Outpatient burn center finds its niche
1,500 patients were treated the first year
When managed care payers began slashing the lengths of stay for patients in its inpatient burn treatment center, Crozier-Chester Medical Center opened an outpatient burn wound center to provide multidisciplinary care for burn patients. The outpatient center was so successful that it attracted 1,500 patients its first year with no advertising or marketing. It has expanded from two treatment rooms to five and now occupies a renovated space in the hospital designed for burn treatment.
Some patients who ordinarily would have been hospitalized with second- and third-degree burns have been successfully treated as outpatients because of the burn wound center’s aggressive treatment program, says Cynthia Lynn Reigart, BSN, RN, clinical coordinator of the Nathan Speare Regional Burn Treatment Center and the outpatient burn wound care center. The medical center is part of the Crozier-Keystone Health System, with headquarters in Upland, PA.
"Managed care is forcing burn treatment centers to discharge patients much earlier when they still need wound care and intensive therapy," Reigart says. In fact, at Speare, the length of stay has been cut in half in recent years.
A study of patients discharged from the acute burn center showed that 30% were being seen in a clinic setting by a physician and nurse, and the rest were being treated in physicians’ offices. If they needed physical therapy or occupational therapy, they went to a general outpatient rehab center close to their homes. "We felt we were losing a lot of patients and that the continuity of care was missing," Reigart says.
After researching other outpatient burn programs and visiting several, the hospital opened its center in March 1996. The outpatient program is staffed by the specialized burn team from the inpatient unit to maintain quality of care and provide consistent care, Reigart says.
"It’s very efficient for the facility to have dually trained individuals in the burn program who can provide inpatient and outpatient care at the same time," she says.
It takes a team
All of the treatment team members including staff from both the inpatient and outpatient programs rotate through the two programs. The treatment team includes a burn physician; either a general or plastic surgeon, depending on the patient’s needs; a burn nurse; a burn technician; physical therapist; occupational therapist; case manager; social worker; nutritionist; psych-liaison nurse; and the health unit secretary. Support is available from the admissions registration area, the pharmacy, and the phlebotomy department.
The burn nurses and burn technicians rotate through the two programs on a monthly basis. Physical therapists and occupational therapists rotate every six months. However, staff may flex between the two areas more frequently if the census changes or in case of vacancies and illnesses.
The nursing staff must have at least one year of critical care experience. When nurses come to the burn center, they go through a special 12-week orientation conducted by clinical educators. Physical and occupational therapists must have specialized training in dealing with burn patients.
Many can avoid hospitalization
All patients on the inpatient side are referred to the burn wound care center after discharge unless they live too far away to travel for day-to-day care. In that case, the center evaluates them a week after discharge, monitors them at regular intervals, and helps coordinate their care with local health care providers. The center also monitors patients whose HMOs insist that they go to capitated sites for treatment.
Other sources of patients include emergency rooms in the region, primary care physicians, and companies that contract with the hospital’s occupational health department.
When a patient is admitted to the program, the physician and physical therapists do a functional and wound assessment from head-to-toe, with assistance from the burn nurse. Then the team determines the treatment needs and goals based on the assessment.
Patients are referred to the outpatient burn center for evaluation within 24 hours of their injury. Most can be treated as outpatients and avoid hospitalization, Reigart says.
In burn treatment, it often takes as long as three days to determine if patients should be admitted, Reigart notes. For example, if patients’ dressing changes are so complex they can’t be handled at home, or if they require intravenous medication for pain, they must be admitted.
Because of the specialized, aggressive treatment from the multidisciplin-ary team, some patients who ordinarily would have been hospitalized for burns are now treated as outpatients. The American Burn Association admission criteria call for admitting patients under age 10 and over 50 if they have second- and third-degree burns over 10% of their bodies; patients between ages 20 and 50 should be admitted if they have second- and third-degree burns over 20% of their bodies. The outpatient treatment center has been able to keep many of these patients out of the hospital.
"If we keep a wound in aggressive therapy, it can heal quicker with fewer complications," Reigart says.
If the staff see problems develop with infection or the patients need grafting or pain management, they will be admitted to the burn center. The outpatient burn center staff does not dispense medication. Patients who need pain medicine for dressing changes receive prescriptions and take their medicine before coming to the center.
Most patients initially visit the center for treatment three days a week. Patients whose hands are burned or who have more severe wounds may need treatment five days a week.
The program operates five days a week. Patients who can’t manage at home are seen by a home care agency on weekends. The hospital’s own home care agency has staff trained in burn care, but in the case of patients who live outside the coverage area, Reigart and her staff have given burn wound care instructions over the phone to a home care nurse.
Patients are usually followed actively up to one year after the burn. Some patients may be followed much longer. Children come back to the center for monitoring until they have stopped growing, for example. Young adults who receive cosmetic surgery come back for more therapy and treatment until all of their surgery is done.
"It’s hard to put an end point on it. If patients develop contractures, they need surgery to release them, and then they need more physical therapy. Patients with skin grafts sometimes develop complications later on," Reigart says.
[Editor’s note: For more information on the outpatient burn treatment center, contact Cynthia Reigart at (610) 447-2814.]
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