maintain range of motion
by applying force across scar and, through repetition, increase
the resting length of the tissue. Exercises should begin during
the acute phase of injury and continue throughout the period
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