Understanding Burn Care

Burn injuries require specialized care that is only available at a Burn Center.

It is important to understand that of all the different types of traumatic injuries, burns are among the most complex and difficult to treat. As a unique type of trauma, and because of the complex nature of burn injuries, which frequently require lengthy treatment and rehabilitation, specialized medical personnel and facilities are required.

A burn center is a hospital-based health care facility with specially trained professionals and resources to treat patients from the earliest stages of burn injury through rehabilitation.

Burn injuries are suffered by people of all ages and occupations, ranging from infants scalded by hot liquids to fire fighters battling a house fire. The hospital Emergency Department is typically the first point of contact whenever medical treatment is sought after a burn injury occurs; however, many burn centers also take calls directly from the local community. Ideally, continued care for serious burn injuries should occur at a burn center.

There are approximately 120 burn care facilities across the U.S. Of those, 64 are verified burn centers – meaning they have met stringent national requirements set by the American Burn Association (ABA) and American College of Surgeons (ACS).

The American Burn Association (ABA) Verified Burn Centers are accredited to ensure optimal care, recovery, rehabilitation, reintegration and support for the burn injury survivor and families of the survivor.

Verified burn centers also track a wide variety of burn injury data in support of advancing medical research to improve outcomes and to promote burn injury prevention measures. Additional information on verified burn centers and burn care treatment hospitals can be found at www.ameriburn.org.

Expertise of Burn Centers:

• Proper wound management, including surgical debridement and skin grafting
• Adequate pain control
• Infection control
• Nutritional support
• Surgical debridement and skin grafting
• Active rehabilitative therapies for joint function, mobility and self-care
• Specialized emotional and social support, including the special needs of fire fighters

Fire Fighters and Burn Centers

Fire fighters carry the unique risk of repeated burn injuries and heat exposure because of the work they do. All fire fighters who have suffered any type or size of burn injury should be referred to or consult with a burn specialist. If there is not a burn center in geographical close proximity, this can be done remotely or through telemedicine to ensure proper treatment.

The skin is the body’s first line of defense. It protects against infection, helps regulate body temperature and its elastic nature supports movement. When skin is burned, these and other life-saving properties are greatly impacted. Treating burns involves more than just getting a wound to heal. Once the burn site closes over, newly healed areas remain delicate and extremely heat-sensitive for many weeks thereafter. A fire fighter’s work environment consists of repeated exposure to heat sources. Returning to work too soon increases the risk of further damage to the burn injury site.

Transportation destinations should be based on hospital capabilities, timely access and need for stabilization before transferring to another facility.

Initially, a burn patient may have to gain access to care through an emergency department. Access to burn center facilities may be limited as a result of geography, and the patient may need emergency stabilization beyond the scope and capability of pre-hospital care. Through the availability of Telemedicine (health care professionals evaluate, diagnose and treat patients in remote locations using telecommunications technology), medical professionals can access guidance from burn specialists, in providing the early necessary care of the patient with burn injuries.

There are national standards and referral criteria that guide when a burn-injured patient is best managed by being transferred to a burn center:

• Burn Center Referral Criteria (American Burn Association)
• American Burn Association Burn Center Verification
• Guidelines for the Operation of Burn Centers
• The American College of Surgeons’ “Resources for the Optimal Care of the Injured Patient, 2014 edition” (Chapter 14)
• National Burn Referral Criteria

If there is no burn center in your local area, here are short- and long-term options:

• Ask about the presence of transfer agreements and/or state and regional care and transfer plans. If you have confirmed that there aren’t any, start a discussion with local, township, county, state or regional partners to establish coordinated plans.
• Seek out telemedicine (e.g., telehealth, connected care, mhealth, ehealth) options, and partner with non-burn center healthcare facilities in order to ensure optimal, initial and ongoing care are delivered.

Verifying Burn Centers

The verification for burn centers is a joint program of the ABA and the American College of Surgeons (ACS). It is a rigorous review program designed to verify a burn center’s resources that are required for the provision of optimal care to burn patients from the time of injury through rehabilitation. This requires a multi-disciplinary “Burn Team” of trained professionals, including physicians, nurses, occupational and physical therapists, social workers, psychologists, dietitians, researchers and those involved in support services such as fire fighters and burn survivors. Not all hospital care facilities have the training, personnel and resources necessary to deal with the physical, psychological, emotional, functional and dietary needs of post-burn patients and their families. The many challenges faced by burn patients and their families are oftentimes long-term, requiring ongoing care and support for optimal outcome.

Not all burn centers have been verified, but the ABA has a step by step verification process which burn care facilities can follow. Some burn care facilities offer treatment to adults, children or both. In some instances, emergent care and stabilization of the patient may take place in a hospital emergency room before transferring the patient to a burn center.

In addition to standardized burn care, there are other considerations that are also a priority. Adhere to standard principles of trauma management in accordance with local protocols, before EMS or healthcare providers address the burn injury. Primary stabilization takes place at the scene, and/or at a local Emergency Department or Trauma Center. Transfer to a verified burn center or burn center should be arranged after a patient has been stabilized initially. Consult the American Burn Association website at www.ameriburn.org for a list of verified and non-verified burn centers, details about transfer guidelines or how to consult with a burn physician on patient care.

Step-by-Step Guide to Basic Burn Center Treatment Standards

• Stabilize and assess the patient following the standard principles of trauma and burn care management
• Assess wounds and calculate the percentage of total body surface area (%TBSA) of burn injury sustained
• Based on %TBSA and treatment guidelines, initiate intravenous (IV) fluid resuscitation per burn resuscitation formulas
• As indicated, insert an in-dwelling urinary catheter to guide fluid resuscitation and management
• Closely monitor pain levels, and adjust analgesics to individual patient needs
• Clean wounds and dress with an antimicrobial agent or other dressing as determined by the treatment facility
• Assess wounds on a frequent basis, and adjust treatment as indicated by the wound progression and patient status
• Encourage adequate nutrition to promote healing, and – as indicated – insert a feeding tube
• Consult physical/occupational therapy to determine patient readiness for mobility. During the acute resuscitation phase, ambulation may be delayed depending on the severity of the injury, possible complications and patient status or response
• Many factors impact a patient’s length of hospitalization, including: severity of burns, infection or other potential complications; surgeries; wound healing; pain control; individual patient response and discharge location and considerations
• Return-to-work or school plans vary from patient to patient; each patient’s condition and circumstance is different
• Provide on-going psycho-social support of the patient and family
• Promote open communication among the burn team, patient and family members (including active patient/family participation in care and treatment planning) throughout the hospital course and beyond, as the road to recovery can be long-term and challenging

Review the Practice Guidelines for Burn Care or the additional resources listed below for more details on specific burn treatment guidelines and protocols.

*The above are all steps to stabilize a burn patient, but not all of these steps are done on-scene.

Two Types of Telemedicine

Burn Center Telemedicine Programs

Burn centers represent a small but vital component of the healthcare community, and as such have an inherent obligation to provide critical education and specialty services to the population served. Burn Telemedicine allows top-of-the-line care and consultation for burn and soft tissue injuries, such as frostbite, to be made available to those who may be hundreds of miles away from a burn center. Through video conferencing equipment or the sending of images, burn experts can see patients remotely – allowing them to evaluate wounds and make clinical recommendations. Wound treatment and follow-up may often continue long term through the rehabilitation phase, allowing burn specialty centers to collaborate with local healthcare facilities in order to provide the most appropriate care for patients and their loved ones.

Potential Benefits of Burn Telemedicine:

• Proper and Accurate Triage: With Burn Telemedicine, many patients are able to be assessed by burn specialists who otherwise would not be available to assist them. The burns are triaged/assessed in a manner that helps determine the appropriate level of care that the patient needs to receive as the next step (e.g., transfer to a Burn Center, schedule an outpatient visit with the burn specialist, treat the wound locally).
• Reduced Costs: Given that Burn Telemedicine is used for specialized assessment of a patient’s burn(s), the need for expensive or unnecessary travel is often eliminated, resulting in cost savings both to the patient and the healthcare system as a whole.
• Greater Accessibility: Rural residents, children, the elderly and those living in poverty are known to suffer an increased risk of burn injuries; yet, their access to burn treatment is restricted by distance and resources. Burn Telemedicine makes burn services accessible, especially to those who may need it the most.
• Enhanced Outcomes: Research has shown that patients treated in verified burn centers have improved outcomes and higher survival rates. Burn Telemedicine allows the patient and providers to connect instantly with burn specialists both on an acute and continued basis in order to manage care that is often complicated and prolonged.
• Increased Community Disaster Preparedness and Resilience: National and international disasters (e.g., earthquakes, terror attacks, hurricanes) remind us that we can take nothing for granted. These disasters are characterized by an overwhelming imbalance between needs and resources. In the face of this imbalance, difficult decisions regarding patient care might need to be made when transfer to a burn center may not be possible. Telemedicine allows physicians at a burn center to connect with providers not only on an everyday basis, but also in a disaster situation – so that patients can experience the best possible care even in a challenging situation.
• Wildland Fire Fighters: Wildland fire fighters may be stationed far from home or far from a verified burn center for long periods of time. These fire fighters encounter multiple occupational hazards, which could result in burn injuries, impaired burn wound healing and potential infection if appropriate treatment and follow up is not delivered. Burn Telemedicine is an excellent option in this instance as most injuries occur in rural areas without access to burn centers. Because of workers’ compensation considerations, care providers must be diligent when documenting these types of burn injuries and the associated burn care strategies. Wildland fire fighter employers and government oversight agencies should develop Standard Operating Guidelines (SOGs) to ensure the needs of the wildland fire fighter are met.

For information regarding individual telemedicine programs, please contact the burn center in closest proximity to you.