Opportunities for Palliative Care in Patients With Burn Injury—A Systematic Review

Journal Pre-proof Opportunities for Palliative Care in Patients with Burn Injury – A Systematic Review Allyson C. Cook, MD, Jessica A. Langston, MD, MPH, Joshua D. Jaramillo, MD, Kristin Edwards, MD, Hong-nei Wong, MLIS, MPVM, DVM, Rebecca A. Aslakson, MD, PhD, The American Academy of Hospice and Palliative Medicine Research Committee Writing Group PII:

S0885-3924(19)30669-4

DOI:

https://doi.org/10.1016/j.jpainsymman.2019.11.014

Reference:

JPS 10305

To appear in:

Journal of Pain and Symptom Management

Received Date: 6 September 2019 Revised Date:

12 November 2019

Accepted Date: 13 November 2019

Please cite this article as: Cook AC, Langston JA, Jaramillo JD, Edwards K, Wong H-n, Aslakson RA, The American Academy of Hospice and Palliative Medicine Research Committee Writing Group, Opportunities for Palliative Care in Patients with Burn Injury – A Systematic Review, Journal of Pain and Symptom Management (2019), doi: https://doi.org/10.1016/j.jpainsymman.2019.11.014. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine

Title: Opportunities for Palliative Care in Patients with Burn Injury – A Systematic Review Running title: Systematic review of palliative care in burn patients Authors: Allyson C. Cook MD1 Jessica A. Langston MD, MPH6 Joshua D. Jaramillo MD2 Kristin Edwards MD5 Hong-nei Wong MLIS, MPVM, DVM3 Rebecca A. Aslakson MD, PhD4 The American Academy of Hospice and Palliative Medicine Research Committee Writing Group

Author Affiliations: 1

Department of Medicine, University of California San Francisco, San Francisco, California, USA

2

Department of Surgery, Stanford University, Stanford, California, USA

3

Lane Medical Library & Knowledge Management Center, Stanford University School of Medicine, Stanford, California, USA 4

Departments of Medicine & Anesthesiology, Stanford University, Stanford, California, USA

5

Department of Medicine-Palliative Care, Bridgeport Hospital, Yale New Haven Health, Bridgeport, Connecticut, USA

6

Department of Medicine, VA NorCal Health Care System, Sacramento, California, USA

Correspondence concerning this article should be addressed to: Allyson C. Cook, MD Department of Medicine, Division of Palliative Medicine University of California San Francisco 533 Parnassus Ave Box 0125, Room 109 San Francisco, CA 94143-0125 [email protected] [email protected] Tables: 7 Figures: 1 Appendices: 1 Word Count: 3829 References: 38

ABSTRACT Context: Patients with significant burn injuries likely have palliative care needs. Objective: We performed a systematic review of existing evidence concerning the palliative care needs of burn patients. Methods: Through November 26, 2018, we systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using terms representing burn injuries and the eight domains of quality palliative care as outlined by the National Consensus Project for Quality Palliative Care. Eligible articles involved burn injured patients treated with an intervention targeting at least one of the eight domains. Results: Our searches yielded 7,532 unique records which led to 238 manuscripts for full review and 88 studies which met inclusion criteria. Seventy-five studies addressed the domain “Physical Aspects of Care” and merit a separate systematic review; 13 studies were included in our final review. Four of the 7 domains – processes of care, psychologic symptoms, social aspects, and end-of-life – were addressed by studies but three domains – spiritual, cultural, or ethics – were unaddressed. Included studies highlight potential benefits from peri-discharge self-care education programs, peer support and group therapy in improving quality-of-life. In patients with severe injuries, end-of-life decision making protocols were associated with increased utilization of comfort-focused treatments. Conclusion: Most existing palliative care-related research in burn patients addresses interventions for physical symptoms with minimal literature concerning other domains. Opportunities exist for further research of palliative care in burn populations with emphasis on: addressing interventions for all domains and better standardizing the language and outcomes for the palliative care interventions. Abstract word count: 244 Keywords: Burn, Palliative Care, Domains of Quality Palliative Care

BACKGROUND Optimal care for patients with burn injury can involve hours, weeks, or even years of treatment. (1–3) Burn care necessitates a unique, multidisciplinary approach to reduce suffering, improve function, and support patients and their families throughout their often-prolonged disease course. While burn care has improved significantly over the last several decades with notable improvements in survival, burn-related mortality and morbidity remain significant.(4–6) Patients who survive their injuries are often left with ongoing symptoms, rehabilitation needs, and quality of life challenges. To this end, specialized burn centers have been developed across the country and care for the majority of burn patients in the United States.(7,8) These centers are designed to provide aggressive and multimodal symptom control, integrate the burn interdisciplinary team into all aspects of treatment, and standardize evaluation, management, rehabilitation, and supportive services to provide high-quality care for patients and their family members; this post-burn care is frequently life-long.(9–11) As burn centers are often located in large academic hospitals with palliative care programs, multiple opportunities arise to integrate palliative care into burn patient care.(12) Despite the many similarities between the principles of burn care(13) and palliative care(14), scant literature exists regarding primary or specialist palliative care for burn patients. As a specialty, palliative medicine focuses on transitions in care settings and seeks to alleviate suffering through symptom management, psychosocial care and interdisciplinary support; these are all also critical components of quality burn care.(15) As articulated by the esteemed surgical palliative care pioneer, Dr. Geoffrey Dunn, burn care provides the most well developed paradigm for surgical palliative care: ‘Burn care has taught us that the first step towards salvaging a patient involves attending to pain control…[but] the threat of physical mortality is only a part of the existential threat resulting from devastating injury because we also exist in social and spiritual contexts. Nowhere else in the practice of

surgery is it so obvious as in burn care that existential salvation for patient and caregivers alike begins with the response to suffering.” Unfortunately, as Dunn also points out, many barriers to palliative care utilization within surgery still exist within burn treatment team culture.(15) To better identify and delineate existing interventions for the palliative care needs of burn patients, as well as potentially under-represented palliative care quality domains, we completed a systematic review of the literature (Table 1). With scarce current integration of palliative care specialists in the management of burn patients (16) and a rudimentary literature review having revealed no palliative care specialist interventions involving burn patients, we developed our systematic review to specifically identify interventions aimed at the palliative care needs of burn patients and conceptualized those interventions, specialist or otherwise, using the eight domains of quality palliative care as outlined by the Clinical Practice Guidelines for Quality Palliative Care, 4th edition.(14) (Table 2).

Methods Search Strategy We systematically searched five databases: PubMed, CINAHL, Embase, Web of Science, and Scopus databases for articles published from inception to November 26, 2018. Each search used keywords and medical subject headings representing palliative care, patients with burn injury, and keywords from each of the eight domains of quality palliative care as outlined in the Clinical Practice Guidelines for Quality Palliative Care, 4th Edition.(14) Appendix A details the search strategy for PubMed with that search strategy then adapted to the other four databases. The study was registered on Prospero (ID # CRD42019115534). Study Selection

We downloaded the search results into Proquest® Refworks (17) software and then into the Covidence (18) web-based software platform for systematic reviews. Duplicates were removed. Eligible studies were screened based upon the inclusion and exclusion criteria in Table 1. The titles and abstracts followed by the full texts of articles were independently reviewed by two members of the study team with conflicts resolved through group discussion. Studies were grouped into domains based on team consensus of primary intervention. We reported our results following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.(19) Data Extraction For each article meeting criteria to undergo data extraction, two members of the study team abstracted independently the following data (when available): study design, inclusion/exclusion criteria, baseline characteristics of study populations, details of the intervention and control arms, and summary data of intervention outcomes. All extracted data with discrepancies were reviewed and adjudication was performed by group consensus. Data Synthesis Results from the identified studies were presented in a tabular summary and summarized in a qualitative synthesis. Meta-analysis was not possible due to the varied detail and content of the interventions and data reported. Quality Appraisal The methodological quality of included studies were assessed by two members of the study team independently using the Cochrane Collaboration Risk-of-Bias Tool Version 1.0.10.(20) for randomized controlled trials and the Newcastle-Ottawa Scale(21) for non- randomized control trials

when appropriate. Disagreements were adjudicated by consensus between the two reviewers. No articles were excluded based on quality.

Results The database searches generated 10,555 records, (Figure 1). After duplicates were removed, we screened the abstracts of 7,532 articles for inclusion and exclusion criteria. The abstract review resulted in 238 articles for full manuscript screening and 88 studies which met inclusion criteria. Seventy-five of our included studies represented Domain 2: Physical Aspects of Care. The large size and breadth of this literature merits its own separate systematic review and so, to allow for adequate analysis of interventions for physical aspects of care as well as provide a clear evaluation of the remaining 7 domains, we excluded interventions for physical aspects of care from this current review. Thus, 13 unique references addressing the other seven palliative care domains were included(Table 3). The included studies represent four of the remaining seven domains, with no studies representing Domain 5: Spiritual, Religious, and Existential Aspects of Care, Domain 6: Cultural Aspects of Care, and Domain 8: Ethical and Legal Aspects of Care. Out of the thirteen included studies, three represented Domain 1: Structure and Processes of Care(22–24), four characterized Domain 3: Psychological and Psychiatric Aspects of Care(25–28), two addressed Domain 4: Social Aspects of Care(29,30), and four encompassed Domain 7: Care of the Patient at the End of Life(31–34). The included studies were published between 1989 and 2018 and represent 2,472 burn patients, with the number of included patients in each study ranging from 22-808. The studies represent five countries, with eight of the studies originating in the United States(23,24,26,29–32,34). Six of the thirteen studies were retrospective cohort studies(23,26,31–34), one was a prospective cohort study(30), one a retrospective cross-sectional study(29), and five were randomized control

trials(22,24,25,27,28). The studies represent all settings of patient care, with six studies focusing on inpatient interventions(26,30–34), three on outpatient interventions(23,24,29), three on peri-discharge interventions(22,25,28), and one study including both inpatient and outpatient settings(27). When reported, the average age of patients ranged from 27.6 years to 79.1 years. Average Total Body Surface Area burned, or %TBSA, when reported, ranged from 11.98% to 78.6%. Gender was predominately male, ranging from 47.9% to 87% male, when reported. Average length of stay, when reported, varied from 1 to 26 days. Domain 1: Structure and Processes of Care: Three studies focused on interventions in Domain 1: Structure and Processes of Care and all highlight peri-discharge interventions to increase support and education of patients at this transition. None of the papers discuss readmissions or protocols for ongoing therapy or further medical interventions. Lofti et al(22) utilized a pre-discharge individualized education program along with three months of additional access to the research team for questions post-discharge. The education program included an initial assessment of each patient’s physical, spiritual, psychological, and social needs with educational sessions tailored by this assessment through collaboration with patient and family. Face-toface training as well as booklets/pamphlets were provided to patients. Training began early in the patient’s hospital course and education materials were adjusted based on the specific needs of each patient and family. The primary outcome was quality of life (QOL) as assessed by the Burn Specific Health Scale- Brief (BSHS-B). Intervention and non-intervention cohorts were compared, and while both groups showed improved QOL at 1 month and 3 months post-discharge, the trend was significantly stronger in the pre-discharge training intervention group (p values of 0.037 pre-discharge, 0.001 at onemonth post-discharge, and <0.001 at three months post discharge). The authors concluded that a predischarge training program significantly improved QOL in burn patients. In the outpatient setting,

Hickey et al(23) evaluated the effect of an interactive home telehealth (IHT) program for burn patient follow-up. Primary outcomes were exploratory and found that IHT was safe and feasible for burn patients, and that clinic utilization and cost were improved based on decreased travel obligations (calculated at $108.50 per patient based on mileage). No adverse events were reported. Also in the outpatient setting, Wiechman et al(24) showed no difference between patients who received access to a supplemental expanded care coordinator providing: outpatient care coordination, individualized problem solving techniques, and peri-clinic support; and those who did not. The authors suggest that the negative study results may have been secondary to an already robust outpatient team and support structure for burn patients. Domain 3: Psychological and Psychiatric Aspects of Care Domain 3: Psychological and Psychiatric Aspects of Care were addressed in four of the included studies. Two studies represent self-care programs(25,28), one highlights group therapy(27), and the fourth explored specialty psychiatrist evaluation(26). Goncalves et al(25) and Hashemi et at(28) both utilized a peri-discharge self-care program in an attempt to improve QOL in patients with burn injuries. Both studies were non-blinded randomized control trials and used the Burn-Specific Health Scale-Brief (BSHS-B) to assess QOL. Self-care education prior to discharge in both studies addressed individualized instruction in wound care, medications, and other standard discharge practices, as well as instruction in social interactions with family and friends, leisure, and other individualized topics. In the Goncalves study, participants were contacted every 4-6 weeks with psychological interventions including positive reinforcement for good self-care, attention to barriers to good self-care, as well as guidance for problem-solving and overcoming these barriers. The Hashemi group monitored patients every 15 days and provided support in the form of coping strategies, self-esteem enhancement, relaxation techniques, as well as attention to mental health and sexual well-being, when indicated. Goncalves and colleagues did not find a statistically significant improvement in quality of life after implementation of a self-care

program, though they did note a trend towards decreased anxiety and post-traumatic stress (PTS) at 6 months in the intervention group; the authors suggest a larger study to further assess self-care program effectiveness. In contrast, the Hashemi group found that the Orem Self-Care Model significantly improved QOL in burn patients at one month and two months post discharge (P<0.001). Moore et al(26) studied a retrospective cohort of patients with burn injury in Germany who were evaluated by a staff psychiatrist while admitted after burn injury. The psychiatric evaluation was associated with increased identification of psychiatric disorders and recommendations of psychiatric pharmacologic therapy in 91% of patients evaluated. This descriptive study did not discuss interventions or psychiatric diagnoses in those not evaluated by a psychiatrist. In another trial, Seehausen et al(27) studied the impact of a burn-specific cognitive behavioral group intervention on QOL and psychological distress in burn patients in the inpatient and outpatient settings. The intervention group included 86 patients with 128 in the control arm. The intervention was associated with a decrease in symptom severity and post-traumatic symptoms as well as an increase in optimism when compared to the control group. No significant decrease in depression or anxiety was noted in either group. The authors conclude that a burn-specific cognitive behavioral group intervention was well accepted by patients and had a significant positive effect on psychological well- being, resulting in its implementation in other burn centers within Germany. Domain 4: Social Aspects of Care Grieve et al(29) and Williams et al(30) examined peer support as an intervention for burn patients and represent the only two studies captured in Domain 4: Social Aspects of Care. Grieve completed a retrospective cross-sectional study of 596 burn patients, 330 of whom had attended a peer support group. Using the Life Impact Burn Recovery Evaluation Questionnaire (LIBRE-192), the investigators found that attendance in the peer support groups was associated with long term improved

social re-integration. Williams completed a prospective cohort study to evaluate the usefulness of an inpatient peer visitor among burn patients. Three trained peer consultants made 167 visits to 108 patients. Results showed that a majority of patients felt they were approached appropriately, had their questions answered, and that the peer consultant provided useful support and information; no comparison group was utilized and no long-term outcomes follow-up was reported. Of note, no included studies represented interventions involving family members, caregivers, or other social supports for burn injured patients. Domain 7: Care of the Patient Approaching the End of Life Four studies addressed end-of-life (EOL) care among burn patients. Patients captured within this domain had higher %TBSA portending a more unfavorable prognosis. Three of the four studies(31,33,34) focused on the implementation of protocols for decision-making and care prevision for severely burninjured patients assessed to have nonsurvivable injuries, while the fourth (32) focused of end of life/ goals of care discussions. Pham et al(31) retrospectively evaluated a cohort of 126 patients with burn injuries who died within 72 hours of admission, noting that of these, 106 died after cessation of life support. Of these, 61 died after the implementation of a life-support cessation protocol. After the implementation of this EOL protocol, patients who died after stoppage of life support were noted to receive more frequent use of symptom focused medications (opioids 98% vs 87%, p=0.07, benzodiazepines 95% vs 49%, p< 0.01) without hastening time to death. Hemington-Gorse et al(33) describe the implementation of the Burn Modified- Liverpool Care Pathway (BM-LCP) for a small cohort (N=11) of patients where life-prolonging treatments were deemed futile by a multidisciplinary team. The control group (N=11) were patients who died either while receiving life- prolonging treatments or when futility was invoked without sufficient time to utilize the pathway prior to death. The primary reported outcome was adherence to the pathway, which was universal when initiated and thus suggested

feasibility of its broader use. Hammond and Ward(34) describe the implementation of a protocol for issuing a Do Not Resuscitate (DNR) order for patients who are deemed by an attending physician to have nonsurvivable injuries. Awake patients and family members were informed and if dissent or disagreement existed, resuscitative treatments were initiated. The descriptive retrospective cohort study evaluated 16 patients who had a DNR order placed; these patients were thought by the burn team to have overwhelming burn injury and had both greater %TBSA burns and older age. Partain and colleagues(32) evaluated the burn team’s EOL and/or goals of care discussions for geriatric burn patients who died during their index admission. The investigators found that the vast majority of geriatric burn patient decedents had an EOL discussion, that the timing of these discussions (within 24 hours of admission or later) was influenced by severity of injury, and that having these discussions did not result in a higher rate of immediate transition to comfort care. They did note, however, that earlier discussions were associated with fewer trips to the operating room. The authors suggest that an early EOL discussion may be a useful marker of quality EOL care in the geriatric burn population. As noted previously, no studies were identified for Domain 5: Spiritual, Religious, and Existential Aspects of Care, Domain 6: Cultural Aspects of Care, or Domain 8: Ethical and Legal Aspects of Care. In contrast, Domain 2: Physical Aspects of Care, recovered 75 studies that primarily addressed pharmacologic interventions for pain, pruritis, and peri-wound care distress. It is important to highlight that the included studies varied widely with regards to structure, terminology, and assessment of outcomes. Six studies(22,24,25,27–29) utilized quality of life as an outcome measure, however, each employed varying assessment scales which precludes comparison of impact (see Table 3). Four of the six (22,27–29) showed improvement in quality of life with the remaining two (24,25) showing no change. Four studies reported exploratory outcomes around EOL decision making in burn injured patients (31–34) and the remaining three studies assess health utilization(23), use of dedicated staff member (psychiatrist)(26) with secondary outcomes exploring

characteristics of consultation, patient factors, and recommendations, as well as patient reported usefulness of intervention(30). Risk for Bias/Quality Assessment of Included Studies The results of our risk of bias/quality assessment are shown in Table 5 (Cochrane Review of Bias for Randomized Control Trials)(20) and Table 6 (Newcastle-Ottawa Quality Assessment Scale for nonrandomized trials)(21). The domains found to be most at risk for bias were Blinding of Participants and Personnel and Blinding of Outcome Assessors in clinical trials. In the non-randomized studies evaluated for quality, Comparability and Outcome Assessment were at highest risk of bias.

Discussion Our systematic review of palliative care in the burn population revealed significant gaps in the literature that merit further investigation. Three of the eight domains of palliative care were not represented by any interventional studies. A significant majority of existing studies focused on interventions addressing physical aspects of care. Only 13 studies encompassed the remaining four domains of quality palliative care and these studies were predominantly small, single center, and of moderate to poor quality with high potential for bias. Four existing studies addressed burn patient care at the end-of-life; three studies examined protocols for decision making and implementation of DNR and comfort-focused treatments and one study analyzed the timing of goals of care discussions.(31–34) Yet, none of these studies evaluated patient- or family-centered outcomes or protocol impact on clinicians and clinician behaviors. Furthermore, while existing evidence suggested that palliative care specialist involvement with dying burn patients may be associated with fewer surgical interventions(16,32), there were many potential

confounders and no existing evidence addressed whether palliative care specialist involvement impacted the quality of death and/or bereavement among family members. While burn research has historically focused on improvements in mortality and morbidity, outcome priorities are increasingly shifting towards function and health related QOL.(7) Indeed, the large body of burn literature on physical symptoms could be interpreted as attempts to address the most outward signs of suffering. Yet, though vitally important to the care of burn patients, focusing research interventions primarily on mortality and physical symptoms negates that burn patients suffer from not only pain but also threats to their wholeness and personhood which impact their lifestyle, social life, psyche, and spiritual life.(15) Focusing on the concept of the whole person, with the distinct objective of minimizing suffering in all of its forms, palliative care and palliative care specialists likely offer many potential benefits for burn patients, their family members, and their clinicians. Burn units were developed to provide high quality care for critically ill burn patients, and by necessity, have evolved into an interdisciplinary team equipped and potentially able to provide quality primary palliative care.(11,12) Further research is needed to address both better facilitation of primary palliative care delivery in burn ICUs and incorporation of quality measures to assess the competence and effectiveness of that primary palliative care. Moreover, just as barriers exist to the integration of palliative care specialists in many other surgery care settings, there is similar reticence in the burn community to include palliative care specialists.(15,16,35) Cunningham and colleagues note in a survey of primary burn surgeons and palliative care providers that each group thought themselves better at performing goals of care discussions than the other group perceived them to be, and both groups disagreed as to which provider - burn surgeon or palliative care specialist - should lead palliative care discussions.(36) Given that interdisciplinary burn unit teams are often well-versed in many principles of palliative care such as physical symptom management, Ray and colleagues suggest specialty palliative care involvement in the care of complex and/or imminently dying burn unit patients; they note that it

would not only benefit patients, families, and burn clinicians but also likely potentiate palliative care education among burn fellows and other trainees.(12) Further research could also identify gaps in primary palliative care in burn units that could be better addressed by further education of burn clinicians and/or supplementary protocols, particularly triggered involvement of palliative care specialists. Clinical implications of study findings include that significant literature gaps exist concerning both the palliative care needs of burn patients and ways that palliative care specialists could improve burn patient management. Evidence supports that peer support, group therapy, and peri-discharge education improve quality of life of burn patients. Protocols for decision making and goals of care at the end-of-life are feasible and improve end-of-life processes, including attention to symptoms. This study highlights many opportunities for further research, including: studying and incorporating all palliative care domains among burn patients and their family members, developing a common language for describing palliative interventions in this population, and reporting consistent outcomes as a means of comparing studies and providing comprehensive care to burn patients (Table 7). Several limitations to this systematic review should be noted. As mentioned, due to the large body of interventional studies on physical aspects of care, these studies merit their own systematic review and are not included here. A systematic review of this literature is needed and is a priority of our group. It should also be noted that burn units in the United States often treat both adults and children and as our criteria excluded children, we may have missed studies that incorporated both adult and pediatric participants. There is also always risk of publication bias with smaller studies with nonsignificant odds ratios and effect sizes being less likely to be published. Lastly, as the language used to describe palliative care practices in the burn literature is often ambiguous, we utilized broad search terms for each of the eight domains of quality palliative care to capture relevant studies. Despite these efforts, related studies could still have been missed in our search.

Conclusions This study is the first systematic review to assess the current state of the science for palliative care in the burn population. To be burned is to suffer, not just physically, but psychologically, spiritually, and socially; it is an event that permeates the entire person and attention to all aspects of suffering should be integrated into burn patient care. Our study supports a large number of studies addressing physical aspects of burn care but relatively scant research for other palliative care domains and no research on interventions for the domains of spirituality, cultural sensitivity, and ethics. Existing studies address care for patients at the end of life, with some exploration into peer support, self-care, and enhanced peri-discharge programs for improving quality of life. Opportunities for future research include: further exploring the potential role of primary palliative care and palliative care specialists in managing burn patients and their family members; studying all eight domains of palliative care in burn populations; developing a common language for describing palliative interventions among burn patients; and reporting consistent outcomes across studies.

Disclosures/ Conflict of Interest The Authors have nothing to disclose.

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37. 38.

Burn Care Res. 2018;39(6):1000–5. PRISMA Diagram [Internet]. [cited 2019 Mar 6]. Available from: http://www.prismastatement.org/PRISMAStatement/FlowDiagram Home - PubMed - NCBI [Internet]. [cited 2019 Mar 24]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/

Identification

Figure 1: PRISMA diagram (37)

Records identified through database searching (n = 10,555)

Duplicates Removed (n = 3,023)

Included

Eligibility

Screening

Records after duplicates removed (n =7532)

Records screened (n = 7532)

Records excluded (n =7294)

Full-text articles assessed for eligibility (n = 238)

Full-text articles excluded, with reasons (n = 225) 75 43 36 24 21 15 11

Studies included in qualitative synthesis (n =13)

Domain 2 – Physical Aspects of Care Wrong study design Pediatric population Wrong outcomes Not peer reviewed Wrong patient population Wrong intervention

Table 1: Study Eligibility Criteria

PICOTS question: Among adults with burn injury, do interventions targeting the eight domains of quality palliative care as outlined by the National Consensus Guidelines for Quality Palliative Care, as compared to no targeting of these domains, improve patient and family outcomes and healthcare utilization after burn in any setting?

Population – Adults sustaining burn injury Intervention – Interventions targeting the 8 domains of quality palliative care as outlined by the National Consensus Guidelines for Quality Palliative Care, 4th Edition Comparator – No targeting of these domains Outcome(s) – All patient and family outcomes and healthcare utilization Timing – After burn injury Setting(s) – Any Inclusion Criteria

• • •

Adults (>18 years of age) Burn Injury Interventions addresses at least one of the eight domains of quality palliative care(14)

Exclusion Criteria

• • • •

Single case reports, case series "Gray literature" - abstracts, non-peer reviewed publications Narrative reviews No original data reported (e.g. commentary)

1

2

Table 2: Eight Domains of Quality Palliative Care(14) • • • • • • • •

1: Structure and Processes of Care 2: Physical Aspects of Care 3: Psychological and Psychiatric Aspects of Care 4: Social Aspects of Care 5: Spiritual, Religious, and Existential Aspects of Care 6: Cultures Aspects of Care 7: Care of the Patient Approaching the End of Life 8: Ethical and Legal Aspects of care.

Table 3: Summary of Included Studies SOURCE (COUNTRY OF ORIGIN)

INTERVENTION

STUDY DESIGN

SETTING

SAMPLE DESCRIPTION

STUDY OBJECTIVE

INCLUSION/ EXCLUSION CRITERIA

OUTCOMES MEASURES

FINDINGS

Outpatient

N: Overall: -Control: -Intervention:31

Explore feasibility of a home telehealth program for burn care followup

Inclusion: - Patients enrolled on IHT between March 2015 and June 2016 - Willing to participate - Access to own electronic video device - Had barriers to follow upinability to drive, lived far away, significant comorbidities

Primary: Exploratory including number of patient/ physician visits, types of visit, travel distance saved and associated cost savings, barriers to care, readmission

-IHT is a safe and feasible modality for delivering follow up care to burn patients - Providers benefit from improved outpatient clinic utilization, patients benefit from having access to multiple members of the care team, costs are reduced due to decreased travel obligations.

Primary: QOL, [based on Persian version BSHS-B]

- Pre-discharge training was shown to increase QOL at time of DC, 1 month post DC, and 3 months post DC in burn patients - While both groups showed increased QOL with increasing time, the trend was stronger in the pre-DC training group - Quality of life was also negatively impacted by increased TBSA

Domain 1: Structure and Processes of Care Hickey et al, 2017 (USA)(23)

Interactive home telehealth program

Retrospective Cohort

Age: Overall: -Control :-Intervention: 44 % TBSA: Overall: -Control: -Intervention: 12

Lotfi et al, 2018 (Iran)(22)

Pre-discharge training program

RCT- Not blinded

Peridischarge

LOS: Overall: -Control: -Intervention: 13.6 N: Overall: 128 Control: 64 Intervention:64 Age: Overall: -Control :40.64 Intervention: 39.45 % TBSA: Overall: -Control: 11.98 Intervention: 14.63 LOS: Overall: -Control: 13.45 Intervention: 18.03

Exclusion: - No access to own electronic video device

Assess if predischarge training for burn patients improves quality of life after discharge

Inclusion: - Native (to Iran), aged over 18 - not suffering from chronic diseases - not suffering from confirmed mental diseases -mentally disabled - burns under 60% of the body surface - burns unintentional Exclusion: - changing place of residence - reluctant to continue to participant in the study

SOURCE (COUNTRY OF ORIGIN)

INTERVENTION

STUDY DESIGN

SETTING

SAMPLE DESCRIPTION

STUDY OBJECTIVE

INCLUSION/ EXCLUSION CRITERIA

OUTCOMES MEASURES

FINDINGS

Wiechman et al, 2015 (USA)(24)

Expanded outpatient care coordinator

RCT- Single Blinded

Outpatient

N: Overall: 81 Control: 41 Intervention:40

The goal of this study was to overcome the barriers to effective burn rehabilitation by utilizing an expanded care coordinator (ECC) to supplement the existing outpatient services

Inclusion: - ≥18 years of age - burn size greater than 15% TBSA - burn size less than 15% TBSA that required surgery for wound closure - burn size less than 15% TBSA located on the face, hand, or over the joint - informed written consent for study participation

Post intervention survey- QOL

- Randomized single blind control trial with expanded outpatient care coordinator intervention showed no difference in any outcomes. - Authors postulate that this could be due to already excellent standard care, goal attainment discussion strengthening the control group satisfaction, and small burn size which may have not required extensive follow up.

assess effect of an individualized educational program on self-care with telephone reinforcement on the perceived health status, self-efficacy, depression, anxiety, and PTSD of burn survivors 6 and 12-months after hospital discharge

Inclusion: - hospitalized at inpatient burn unit of Univ Sao Paulo Medical School - age >=18yr - no cognitive impairment able to perform self-care after discharge - access to a telephone

Age: Overall: 43.46 Control : 43.68 Intervention: 43.23 %TBSA: Overall: 36.75 Control: 38 Intervention: 35.5

Exclusion: - Not above

LOS: Overall: 18.79 Control: 18.42 Intervention: 19.15

Primary: goal attainment scale and burn specific health scale Secondary: SF-12, patient satisfaction survey, return to work survey, number of days to return to work/ school

Domain 3: Psychological and Psychiatric Aspects of Care Gonçalves et al, 2016 (Brazil)(25)

Individualized self-care program

RCT- Not blinded

Peridischarge

N: Overall: 108 Control: 55 Intervention: 53 Age: Overall: -Control : 34 Intervention: 40.4 %TBSA: Overall: -Control: 12.7 Intervention: 13.1 LOS: Overall: -Control: 19.9 Intervention: 22

Exclusion: - burned in an attempted suicide - had had previous psychiatric diagnoses - had cognitive difficulties that would not allow them to answer the instrument questions or take care of themselves - had impairments that would not allow the person to receive the intervention

Post intervention survey- QOL Primary: Health Status and Perceived Selfefficacy (BSHSR), Perceived Self-Efficacy (PSE) Secondary: Depression, Anxiety, and PTSD (HADS) and Impact of the Event (IES)

-In a Brazilian burn center, an individualized educational program on self-care with reinforcement by telephone contact failed to improve patient perceived health status, self-efficacy, or depression compared to usual care. - Authors note improvements in anxiety and PTSD at 6 months post-discharge in this group, again compared to usual care.

SOURCE (COUNTRY OF ORIGIN)

Hashemi et al, 2014 (Iran)(28)

INTERVENTION

Self-care program

STUDY DESIGN

RCT- Not blinded

SETTING

Peridischarge

SAMPLE DESCRIPTION

N: Overall: 110 Control: 54 Intervention: 56 Age: Overall: -Control : 26.7 Intervention: 28 %TBSA: Overall: -Control: 25.6 Intervention: 26.2 LOS: Overall: -Control: 19 Intervention: 20.4

STUDY OBJECTIVE

identify if participation in a self-care program significantly improved quality of life for burn survivors

INCLUSION/ EXCLUSION CRITERIA (deaf, blind or mute) -inmates at the time of discharge. Inclusion: - age 18-60 years - willingness to participate in research - Persian written and reading literacy - no recorded mental illness or mental retardation or other chronic disease - access to telephone - >10% BSA burn - outpatient status - active participation in training sessions Exclusion: - death - new stressful event during research protocol - reluctance to continue work with researcher - involvement in any other training or counseling program

OUTCOMES MEASURES

FINDINGS

Post intervention survey

- After one month and two months of the use of self-care model, QOL of the cases improved from 73.33% to 83.78% and 98.12%, respectively (P<0.001). - The changed in the QOL of the patients in the control group were not statistically significant (P>0.05). -Based on the obtained results of this study, designing and implementing a self-care program based on Orem’s model and the needs of burn patients will improve their QOL

Primary: QOL (BSHS-B)

SOURCE (COUNTRY OF ORIGIN)

INTERVENTION

STUDY DESIGN

SETTING

SAMPLE DESCRIPTION

STUDY OBJECTIVE

INCLUSION/ EXCLUSION CRITERIA

OUTCOMES MEASURES

FINDINGS

Moore et al, 2013 (USA)(26)

Evaluation by staff psychiatrist

Retrospective Cohort

Inpatient

N: Overall: -Control: -Intervention: 83

To identify if addition of a staff psychiatrist to the burn unit team would add benefit to the patient care.

Inclusion: - burn subjects admitted to service from June 15, 2009 to April 30, 2010 – patient examined by psychiatrist

Primary: evaluation by staff psychiatrist

- Addition of psychiatrist to the Burn Service helped identify prevalence of psychiatric disorders (including pre-burn injury) and substance abuse prevalence. - Pharmacologic therapy was recommended in 91% of those evaluated by the psychiatrist.

Age: Overall— Control : -Intervention: 43.3 % TBSA: Overall-Control: -Intervention: 17.2/8.8/4.4 (Flame/Scald/Cont act) LOS: Overall: -Control: -Intervention: 20.1/8.7/10.7 (Flame/Scald/Cont act)

Exclusion: - Not above

Secondary: Exploratory including reasons for consultation, outcomes of diagnoses made by the psychiatrist and pharmacologic recommendations

SOURCE (COUNTRY OF ORIGIN)

INTERVENTION

STUDY DESIGN

SETTING

SAMPLE DESCRIPTION

STUDY OBJECTIVE

INCLUSION/ EXCLUSION CRITERIA

OUTCOMES MEASURES

FINDINGS

Seehausen et al, 2015 (Germany)(27)

Cognitive behavioral group training program

RCT- Not blinded

Inpatient and Outpatient

N: Overall: 214 Control: 128 Intervention: 86

The aim of the present study was to evaluate the efficacy of a newly developed cognitivebehavioral group training, specifically designed for burn patients

Inclusion: - inpatient or outpatient medical treatment due to burn injury - age 18-65 years - sufficient knowledge of the German language - no acute psychosis, advanced dementia or other severe cognitive impairment

Post intervention surveys, QOL

- Burn-specific cognitive-behavioral group intervention had positive effects on the psychological well-being and resources of burn participants. -As a consequence, the group intervention has been implemented as inherent part of the regular burn treatment in two rehabilitation centers in Germany.

Age: Overall: -Control : 40 Intervention: 44 %TBSA: Overall: -Control: 17 Intervention: 27

Exclusion: - Not above

LOS: Overall: -Control: -Intervention: --

Primary: Surveys used: SCL K-9, PSS, WHOQOL-Brief, F-SozU-K-14, HADS, LOT Psychological distress defined based on symptoms of depression, PTSD, anxiety, quality of life, and optimism rated using survey/ scale instruments as per above

Domain 4: Social Aspects of Care Grieve et al, 2018 (USA)(29)

Peer support group

Retrospective Cross Section

Outpatient

N: Overall: 596 Control: 266 Intervention: 330 Age: Overall: 40.5 Control : -Intervention: -%TBSA: Overall: -Control: 36.8 Intervention: 43.4 LOS: Overall: -Control: -Intervention: --

examine if peer support group attendance has an effect on social reintegration long-term for burn survivors

Inclusion: - age >=18 - TBSA >=5% or burns to hands/feet/face/genitals Exclusion: - participated in earlier phases of LIBRE study - did not provide information on peer support participation

Post intervention Survey- Social reintegration Primary: LIBRE-192 Social reintegration as assessed by LIBRE scales: participation among family and Friends, Social Interactions, Social Activities, Work and Employment, Romantic Relationships, and Sexual Relationships

- Burn survivors who reported peer support attendance showed improved long-term social reintegration compared with nonattending peers

SOURCE (COUNTRY OF ORIGIN)

INTERVENTION

STUDY DESIGN

SETTING

SAMPLE DESCRIPTION

STUDY OBJECTIVE

INCLUSION/ EXCLUSION CRITERIA

OUTCOMES MEASURES

FINDINGS

Williams et al, 2002 (USA)(30)

Inpatient peer visit

Prospective Cohort

Inpatient

N: Overall: -Control: -Intervention: 108

Goal of study to determine whether or not burn patients found a peer visit useful.

Inclusion: - inpatients being treated at a major burn center

Post intervention survey of patients/families

Exclusion: - patients who showed a thought disorder, impaired cognitive function, extreme behavioral acting out - reluctance to participate

Primary: Usefulness of intervention

- Three trained peer consultants made167 visits to 108 patients. Patients reported that the peer consultants approached them in an appropriate manner, answered their questions, and provided useful support and information. - No comparison group and no long-term outcomes captured.

Retrospective analysis of 808 burn patients, 365 major injuries, 66 deaths, with 16 of these made DNR with descriptive evaluation of decision making protocol and care provision for DNR patients.

Inclusion: - admission to University of Miami/Jackson Memorial Burn center - "overwhelming" burn injury based on clinical experience by the attending physician

Primary: Exploratory: analysis of DNR patient characteristics

Age: Overall: -Control : -Intervention: 32 %TBSA: Overall: -Control: -Intervention: 15.6 LOS: Overall: -Control: -Intervention: 26 Domain 7: Care of the Patient at the End of Life Hammond et al, 1989 (USA)(34)

Patients Made DNR - Protocol for decision making and care provision for nonsurvivable burn injuries

Retrospective Cohort

Inpatient

N: Overall: 808 (66 deaths) Control: -Intervention: 16 Age: Overall: -Control : -Intervention: 52.5 %TBSA: Overall: -Control: -Intervention: 78.6 LOS: Overall: -Control: -Intervention: --

Exclusion: - Dissent regarding prognosis

- Implementation of a protocol for decision making and care provision for patients with non-survivable burn injuries was effective at this institution - Retrospective analysis of 808 burn patients, 365 major injuries, 66 deaths, with 16 of these made DNR - Patient made DNR were thought to have overwhelming burn injury, older age, greater TBSA. - DNR was decided based on unprecedented survival.

SOURCE (COUNTRY OF ORIGIN)

INTERVENTION

STUDY DESIGN

SETTING

SAMPLE DESCRIPTION

STUDY OBJECTIVE

INCLUSION/ EXCLUSION CRITERIA

OUTCOMES MEASURES

FINDINGS

HemingtonGorse et al, 2011 (UK)(33)

Burn ModifiedLiverpool Care Pathway

Retrospective Cohort

Inpatient

N: Overall: 22 Control: 11 Intervention: 11

Primary objective was to assess adherence to the BM-LCP and to assess any variance from the pathway.

Inclusion: - All burn deaths occurring between 1st January 2008 and 31st December 2009

Primary: Exploratory: adherence to the BM-LCP and assessment of any variance from the pathway

- BM-LCP is the first example of a specific EOL pathway for use in burns patients. - easy to adhere to and is well received by the staff using it. - Authors recommend it to the burn community both to improve care and to standardize EOL care in burns patients throughout the UK and beyond

To examine the practices of burn surgeons for initiating EOL discussions (early vs late) and the impact of decisionsmade on the courses of geri-burn patients who died after injury.

Inclusion: -aged 65 years or older - admitted to the Parkland burn service between April 1, 2009 and December 31, 2014 - died during their index admission

Primary: Exploratory: Timing of EOL discussion (<24hr or >24hr)

- The vast majority of geri-burn deaths on our burn service occur after a discussion about EOL care - The timing of these discussions is driven by magnitude of injury as early EOL discussions were statistically more prevalent with higher Baux score, and it does not lead to higher proportions of an immediate decision for comfort care.

Age: Overall: 22-76 (range) Control : -Intervention: 59 (mean)

Exclusion: - non burn patients -died elsewhere - sets of notes were not available for review

%TBSA: Overall: 55 Control: -Intervention: 65.4

Partain et al, 2016 (USA)(32)

Early (<24 hours) end-of-life goals discussion in severely burned geriatric patients

Retrospective Cohort

Inpatient

LOS: Overall: -Control: -Intervention: -N: Overall: 57 Control: 16 Intervention: 38 Age: Overall: -Control : 78.5 Intervention: 79.1 %TBSA (Reported as Baux Score: (Age+TBSA): Overall: -Control: 96.5 Intervention: 121.1 LOS: Overall: -Control: 18.1 Intervention: 4.3

Exclusion: - Did not have a EOL discussion

Secondary: decision made, patient characteristics

SOURCE (COUNTRY OF ORIGIN)

INTERVENTION

STUDY DESIGN

SETTING

SAMPLE DESCRIPTION

STUDY OBJECTIVE

INCLUSION/ EXCLUSION CRITERIA

OUTCOMES MEASURES

FINDINGS

Pham et al, 2012 (USA)(31)

Implementation of standardized end-of-life protocol

Retrospective Cohort: Pre/Post Protocol

Inpatient

N: Overall: 126 Control: -- 20 Intervention: 106

In this study, the authors evaluated the frequency of early withdrawal and the protocol impact on endof-life processes of care in burn patients who died within 72 hours of hospitalization.

Inclusion: - age >18 - admitted to University of Washington burn unit - death within 72 hours of admission - admitted between January 1995 and December 2007

Primary: Exploratory: Median time from removal of life support to death, processes of care at time of withdrawal (opioid infusion use, benzodiazepine infusion use, offering of bereavement support services, ongoing use of ventilator at time of death, use of family conference in decisionmaking)

- Implementation of a standardized protocol for withdrawal of life support in cases of severe burn injury at a large regional burn center resulted in improved EOL processes, including more frequent use of symptom-focused medications, without hastening death.

Age: Overall: -Control : -Intervention: 59 %TBSA: Overall: -Control: -Intervention: 61 LOS: Overall: -Control: -Intervention: 1

Exclusion: - missing data on chart review

Abbreviations: BM-LCP, Burn Modified Liverpool Care Pathway; BSHS-B, burn-specific health scale-brief; BSHS-R, Burn Specific Health Scare Revised; DC, discharge; DNR, Do not resuscitate; F-SozU-K-14, Social Support Questionnaire- Brief; geri, geriatric; HADS, Hospital Anxiety and Depression Scale; IES, Impact of the Event Scale; IHT, Interactive Home Telehealth; LIBRE, Life Impact Burn Recovery Evaluation; LOS, Length of stay; LOT, Life Orientation Test; N, Number of patients; PSE, Perceived Self-Efficacy Scale; PSS, PTSD Symptoms Scale; PTSD, post-traumatic stress disorder; QOL, Quality of Life; RCT, Randomized Control Trial; SCL K-9, Symptoms Checklist K-9; SF-12, Short Form Health Survey; TBSA, total body surface area; UK, United Kingdom; USA, United States of America; WHOQOL, World Health Organization Quality of Life- Brief

Table 4: Summary of Interventions by Domain Domain 1: Structure and Processes of Care • Pre-discharge Training Program (N=1) • Telehealth Program (N=1) • Expanded Outpatient Care Coordinator (N=1) Domain 3: Psychological and Psychiatric Aspects of Care • Self-Care Program (N=2) • Psychiatrist Evaluation (N=1) • Cognitive Behavioral Group Therapy (N=1) Domain 4: Social Aspects of Care • Peer Intervention (N=2) Domain 7: Care of the Patient at the End of Life • End of Life Protocol (N=3) • Goals of Care Discussion (N=1)

Table 5: Quality of Randomized Controlled Trials Studies, as assessed by the Cochrane Review of Bias(20) STUDY REFERENCE (FIRST AUTHOR, YEAR)

SEQUENCE GENERATION

ALLOCATION CONCEALMENT

BLINDING OF PARTICIPANTS AND PERSONNEL

BLINDING OF OUTCOME ASSESSORS

INCOMPLETE OUTCOME DATA

SELECTIVE OUTCOME REPORTING

OTHER SOURCES OF BIAS

Gonçalves et al, 2016(25)

Low

Low

High

High

Unclear

Unclear

Unclear

Hashemi et al, 2014(28)

Low

Low

High

High

Unclear

Low

Low

Lotfi et al, 2018(22)

Low

Unclear

High

High

Low

Unclear

Unclear

Seehausen et al, 2015(27)

High

High

High

High

High

Low

Low

Wiechman et al, 2015(24)

Unclear

Unclear

High

High

Unclear

Low

Unclear

Table 6: Quality of Non-Randomized Studies as assessed by the Newcastle-Ottawa Quality Assessment Scale(21), when applicable STUDY REFERENCE (FIRST AUTHOR, YEAR)

SELECTION (MAX 4)

COMPARABILITY (MAX 2)

OUTCOME (MAX 3)

TOTAL (MAX 9)

Grieve et al, 2018(29)

**

*

*

****

Pham et al, 2012(31)

****

*

***

*******

Table 7: Summary of Key Results of the Systematic Review • Nearly all existing studies addressed only the domain of “physical aspects of care”. • Some studies addressed care at the end of life, psychologic symptoms, social aspects of care, and structure/ processes of care. • Spiritual, cultural, and ethical domains were not addressed in the current literature. • Peer support, group therapy, and peri-discharge education may improve quality of life for burn patients. • Protocols for decision making and goals of care at the end of life are feasible and may improve end of life processes including attention to symptoms.

Appendix A: Example of Search Strategy- PubMed(38)

((((((((((((“Palliative care” [Mesh] OR "palliative care" [tiab] OR “Hospice and Palliative Care Nursing” [Mesh] OR “Hospice care”[Mesh] OR "hospice care" [tiab] OR palliati*[tiab] OR “Terminal care” [Mesh] OR “end of life”[tw] OR “terminal care” [tiab] OR (“Referral and Consultation”[Mesh] AND (palliative [tiab] OR hospice [tiab])) OR “quality of life”[tw] OR “patient comfort”[Mesh] or comfort*[tiab] OR “goals of care”[tw] OR “goal of care”[tw] OR “End-of-life”[tw]) OR ((“interdisciplinary”[tiab] OR “interprofessional”[tiab] OR “multidisciplinary”[tiab]) AND (care [tiab] OR cares[tiab] OR caring[tiab] OR plans[tiab] OR planning[tiab] OR plan[tiab] OR consult*[tiab])) OR (Pain management [Mesh] OR paresthesia [Mesh] OR analgesics[Mesh] OR pain [tiab] OR sedate*[tiab] OR sedation*[tiab]OR sedative*[tiab] OR analgesia[tiab] OR analgesic*[tiab] OR nutrition [tiab] OR “life support care” [Mesh] OR “life support” [tiab] OR “patient comfort”[Mesh] OR comfort*[tiab] OR “symptom management”[tw] OR “symptom-based”[tiab] OR “symptom control”[tiab] OR (symptom*[tiab] AND (reduc*[tiab] OR improve*[tiab] OR control*[tiab]))) OR (Psychiatry[Mesh] OR delirium[tw] OR agitat*[tw] OR psychology[Mesh] OR anxiety[Mesh] OR delirium [Mesh] OR depression[Mesh] OR stress[tiab] OR “Adaptation, Psychological”[Mesh] OR “psychological needs”[tiab] OR psycholog*[tiab] OR psychiatry*[tiab] OR anxiety[tiab] OR depress*[tiab]) OR (Caregivers[Mesh] OR “family relations”[Mesh] OR caregiver*[tiab] OR “family nursing”[Mesh] OR “professional-family relations”[Mesh] OR “social support”[Mesh]) OR (Spirituality[Mesh] OR “pastoral care”[Mesh] OR religion [Mesh] OR spiritual*[tiab] OR religi*[tiab]) OR (“cultural competency”[Mesh] OR cultural* [tiab]) OR (((death[Mesh] OR death [tiab]) AND (counseling[Mesh] OR adaptation[Mesh] OR adapt*[tiab] OR counsel*[tiab])) OR “attitude to death"[Mesh] OR (transit*[tiab] AND “comfort care”[tiab]) OR “withdrawal of care”[tiab] OR ((withhold*[tiab] OR withdraw*[tiab]) AND (treatment[tiab] OR care[tiab]))))) AND ((“burn units” [Mesh] OR burns/diet therapy [Mesh] OR burns/drug therapy[Mesh] OR burns/nursing [Mesh] OR burns/psychology[Mesh] OR burns/rehabilitation[Mesh] OR burns/surgery[Mesh] OR burns/therapy[Mesh] OR “burn centers” [tw] OR “burn units” [tw] OR “burn patients” [tw] OR burn [tiab] OR burned [tiab] OR burns [tiab])))) NOT ((paediatric*[tiab] OR pediatric*[tiab] OR child[ti] OR children[ti] OR childrens[tiab] OR child’[ti] OR “burn out”[tw] OR “burnedout”[tiab] OR “burn-out”[tw] OR “burnout”[tw] OR practitioner*[tiab] OR oxidat*[tw] OR “Robert Burns”[tiab] OR apoptosis[tiab] OR acne[tiab] OR “oral ulcer”[tiab] OR assay[tiab] OR cellular[tiab] OR "spectral hole burning"[tw] OR “animal model”[tw] OR “models, animal”[Mesh] OR “in-vivo”[tiab] OR “animal experimentation”[Mesh] OR “wound culture”[tw] OR “wound cultures”[tw] OR “culture and sensitivity”[tiab] OR histolog*[tiab] OR “Clinical Conference”[pt] OR “Comment”[pt] OR “editorial”[PT] OR “Lectures”[pt] OR “Letter”[pt] OR greenhouse[tiab] OR methane[tiab])))) NOT ((animals[Mesh] NOT humans[Mesh])))) AND English[la])))