- Email: [email protected]
Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns
JBUR-4767; No. of Pages 6 burns xxx (2015) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns Sarah T. Smailes a,b,*, Kayleen Engelsman c, Louise Rodgers d, Clara Upson e a
St Andrew’s Centre for Plastic Surgery and Burns, Chelmsford, Essex CM1 7ET, United Kingdom St Andrew’s Anglia Ruskin Research Unit (STAAR) Post Graduate Medical Institute, Anglia Ruskin University, Essex, United Kingdom c Chelsea and Westminster Hospital, 369, Fulham Road, London SW10 9NH, United Kingdom d Queen Victoria Hospital, Holtye Road, East Grinstead, W Sussex RH19 3DZ, United Kingdom e Stoke Mandeville Hospital, Mandeville Road, Aylesbury, Buckinghamshire HP21 8AL, United Kingdom b
article info
abstract
Article history:
The Functional Assessment for Burns (FAB) score is established as an objective measure of
Received 2 July 2015
physical function that predicts discharge outcome in adult patients with major burn.
Received in revised form
However, its validity in patients with minor and moderate burn is unknown. This is a
23 September 2015
multi-centre evaluation of the predictive validity of the FAB score for discharge outcome in
Accepted 24 September 2015
adult inpatients with minor and moderate burns. FAB assessments were undertaken within
Available online xxx
48 h of admission to (FAB 1), and within 48 h of discharge (FAB 2) from burn wards in 115
Keywords:
improvements in the patients’ FAB scores ( p < 0.0001), 98 patients were discharged home
patients. Median age was 45 years and median burn size 4%. There were significant Functional Assessment for Burns
(no social care) and 17 patients discharged to further inpatient rehabilitation or home with
Physical function outcome score
social care. FAB 1 score (14) is strongly associated with discharge to inpatient rehabilitation
Discharge Outcome
or home with social care ( p = 0.0001) and as such can be used to facilitate early discharge
Minor and moderate burns
planning. FAB 2 (30) independently predicts discharge outcome to inpatient rehabilitation or home with social care ( p < 0.0001), increasing its utility to patients with minor and moderate burns. # 2015 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
The need to develop ‘‘user friendly’’, valid outcome measures that score physical function in burn patients has never been greater. This is because more patients survive their injuries and therefore burn multidisciplinary teams need to physically and psychologically rehabilitate these patients and measure their progress. In addition, accurate physical function scoring
in the early stages post burn enables early discharge plans to be made, a process that can be lengthy in its duration [1]. In recent years investigators have applied physical function outcome measures that were developed in other patient populations to burn patients at various stages of their recovery e.g. Functional Independence Measure (FIM), Chelsea Critical Care Physical Assessment (CPAx) [2,3]. However, the specific nature of burns and resultant scars can present as confounding variables to a physical function scoring system developed in
* Corresponding author at: Broomfield Hospital, Court Road, Chelmsford. Essex CM1 7ET, United Kingdom. Tel.: +44 1245 516037; fax: +44 1245 516007. E-mail address: [email protected] (S.T. Smailes). http://dx.doi.org/10.1016/j.burns.2015.09.020 0305-4179/# 2015 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Smailes ST, et al. Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.09.020
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other patient groups. This is because the oedema, pain, and tightness related to burn wounds and scars are not experienced by patients without burn, but these symptoms have profound effects on their physical functional ability. The Functional Assessment for Burns (FAB) score was developed to measure physical functional recovery and independence of adult burn inpatients. The FAB score is an easy to use, objective measure of burn patients’ ability to complete basic, self-caring functional tasks. Physiotherapists and Occupational Therapists undertake the FAB assessment on patients within 48 h of admission (FAB 1) to the burn ward and within 48 h of discharge (FAB 2). Previous work identified FAB 2 as an independent predictor of discharge outcome, and FAB 1 as a useful early indicator of likely discharge outcome in a population of adult patients with major burn after ICU discharge and as such can be used to guide discharge plans [4]. The majority of burns admitted to UK burn services are minor [5]. Therefore, there is a need to extend the utility of the FAB score to this group, as well as those with moderate sized burn, thus extending its utility to all burn patients. For the current study we evaluate the predictive validity of the FAB score for discharge outcome in adults with minor and moderate burn admitted to burn wards of four UK burn services over a 3 month period. The aims of this study are: 1. To measure the progress in the patients’ FAB scores between admission and discharge from the burn ward. 2. To evaluate the predictive validity of the FAB score for discharge outcome in adult patients with minor and moderate burn.
2.
Materials and methods
This is a retrospective review of the case notes of 115 consecutive patients with minor and moderate burns [6], admitted to the burn wards of 4 different burn services over a 3 month period (July–October 2012). Patients were excluded if they did not receive the full course of treatment at each particular burn service or if they died. All patients received the usual care at each particular burn service. This included use of the Parkland formula regime for patients receiving fluid resuscitation. Patients with full thickness burn wounds underwent early wound excision and autografting. Newly autografted limbs were immobilised for 48 h in most cases. Smoke inhalation injury was diagnosed by fibre- optic bronchoscopy. Appropriate antibiotics were prescribed for clinical infection and antibiotics were used prophylactically for patients undergoing wound excision. No specific physical function measures were used to guide decisions regarding discharge outcome of patients. Physical rehabilitation commenced on the patients’ first admission day and continued throughout their stay on the burn ward. The teams of Physiotherapists (PT) and Occupational therapists (OT) carried out active and passive mobilisation and functional exercises 5 days per week at each burn service. Standard contracture prevention techniques were employed including joint positioning and splintage 7 days per week by PT, OT and nursing staff. Other therapies available to patients
throughout their inpatient stay included psychotherapy and counselling, dietetics and speech and language therapy. FAB scores were measured prospectively, during each patient’s episode of care and as part of normal daily therapy practice, for all patients aged 15 years within 48 h of admission to (FAB 1), and within 48 h of discharge from the burn ward (FAB 2). The FAB score is an objective measure of the patients’ ability to perform the following key activities of daily living; washing, toileting, feeding, dressing, transfers, walking and stair climbing. The Physiotherapist or Occupational Therapist undertakes the FAB assessment; each patient is scored on their ability to independently complete 100% of each activity or on the minimum amount of assistance necessary to complete the activity [4]. The minimum FAB score is 7 and the maximum is 35. The score for each activity is as follows: 1. Fully dependent, unable to complete any part of the activity, needs full assistance – 1 point 2. Completes activity with physical assistance – 2 points 3. Completes activity with supervision/verbal prompting/ requires set up of activity – 3 points 4. Independently completes activity with an assisting device/ aid (e.g. adapted cutlery, walking stick, wheelchair, stair lift) – 4 points 5. Independently completes activity without devices/aids – 5 points 6. Unable to assess – 1 point We collected the following demographic and injury variables; patient age, %Total Body Surface Area burn (%TBSA), %full thickness burn, smoke inhalation injury, past medical history (number of patients undergoing medical treatment for cardiopulmonary disease, neurological disorder and psychiatric conditions). We also collected FAB scores (FAB 1 and FAB 2), length of stay on the burn ward (LOS) and discharge outcome. Discharge outcome is classified as home (no social care) versus inpatient rehabilitation or home with social care. Social care includes assistance with patients’ daily personal care, and this may also include moisturisation of scars, but does not include therapy, housekeeping tasks or wound management. Data was stored on a secure centralised spread sheet.
2.1.
Statistical analysis
Data were entered onto the Medcalc statistical program which was used for all analyses. An independent samples t test was used to compare Means and a Mann Whitney Rank Sum test was employed to compare Medians as appropriate. For categorical variables, a Chi Square test or Fishers Exact test was used if n < 5. A Paired Wilcoxon Test was used to compare patients’ FAB 1 and FAB 2 scores. Statistical associations between injury and demographic variables and patients’ discharge outcome were tested for using Spearman’s Rank Correlation Coefficient. Multiple Logistic Regression Analysis was used to evaluate the effects of variables on patients’ discharge outcome. Receiver operating characteristic (ROC) curve analysis was employed to identify cut off values for FAB 1 and FAB 2 with the greatest accuracy for prediction of discharge outcome. Statistical significance was defined as 0.05.
Please cite this article in press as: Smailes ST, et al. Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.09.020
JBUR-4767; No. of Pages 6
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3.
Table 2 – Comparison of paired observations of Functional Assessment for Burns Scores.
Results
There were 115 patients with minor or moderate burn in the cohort and their data were entered into the analysis. There were no deaths and no other patients were excluded. The pattern of admission over the 4 burn care providers was as follows; service 1 (46 patients), service 2 (40 patients), service 3 (26 patients) and service 4 (3 patients). Median age was 45 years and median burn size was 4%. In terms of discharge outcome 98 patients (85%) were discharged home (no social care) and 17 (15%) were discharged either to further inpatient rehabilitation or home with social care. Table 1 shows the demographic variables and FAB scores of the cohort grouped according to discharge outcome. The patients who were discharged to inpatient rehabilitation or home with social care were significantly older ( p < 0.0001), had a higher incidence of psychiatric conditions ( p = 0.05) and longer LOS ( p = 0.0001). Additionally, these patients had lower FAB 1 ( p = 0.0002) and FAB 2 ( p < 0.0001) scores. The Paired Wilcoxon test applied to the patients’ FAB 1 and FAB 2 scores (Table 2) illustrates the significant increase of these ( p < 0.0001), and thus improvement in patients’ physical functional independence between admission and discharge from the burn wards. Correlation analysis of all of the variables for patient discharge outcome (Table 3) identifies that increasing patient age ( p < 0.0001), longer LOS ( p = 0.0001) and presence of psychiatric conditions ( p = 0.03) are associated with discharge to inpatient rehabilitation or home with social care. On the other hand, decreasing level of functional independence, FAB 1 ( p = 0.0001) and FAB 2 ( p < 0.0001), is strongly associated with discharge to inpatient rehabilitation or home with social care. Table 4 illustrates the results of the multiple regression analysis and the model with the greatest predictive accuracy for discharge outcome as denoted by its regression coefficient ( p < 0.0001). This model contains the variables patient age, FAB 2 score, LOS and presence of psychiatric conditions. Within this model, each of the variables FAB 2 score, LOS and
Functional Assessment for Burns 1 Score (FAB 1) (95% CI) 27 (25–29)
Functional Assessment for Burns 2 Score (FAB 2) (95% CI)
P
35 (33–35)
<0.0001
Numbers in bold denote statistical significance.
presence of psychiatric conditions independently predict the patients’ discharge outcome as illustrated by their regression coefficients. This analysis confirms that FAB 2 score has predictive validity for discharge outcome for patients with minor and moderate burn. In addition, this 4 variable model has excellent accuracy for discriminating between the patients discharged home (no social care) versus those discharged to inpatient rehabilitation or home with social care (area under receiver operating characteristic curve (AUC) = 0.96). The ROC curve analyses of the performance of FAB 1 and FAB 2 scores to correctly classify patients’ discharge outcome are shown in Tables 5 and 6. Table 5 identifies the optimum cut off value for FAB 1 is 14 to predict discharge to further inpatient rehabilitation or home with social care and this has good predictive ability (AUC = 0.79) and excellent specificity (93%). The cut off value for FAB 2 score that has the greatest ability to correctly classify patients’ discharge outcome is 30 and this, again, has good discriminative ability (AUC = 0.81).
4.
Discussion
This is the first multi-centre evaluation of a physical function outcome measure, developed specifically for burn patients – the FAB Score. In short, this study has confirmed that FAB 1 is strongly associated with discharge outcome and therefore can be used to facilitate early discharge planning for patients with minor and moderate burn. In addition, we found that FAB 2 is
Table 1 – Demographic variables and FAB scores of the cohort grouped according to discharge outcome. Variable Patient age (years)b 95% CI Total burn surface area (%TBSA) 95% CIb Full thickness (%TBSA) 95% CIb Smoke inhalation injurya Gendera (males) Cardiopulmonary diseasea Neurological disordera Psychiatric conditionsa LOS (days)b FAB 1 Scoreb FAB 2 Scoreb
Discharged home (n = 98)
Discharged home with care/inpatient rehabilitation (n = 17)
44.5 (35–51.1) 3 (2.5–4)
76 (54.5–89) 6 (2–11.4)
0.5 (0–1) 4 56 9 5 10 8 (7–8.1) 28 (26–31) 35 (33–35)
1 (0.2–4) 1 8 2 1 5 18 (9–24.7) 14 (10.6–25) 22 (16.7–33.4)
P <0.0001 0.06 0.08 0.75 0.6 0.67 1.0 0.05 0.0001 0.0002 <0.0001
95% CI = 95% confidence intervals; numbers in bold denote statistical significance. Number of patients.
a
Please cite this article in press as: Smailes ST, et al. Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.09.020
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Table 3 – Correlation analysis of variables for patient discharge outcome. Variable
Spearman’s Rank Correlation Coefficient (Rho) (95% CI)
Patient age Gender Total Burn Surface Area (%TBSA) Full thickness burn surface area (%TBSA) Smoke Inhalation injury Cardiopulmonary disease Neurological disorder Psychiatric conditions FAB 1 FAB 2 LOS
0.4 (0.24–0.54) 0.07 ( 0.11 to 0.25) 0.18 ( 0.003 to 0.35)
P
<0.0001 0.44 0.06
0.17 ( 0.01 to 0.34)
0.07
0.03 ( 0.15 to 0.21) 0.03 ( 0.2 to 0.21)
0.74 0.74
0.01 ( 0.17 to 0.2) 0.2 (0.02–0.37) 0.36 ( 0.5 to 0.2) 0.4 ( 0.55 to 0.25) 0.38 (0.21–0.52)
0.89 0.03 0.0001 <0.0001 0.0001
Numbers in bold denote statistical significance.
Table 4 – Multiple Logistic Regression Analysis of variables for patient discharge outcome. Model
Patient age FAB 2 LOS Psychiatric conditions
Regression Significant Area under coefficient for ROC curve regression independent (AUC) for coefficient variable (P) for model (P) model (95% CI) 0.06 0.02 0.02 0.001
<0.0001
0.96 (0.91–0.99)
Numbers in bold denote statistical significance.
Table 5 – Receiver operating characteristic curve of FAB 1 cut off value =14 for patients’ discharge to inpatient care or home with social care. Cut off value 14
Sensitivity (95%CI)
Specificity (95%CI)
Area under ROC curve (AUC) (95%CI)
53 (28–77)
93 (86–97)
0.79 (0.70–0.86)
Table 6 – Receiver operating characteristic curve of FAB 2 cut off value =30 for patients’ discharge to inpatient care or home with social care. Cut off value 30
Sensitivity (95%CI)
Specificity (95%CI)
Area under ROC curve (AUC) (95%CI)
77 (50–93)
84 (75–91)
0.81 (0.73–0.88)
an independent predictor of discharge outcome, thus enhancing the utility of the FAB score, as a physical function outcome measure that predicts discharge outcome, to all burn inpatients. A necessary requirement of a new outcome measure is not only that it is valid, but also it must also be simple to use and therefore can be introduced into clinical practice within a variety of different settings with ease. The FAB score was developed at a single burn centre and is established as a
routine measure of physical function outcome within that setting. For this study, the FAB score was introduced to 3 new burn care settings where its uptake and routine use was rapid and this lends evidence that the FAB score meets this requirement. Training of therapists based at the other 3 burn care providers by the FAB ‘‘champions’’ was not time consuming, it was achieved at one face to face meeting of senior therapists, by distribution of FAB guidance notes and support given through email and telephone calls. We have found that the FAB score has 2 major advantages over other physical function outcome measures that were developed in other patient populations. Firstly, the nature of the therapist - patient relationship is integral to successful physical rehabilitation of burn patients. The therapist and patient must work together to set realistic rehabilitation/ functional goals and the therapist must then motivate patients to work towards achieving them. We have found that use of the FAB score facilitates this process since the therapist alone is able to undertake FAB assessments which can be done in the interim (at a time between FAB 1 and FAB 2) to score patients and assist in their motivation. The flexibility to undertake interim physical function scoring is less possible with other physical function scores which require assessment from other members of the multi-disciplinary team. Secondly, unlike other physical function scores, the FAB score assessment is based on the patients’ ability to complete 100% of each functional task and therefore it does not require therapists to subjectively divide each of these tasks into components. This simplifies the assessment process and possibly limits variation in scores between different therapists. This study identified that there were significant improvements in the patients’ FAB scores between admission to, and discharge from the burn wards and that 85% patients discharged home (no social care). The improvement in FAB scores mirrors findings from previous work with adults with major burn [4] and perhaps is to be expected as patients undergo intensive therapy after burn, achieve rehabilitation goals and as burn wounds are closed. This study confirmed that FAB 1 is associated with discharge outcome, and that FAB 2 independently predicts discharge outcome in patients with minor and moderate burn across 4 different burn care settings. These results are noteworthy for two reasons; firstly they confirm previous findings in a cohort of patients with major burn treated in a single burn care setting [4] to patients with minor and moderate burn treated in a variety of different burn care settings. Thus, the findings from the current study extend the utility of the FAB score to all burn inpatients. Secondly, the largest proportion of burn patients’ hospital length of stay is on the burn ward and is likely to be related to social issues [1]. Within this setting, the earlier discharge plans are made the better to avoid excessive length of stay on the ward. Our findings indicate that FAB 1 score can be used to facilitate early (within 48 h of admission to burn ward) discharge plans for burn patients. Increasing patient age was associated with discharge to inpatient rehabilitation or home with social care in our population of patients with predominantly minor burn. Interestingly, this finding contrasts that from previous work to evaluate the FAB score in patients with major burn. In that study patient age was not associated with discharge outcome
Please cite this article in press as: Smailes ST, et al. Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.09.020
JBUR-4767; No. of Pages 6 burns xxx (2015) xxx–xxx
in patients with major burn who had been discharged from ICU [4]. A reasonable explanation for this finding is that perhaps many of the elderly patients in that cohort did not survive the physiological consequences of major burn and ICU, and thus age was not singled out as a factor affecting discharge outcome in the analysis. The concept of increasing age adversely affecting physical and psychosocial outcomes following burn is not a new one and provides the burn team with additional challenges to meet the needs of older patients. Edgar et al. quantified the impact of ageing on quality of life after burn and concluded that physical function suffered to the greatest extent [7]. One possible explanation to account for negative outcomes in the elderly population is ‘‘frailty’’. Frailty is concerned with an elderly patient’s physiological rather than actual age and has been reported to be predictive of mortality in elderly burn patients [8]. Our findings suggest that there is an increased need for social care at home and need to discharge elderly patients with minor and moderate burn for further inpatient rehabilitation after closure of their burn wound, and this also supports other work which reported that elderly burn patients benefit from more prolonged rehabilitation programmes [9]. This study also identified that presence of psychiatric conditions independently predicts discharge to inpatient rehabilitation or home with social care in patients with minor and moderate burn and this supports 2 previous studies. The negative impact of psychiatric conditions on recovery following burn was reported by Wisely et al. who identified that patients underwent more surgical procedures and had longer hospital stays [10]. More recently, Oster and Sveen reported that pre-existing psychiatric conditions was the strongest contributing factor to depression and post-traumatic stress disorder after burn [11], arguably conditions that increase patients’ dependence on carers and prevent independent living. This study indicates that early discharge plans can be made on the basis of the FAB 1 score for patients with minor and moderate burn and, in addition, presence of psychiatric conditions and patient age should be taken into account when formulating discharge plans. Increasing length of stay on the burn ward predicts discharge outcome to inpatient rehabilitation or home with social care in patients with minor and moderate burn and this supports earlier work with other burn populations [2,4]. Perhaps this is not surprising as length of stay is considered to be a surrogate marker of morbidity or dysfunction after burn [12] such that sicker patients can be expected to have a longer length of stay, be dependent on carers for longer, and are likely to benefit from longer rehabilitation programmes. The ROC curve analysis identified cut off values for FAB 1 and FAB 2 scores and these allow clinical application of the FAB score so that it can be used to facilitate discharge planning for patients. The cut off values with greatest discriminative accuracy to predict discharge to inpatient rehabilitation or home with social care versus home (no social care) for FAB 1 is 14 and FAB 2 is 30. These values are at variance with our previous work which identified FAB 1 9 and FAB 2 26 in patients with major burn [4] following discharge from ICU and this reflects the impact of extensive burn and ICU acquired weakness on physical function, and highlights the need to study ICU patients with major burn separately.
5
A potential confounding factor to the patients’ discharge outcome is the availability of family or friends who could assist with some patients’ personal care at home, lessening the need for social care. This is unlikely to be a significant confounding factor because it is not borne out by the statistics which identify that the patients’ functional independence, the FAB score, is one of the most predictive factors determining discharge outcome in this study. The weakness of this study relates to the timing of the FAB 1 measurement in patients who had full thickness burn and had undergone burn excision and autografting. To explain this, in order to unify the methods of the current study with previous work [4], the FAB 1 assessment was required to take place within 48 h of admission to the burn ward. It is likely that some patients received FAB 1 assessments on the first or second post-operative day when affected limbs were immobilised to protect newly applied autografts, preventing a full FAB assessment. This is likely to have affected the ROC curve results for FAB 1 giving a lower sensitivity and wider confidence interval than perhaps is desired. To avoid this in the future, we recommend undertaking full FAB 1 assessments once autografts are stable and limbs can be mobilised.
5.
Conclusion
We conclude that since FAB 1 is strongly associated with discharge outcome in patients with minor and moderate burn it is a useful early indicator of likely discharge outcome and can, as such, be used to facilitate early discharge planning. FAB 2 independently predicts, and therefore has predictive validity for, discharge outcome in patients with minor and moderate burn. This finding extends the utility of the FAB score as a measure of physical function independence that predicts discharge outcome to patients with minor and moderate burn.
Conflict of interest statement The authors declare that there are no conflicts of interest relating to this work.
Acknowledgements The authors would like to thank all therapists involved with FAB score assessments. The corresponding author would like to thank Professor Peter Dziewulski for reading the manuscript.
references
[1] Maan ZN, Frew Q, Din AH, Unluer Z, Smailes S, Philp B, et al. Burns ITU admissions: length of stay in specific levels of care for adult and paediatric patients. Burns 2014;40(8):1458–62. [2] Choo B, Umraw N, Gomez M, Cartotto R, Fish JS. The utility of the functional independence measure (FIM) in discharge planning for burn patients. Burns 2006;32(1):20–3.
Please cite this article in press as: Smailes ST, et al. Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.09.020
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[3] Corner EJ, Hichens LV, Attrill KM, Vizcaychipi MP, Brett SJ, Handy JM. The responsiveness of the Chelsea Critical Care Physical Assessment tool in measuring functional recovery in the burns critical care population: an observational study. Burns 2015;41(2):241–7. [4] Smailes ST, Engelsman K, Dziewulski P. Physical functional outcome assessment of patients with major burn injury admitted to a UK Burn Intensive Care Unit. Burns 2013;39(1):37–43. [5] Chipp E, Walton J, Gorman DF, Moieman NS. A 1 year study of burn injuries in a British Emergency Department. Burns 2008;34(4):516–20. [6] Hartford CE, Kealey GP. Care of outpatient burns. In: Herndon DN, editor. Total Burn Care. Philadelphia: Saunders Elsevier; 2007. p. 67–80. [7] Edgar DW, Homer L, Phillips M, Gurfinkel R, Rea S, Wood FM. The influence of advancing age on quality of life and
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rate of recovery after treatment for burn. Burns 2013;39(6):1067–72. Masud D, Norton S, Smailes S, Shelley O, Philp B, Dziewulski P. The use of a frailty scoring system for burns in the elderly. Burns 2013;39(1):30–6. Klein M, Lezotte DC, Heltshe S, Fauerbach J, Holavanahalli RK, Rivara FP, et al. Functional and psychosocial outcomes of older adults after burn injury: results from a multicenter database of severe burn injury. J Burn Care Res 2010;32: 66–78. Wisely JA, Wilson E, Duncan RT, Tarrier N. Pre-existing psychiatric disorders, psychological reactions to stress and the recovery of burn survivors. Burns 2010;36(2):183–91. Oster C, Sveen J. The psychiatric sequelae of burn injury. Gen Hosp Psychiatry 2014;36(5):516–22. Pereira C, Murphy K, Herndon D. Outcome measures in burn care: is mortality dead? Burns 2004;30(8):761–71.
Please cite this article in press as: Smailes ST, et al. Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.09.020
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns Sarah T. Smailes a,b,*, Kayleen Engelsman c, Louise Rodgers d, Clara Upson e a
St Andrew’s Centre for Plastic Surgery and Burns, Chelmsford, Essex CM1 7ET, United Kingdom St Andrew’s Anglia Ruskin Research Unit (STAAR) Post Graduate Medical Institute, Anglia Ruskin University, Essex, United Kingdom c Chelsea and Westminster Hospital, 369, Fulham Road, London SW10 9NH, United Kingdom d Queen Victoria Hospital, Holtye Road, East Grinstead, W Sussex RH19 3DZ, United Kingdom e Stoke Mandeville Hospital, Mandeville Road, Aylesbury, Buckinghamshire HP21 8AL, United Kingdom b
article info
abstract
Article history:
The Functional Assessment for Burns (FAB) score is established as an objective measure of
Received 2 July 2015
physical function that predicts discharge outcome in adult patients with major burn.
Received in revised form
However, its validity in patients with minor and moderate burn is unknown. This is a
23 September 2015
multi-centre evaluation of the predictive validity of the FAB score for discharge outcome in
Accepted 24 September 2015
adult inpatients with minor and moderate burns. FAB assessments were undertaken within
Available online xxx
48 h of admission to (FAB 1), and within 48 h of discharge (FAB 2) from burn wards in 115
Keywords:
improvements in the patients’ FAB scores ( p < 0.0001), 98 patients were discharged home
patients. Median age was 45 years and median burn size 4%. There were significant Functional Assessment for Burns
(no social care) and 17 patients discharged to further inpatient rehabilitation or home with
Physical function outcome score
social care. FAB 1 score (14) is strongly associated with discharge to inpatient rehabilitation
Discharge Outcome
or home with social care ( p = 0.0001) and as such can be used to facilitate early discharge
Minor and moderate burns
planning. FAB 2 (30) independently predicts discharge outcome to inpatient rehabilitation or home with social care ( p < 0.0001), increasing its utility to patients with minor and moderate burns. # 2015 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
The need to develop ‘‘user friendly’’, valid outcome measures that score physical function in burn patients has never been greater. This is because more patients survive their injuries and therefore burn multidisciplinary teams need to physically and psychologically rehabilitate these patients and measure their progress. In addition, accurate physical function scoring
in the early stages post burn enables early discharge plans to be made, a process that can be lengthy in its duration [1]. In recent years investigators have applied physical function outcome measures that were developed in other patient populations to burn patients at various stages of their recovery e.g. Functional Independence Measure (FIM), Chelsea Critical Care Physical Assessment (CPAx) [2,3]. However, the specific nature of burns and resultant scars can present as confounding variables to a physical function scoring system developed in
* Corresponding author at: Broomfield Hospital, Court Road, Chelmsford. Essex CM1 7ET, United Kingdom. Tel.: +44 1245 516037; fax: +44 1245 516007. E-mail address: [email protected] (S.T. Smailes). http://dx.doi.org/10.1016/j.burns.2015.09.020 0305-4179/# 2015 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Smailes ST, et al. Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.09.020
JBUR-4767; No. of Pages 6
2
burns xxx (2015) xxx–xxx
other patient groups. This is because the oedema, pain, and tightness related to burn wounds and scars are not experienced by patients without burn, but these symptoms have profound effects on their physical functional ability. The Functional Assessment for Burns (FAB) score was developed to measure physical functional recovery and independence of adult burn inpatients. The FAB score is an easy to use, objective measure of burn patients’ ability to complete basic, self-caring functional tasks. Physiotherapists and Occupational Therapists undertake the FAB assessment on patients within 48 h of admission (FAB 1) to the burn ward and within 48 h of discharge (FAB 2). Previous work identified FAB 2 as an independent predictor of discharge outcome, and FAB 1 as a useful early indicator of likely discharge outcome in a population of adult patients with major burn after ICU discharge and as such can be used to guide discharge plans [4]. The majority of burns admitted to UK burn services are minor [5]. Therefore, there is a need to extend the utility of the FAB score to this group, as well as those with moderate sized burn, thus extending its utility to all burn patients. For the current study we evaluate the predictive validity of the FAB score for discharge outcome in adults with minor and moderate burn admitted to burn wards of four UK burn services over a 3 month period. The aims of this study are: 1. To measure the progress in the patients’ FAB scores between admission and discharge from the burn ward. 2. To evaluate the predictive validity of the FAB score for discharge outcome in adult patients with minor and moderate burn.
2.
Materials and methods
This is a retrospective review of the case notes of 115 consecutive patients with minor and moderate burns [6], admitted to the burn wards of 4 different burn services over a 3 month period (July–October 2012). Patients were excluded if they did not receive the full course of treatment at each particular burn service or if they died. All patients received the usual care at each particular burn service. This included use of the Parkland formula regime for patients receiving fluid resuscitation. Patients with full thickness burn wounds underwent early wound excision and autografting. Newly autografted limbs were immobilised for 48 h in most cases. Smoke inhalation injury was diagnosed by fibre- optic bronchoscopy. Appropriate antibiotics were prescribed for clinical infection and antibiotics were used prophylactically for patients undergoing wound excision. No specific physical function measures were used to guide decisions regarding discharge outcome of patients. Physical rehabilitation commenced on the patients’ first admission day and continued throughout their stay on the burn ward. The teams of Physiotherapists (PT) and Occupational therapists (OT) carried out active and passive mobilisation and functional exercises 5 days per week at each burn service. Standard contracture prevention techniques were employed including joint positioning and splintage 7 days per week by PT, OT and nursing staff. Other therapies available to patients
throughout their inpatient stay included psychotherapy and counselling, dietetics and speech and language therapy. FAB scores were measured prospectively, during each patient’s episode of care and as part of normal daily therapy practice, for all patients aged 15 years within 48 h of admission to (FAB 1), and within 48 h of discharge from the burn ward (FAB 2). The FAB score is an objective measure of the patients’ ability to perform the following key activities of daily living; washing, toileting, feeding, dressing, transfers, walking and stair climbing. The Physiotherapist or Occupational Therapist undertakes the FAB assessment; each patient is scored on their ability to independently complete 100% of each activity or on the minimum amount of assistance necessary to complete the activity [4]. The minimum FAB score is 7 and the maximum is 35. The score for each activity is as follows: 1. Fully dependent, unable to complete any part of the activity, needs full assistance – 1 point 2. Completes activity with physical assistance – 2 points 3. Completes activity with supervision/verbal prompting/ requires set up of activity – 3 points 4. Independently completes activity with an assisting device/ aid (e.g. adapted cutlery, walking stick, wheelchair, stair lift) – 4 points 5. Independently completes activity without devices/aids – 5 points 6. Unable to assess – 1 point We collected the following demographic and injury variables; patient age, %Total Body Surface Area burn (%TBSA), %full thickness burn, smoke inhalation injury, past medical history (number of patients undergoing medical treatment for cardiopulmonary disease, neurological disorder and psychiatric conditions). We also collected FAB scores (FAB 1 and FAB 2), length of stay on the burn ward (LOS) and discharge outcome. Discharge outcome is classified as home (no social care) versus inpatient rehabilitation or home with social care. Social care includes assistance with patients’ daily personal care, and this may also include moisturisation of scars, but does not include therapy, housekeeping tasks or wound management. Data was stored on a secure centralised spread sheet.
2.1.
Statistical analysis
Data were entered onto the Medcalc statistical program which was used for all analyses. An independent samples t test was used to compare Means and a Mann Whitney Rank Sum test was employed to compare Medians as appropriate. For categorical variables, a Chi Square test or Fishers Exact test was used if n < 5. A Paired Wilcoxon Test was used to compare patients’ FAB 1 and FAB 2 scores. Statistical associations between injury and demographic variables and patients’ discharge outcome were tested for using Spearman’s Rank Correlation Coefficient. Multiple Logistic Regression Analysis was used to evaluate the effects of variables on patients’ discharge outcome. Receiver operating characteristic (ROC) curve analysis was employed to identify cut off values for FAB 1 and FAB 2 with the greatest accuracy for prediction of discharge outcome. Statistical significance was defined as 0.05.
Please cite this article in press as: Smailes ST, et al. Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.09.020
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3.
Table 2 – Comparison of paired observations of Functional Assessment for Burns Scores.
Results
There were 115 patients with minor or moderate burn in the cohort and their data were entered into the analysis. There were no deaths and no other patients were excluded. The pattern of admission over the 4 burn care providers was as follows; service 1 (46 patients), service 2 (40 patients), service 3 (26 patients) and service 4 (3 patients). Median age was 45 years and median burn size was 4%. In terms of discharge outcome 98 patients (85%) were discharged home (no social care) and 17 (15%) were discharged either to further inpatient rehabilitation or home with social care. Table 1 shows the demographic variables and FAB scores of the cohort grouped according to discharge outcome. The patients who were discharged to inpatient rehabilitation or home with social care were significantly older ( p < 0.0001), had a higher incidence of psychiatric conditions ( p = 0.05) and longer LOS ( p = 0.0001). Additionally, these patients had lower FAB 1 ( p = 0.0002) and FAB 2 ( p < 0.0001) scores. The Paired Wilcoxon test applied to the patients’ FAB 1 and FAB 2 scores (Table 2) illustrates the significant increase of these ( p < 0.0001), and thus improvement in patients’ physical functional independence between admission and discharge from the burn wards. Correlation analysis of all of the variables for patient discharge outcome (Table 3) identifies that increasing patient age ( p < 0.0001), longer LOS ( p = 0.0001) and presence of psychiatric conditions ( p = 0.03) are associated with discharge to inpatient rehabilitation or home with social care. On the other hand, decreasing level of functional independence, FAB 1 ( p = 0.0001) and FAB 2 ( p < 0.0001), is strongly associated with discharge to inpatient rehabilitation or home with social care. Table 4 illustrates the results of the multiple regression analysis and the model with the greatest predictive accuracy for discharge outcome as denoted by its regression coefficient ( p < 0.0001). This model contains the variables patient age, FAB 2 score, LOS and presence of psychiatric conditions. Within this model, each of the variables FAB 2 score, LOS and
Functional Assessment for Burns 1 Score (FAB 1) (95% CI) 27 (25–29)
Functional Assessment for Burns 2 Score (FAB 2) (95% CI)
P
35 (33–35)
<0.0001
Numbers in bold denote statistical significance.
presence of psychiatric conditions independently predict the patients’ discharge outcome as illustrated by their regression coefficients. This analysis confirms that FAB 2 score has predictive validity for discharge outcome for patients with minor and moderate burn. In addition, this 4 variable model has excellent accuracy for discriminating between the patients discharged home (no social care) versus those discharged to inpatient rehabilitation or home with social care (area under receiver operating characteristic curve (AUC) = 0.96). The ROC curve analyses of the performance of FAB 1 and FAB 2 scores to correctly classify patients’ discharge outcome are shown in Tables 5 and 6. Table 5 identifies the optimum cut off value for FAB 1 is 14 to predict discharge to further inpatient rehabilitation or home with social care and this has good predictive ability (AUC = 0.79) and excellent specificity (93%). The cut off value for FAB 2 score that has the greatest ability to correctly classify patients’ discharge outcome is 30 and this, again, has good discriminative ability (AUC = 0.81).
4.
Discussion
This is the first multi-centre evaluation of a physical function outcome measure, developed specifically for burn patients – the FAB Score. In short, this study has confirmed that FAB 1 is strongly associated with discharge outcome and therefore can be used to facilitate early discharge planning for patients with minor and moderate burn. In addition, we found that FAB 2 is
Table 1 – Demographic variables and FAB scores of the cohort grouped according to discharge outcome. Variable Patient age (years)b 95% CI Total burn surface area (%TBSA) 95% CIb Full thickness (%TBSA) 95% CIb Smoke inhalation injurya Gendera (males) Cardiopulmonary diseasea Neurological disordera Psychiatric conditionsa LOS (days)b FAB 1 Scoreb FAB 2 Scoreb
Discharged home (n = 98)
Discharged home with care/inpatient rehabilitation (n = 17)
44.5 (35–51.1) 3 (2.5–4)
76 (54.5–89) 6 (2–11.4)
0.5 (0–1) 4 56 9 5 10 8 (7–8.1) 28 (26–31) 35 (33–35)
1 (0.2–4) 1 8 2 1 5 18 (9–24.7) 14 (10.6–25) 22 (16.7–33.4)
P <0.0001 0.06 0.08 0.75 0.6 0.67 1.0 0.05 0.0001 0.0002 <0.0001
95% CI = 95% confidence intervals; numbers in bold denote statistical significance. Number of patients.
a
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Table 3 – Correlation analysis of variables for patient discharge outcome. Variable
Spearman’s Rank Correlation Coefficient (Rho) (95% CI)
Patient age Gender Total Burn Surface Area (%TBSA) Full thickness burn surface area (%TBSA) Smoke Inhalation injury Cardiopulmonary disease Neurological disorder Psychiatric conditions FAB 1 FAB 2 LOS
0.4 (0.24–0.54) 0.07 ( 0.11 to 0.25) 0.18 ( 0.003 to 0.35)
P
<0.0001 0.44 0.06
0.17 ( 0.01 to 0.34)
0.07
0.03 ( 0.15 to 0.21) 0.03 ( 0.2 to 0.21)
0.74 0.74
0.01 ( 0.17 to 0.2) 0.2 (0.02–0.37) 0.36 ( 0.5 to 0.2) 0.4 ( 0.55 to 0.25) 0.38 (0.21–0.52)
0.89 0.03 0.0001 <0.0001 0.0001
Numbers in bold denote statistical significance.
Table 4 – Multiple Logistic Regression Analysis of variables for patient discharge outcome. Model
Patient age FAB 2 LOS Psychiatric conditions
Regression Significant Area under coefficient for ROC curve regression independent (AUC) for coefficient variable (P) for model (P) model (95% CI) 0.06 0.02 0.02 0.001
<0.0001
0.96 (0.91–0.99)
Numbers in bold denote statistical significance.
Table 5 – Receiver operating characteristic curve of FAB 1 cut off value =14 for patients’ discharge to inpatient care or home with social care. Cut off value 14
Sensitivity (95%CI)
Specificity (95%CI)
Area under ROC curve (AUC) (95%CI)
53 (28–77)
93 (86–97)
0.79 (0.70–0.86)
Table 6 – Receiver operating characteristic curve of FAB 2 cut off value =30 for patients’ discharge to inpatient care or home with social care. Cut off value 30
Sensitivity (95%CI)
Specificity (95%CI)
Area under ROC curve (AUC) (95%CI)
77 (50–93)
84 (75–91)
0.81 (0.73–0.88)
an independent predictor of discharge outcome, thus enhancing the utility of the FAB score, as a physical function outcome measure that predicts discharge outcome, to all burn inpatients. A necessary requirement of a new outcome measure is not only that it is valid, but also it must also be simple to use and therefore can be introduced into clinical practice within a variety of different settings with ease. The FAB score was developed at a single burn centre and is established as a
routine measure of physical function outcome within that setting. For this study, the FAB score was introduced to 3 new burn care settings where its uptake and routine use was rapid and this lends evidence that the FAB score meets this requirement. Training of therapists based at the other 3 burn care providers by the FAB ‘‘champions’’ was not time consuming, it was achieved at one face to face meeting of senior therapists, by distribution of FAB guidance notes and support given through email and telephone calls. We have found that the FAB score has 2 major advantages over other physical function outcome measures that were developed in other patient populations. Firstly, the nature of the therapist - patient relationship is integral to successful physical rehabilitation of burn patients. The therapist and patient must work together to set realistic rehabilitation/ functional goals and the therapist must then motivate patients to work towards achieving them. We have found that use of the FAB score facilitates this process since the therapist alone is able to undertake FAB assessments which can be done in the interim (at a time between FAB 1 and FAB 2) to score patients and assist in their motivation. The flexibility to undertake interim physical function scoring is less possible with other physical function scores which require assessment from other members of the multi-disciplinary team. Secondly, unlike other physical function scores, the FAB score assessment is based on the patients’ ability to complete 100% of each functional task and therefore it does not require therapists to subjectively divide each of these tasks into components. This simplifies the assessment process and possibly limits variation in scores between different therapists. This study identified that there were significant improvements in the patients’ FAB scores between admission to, and discharge from the burn wards and that 85% patients discharged home (no social care). The improvement in FAB scores mirrors findings from previous work with adults with major burn [4] and perhaps is to be expected as patients undergo intensive therapy after burn, achieve rehabilitation goals and as burn wounds are closed. This study confirmed that FAB 1 is associated with discharge outcome, and that FAB 2 independently predicts discharge outcome in patients with minor and moderate burn across 4 different burn care settings. These results are noteworthy for two reasons; firstly they confirm previous findings in a cohort of patients with major burn treated in a single burn care setting [4] to patients with minor and moderate burn treated in a variety of different burn care settings. Thus, the findings from the current study extend the utility of the FAB score to all burn inpatients. Secondly, the largest proportion of burn patients’ hospital length of stay is on the burn ward and is likely to be related to social issues [1]. Within this setting, the earlier discharge plans are made the better to avoid excessive length of stay on the ward. Our findings indicate that FAB 1 score can be used to facilitate early (within 48 h of admission to burn ward) discharge plans for burn patients. Increasing patient age was associated with discharge to inpatient rehabilitation or home with social care in our population of patients with predominantly minor burn. Interestingly, this finding contrasts that from previous work to evaluate the FAB score in patients with major burn. In that study patient age was not associated with discharge outcome
Please cite this article in press as: Smailes ST, et al. Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.09.020
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in patients with major burn who had been discharged from ICU [4]. A reasonable explanation for this finding is that perhaps many of the elderly patients in that cohort did not survive the physiological consequences of major burn and ICU, and thus age was not singled out as a factor affecting discharge outcome in the analysis. The concept of increasing age adversely affecting physical and psychosocial outcomes following burn is not a new one and provides the burn team with additional challenges to meet the needs of older patients. Edgar et al. quantified the impact of ageing on quality of life after burn and concluded that physical function suffered to the greatest extent [7]. One possible explanation to account for negative outcomes in the elderly population is ‘‘frailty’’. Frailty is concerned with an elderly patient’s physiological rather than actual age and has been reported to be predictive of mortality in elderly burn patients [8]. Our findings suggest that there is an increased need for social care at home and need to discharge elderly patients with minor and moderate burn for further inpatient rehabilitation after closure of their burn wound, and this also supports other work which reported that elderly burn patients benefit from more prolonged rehabilitation programmes [9]. This study also identified that presence of psychiatric conditions independently predicts discharge to inpatient rehabilitation or home with social care in patients with minor and moderate burn and this supports 2 previous studies. The negative impact of psychiatric conditions on recovery following burn was reported by Wisely et al. who identified that patients underwent more surgical procedures and had longer hospital stays [10]. More recently, Oster and Sveen reported that pre-existing psychiatric conditions was the strongest contributing factor to depression and post-traumatic stress disorder after burn [11], arguably conditions that increase patients’ dependence on carers and prevent independent living. This study indicates that early discharge plans can be made on the basis of the FAB 1 score for patients with minor and moderate burn and, in addition, presence of psychiatric conditions and patient age should be taken into account when formulating discharge plans. Increasing length of stay on the burn ward predicts discharge outcome to inpatient rehabilitation or home with social care in patients with minor and moderate burn and this supports earlier work with other burn populations [2,4]. Perhaps this is not surprising as length of stay is considered to be a surrogate marker of morbidity or dysfunction after burn [12] such that sicker patients can be expected to have a longer length of stay, be dependent on carers for longer, and are likely to benefit from longer rehabilitation programmes. The ROC curve analysis identified cut off values for FAB 1 and FAB 2 scores and these allow clinical application of the FAB score so that it can be used to facilitate discharge planning for patients. The cut off values with greatest discriminative accuracy to predict discharge to inpatient rehabilitation or home with social care versus home (no social care) for FAB 1 is 14 and FAB 2 is 30. These values are at variance with our previous work which identified FAB 1 9 and FAB 2 26 in patients with major burn [4] following discharge from ICU and this reflects the impact of extensive burn and ICU acquired weakness on physical function, and highlights the need to study ICU patients with major burn separately.
5
A potential confounding factor to the patients’ discharge outcome is the availability of family or friends who could assist with some patients’ personal care at home, lessening the need for social care. This is unlikely to be a significant confounding factor because it is not borne out by the statistics which identify that the patients’ functional independence, the FAB score, is one of the most predictive factors determining discharge outcome in this study. The weakness of this study relates to the timing of the FAB 1 measurement in patients who had full thickness burn and had undergone burn excision and autografting. To explain this, in order to unify the methods of the current study with previous work [4], the FAB 1 assessment was required to take place within 48 h of admission to the burn ward. It is likely that some patients received FAB 1 assessments on the first or second post-operative day when affected limbs were immobilised to protect newly applied autografts, preventing a full FAB assessment. This is likely to have affected the ROC curve results for FAB 1 giving a lower sensitivity and wider confidence interval than perhaps is desired. To avoid this in the future, we recommend undertaking full FAB 1 assessments once autografts are stable and limbs can be mobilised.
5.
Conclusion
We conclude that since FAB 1 is strongly associated with discharge outcome in patients with minor and moderate burn it is a useful early indicator of likely discharge outcome and can, as such, be used to facilitate early discharge planning. FAB 2 independently predicts, and therefore has predictive validity for, discharge outcome in patients with minor and moderate burn. This finding extends the utility of the FAB score as a measure of physical function independence that predicts discharge outcome to patients with minor and moderate burn.
Conflict of interest statement The authors declare that there are no conflicts of interest relating to this work.
Acknowledgements The authors would like to thank all therapists involved with FAB score assessments. The corresponding author would like to thank Professor Peter Dziewulski for reading the manuscript.
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Please cite this article in press as: Smailes ST, et al. Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.09.020
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Please cite this article in press as: Smailes ST, et al. Increasing the utility of the Functional Assessment for Burns Score: Not just for major burns. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.09.020