Evolving Treatment in a Decade of Pediatric Burn Care

By Robert P. Foglia, Robin Moushey, Lisa Meadows, Jennifer Seigel, and Maureen Smith St Louis, Missouri

Backround: Over the last decade, an ambulatory burn care (ABC) and procedural sedation (PS) program was instituted at St Louis Childrens Hospital (SLCH). This study assessed the effect of these interventions on resource utilization. Methods: The authors reviewed the hospital experience comparing 1993 with 2002 data regarding gender, age, burn depth, patient admissions, inpatient days, and ABC visits. Outcome measures included length of stay (LOS), incidence of infection, and hospital charges. Results: Gender, age, and burn depth were similar; 192 patients were admitted in 1993. In 2002, there were 167 admissions and 118 patients treated solely on an ABC basis resulting in a total of 285 burn patients treated ( 48%). Hospital days decreased from 2,041 (1993) to 963 (2002 [ 53%]). LOS declined from 10.4 8.3 days (1993) to 5.8

14.2 days (2002 [ 44%; P .05]). PS was used sporadically in 1993, and increased to 71% in patients in 2002. There were no ABC visits in 1993 and 501 visits in 2002. The incidence of infection was 5.2% in 1993 versus 3.0% in 2002 (P .05) Average charge per patient fell 45% from $13,286 (1993) to $7,372 (2002), adjusted to 1993 dollars using medical care price index. Conclusions: Over a 10-year period, the program achieved a signicant reduction in resource utilization while increasing the number of patients treated and maintaining a low incidence of infection. This was due in large part to a shift to ABC and the use of PS. J Pediatr Surg 39:957-960. 2004 Elsevier Inc. All rights reserved. INDEX WORDS: Burns, ambulatory care, resource utilization.

RAUMA CONTINUES to be a major cause of mortality and morbidity in children. Burn injuries are the third most common cause of childhood trauma deaths and account for a signicant number of hospital admissions in the United States. Others have described the costs and strategies used to decrease hospitalization in burn patients.1,2 St Louis Childrens Hospital (SLCH) is a level I pediatric trauma center and is the only dedicated burn unit treating solely children in a 250 mile radius. The SLCH burn program is a component of the pediatric surgical program. Over the last decade, the hospital instituted an ambulatory burn care (ABC) program utilizing early hospital discharge with daily outpatient care. In addition, a procedural sedation (PS) program was developed that allowed debridement and wound care with less patient discomfort. We wished to assess what effects the use of ABC and PS had on burn care and resource utilization. Outcome measures included length of stay (LOS), incidence of infection, and hospital charges.
MATERIALS AND METHODS
Hospital records and burn registry data from 1993 to 2002 were reviewed. Appropriate Institutional Review Board (IRB) approval, HSC #03-0901, was obtained. An analysis of 1993 and 2002 admissions, LOS, patient age, gender, burn depth, incidence of infection, inpatient (INPT) days, and ABC visits was done. Data regarding infection were obtained from the hospital records and the hospital infection surveillance team. Hospital charges were obtained from the hospital medical information systems database. In the rst several years of the study, all burn patients were treated as INPT. A pilot study was begun in 1996 in which patients with burns were initially hospitalized
Journal of Pediatric Surgery, Vol 39, No 6 (June), 2004: pp 957-960

and then were treated on a daily ABC. The program has evolved over the last several years, to a point at which a signicant number of patients were not admitted to the hospital. Instead, all their burn care was delivered on an ambulatory basis. The burn care protocol was similar whether it was an INPT or an ABC patient. This consisted of daily removal of dressings; whirlpooling; burn wound debridement; physical therapy treatment; wound assessment; application of Silvadene (Monarch Pharmaceuticals, Bristol, TN), Acticoat (Smith & Nephew, Fort Saskatchewan, Alberta), or Biobrane (Bertek Pharmaceuticals, Morgantown, WV); and wound coverage. PS was dened as the use of an inhalation agent (nitrous oxide), or parenteral or oral medication (ketamine, versed, fentanyl, or valium) to alleviate pain. The use of an oral narcotic alone was not considered to be PS. Inhalation and intravenous PS was administered by a member of the pain management team. Patients were monitored with electrocardiogram (EKG) and pulse oximetry and were transferred from the treatment room to an adjacent recovery room. The children were there for approximately 30 minutes depending on the type of PS. They were either brought back to their hospital room, if they were an INPT, or discharged home with a parent (ABC). If they were to be treated on an ABC basis they would come in the day following; have

From the Division of Pediatric Surgery and Department of Nursing, Washington University School of Medicine and St Louis Childrens Hospital, St Louis, MO. Presented at the 55th Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, New Orleans, Louisiana, October 31-November 2, 2003. Address reprint requests to Robert P. Foglia, MD, Division of Pediatric Surgery, 5S60, St Louis Childrens Hospital, 1 Childrens Place, St Louis, MO 63110. 2004 Elsevier Inc. All rights reserved. 0022-3468/04/3906-0036$30.00/0 doi:10.1016/j.jpedsurg.2004.04.001
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Table 1. A Comparison of Inpatient and Ambulatory Burn Care Admissions Days and Charges for Patients Treated in 1993 and 2002
Hospital Charges Patients 1993 2002

Admitted Hospital days Treated with ABC alone Total treated ABC days INPT charges ABC charges Total charges Adjusted to 1993 dollars* Charge per patient INPT charge/d ABC charge/d

192 2041 0 192 0 $2,550,827 Not applicable $2,550,827 $2,550,827 $13,286 $1,250 Not applicable

167 963 118 285 501 $2,875,630 $103,968 $2,979,598 $2,101,159* $7,372* $2,105* $147

in a charge per patient of $13,286. In 2002, there were 167 burn admissions, and inpatient charges totaled $2,875,630. In 2002 the total ABC charges were $103,968. Thus, in 2002 total INPT and ABC charges were $2,979,598. This dollar gure was adjusted to 1993 dollars to correct for ination using the Medical Care Price Index (US Department of Labor) resulting in adjusted 2002 charges of $2,101,159. Because 285 burn patients were treated in 2002, the charge per patient with this adjustment was $7,372, a 45% decrease compared with 1993. In 2002, adjusted for ination, the average ABC charge was $147 compared with the average INPT daily charge of $2,105.
DISCUSSION

*Based on the Medical Care Price Index (US Dept. of Labor).

taken nothing orally, if needed; receive PS, if scheduled; have their burn wound care; and then sent home. All data are presented as mean SD. Statistical analysis was performed using StatView (SAS Institute Inc, Cary, NC). Data were analyzed using nonparametric statistics (Mann-Whitney) with a P value of less than .05 considered statistically signicant.

RESULTS

The mean age of patients in 1993 was 3.8 4.0 years and in 2002, 5.3 4.9 years. Boys constituted 63% of the patients in 1993 and 55% of the patients in 2002. Full-thickness burns were noted in 25% of the patients in 1993 and 19% of patients in 2002. In comparing data from 1993 to 2002 (Table 1), there were 192 INPT admissions in 1993 versus 167 INPT admissions in 2002. Total hospital days fell from 2,041 (1993) to 963 (2002), a decrease of 53%. LOS fell from 10.4 8.3 days to 5.8 14.2 days ( 44%; P .05). In 2002, of the 167 admissions, 71 patients were treated on an INPT basis alone, and 96 patients were initially INPT and then entered in the ABC program. There was no difference in LOS between these 2 groups of patients. Additionally, there were 118 patients who were exclusively treated in the ABC program. Thus, 285 burn patients were treated in 2002 compared with 192 patients treated in 1993, an increase of 48%. A total of 214 burn patients were treated in the ambulatory program in 2002 accounting for 501 ABC visits. The infection surveillance nurses documented 10 patients with infections in 1993, an incidence of 5.2%. In 2002 there were, of 5 patients with infection, an incidence of 3.0% (P .05). Procedural sedation was used sporadically in 1993 with approximately one half of the patients receiving some form of PS, whereas in 2002, 71% of the children received PS. Hospital charges are listed in Table 1. In 1993, total charges were $2,550,827 for 192 patients. This resulted

Trauma continues to be the major cause of mortality and morbidity in children between 1 month and 16 years of age.3,4 In the pediatric age group, burns are one of the most common causes of trauma-related injuries.5,6 The aim of this study was to identify whether burn care for many of the children could be shifted from an INPT program to an ABC program. Daily burn care along with the recovery time from PS took approximately 2 hours. Others have previously identied the efcacy of once-daily burn care.7 For many of these children, the remaining 22 hours of each day in our hospital was a hotel function. With a small grant from the BJC Health System, the SLCH burn program developed a randomized prospective trial of INPT versus ABC for children with burns of less than 10% TBSA. No difference in infection or time to wound healing was found between patients treated totally as INPT compared with a portion of their care on an ABC basis.8 The one major difference was an approximate 50% reduction in hospital charges.8 There was no signicant difference in patients treated between 1993 and 2002 with regard to age, gender, and depth of burn. Burn admissions decreased from 192 patients (1993) to 167 children (2002), a reduction of 13%, which may be attributed to treating some patients without hospital admission. To this end, the total number of burn patients treated in the program increased to 285 in 2002, a 48% increase. This number was owing to the 167 INPT admissions and 118 treated exclusively on an outpatient basis. The LOS changed from 10.4 days in 1993 to 5.8 days in 2002, a signicant decrease of 44%. In 2001 we began to treat children in the Emergency Unit and scheduled them for ABC without any INPT stay. This group made up 41% of all burn patients treated in 2002. Similarly, 75% of burn patients received a portion of their care through the ABC program. Burn patients accounted for 12% of all admissions to the pediatric surgical service in 2002 compared with 19% in 1993. Guidelines have been described for the use of anes-

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thesia and PS outside the operating room.9-12 Initially, the ABC program had a requirement that children would be admitted so that the rst PS could be done as an INPT. The initial INPT requirement allowed the PS team to observe how the child did with PS and determine whether he or she could be treated appropriately on an ABC basis. It also allowed the burn team (nursing, medical social worker, MD), to assess the family circumstances and decide whether there would be compliance with regard to the ambulatory program. During this time frame, the SLCH emergency unit reported good success with PS in treating orthopedic injuries.13 The ABC program then moved to eliminate the INPT requirement. In many cases, the child could be treated in the emergency unit with PS sedation without the need to admit the child to the hospital and return the next day for ambulatory burn care. The second aim was to optimize burn care for children. Dressing changes have been an integral part of daily burn care and often are painful. Over the last 2 decades, recognition and treatment of children with pain have made huge strides.14 Many remember the cries and tears associated with dressing changes and debridements. One of our clinical nurse specialists was succinct in saying, You can do anything with a child once, but if that was a painful experience you then have a fearful child for the rest of their hospitalization and subsequently. Thus, pain management became a focus for our burn program, as it has for others.15,16 The pediatric anesthesiologists were involved with burn wound care and the development of the PS program. The hospital was supportive of the program by installing medical gas lines and monitoring equipment in the 2 treatment rooms and the recovery room. With the use of PS, 2 major benets were noted. First, patient discomfort could be decreased signicantly. Second, aggressive wound de-

bridement could be done, which allowed prompt decisions in regard to which patients might reepithelialize their wounds spontaneously and which would benet from early tangential excision and grafting.17 We have shown previously that this could be done safely and could contribute to decreasing hospital LOS.17 As a corollary, families were gratied by the care given to their child, and both the family and the staff identied this type of care as important and benecial. The use of PS became part of burn care for the majority of our patients. The hospital charges represent charges and not costs or revenue collected. One aim of this study was to look at resource utilization in the burn program. Total charges for burn care dropped from 2.55 million dollars in 1993 to 2.10 million dollars in 2002, whereas there was a 48% increase in the total number of burn patients treated. Adjusting dollars in 2002 for ination to 1993, burn care charges per patient decreased signicantly from $13,286 to $7,372, a reduction of 46%. Additionally, there was a marked difference between INPT and ABC daily charges in 2002 ($2105 v $147). This reduction of charges and decreased LOS are benecial only if the clinical outcome of the patient does not suffer. Families would rather have their child come home and return to the hospital for ABC daily, rather than remain in the hospital. Finally, this program has eliminated 1,078 hospital days when comparing 1993 with 2002. Although the charges decreased by 46% per patient, the hospital gained that number of bed days for patients with other medical problems. Thus, this program also is a method to conserve a nite resource and use it for other patients. The evolution of the burn program to increase ambulatory care and procedural sedation appears to benet the hospital, the insurers, and, most importantly, the patient and family.

REFERENCES
1. McLaughlin E, McGuire A: The causes, costs and prevention of childhood burn injuries. Am J Dis Child 144:677-683, 1990 2. Lukish JR, Eichelberger MR, Newman KD, et al: The use of bioactive skin substitute decreases length of stay for pediatric burn patients. J Pediatr Surg 36:1118-1121, 2001 3. ONeill JA: Advances in the management of pediatric trauma. Am J Surg 180:365-369, 2000 4. Vane D, Shedd FG, Grosfeld JL, et al: An analysis of pediatric trauma deaths in Indiana. J Pediatr Surg 25:955-959, 1990 5. Crowin KJ, Butler PE, McHugh M, et al: A 1 year prospective study of burns in an Irish paediatric burn unit. Burns 22:221-224, 1996 6. Agran PF, Anderson C, Winn D, et al: Rates of pediatric injuries by 3 month intervals for children 0 to 3 years of age. Pediatrics 111:e683-692, 2003 7. Sheridan RL, Petras L, Lyndon M: Once daily wound cleansing and dressing. Efcacy and cost. J Burn Care Rehabil 18:139140, 1997 8. Foglia RP, Moushey R, Smith M, et al: Use of ambulatory burn care in children. Presented at the European Burn Organization Meeting on 9/12/03 in Bergen, Norway (abstr) 9. Parker J: Burn care protocols: Administration of ketamine. Review of feature protocol Shriners Hospital for Crippled Children Burn Institute, Galveston TX. J Burn Care Rehabil 8:149, 1987 10. Murphy MS: Sedation for invasive procedures in paediatrics. Arch Dis Child 77:281-286, 1997 11. Hall S: Anesthesia outside the operating room, in Gregory G (ed): Pediatric Anesthesia. New York, NY, Churchill Livingstone, 1994, pp 813-835 12. Cote CJ: Sedation for the pediatric patient. A review. Pediatr Clin North Am 41:31-58, 1994 13. Graf KJ, Kennedy RM, Jaffe DM: Conscious sedation for pediatric orthopedic emergencies. Pediatric Emerg Care 12:31-35, 1996 14. Schechter NL: Pain and pain control in children. Curr Probl Pediat 15:1-67, 1985

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15. Sharar SA, Bratton SL, Carrougher GJ, et al: A comparison of transmucosal fentanyl citrate and hydromorphone for inpatient pediatric burn and wound analgesia. J Burn Care Rehab 19:516-521, 1998 16. Coimbra C, Choinere M, Hemmerling TM: Patient controlled

sedation using propofol for dressing changes in burn patients: a dose nding study. Anesth Analg 19:839-842, 2003 17. Ebach DR, Foglia RP, Jones MR, et al: Experience with procedural sedation in a pediatric burn center. J Pediatr Surg 34:955-958, 1999

Discussion
S. Engum (Indianapolis, IN): Can you break out the ABC costs? Two hundred dollars per visit, does that include the anesthesiologist, yourself, the nursing costs, the expense of all the equipment? R. Foglia (response): They were all the hospital charges. These data came from the hospital itself, so this was a combination. It was not an anesthesia professional fee, but all the technical fees and charges for the hospital. D.A. Caniano (Columbus, OH): Bob, I congratulate you on a very innovative approach. My rst question is, how do you administratively organize the unit so that you have the tub in the room ready? How do you schedule the anesthesia time and the scheduling? Just give us a little insight into how you do that on a busy ward? And, is there an attending surgeon available during the burn dressing, and, if so, do you charge for that process? My other question relates to child abuse. Did you see any change in number of child abuse cases during the study, and how do you select out for that so that you dont inadvertently send an abused child home from the ER? R. Foglia (response): Ten percent to 15% of our patients are either victims of child abuse, overt abuse, or neglect, and we would screen the patients initially for the ambulatory burn study we did, and subsequently weve screened them through our medical social worker. And so we would not send children home who were at risk for that. The other part of the question has to do with setting up things with anesthesiologists. We have one anesthesiologist who is available for our burn program each day, and that schedule is pretty much made up by 5 PM the day previous. Initially, when we did this, all the patients were going to be treated on an ambulatory burn care basis, were admitted to the hospital at least overnight so that they were, if you will, a captive audience. The program worked relatively well, to the point that the anesthesiologist felt subsequently that they didnt need to see every patient in the hospital beforehand. We then started having patients who were treated in the EU, not be admitted, and then would come in to the ambulatory program the next day. Its still problematic for patients who come in after 6 PM. Our program has moved from our nurses love these little terms and acronymsan ambulatory burn care (ABC) program, to a PAWS program, which is a pediatric ambulatory wound service. This past year, 45% of our patients were wound patients. If we have, for example, 3 patients scheduled at 5 oclock on Thursday afternoon, and 2 burns and an abscess come in Thursday in the evening, the anesthesiologists are already often committed to something else later in the day. We then are scrambling to get the help we may need for those extra several children. So were still fussing with that issue. The nurses are the key to the whole program. The charge nurse sets up the schedule for that. The hospital likes it because its another, if you will, cost center for them, but the issue is for the nurses now theyre switching from inpatient to the ambulatory side of it, and there can be more problems with logistics with that, but its taken us about 5 years to work through this, and were still doing it. Finally, we try to have an attending surgeon see the patients daily. If they do, the service is billed, and we have been reimbursed. W. Hardin (Birmingham, AL): Bob, I applaud this study. Its a great illustration of whats happening in burn care with the move toward outpatient care of less serious burns. The question that I would ask you is, how are you reimbursed for your burn care? Is it on a per diem basis, or is it on a DRG basis, because with the per diem type reimbursement you take a nancial hit when youre moving these patients to an outpatient setting. R. Foglia (response): Well, initially when we set the study up, it was a royal pain in the neck because a number of the insurers wouldnt let us treat patients on an ambulatory basis. They had to stay in hospital. And other insurers said, No, if you have an ambulatory program, youve got to switch to that. And it took about 4 months to write letters to all the insurance companies from the small number of commercial through the managed care programs through Illinois Public Aid and Missouri Medicaid saying we need to do this so we can identify it. Our charges and our reimbursement on the professional side is very different from the hospital. Missouri Medicaid pays about 69 cents on the dollar, so the hospital does overall relatively well, where on the professional side we dont. Our patient mix at our hospital is about 47% Medicaid. Regarding our trauma and burn patients, about 75% of those are Medicaid. But the hospital felt that this was the right program, invested in things like medical gas lines up in the treatment room. Their reimbursement is on a per diem basis, but they also can bill for the outpatient care. Additionally, the bed that was previously lled with a burn patient is now being used by someone else. So overall, the hospital comes out ahead.