Burns are a major source of pediatric morbidity and are associated with significant national healthcare resource utilization. They are among the top 10 leading causes of accidental death in the United States for children from birth to the age of 19 years (Centers for Disease Control and Prevention [CDC], 2015a). Every day, over 300 children aged 0–19 years receive treatment in emergency rooms for burn-related injuries; two of whom die because of their burns (CDC, 2012). In 2013, 126,035 children received treatment in emergency departments (EDs; CDC, 2015b).
Although mortality from serious burn injuries has declined because of advances in burn care and implementation of prevention strategies, children with moderate and severe burn injuries require intensive treatment and often experience scarring and possibly long-term disability. Burn-related injuries leave pediatric patients with lifelong physical and psychological trauma. Burns can also result in significant physical, financial, and emotional burdens to patients' families and caregivers.
Most pediatric burn injuries are initially cared for in an ED. Patients, who are stable and can be followed as outpatients, are usually referred to their primary care physicians or return to the ED because there are no pediatric outpatient burn specialists. Most patients are only referred to a designated burn center or a pediatric surgeon when the burn meets certain criteria established jointly by the American Burn Association (ABA) and American College of Surgeons (Appendix A), especially those whose burns cover more than 10% of their total body surface area (American College of Surgeons & American Burn Association, 2014). However, smaller burns not warranting hospital admission under ABA guidelines can still result in long, painful outpatient treatments, long recovery times, and eventual scarring. Many pediatric patients receive outpatient care by pediatricians and/or emergency room physicians, who may not have specialty burn training. Other children may require hospital admission for daily inpatient treatments because no outpatient treatment exists. These treatment options lead to high medical costs and delay adequate treatment by burn specialists.
For the purposes of this article, a pediatric burn team refers to a team of healthcare professionals who specialize in pediatric burn care. Early referral to an outpatient pediatric surgery team for burn treatment can lead to faster healing, less pain, use of advanced wound dressings, and more cost-effective care.
STATEMENT OF THE PROBLEM
In 2007, the pediatric surgery team at a children's hospital consisted of one pediatric nurse practitioner and four pediatric surgeons. This children's hospital serves the metropolitan area and 16 surrounding counties and includes many international visitors. The total population in the metropolitan area equals 3.2 million, with more than 50,000 children under the age of 18 years. This 255-bed children's hospital has a pediatric ED and is a designated Level 1 pediatric trauma center, but not a designated burn center. The pediatric surgery team treats many burns each year, most of which are second degree and less than 10% of the total body surface area. Unless designated as trauma, these patients with burns are referred to the pediatric burn team by the in-hospital pediatric ED, outlying hospital EDs, or local pediatricians.
With the volume of patients with burns growing, the pediatric surgery team needed a designated space within the hospital to treat and manage outpatient burns, and the off-site clinic was not equipped to treat patients with pediatric burns, requiring the patients to utilize the ED for treatment. The ED staff evaluated the patients first and requested consultation of the burn team, which often caused a treatment delay. Sometimes, patients transferred from an outlying ED were directly admitted by the in-hospital pediatric team, further delaying access to the burn team, which could take up to 24 hours. After discharge, patients returned to the ED for follow-up care, which required additional registration and delay. Patients incurred large charges for transfers to the hospital and overnight stays and received multiple standard ED charges for return outpatient visits. Patients and their families could wait more than an hour to be treated by the pediatric burn team. These financial and emotional burdens impacted the referral pattern, not to mention added undue stress to the patients and their family members.
The team performed a gap analysis to address a way to decrease costs to families and the hospital, decrease hospital admissions, and increase accessibility to pediatric outpatient burn team. The pediatric outpatient burn clinic opened in June 2007.
Kurt Lewin's three-step change theory was developed in the 1950s and has utility even today. The model incorporates the three concepts required for change to occur: unfreeze, change, and refreeze. This requires old thinking to be rejected and replaced with more current understanding (“Kurt Lewin's Change Theory,” 2011). “Unfreezing” is the first stage that makes it possible for people to gain new understanding of a problem and let go of historical previous methods that may now be counterproductive to the present goal. The second stage is “change.” This stage involves changing the actual process, activity, and opinions. The third stage is “refreeze,” which operationalizes the new process. The “refreeze” process must occur to not sustain the change (Kritsonis, 2004).
FROM PROPOSAL TO IMPLEMENTATION
Changing the broken process motivated the team and the organization. The goals of the plan included decreasing visit costs to the patient and improving streamlined access to a burn specialist. Stage 1 in Lewin's theory, or “unfreezing,” occurred when the organization examined the best practices related to pediatric burn care.
The pediatric nurse practitioner (PNP) and the pediatric surgeons suggested a model that would create a more efficient outpatient process for patients with burns. The team established a set of criteria for what patients could be treated in this way. These include patients with burns referred to the surgical service who did not require admission and met outpatient ABA and American College of Surgeons guidelines. The team approached the hospital leadership, who initially did not understand the goals of the new program. The team emphasized the benefits to the patient and the organization, specifically decreased patient wait times, and decreased costs of outpatient burn care. The ED allocated space that was underutilized allowing the clinic to open from 7:00 to 9:00 a.m. The organization established a business model, including establishing a cost center and naming the acute care burn clinic (ACBC) department. The new process includes outpatient registration, no longer utilizing ED accounting and avoiding the standard ED bed charge. After registration, patients are taken directly to one of the designated burn clinic rooms. Usually, the PNP works in the ACBC each morning. The wait time for treatment to begin has decreased to 30 minutes. Because of the proximity to the ED, pain medication and topical treatment are available if needed during treatment. Burn dressings and supplies are now accessible, which contributes to efficiency and staff and patient satisfaction.
In Lewin's change theory, Stage 2 refers to the change process itself. Implementation of the new model occurred by word of mouth initially, so utilization of the burn clinic was slow. Because communication about the change did not occur broadly, patients were often initially misdirected.
The first burn clinic patient was seen in June 2007. As of December, 2015, staff has treated almost 1,200 patients. In 2010, a second nurse practitioner joined the team. The two nurse practitioners operate the burn clinic 7 days a week from 7:00 to 9:00 a.m. The hospital recently hired two clinical technicians to assist the nurse practitioners 7 days a week.
BURN CLINIC EFFECTIVENESS
To evaluate the ACBC effectiveness, the team collected data prospectively. In its first 12 months, the team treated 56 patients. In the past 12 months, that number increased to 199. Of the total 1,200 patients treated thus far, only one required admission to the hospital from the ACBC, because of a circumferential, full-thickness third-degree burn to an extremity in a child less than 1 year old.
Referrals to the ACBC come from the in-house pediatric ED, outlying hospitals, and primary care practitioners. During our first and second years, the largest number of referrals (40%) came from outlying hospitals, 39% were referred by the in-house pediatric ED, and 19.6% of patients were referred by primary care providers. In the last fiscal year (June 2014–June 2015), our largest percentage of referrals continue to be from the in-house ED at 41%, followed by outlying hospital EDs (38%) and then primary care provider referrals (21%; Table 1).
Since opening the burn clinic, yearly patient referrals and the number of children treated have increased by over 250%. Benefits to the patients and families included more efficient and streamlined specialty care and cost savings to families by utilizing outpatient treatment and eliminating high ED treatment charges. Benefits to the hospital include improved efficiency and bed utilization.
SUSTAINING THE CHANGE
The third step in Lewin's three-step change model is “refreezing.” This step takes place after the change has been implemented and is needed for the change to be sustained over time (Robbins, 2003). To implement Lewin's third step, the team evaluated and reinforced the referral process. This is being done through advertising and direct, in-person meetings with those providers who refer patients.
The team retrieved data that showed the need to concentrate the clinic's promotional activities on outlying EDs and primary care pediatricians. Outlying EDs are a large referral base, and primary care pediatricians have been the lowest. The burn team met with the hospital leaders in January 2010 to discuss marketing strategies. The hospital marketing team created an advertising campaign about the ACBC after meeting with the referral providers. Using their feedback, they created brochures and patient information cards in a joint effort between the hospital advertising group and our pediatric burn team. These brochures are provided to local pediatricians and outlying ED providers during meetings, conferences, and other medical gatherings. These brochures provide information about the burn clinic and the types of patients treated as well as how to make a referral. Through community promotional and educational activities, the team sets a goal to increase local pediatrician and outlying ED provider knowledge, increase outpatient referrals, and decrease unnecessary hospital-to-hospital burn patient transfers.
In the 9 years since the burn clinic has opened, 1,200 patients with pediatric burn have been treated, and the numbers are increasing each year. Now that these patients can be treated in the outpatient setting, both out-of-pocket and insurance costs have decreased. ED utilization rates have improved. Outpatient treatment also provides families with an emotional advantage, as they are able to go home each day, instead of having to miss time from work and school that occurs with inpatient treatment or extended time in a busy ED waiting room. Using Lewin's theory of change, the first step was recognizing and unfreezing the inefficient and costly process of pediatric burn care. Second, opening an outpatient clinic created the necessary change that improved the care. Lewin's third step, the refreezing process, was set in motion by marketing this new service, which solidified the burn clinic as a much needed community resource. Its continued growth is evidence that the clinic staff has fully engaged its community partners.
FUTURE OF THE ACBC?
The rapid growth of burn clinic volume is expected to continue. In addition to an advertising campaign started in 2010, the pediatric burn team now conducts burn management presentations to pediatric healthcare professionals throughout the state, where team members also introduce the ACBC. There is ongoing assessment of the patient database to determine the demographic regions where patients live. With this knowledge, the staff has set the next goal to appropriately target burn safety awareness and community outreach programs.
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