Identifying and Assisting Burn Patients and Their Families With Needs Through Administration of an Assessment Tool on Admission

Abstract

Using a modified Safe Environment for Every Kid Questionnaire (Needs Survey), we previously showed a significant correlation between adverse childhood experiences (ACEs) and family needs. Herein, we retrospectively assessed whether patients’ and their families’ needs identified using the Needs Survey were addressed prior to discharge. We hypothesized that, without the knowledge gained by administering this tool, many basic needs may not have been fully addressed. Seventy-nine burn patients and families previously enrolled in our ACE studies were included. Answers to the Needs Surveys were reviewed to identify families with needs. Medical records were reviewed to determine if a social worker assessment (SWA) was completed per standard of care and if their needs were addressed prior to discharge. Of the 79 burn patients who received inpatient care and completed the Needs Survey, family needs were identified in 67 (84.8%); 42 (62.7%) received an SWA, and 25 (37.3%) did not. Those who did not receive a SWA had a shorter hospitalization and suffered less severe burns. Demographics, socioeconomics, ACEs, and identified needs were similar between the groups. Our study showed that SWA was performed on many patients with basic needs. However, with the focus of SWAs being on discharge arrangements, not all needs were addressed, and individualized resources were often not provided. Administering the Needs Survey on admission may help our social workers streamline and expedite this process to help support successful recovery for our burn patients and their families.

INTRODUCTION

Healing from a burn injury is a complex process that often takes months to years.¹ Immediately following the burn injury, the survivor is often dependent on family and friends for activities of daily living, transportation to and from follow-up and therapy appointments, and wound care. Optimal wound healing requires time consuming care, access to dressing supplies, and good nutrition. For survivors and families with social determinants of health (SDH) or mental health issues, the immediate burn recovery period can be an especially difficult and challenging time. In the trauma and burn population, worse baseline health, lower socioeconomic status, and insurance type have all been associated with worse outcomes.^2–4 Doctor and colleagues found that those from the lowest socioeconomic group had five times the odds of graft loss than those in the highest socioeconomic group. Moreover, there was a strong correlation between the type of insurance and the likelihood of readmission in burn patients.⁵ SDH and mental health issues may also complicate eventual reintegration back into family, school, work, and recreational activities.

SDH are prevalent in burn populations. Poverty, single-parent homes, substandard housing, increased occupancy, rental property, unemployment, and community violence have all been associated with an increased burn incidence rate.^6–12 Preinjury mental health issues are also prevalent in burn patients and their families.^{5,7,9,13–15} Given the high incidence of mental health issues, psychosocial burn experts (psychologists, LCSWs, and counselors) are critical team members and can work in tandem with nonclinical social workers to promote psychosocial rehabilitation of burn patients.¹⁶ Secondary to shortage of mental health professionals, the nonclinical burn social worker is a key member of the interprofessional burn team and is often required to have a wide range of specialized skills to successfully prepare these burn patients and their families for recovery.^17–22 Hospital-based social workers, however, often have different roles at different hospitals and more than half (65.5%) have duties outside of the specific burn units, decreasing the amount of time they can spend with burn patients.¹⁷ Abrams and colleagues found that social workers practicing in U.S. burn centers identified discharge planning, case management, patient and family counseling, burn support group facilitation, and burn education as their primary duties.²¹ Assessments of burn patients and family strengths, risks, and needs in their support systems is a critical evaluation that helps prepare them for a discharge and recovery. As time is limited, these assessments need to be streamlined.

In our previous studies assessing adverse childhood experiences (ACEs) in the burn population, we showed a positive correlation between ACEs and family needs using a modified Safe Environment for Every Kid Questionnaire (SEEK, referred to as the Needs Survey),^23–26 Our data showed a significant and positive correlation between ACEs and number of needs (r = 0.5), housing insecurity (r = 0.23), food insecurity (r = 0.34), stress (r = 0.39), and symptoms of depression (r = 0.44) in our adult burn patients.²³ Similarly, within our pediatric burn population, we demonstrated a significant correlation between family needs and number of parent and child ACEs (r = 0.522 and 0.707; P < .001).²⁴ In the current study, we sought to assess whether identifying patients with needs using the Needs Survey on admission may help support our social workers in identifying burn patients and families in need, thereby, supporting a successful discharge and recovery.

METHODS

Ethics Statement

This study extends our prospective observational ACEs study reviewed and was approved by our institutional review board (#201704832).

Study Participants and Design

Of the 175 subjects enrolled in our ACEs study, 79 were admitted to our burn unit. Medical charts of these 79 burn inpatients were reviewed to determine whether a social worker assessment (SWA) was performed. As part of our ACEs study, subjects or their parents completed initial surveys on REDCap including the Needs Survey.^23–26

Needs Survey

The Needs survey was adapted from the SEEK Questionnaire developed by the University of Maryland.^25,26{Dubowitz, 2014 #18} We adapted the SEEK questionnaire survey as part of a prospective study assessing the impact of exposure to ACEs on burn patients’ outcomes. The unvalidated survey includes 16 items with one question specifically for participants with children (#6) and one question specifically for those currently in a relationship (#10). Questions were added to the survey addressing fear of eviction, residence in temporary housing, law enforcement involvement, and incarceration of a family member in the past year. The needs identified on the Needs Survey were grouped into the following categories: psychosocial needs which included questions assessing a child-related question, intimate partner violence, and criminal involvement (survey questions 6, 10, 15, and 16); mental health needs which included questions assessing depressive symptoms, stress, and substance use (survey questions 7, 8, 9, 11, and 12); and SDH needs which included questions assessing food and housing (survey questions 4, 5, 13, and 14). Each individual item required a yes or no answer.

Data Collection

The answers to the Needs Survey were retrieved from our REDCap database to identify patients and families with needs. Medical records were reviewed for demographics, comorbidities, length of stay (LOS), surgeries, burn injury data, hospital course, and follow-up information. Rural–urban commuting area codes were used to assess rural vs urban living.^24,27,28 Rural–urban commuting area codes organize U.S. census tracts by population density, urbanization, and daily commute. The classification differentiates zip codes into metropolitan areas (codes 1, 2, and 3), micropolitan areas (codes 4, 5, and 6), small town areas (7, 8, and 9), and rural areas (10).

To evaluate whether our subjects’ needs were addressed prior to being discharged from the burn center, we reviewed our SWA. These assessments are primarily conducted to discuss discharge disposition. SWAs are preformed after admission on all patients to assess the current situation of the patient (inpatient, outpatient, in emergency department, or other) and social resources available to and/or used by the patients, including living situation, access to community resources, etc. Additional information recorded includes insurance status and need to apply for health care benefits assistance program, Veteran status, employment status, income resources, prior living situation, home description (location of bedroom and bathroom), and advance directives. A clinical impression of the patient and/or family including participation in interview and decision-making, patient and family distress screening, substitute decision-maker identification if required is performed and recorded. Discharge assessment is performed, including an evaluation of the patient and family capacity for care, an assessment of anticipated discharge planning and psychosocial needs, and the identification of issues to discharge/psychosocial planning. Education needs are identified including areas for which the patient/family needs education and what education was provided. Finally, a tentative discharge plan is formulated.

Mental health consultations during their inpatient stay were also determined by medical record review. All mental health consultations were scheduled based on SWA. In addition, we assessed if social work recommended or offered additional services such as food stamps or community referrals. Finally, we recorded whether patients or their family received the informational unit developed recovery kit that includes information on support programs, burn/wound care, alternative dressings, posttraumatic stress disorder, and intimacy; the latter being only distributed to adult patients.

Data Analysis

For analysis, subjects with needs identified on the Needs Survey were divided into two groups, those who received a SWA and those who did not receive a SWA (No SWA). Demographics, socioeconomic, injury characteristics, as well as family needs, number of needs, and ACE scores were compared between the two groups. Normality was assessed using the Kolmogorov–Smirnov test for all continuous variables. All nonnormally distributed continuous variables are presented as median and interquartile range. Mann-Whitney U test was used for continuous variables while chi-square and Fisher’s exact test were used for categorical variables as appropriate. Statistical analysis was performed using SPSS 28.0 (IBM, Chicago, IL). P < .05 was considered significant.

RESULTS

Patient and Family Characteristics

Of the 79 patients who received inpatient care for their burn injury and completed the Needs Survey, family needs were identified in 67 (84.8%), of which 42 (62.7%) received a SWA and 25 (37.3%) did not. As shown in Table 1, there was no statistically significant difference between the SWA and the No SWA groups in terms of sex, self-identified race, age, living situation, insurance type, number of household members, and number of needs of either the adult patients or the parents of the pediatric subjects who indicated family needs on the Needs Survey. Patients who received a SWA were more likely to live in metropolitan and rural areas and less likely to live in small town areas.

Table 1.

Population characteristics of patients and families with needs who did or did not receive a SWA

Variables	No SWA	SWA	P
	n = 25	n = 42
Male, n (%)	18 (72)	28 (66.7)	.787
Caucasian, n (%)	22 (88)	31 (73.8)	.343
Age (median [IQR])*	35 [26.5–41.5]	35 [24–50.5]	.962
Patient type, n (%)
Pediatric	7 (28)	16 (38.1)	.438
Adult	18 (72)	26 (61.9)
Housing, n (%)
Own	12 (48)	15 (35.7)	.48
Rent	10 (40)	19 (45.2)
Shared/temporary/homeless	3 (12)	5 (11.9)
Other	0	3 (7.1)
Insurance, n (%)
Public	5 (20)	16 (38.1)	.221
Private	17 (68)	23 (54.8)
Other/unknown	2 (8)	3 (7.1)
Self-pay	1 (4)	0
Number in household (median [IQR])
Living in rural areas, n (%)	4 [2–5]	3 [2–5]	.549
Metropolitan	11 (44)	25 (59.5)	.011
Micropolitan	5 (20)	10 (23.8)
Small town	8 (32)	2 (4.8)
Rural	1 (4)	5 (11.5)
Number of needs (median [IQR])	3 [2–5]	2 [1–5]	.917

IQR, interquartile range.

Bold values are significant P values.

*The reported age is an average age of the adult patient or parent of the pediatric subject who filled out the surveys.

Subjects who did not receive a SWA had a significantly shorter hospitalization compared to those who received a SWA (0.9 [0.5–3.5] vs 8.5 [3–13.3], P < .001). As shown in Table 2, there was no significant difference in terms of mechanism of burn injury or the presence of inhalation injury between the groups. Patients who did not receive a SWA presented with less severe burn injury as indicated by lower %TBSA and were less likely to present with burn injury on the anterior chest as compared to patients who received a SWA.

Table 2.

Burn injury characteristics of patients and families who received or did not receive a SWA

Variables	No SWA	SWA	P
	n = 25	n = 42
Burn injury mechanism, n (%)
Flame	11 (44)	14 (33.3)	.439
Flash	1 (4)	6 (14.3)	.244
Scald	4 (16)	14 (33.3)	.159
Chemical	4 (16)	1 (2.4)	.061
Electrical	2 (8)	2 (4.8)	.626
Contact	3 (12)	4 (9.5)	>.999
Other	2 (8)	1 (2.4)	.551
Inhalation injury, n (%)	1 (4)	3 (7.5)	>.999
% TBSA, median [IQR]	2 [1–6]	7 [4–16.8]	.003
% 2nd degree burn, median [IQR]	1.5 [0.7–5.3]	6.3 [2.4–12.8]	.069
% 3rd degree burn, median [IQR]	0 [0–1]	0.5 [0–4.1]	.448
Burn anatomical location, n (%)
Head/neck	4 (16)	16 (38.1)	.960
Anterior chest	4 (16)	18 (42.9)	.032
Posterior chest	2 (8)	8 (19)	.300
Upper arm	5 (20)	17 (40.5)	.110
Lower arm	3 (12)	13 (31)	.137
Hand	12 (48)	20 (47.6)	>.999
Thighs	8 (32)	15 (35.7)	.797
Lower legs	8 (32)	16 (38.1)	.793
Feet	2 (8)	9 (21.4)	.189
Genitals	0	2 (4.8)	.525
Buttocks	2 (8)	4 (9.5)	>.999
Surgery, n (%)	14 (56)	27 (67.5)	.431
Hospital LOS, median [IQR]	0.9 [0.5–3.5]	8.5 [3–13.3]	< .001

IQR, interquartile range.

Needs Survey and SWA Results

As shown in Table 3, the patients and families who did not or did receive a SWA were similar. Of the 14 patients and families who had identified psychosocial needs on the survey, 4 (28.6%) did not have a SWA. Of the 50 patients with identified mental health needs, 20 (40%) did not have a SWA. Only 12 adult inpatients (15%) were seen by mental health providers, 2 did not indicate needs on the Needs Survey but were identified by SWA, 10 had indicated mental health needs on the Needs Survey and had an SWA. Of the 20 patients indicating SDH, 5 (25%) did not have a SWA. Fifteen patients who indicated having SDH needs on the Needs Survey had a SWA done during their hospitalization. Food insecurity was addressed in only five SWA, with only one patient being provided information on food stamps. Housing was addressed in only three SWA.

Table 3.

Family strengths and needs of patients and families who received or did not receive a SWA

Family Needs and Strengths, answered yes; n (%)	Overall population	No SWA	SWA	P
	n = 67	n = 25	n = 42
Fire safety needs	21 (31.3)	10	11	.283
1. Do you need the number for Poison Control?	6 (9)	1	5	.399
2. Do you need a smoke detector in your home?	17 (25.4)	9	8	.152
3. Does anyone smoke tobacco at home?	30 (44.8)	11	19	>.999
Psychosocial needs	14 (20.9)	4	10	.544
6. Do you sometimes find you need to hit/spank your child?	8 (11.9)	2	6	.700
10. In the past year, have you been afraid of your partner?	2 (3)	0	2	.525
15. In the past year, did police come to your house for a suspected crime?	11 (16.4)	3	8	.518
16.  In the past year, did anybody in your household go to jail?	5 (7.5)	1	4	.643
Mental health needs	50 (74.6)	20	30	.565
7. Do you often feel under extreme stress?	37 (55.2)	17	20	.131
8. In the past month, have you often felt down, depressed, or hopeless?	33 (49.3)	15	18	.212
9.   In the past month, have you felt very little interest or pleasure in things you used to enjoy?	27 (40.3)	13	14	.198
11. In the past year, have you had a problem with drugs or alcohol?	6 (9)	4	2	.186
12. In the past year, have you felt the need to cut back on drinking or drug use?	8 (11.9)	4	4	.459
SDH needs	20 (29.9)	5	15	.270
4.   In the past year, did you worry that your food would run out before you got money to buy more?	17 (25.4)	5	12	.565
5.    In the past year, did the food you bought just not last, and you didn’t have the money to get more?	11 (16.4)	3	8	.518
13. In the past year, did you worry you might lose your house/apartment?	8 (11.9)	2	6	.700
14. In the past year, did you live in a shelter?	3 (4.5)	1	2	>.999

The informational recovery kit was provided to 3 patients with needs in the No SWA group and 24 in the SWA group (11.1% vs 88.9%, P < .001). Overall, the informational recovery kit was provided to seven families of pediatric patients and 20 adult burn patients.

DISCUSSION

Compared to other traumas, burn injuries can be distinguished based on the intensity, extent, duration, and frequent prolonged hospitalization.²⁹ Recovery can be a demanding time that requires a healthy support system for success. Unfortunately, for a disproportionate number of burn patients and their families, the support system is lacking. Many of these patients and families also have psychosocial issues,^30,31 mental health concerns and SDH, including food, home and financial insecurities, and mental health issues.³² Addressing these needs during admission can help survivors’ recover and reintegrate. In this study, we identified a gap in meeting the psychosocial, mental health, and SDH needs of our burn patients and their families during admission.

The presence of SDH is associated with burn injuries. Multiple studies have associated lower socioeconomic status, including lower home ownership and education attainment, family structure, living conditions, and census track with increased burn incidence both in the U.S. and in other parts of the world.^11,33–35 These economic challenges are significant risk factors for development of psychosocial problems among acute burn patients.^32,36 While there is a paucity of literature addressing SDH in burn injury, in other populations, these needs increase the risk of poor baseline health and increase the potential for a complicated recovery. Food insecurity, for instance, is associated with stress, exacerbation of exiting diseases, impaired health, and impaired recovery with greater reliance on emergency departments for nonemergency care.^37–39 Although studies are more scarce regarding home ownership and health, small houses have been associated with the development of several diseases as well as worse health outcomes.^40,41 However, the relationship between race, socioeconomic status, and home ownership is complex.⁴²

Other barriers to reintegration include mental health disorders.^30,31 The prevalence of mental health issues in burn patients is seven times higher than that in the general public.⁴³ The period postburn is particularly difficult with an increase in mental health needs.^30–32 Development of new psychological disorders such as mood, psychotic, and substance-related disorders, and anxiety, have also been reported.^15,44–47

In the current study, out of 79 inpatients, we identified 67 (84.8%) patients and families with psychosocial, mental health, and/or SDH needs. Of those, only 42 (62.7%) received a SWA during admission. Over one quarter of those with psychosocial needs (28.6%), 40% with mental health needs, and 25% with SDH did not receive a SWA.

Burn care has a long history of providing interprofessional care. Interprofessional care is required for optimal burn patient outcomes.⁴⁸ A crucial component of the team is the social worker who can identify patients’ living situations, health literacy, and resources. Previous work has demonstrated that patients with complex care require the integration between health and social services.^16,49,50 Sadly, in a recent study examining burn unit social worker responsibilities, it was found that more than half of respondents reported responsibilities in another hospital unit, hypothetically decreasing the time available to connect burn survivors with community-based services.¹⁷ As time is limited, especially in shorter LOS or outpatient areas, we propose a tool that can be used to aid social workers in better addressing family needs prior to discharge. The Needs Survey used in our prior ACEs studies identified family needs that were significantly correlated to the number of ACEs that our pediatric burn population and their parents as well as our adult burn population presented.^23,24 The Needs Survey or a similar survey such as Accountable Health Communities, Your Current Life Situation, or Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences Screening tools can be administered on admission using tablets or similar technology. The information collected within this survey can be available to social workers before they conduct their assessment, better enabling them to develop individualized recovery needs and plans. We believe this method would reduce the workload on social workers, potentially allotting them more time to find individualized community resources for patients and their families. The need to connect burn survivors with community-based services within their home community is crucial, as especially patients who live in rural areas or lack transportation may not be able to tap into the resources provided by the burn center. Unfortunately, in a national survey, only 34.3% of social work respondents included “community education and outreach” as part of their roles and responsibilities.¹⁷

Mental health workers and nonclinical social workers are key members in the burn interdisciplinary team. Burn injuries often require substantial care post-discharge and require a well-articulated plan, especially if the patient or their family is stressed with psychosocial, mental health, or SDH needs. Unfortunately, this study shows that, while a SWA was completed on two-thirds of our inpatients with these needs (62.7%), there is room for improvement. In addition, the receipt of the informational recovery kit was biased toward those patients and families that received the SWA. A potential barrier to a SWA identified in this study was shorter LOS. With the continued push for shorter LOS and outpatient care, this system will be further stressed requiring a more streamlined, time sensitive workflow. Our data shows that, using the Needs Survey, we were not only able to identify patients and families with needs, but also able to identify the type of needs. We propose administration of the Needs Survey or a similar survey on admission to help identify those patients and families with needs to assist our social workers identification of these at-risk patients.

This study presents several limitations. First, this is a single-institution study. Therefore, our results may not be generalizable to other centers. For instance, the social workers’ roles may vary from center to center and patient needs may be better captured in some centers than in others, or a psychosocial expert (Psychologist or Counselor) may serve in this role. In fact, many institutions have Registered Nurse Discharge Planners coordinating community resources.⁵¹ Moreover, our sample size was small. Furthermore, we included patients who agreed to participate in our ACEs study. Our ACEs study is a single-institution prospective study that relied on voluntary involvement. Of the 352 patients approached for our ACEs study, 39% refused to participate. Thus, we may have under- or over-estimated the number of patients with needs as those who did not enroll in our ACEs study did not fill out the Needs Survey. Moreover, we counted each identified need on the survey by a patient or family as a problem needing a solution, which may not be the case. In addition, the Needs Survey does not include strength- or resilience-based items. Factors such as resilience, social support, access to insurance and transportation, or adaptive coping strategies should be incorporated to fully capture protective as well as risk factors. Finally, we were only able to reliably assess what was in the social work note and what the patient received; therefore, we focused on the receipt of a social work visit instead of identification of needs.

CONCLUSIONS

By further assessing our patients’ needs, we will be able to better connect them with relevant resources to lighten the burden they face during their recovery. Furthermore, studies are warranted to develop a targeted approach to better meet the needs of our burn patients and their families.

Funding Research reported in this publication was supported by the National Center For Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002537. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflict of interest statement. No conflict of interest to declare.