Management of an inpatient-outpatient clinic an eight-year review.

Healthcare organizations have historically separated outpatient from inpatient facilities. In order to streamline the continuity of high quality care, an outpatient burn clinic was established on our inpatient burn center in 1991. Management of the outpatient clinic required alternate staffing patterns and supply allocation plus training in managed care and third party payors. Budget decisions and health care trends affected the number of full time equivalents (FTEs). Between 1990 and 1998, a 33% RN FTE reduction occurred with an overall 22% decrease in total inpatient care providers. Clinic positions were allocated as patient volume and workload data could justify additional staff. Enhanced flexibility in assignment and use of personnel with varying skill levels led to efficient integration of inpatient and outpatient care with an overall reduction in RN FTEs. The purpose of this study is to review the changes in nursing management strategies required by this consolidation.

Osteocutaneous pedicle flap of the foot for salvage of below-knee amputation level after burn injury.

Lower extremity amputations are occasionally required after high-voltage electric and deep thermal burns. The extensive loss of skin and soft tissue after these injuries may make it difficult to fashion below-knee amputation that will readily tolerate a prosthesis. We have found an osteocutaneous pedicle fillet flap of the foot useful in the salvage of below-knee amputation after severe burn injury. Three patients have undergone this procedure after burn injury, 1 with burn secondary to high-voltage electric injury and 2 after deep thermal burns. All became ambulatory with artificial prostheses. There were no postoperative infections and no need for further revisions. The osteocutaneous pedicle fillet flap of the foot has proven to be a reliable form of below-knee stump coverage in patients with extensive soft tissue necrosis after burn injury.

Music therapy for assistance with pain and anxiety management in burn treatment.

The management of pain is one of the primary issues in burn care. Pain is not only a physiologic experience, but a psychological one as well. With this in mind, the treatment of burned patients must incorporate a holistic view of pain management and healing. Cognitive, behavioral, and pharmacologic interventions all have a role in pain management. Studies, as well as clinical experience, have shown that musical intervention has been helpful in assisting patients with pain management in a variety of medical settings. Music is an element of normal life that can be easily adapted for the needs of individual patients and their current environment while providing a means for self expression and for normalizing the environment. This article examines the rationale for using music therapy with burned patients, describes several protocols that have been adapted to meet the specific needs of burned patients, and summarizes our preliminary findings, which demonstrate significant response to music therapy protocols employed on our patients.

The effect of music-based imagery and musical alternate engagement on the burn debridement process.

Management of pain is a primary concern in the treatment of burn patients. The intent of this study was to test the efficacy of music-based imagery and musical alternate engagement in assisting burn patients in managing their pain and anxiety during debridement. Twenty-five patients, 7 years of age and older, who were admitted to the Comprehensive Burn Care Center were enrolled in the study, which used a repeated-measures design with subjects serving as their own control. Subjects were randomly assigned to 1 of 2 groups. Those placed in Group A received music therapy intervention during their first dressing change, and no music therapy on the following day. Group B received no music therapy intervention during their first dressing change and music therapy during their next dressing, on the following day. Data were collected at 4 intervals in the medical procedure; in the patient's room before transfer to the treatment room, in the treatment room during debridement, in the treatment room after debridement, and upon returning to the patient's room. The measurements taken were pulse, patients' self-report of pain, patients' self-report of anxiety, and the nurse's observation of patients' tension. There was a significant reduction in the self-reporting of pain in those who received music therapy in contrast to those who did not receive music therapy (P < .03). Music therapy is a valuable noninvasive intervention for the treatment of pain after burn injury.

Hydrogen sulfide inhalation injury.

Hydrogen sulfide is a colorless, noxious gas with the distinctive smell of rotten eggs. This compound is a powerful reducing agent that is encountered in a number of industrial processes. When hydrogen sulfide is present, it exposes workers to the potentially lethal effects of the rapid hypoxemia that results from exposure to this agent. The "warning sign" is the characteristic smell of rotten eggs; this smell should alert anyone in the area that a potentially serious risk exists. The immediate removal of the victim and administration of high-flow oxygen is essential. Neurologic sequelae may require anticonvulsants and care must be exercised to observe for cardiac, hepatic, and renal insufficiency. Depending on the concentration, hydrogen sulfide can rapidly overcome a potential victim.

Vancomycin-dependent enterococcal strains: case report and review.

We report, to our knowledge, the first isolation of VDE from a burn unit. Our experience was similar to earlier reports, in that continuous administration of vancomycin and previous VRE isolation preceded the recovery of VDE. Given the increasing prevalence of VRE as a nosocomial pathogen, intensive care units must now be attuned to the emergence of VDE as serious pathogen.

Triage of minor burn wounds: avoiding the emergency department.

Many patients with minor burn wounds will initially be evaluated in an emergency department (ED) and incur unnecessary costs that could be avoided through a direct referral to a burn center. In June 1997, use of an ED burn triage protocol was begun at our hospital. Adults with uncomplicated burns that covered more than 1% and less than 15% of total body surface area (TBSA) and children with burns that covered more than 1% and less than 10% of TBSA were to be triaged directly to the outpatient clinic of the burn center without registering in the ED. From 1996 to 1997, 653 patients were seen in the ED for burn injuries. Approximately 500 patients fit the present criteria for direct triage to the burn center. Since the triage protocol began, the percentage of patients triaged to the burn center has increased from 27% in the first month of use (July 1997) to 73% in December 1997. At least 33% of ED patients were eligible by protocol but not triaged. The average ED visit time for these patients was 103 minutes versus 44 minutes for patients who were sent directly to the burn clinic. An estimated $125,000 per year decrease in charges would occur with use of the protocol. Implementation of an ED triage protocol leads to avoidance of emergency room visits for the majority of patients with minor burn injuries, which results in more efficient, less expensive, faster care.

Current status of burn resuscitation.

Rapid assessment and management of airway and breathing problems are required in the patient with severe burns complicated by significant facial burns and inhalation injury. A policy that results in intubation of all patients at potential risk for airway compromise can be both foolish and dangerous. At the same time, it is recognized that intubation of patients who are likely to develop unstable airways is necessary if transport times to burn centers are long and if i.v. resuscitation is initiated during transport. The ideal burn resuscitation formula does not exist. Whichever formula is used, patients must be monitored closely and the fluid resuscitation individualized according to their responses. Patients with delay in resuscitation, associated trauma, inhalation injury, or alcohol abuse may require fluid resuscitations greater than those predicted. The goal is to maintain urine outputs in the range of 0.5 to 1 mL/kg/hr for adults and 1 to 1.5 mL/kg/hr in children. In patients with fluid requirements greater than 150% of that predicted by formula, the addition of colloid at 12 hours can reduce total fluid requirements and burn edema. Early placement of pulmonary artery catheters can be useful in patients with known myocardial dysfunction, age greater than 65 years, severe inhalation injury, or fluid requirements greater than 150% of that predicted by formula.

Physical therapy acute burn evaluation tool.

A physical therapy acute burn evaluation tool was developed to provide a concise evaluation of the patient with burns in accordance with our hospital's physical therapy department protocols. Previous burn evaluations were either written on a generic physical therapy form or written out in the subjective, objective, assessment, and plan format. They required 20 to 30 minutes for completion, depending on the extent of the burn and any subsequent physical impairment. The new form is primarily laid out in a check-off design, with additional space for comments. Documentation time has decreased to 10 to 15 minutes, and that time does not appear to be affected by the burn experience of the therapist. This new evaluation tool has also proved useful for educating the student physical therapists that have rotated through our unit.

Improved survival of adults with extensive burns.

Before 1988, survival of adults with burns > or = 75% total body surface area was uncommon in our burn unit. In 1988 a revised treatment plan for adult patients with burns > or = 75% was instituted. This plan included rapid disciplined eschar removal to fascia within 7 days, sequential meshed autografting with concomitant fresh allograft application, and early enteral feedings.

Determining when care for burns is futile.

Age, burn size, inhalation injury, and comorbid diseases are important factors in predicting survival of patients with burn injuries. These same factors are important in attempting to objectively define the point when burn care is futile. We reviewed the records of 3301 patients admitted to our Burn Center between January 1, 1986, and December 31, 1994. There were 114 deaths (3.45%), of which 44 occurred within the first few days of admission. Seventy patients died at a later date. A do-not-resuscitate with comfort-measures-only order was written on 33 patients (26.7%). We have developed objective criteria that include age, extent of burn, presence of inhalation injury, and major organ dysfunction to be applied in the determination of futility of further therapy, either at the time of admission or when patients develop progressive multi-organ system failure during the hospital course.

Use of burn intensive care unit gymnasium as an adjunct to therapy.

One primary goal for patients with burns is to prevent loss in range of motion and function in the involved extremities. Because therapies were provided only on weekdays at our facility, the burn team designed a gymnasium that was built in the burn unit where patients can carry out their exercise programs after hours and on weekends. Patients assume responsibility to complete their occupational and physical therapy assignments, in addition to their other scheduled therapy sessions. The development of the burn intensive care unit gymnasium has increased the opportunity for patients to improve their range of motion and overall functional status. We have also noted that patients feel a greater sense of motivation and accomplishment when they are invited to take more control of their recovery. Assuming responsibility for their programs enables patients to achieve their goals, thus increasing their self-esteem after what is often a very devastating injury.

Diagnosis and management of common industrial burns.

Workers are at risk for a wide variety of occupational burns, secondary to thermal, electrical, or chemical sources. The diagnosis and management of common industrial burns is reviewed and outlined. Proper evaluation and management is necessary to minimize the disability that can result from these injuries.

Stapled tie-over stent: a simplified technique for pressure dressings on newly applied split-thickness skin grafts.

A simplified technique for simultaneously securing a skin graft and applying a stented pressure dressing is described. This method provides good fixation and immobilization of the graft. It is less time-consuming than previously described methods, and it is easier to perform.

Neutrophil lipoxygenase metabolism and adhesive function following acute thermal injury.

Leukotrienes, especially leukotriene B4, are important modulators of various neutrophil functions including adherence and chemotaxis. In previous work, we demonstrated that neutrophil adherence to extracellular matrixes was diminished in the acute stages of burn injury. In this study, we demonstrated that neutrophil adhesion to human and bovine endothelium in the baseline state and after stimulation with leukotriene B4 is depressed markedly after burn injury. The defect in stimulated adherence to endothelium was not specific to leukotriene B4 because impaired adhesion was observed with n-formyl-methionyl-leucyl-phenylalanine and ionophore A23187 as well. Moreover, the adherence defect correlated with 95% and 81% decreases in the release of leukotriene B4 and 5-hydroxy-(6E,87,117,147)-eicosatetraenoic acid, respectively, from burn PMN treated with A23187. Burn neutrophils also released proportionately more byproducts of leukotriene B4 omega oxidation, particularly 20-COOH-leukotriene B4, than did control neutrophils. When examined 3 1/2 weeks after injury, abnormalities in neutrophil leukotriene B4 generation and the adherence of burn neutrophils had recovered to near normal values. To determine whether the decreased release of leukotriene B4 from burn neutrophils was due to increased degradation or diminished synthesis of leukotriene B4, we examined the degradation of exogenous tritiated leukotriene B4 as well as the production of leukotriene B4 from tritiated arachidonic acid in neutrophils. Burn neutrophils converted significantly greater quantities of tritiated leukotriene B4 to tritiated 20-COOH-leukotriene B4 and synthesized markedly less tritiated leukotriene B4 from tritiated arachidonic acid than did control neutrophils, suggesting that decreased leukotriene B4 release by burn neutrophils was the result of both enhanced degradation and decreased synthesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Fibronectin binding and neutrophil aggregation in burn injury.

Fibronectin (Fn) plays an important role in the adhesive function of many cells including neutrophils (PMN). We examined the hypothesis that activated PMN develop binding sites for fibronectin which allows for the aggregation of contiguous PMN. Because PMN adhesive function is altered in acute burn injury, we also investigated the role of Fn in the aggregation of PMN from subjects with acute thermal injury. The chemotactic peptide, n-formylmethionyl leucyl phenylalanine, induced rapid binding of radioiodinated plasma Fn to PMN. Significant binding of Fn was detected as early as 30 sec poststimulus and maximal binding occurred at 5 min. Fn binding was only partially reversible and nonsaturable. The chemotactic peptide induced aggregation and binding of Fn to PMN with similar kinetics, concentration dependence, temperature, and cation requirements. In burn patients, PMN demonstrated a significant decrease in chemotactic peptide-induced aggregation which was associated with decreased binding of Fn. Alterations in the binding of Fn to PMN may be responsible, in part, for diminished aggregation responses of PMN in the early stages of thermal injury.

Mixing inpatient with outpatient care: establishing an outpatient clinic on a burn unit.

Outpatient care of patients with burns is an important aspect of a total health care plan. Changes in the health care system, which focuses on cost containment, force reevaluation of the methods used for delivery of high-tech care, particularly in areas such as burn care. Great advances that have taken place over the past decade in the field of burn care have enabled health care providers to treat more patients with burns as outpatients. Those who are specially trained in burn care continue to be the optimal caregivers. The appropriate facilities, spray tables, hydrotherapy, and dressing rooms in which patients with burns are treated are equally important and must be adapted to meet the needs of patients who are ambulatory. The goals of an outpatient burn clinic should be to provide daily wound care and patient education to prevent unnecessary admissions and to promote early discharge for hospitalized patients. Nurses trained in burn care are the optimal providers of ambulatory burn care; therefore the clinic location should be where the caregivers are available. Several obstacles needed to be overcome before an outpatient clinic could be established on the burn unit itself. Wound care is now provided by burn unit nurses, which leads to better results and more consistent follow-up. Patient satisfaction is increased, patient teaching is provided by experienced staff, unnecessary admissions are prevented, and patients are able to be discharged from the hospital earlier or to be followed as outpatients even if surgery is eventually required.

When is enough enough? Ethical dilemmas on the burn unit.

Modern burn care often leads to the dilemma of what should or should not be done for patients with clinical deterioration and organ system failure who fail to respond to therapy. The questions are, "When is enough enough?" and "Who decides?" We have developed a structured conference to address these issues and to help us decide whether to recommend continued invasive diagnostic and therapeutic intervention or to allow the patient to "die with dignity." This conference can be requested by any member of the burn team who feels uncomfortable with what is being done for and/or to a patient. It is a meeting of the entire team, and its purpose is to discern the judgment of the group. When the consensus decision is to forego additional therapy, the decision is then presented to the patient (if he or she is able to understand and respond) and to the patient's family. The decision made by the group removes the responsibility of any individual from making a stressful decision if the patient's condition deteriorates abruptly. Patients who accept this decision exhibit a peaceful calm that invariably reaffirms the group dynamics. The family often experiences a great deal of relief, because they are not forced to make the decision even though they wanted it made. Inviting nurses to be active participants in the decision process builds their personal and professional self-esteem and binds the team members into a more tightly knit community. The attending staff may perceive this process as an abdication of responsibility; however, in our experience the consensus conference has led to a conviction that the wisdom of the team is always best.

Peripheral lymphocyte membrane fluidity after thermal injury.

Serum cortisol levels are increased in patients after thermal injury. Lymphocyte function is altered in these patients, which renders them susceptible to infections. Elevated cortisol levels may contribute to this compromised state. In this study, we have demonstrated that cortisol directly affects lymphocyte membrane fluidity as measured by the polarization of fluorescence from the membrane-associated probe diphenylhexatriene in peripheral blood lymphocytes. Membrane fluidity increased in vitro with short- or long-term cortisol exposure. However, membranes of control peripheral blood lymphocytes that were previously exposed to cortisol became resistant to the fluidizing effect of cortisol, which implies membrane adaptation to long-term cortisol exposure. Cortisol effects were similar to those associated with ethanol, a known membrane-fluidizing agent, in peripheral blood lymphocytes and cytotoxic T lymphocytes. Membrane fluidity was compared in peripheral blood lymphocytes from thermally injured patients and peripheral blood lymphocytes from normal (control) subjects. Peripheral blood lymphocyte membrane fluidity increased in major thermal injury. Our data suggest that cortisol affects lymphocyte membrane fluidity in vitro in a manner similar to the membrane fluidity alterations that are observed in vivo after thermal injury. These observations reflect a direct membrane effect of cortisol, which may explain, in part, the cellular dysfunction and immunologic suppression that is observed after thermal injury.