Perspectives: Burn claims call for critical care protocols

For injured workers and their families, catastrophic burn injuries are life-changing events that require the highest levels of critical care and are now the second-most-costly class of lost-time workers compensation claims, trailing only motor vehicle accidents.

Paradigm catastrophic injury data shows that 38% of cases with a primary diagnosis of a burn injury have a medical spend of over $1 million, and 57% of injured workers with burns spend more than a month in an acute care hospital.

Non-thermal sources of burns — such as those caused by chemicals and electrical currents — are associated with extensive bodily damage involving every organ system in the body, including skin, muscles, nerves, blood vessels and bones. Treating complex and multifaceted burn cases requires highly specialized and compassionate surgical and medical care experts with proficiency in burn care.

Workplace burn injury rates have been declining for decades due to increased focus on safety measures. Additionally, steadfast advances in surgical critical care, antimicrobials, nutritional replacements, medical technologies, skin substitutes and novel skin grafting techniques have led to meaningful improvements in survivability rates.

Despite this progress, serious burn injuries — like those most often referred from the food service, construction and wholesale industries — continue to be one of the most significant challenges in the workers compensation system.

As medical innovations add to available care options, balancing appropriate, evidence-based treatment with the financial considerations of stakeholders requires high-level expertise and extensive experience with burn injuries. By understanding the complex needs and best practices at each phase of the recovery journey, stakeholders will be better positioned to deliver on the aligned outcomes.

What makes serious burn injuries so unique is the intensity and variety of care interventions these injuries require throughout the treatment process. Unlike other high-acuity injuries — which typically have intensive needs at the beginning but stabilize during recovery — catastrophic burns need months and sometimes years of extremely specialized treatments that address an extensive list of burn-related complications. These include severe organ dysfunctions, hypertrophic scarring and contractures, disfigurement and other impairments.

In the immediate days after a major burn injury, 89% of cases with a primary diagnosis of a burn injury required skin graft procedures to mitigate extremely high rates of fluid loss and risk of infection. While undergoing treatment in intensive care, these patients will require constant vital sign monitoring, antibiotic administration and fluid infusions.

Although this initial phase of care is risky, complex and strenuous, it is unmistakably a sign of progress for severe burn treatment. In the past, sustaining burns over 50% of the body was considered essentially fatal. One key advancement that has helped reverse this trend is the cellular regeneration technique, which allows burn patients’ skin cells or keratinocytes to be cultured in a lab at an accelerated pace. Once enough skin cells have been grown into form sheets — over several days to weeks — these “cultured epithelial autografts” can be transplanted onto the burn wound to promote healing and reduce complications.

Following a very long and difficult healing process, injured patients must adjust to the absence of sweat and oil glands on the grafted skin, resulting in decreased ability to regulate body temperature and relentless itching. As the skin begins to scar, it must be re-mobilized each day through topical care and often painful stretching and therapy. However, this treatment process is critical because new scars are far more pliable and responsive to stretching than mature, thick and rigid scars.

One novel advancement for burn care is laser therapy, which can help reduce the development of severe scars while moderating scarring and contractures. Because skin contracture has such a negative impact on joint and muscle mobility, laser treatments can be an effective method for improving the range of motion, as well as the degree of disfigurement, and can be a viable alternative to additional surgeries in some cases.

As the skin heals and recovery progresses, injured workers with burns require close attention to nutritional needs due to the extreme metabolic and catabolic stress on the body. The detrimental effect on the musculoskeletal system is compounded by the tremendous muscle atrophy that comes with extended hospitalization.

Even with a successful initial recovery, the long-term care needs resulting from catastrophic burns will continue for a lifetime, including the significant psychological impacts they can have on self-image, social relationships and readiness to return to work. To achieve optimal outcomes, issues of depression, social anxiety and post-traumatic stress disorder should be anticipated and addressed before they become recovery barriers. Psychological and behavioral health management interventions must be carefully and swiftly integrated into the treatment plan, with an emphasis on evidence-based practice approaches.

Effective severe burn treatment requires specialized care management and an army of medical professionals, including surgeons, medical specialists, wound care specialists, pain management specialists, therapists, nutritionists and behavioral health professionals. Managing this whole-person care and ensuring smooth transitions between different care settings requires experiential knowledge and expertise and an established network of accountable providers who deliver successful outcomes.

Understanding the criteria for being designated as an American Burn Association-verified burn center is an important step toward quality burn care. Although there are unverified burn centers that deliver excellent care, the goal of the verification process is to ensure burn center quality, patient safety, cost containment, education, innovation research, and patient advocacy, giving burn-injured individuals their best chance for a healthy, stable recovery.

Care managers must also build trust with caregivers. With catastrophic burns, families play a key role in injured workers’ recovery by supporting and monitoring them during critical recovery periods. Their vigilance in looking for signs of infections and other complications facilitates timely and appropriate interventions.

Despite the complexities and challenges of burn injuries, effective, high-quality care with predictable costs is possible. By adhering to a systematic care management framework that promotes collaborative, expert-driven specialized approaches, the workers compensation system can be better positioned to provide the best possible care for injured workers and their families after these life-changing injuries.

Dr. Michael Choo serves as the chief medical officer of workers compensation at Paradigm. He can be reached at [email protected].