Burn rehab program cuts LOSby 12 days
Patients can start rehab earlier
A comprehensive burn rehabilitation program that allows severely burned patients to leave the acute care hospital much earlier has slashed the average rehabilitation length of stay from 27 to 19 days at Braintree Hospital Rehabilitation Network in Boston.
The program is equipped to take Level 1 burn patients who require up to four hours of burn care a day. That means patients can be admitted to Braintree as much as three weeks earlier than at other rehab programs. Most rehab programs provide only two hours of burn care a day.
Some of the patients begin their rehab at Braintree, transfer to an acute care hospital for grafting, then transfer back to Braintree when they are medically stable. Because of the special training and equipment at Braintree, burn patients can be admitted as early as 48 hours after surgical grafting.
"Our program allows them to start rehab earlier, and that cuts the entire length of stay," says Lynn Belmosto, RN, CRRN, nurse manager for the burn unit.
The chart on p. 17 compares length of stay for burn patients going through the Braintree program with those going through other regional rehab programs.
The program was established in 1995 at the request of Boston burn trauma specialist Robert Demley, MD, who worked with Braintree to set up the protocols and admission system, says Ann Bordeianu, MS, director of marketing at Braintree.
Payer pressure
"Acute care hospitals were under pressure to get patients into rehab much sooner, but Dr. Demley felt that a special program was needed to handle the complex medical and psychosocial issues that burn patients face," Bordeianu explains.
The program now admits patients from acute hospitals throughout Massachusetts.
Braintree’s burn rehabilitation program is on a 43-bed unit that also treats amputees, orthopedic patients, and complex medical patients. The unit has four telemetry beds, which allows admission of burn patients who also need cardiac monitoring.
The burn treatment team includes nursing (RNs and licensed practical nurses), case management, dietetics, social services, and psychology. The physicians who work with the patients are mostly internal medicine specialists and are on the Braintree staff.
A pain management team is available to consult with patients who need those services. The team includes nursing, physical therapy, occupational therapy, medicine, and neuropsychology.
All staff who work on the unit are cross-trained to treat the burn patients.
In addition to up to four hours of burn care, the burn patients receive at least three hours of therapy a day during the week and at least an hour per day on Saturday and Sunday.
The hospital chose not to dedicate a certain number of beds to the burn unit. Instead, when the census is high, the unit can call on a per diem pool of nurses and therapists who have completed the competencies involved in caring for all types of patients in the unit.
When patients are referred to the Braintree program, they are screened before admission by nurses with specialized training in burn and trauma needs. The treatment team meets before admission and has a comprehensive treatment plan in place before patients arrive.
The nurses who work in the burn unit are rehab nurses who have received additional training in treating burn patients. They have undergone a program of classroom training, inservice programs, and independent study developed by Leslie Desanti Matossian, RN, BS, a burn trauma resource clinician, who works part-time for Braintree and who oversees competency testing for the clinicians in the burn program.
Before working with patients, the nurses must pass a competency test showing they are qualified to provide care to burn patients and to recognize when treatment is no longer effective, Belmosto says. The training covers assessing and treating burns, dealing with psychosocial issues, and meeting the special nutritional needs of burn patients.
Therapists on the burn team have attended conferences on burn care and have been trained to assist in some of the wound management. They have received special training from vendors on how to use specialized burn treatment products and equipment.
Nurses and therapists who work with burn rehab patients have a close-knit relationship, similar to those among staff on traumatic brain injury programs, Belmosto says.
"The treatment team must work together closely literally planning the patients’ day from the moment they wake up until they go to sleep," Belmosto says.
Because three hours of therapy and up to four hours of burn care occupy a sizeable portion of the patient’s day, the therapist and nurse often meet early in the morning to decide who treats the patient at what time and when more than one clinician is needed, she adds.
The Braintree program includes a significant psychological component to help deal with the problems that accompany a burn trauma. In addition to helping the patient deal with adjustment issues and post traumatic stress, the psychosocial team works with the family to help them adjust.
"Because the patient has been in the acute care setting, we receive information before admission about how the family is coping and any particular nuances we need to cover. This puts us in a position to be proactive and to anticipate the patient and family’s needs," she says.
Braintree has developed a network of former patients willing to return to the hospital and visit with new patients. The hospital staff tries to pair former patients with current patients who are about the same age. For instance, in addition to all the other traumas associated with a severe burn, geriatric patients often have to cope for the first time with role reversals because they depend on their children for help. Meeting with a former patient who has been through the same situation is often a help, Belmosto says.
Braintree Hospital Rehabilitation Network has recently developed a program to treat burn patients in the outpatient setting after their discharge from acute rehabilitation. Therapists at Braintree’s satellite clinics throughout northeast Massachusetts were trained to treat the burn patients at the Shriner Burn Program in Boston, Bordeianu says.
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