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A survey on the current status of burn rehabilitation services in China
burns 39 (2013) 269–278
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
A survey on the current status of burn rehabilitation services in China Jian Chen a,*, Cecilia W.P. Li-Tsang b, Hong Yan a, Guangping Liang a, Jianglin Tan a, Sisi Yang a, Jun Wu a,* a
Institute of Burn Research, State Key Laboratory of Trauma, Burn and Combined Injury, Chongqing Key Lab for Disease Proteomics, Southwest Hospital, Third Military Medical University, Chongqing 400038, China b Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
article info
abstract
Article history:
Background: In China, there is a very long history of burn wound treatment, but the
Accepted 29 June 2012
specialised burn care units were set up only from 1958. With more than 50 years of practice, great achievements have been made in burn wound care and operations in the country.
Keywords:
However, in terms of burn rehabilitation, the development appears to be slow. In order to
Burns
determine the current status of burn rehabilitation services in China, a survey was con-
Rehabilitation
ducted to various burn centres in China.
Survey
Methods: A comprehensive survey was conducted as well as to collect data related to (1) the admissions and staffing of the burn centres; (2) availability of rehabilitation services, number and educational background of specialised personnel dedicated in burn rehabilitation therapy; and (3) the difficulties leading to the lag of the burn rehabilitation services. The survey was sent to the chiefs of 87 burn centres via e-mail and they were requested to fill out the survey questionnaire and to send it back. For those who did not respond within 1 month, a reminder was sent. Results: There are totally 39 (44.8%) burn centres responding to our survey. These centres were geographically distributed in nearly 70% of the administrative provinces in China; hence, the results could well represent the current burn care system. Most centres have recognised the importance of rehabilitation therapy and remarkable improvements of outcome in burn patients have been achieved. There are a very huge number of burn patients that need rehabilitation therapy, but most centres face the problems of shortage of rehabilitation therapists, which apparently could lead to the difficulties in delivering a quality rehabilitation programme for patients. Although the time of rehabilitation therapy is instituted far earlier than before, it is still not widely accepted in the acute burn care stage. There are more specialists joining the burn centre and becoming members of the professional burn team. However, professional education and training in the burn specialty appear to be sparse. There is room for improvement. Problems that impede the progress of rehabilitation therapy are: lack of rehabilitation knowledge in medical staff as well as the public, the shortage of specialised personnel and relatively low educational background of this team, lack of standard guidelines for rehabilitation treatment instructions and lack of funding from the government.
* Corresponding authors. Tel.: +86 023 65219862. E-mail addresses: [email protected] (J. Chen), [email protected] (J. Wu). 0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2012.06.016
270
burns 39 (2013) 269–278
Conclusion: After 20 years of clinical practice, rehabilitation concepts are well accepted and many forms of rehabilitation techniques are carried out in most burn centres that responded to the survey. Yet, the results also indicate that there is a short history of rehabilitation practice among the burn centres. There is a burning need to enhance the development of rehabilitation services so as to meet the demands of management of severely burned patients in China. Some suggestions are made to improve the current burn rehabilitation services which would include: (1) provide rehabilitation education programmes for burn surgeons, therapists, nurses, as well as patients, families and the public; (2) set up standard guidelines for clinical instruction of rehabilitation therapy; (3) build an interdisciplinary burn team; (4) more investigation and research on the physical and psychological outcomes of burn patients; and (5) implement administrative measures in terms of staffing, funding and offering insurance to burn survivors. # 2012 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
China has a long history of burn wound treatment; however, special burn units were established ever since 1958. With the advancement in surgical and burn management techniques in the past 50 years, the burn care and management among these centres have demonstrated significant improvements and achievements, particularly in the survival of severely burned victims [1]. In some centres, the survival rate can reach up to 98.9% [2]. As more and more patients with severe burns survive, there is a great challenge to help these patients to lead a higher quality life. Functional and psychological recovery, quality of life, and social re-integration become the goals of management, which increases the need for comprehensive rehabilitation services [3]. When compared to the development of burn management in the medical field, the development of rehabilitation medicine only emerged in the past 30 years. It is vital to review the current rehabilitation model and services for the patients with severe burns such that appropriate action could be taken to enhance the quality of life of burn survivors in China. A survey was conducted to determine the current burn rehabilitation services using a questionnaire sent out to burn centres in the country. The study also aimed to find out if there are any inadequate service provisions and to make recommendations where necessary to enhance future service delivery in China.
2.
Methods
A survey questionnaire (Appendix I) was developed to obtain information in the following areas: (1) demographic information of burn centres, inpatients treated per year, patients with >50% total body surface area (TBSA) burns per year, number of burn surgeons and nurses, etc.; (2) availability of rehabilitation services, number, composition and educational background of specialised personnel dedicated in burn rehabilitation therapy, and type of rehabilitation therapy; and (3) difficulties leading to the lag of the burn rehabilitation service. The questionnaire was sent to the directors of 87 burn centres via e-mail inviting them to respond within a month. For those who did not respond in the first month, a second email was sent to remind them to fill out the form. There were a total of 39 centres completing the questionnaire. The
overall response rate was 44.8%. For those who did not respond after two invitations, we tried to contact directors of some centres by phone and asked the situation of their burn rehabilitation service. The data were analysed using a descriptive statistical method. Correlation analysis was also conducted.
3.
Results
3.1.
The geographic distribution of burn centres
Fig. 1 shows the geographic distribution of those burn centres that responded to the survey. Thirty-nine centres joined the survey. These centres are located in 17 provinces, three autonomous regions and three municipalities (China administers 23 provinces, five autonomous regions, four municipalities and two special administrative regions). Thirty-seven centres are from Grade 3A hospitals (the highest grade in the hospital classification by Ministry of Health, and those hospitals are capable of providing the best medical services in the country) and two are from Grade 2A hospitals. These centres include most of the biggest and influential burn centres in China and are geographically distributed in nearly 70% of our administrative provinces and the results could well represent the current burn care system in China. There were 48 burn centres that did not join the survey. They were 44 from Grade 3A hospitals, two from Grade 3B hospitals and two from Grade 2A hospitals. A follow-up telephone contact was made after the e-mails, directors of some centres were contacted and most of them responded that there were no rehabilitation services in their centres.
3.2.
Staffing situation
The 39 centres were categorised into three groups based on the number of admissions per year. Those with less than 500 admission of burn cases per year were categorised into group 1, those between 500 and 1000 cases were in group 2 while those with more than 1000 admissions were categorised into group 3. The total inpatients per year of all the 39 centres was 33 837 (867.6 per centre per year), which indicated a huge number of
271
burns 39 (2013) 269–278
Fig. 1 – The geographic distribution of responding burn centres. , centres from Grade 2A hospitals; , centres from Grade 3A hospitals.
burn patients in China. The large burn centres with more than 1000 admissions per year had more patients with severe burns (patients with >50% TBSA burns). The patient/surgeon ratio was much higher when compared to those centres with less number of patients. Each surgeon had to treat more than 80 patients per year and their workload was most heavy in centres from group 3. Although almost all the centres responded that there was at least one type of rehabilitation
service offered to the patients with burns, almost half of the centres had no full-time staff working in the rehabilitation field (Table 1).
3.3.
Rehabilitation services
There are totally 38 centres that can provide at least one kind of related rehabilitation service (Table 2). Pressure garment,
Table 1 – The admissions and staffing of the burn centres. Group Number of centres Number of inpatients annually Number of inpatients with >50% TBSA burns annually Number of burn surgeons per centre Number of nurses per centre Number of inpatients a surgeon treated annually Number of centres that could provide rehabilitation services Number of centres with full-time rehabilitation staff
Group 1 (0–500 admissions)
Group 2 (501–1000 admissions)
Group 3 (1001+) admissions
11 335.5 142.7 22.9 18.5
16 749.3 160.8 43.6 54.8
12 1586.6 340.4 86.1 87.8
8.3 2.9 13.5 4.4 41.9 20.9
9.9 3.2 17.3 6.1 81.6 23.1
22 8.0 46.9 22.3 83.1 36.9
11 (100%)
16 (100%)
11 (91.7%)
6 (54.5%)
9 (56.3%)
9 (75%)
272
burns 39 (2013) 269–278
Table 2 – The rehabilitation services provided by the centres. Rehabilitation services provided Physical therapy Occupational therapy Pressure garment Splinting Hydrotherapy Sound frequency electrotherapy Shortwave Microwave Infrared
Number of centres
%
Rehabilitation services provided
Number of centres
%
31 21 38 32 20 14 9 10 18
81.6 55.3 100 84.2 52.6 36.8 23.7 26.3 47.4
Ultraviolet radiation Laser Paraffin Air pressure Magnetism Ultrasonic Psychotherapy Occupational rehabilitation Social reintegration
5 15 14 6 5 6 14 4 3
13.2 39.5 36.8 15.8 13.2 15.8 36.8 10.5 7.9
Table 3 – The initiation time of rehabilitation therapy in 24 centres with full-time rehabilitation staff. Time to start rehabilitation therapy (postburn days) 0–7 8–14 15+
Number of centres
Mean start time (postburn days)
7 (29.2%) 8 (33.3%) 9 (37.5%)
5.9 13.3 24.1
splinting and physical therapy are reported to be carried out in most centres. Out of these 38 centres, only 24 had totally 82 full-time burn rehabilitation staff, which equates to 3.4 (range from 1 to 9) staff per centre. Nearly 70% centres had only 2.2 (range from 1 to 3) staff each. When considering the annual inpatients number reached 867.6 per centre, the workload of these rehabilitation personnel was heavy, and also showed significant shortfall of staffing in this discipline to serve the patients with burns, particularly for those with severe burns. At the present time, the rehabilitation services were conducted by either nurses or non-skilled therapists in China. From our survey, the rehabilitation team mainly consisted of nurses (42.7%), physical or occupational therapists (45.1%) and rehabilitation doctors (8.5%). In some centres, there were specialists with psychological (only one) and rehabilitation engineer (only one) background. Among these 82 practitioners, there was one staff with a doctorate degree (medical doctor), three had master’s degrees, 30 (36.6%) were graduates, 19 (23.2%) graduated from tertiary colleges and 29 (35.4%) graduated from junior technical schools. The initiation time of rehabilitation therapy for patients is summarised in Table 3. More than 70% centres began their rehabilitation therapy 1–2 weeks after burn.
3.4.
Challenges in burn rehabilitation
There are many challenges for burn rehabilitation to develop in China. Most directors reported that there was a lack of understanding regarding burn rehabilitation for medical professionals as well as the public. There was a shortage of qualified rehabilitation personnel specialised in burn rehabilitation. The qualification of rehabilitation personnel was not standardised and properly accredited in Mainland China. There was a lack of standardised guidelines for rehabilitation treatment instructions. Moreover, there was a lack of funding support from the government to provide rehabilitation therapy for patients with burns who would require more long-term rehabilitation. Patients with financial problems could not afford the cost in the long run (Table 4). When rehabilitation treatment is carried out in clinical practice, there are still many controversial opinions among burn surgeons, patients, therapists and nurses. It is common that the burn surgeons neglect the importance of rehabilitation therapy in the burn treatment and are worried more about the rehabilitation interventions that would lead to wound healing problems such as bleeding, blistering and laceration of scars. As for patients, they know little about the significance of rehabilitation therapy and are worried more about how the treatment would increase their costs (Table 5).
4.
Discussion
China is the most densely populated country in the world, with more than 1.3 billion people. There are no official statistical data available on the incidence and mortality of burn of the country until now. It was reported that the ageadjusted burn incidence was 136 per 100 000 population in 2008 in the US. Patients with the vast majority of these burns were treated and released from the emergency department
Table 4 – Difficulties in rehabilitation improvements. Difficulties Not supported by the hospital Not supported by the centre chief Lack of rehabilitation knowledge in burn surgeons Lack of professional rehabilitation guidelines Short of staffing
Number of centres
Difficulties
Number of centres
9 (23.1%) 4 (10.3%) 16 (41.0%)
Limited space for rehabilitation therapy Short of funding Limited professional knowledge of rehabilitation team Lack of an interdisciplinary team work system Financial problems of the patients
30 (76.9%) 25 (64.1%) 23 (59.0%)
26 (66.7%) 33 (84.6%)
33 (84.6%) 24 (61.5%)
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Table 5 – Problem and knowledge of the rehabilitative processes. Problems
Number of centres
Worry about new wound/bleeding/delay of wound healing as a result of rehabilitation therapy Know the necessities of rehabilitation therapy Know how to choose rehabilitation treatments Know when to start rehabilitation therapy
19 (48.7%) 9 (23.1%) 18 (46.2%) 23 (59.0%)
Patients
Worry about wound healing process affected by rehabilitation therapy Worry about new wound/bleeding as a result of rehabilitation therapy Increased costs Know little about the importance of rehabilitation Bad compliance with rehabilitation therapy
21 25 24 20 11
Rehabilitation therapists
Know when to start rehabilitation therapy Know the best treatment in different time
20 (51.3%) 21 (53.8%)
Nurses
Have specialised nurses dedicated to rehabilitation nursing
19 (48.7%)
Burn surgeons
and only 5% were hospitalised [4]. As one of the low- and middle-income countries (LMICs), China had a much higher burn incidence when compared with that of the US. Further combined with the large population, it would be a very large number of burn patients that need hospitalisation. Burn is one of the most disabling medical problems, which will bring along physical, psychological and financial problems to the patients, their families and society [5–7]. With such a large population of burns and consequent disabilities, there is growing recognition for better rehabilitation efforts in patients and their families as well as burn centres [8]. The responding centres were geographically distributed in nearly 70% provinces of China; hence, their reports on rehabilitation practices would reflect the current situation in the country. Those who did not respond to the survey may indicate that their rehabilitation services have not been started. This was reflected by follow-up telephone confirmations to the directors of some non-responding centres. Although not all the centres responded to this short telephone survey, it is possible that the real situation could be more drastic when compared to the results presented with the 39 centres, because these non-responding centres are mainly from Grade 3A hospitals located in large cities and for those from Grade 2A or 1A hospitals, the situation could be more adverse. With more and more international exchange and visits, the concept of rehabilitation has been promoted to burn centres and burn surgeons. The impact of rehabilitation towards better outcomes on patients was demonstrated in a number of clinical burn centres where rehabilitation services were provided directly at the burns unit right after admission. There are more burn research centres or units that recognised the importance of rehabilitation for burn patients and started to establish their own rehabilitation team at their own wards or centres. However, there are still a lot of challenges to establish a quality rehabilitation system for burn patients. In the survey of Seighiou [9], in 70 randomly selected burn centres in North America, the majority of centres reported treating less than 200 inpatients and more than 200 outpatients annually. However, in our survey, the average inpatients annually per centre reached 867.6, which indicated the high incidence and great number of burns in China and therefore a very huge number of burn patients who require intensive rehabilitation therapy (including occupational therapy,
(53.8%) (64.1%) (61.5%) (51.3%) (29.7%)
physiotherapy, prosthetics and orthotics). According to the criteria from Ministry of Health of China, in Grade 3A hospitals, the ratio of staff/patient (no. of beds) should be around 1.03, while in our survey, the staff/patient ratio was only 0.77 0.25. This shows the severe shortage of health-care professionals serving burn patients who often require very intensive rehabilitation soon after injuries. Most burn centres have a strong medical team and the survival rate of patients with burns is very high (almost 99.9%, as reported by the China Burns Association, 2003). The shortage of burn nursing specialists was also noted in this study. In Yurko’s survey [10], for those patients with 60–90% TBSA burns, the nursing staff/patient ratio is 1:1 in 81% of the burn units. This ratio is far too ideal in our burn centres. Burns could cause significant physical and psychological complications, which require an intensive interdisciplinary rehabilitation team to work closely with the burn surgeons, particularly at the early stage of burns [11]. Despite a call for the development of an interdisciplinary burn care team for years, the burn surgeon continues to dictate how the care is provided to the burn patient. In some circumstances, they might pay more attention to the surgical techniques, wound care and infection control. Some may not have a clear understanding of concept and principles in burn rehabilitation. Thus, the rehabilitation process was often delayed and by then patients already developed contractures, deformities and other complications associated with burns. The concept of physical therapy began in 1940s [12]. In China, physical therapy was first introduced in late 1970s, began to be widely accepted in the late 1990s and was applied mainly in diseases such as fracture, brain damage, spinal cord injury and cerebral palsy. Burn patients who finished with wound closure/grafting stage could be transferred to the rehabilitation department or discharged home. Undoubtedly, functional disabilities and scar contractures were common at that time. The overall outcomes of the severely burned patients were not satisfying. As rehabilitation concepts were gradually accepted in clinical practices, the initiation time of rehabilitation therapy was 1–2 weeks post-burn in most centres in this survey which was much earlier than before, but still had a long way to meet the standard requirements that rehabilitation should begin as the injury starts [13]. Positioning, splinting, range of motion (ROM) exercises and ambulation in acute stage are rare in clinical practices.
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Once realising the importance of rehabilitation therapy during burn care treatment, specialised personnel began to join some burn centres since late 1990s. The first group dedicated to rehabilitation therapy mostly came from nurses with or without a rehabilitation education background, and the treatments mainly focus on pressure garments and some kinds of physical therapies such as electricity, infrared and paraffin. In recent years, rehabilitation therapists began to join this group, and made physical and occupational therapy more and more accepted by doctors and patients. In our survey, the full-time rehabilitation staff only equates to 3.4 per centre. Cromes and Helm [14] suggested that, in a burn unit with 10 acute beds, the following personnel would be necessary: 2.5 full-time physical therapists, 2.0 full-time occupational therapists, 1.0 full-time social worker, 2.5 fulltime wound care personnel and 0.25 full-time psychologists/ psychiatrists. It indicates a significant shortfall of staffing in this discipline in China, particularly for those with severe burns. Biggs et al. [15] reported that there is a common division of responsibility for certain duties in burn rehabilitation, while in the current situation, most centres are not capable of dividing their therapists to physical and occupational therapists, which means that most centres could not provide more specialised burn rehabilitation therapies to the patients by now. Although the high incidence of psychological problems after burn had been widely known years ago [16], we just began our attempts to explore into the inside world of our patients underneath their changed appearances. This work is mainly done by nurses now and despite the fact that it may not be so professional, it shed light on the need of future improvement. In searching for the problems that impede rehabilitation therapy in China, the results showed that, all the concerns from doctors, patients or therapists are due to the lack of burn rehabilitation knowledge. This appeals to an educational programme for improving rehabilitation concepts as well as techniques among all the medical students, clinical staff and the public. Cromes and Helm reported that there were education programmes for not only inpatients and staff but also support groups for patients with burns in 1988 in USA; the ongoing education was an important factor in maintaining high quality of specialised burn rehabilitation care [14]. Further, it also calls for establishing standard guidelines that could instruct on the rehabilitation therapy processes. Model systems [17] and guidelines [18] for burn care of other countries may serve as examples. Although there are many recommendations for rehabilitation of burn patients in the literature and the treatment must be individualised for each patient, it is still necessary to institute a guideline suitable for our situation. Barillo et al. [19] discussed some of the benefits of institutional guidelines such as established protocols, immediate institution of therapy, consistent care, facilitation of data collection for research and quality assurance programmes. Although the awareness of the importance of burn rehabilitation in China is increasing, the shortage of specialised and well-educated personnel is not going to be solved in the near future. Thus, in the mean time the development of standard practice guidelines would provide a foundation on which the existing personnel can build and develop with experience and time.
5.
Conclusion
After 50 years of improvement, burn care in China made great strides. Functional and psychological recovery, quality of life and social re-integration are more and more important in outcome assessment. This survey outlined the approximate status of rehabilitation services in the current burn care system in China. Rehabilitation concepts are accepted universally and therapies were carried out in most centres. However, the relatively short history explains the overall condition of burn rehabilitation therapy in China, which still faces problems like the lack of rehabilitation knowledge by medical staff as well as the public. The shortage of specialised personnel and the relatively low educational background of this team contribute to the lack of standard guidelines. Finally, the lack of funding from the government hinders the advancement of burn rehabilitation in the country. Rehabilitation therapy plays important roles in burn patient recovery: more efforts should be made to improve the current burn care system in China. Here are some of the future directions and suggestions: (1) provide rehabilitation education programmes to burn surgeons, therapists, nurses, as well as patients, families and the public; (2) set up standard guidelines for clinical instruction of rehabilitation therapy; (3) build an interdisciplinary burn team; (4) more investigation and research on the physical and psychological outcomes of burn patients; and (5) implement administrative measures in terms of staffing, funding and offering insurance to burn survivors.
Conflict of interest There is no conflict of interest with any personnel or financial organisation.
Acknowledgements We would like to express our thanks to those directors of burn centres who responded to our survey and provided invaluable comments on the current rehabilitation services at their centre. They are from: Liaoning Provincial Corps Hospital of CPAPF; the Second Affiliated Hospital Zhejiang University College of Medicine; Tibet Military General Hospital; the PLA Second Artillery General Hospital; the First Affiliated Hospital of Fujian Medical University; Jinan Central Hospital Affiliated to Shandong University; Guangzhou Red Cross Hospital; the First Affiliated Hospital, Sun Yat-Sen University; the First Affiliated Hospital of Nanjing Medical University; Hainan Provincial People’s Hospital; the Second Affiliated Hospital of the Fourth Military Medical University; the First Affiliated Hospital of Anhui Medical University; Plastic Surgery Hospital, CAMS, PUMC; the Second Provincial People’s Hospital of Shenzhen; Xijing Hospital of the Fourth Military Medical University; the 175th Hospital of PLA, Nanjing; the First Provincial People’s Hospital of Zhengzhou; the First Affiliated Hospital of Wenzhou Medical College; Lanzhou Military General Hospital; Nanfang Hospital of Nanfang Medical University; Nanjing Drum Tower Hospital the Affiliated
burns 39 (2013) 269–278
Hospital of Nanjing University Medical School; the Second Affiliated Hospital of Nanjing Medical University; Changhai Hospital of the Second Military Medical University; Ruian People’s Hospital; the First Affiliated Hospital of Nanchang University; the First Affiliated Hospital of the Third Military Medical University; Xiangya Hospital Central-South University; Urumqi Military General Hospital of Lanzhou; the First Affiliated Hospital of Hebei Medical University; the Third
Appendix I. A questionnaire on current status of burn rehabilitation
275
Hospital of Wuhan City; the General Hospital of CNPC in Jilin; the 309th Hospital of Chinese People’s Liberation Army; People’s Hospital of Uygur Autonomous Region; Ruijin Hospital of Shanghai; Burn Institute of Inner Mongolia; the First Affiliated Hospital of Nanjing Military General Hospital; the 181st Hospital of PLA, Guangzhou; Linyi People’s Hospital of Shandong Province; and the Affiliated Jiangyin Hospital Medical College Southeast University.
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[11] Holavanahalli RK, Helm PA, Parry IS, Dolezal CA, Greenhalgh DG. Select practices in management and rehabilitation of burns: a survey report. J Burn Care Res 2011;32:210–23. [12] Richard RL, Hedman TL, Quick CD, Barillo DJ, Cancio LC, Renz EM, et al. A clarion to recommit and reaffirm burn rehabilitation. J Burn Care Res 2008;29:425–32. [13] Whitehead C, Serghiou M. A 12-year comparison of common therapeutic interventions in the burn unit. J Burn Care Res 2009;30:281–7. [14] Cromes GF, Helm PA. The status of burn rehabilitation services in the United States: results of a national survey. J Burn Care Rehabil 1992;13:656–62. [15] Biggs KS, de linde L, Banaszewski M, Heinrich JJ. Determining the current roles of physical and occupational therapists in burn care. J Burn Care Rehabil 1998;19:442–9. [16] Willebrand M, Ersson G, Ekselius L. Prediction of psychological health after an accidental burn. J Trauma 2004;57:367–74. [17] Feck G, Blair EL, Lawernce CE. A system model for burn care. Med Care 1980;XVIII:211–8. [18] Simons M, King S, Edgar D. Occupational therapy and physiotherapy for the patient with burns: principles and management guidelines. J Burn Care Rehabil 2003;24:32–5. [19] Barillo DJ, Harvey KD, Hobbs CL, Mozingo DW, Cioffi WG, Pruitt Jr BA. Prospective outcome analysis of a protocol for the surgical and rehabilitative management of burns to the hands. Plast Reconstr Surg 1997;100:1442–51.
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
A survey on the current status of burn rehabilitation services in China Jian Chen a,*, Cecilia W.P. Li-Tsang b, Hong Yan a, Guangping Liang a, Jianglin Tan a, Sisi Yang a, Jun Wu a,* a
Institute of Burn Research, State Key Laboratory of Trauma, Burn and Combined Injury, Chongqing Key Lab for Disease Proteomics, Southwest Hospital, Third Military Medical University, Chongqing 400038, China b Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
article info
abstract
Article history:
Background: In China, there is a very long history of burn wound treatment, but the
Accepted 29 June 2012
specialised burn care units were set up only from 1958. With more than 50 years of practice, great achievements have been made in burn wound care and operations in the country.
Keywords:
However, in terms of burn rehabilitation, the development appears to be slow. In order to
Burns
determine the current status of burn rehabilitation services in China, a survey was con-
Rehabilitation
ducted to various burn centres in China.
Survey
Methods: A comprehensive survey was conducted as well as to collect data related to (1) the admissions and staffing of the burn centres; (2) availability of rehabilitation services, number and educational background of specialised personnel dedicated in burn rehabilitation therapy; and (3) the difficulties leading to the lag of the burn rehabilitation services. The survey was sent to the chiefs of 87 burn centres via e-mail and they were requested to fill out the survey questionnaire and to send it back. For those who did not respond within 1 month, a reminder was sent. Results: There are totally 39 (44.8%) burn centres responding to our survey. These centres were geographically distributed in nearly 70% of the administrative provinces in China; hence, the results could well represent the current burn care system. Most centres have recognised the importance of rehabilitation therapy and remarkable improvements of outcome in burn patients have been achieved. There are a very huge number of burn patients that need rehabilitation therapy, but most centres face the problems of shortage of rehabilitation therapists, which apparently could lead to the difficulties in delivering a quality rehabilitation programme for patients. Although the time of rehabilitation therapy is instituted far earlier than before, it is still not widely accepted in the acute burn care stage. There are more specialists joining the burn centre and becoming members of the professional burn team. However, professional education and training in the burn specialty appear to be sparse. There is room for improvement. Problems that impede the progress of rehabilitation therapy are: lack of rehabilitation knowledge in medical staff as well as the public, the shortage of specialised personnel and relatively low educational background of this team, lack of standard guidelines for rehabilitation treatment instructions and lack of funding from the government.
* Corresponding authors. Tel.: +86 023 65219862. E-mail addresses: [email protected] (J. Chen), [email protected] (J. Wu). 0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2012.06.016
270
burns 39 (2013) 269–278
Conclusion: After 20 years of clinical practice, rehabilitation concepts are well accepted and many forms of rehabilitation techniques are carried out in most burn centres that responded to the survey. Yet, the results also indicate that there is a short history of rehabilitation practice among the burn centres. There is a burning need to enhance the development of rehabilitation services so as to meet the demands of management of severely burned patients in China. Some suggestions are made to improve the current burn rehabilitation services which would include: (1) provide rehabilitation education programmes for burn surgeons, therapists, nurses, as well as patients, families and the public; (2) set up standard guidelines for clinical instruction of rehabilitation therapy; (3) build an interdisciplinary burn team; (4) more investigation and research on the physical and psychological outcomes of burn patients; and (5) implement administrative measures in terms of staffing, funding and offering insurance to burn survivors. # 2012 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
China has a long history of burn wound treatment; however, special burn units were established ever since 1958. With the advancement in surgical and burn management techniques in the past 50 years, the burn care and management among these centres have demonstrated significant improvements and achievements, particularly in the survival of severely burned victims [1]. In some centres, the survival rate can reach up to 98.9% [2]. As more and more patients with severe burns survive, there is a great challenge to help these patients to lead a higher quality life. Functional and psychological recovery, quality of life, and social re-integration become the goals of management, which increases the need for comprehensive rehabilitation services [3]. When compared to the development of burn management in the medical field, the development of rehabilitation medicine only emerged in the past 30 years. It is vital to review the current rehabilitation model and services for the patients with severe burns such that appropriate action could be taken to enhance the quality of life of burn survivors in China. A survey was conducted to determine the current burn rehabilitation services using a questionnaire sent out to burn centres in the country. The study also aimed to find out if there are any inadequate service provisions and to make recommendations where necessary to enhance future service delivery in China.
2.
Methods
A survey questionnaire (Appendix I) was developed to obtain information in the following areas: (1) demographic information of burn centres, inpatients treated per year, patients with >50% total body surface area (TBSA) burns per year, number of burn surgeons and nurses, etc.; (2) availability of rehabilitation services, number, composition and educational background of specialised personnel dedicated in burn rehabilitation therapy, and type of rehabilitation therapy; and (3) difficulties leading to the lag of the burn rehabilitation service. The questionnaire was sent to the directors of 87 burn centres via e-mail inviting them to respond within a month. For those who did not respond in the first month, a second email was sent to remind them to fill out the form. There were a total of 39 centres completing the questionnaire. The
overall response rate was 44.8%. For those who did not respond after two invitations, we tried to contact directors of some centres by phone and asked the situation of their burn rehabilitation service. The data were analysed using a descriptive statistical method. Correlation analysis was also conducted.
3.
Results
3.1.
The geographic distribution of burn centres
Fig. 1 shows the geographic distribution of those burn centres that responded to the survey. Thirty-nine centres joined the survey. These centres are located in 17 provinces, three autonomous regions and three municipalities (China administers 23 provinces, five autonomous regions, four municipalities and two special administrative regions). Thirty-seven centres are from Grade 3A hospitals (the highest grade in the hospital classification by Ministry of Health, and those hospitals are capable of providing the best medical services in the country) and two are from Grade 2A hospitals. These centres include most of the biggest and influential burn centres in China and are geographically distributed in nearly 70% of our administrative provinces and the results could well represent the current burn care system in China. There were 48 burn centres that did not join the survey. They were 44 from Grade 3A hospitals, two from Grade 3B hospitals and two from Grade 2A hospitals. A follow-up telephone contact was made after the e-mails, directors of some centres were contacted and most of them responded that there were no rehabilitation services in their centres.
3.2.
Staffing situation
The 39 centres were categorised into three groups based on the number of admissions per year. Those with less than 500 admission of burn cases per year were categorised into group 1, those between 500 and 1000 cases were in group 2 while those with more than 1000 admissions were categorised into group 3. The total inpatients per year of all the 39 centres was 33 837 (867.6 per centre per year), which indicated a huge number of
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Fig. 1 – The geographic distribution of responding burn centres. , centres from Grade 2A hospitals; , centres from Grade 3A hospitals.
burn patients in China. The large burn centres with more than 1000 admissions per year had more patients with severe burns (patients with >50% TBSA burns). The patient/surgeon ratio was much higher when compared to those centres with less number of patients. Each surgeon had to treat more than 80 patients per year and their workload was most heavy in centres from group 3. Although almost all the centres responded that there was at least one type of rehabilitation
service offered to the patients with burns, almost half of the centres had no full-time staff working in the rehabilitation field (Table 1).
3.3.
Rehabilitation services
There are totally 38 centres that can provide at least one kind of related rehabilitation service (Table 2). Pressure garment,
Table 1 – The admissions and staffing of the burn centres. Group Number of centres Number of inpatients annually Number of inpatients with >50% TBSA burns annually Number of burn surgeons per centre Number of nurses per centre Number of inpatients a surgeon treated annually Number of centres that could provide rehabilitation services Number of centres with full-time rehabilitation staff
Group 1 (0–500 admissions)
Group 2 (501–1000 admissions)
Group 3 (1001+) admissions
11 335.5 142.7 22.9 18.5
16 749.3 160.8 43.6 54.8
12 1586.6 340.4 86.1 87.8
8.3 2.9 13.5 4.4 41.9 20.9
9.9 3.2 17.3 6.1 81.6 23.1
22 8.0 46.9 22.3 83.1 36.9
11 (100%)
16 (100%)
11 (91.7%)
6 (54.5%)
9 (56.3%)
9 (75%)
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Table 2 – The rehabilitation services provided by the centres. Rehabilitation services provided Physical therapy Occupational therapy Pressure garment Splinting Hydrotherapy Sound frequency electrotherapy Shortwave Microwave Infrared
Number of centres
%
Rehabilitation services provided
Number of centres
%
31 21 38 32 20 14 9 10 18
81.6 55.3 100 84.2 52.6 36.8 23.7 26.3 47.4
Ultraviolet radiation Laser Paraffin Air pressure Magnetism Ultrasonic Psychotherapy Occupational rehabilitation Social reintegration
5 15 14 6 5 6 14 4 3
13.2 39.5 36.8 15.8 13.2 15.8 36.8 10.5 7.9
Table 3 – The initiation time of rehabilitation therapy in 24 centres with full-time rehabilitation staff. Time to start rehabilitation therapy (postburn days) 0–7 8–14 15+
Number of centres
Mean start time (postburn days)
7 (29.2%) 8 (33.3%) 9 (37.5%)
5.9 13.3 24.1
splinting and physical therapy are reported to be carried out in most centres. Out of these 38 centres, only 24 had totally 82 full-time burn rehabilitation staff, which equates to 3.4 (range from 1 to 9) staff per centre. Nearly 70% centres had only 2.2 (range from 1 to 3) staff each. When considering the annual inpatients number reached 867.6 per centre, the workload of these rehabilitation personnel was heavy, and also showed significant shortfall of staffing in this discipline to serve the patients with burns, particularly for those with severe burns. At the present time, the rehabilitation services were conducted by either nurses or non-skilled therapists in China. From our survey, the rehabilitation team mainly consisted of nurses (42.7%), physical or occupational therapists (45.1%) and rehabilitation doctors (8.5%). In some centres, there were specialists with psychological (only one) and rehabilitation engineer (only one) background. Among these 82 practitioners, there was one staff with a doctorate degree (medical doctor), three had master’s degrees, 30 (36.6%) were graduates, 19 (23.2%) graduated from tertiary colleges and 29 (35.4%) graduated from junior technical schools. The initiation time of rehabilitation therapy for patients is summarised in Table 3. More than 70% centres began their rehabilitation therapy 1–2 weeks after burn.
3.4.
Challenges in burn rehabilitation
There are many challenges for burn rehabilitation to develop in China. Most directors reported that there was a lack of understanding regarding burn rehabilitation for medical professionals as well as the public. There was a shortage of qualified rehabilitation personnel specialised in burn rehabilitation. The qualification of rehabilitation personnel was not standardised and properly accredited in Mainland China. There was a lack of standardised guidelines for rehabilitation treatment instructions. Moreover, there was a lack of funding support from the government to provide rehabilitation therapy for patients with burns who would require more long-term rehabilitation. Patients with financial problems could not afford the cost in the long run (Table 4). When rehabilitation treatment is carried out in clinical practice, there are still many controversial opinions among burn surgeons, patients, therapists and nurses. It is common that the burn surgeons neglect the importance of rehabilitation therapy in the burn treatment and are worried more about the rehabilitation interventions that would lead to wound healing problems such as bleeding, blistering and laceration of scars. As for patients, they know little about the significance of rehabilitation therapy and are worried more about how the treatment would increase their costs (Table 5).
4.
Discussion
China is the most densely populated country in the world, with more than 1.3 billion people. There are no official statistical data available on the incidence and mortality of burn of the country until now. It was reported that the ageadjusted burn incidence was 136 per 100 000 population in 2008 in the US. Patients with the vast majority of these burns were treated and released from the emergency department
Table 4 – Difficulties in rehabilitation improvements. Difficulties Not supported by the hospital Not supported by the centre chief Lack of rehabilitation knowledge in burn surgeons Lack of professional rehabilitation guidelines Short of staffing
Number of centres
Difficulties
Number of centres
9 (23.1%) 4 (10.3%) 16 (41.0%)
Limited space for rehabilitation therapy Short of funding Limited professional knowledge of rehabilitation team Lack of an interdisciplinary team work system Financial problems of the patients
30 (76.9%) 25 (64.1%) 23 (59.0%)
26 (66.7%) 33 (84.6%)
33 (84.6%) 24 (61.5%)
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Table 5 – Problem and knowledge of the rehabilitative processes. Problems
Number of centres
Worry about new wound/bleeding/delay of wound healing as a result of rehabilitation therapy Know the necessities of rehabilitation therapy Know how to choose rehabilitation treatments Know when to start rehabilitation therapy
19 (48.7%) 9 (23.1%) 18 (46.2%) 23 (59.0%)
Patients
Worry about wound healing process affected by rehabilitation therapy Worry about new wound/bleeding as a result of rehabilitation therapy Increased costs Know little about the importance of rehabilitation Bad compliance with rehabilitation therapy
21 25 24 20 11
Rehabilitation therapists
Know when to start rehabilitation therapy Know the best treatment in different time
20 (51.3%) 21 (53.8%)
Nurses
Have specialised nurses dedicated to rehabilitation nursing
19 (48.7%)
Burn surgeons
and only 5% were hospitalised [4]. As one of the low- and middle-income countries (LMICs), China had a much higher burn incidence when compared with that of the US. Further combined with the large population, it would be a very large number of burn patients that need hospitalisation. Burn is one of the most disabling medical problems, which will bring along physical, psychological and financial problems to the patients, their families and society [5–7]. With such a large population of burns and consequent disabilities, there is growing recognition for better rehabilitation efforts in patients and their families as well as burn centres [8]. The responding centres were geographically distributed in nearly 70% provinces of China; hence, their reports on rehabilitation practices would reflect the current situation in the country. Those who did not respond to the survey may indicate that their rehabilitation services have not been started. This was reflected by follow-up telephone confirmations to the directors of some non-responding centres. Although not all the centres responded to this short telephone survey, it is possible that the real situation could be more drastic when compared to the results presented with the 39 centres, because these non-responding centres are mainly from Grade 3A hospitals located in large cities and for those from Grade 2A or 1A hospitals, the situation could be more adverse. With more and more international exchange and visits, the concept of rehabilitation has been promoted to burn centres and burn surgeons. The impact of rehabilitation towards better outcomes on patients was demonstrated in a number of clinical burn centres where rehabilitation services were provided directly at the burns unit right after admission. There are more burn research centres or units that recognised the importance of rehabilitation for burn patients and started to establish their own rehabilitation team at their own wards or centres. However, there are still a lot of challenges to establish a quality rehabilitation system for burn patients. In the survey of Seighiou [9], in 70 randomly selected burn centres in North America, the majority of centres reported treating less than 200 inpatients and more than 200 outpatients annually. However, in our survey, the average inpatients annually per centre reached 867.6, which indicated the high incidence and great number of burns in China and therefore a very huge number of burn patients who require intensive rehabilitation therapy (including occupational therapy,
(53.8%) (64.1%) (61.5%) (51.3%) (29.7%)
physiotherapy, prosthetics and orthotics). According to the criteria from Ministry of Health of China, in Grade 3A hospitals, the ratio of staff/patient (no. of beds) should be around 1.03, while in our survey, the staff/patient ratio was only 0.77 0.25. This shows the severe shortage of health-care professionals serving burn patients who often require very intensive rehabilitation soon after injuries. Most burn centres have a strong medical team and the survival rate of patients with burns is very high (almost 99.9%, as reported by the China Burns Association, 2003). The shortage of burn nursing specialists was also noted in this study. In Yurko’s survey [10], for those patients with 60–90% TBSA burns, the nursing staff/patient ratio is 1:1 in 81% of the burn units. This ratio is far too ideal in our burn centres. Burns could cause significant physical and psychological complications, which require an intensive interdisciplinary rehabilitation team to work closely with the burn surgeons, particularly at the early stage of burns [11]. Despite a call for the development of an interdisciplinary burn care team for years, the burn surgeon continues to dictate how the care is provided to the burn patient. In some circumstances, they might pay more attention to the surgical techniques, wound care and infection control. Some may not have a clear understanding of concept and principles in burn rehabilitation. Thus, the rehabilitation process was often delayed and by then patients already developed contractures, deformities and other complications associated with burns. The concept of physical therapy began in 1940s [12]. In China, physical therapy was first introduced in late 1970s, began to be widely accepted in the late 1990s and was applied mainly in diseases such as fracture, brain damage, spinal cord injury and cerebral palsy. Burn patients who finished with wound closure/grafting stage could be transferred to the rehabilitation department or discharged home. Undoubtedly, functional disabilities and scar contractures were common at that time. The overall outcomes of the severely burned patients were not satisfying. As rehabilitation concepts were gradually accepted in clinical practices, the initiation time of rehabilitation therapy was 1–2 weeks post-burn in most centres in this survey which was much earlier than before, but still had a long way to meet the standard requirements that rehabilitation should begin as the injury starts [13]. Positioning, splinting, range of motion (ROM) exercises and ambulation in acute stage are rare in clinical practices.
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Once realising the importance of rehabilitation therapy during burn care treatment, specialised personnel began to join some burn centres since late 1990s. The first group dedicated to rehabilitation therapy mostly came from nurses with or without a rehabilitation education background, and the treatments mainly focus on pressure garments and some kinds of physical therapies such as electricity, infrared and paraffin. In recent years, rehabilitation therapists began to join this group, and made physical and occupational therapy more and more accepted by doctors and patients. In our survey, the full-time rehabilitation staff only equates to 3.4 per centre. Cromes and Helm [14] suggested that, in a burn unit with 10 acute beds, the following personnel would be necessary: 2.5 full-time physical therapists, 2.0 full-time occupational therapists, 1.0 full-time social worker, 2.5 fulltime wound care personnel and 0.25 full-time psychologists/ psychiatrists. It indicates a significant shortfall of staffing in this discipline in China, particularly for those with severe burns. Biggs et al. [15] reported that there is a common division of responsibility for certain duties in burn rehabilitation, while in the current situation, most centres are not capable of dividing their therapists to physical and occupational therapists, which means that most centres could not provide more specialised burn rehabilitation therapies to the patients by now. Although the high incidence of psychological problems after burn had been widely known years ago [16], we just began our attempts to explore into the inside world of our patients underneath their changed appearances. This work is mainly done by nurses now and despite the fact that it may not be so professional, it shed light on the need of future improvement. In searching for the problems that impede rehabilitation therapy in China, the results showed that, all the concerns from doctors, patients or therapists are due to the lack of burn rehabilitation knowledge. This appeals to an educational programme for improving rehabilitation concepts as well as techniques among all the medical students, clinical staff and the public. Cromes and Helm reported that there were education programmes for not only inpatients and staff but also support groups for patients with burns in 1988 in USA; the ongoing education was an important factor in maintaining high quality of specialised burn rehabilitation care [14]. Further, it also calls for establishing standard guidelines that could instruct on the rehabilitation therapy processes. Model systems [17] and guidelines [18] for burn care of other countries may serve as examples. Although there are many recommendations for rehabilitation of burn patients in the literature and the treatment must be individualised for each patient, it is still necessary to institute a guideline suitable for our situation. Barillo et al. [19] discussed some of the benefits of institutional guidelines such as established protocols, immediate institution of therapy, consistent care, facilitation of data collection for research and quality assurance programmes. Although the awareness of the importance of burn rehabilitation in China is increasing, the shortage of specialised and well-educated personnel is not going to be solved in the near future. Thus, in the mean time the development of standard practice guidelines would provide a foundation on which the existing personnel can build and develop with experience and time.
5.
Conclusion
After 50 years of improvement, burn care in China made great strides. Functional and psychological recovery, quality of life and social re-integration are more and more important in outcome assessment. This survey outlined the approximate status of rehabilitation services in the current burn care system in China. Rehabilitation concepts are accepted universally and therapies were carried out in most centres. However, the relatively short history explains the overall condition of burn rehabilitation therapy in China, which still faces problems like the lack of rehabilitation knowledge by medical staff as well as the public. The shortage of specialised personnel and the relatively low educational background of this team contribute to the lack of standard guidelines. Finally, the lack of funding from the government hinders the advancement of burn rehabilitation in the country. Rehabilitation therapy plays important roles in burn patient recovery: more efforts should be made to improve the current burn care system in China. Here are some of the future directions and suggestions: (1) provide rehabilitation education programmes to burn surgeons, therapists, nurses, as well as patients, families and the public; (2) set up standard guidelines for clinical instruction of rehabilitation therapy; (3) build an interdisciplinary burn team; (4) more investigation and research on the physical and psychological outcomes of burn patients; and (5) implement administrative measures in terms of staffing, funding and offering insurance to burn survivors.
Conflict of interest There is no conflict of interest with any personnel or financial organisation.
Acknowledgements We would like to express our thanks to those directors of burn centres who responded to our survey and provided invaluable comments on the current rehabilitation services at their centre. They are from: Liaoning Provincial Corps Hospital of CPAPF; the Second Affiliated Hospital Zhejiang University College of Medicine; Tibet Military General Hospital; the PLA Second Artillery General Hospital; the First Affiliated Hospital of Fujian Medical University; Jinan Central Hospital Affiliated to Shandong University; Guangzhou Red Cross Hospital; the First Affiliated Hospital, Sun Yat-Sen University; the First Affiliated Hospital of Nanjing Medical University; Hainan Provincial People’s Hospital; the Second Affiliated Hospital of the Fourth Military Medical University; the First Affiliated Hospital of Anhui Medical University; Plastic Surgery Hospital, CAMS, PUMC; the Second Provincial People’s Hospital of Shenzhen; Xijing Hospital of the Fourth Military Medical University; the 175th Hospital of PLA, Nanjing; the First Provincial People’s Hospital of Zhengzhou; the First Affiliated Hospital of Wenzhou Medical College; Lanzhou Military General Hospital; Nanfang Hospital of Nanfang Medical University; Nanjing Drum Tower Hospital the Affiliated
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Hospital of Nanjing University Medical School; the Second Affiliated Hospital of Nanjing Medical University; Changhai Hospital of the Second Military Medical University; Ruian People’s Hospital; the First Affiliated Hospital of Nanchang University; the First Affiliated Hospital of the Third Military Medical University; Xiangya Hospital Central-South University; Urumqi Military General Hospital of Lanzhou; the First Affiliated Hospital of Hebei Medical University; the Third
Appendix I. A questionnaire on current status of burn rehabilitation
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Hospital of Wuhan City; the General Hospital of CNPC in Jilin; the 309th Hospital of Chinese People’s Liberation Army; People’s Hospital of Uygur Autonomous Region; Ruijin Hospital of Shanghai; Burn Institute of Inner Mongolia; the First Affiliated Hospital of Nanjing Military General Hospital; the 181st Hospital of PLA, Guangzhou; Linyi People’s Hospital of Shandong Province; and the Affiliated Jiangyin Hospital Medical College Southeast University.
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