Pediatric Burn Teams: Moving from Multidisciplinary to Transdisciplinary

Abstract

Pediatric burn care has improved to the point where even patients with massive burns have a reasonable chance of survival. An important component of this success is the pediatric multidisciplinary burn team. The pediatric burn team is made up of all the disciplines that are required to provide optimal care of the patient as well as their family. The pediatric burn team in its initial iteration was multidisciplinary, with each discipline focusing on their own area without much overlap. However, over time the burn team has become more cooperative and interdisciplinary leading to improved outcomes for children with burn injuries. Ultimately, pediatric burn teams may be able to function in a transdisciplinary manner which would potentially allow for even more innovation in the care of burn patients.

Over the last 75 years, there have been dramatic improvements in the survival of pediatric burn patients. In 1954, a study found that the lethal dose 50 (LD50) for burn size (% total body surface area [TBSA]) in children aged 0 to 14 years-old was 49% TBSA. ¹ In the intervening years there have been advances in fluid resuscitation, wound care, topical antimicrobials, treatment of sepsis, nutritional support, surgical care with early excision and grafting, treatment for inhalation injury, and the team approach to burn care. These changes have greatly improved survival in children, and more recent studies have found that the LD50 is now 99% TBSA. ²

The treatment of burn-injured children is highly specialized and requires substantial hospital resources. These specific needs have led to the centralization of care through the creation of regional burn centers that are able to best provide both acute burn care, long-term rehabilitation, and reconstructive care. In addition to bringing all levels of care together, the creation of burn centers allowed for the creation of multidisciplinary teams for the care of burn-injured children. The first dedicated burn unit in the United States was at the Medical College of Virginia in 1946, but the concept of team care for burn patients predates this unit. ³ In fact, there is some evidence that the theory of a team approach to medical care originated with the treatment of burn injuries. The first documented use of the term “burn team” occurs in 1938 in an article by Dr. Donald MacCuollum entitled “The early and late treatment of burns in children.” ⁴ Burn teams have become the cornerstone of burn care for both adults and children. In this review, we will discuss the members of the burn team and their importance to the care of the child, the current state of the multidisciplinary burn team, and how we move beyond multidisciplinary to make burn teams even more collaborative to better treat patients.

Members of the Multidisciplinary Burn Team

The number and variety of professions included within the burn team is large compared to many other multidisciplinary teams in medicine. This is due to the complexity of the care that is required by burn-injured children. It is not possible for one person or specialty to possess all the skills needed to ensure the best outcomes when the care required crosses so many disciplines. Like all teams, the burn team is at its best when it is unified in its dedication to a single goal. For burn patients this goal is to restore the child to the greatest physical, emotional, psychological, and social health as possible. The members of the multidisciplinary team include the following.

The Patient

The patient is undoubtably the most important member of the burn team; however, they are often excluded from academic discussions and writings describing the members of the burn team. Patients and their families are a key component to the success of the entire team and can shape significantly to their own recovery. ⁵ Individual factors that affect healing include personal motivation, comorbid conditions, preinjury nutritional status, mental health conditions, family support, and social integration in their community. Each patient and their family bring with them to the therapeutic relationship their own needs, agendas, and prior interactions with the health care system that may positively or negatively influence the way they interact with the rest of the burn team. In some circumstances, this may require the rest of the multidisciplinary team to change their approach to best work with the family and patient where they are with respect to recovery. Allowing patients and their caregivers to participate in their care, making them part of care decisions, listening to their concerns, and empathizing with their situation help to build the care relationship with the rest of the burn team.

Burn Surgeons

A burn surgeon is a surgeon who initially completed training in general surgery, plastic surgery, or pediatric surgery before going on to acquire the skills necessary to care for burn-injured children either through fellowship training or as an apprentice to an experienced burn surgeon. The skills that these surgeons need to possess include initial burn care, resuscitation, wound assessment, critical care, and surgical treatment of burns (tangential excision, skin grafting, use of dermal substitutes, amputations, and basic reconstruction).

Plastic Surgeons

Plastic surgeons (who are not also trained in burn surgery) are often involved in the long-term, reconstructive care of burn survivors. Plastics surgeons provide care that is focused on helping burn surgeons achieve the best functional and aesthetic results possible in collaboration with the burn surgeon and the rest of the multidisciplinary team. It is best if the plastic surgeon can be involved in the care and plan for a patient with a burn injury from early in their initial hospital care so that a comprehensive plan can be developed. This comprehensive plan often involves multiple operations over the course of many years.

Anesthesiologists/Intensivists

The management of patients with burn injury in the operating room can be challenging and requires a skilled anesthesia team that is familiar with the unique physiology of a burn patient and this physiology changes over time. In addition to their role in the operating room, anesthesiologists also play an important role in the care of burn-injured patients in the intensive care unit. In some units, the day-to-day critical care for burn patients is managed by anesthesiologists or other intensivists. Finally, anesthesiologists can be utilized to provide sedation in the burn unit for painful procedures such as dressing changes or staple removal.

Nurses

Nursing represents the largest number of providers who are part of the burn team. The nursing staff provides 24-hour care for the patient, ensuring that not only their physical health, but also emotional health is attended to. Since the recovery from a burn injury can take months, the nursing staff must be able to adopt many different nursing styles and shift between them on any given day as the patient situation changes. As they are continuously caring for the patient, the nurses are often the first to identify changes in the patient's physiology, initiate treatment, and bring issues to the attention of the physicians. In addition to caring for the patient, they also provide important emotional support and education on care to the patient's family. The unique nature of burn nursing has recently been recognized by the Accreditation Board for Specialty Nursing Certification, and there is now a board certification for burn nursing available. ⁶

Respiratory Therapists

Respiratory therapists are critical to the care of patients with burns and an essential part of the multidisciplinary team. Patients with burns often present with inhalation injury which can significantly impact their respiratory system. In addition, they undergo prolonged bed rest, large volume fluid resuscitation, and have a decreased ability to fight infections making them susceptible to pneumonia. Respiratory therapists work with the patient to perform therapy that facilitates pulmonary hygiene, evaluates their pulmonary mechanics, and monitors their respiratory status to make any necessary changes to their treatment plan.

Physical and Occupational Therapists

The work of the physical and occupational therapists on the multidisciplinary burn team starts on admission of the patient to the hospital and continues well beyond their discharge. Starting at admission, they introduce therapeutic interventions designed to maximize the patient's functional outcomes. Initially, their focus is primarily on positioning and splinting but transitions over time as the patient's clinical status allows for early mobilization, strengthening, and flexibility. As the patient nears discharge and continues their care as an outpatient, occupational and physical therapists shift their focus to scar management (scar massage, silicone, and pressure garments), return to normal activities of daily living, and catching up on developmental milestones that may have been altered by the burn injury. Occupational and physical therapists who are part of a burn team must be creative in how they design splints and therapies to meet the changing physiology of the burn patient across the course of their recovery. As we discussed with the nurses, the physical and occupational therapists must treat the emotional health of their patients too. Forging a therapeutic relationship while asking a burn survivor to participate in often painful activities is a challenge, but when successful allows for the best functional and emotional outcome possible.

Speech Language Pathologists

Speech language pathologists (SLPs) are important part of the pediatric multidisciplinary burn team in certain circumstances. SLPs work to treat disorders of communication and swallowing. Following burn injury, many patients have difficulties swallowing. Especially in patients who are intubated or have a tracheostomy in place for a prolonged period of time, it is important for the SLP to work with the patient throughout their hospital stay, as appropriate, to maintain their oral motor skills. Additionally, in young children who are still developing their ability to eat, the SLP on the burn team can assure that they continue to develop appropriately during and after their hospitalization.

Dieticians

Dieticians work closely with the patient, nurses, and physicians to monitor the patient's caloric requirements, daily caloric intake, and weight maintenance. They recommend dietary interventions that are designed to provide optimal nutrition in order to combat the hypermetabolic state that occurs with burn injury. Additionally, they monitor patients to make sure they are meeting their needs for vitamins, minerals, and trace elements so that their wounds can heal appropriately. Beyond their role in managing the nutritional care of the patient, they also help emotionally support patients by providing the patient with encouragement to take in adequate nutrition as well as making sure their food preferences are noted and preferred foods provided when possible.

Psychiatry, Psychology, and Social Work

Ideally, the pediatric burn multidisciplinary team will contain multiple members that are tasked with monitoring the psychosocial health of the burn-injured child. Psychiatrists, psychologists, and social workers all play a role in caring for the social and emotional health of burn patients, although they do so in somewhat different ways. These specialists work to provide sensitivity in caring for the emotional and mental well-being of patients by working with the rest of the care team, the patient, and their families, active as confidants and support. ⁷ In order to do their jobs well, these team members must have a thorough understanding of the burn recovery process as well as common emotional reactions to stress, illness, guilt, and grief. Additionally, psychosocial experts can assist when the therapeutic relationship between the patient and the care team is not going well. They can help to develop behavioral interventions that allow the patient and the care team to work to their best potential, achieving good physical and emotional outcomes. ⁸ Over the course of the hospitalization, psychosocial experts shift from managing the acute pain, anxiety, and stress of the burn injury to preparing the patient and family for rehabilitation and life outside the hospital.

Child Life Specialists

Child life specialists are health care professionals who help children and their families deal with the challenges of hospitalization, illness, disability, trauma, or injury and therefore are critical members of the pediatric multidisciplinary team. Given that burns are painful, patients can be hospitalized for a long period of time, and patients often require multiple procedures, the role of the child life specialist is critical to provide patients an outlet to deal with their emotions and to lead medical play that prepares them for what they are going to experience. As children recover from their injuries, the child life specialist works with the patient and their families to help them return to activities that they enjoyed prior to injury and adjust them as necessary for their current abilities.

Music Therapists

Music therapists use musical interventions to help promote wellness, improve stress, lessen pain, enhance memory, increase communication, and promote physical rehabilitation. As part of the burn multidisciplinary team, music therapy has been found to decrease the pain and anxiety associated with wound care and procedures. ⁹ In addition, music therapy has been found to help with physical rehabilitation as it improves range of motion in children with burn injuries. ¹⁰

Teachers

School teachers are part of the pediatric burn multidisciplinary team in some hospitals. Again, due to the long hospital course for some children with burn injuries, they need to have their educational needs met when clinically appropriate. The teacher on the team is responsible for communicating with the child's home school to get individualized education plans if needed, coordinate assignments to be done while the child is in the hospital, and planning for the child's reentry into school when they have recovered from their injuries.

Clergy or Other Spiritual Advisors

Children who sustain burn injuries and their families may or may not be religious or spiritual, but having clergy or other spiritual advisors available to be part of the multidisciplinary burn team can be helpful.

Students, Residents, and Fellows

Trainees at various stages of training are often part of the multidisciplinary burn team and serve a vital role in caring for children with burn injuries. They participate in all aspects of the care of patients both in the burn unit and in the operating room. Additionally, they often help move academic pursuits such as research forward. They are also the future of the physician workforce as those who enjoy their experience rotating on the burn service, may choose burn surgery as a career.

Others

The pediatric multidisciplinary team at its core truly encompasses everyone who works in the burn unit from the environmental service team that works to keep the unit clean to the hospital administrators that help the unit run efficiently, and many others who support the day-to-day operations of a burn center working to improve the outcomes for pediatric patients with burns.

Current State of the Multidisciplinary Burn Team

The article that first introduced the term “burn team” to the world was in 1938 and was trying to describe how different treatments for burns by different institutions yielded different results. ⁴ Even with the passage of time, this concept somewhat remains true even now. While some elements of burn care are consistent across centers, each center also has unique practice patterns. As Dr. Daniel Butler described in 2013, “burn care arose from, rather than evolved into, a multidisciplinary team,” and since its inception, the burn team has continued to evolve with the changing times. ¹¹ As burn care has evolved, so has the multidisciplinary team.

The present-day burn multidisciplinary team must be able to communicate effectively with each other as well as with patients and families. This can be a challenge given the diversity of burn team members, the stress experienced by both the medical professionals, the patient, and their family, as well as the potential for confusing or contradictory information being provided by each member of the team. ¹² As is the case with all teams, it can be expected that team members will have different opinions with respect to the best course of action for a patient during their care. How these differences are managed is a key to the success or failure of the team. It is also critical to remember that the patient and their parents are integral members of the team. They need to be agreeable to the treatment plan set out by the burn multidisciplinary team and may have their own conflicts or differences of opinion with members of the team which can influence the functioning of the team and the ultimate outcome for the patient. In general, disagreements between team members are minimized when there is frequent and open communication between team members and with the patient and their family.

While many consider the burn surgeon the leader of the burn team (and this was certainly the case in the past), the leader of the modern burn team shifts between burn team members depending on the clinical situation and phase of care. Often it is the responsibility of the burn surgeon to provide guidance to the rest of the team on the initial care of the child when managing acute burn physiology as it is the key to a good outcome. As time goes on, the leader of the team shifts first to the nursing staff who are at the bedside providing the moment-to-moment medical care as well as the wound care for the child. As the child gets closer to discharge, the importance of the occupational and physical therapists increases and their determination of need for further treatment of the child often determines discharge plans.

The shift in leadership throughout the course of a hospital stay can also help with managing the emotional dynamics of the team to resolve conflicts when they arise, as nurses and the psychosocial experts that are part of the burn multidisciplinary team have a skill set and education that is different from physicians. Their ability to understand human emotions, training to acknowledge diverse perspectives, and skills in working through difficult situations can allow for improved functioning of the burn multidisciplinary team.

Moving Beyond Multidisciplinary Team

Although it is believed that the concept of the multidisciplinary team began in the treatment of burn, there has been research into the functioning of multidisciplinary team throughout health care. It is a generally held belief that multidisciplinary teams in health care improve care for patients, ^{13 14} but just like any team, their level of function can be affected by several team factors. ¹⁵ Things such as team size, composition, leadership, leadership style, organizational support, and interpersonal relationships, all affect the functioning of the multidisciplinary team. The importance of these team dynamics is especially true with the modern burn multidisciplinary team, as they must adapt to the ever-changing face of the health care system, as was discussed in the previous section.

The definition of multidisciplinary is multiple different disciplines studying a central subject at the same time. The expertise of the different disciplines leads to a broader understanding of the subject than was possible looking at it through the lens of a single discipline. However, despite this increased understanding, in a multidisciplinary approach, the boundary of each discipline is not crossed, and the goal is not to integrate the ideas of each discipline. While this definition of multidisciplinary certainly fits with the burn team as described by Dr. Basil Pruitt (multiple disciplines working together around a common goal), it likely does not fit with the way that modern burn teams function. ¹⁶

The next level of increased integration of a team is an interdisciplinary team. An interdisciplinary team strives to integrate the skills and viewpoints of each team member/discipline through routine interaction to better understand the needs of the child with burn injuries. Interdisciplinary teams understand that they can do more for their patients together than they can alone and that through greater integration, they can achieve better outcomes. The current state of the pediatric burn team is more accurately described as interdisciplinary, rather than multidisciplinary. Through conducting team rounds at least once a week as well as frequent interactions of the various disciplines of the pediatric burn team we have become an interdisciplinary team whose whole is greater than the sum of each discipline's contribution.

The transition of the pediatric burn team from multidisciplinary to interdisciplinary over the last 80 years proves that our teams can evolve and change over time. In her American Burn Association presidential address, Ingrid Parry suggests that our teams may one day move beyond interdisciplinary to become transdisciplinary. ¹⁷ A transdisciplinary team is unified, cohesive, and aligned to the point where the team works collectively to develop treatment plans and to care for patients. In a transdisciplinary approach, the delineation of disciplines becomes almost irrelevant because while each team member contributes their experience and wisdom to caring for a patient, the problem solving and care is truly collaborative. Keys to transdisciplinary teamwork include creation of a team that comes from diverse backgrounds, free exchange of ideas among team members, and dedication to a common goal.

While importance of multidisciplinary and interdisciplinary teams in medicine are well established, ¹⁸ the utility and potential advantages to the transdisciplinary care in medicine are just starting to be examined and understood. Work in autism has shown that a multidisciplinary approach is less effective with respect to outcomes due to the team not having a shared goal and clear direction which can lead to miscommunication, lack of clarity of purpose, and potential team conflicts ¹⁹ ( www.autism.org.uk ). However, work in this population with transdisciplinary teams has been shown to improve outcomes, reduce fragmentation of service delivery, reduce confusion between team members, improve communication with families, and promote cooperation. ^{20 21} The future of the pediatric burn team could be one of transdisciplinary collaboration. We already have many of the pieces in place to make this a reality. It would only require a moderate shift in mindset of the burn team to work in a more transdisciplinary manner. This would potentially allow us to improve the care of burn-injured children and create new innovations that move the treatment of all burns forward.

Conclusion

The multidisciplinary pediatric burn team is a large part of the success of pediatric burn care. This team has existed in various forms for over 80 years and continues to move the care of pediatric burn survivors forward. Each member of the team has an important role in assuring good patient outcomes, and with more interconnectedness of the team through a transdisciplinary approach, we can move the care of pediatric patients with burn injuries even further forward.