Alleviating Distress in Pediatric Burn Patients Through Psychosocial Risk Assessment and Transition Improvement Processes

Abstract

This retrospective study aims to valuate the efforts of implementing a validated pediatric psychosocial risk screening tool with pediatric patients admitted to the burn unit. Outcome interventions included providing targeted psychosocial interventions of a child life specialist during inpatient stay, with the objective of assessing emotional outcomes during the transition to outpatient care. This study analyzes the adaptive and maladaptive behaviors recorded in Certified Child Life Specialist (CCLS) documentation to calculate a weighted score for interpretation of pediatric patients’ behavior at outpatient follow-up. Results before and after the implementation of the Psychosocial Risk Assessment in Pediatrics (PRAP) tool to identify and subsequently provide a multidisciplinary support plan to the moderate–high-risk patients were compared. Utilization of the Psychosocial Risk Assessment in Pediatrics tool at a large burn center identified inpatient burn patients ages 3–17 years who were at moderate risk or high risk for increased psychosocial distress. Subsequent Certified Child Life Specialist psychosocial interventions did not yield significant results; however, the use of thethis screening tool for pediatric patients in the inpatient setting predicted weighted scores measured at the outpatient appointment. The benefits of screening by the Psychosocial Risk Assessment in Pediatrics and Certified Child Life Specialist intervention warrant further investigation on long-term benefits of such interventions on reducing adverse psychological outcomes in pediatric burn patients.

INTRODUCTION

Pediatric burn injuries can result in significant physical and psychological trauma. Recent data indicates hospitalized pediatric burn patients have mortality rates of 3.2%, marking a decrease from historically higher mortality rates.^1,2 As survival rates improve, so does an awareness of the psychological consequences that can be associated with burn injuries. Pediatric burn patients are at risk for developing both acute and long-term psychological issues from their injuries.³ Multiple studies have demonstrated that burns in early childhood are a predictive indicator of developing PTSD, with children in younger age groups being at higher risk for long-term psychological effects.^4–6 Additionally, studies report that the burn injury, dressing change process, and the hospital experience were each associated with developing disorders associated with trauma for pediatric burn injuries.^4,7 Anxiety disorders were the highest reported feature following pediatric burn injuries, including generalized anxiety disorder as well as social anxiety in adolescents related to the physical appearance of scarring burns.^7–10 Children with burn injuries also demonstrated an increase in the incidence of depression and emotional development challenges.^4,5 Overall, current research indicates an increased incidence of psychosocial issues related to burn injuries, and psychosocial intervention is recommended across the board to decrease the rate of adverse mental health outcomes for survivors reaching adulthood.^4,11–13

The transition from inpatient to outpatient care for discharged pediatric patients poses significant and unique challenges. Patients face new stressors related to burn dressing changes, exposure to unfamiliar medical personnel and processes, increased independence in self-care, and reintegration into their schools and communities.¹⁴ These changes can be stressful and anxiety-provoking for both the children and parents, exacerbating their already vulnerable mental status post-discharge.^14–16 Lack of proactive psychosocial risk screening and intervention may result in greater anxiety, maladaptive coping, and trauma during the transition to outpatient care with this population.¹⁷ In their systematic review, Hornsby et al. detailed current promising psychosocial interventions to improve outcomes for pediatric burn patients, with distraction interventions yielding the most significant positive outcomes.¹⁸ One reviewed study showed that the psychosocial interventions of the child life care team reduced acute pain and anxiety during burn wound dressing changes.⁸ This, in turn, helped to decrease the chance of pediatric patients developing long-term traumatic consequences.

The high incidence of psychiatric issues suggests the potential need for the expertise of child life specialists in decreasing the severity and burden of psychiatric disorders in children, particularly in the critical transition from inpatient to outpatient burn care. Certified Child Life Specialists (CCLS) are trained in promoting the growth and development of infants through young adults with a focus on promoting coping skills in order to minimize the adverse effects of the hospital environment.^19,20 As pediatric burn patients may experience many stressful events during the healing journey; not limited to multiple surgeries and painful dressing changes and procedures, child life specialists are trained to provide psychosocial support and facilitate coping skills for pediatric burn injured patients not only during the inpatient stay, but through the transition to outpatient services. Studies indicate psychosocial screening tools are underutilized for pediatric burn populations.^14,15 Evidence-based interventions are needed at this critical transition period to identify at-risk patients, minimize trauma, promote adaptive coping, and ultimately improve psychosocial outcomes. The Psychosocial Risk Assessment tool in Pediatrics (PRAP) is a standardized, reliable, and valid tool to assess the behavioral and emotional status of children suffering from illness or injury.²¹ Thus, implementation of the PRAP screening tool by child life teams could be a beneficial intervention to identify and counsel pediatric burn patients at higher risk for adverse emotional outcomes. This is of value, as of this time of writing, there are no current recommended patient ratios for child life specialists working with burn injured pediatric patients.²²This study aimed to demonstrate that use of a validated psychosocial risk screening tool on the inpatient unit may aid in better identifying and allocating additional psychosocial support resources towards higher risk pediatric burn patients to improve emotional outcomes during the transition to outpatient care.

METHODS

Overview

This retrospective study was a process improvement project that assessed the impact of utilizing the PRAP tool to identify inpatient pediatric burn patients who scored moderate to high risk for increased psychosocial distress so that targeted multidisciplinary psychosocial support could be coordinated during outpatient follow-up. The goal was to improve coping mechanisms and reduce medical trauma during the transition from inpatient to outpatient burn and wound clinic appointments. This study assessed adaptive versus maladaptive behaviors of pediatric burn patients at outpatient follow-up before and after the implementation of using the PRAP tool to identify and subsequently provide a multidisciplinary support plan to patients assessed at moderate or high risk for increased psychosocial distress during their inpatient stay. The PRAP tool was given to all patients meeting inclusion criteria during inpatient stay as part of the child life assessment. Scores were documented in the electrical medical record (EMR) via child life documentation template, which included adaptive and maladaptive coping styles assessed by the CCLS according to their expertise.

PRAP tool

The PRAP is a standardized, valid, and reliable assessment tool that healthcare providers use to help identify if pediatric patients are considered low, moderate, or high risk of experiencing elevated distress during healthcare encounters. The tool assesses patients for evidence-based predisposing factors that may affect the pediatric patient’s ability to cope during medical encounters. This assessment tool takes approximately 5–10 minutes to complete. The variables account for each patient’s communication, anxiety, parental stress, special needs, temperament, past healthcare experiences, invasiveness of the procedure, and developmental considerations. The tool is validated for use with general patients aged 3–17 years. The PRAP tool is used as a cost-effective and more time-efficient approach to determine how psychosocial resources and staffing should be allocated to meet the greatest need.²¹

Study population

Retrospective chart review was utilized to collect data from August 2021 to August 2023 from a large American Burn Association (ABA) adult and pediatric verified hospital in the Southeastern United States. The PRAP tool was purchased by the hospital burn administration and introduced in May 2022 by the child life team. This serves as the cutoff date between the 2 study groups. Table 1 describes the inclusion and exclusion criteria. Inclusion criteria included patients 3–17 years of age, admitted to the pediatric burn services with >9% total body surface area (TBSA), receiving surgical intervention, and attending first follow-up outpatient appointment at the same burn center. Patients were excluded if they did not meet the criteria, if they had multiple injuries in addition to the burn wounds, and/or if English was not their first language.

Table 1.

Criteria for Inclusion and Exclusion of Patients in the Retrospective Study

Inclusion criteria	Exclusion criteria
3–17 years old	Failing to meet inclusion criteria
Burn injury of >9% TBSA	Multiple injuries beyond burn wounds
Requiring surgical intervention	Did not attend follow-up at same burn center
Requiring outpatient follow-up	English not first language

Abbreviation: TBSA, total body surface area.

The control group included all patients admitted between August 2021 and April 2022 who met the inclusion criteria. Twenty patients were identified in the control group. Control group data was not included prior to August 2021 due to the gaps in child life FTE, which created inconsistent staffing at this burn center. The study group included all patients admitted between May 2022 and August 2023, assessed with the PRAP tool by the CCLS. All patients identified by the PRAP tool as being moderate or high risk received an automatic referral to the CCLS assigned to the outpatient pediatric burn population. Patients identified as higher risk for increased distress received targeted coping support during their first outpatient burn and wound clinic appointment. Support plans included collaborating with the patient, family, and healthcare team to create a coping plan specific to patient needs, a tour of the wound clinic prior to discharge, non-pharmacological pain management techniques facilitated by the CCLS during wound dressing procedures, providing developmentally appropriate medical education to patient and family, and introduction and rapport building with outpatient multidisciplinary team before discharge. Eighteen patients were included in the study group. Due to the individualized support needs for each patient, interventions provided by the CCLS were not standardized. All patients, both in the control group and the PRAP group, were seen by the child life specialist during their inpatient stay as well as during their first outpatient clinic appointment.

Data collection

During the outpatient visit for both study groups, a CCLS assessed each patient’s coping behaviors using the MediTech Child Life Assessment form located in the electronic medical record (EMR). The subjective data entry included specific behaviors such as tearful, anxious, agitated, combative, calm, cooperative, and compliant, which were assessed based on CCLS knowledge and expertise. An overall adaptive and maladaptive patient response was also recorded. Data for this study were collected retrospectively using documentation from the CCLS.

Data analysis

The positive and negative behaviors were used to calculate a weighted score. A positive behavior adds 1 point, and a negative behavior subtracts 1 point. Positive behaviors included “compliant,” “cooperative,” “calm,” and “adaptive.” Negative behaviors included “tearful,” “anxious,” “agitated,” “combative,” and “maladaptive.” The mean weighted score was compared across each PRAP risk level (low, moderate, and high) to assess the validity of the tool to predict behavior in our study population. Not all behaviors were selected by the CCLS if not applicable to the patient encounter. Any behaviors not assessed were given a 0-point value to ensure normal distribution of the data. Additionally, the average weighted scores between the study group and the control group were compared.

RESULTS

The demographics of the control and study groups are summarized in Table 2 (demographics) and Table 3 (descriptive statistics). No significant differences between the 2 groups’ sex, age, TBSA, or etiology of burn were identified. No significant difference in the average weighted score between the PRAP group and control group was found when measuring adaptive/maladaptive characteristics during first outpatient burn and wound clinic appointment. The assessment and subsequent psychosocial interventions implemented by the child life specialists yielded results that indicate more adaptive coping behaviors and less maladaptive coping behaviors at outpatient follow-up appointments compared to the control group. Adaptive and maladaptive coping characteristics were assessed and documented in the MediTech Child Life Assessment form and are summarized in Table 4. There was no significant difference between the PRAP and Control groups found.

Table 2.

Demographics

	Control	PRAP	P-value
Sex			.20322
Male	13 (65%)	8 (44%)
Female	7 (35%)	10 (56%)
Age (mean)	10.7	9.2	.31086
TBSA (%)	23.9	24.1	.96244
Etiology			.50145
Friction	1	0
Scald	5	8
Grease	2	0
Thermal	12	10

Abbreviations: PRAP, Psychosocial Risk Assessment in Pediatrics; TBSA, total body surface area.

P-values were calculated via Chi-square test of Independence for sex and etiology, and P-values were calculated via t-test assuming unequal variance for age and TBSA. There were no significant differences found in sex, age, TBSA, or etiology between Control and PRAP groups.

Table 3.

Descriptive Statistics and Comparisons

		Mean	SD	IQR	Mann–Whitney test
TBSA					U-Statistic	204.5
	<20	0.63	2.69	3.5	P-value	.4846
	20+	0.21	2.37	4.5
Age					U-Statistic	159.5
	<10	0.06	2.88	4	P-value	.58
	10+	0.71	2.19	3
Sex					U-Statistic	188.5
	M	0.62	2.25	4	P-value	.7763
	F	0.18	2.86	4
Cohort					U-Statistic	122.5
	Control	−0.35	2.89	5.25	P-value	.0896
	PRAP	1.28	1.71	3
Shapiro–Wilks
	Statistic	0.875
	P-value	<.05

Abbreviations: IQR, interquartile range; TBSA, total body surface area.

Table 4.

Coping Behaviors

	Control	PRAP
Tearful	11	7
Anxious	13	10
Agitated	9	0
Combative	3	0
Compliant	14	11
Cooperative	10	14
Calm	10	10
Adaptive	13	13
Maladaptive	7	2
Total in study	20	18
Chi-squared
Chi-squared statistic	14.02
P-value	.0813

Abbreviation: PRAP, Psychosocial Risk Assessment in Pediatrics; TBSA, total body surface area.

This table describes the characteristic emotions of pediatric patients being assessed by the MediTech Child Life Assessment. Also, it describes individual emotions and overall adaptive versus maladaptive coping behaviors.

As demonstrated in Table 5, use of the PRAP screening tool for pediatric burn patients in the inpatient setting predicts an increase in weighted score measured at outpatient follow-up. Additionally, age was also found as a positive predictor of weighted score. Sex, TBSA, and type of burn did not have significant predictive value for the weighted score.

Table 5.

Weighted Score Linear Regression Results

	Weighted score
PRAP	2.107** (0.756) P = 0.009
Age	0.203* (0.084) P = 0.022
Sex—Male	0.834 (0.790) P = 0.299
TBSA	−0.037 (0.029) P = 0.214
Constant	−2.172 (1.181) P = 0.075
Observations	38
R 2	0.284
Adjusted R2	0.197
Residual std. error	2.249 (df = 33)
F-statistic	3.276* (df = 4; 33)

Abbreviation: PRAP, Psychosocial Risk Assessment in Pediatrics.

This table describes the result from the linear regression model, where the predictor independent variables were described as PRAP Treatment, Age, Sex, and TBSA (Total Body Surface Area). R-squared values depict limited variance of the sample. P-values for each individual variable indicate that PRAP Treatment and Age had predictive value, while Sex and TBSA had no predictive value for the weighted-psychosocial score.

*P < .05; **P < .01; ***P < .001.

DISCUSSION

Using the PRAP tool in a large ABA-verified burn center helped identify inpatient pediatric burn patients at moderate or high risk for potentially increased psychosocial distress. CCLS interventions for at-risk pediatric burn patients aimed to ease the transition from inpatient to outpatient care and reduce anxiety. Psychosocial assessment with the PRAP tool and subsequent CCLS interventions yielded results that demonstrate an increase in adaptive coping behaviors and a decrease in maladaptive coping behaviors in the treatment group. These results yield the potential benefits of early identification of psychosocial distress to implement proactive psychosocial interventions with the goal of enhancing coping outcomes with the healthcare experience. As over 8,000 pediatric patients are admitted to the hospital for burns yearly, child life specialists and burn centers may find this tool useful to assist in prioritizing patients in a high-volume outpatient setting to ensure patients are receiving appropriate psychosocial care.²³ Subsequently, the PRAP tool could help burn care leaders ensure child life professionals are targeting their services to those who have the greatest needs. This also has implications for the benefits of continuity of care provided by child life specialists in the inpatient and outpatient burn settings. The finding of age as a predictor of a higher weighted score underscores previous research findings that children of younger ages are at higher risk for psychological consequences.^4–6

Though the results are encouraging, this retrospective study had limitations. The sample size for both the control and intervention groups was limited due to staffing and time constraints. The opportunity for blind assessment was limited in the study by the number of CCLS at the facility. The use of the PRAP screening tool and its results were not blinded to the outpatient CCLS who assessed the patients’ adaptive versus maladaptive characteristics after giving supportive interventions. The subjective nature of the PRAP screening tool may also contribute to bias. Further, the support plan implemented for each patient in the moderate–high-risk group was nonstandardized, and individual variations in supportive interventions may have impacted the outcomes. Data gathered were limited by insufficient documentation in the EMR regarding the mechanism of injury and percentage of partial thickness versus full thickness burns. Finally, the study occurred over a broad time period, with the control patients assessed from August 2021 to April 2022 and the treatment patients assessed from May 2022 to August 2023. This finite amount of time yielded small sample sizes for the control and intervention groups. Environmental circumstances, such as the COVID-19 pandemic, may play a role in the emotional state of pediatric patients at different times and thus skew the results.

In conclusion, identifying patients at increased risk for psychosocial distress allows for more efficient utilization of CCLS expertise as part of a multidisciplinary team approach to patient care. The results demonstrated that use of the PRAP tool predicted an increase in weighted score measured at outpatient follow-up. The child life specialists currently still use the PRAP tool for every inpatient meeting criterion to provide targeted child life services to those who need it most as part of a process improvement initiative. The positive results of the interventions emphasize the benefit of proactive support interventions aimed at reducing trauma, and the critical role of CCLSs in longitudinal pediatric burn treatment. As pediatric burn patients can be lifelong consumers of the burn service, early coordinated psychosocial interventions, resulting in more comfort with the burn care team and processes, could increase compliance with burn care regimens and decrease time and personnel needed for safe clinic dressing changes. To improve upon limitations, future investigations could be designed as randomized prospective studies with standardized support interventions and a bigger sample size to reduce bias in results. Future studies could also measure the length of CCLS intervention time with the patient to assess if there is a significant correlation between PRAP score and intervention time required. The benefits of PRAP screening and CCLS intervention warrant further investigation on potentially increased positive outcomes that child life interventions can facilitate in pediatric burn injury patients. This may include the impact of employing more child life specialists in burn centers serving pediatric patients to increase screening and psychosocial intervention capabilities. This may also help to establish an accepted ratio of CCLS to pediatric burn patients. Further, future studies that quantify cost savings from use of psychosocial interventions (eg, reduced need for sedation, reduction in personnel needed for dressing changes, reduction in wound dressing procedure times, increase in patient experience scores, etc.) may monetize the value of adding child life specialists to the pediatric burn team.

Funding

National Institutes of Health, Welcome Trust, and Howard Hughes Medical Institute: No funding to disclose.

Conflict of interest statement

None declared.