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352
B. T. Stewart and N. S. Gibran
of scar remodeling, which may last up to 24months. The principles of stretching and exercise plans include the following:
1. Observe tissue reaction without dressings or garments
2. Monitor blanching of the wound to avoid prolonged vascu-
lar compromise
3. Slow, sustained stress is more tolerable and effective for
lengthening tissue than quick, short stretches
4. Elongate skin, scar, and muscle with combined joint
movements
5. Use functional exercises that mimic daily and work-related
activities
6. Position limbs and joints to maintain increased range of
motion after exercise
Splinting and casting can be used to prevent or modify scar
contracture formation (See Chap. 21) [68]. Indications for
splinting include the prevention of deformity, lengthening of
tissue, preservation of length, and protection of skin grafts.
Splints allow the application of low force over long periods of
time, which maintains range of motion and function during
periods of immobility, such as sleep. Splints may be static,
static progressive, or dynamic; the latter is employed if exercise and static splinting fail to gain adequate range of motion.
The indications for splinting change with the phase of outpatient burn care. In the acute phase, splinting focuses on
edema control, maintaining position, and relief of pressure
points to facilitate uniform healing. In the intermediate
phase, protection of grafts and maintaining adequate range of
motion become more important. In the long term, emphasis
is on the mitigation of scar contracture. It should be explicitly
stated that splints and casts are not substitutes for range of
motion exercises.
Serial casting also allows application of low force over
time to stretch tissue [69]. Casts may be useful for patients
with low adherence to a rehabilitation plan, as they are more
difficult to remove than splints. However, casting eliminates
the ability to perform regular range of motion exercises and
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causes muscle atrophy of the casted extremity. Additionally,
casts require reapplication at regular intervals to apply equal
and adequate forces over time.
Educate Patients andTheir Support System
There are few injuries and conditions that require as much
participation from patients and families to achieve a good
outcome than burn injuries. It is vital to educate patients and
their support systems and incorporate them into the care
process as collaborators. Clinic visits should include ample
time for education to maintain their understanding of and
participation in the recovery processes. Education can be
augmented by factsheets (https://msktc.org/burn/factsheets),
videos, and augmented reality tools. The Model Systems
Knowledge Translation Center (MSKTC) has factsheets for
burn-injured patients and their providers on topics such as
wound care, pain, psychological distress, exercise, itchy skin,
employment after injury, scar management, sleep problems,
sexuality and intimacy, social interaction, sun protection, and
body image. Additionally, survivorship communities, like the
Phoenix Society for Burn Survivors (https://www.phoenix-
society.org), provide people living with burn injury and their
providers with resources to improve care and understanding
and connects survivors to others who have experienced similar injuries.
Define Return Conditions andSchedule
In the acute phase, specific signs and symptoms that mandate
early reassessment should be discussed. Such issues include
increasing pain or anxiety associated with dressing changes,
signs of infection, functional decline, inability to sleep, and
safety concerns. Frequency of clinic visits varies based upon
the needs of the patient. Generally, patients with an acute
injury should be evaluated 1–2 times per week. Patients who
354
B. T. Stewart and N. S. Gibran
live close to a clinic could be seen daily for wound care if
needed, and those who liver further away could be managed
with a combination of in-person and telemedicine visits during the healing process.
Consider Need forLong-Term Follow-Up
toAssess thePatient andTheir Scar
Patients with wounds that do not heal within 14 days have
increased scarring risk; the majority of wounds that remain
open for longer than 21days develop some degree of hypertrophic scarring [26]. A hypertrophic scar is a raised, erythematous, pruritic, and inelastic mass of tissue that results
from a large amount of extracellular matrix of altered composition and organization compared to normal dermis.
Hypertrophic scarring is common, with a prevalence that
ranges between 32 and 72% depending on factors such as
presence of specific genes, TBSA burn, location of injury, and
time to healing [70–72]. Scar formation can result in contracture, pain, itch, loss of thermal regulation, stigmatization, and
psychological distress [26]. Some patients develop
hypertrophic scar without risk factors. Therefore, follow-up
visits should be planned for patients to return to the clinic or
send photographs of their wounds within 1–3 months after
wound closure and until the scar has matured, which may be
a year or more after injury. During these encounters, providers can assess the scar, discuss its impact on the patient’s function and quality of life, and develop a scar management plan
(see Chap. 21).
Outreach toSupport Community-Based
BurnCare
There will be circumstances when patients are unable or
unwilling to travel the long distances necessary to access
interdisciplinary burn centers for in-person care. Additionally,
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355
some patients, injuries, and problems need initial consultation
and close surveillance by an interdisciplinary burn team but
not the intensity of an in-person encounter. Therefore, burn
centers should establish outreach programs to support
community- based providers, particularly in regions and contexts where travel can be long or burdensome. These programs have taken the form of satellite clinics managed and
staffed by a regional burn center or indirectly by identifying,
training, and supporting community-based care providers.
Ways in which burn centers have optimized outpatient care
include the creation of specific care and consultation pathways, implementation of locoregional quality improvement
programs, continuing education opportunities, and dissemination of best-practice guidelines.
Pathways
With a mature trauma system with established referral practices, burn care pathways can streamline consultation and
transfer requests, reduce under- and over-triage rates, extend
burn care expertise within a geographic region, increase the
efficiency of burn center services, and improve patient satisfaction. As an example, the UW Medicine Regional Burn
Center developed four pathways (Table16.2) to make referring practitioners comfortable with emergency care of burn
wounds and facilitate burn expert assessment of burn wounds.
Practitioners at emergency departments and clinics within
the region call UW Medicine Transfer Center and provide
information regarding the patient, injury, local capacity, and
specific request. Nurses at the Transfer Center then determine which of four pathways the patient should follow and
enact the respective protocol. In addition to collating information, the Transfer Center coordinates photos of the injury
to inform recommendations by a burn surgeon at the UW
Medicine Regional Burn Center. When appropriate, the
Transfer Center notifies the Burn Clinic via an electronic
platform and the Burn Clinic calls the patient the next busi-
356
Consulng
outpaent criteria
B. T. Stewart and N. S. Gibran
T . Example of regional consultation and transfer pathways
adapted from UW Medicine Regional Burn Center
Pathway
Black
Red
Blue
Green
praconer request
Urgent consult with a burn
surgeon
Transfer due to inadequate
capacity for inpaent or
outpaent care
Brief consultaon to
facilitate local care without
transfer to the Burn Center
Outpaent follow-up at
the Burn Center
Indicaons Protocol highlights
Airway concerns, >5%
TBSA and fullthickness injuries,
electrical and
chemical injuries,
concomitant burn
and other injuries,
and/or a social
concern (e.g., abuse
or neglect)
Paent and/or burn
injury that exceeds
local capacity
Paent and injury
that can be managed
locally with the
consultaon with and
support of an
experienced burn
care provider
Small burn injuries
and paents who
otherwise meet
Transfer Center connects
the referring praconer to
the on-call burn surgeon.
Depending on the case, the
paent is then either
transferred for inpaent
care at the Burn Center or a
Burn Clinic follow-up plan is
made.
Transfer Center connects
the referring praconer to
the on-call burn surgeon.
Paent transfer to the Burn
Center is arranged.
Burn Clinic coordinaon is
provided based on the
paent and injury.
Transfer Center and Burn
Clinic create a follow-up
plan.
ness day with appointment details. This system manages
about 150 consultations per month, 75% of which are treated
locally with guidance by the Burn Center. This triage tool has
significantly reduced under- and over-triage of patients to the
Burn Center.
Quality Improvement
Local and burn center quality improvement (QI) programs
should systematically collect burn care metrics (e.g., underand over-triage, adherence to best-practice guidelines, wound
infection rate, unplanned hospital admission rates, patient
satisfaction) and review them individually and within the
context of a wider burn care system. Such QI programs serve
to identify opportunities to improve triage performance and
the quality of care provided to inpatients and outpatients.
Detailed guidance for local and regional burn care quality
improvement programming in low- and middle-income coun-
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357
Establish contextually
appropriate standards
Evaluate the impact of
qualityimprovement
efforts
Assess services and
reasonsfor gaps in
light of agreed
standards
Buildcapacity based
on findingsfromgap
analysis
F. . Framework for local and regional burn care quality
improvement programs adapted from Interburns (International
Network for Training, Education and Research in Burns) [73]
tries has been published by Interburns (International
Network for Training, Education and Research in Burns) [73].
The Interburns framework describes the steps to define clinical standards, evaluate service delivery and perform a gap
analysis, build targeted capacity, and assess the impact of the
efforts (Fig.16.1). Ethiopia, Ghana, Malawi, India, Bangladesh,
Cote D’Ivoire, Pakistan, Palestine, and Nepal have taken part
in all or parts of this process to improve care for burn patients
[73, 74].
Training
Burn center outreach should include training programs for
community practitioners that strengthen their ability to triage
burn-injured patients, provide outpatient care, and recognize
the need for consultation and referral. Training programs
might take the form of continuing medical education courses,
workshops to target specific capacity deficiencies, and/or
webinars. The use of social media platforms can extend burn
prevention, first aid and care messaging and support outreach
initiatives. Over time, the cumulative effect of these activities
will increase burn care knowledge and capacity in communities more proximate to patient homes.
358
B. T. Stewart and N. S. Gibran
Use ofOutcome Measures forQuality
Improvement
Assessing the performance of clinical services using PRO
measures is a core function of burn care. People living with
small or large burn injuries may sustain temporary or irreparable loss of function due to the injury, burn care system
dysfunction, failure of social support, and/or patient characteristics. When burn care and rehabilitation efforts fail to
return patients to a preinjury functional state, it is imperative
that patients retain a good quality of life. Quality of life data
can determine the effectiveness of the care being provided
and inform long-term expectations of patients and their support systems.
A United States program (Burn Model System, BMS) was
established in 1993 by the predecessor of the National
Institute of Disability, Independent Living and Rehabilitation
Research (NIDILRR). The BMS National Database now
includes >7200 participants from six major interdisciplinary
burn centers with follow-up ranging from 6 months to
20 years. Reports from the BMS have contributed valuable
information about participants’ experiences during recovery
from a burn injury, risk factors for poor outcomes, and opportunities to engineer burn care systems to be more responsive
to patients’ needs. Additionally, BMS and the NIDILRR
Model Systems Knowledge Translation Center have produced resources and educational materials for patients and
providers that are essential to outpatient burn care and
improving outcomes for burn survivors [75].
The challenge for burn care systems becomes incorporating the systematic use of PRO measures into clinical care and
using those data to inform individual patient care needs,
opportunities for quality improvement, and the impacts of
specific burn care system interventions. These challenges are
even greater where care is distributed across multiple envi-
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359
ronments and when it is delivered across multiple platforms.
However, these changes in the delivery of outpatient burn
care are all the more reasons to ensure patients receive the
services they need and achieve optimal outcomes.
Conclusion
The goal of outpatient burn care is to manage acute injuries
and return patients to their preinjury level of function. To
maximize this potential, an interdisciplinary team approach
with specific, measurable functional goals is needed. This
approach can be achieved at a regional burn center or at nonspecialty clinics with incorporation of burn expert outreach,
consultation, and telemedicine. Regular assessment of patient
progress, wound healing, scar formation, and creation of personalized treatment plans is essential. Given the lack of strong
evidence-based guidelines for outpatient burn management,
care should be performed in consultation with experienced
providers from interdisciplinary burn centers [1, 45]. Regardless
of the burn care system structure, use of PROs should define
therapeutic requirements, referral to advanced specialty care,
and evaluate burn care performance.
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