Burn Centers and the Multidisciplinary Team, Centralized Burn Care, and Burn Care Quality Control Work

Abstract

The incidence and prevalence of burn injuries is decreasing worldwide and in parallel there is an increase in outpatient type of care and a shortening in length of stay [1] that has been significant during the last 20 years [2, 3]. This is particularly so for the high income countries [4]. For the low income countries, data is still lacking [4]. This has led to a decreasing demand on health care volume for the care of burns. This has during the last 10 years been a contributing factor for a decrease in the availability of burn care facilities and has boasted the process for centralized care [5–7].

Appendix: Verification Criteria

#	Criterion	Criterion level
1	The burn center hospital is currently accredited by the Joint Commission or equivalent	1
2	The burn center has an identifiable medical and administrative commitment to the care of the patient with burns	1
3	The burn center maintains an organizational chart of personnel within the burn center and the hospital	2
4	The burn center hospital maintains a specialized unit dedicated to acute burn care	1
5	The burn center has designated ICU capable beds	1
6	The burn center maintains an appropriate policy and procedure manual that is reviewed regularly with appropriate documentation by the burn center director and the nurse manager	1
7	Multidisciplinary patient care conferences are held and documented at least weekly	1
8	Renal dialysis, radiological services, including computed tomography scanning, and clinical laboratory services are available 24 h per day	2
9	The burn center has timely access to operating rooms available 24 h a day	1
10	A dedicated OR team with burn experience is available for the burn operating theatre	2
11	The burn center hospital’s policies and procedures regarding the use of allograft tissues are in compliance with all federal, state, and the Joint Commission (or equivalent) requirements, and, when feasible and appropriate, with standards of the American Association of Tissue Banks (or equivalent)	1
12	The burn center has liaisons with a designated trauma center to coordinate care of patients with multi-trauma	1
13	The burn center must have a sufficient volume of acute burn admissions on an ongoing basis to demonstrate to the site reviewers and to the Verification Review Committee that the burn center has a quality burn care program; centers with less than 100 admissions per year should anticipate that site reviewers will audit patient charts for demonstration of quality of care	1
14	80% of admissions to the center must constitute acute burn injuries; for centers with numbers less than 100 admissions per year (including observation status patients) the center can consider that 5 new patient outpatients equates to 1 inpatient	1
15	Burn centers caring for pediatric patients and geriatric patients must demonstrate facilities, protocols, and personnel specific to the care of critically ill patients; centers with less than 100 admissions per year should anticipate that site reviewers will audit charts for demonstration of quality of care	1
16	The burn center maintains an average daily census of three or more patients with acute burns	1
17	No more than 5% of all patients with a primary diagnosis of a burn injury are admitted to another service per year (e.g., geriatrics, pediatrics, medicine)	1
18	The burn center has written guidelines for the triage, treatment, and transfer of burned patients from other facilities	1
19	The burn center maintains access to an EMS system for the transport of patients with burns from referral sources within the service area	1
20	The burn center offers input into the performance improvement of pre-hospital care of burn patients	2
21	The emergency department has written protocols mutually developed with the burn service for the care of acutely burned patients	2
22	The burn center interfaces with regional trauma centers to coordinate care of patients with multiple injuries and to develop regional educational programs, disaster planning, and advocacy efforts	2
23	The burn center has a written mass casualty disaster plan for the triage and treatment of those patients burned in a mass casualty incident occurring within its service area	1
24	The mass casualty disaster plan is reviewed and updated as needed and on an annual basis by EMS representatives and the burn center director	2
25	There are current (within the past 3 years) written memoranda of understanding with other burn centers regarding secondary triage	1
26	The burn center must maintain accurate and up-to-date contact information for burn surgeons and managers on the ABA website	2
27	The burn center director is a licensed surgeon (MD or DO) with board certification by American Board of Surgery or American Board of Plastic Surgery (or equivalent for international burn centers in which case a surgeon must co-manage the center)	1
28	The burn center director has completed a 1-year fellowship in burn treatment and/or has experience in the care of patients with acute burn injuries for 2 or more years during the previous 5 years	1
29	The burn center director has current ABLS (or equivalent) training	2
30	The burn center director is responsible for the direction of burn center administrative functions	1
31	The burn center director is responsible for the creation of policies and procedures within the burn center specifying all aspects of care for burned patients	1
32	The burn center director is responsible for ensuring that all burn center providers conform to the burn center’s locally established policies and procedures	1
33	The burn center director is responsible for the coordination with regional EMS authorities regarding triage and transport of burn patients	1
34	The burn center director is responsible for the approval of privileges for physicians participating in the burn service based on medical staff credentialing process	1
35	The burn center director is responsible for the development and active participation in internal and external continuing medical education programs in the care and prevention of burn injuries	1
36	Burn center director is responsible for direction and active participation in the burn center Quality and Process Improvement Programs	1
37	The burn center director is responsible for the communications on a regular basis with referring physicians regarding patients who have been transferred	1
38	In the event that the Burn Center Director is not available an accessible burn center staff surgeon is designated for administrative or clinical decisions	1
39	The Burn Center Director regularly participates in regional, national, or international burn meetings	1
40	The Burn Center Director has directed the total burn care of 50 or more acutely burned patients annually over a 3-year period	1
41	The Burn Center Director demonstrates ongoing involvement in burn-related research, community education, continuing medical education, prevention efforts, and local regional or national burn advocacy	1
42	Attending staff burn surgeons are licensed surgeons with board certification by American Board of Surgery, American Board of Plastic Surgery or equivalent based on review by Verification Committee	1
43	Attending staff burn surgeons have demonstrated expertise in burn treatment as evidenced by completion of a 1-year fellowship in burn treatment or by 2 or more years of mentored experience in the management of patients with acute burn injuries	1
44	Each attending staff surgeon must participate in continuing medical education in burn treatment	1
45	Attending staff surgeons have current ABLS (or equivalent) training	2
46	Each attending staff surgeon has participated, including primary decision-making, in the care of 35 or more acutely burned patients annually	1
47	The burn center maintains an on-call schedule for residents, qualified health care professionals, and attending staff surgeons for continuous responsibility of burn patients	1
48	All physicians (and physician extenders) who are routinely responsible for the care of burn patients conform to burn center criteria documenting appropriate training, patient care experience, continuing medical education, and commitment to the care of the burned patient	1
49	All physicians (and physician extenders) participating in the burn service are credentialed by the hospital medical staff credentialing process and are approved by the burn center director	1
50	Assigned burn center medical staff are promptly available on a 24-h basis	1
51	Specialty consultants (e.g., nephrology, cardiology, neurosurgery) are available in a timely manner determined by the acuity of the diagnosis	2
52	A dedicated anesthesia team with burn experience is available for the burn operating theater	2
53	The nurse manager is a licensed registered nurse (RN) in the state the burn center resides with a minimum of a baccalaureate degree in nursing	1
54	There is at least one nurse manager who is administratively responsible for the nursing care provided within the burn center for the unit he/she is assigned	1
55	In the eyes of the site reviewers, a nurse manager must have sufficient experience in burns and nursing leadership to lead the staff and manage the nursing program of the burn center	1
56	An organizational chart outlines the relationship between the nurse manager and other members of the burn team	2
57	An acuity-based or alternative equivalent staffing system is in place to determine nurse-staffing needs for patients in the burn center	2
58	There is a burn-specific competency-based training and continuing educational program for all nurses assigned to the burn center	1
59	The burn nurse manager routinely participates in multidisciplinary patient care rounds and there is adequate dissemination to the nursing staff	1
60	The nurse manager attends burn-specific continuing educational opportunities at least once every 2 years. These requirements can be addressed by attending regional, national, or international burn meetings; being an ABLS instructor; and being involved in the ABA	1
61	There is nurse representation within burn center quality improvement/performance improvement processes	1
62	A comprehensive rehabilitation program is designed for burned patients within 24 h of admission	1
63	Physical and occupational therapists in the burn center are appropriately licensed in their respective disciplines and demonstrate ongoing continuing education in burn rehabilitation	1
64	Therapy staffing is based upon burn center inpatient and therapy-specific outpatient activity with at least one designated full-time equivalent burn physical therapist and one occupational therapist but more depending on center volume	1
65	In-patients with an active rehabilitation plan must have care delivered as prescribed in the evaluation which should determine duration and frequency based on acuity, include goals, outcome, and plan for follow-up	1
66	Burn therapy services are provided 7 days per week for care of burn inpatients	1
67	Burn therapists participate in multidisciplinary rounds and quality improvement	1
68	There is a competency-based burn therapy training program for all therapists assigned to the burn center	2
69	Therapists assigned to the burn unit must demonstrate burn therapy competence after initial training and at a minimum of once every 2 years	2
70	Burn team members are provided with a minimum of one regional, national, or international burn-related continuing education opportunity annually or demonstrate annual participation in internal educational process specific to burn care	2
71	Social service consultation is available to the burn service 7 days per week and on an as-needed basis in off-hours	1
72	A dietitian with adequate critical care and burn experience is available on a daily basis for consultation	1
73	A pharmacist with adequate critical care and burn experience is available on a 24-h basis	1
74	Respiratory therapists are available for the assessment and management of patients on the burn service on a continuous basis	1
75	A child life/recreational therapist is available for children cared for in the unit (for Pediatric Burn Centers)	1
76	A psychologist or psychiatrist is available to the burn service on an as-needed basis	1
77	The burn center has appropriate outpatient facilities to care for new outpatients and discharged patients	1
78	The outpatient facility ideally should be an integral and physical part of the burn center and should ideally be contiguous with/adjacent to the in-patient unit	2
79	If the outpatient services are at a site remote to the burn center, there must be adequate facilities for wound care	2
80	Outpatient examination room must be of adequate size to allow for dressing changes, wound cleansing, splinting, casting, and reapplication of wound dressings	1
81	The outpatient facility must be able to provide for appropriate pain management during wound care	2
82	For continuity of care, staffing of the outpatient area should be by multidisciplinary experienced burn team members approved by the burn center director and nurse manager	2
83	The outpatient staff participates in weekly multidisciplinary burn conferences and the burn center PI program	1
84	The burn center follows >75% of all patients who transition to the outpatient setting	1
85	The burn center provides coordinated transition of care to the outpatient status	1
86	The burn center provides appropriate follow-up after hospital discharge	1
87	The burn center provides brief psychological screening/intervention	1
88	The burn center provides evaluation of patient developmental status	2
89	The burn center provides access to burn-specific OT/PT evaluation and treatment	2
90	The burn center provides access to reconstructive surgery	2
91	The burn center provides access to peer support groups (such as but not exclusively a Phoenix Society SOAR program)	2
92	The burn center provides access to social service, pharmacist, and dietary consultations as needed	2
93	The burn center provides access to vocational counseling	2
94	No more than 5% of hospital admissions are transferred to another acute care facility	1
95	Physiatrist consultation is available	2
96	The burn center coordinates with local and/or regional rehabilitation centers for inpatient rehabilitation	1
97	The burn center coordinates with local and/or regional outpatient facilities for ongoing outpatient therapy needs of patients needing rehabilitation after discharge	1
98	The burn center director is responsible for the risk-adjusted performance improvement program	1
99	A multidisciplinary burn center committee oversees the performance improvement program, meets at least quarterly, and is integrated into the hospital QI structure	1
100	Sufficient QI documentation is available to verify problems, identify opportunities for improvement, resolve the problem, and provide loop-closure	1
101	The morbidity and mortality conferences are held at least monthly	1
102	The morbidity and mortality conferences include specialist peer staff members other than those practicing in the burn center	1
103	The morbidity and mortality conferences include discussion of all life-threatening complications and deaths with classification according to level of concern and preventability	1
104	The morbidity and mortality conferences include documentation of loop closure	1
105	The morbidity and mortality conferences are attended by clinical team members involved in the direct care of the burn patients who participate in at least 50% of the morbidity and mortality conferences	1
106	Sentinel events are discussed in a timely manner at multidisciplinary intensive reviews during which time a non-involved peer leads a discussion with all involved parties and areas for improvement and loop closure are identified	1
107	The burn service conducts audits of their benchmarked outcomes data (using available resources such as NBR, UHC, NHSN, or CMS) at least quarterly	1
108	The burn center develops ongoing PI projects to create a culture of safety and promote value-based programs	1
109	The burn center has policies for infection control with regular monitoring for hospital-acquired infections, multi-drug-resistant organisms, and compliance	1
110	The burn center participates in the ABA’s National Burn Repository and submits data every year	1
111	The burn center database includes all patients who are admitted to the burn center hospital for burn care	1
112	Burn team members are provided with a minimum of one regional, national, or international burn-related continuing education opportunity annually OR demonstrate annual participation in internal educational process specific to burn care	1
113	A burn center orientation and ongoing continuing education program documents staff competencies specific to age-appropriate care and treatment of burn patients, including critical care, wound care, and rehabilitation	1
114	The burn center offers regional education related to emergency and inpatient burn care such as that included the ABA Advanced Burn Life Support course	2
115	For centers that have residents involved in care of the burn patients an orientation program is provided for new residents	2
116	The burn center staff participates regularly in public burn outreach programs	2
117	Burn center staff is involved in local, regional, national, or international prevention outreach efforts	1
118	Burn center multidisciplinary staff under the leadership of the burn center director, work locally, regionally, or nationally to advocate for burn-related two health care issues	1
119	The burn center multidisciplinary staff is involved in research (including basic science, clinical, industry-sponsored, QI, multi-center) and presents posters or oral presentations at hospital based, regional, national, or international meetings	2