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Burn injuries often require complex interdisciplinary care. Despite potential benefits, consultation with specialist palliative care typically occurs in 2% of burn admissions, due largely to lack of availability and misconceptions concerning palliative care. Criteria to guide consultation with specialist palliative care have been developed at this institution. The purpose of this study was to quantify the sensitivity and specificity of these criteria, and then optimize them. Retrospective examination of 388 admissions over 15 months at this adult and pediatric Burn Center were conducted. Chi-square or Fisher’s exact test for categorical variables and Wilcoxon Rank Sum test for continuous variables were used to test for between-group differences in demographic and clinical characteristics. Logistic regression model was built to determine modified Baux cut-off score using Youden index (J) value. Criteria were sensitive (0.96) and specific (0.90), though with a low positive predictive value (0.43). Persons with lengths of stay greater than one week, advanced directives, Allow Natural Death orders, and/or deterioration events were significantly more likely to have had palliative care consulted. There were significant between-group differences (with/without palliative care consultation) based on burn surface area, modified Baux score, and mortality risk. Potential criteria revisions are proposed. Prospective adherence to revised criteria could provide useful guidance to providers and benefit to patients and families.

Introduction Palliative Care (PC) is a limited resource, requiring allocation to those most likely to benefit. One currently underserved population is persons sustaining burns, as these injuries may severely limit quality of life, psychosocial and physical health. Additionally, treatment decisions must frequently be made on an emergent basis on behalf of someone unable to participate in decision making. PC services could benefit patients and caregivers substantially, yet only 2% of persons who have been burned are referred to PC. We developed empirically-derived referral criteria; the purpose of this study was to quantify the sensitivity, specificity, and predictive value of the criteria when retrospectively applied. Methods Retrospective review of regional burn center admissions (1/1/2019-1/31/2022) to determine adherence to criteria indicating referral to PC should be made or considered. Descriptive statistics characterizing the sample and criteria performance were calculated. Results N=388 admissions occurred study period (29.9% female; mean(SD) age=39.9 (24.1) years. N=28 persons were referred to PC; n=27 met consult criteria, and n=1 met consider criteria. Criteria for PC consultation indicated referral for n=62, and had 0.96 sensitivity, 0.90 specificity, 0.44 positive predictive value, 1.00 negative predictive value, 0.91 total accuracy. Criteria for considering PC consultation were indicated for n=181 and had 1.00 sensitivity, 0.45 specificity, 0.01 positive predictive value, 1.00 negative predictive value, 0.45 total accuracy. Conclusions Criteria for PC consultation were sensitive and specific, though the positive predictive value was low. Criteria for consideration show low values; however, documentation did not reveal whether referral was considered or not. Presence of comorbidities was the most commonly-met criterion for referral consideration. Despite the robust sample size, data from a single site may have limited generalizability. Criteria have promising characteristics, may be used as basis for quality improvement efforts, and merit ongoing study and revision to improve predictive ability. Applicability of Research to Practice These criteria advance clinical practice by providing guidance on identifying persons most likely to benefit from specialist PC.

Burns frequently require complex interdisciplinary care. Specialist palliative care (PC) minimizes suffering, aids in decision making, and provides family support in addition to end-of-life care. Specialist PC is a limited resource, best conserved by identifying persons most likely to benefit from a PC referral. Little guidance is available for clinicians on whether and when to refer to PC. This study’s purpose was to identify referral criteria using a mixed-methods approach. Data were examined for between-group differences using Fisher’s exact, chi-square, or Wilcoxon Rank Sum tests. Qualitative thematic analysis was used to analyze PC provider notes to describe interventions provided. These data formed initial referral criteria, which were reviewed by an expert panel. Significant between-group differences included dying in the burn center; whether multiple patients were transported to the burn center from one event; and ventilator days. Four themes emerged from qualitative analysis. These included managing physical aspects of care; clarifying goals of care; managing end-of-life care; and managing patient/family psychosocial distress. Expert panel input clarified referral criteria language and supplemented the proposed criteria. We present empirically derived referral criteria to guide burn providers in referring persons for specialist PC. Subsequent testing is required to determine their efficacy in improving patient/family outcomes.

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