Using a Biopsychosocial Model to Understand Long-Term Outcomes in Persons With Burn Injuries

Qualitative Descriptive Research Investigating Burn Survivors' Perspectives on Quality of Care Aspects

Burn care quality indicators are used to monitor and improve quality of care and for benchmark purposes. The perspectives of burn survivors, however, are not included in current sets of quality indicators while patient-centred care gains importance. The aim of this study was to explore burn survivors' perspectives on quality aspects of burn care, which was used to translate their perspectives into patient-centred quality of care indicators. Qualitative descriptive research was conducted in a patient panel group. First, thematic analysis was applied to the focus groups to identify overarching themes. Second, patient-centred quality indicators, informed by burn survivors' valued aspects of care, were defined. Ten burn survivors with an average age of 54 years (SD = 11; range 38-72 years) and mean TBSA burned of 14% (SD = 11%; range 5-35%) participated in two focus groups. Four overarching themes were identified, pointing to the importance of (1) information tailored to the different phases of recovery, (2) significant others' wellbeing and involvement, (3) a therapeutic relationship and low-threshold access to healthcare professionals and (4) to participate in decision-making. Eighteen patient-centred process quality of care indicators within nine aspects of care were formulated. The overarching themes are reflected in patient-centred quality indicators, which present a broadened and complementary view of existing clinical quality indicators for burn care. Evaluating these patient-centred quality indicators may increase quality of care and refine patient-centred care.

Evaluation of patient-reported outcome measures in burn-specific tools: A systematic review

INTRODUCTION

Patient-reported outcome measures (PROMs) are now well-established tools to evaluate the quality of patient-centred care. Due to the multi-faceted and multi-disciplinary nature of the practice of burn care, as well as the range of significant potential sequelae, PROM's should form a fundamental component of burn quality improvement programs. We aim to 1. Explore biological, psychological, and social considerations that are currently listed in burn-specific PROM tools, as well as their efficacy, 2. Evaluate biological, psychological, and social factors that are considered in new burn-specific PROM tools or those under development, and 3. Identify any opportunities with respect to burn-specific PROM tools, in order to inform future investigation in this area.

METHODS

A search was performed of MEDLINE (Ovid), EMBASE, CINAHL, and the Cochrane Library databases. Two independent reviewers screened article titles/abstracts and then the full texts using Covidence. All studies were graded independently according to the Quality Rating Scheme for Studies and Other Evidences.

RESULTS

The initial search yielded 552 references. Based on ab initio inclusion and exclusion criteria, 133 full-text studies were assessed for eligibility, and 21 articles were ultimately included in the systematic review. Due to study heterogeneity, a qualitative synthesis was conducted. Existing burn-specific PROMs covered a range of biological, psychological, and social factors affecting adult and paediatric patients with burn injury, but several studies required additional PROMs for a thorough evaluation. Burn-specific PROM tools under development are poised to fill this deficit.

CONCLUSION

Major burn injuries are a unique form of trauma, requiring coordinated management that considers numerous factors not relevant to other patient populations. Further research is necessary to validate existing burn-specific PROM tools and to develop more comprehensive burn-specific PROM measures that more comprehensively incorporate the bio-psycho-social model of health.

Return-to-employment for working-aged adults after burn injury: A mixed methods scoping review

BACKGROUND

This scoping review aimed to identify the barriers, facilitators and benefits of returning to work following burn injury, outcome measures used, management strategies, and models of care.

OBJECTIVE

To provide a comprehensive overview about working-aged adults returning to their preinjury employment after burn injury.

METHODS

We followed a pre-determined scoping review protocol to search MEDLINE, CINAHL, Embase, PsycINFO, PubMed, Scopus, CCRCT and CDSR databases between 2000 to December 2023. Papers reporting primary data from previously employed adults with cutaneous burn injuries were included.

RESULTS

In all, 90 articles met the review criteria. Return-to-work was both an outcome goal and process of recovery from burn injury. Physical and psychological impairments were identified barriers. Job accommodations and modifications were important for supporting the transition from hospital to workplace. Employment status and quality of life sub-scales were used to measure return-to-work.

CONCLUSIONS

Consistent definitions of work and measurements of return-to-employment after burn injury are priorities for future research. Longitudinal studies are more likely to capture the complexity of the return-to-employment process, its impact on work participation and changes in employment over time. The social context of work may assist or hinder return-to-work more than physical environmental constraints. Equitable vocational support systems would help address disparities in vocational rehabilitation services available after burn injury.

Posttraumatic stress symptoms and interpersonal processes in burn survivors and their partners

Background: A burn event can elicit symptoms of posttraumatic stress disorder (PTSD) in survivors and their partners and may impact the way these couple members interact with each other. They may try to protect each other from further emotional distress by avoiding talking about the burn event, but they may also show concern towards each other.Objective: The aim of this study was to investigate bidirectional relationships between survivor's and partner's PTSD symptoms and two interpersonal processes: partner-oriented 'self-regulation', which is avoidance-oriented, and 'expressed concern', which is approach-oriented.Method: In this longitudinal multi-centre study, 119 burn survivors and their partners participated. Measures of PTSD symptoms, self-regulation, and expressed concern were administered in the acute phase following the burns, and follow-ups took place up to 18 months postburn. Intra- and interpersonal effects were examined in a random intercept cross-lagged panel model. Exploratory effects of burn severity were also investigated.Results: Within individuals, survivor's expressed concern predicted later higher levels of survivor's PTSD symptoms. In their partners, self-regulation and PTSD symptoms reinforced each other in the early phase postburn. Between the two couple members, partner's expressed concern predicted later lower levels of survivor's PTSD symptoms. Exploratory regression analyses showed that burn severity moderated the effect of survivor's self-regulation on survivor's PTSD symptoms, indicating that self-regulation was continuously related to higher levels of PTSD symptoms over time within more severely burned survivors, but not in less severely burned survivors.Conclusion: PTSD symptoms and self-regulation reinforced each other in partners and possibly also in more severely burned survivors. Partner's expressed concern was related to lower levels of survivor's PTSD symptoms, whereas survivor's expressed concern was related to higher levels of survivor's PTSD symptoms. These findings emphasize the importance of screening for and monitoring PTSD symptoms in burn survivors and their partner and of encouraging couple's self-disclosure.

Tell Me Your Story: A Case Report on the Use of Occupational Storytelling in the Treatment of a Subject with an Upper Extremity Burn Injury and Complex Psychosocial Issues

Recovering from a burn can leave a burn survivor struggling to cope with the physical and psychological trauma of their injury. Finding new ways to encourage positive coping strategies and strengthen their sense of self-efficacy and occupational identity can help to encourage the burn survivor to actively participate in their recovery and thereby increase their resiliency after injury. Occupational storytelling is a treatment strategy that utilizes the client's occupational history and experiences to form their life story. Utilizing this technique with the Kawa Model as the practice model and guide uses the image of life as a river to facilitate the formation of the survivor's story. The survivor is able to form a narrative of their life story by using their past, present and future occupational identities as a means cope and problem solve after their injury. This case report will illustrate how the subject "Ray," a pseudonym, used occupational storytelling to create a narrative of his past strengths to aid in recovering from his burn injury. Through his story, Ray was able to connect to a new occupational identity as a burn survivor rather than victim.

Long-term mental health outcomes of severe burn injury: A 5-year follow-up of the 2015 Formosa Fun Coast Water Park fire disaster

OBJECTIVE

Severe burn injuries have profound mental health impacts on individuals, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Many burn survivors also report positive psychosocial changes, termed posttraumatic growth (PTG). This study investigated long-term mental health of severe burn injury (i.e., PTSD, MDD, and PTG) and the longitudinal influences of coping strategies and social support.

METHODS

Ninety-nine adult burn survivors of the 2015 Formosa Fun Coast Water Park fire disaster participated in the 5-year follow-up (Wave 3, W3), with 93% completing the earlier 2- (Wave 1, W1) and 3-year follow-up (Wave 2, W2). Participants averaged 22.1 years of age at burn, and 62.6% were females. The mean total body surface area burned (TBSA) was 50.3%, with a mean length of hospital stay of 87.6 days.

RESULTS

Five years after the 2015 fire disaster, 13.1%, and 14.1% of the survivors met probable DSM-5 PTSD and MDD, while 51.5% reported significant PTG. After controlling for demographic, burn-specific, and baseline outcome variables, avoidance coping at W2 prospectively predicted PTSD and depressive symptoms at W3 (p = .003 and 0.04), with medium-to-large and medium effect sizes (sr² = 0.10 and 0.05). Approach coping at W2 prospectively predicted PTG at W3 (p = .014), with a medium-to-large effect size (sr² = 0.07).

CONCLUSION

Rates of probable PTSD and MDD were still relatively high in long-term burn survivors. However, PTG continued to be highly prevalent. Our findings highlight the importance of coping in affecting the long-term mental health of severe burn injury.

The Effect of Music Therapy on Perceived Pain, Mental Health, Vital Signs, and Medication Usage of Burn Patients Hospitalized in the Intensive Care Unit: A Randomized Controlled Feasibility Study Protocol

Background: Burn patients experience major physiological and psychological stressors during treatment and rehabilitation, including elevated levels of pain, anxiety, stress, or depression. Music interventions inclusive of music therapy (MT) have been shown to improve such symptoms, but rigorous clinical trials investigating specific music therapy methods in adult burn patients are scarce. Methods: This is a single center Randomized Controlled Trial (RCT) protocol with two parallel arms. Participants are 81 adult burn patients admitted to the Intensive Care Unit (ICU) of the University Hospital Fundación Santa Fe de Bogotá in Colombia. The intervention consists of a Music Assisted Relaxation (MAR) protocol, a music therapy technique composed of entrained live music combined with a guided relaxation and/or the use of imagery. The effects of the MAR will be compared to a control group (treatment as usual) over a period of maximum 2 weeks or six interventions. The primary outcome measure is perceived background pain, as measured with a Visual Analog Scale (VAS) before and after each intervention. Secondary outcomes are anxiety and depression levels; vital signs; and the use of pain medication. Additionally, some patients in the intervention group will be invited to participate in electroencephalography, electromyography, and electrocardiography recordings during the MAR. Discussion: This study protocol follows the SPIRIT guidelines for defining items of clinical trials and is the first study in Colombia to evaluate the effects of music therapy for adult burn patients. With this RCT it is hoped to gather new knowledge about the potential of music therapy to help critical care patients cope and recover from their injuries during the hospitalization in the ICU. Trial registration: www.clinicaltrials.gov, Identifier: NCT04571255. Protocol version: V1.0, May 24th 2021.

Contemporary Aspects of Burn Care

The past one hundred years have seen tremendous improvements in burn care, allowing for decreased morbidity and mortality of this pathology. The more prominent advancements occurred in the period spanning 1930-1980; notably burn resuscitation, early tangential excision, and use of topical antibiotic dressings; and are well documented in burn literature. This article explores the advancements of the past 40 years and the areas of burn management that are presently topics of active discussion and research.

"On the Recovery Journey:" An Integrative Review of the Needs of Burn Patients From Immediate Pre-Discharge to Post-Discharge Period Using the Omaha System

BACKGROUND

To establish a conceptual understanding of the needs of burn patients, the specific research question asked is: "What are the needs of burn patients from 1-week pre-discharge to the post-discharge period?"

METHODS

Whittemore and Knafl's integrative review approach was used to answer the review question. The databases searched were the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Embase, and Scopus. Thirty-two primary studies were retained at the end of the screening process. Directed content analysis was undertaken, with the Omaha system as an organizing framework.

RESULTS

Recovery after burns is not a linear process, but an intricate one filled with varied needs in the physiological (pain, skin, neuro-musculo-skeletal, and infection), psychosocial (social contact, role changes, spirituality, grief, mental health, and sexuality), health-related behavior (nutrition, sleep and rest patterns, and physical activity), and environmental (income) domains of the Omaha system. The nature and intensity of these needs change over time, suggesting that recovery for the burn patient is an ongoing process.

CONCLUSIONS

Several needs exist from 1 week before discharge to the post-discharge period. The mutual relationship and evolving nature of these needs create an avenue for a flexible, regular, holistic transitional program, similar to the support offered to persons living with chronic conditions.

CLINICAL RELEVANCE

Hospital discharge does not imply an end to the recovery of burn patients, and burn survivors still require holistic care even after discharge. The review shows the applicability of the Omaha system in exploring and classifying the needs of burn survivors and situates nursing at the core of such a program. It is possible that a nurse-led program of care needs to be considered.

Evaluating a screener to quantify PTSD risk using emergency care information: a proof of concept study

BACKGROUND

Previous work has indicated that post-traumatic stress disorder (PTSD) symptoms, measured by the Clinician-Administered PTSD Scale (CAPS) within 60 days of trauma exposure, can reliably produce likelihood estimates of chronic PTSD among trauma survivors admitted to acute care centers. Administering the CAPS is burdensome, requires skilled professionals, and relies on symptoms that are not fully expressed upon acute care admission. Predicting chronic PTSD from peritraumatic responses, which are obtainable upon acute care admission, has yielded conflicting results, hence the rationale for a stepwise screening-and-prediction practice. This work explores the ability of peritraumatic responses to produce risk likelihood estimates of early CAPS-based PTSD symptoms indicative of chronic PTSD risk. It specifically evaluates the Peritraumatic Dissociative Experiences Questionnaire (PDEQ) as a risk-likelihood estimator.

METHODS

We used individual participant data (IPD) from five acute care studies that used both the PDEQ and the CAPS (n = 647). Logistic regression calculated the probability of having CAPS scores ≥ 40 between 30 and 60 days after trauma exposure across the range of initial PDEQ scores, and evaluated the added contribution of age, sex, trauma type, and prior trauma exposure. Brier scores, area under the receiver-operating characteristic curve (AUC), and the mean slope of the calibration line evaluated the accuracy and precision of the predicted probabilities.

RESULTS

Twenty percent of the sample had CAPS ≥ 40. PDEQ severity significantly predicted having CAPS ≥ 40 symptoms (p < 0.001). Incremental PDEQ scores produced a reliable estimator of CAPS ≥ 40 likelihood. An individual risk estimation tool incorporating PDEQ and other significant risk indicators is provided.

CONCLUSION

Peritraumatic reactions, measured here by the PDEQ, can reliably quantify the likelihood of acute PTSD symptoms predictive of chronic PTSD and requiring clinical attention. Using them as a screener in a stepwise chronic PTSD prediction strategy may reduce the burden of later CAPS-based assessments. Other peritraumatic metrics may perform similarly and their use requires similar validation.

TRIAL REGISTRATION

Jerusalem Trauma Outreach and Prevention Study (J-TOPS): NCT00146900.

Evaluation of an International Classification of Functioning, Disability and Health-based rehabilitation for thermal burn injuries: a prospective non-randomized design

Background

Severe burn injuries result in relevant restrictions of physical capacity as well as psychological and social integrity and require a specialized rehabilitation. There is a common agreement, among national as well as international burn associations, that burn rehabilitation is a complex, dynamic process which needs an interdisciplinary and specialized treatment team. There is wide agreement that more research is needed in this field.

Methods/design

The aim of the study is to examine the effectiveness and efficiency of our new ICF (International Classification of Functioning, Disability and Health)-based rehabilitation for thermal injuries. Because of ethical reasons, we have chosen a prospective non-randomized design, which takes place at two different rehabilitation centers. At center A, a newly developed ICF-based rehabilitation program was established; at rehabilitation center B, a well-established rehabilitation program has existed for 20 years and is used as reference. The primary research question addresses the “Pre-post comparison of the physical and psychological outcome measurements,” secondary question I looks at the “Examination of the non-inferiority of the new treatment concept with the established concept,” and secondary question II is the “Analysis of the rehabilitation process based on the rehabilitation cycle.”

Only patients of the two burn rehabilitation centers who are insured by workers’ compensation will be asked to participate in this study to avoid outcome bias by insurance status. A physical examination (physical working capacity testing, grip strength, range of motion, and scar evaluation by Cutometer and Vancouver Scar Scale) and a standardized questionnaire battery (Burn Specific Health Scale-Brief , Short Form 36, Impact of Event Scale-Revised, the German version of the Symptom Checklist, the Freiburg Social Support Questionnaire, Patient/Client Satisfaction Questionnaire, Disabilities of the Arm, Shoulder and Hand, and Lower Extremity Functional Scale ) measure physical and psychological conditions. Data will be taken on admission, during stay, and on discharge of the rehabilitation program and at follow-up 3 and 12 months after discharge. A minimum of 162 participants will be enrolled in this clinical longitudinal, prospective, observational study.

Discussion

The proof of the effectiveness of the ICF-based rehabilitation program for thermal injuries will give evidence in a comprehensive way for the first time in this field. As result, a standardized rehabilitation concept will be introduced, which can be provided to other rehabilitation institutions treating thermal injuries.

Trial registration

German Clinical Trials Register, DRKS00017702. Registered on 2 September 2019.

Introduction to the NIDILRR Burn Model System (BMS) Program: Selected Findings II

A special supplement to the Archives of Physical Medicine and Rehabilitation in 2007 reported selected findings of research from the first 13 years of the BMS Centers and Database Coordinating Center. This special supplement is the second such effort and reports on the growth of the BMS National Longitudinal Database (BMS NDB) since that time and select new research findings from the BMS centers.