A Pilot Study to Validate the Burn Center Pediatric Early Warning Score Tool in Clinical Practice.

The pediatric early warning score (PEWS) tool helps providers to detect subtle clinical deterioration in non-intensive care unit pediatric patients and intervene early to prevent significant adverse outcomes. Although widely used in general pediatrics, limited studies report on its validation; none report on use with burn-injured patients. New York-Presbyterian/Weill Cornell Medical Center modified a general PEWS system to a burn-specific PEWS and integrated its use into standard practice. This study investigated the external validity of the PEWS process in clinical practice. Fifty cases of patients aged 0 to 15.9 years admitted between January 2012 and June 2013, whose length of stay (LOS) more than 3 days were selected for review from this cohort of n equal to 187. Demographics, total PEWS and score changes, and compliance with PEWS documentation and with resultant interventions were reviewed. Continuous variables are presented as mean ± SD, P less than 0.05. Mean age, burn size, and LOS were 3.2 ± 3.3 years, 4.8 ± 5.7%, and 9.8 ± 7.0 days; 26% required grafting, and 50% were male. No mortalities occurred. One thousand six hundred and twelve PEWS from 1745 opportunities were documented (92.4%). For all PEWS (n = 1612) and PEWS greater than 0 (n = 912), means were 0.9 ± 1.2 and 1.6 ± 1.2, respectively. Among the 162 PEWS increase events, intake (54.1%) and output (4.5%) parameters increased most commonly. Of these, 129 PEWS increases (79.6%) were followed by an intervention that most commonly included text notation of score increase (93.7%), physician/physician assistant notification (70.5%), and feeding-tube insertion (25.6%). Patients with PEWS greater than 0 had similar age, LOS, and larger burn size (5.2% vs 1.4%, P < 0.05) than those with PEWS equal to 0. Compliance with PEWS performance and resultant actions based on score increases are high. Data support that even small changes in burn-injury specific PEWS stimulate provider discussion and intervention and support its validation; further studies on its effect on practice are warranted.

Predictors of Mortality Among Pediatric Burn Patients in East Africa.

Little is known about the outcomes of pediatric burn patients in resource-limited and rural locations of the developing world. In March 2013, our pediatric burn unit existing in this setting established an electronic registry of all patients. The authors analyzed the registry to determine overall mortality rates and predictors of mortality, including that of underweight status and body part burned. The secure electronic database of all admissions was reviewed for age, gender, weight, burn percentage (TBSA%), body part burned, cause/place of injury, length of stay, underweight status, surgery performed, reason for discharge, and mortality. Univariable and multivariable logistic regression was used to determine the variables associated with mortality. Kaplan-Meier curves were also analyzed. A total of 211 cases (59.7% male) admitted from March 2013 to June 2014 were reviewed. The median age, %TBSA, and length of stay were 2.0 years (1.3-3.3), 8.0% (5.0-13.4), and 8.5 days (4-14). The overall mortality rate was 15/211 (7.1%). Most injuries were unintentional (93.8%) scalds (85.3%) occurring in the home (98.1%). Two factors were significantly associated with mortality in the final multivariable model: %TBSA (odds ratio = 1.31 for 1% increase in %TBSA; 95% confidence interval = 1.17-1.46) and younger age (odds ratio = 0.20; 0.07-0.63). This study characterizes mortality among patients at a pediatric burn unit serving a rural population in the developing world. The majority of pediatric burns were unintentional scalds occurring in the home. %TBSA and lower age were the strongest predictors of mortality. Burn location and underweight status were not independent predictors of mortality. Overall mortality was 7.1%. These data are applicable to improving outcomes for patients in this burn unit and similar settings of its kind.

The treatment of posttraumatic stress disorder and related psychosocial consequences of burn injury: a pilot study.

Burn injuries are unique in their medical and psychological impact, yet there has been little exploration of psychiatric treatment for this population. This uncontrolled pilot study assessed feasibility, acceptability, and preliminary efficacy of a treatment protocol designed to address posttraumatic stress disorder, depression, coping with scarring, and community integration among adult burn survivors. A 14-session, manualized treatment protocol was created using cognitive-behavioral interventions including imaginal exposure, behavioral activation, cognitive restructuring, modeling, and in vivo exposure. Responses were measured using the Clinician Administered PTSD Scale, Beck Depression Index, Community Integration Questionnaire, Oswestry Disability Questionnaire, and Burn Specific Health Scale. Nine of 10 enrolled patients (60% women; mean = 42 years old) completed treatment. Burn size was 0.5% to 65%; mechanism of injury included flame (4), scald (5), and contact (1) burns. Mean acute hospitalization was 30.1 days (range = 13-87); mean time from injury to treatment was 3.2 months (range = 1-7). Baseline mean posttraumatic stress score was 68 on the Clinician Administered PTSD Scale (severe); scores decreased by 36% to a mean of 45.3 at posttreatment, with a large effect size. Baseline self-reported depression was 21 (moderate) on the Beck Depression Index, decreasing by 47% to a mean of 12 posttreatment (nonclinical). Change in community reintegration score was significant and large, and body image showed significant improvement. The protocol showed promise in the treatment of posttraumatic stress disorder, depression, self-image, and community reintegration following burn injury. These findings suggest that coping may improve with treatment and symptoms should not be dismissed as unavoidable consequences of burn injury.

Simulation of Tangential Excision: A Test for Construct Validity.

A foundational skill in burn surgery is tangential excision (TE). The purpose of this study was to develop a simulation model for TE, hypothesizing that simulation could be used in surgical training. TE simulation was created using the TE knife, foam, mineral oil, and base. Subjects, surgeons, or surgeons in training, were given a pre- and post-task questionnaire about experience with TE. Subjects were divided into three TE experience groups: novice--none, intermediate--some, and expert--TE in current or past practice. The task was to excise pre-marked rectangles, generating four excisional products (EPs). Evaluators blindly assessed performance by EP analysis using a novel scoring tool and reviewed videos using a modified objective structured assessment of technical skill (OSATS) rubric. Inter-rater reliabilities and P values were obtained, comparing Novice and Intermediate with Expert scores. Forty subjects completed the study: 16 were identified as TE novices, 17 as intermediates, and seven as experts. All EPs and videos were reviewed blindly by two evaluators using the EP scoring tool and OSATS methodology, respectively. Intraclass correlation coefficients were calculated to measure inter-rater reliabilities, which were acceptable (ICC => 0.42) for OSATS, time, and EP analysis: border and texture. Statistical differences between Novice and Expert scores were found (P < .0100, P < .0200, P < .0025, and P < .0005, respectively). Statistical differences between Intermediate and Expert scores were also found (P < .0100, P < .0200, P < .0100, and P < .0025, respectively). Post-simulation survey results showed experts 86% of the time agreeing or strongly agreeing that the simulation was similar to the clinical skin and 100% felt it would be a useful for training before clinical performance. Simulation for TE was successfully created to blindly discern level of TE experience. Participants agreed that simulation could play an essential role in burn surgical training.

Pediatric sink-bathing: a risk for scald burns.

Our burn center previously reported a significant incidence of scald burns from tap water among patients treated at the center. However, mechanism of these scalds was not investigated in detail. A recent series of pediatric patients who sustained scalds while bathing in the sink was noted. To evaluate the extent of these injuries and create an effective prevention program for this population, a retrospective study of bathing-related sink burns among pediatric patients was performed. Patients between the ages of 0 and 5.0 years who sustained scald burns while being bathed in the sink were included in this study. Sex, race, age, burn size, length of stay, and surgical procedures were reviewed. During the study period of January 2003 through August 2008, 56 patients who were scalded in the sink were admitted, accounting for 54% of all bathing-related scalds. Among these, 56% were boys and 45% were Hispanic. Mean age was 0.8 ± 0.1 years. Burn size and hospital length of stay averaged 5 ± 0.7% and 11 ± 1 days, respectively. Of this group, 10.7% required skin grafting. The overwhelming majority (94% of patients) were discharged home. The remaining patients were discharged to inpatient rehabilitation, foster care, and others. Pediatric scald burns sustained while bathing in a sink continue to be prevalent at our burn center. Because of limited space and the child's proximity to faucet handles and water flow, sinks are an unsafe location to bathe a child. While such practice may be necessary for some families, comprehensive burn prevention education must address this hazard.

New management strategy for fluid resuscitation: quantifying volume in the first 48 hours after burn injury.

This study evaluated a 24-hour resuscitation protocol, established a formula to quantify resuscitation volume for the second 24 hours, described the relationship between the first and second 24 hours, and identified which patients required high volumes. A protocol for patients with burn >15% TBSA was implemented in 2009. Initial fluid was based on the Parkland calculation and adjusted to meet a goal urine output. Protocol compliance was defined as appropriate fluid titration to maintain urine output. Resuscitation ratio in the second 24 hours was tabulated as total fluid /(evaporative loss + maintenance fluid + estimated colloid). Data were collected prospectively from 2009 to 2011. A Wilcoxon rank test compared differences between groups. Regression analyses analyzed volume administered. P < .05 was statistically significant. Forty patients with burn >15% TBSA met criteria for inclusion. Mean age, burn size, and resuscitation volumes in the first and second 24 hours (mean + SD) were 47+ 20.7 years, 29.9 + 14.6% TBSA, 7.4 + 3.7 ml/kg/% TBSA, and a ratio of 1.9 times expected volume (SD, 1.3), respectively. Protocol compliance was 34%. Intubation, older age, and increased narcotic administration correlated with higher resuscitation volumes. A higher resuscitation volume in the first 24 hours significantly correlated with a higher resuscitation volume in the second 24 hours (P < .001). In conclusion, there is a significant relationship between fluid administration in the first and second 24 hours of resuscitation; intubation, older age, and narcotics correlate with higher volumes. A formula for observed/expected volumes in the second 24 hours is total fluid/(evaporative loss + maintenance fluid +estimated colloid).

Burn disaster response planning in New York City: updated recommendations for best practices.

Since its inception in 2006, the New York City (NYC) Task Force for Patients with Burns has continued to develop a city-wide and regional response plan that addressed the triage, treatment, transportation of 50/million (400) adult and pediatric victims for 3 to 5 days after a large-scale burn disaster within NYC until such time that a burn center bed and transportation could be secured. The following presents updated recommendations on these planning efforts. Previously published literature, project deliverables, and meeting documents for the period of 2009-2010 were reviewed. A numerical simulation was designed to evaluate the triage algorithm developed for this plan. A new, secondary triage scoring algorithm, based on co-morbidities and predicted outcomes, was created to prioritize multiple patients within a given acuity and predicted survivability cohort. Recommendations for a centralized patient and resource tracking database, plan operations, activation thresholds, mass triage, communications, data flow, staffing, resource utilization, provider indemnification, and stakeholder roles and responsibilities were specified. Educational modules for prehospital providers and nonburn center nurses and physicians who would provide interim care to burn injured disaster victims were created and pilot tested. These updated best practice recommendations provide a strong foundation for further planning efforts, and as of February 2011, serve as the frame work for the NYC Burn Surge Response Plan that has been incorporated into the New York State Burn Plan.

Burn survivors' perceptions of rehabilitation.

BACKGROUND: The perspectives of burn survivors offer a powerful tool in assessing the efficacy of burn therapy interventions and methods. Despite this potential wealth of data, comprehensive analysis of burn survivor feedback remains largely uninvestigated and underdocumented. The aim of this study was to evaluate specific burn therapy interventions based on the opinions of a sample of the burn community. METHODS: The survey was distributed to a convenience sample drawn from burn survivors attending the Phoenix Society's 21st Annual World Burn Congress in New York City, New York. Items of inquiry focused on therapeutic intervention and reintegration. The 164 surveys (a 44% response rate) returned included burn survivors from a variety of demographic segments and with burn injuries of disparate size, location, and severity. Interventions of interest included splinting and positioning, pressure garments, therapeutic exercise, group therapy, and nontraditional therapy. Respondents also rated the contribution of acute burn rehabilitation toward reintegration into familial, societal, and professional roles. RESULTS: The vast majority of respondents felt that the rehabilitative interventions they experienced positively affected their long-term physical and psychosocial outcomes. In the areas of improving movement and scarring and expediting reintegration and usefulness, the majority of applicable interventions generated "strongly agree" or "agree" as the most popular responses. CONCLUSIONS: These findings support the efficacy of many practices employed by burn rehabilitation specialists and offer a glimpse into the inherent benefits found in assessment of burn survivors' perspectives.

Engaging older adults in burn prevention education: results of a community-based urban initiative.

The objective of the study is to educate New York City seniors aged 60 years and older about fire safety and burn prevention through the use of a community-based, culturally sensitive delivery platform. The ultimate goal is to reduce burn injury morbidity and mortality among this at-risk population. Programming was developed and provided to older adults attending community-based senior centers. Topics included etiology of injury, factors contributing to burn injuries, methods of prevention, emergency preparedness, and home safety. Attendees completed a postpresentation survey. Of the 234 senior centers invited to participate in the program, 64 (27%) centers requested presentations, and all received the educational programming, reaching 2196 seniors. An additional 2590 seniors received education during community-based health fairs. A majority reported learning new information, found the presentation helpful, and intended to apply this knowledge to daily routines. Data confirm that many opportunities exist to deliver culturally sensitive burn prevention programming to the older adult population of this large metropolitan area in settings that are part of their daily lives. A majority of respondents welcomed the information, perceived it as helpful, and reported that they were likely to integrate the information into their lives.

The Potential of Gaming in Rehabilitation of the Burn-Injured Patient.

The use of videogames for non-entertainment purposes has interested educational and behavioral researchers for decades. Recent technology advances have increased the interactivity of games while maintaining reasonable costs, leading rehabilitation therapists to investigate gaming consoles as an adjunct to traditional techniques. Obstacles to large-scale trials exist, but the transformative potential of gaming consoles should motivate developers and healthcare professionals to find solutions.

Use of Nintendo(®) Wii(™) in Physical Therapy of an Adult with Lower Extremity Burns.

OBJECTIVE: The purpose of this exploratory case study is to describe differences in rehabilitation outcomes for a 47-year-old male with bilateral lower extremity burns when using conventional therapy techniques alone versus such techniques in combination with Nintendo(®) Wii™ (Nintendo of America, Inc., Redmond, WA) videogames. MATERIALS AND METHODS: The patient received three series of rehabilitation therapy over 2 weeks. During the second series, the Wii was introduced for a portion of the otherwise conventional therapy. Under standardized conditions and upon completion of each series, the Limits of Stability test with a SMART Balance Master(®) (NeuroCom(®), Clackamas, OR) was used to measure reaction time (RT), maximum excursion (MXE), endpoint excursion (EPE), movement velocity, and directional control. The Timed Up and Go (TUG) test for functional mobility and a questionnaire assessing level of motivation and interest were administered at the end of each day; these results formed mean scores for each series. RESULTS: The patient performed better on RT and MXE during the series that combined conventional therapy with the Wii than during the two series using conventional therapy alone. Improvement on EPE was greater for combined therapy than for conventional therapy alone and continued to improve after combined therapy. The patient completed the TUG test faster during the combined Wii series. Additionally, the patient reported increased motivation and interest levels for the series using combined therapy. CONCLUSIONS: The Wii may be a feasible and valuable adjunct to traditional therapy. Improvements during the series with Wii were demonstrated for areas of balance and functional mobility. Trends toward improvement in motivation and interest with the Wii suggest its use may elicit increased patient engagement during burn rehabilitation.

The utilization of Nintendo® Wii™ during burn rehabilitation: a pilot study.

The purpose of this study was to demonstrate feasibility and measure outcomes on pain, anxiety, active range of motion (AROM), function, enjoyment, and presence with the adjunctive use of Nintendo® Wii™ (Nintendo of America Inc., Redmond, WA) during acute burn rehabilitation. Participants were alternated and stratified based on the location of burn into Wii or control treatment groups. Joints of interest with limited AROM were the shoulder, elbow, wrist, hip, knee, and ankle. All participants received three consecutive sessions of passive range of motion and predetermined joint-specific exercises. This was followed by either designated Wii games or therapist-chosen interventions (control). The outcomes were compared between groups using t-tests (P < .05) and Cohen's d statistic. Data from 23 participants aged 20 to 78 years were analyzed. The difference in mean slopes suggested that the Wii group experienced less pain (x = -0.97, P = .07) than the control group over time. Overall, trends with anxiety (x = -0.1l, P = .77), AROM (x = 0.55, P = .81), function (x = -0.38, P = .43), and enjoyment (x = 0.09, P = .73) seemed to favor the Wii group. Presence minimally changed between successive treatment sessions for those in the Wii group. Although statistical significance was not reached in any category, feasibility was supported and the overall pattern for outcomes was positive for the Wii group, the most favorable being for pain reduction. Future research with larger sample sizes is warranted to explore best practice with video game technology throughout the continuum of burn rehabilitation with appropriate prescriptions.

Impact of diabetes on burn injury: preliminary results from prospective study.

Reducing diabetes mellitus complications has been a major focus for Healthy People 2010. A prior retrospective cohort of our burn center's admissions revealed worse outcomes among diabetic patients, that is, increased infection rates, grafting and graft complications, and increased length of hospital stay. Therefore, a prospective study has been designed to carefully assess wound repair and recovery of diabetic and nondiabetic burn patients. Our long-term aim is to determine the characteristics of the wound milieu along with global responses to injury that may predict poor outcome among diabetic patients. This is an initial phase of a larger observational study of in-hospital diabetic (types 1 and 2) and nondiabetic patients, prospectively matched for age (18-70 and >70 years) and burn size (<5, 5-15, and 16-25%). Time (days) to complete index wound closure, documented through serial photography, is the main outcome measure. Secondary measures compare delays in presentation, prevalence of infections, graft rates, wound and graft complications, adverse events, and length of hospital stay. Detailed history, physical, and baseline hemoglobin A1C are elicited from all subjects who are assessed daily over the initial 72 hours poststudy entry, then weekly until complete index wound closure, and finally monthly through 3 months. Forty subjects are presented herein, 24 diabetic and 16 nondiabetic patients. Time to index wound closure was significantly prolonged in diabetic patients, despite increased grafting. These findings suggest that excision and grafting in diabetic patients may not alone be sufficient to ensure rapid closure, as graft complications may contribute to protracted closure. Evaluating graft need may be more complex among diabetic patients, suggesting the need for alternative management strategies. The current prospective study confirms our previous retrospective analysis, notably manifested by significant delays in index wound closure. Our efforts continue in identifying the most important predictors of outcome, especially modifiable factors that would create a basis of intervention to improve care.

The development of a regional system for care of the burn-injured patients.

BACKGROUND: In the mid-20th century, it was recognized that patients with major burn injury required a dedicated, multidisciplinary team approach to receive optimal care. In the subsequent years, regionalized systems of care were developed to provide this level of care to the entire populations. There have been no reports on how an individual regional system evolved and the impact it had on the delivery of care for burn-injured patients. METHODS: The number, distribution of patients, and mortality rates of patients who sustained burn injury from the years 1985-2006 were assessed using administrative hospital data obtained from the New York State Department of Health. Data were also obtained from the archives and registry of the first dedicated burn care facility in the region, the Shires Burn Service, from 1976 through 2008. The incidence of fires occurring by year during this period was assessed from data obtained from the Fire Department of New York City. RESULTS: During the period from 1985 through 2006, there were 26,606,463 discharges from hospitals in New York City. Of these, 57,547 patients had a primary diagnosis of burn injury and 33,058 were cared for in designated burn care facilities. Since the inception of regionalized care there appears to be a 43% decrease in hospital admissions for burn injury. In the last year of study, 77.3% of the burn-injured patients were cared for in burn centers. The mortality rate has decreased from 3.8% in 1985 to 2% in 2006. In 1975 there were 137,237 fires in the region, which decreased to 44,054 in 2008. CONCLUSIONS: Although there has been a significant decrease in the number of patients requiring hospitalization for burn injuries, there are still a large number of patients who suffer these injuries. Regionalization of burn care has been associated with care for patients in designated facilities in over 75% of the cases and a reduction in mortality by almost 50%.

Treatments for common psychiatric conditions among adults during acute, rehabilitation, and reintegration phases.

Common and pernicious adult psychiatric disorders consequent to burn injury include post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and new-onset substance abuse disorder. Diagnosing and treating these disorders is complicated by the complex psychosocial issues associated with burns including grief, pain, role impairment, disfigurement, dysfunction, stigma, as well as financial and legal issues. Additionally, pre-morbid psychiatric and neurological illnesses are risk factors for burns, adding to the challenge of diagnosis and treatment. This article will focus on the diagnosis and treatment of PTSD and MDD consequent to burn trauma, as these are the major psychiatric outcomes, addressing the attendant psychosocial problems as threads in this post-trauma tapestry.

Burn disaster response planning: an urban region's approach.

The objective of this study was to describe a draft response plan for the tiered triage, treatment, or transportation of 400 adult and pediatric victims (50/million population) of a burn disaster for the first 3 to 5 days after injury using regional resources. Review of meeting minutes and the 11 deliverables of the draft response plan was performed. The draft burn disaster response plan developed for NYC recommended: 1) City hospitals or regional burn centers within a 60-mile distance be designated as tiered Burn Disaster Receiving Hospitals (BDRH); 2) these hospitals be divided into a four-tier system, based on clinical resources; and 3) burn care supplies be provided to Tier 3 nonburn centers. Existing burn center referral guidelines were modified into a hierarchical BDRH matrix, which would vector certain patients to local or regional burn centers for initial care until capacity is reached; the remainder would be cared for in nonburn center facilities for up to 3 to 5 days until a city, regional, or national burn bed becomes available. Interfacility triage would be coordinated by a central team. Although recommendations for patient transportation, educational initiatives for prehospital and hospital providers, city-wide, interfacility or interagency communication strategies and coordination at the State or Federal levels were outlined, future initiatives will expound on these issues. An incident resulting in critically injured burn victims exceeding the capacity of local and regional burn center beds may be a reality within any community and warrants a planned response. To address this possibility within New York City, an initial draft of a burn disaster response has been created. A scaleable plan using local, state, regional, or federal health care and governmental institutions was developed.

The impact of a legislative intervention to reduce tap water scald burns in an urban community.

To review the efficacy municipal legislation in the reduction of tap water scald burns among an urban population. A retrospective chart and database review of patients hospitalized at this burn center between July 1999 and June 2004 for treatment of tap water scalds were performed. Demographic information and injury details, including extent of injury and age, type and location of the dwelling in which the injury occurred, were reviewed. Citywide incidence of these injuries for periods before and after a local prevention law was enacted was also calculated. Hospital costs for acute care treatment of these injuries were estimated. Tap water scalds increased from 15 to 22 per million/yr after legislation enactment. This burn center treated 281 of these patients during 5 years of the study period. Patients experienced significant morbidity and mortality. All cases (100%) occurred in structures exempt from current legislation. Citywide treatment costs were estimated between $102 and $148,000,000. In New York City, tap water scald burns remain a significant public health risk and continue to occur within buildings exempt from current law. Future injuries may potentially be prevented by expanding the law to include all residential buildings, regardless of building age or minimum occupancy.

Tap water scalds among seniors and the elderly: socio-economics and implications for prevention.

INTRODUCTION: Tap water scalds among those >or=60 years old are often attributed to physical impairments with aging. This study assesses socio-economics associated with tap water scalds among seniors and the elderly. METHODS: Charts of patients admitted to an urban Burn Center between 7/00 and 6/04 for treatment of tap water scalds were reviewed. Demographics, injury details, co-morbidities, surgical interventions/critical care requirements, length of stay (LOS), disposition and related economics were reviewed. RESULTS: During the study period, 68 patients >or=60 years were hospitalized for treatment of these scalds. Mean age and burn size were 78+/-1 years and 7+/-0.9% TBSA. Over 98% of patients were admitted with pre-existing co-morbidities; 60% required ICU care for 40+/-5 days; 22% required mechanical ventilation and 71% required surgery. LOS was 34+/-4 days. Most patients received government assistance income. Pre-injury, 32% resided alone. Post-injury, 10% of patients returned home alone; mortality was 22%. Per patient hospital costs approximated $113,000. CONCLUSION: These findings report that tap water scalds result in significant morbidity, mortality and health care costs for local seniors and the elderly. Socio-economic factors play a significant role in these injuries and must be assessed when planning prevention efforts.

Therapeutic efficacy of a therapeutic cooking group from the patients' perspective.

The purpose of this study was to evaluate the therapeutic efficacy of the cooking group from the burn survivors' perspective. By incorporating concepts of kitchen skills, energy conservation, and desensitization techniques, the cooking group can assist patients with the functional use of their hands, standing tolerance, return to former vocational activities, and socialization with other patients. A questionnaire was developed based on commonly expressed benefits of cooking group. Areas of interest included decreasing anxiety in the kitchen, distraction from their burns, socializing with other burn survivors, and the physical benefits of participating in the group. The results of this study indicate that participants regard the therapeutic cooking group as a valuable treatment modality that effectively combines functional activities with socialization to decrease burn related anxiety and increase motion in a supportive environment for patients with burns.