“The forgotten burns patients: does the development of a burns outreach service make a difference?

1. “The forgotten burns patients: does the development of a burns outreach service make a difference? Introduction: This paper describes the clinical and financial benefits of providing specialist burn care to patients who are receiving in-patient care from acute mental healthcare services. These patients present clinical teams with a challenge because they require input from both psychiatric and burn specialists. When these services are not co-located it is problematic to provide a clinically and cost effective service to this small group of vulnerable patients. One solution is to provide specialist burns nursing care within the acute psychiatric environment by a burns outreach service. This paper describes the experience of a burns outreach service in managing patients with burn injuries with acute psychiatric illnesses. Demonstrating the clinical and cost effectiveness of the burns outreach service helps to justify the development of a new service. The burns outreach service began in March 2009 to provide specialist nurse support to burn patients in their homes or place of residence in the community which was recommended by the National Burn Care Standards. The burns outreach services enables the burn care team to provide the right care, at the right time, in the right environment for the patient. It is also cost effective and enables the burn team to deliver seamless care across complex professional disciplines. The views of nurses involved in the care of 16 patients in the East Midlands provided qualitative data to support the benefits of providing specialist burns nursing care within an acute psychiatric environment. Methodology: Patient records and questionnaires were used to obtain data associated with managing psychiatric patients over a period of 15 months. The sample consisted of 16 patients (12 female and 4 male) they were between 22 and 54 years old. The team made a total of 153 outreach visits to these patients during the 15 months. A cost comparison was made of managing these patients in both psychiatric services (burns outreach) and in the burns service (out patients clinic). Findings, conclusion and discussion To demonstrate insight into the value of this service we have provided three case studies that describe the type of patients that were managed by the outreach team. Patient B is a 47 year old male 5% full thickness TBSA caustic soda burn to his right thigh. He lives in a rural area and would need to travel 100 miles to attend hospital. He was initially treated in a Burns Unit. He underwent debridement and skin grafting on day 2 post injury and was discharged to a psychiatric hospital on day 6 post burn. When attending the buns unit for wound care because of his mental health needs he required an escort of two nurses. After an initial visit to the burns unit his care was transferred to the burns outreach team. Patient N is a 38 year old female who sustained a 5% Full thickness TBSA injury to her chest while she was an inpatient in an acute psychiatric unit (Deliberate Self Harm). She was initially admitted to a Burns Unit where she underwent debridement and skin grafting on day 1 post injury. She was assessed by the psychiatric team on day 2 and required sectioning under the mental health act and constant supervision (1:1) from a registered mental health nurse. On day 3 she was transferred to a psychiatric hospital and her burn care was managed by the burn outreach team. Patient P is a 24 year old male who sustained 85% TBSA flame burn to all four limbs, face and trunk (Deliberate Self Harm). He was initially treated in a Burns Centre (BC) for 120 days after which he was transferred to a Burns Unit (BU) for rehabilitation and management of unhealed burn wounds. After 45 days on the BU he was transferred to a psychiatric assessment unit because of his deteriorating mental health. He remained acutely unwell and on a high level of observations requiring two staff with him at all times, his burn care was managed in the psychiatric hospital by the outreach team. The table below is a summary of the data used to compare the cost of treating patients either in a psychiatric hospital using the outreach team or by them attending the burns clinic. Nursing time and transport costs were used to calculate a unit costs and an over all cost of the treatment episode. Figure below shows the relative costs and the potential savings of treating patients with complex needs in the community. There was a mean saving of £205 per patient for each treatment episode. When considering the potential for saving bed days it was estimated 11 acute burn bed days could be saved per patient with an acute burn and complex mental health needs. These initial results showed that there was a cost savings for patients when they were managed within the psychiatric service with the support from the burns outreach team. Comments from the psychiatric nurses suggested that there were positive indicators for providing the service. These were associated with: increased knowledge and expertise regarding wound care, reduced anxiety and discomfort for the patients and cost benefits of the service. Feedback from psychiatric services “Great service as the patient sometimes becomes distressed when outside their own environment”. “Having to travel to outpatient appointments would have put unnecessary stress on our client. Having the outreach service has been invaluable” “ Keeps interruptions to patient therapies to a minimum” “ Staff have limited experience of wound management and having the burns nurse visit was reassuring”. Outreach Service 400 300 200 Evidence to support the concept of outreach 100 Teaching and education Discussion The burns outreach service has provided an accessible expert resource for psychiatric patients within an appropriate psychiatric setting which has enabled the patient to be treated in the most suitable environment which fulfills the recommendations made by the National Burn Care review (2001). Initial findings suggests that we have reduced bed-days in the Nottingham burns unit by providing an outreach service. Because psychiatric patients with complex burn wounds have complex physical, psychological and social needs they need to be managed in the right environment to optimize their recovery. The provision of a burn outreach service ensures that these vulnerable patients receive quality burn care. References: NBCR. (2001). National Burn Care Review. British Burns Association. Manchester. Collaboration with community services in the East Midlands