Impact of COVID-19 on global burn care.

BACKGROUND: Worldwide, different strategies have been chosen to face the COVID-19-patient surge, often affecting access to health care for other patients. This observational study aimed to investigate whether the standard of burn care changed globally during the pandemic, and whether country´s income, geographical location, COVID-19-transmission pattern, and levels of specialization of the burn units affected reallocation of resources and access to burn care. METHODS: The Burn Care Survey is a questionnaire developed to collect information on the capacity to provide burn care by burn units around the world, before and during the pandemic. The survey was distributed between September and October 2020. McNemar`s test analyzed differences between services provided before and during the pandemic, χ2 or Fisher's exact test differences between groups. Multivariable logistic regression analyzed the independent effect of different factors on keeping the burn units open during the pandemic. RESULTS: The survey was completed by 234 burn units in 43 countries. During the pandemic, presence of burn surgeons did not change (p = 0.06), while that of anesthetists and dedicated nursing staff was reduced (<0.01), and so did the capacity to manage patients in all age groups (p = 0.04). Use of telemedicine was implemented (p < 0.01), collaboration between burn centers was not. Burn units in LMICs and LICs were more likely to be closed, after adjustment for other factors. CONCLUSIONS: During the pandemic, most burn units were open, although availability of standard resources diminished worldwide. The use of telemedicine increased, suggesting the implementation of new strategies to manage burns. Low income was independently associated with reduced access to burn care.

Impact of the COVID-19 pandemic on the epidemiology of severe burns : A single center study from a specialized burn center in Vienna.

INTRODUCTION: Currently, very little detailed information on the epidemiological distribution and specificities of severely burned patients during the coronavirus disease 2019 (COVID-19) pandemic is available. This retrospective study aims to describe and compare this specific patient population based on 114 patients who were treated between March 2019 and March 2021 at the Center for Severe Burn Injuries at the Medical University of Vienna. METHODS: To answer the research questions, a retrospective cohort study has been conducted over a period of 24 months, starting in March 2019 and ending in March 2021. To evaluate the epidemiological differences, the patients were divided into 2 observation periods of 12 months each. RESULTS: In the period from 12 March 2020 to 11 March 2021, a total of 62 patients were admitted to the Center for Severe Burn Injuries. In comparison, only 52 patients were admitted in the same period of the previous year, which corresponds to an increase of 19.2%. In addition, it was noted that during the 2019-2020 observation period, 27% of patients were female and 73% male, whereas during the pandemic the gender distribution was 42% female and only 58% male. During the pre-pandemic observational period, 13 out of 52 patients admitted died (25%), whereas during the pandemic, 17 out of 62 patients succumbed to their injuries (27%). CONCLUSION: Although the severity of the COVID-19 pandemic seems to be decreasing, especially due to the increasing availability of vaccines, there is a need for more data on the impact of the crisis on severely burned patients. In contrast to the current literature, we have seen a greater number of inpatient admissions to the Center for Severe Burn Injuries, as well as significant differences in gender distribution. Our data also suggest that the circumstances of the pandemic have no influence on the likelihood of survival for patients with severe burns.

Trends in Burn Injuries in Northern Israel During the COVID-19 Lockdown.

Coronavirus disease 2019 obliged many countries to apply lockdown policies to contain the spread of infection. The restrictions in Israel included limitations on movement, reduction of working capacity, and closure of the educational system. The present study focused on patients treated at a referral center for burns in northern Israel. Their goal was to investigate temporal variations in burn injuries during this period. Data were retrospectively extracted from the medical records of burn patients treated at our hospital between March 14, 2020 and April 20, 2020 (ie, the period of aggravated lockdown). Data from this period were compared with that from paralleling periods between 2017 and 2019. During the lockdown and paralleling periods, 178 patients were treated for burn injuries, of whom 44% were under 18. Although no restrictions were enforced during the virus outbreak period with regard to seeking medical care, we noticed a decrease in the number of patients admitted to the emergency room for all reasons. Of particular interest was a 66% decrease in the number of adult burn patients (P < .0001). Meanwhile, among the pediatric population, no significant decrease was observed. Nonetheless, subgroups with higher susceptibility to burn injuries included children aged 2 to 5 years (56.3% vs 23.8%, P = .016) and female patients from all pediatric age groups (57.1% vs 25%, P = .027). These findings may be explained by the presumably busier kitchen and dining areas during the lockdown. Overall, the study results can assist with building a stronger understanding of varying burn injuries and with developing educational and preventive strategies.

The effect of COVID-19 on burn management and outcomes in a resource-limited setting.

INTRODUCTION: Optimal burn care includes fluid resuscitation and early excision and grafting. During the COVID-19 pandemic, resource-constrained environments were susceptible to interruptions in burn care. We sought to characterize pre- and intra-pandemic burn-associated outcomes at a busy tertiary hospital in Malawi. METHODS: This is a retrospective analysis of burn patients that presented to Kamuzu Central Hospital Lilongwe from 2011 through December 2021. We compared patients based on whether they presented pre- or intra-pandemic, starting on March 11, 2020, the date of official WHO designation. Comparing these cohorts, we used modified Poisson modeling to estimate the adjusted risk of undergoing an operation and the risk of death. RESULTS: We included 2969 patients, with 390 presenting during the pandemic. Patient factors were similar between the cohorts. More patients underwent surgery pre-pandemic (21.1 vs 10.3 %, p < 0.001) but crude mortality was similar at 17.3 % vs. 21.2 % (p = 0.08). The RR of undergoing surgery during the pandemic was 0.45 (95 % CI 0.32, 0.64) adjusted for age, sex, % TBSA, flame burns, and time to presentation. During the pandemic, the risk ratio for in-hospital mortality was 1.23 (95 % CI 1.01, 1.50) adjusted for age, sex, % TBSA, surgical intervention, flame burns, and time to presentation. CONCLUSIONS: During the pandemic, the probability of undergoing burn excision or grafting was significantly lower for patients, independent of the severity. Consequently, the adjusted risk of mortality was higher. To improve patient outcomes, efforts to preserve operative capacity for burn patients during periods of severe resource constraint are imperative.

The effect of COVID-19 pandemic on the number of patients in burns services.

This study was conducted to examine the effects of the coronavirus disease 2019 (COVID-19) pandemic on the epidemiological characteristics and causes of burns in patients admitted to burns services. A total of 629 patients who applied to the burn center of our hospital on March 11 to June 11, 2019, and March 11 to June 11, 2020, were included in this single-center, retrospective study. The demographic information of the patients, causes of burns, burn degrees, affected anatomical areas, admission times and burn surface areas were recorded retrospectively according to patient records. The findings of our study suggest that gender, age, causes of burns, affected anatomical areas and application times did not differ before and after the COVID-19 pandemic. The number of cases has significantly decreased during the COVID-19 pandemic compared with that of the previous year. As a result, burn trauma is an emergency; it is preventable and cannot be ignored. The COVID-19 pandemic has had many effects on social, cultural and economic fields, as well as on the field of health.

The impact of social isolation by COVID-19 on the epidemiological and clinical profiles of the burn patients. A retrospective study.

BACKGROUND: Social isolation, imposed by the COVID-19 pandemic, may imply changes in the clinical-demographic and epidemiological profiles of burn trauma victims. OBJECTIVE: Evaluate the changes in the epidemiological profile of patients with burns that resulted in hospitalization during the social isolation period due to the COVID-19 pandemic, comparing with the same period in the previous year. METHODS: The medical records of burn patients who were hospitalized in our Burn Center during the local confinement period (March 18th to August 31st, 2020) and during the same period in 2019 were analyzed. Data on demographic, clinical and hospitalization aspects were studied. RESULTS: 470 patients were evaluated. In the pediatric population, a significant increase in the number of cases up to 2 years old (P = 0.0003), median of %TBSA (P = 0.037), full-thickness burns (P < 0.0001), involvement of hands (P = 0.024), debridement (P = 0.046) and grafting (P = 0.032) procedures, and higher scores of severity (P < 0.0001) were noted. In the adult population, it was only observed an increase in the burn-hospitalization interval (P = 0.029). CONCLUSION: The pediatric population was heavily impacted by the imposed period of social isolation, presenting a greater severity of burns. In contrast, the epidemiology of burns for the adult population was slightly altered during the pandemic period.

Impact of COVID-19 and containment measures on burn care: A qualitative exploratory study.

BACKGROUND: Burn care in India is limited by multiple constraints. The COVID-19 pandemic and the containment measures restricted access to non-COVID emergency conditions, including burns. The aim of this study was to explore the impact of the pandemic on burn care in India. METHODS: Using the qualitative exploratory methods, we conducted in-depth interviews (IDI) with plastic and general surgeons representing burn units from across India. Participants were selected purposively to ensure representation and diversity and the sample size was guided by thematic saturation. Thematic analysis was undertaken adopting an inductive coding using NVivo 12 Pro. RESULTS: 19 participants from diverse geographic locations and provider types were interviewed. Three major emerging themes were, change in patient and burn injury characteristics; health system barriers, adaptation, and challenges; and lessons and emerging recommendations for policy and practice. There was change in patient load, risk factors, and distribution of burns. The emergency services were intermittently disrupted, the routine and surgical services were rationally curtailed, follow-up and rehabilitation services were most affected. Measures like telemedicine and decentralising burn services emerged as the most important lesson. CONCLUSIONS: The ongoing pandemic has compounded the challenges for burns care in India. Urgent action is required to prioritise targeted prevention, emergency transport, decentralise service delivery, and harnessing technology for ensuring resilience in burns services.

Compounded Cerium Nitrate-Silver Sulfadiazine Cream is Safe and Effective for the Treatment of Burn Wounds: A Burn Center's 4-Year Experience.

Wound infections and sepsis are significant causes of morbidity after burn injury and can be alleviated by early excision and grafting. In situations that preclude early surgery, topical agents allow for a safer delay. Cerium nitrate compounded with silver sulfadiazine (Ce-SSD) is a burn cream that provides broad antibacterial activity, forms a temporary barrier, and promotes re-epithelialization. Methemoglobinemia is a rare, but oft-cited, systemic complication of Ce-SSD. In this retrospective review, 157 patients treated with Ce-SSD between July 2014 and July 2018 were identified, and the monitoring protocol for methemoglobinemia during Ce-SSD treatment was evaluated. The median age was 59 years (interquartile range [IQR], 47-70.5 years), with TBSA of 8.5% (IQR, 3-27), adjusted Baux score of 76 (IQR, 59-94), and inhalation injury present in 9.9% of patients. Primary endpoints included incidence of symptomatic and asymptomatic methemoglobinemia. Of the 9.6% (n = 15) of patients with methemoglobinemia, 73.3% (n = 11) had maximum methemoglobin levels ≥72 hours from the time of the first application. One patient developed clinically significant methemoglobinemia. Patients with TBSA ≥20% were more likely to develop methemoglobinemia (odds ratio 9.318, 95% confidence interval 2.078-65.73, P = .0078); however, neither Ce-SSD doses nor days of exposure were significant predictors. Ce-SSD application to temporize burn wounds until excision and grafting is safe, effective, and, in asymptomatic patients with TBSA <20%, can be used without serial blood gas monitoring. Vigilant monitoring for symptoms should be performed in patients with TBSA ≥20%, but routine blood gases are not necessary.

Predictors of Follow-up Compliance in Pediatric Burn Patients During the Time of COVID.

The effect of the COVID-19 pandemic has led to increased isolation and potentially decreased access to healthcare. We therefore evaluated the effect of COVID-19 on rates of compliance with recommended post-injury follow-up. We hypothesized that this isolation may lead to detrimental effects on adherence to proper follow-up for children with burn injuries. We queried the registry at an ABA-verified Level 1 pediatric burn center for patients aged 0-18 years who were treated and released from March 30 to July 31, 2020. As a control, we included patients treated during the same time frame from 2016 to 2019. Patient and clinical factors were compared between the COVID and pre-COVID cohorts. Predictors of follow-up were compared using chi-squared and Kruskal-Wallis tests. Multivariable logistic regression was used to evaluate for predictors of compliance with follow-up. A total of 401 patients were seen and discharged from the pediatric ED for burns. Fifty-eight (14.5%) of these patients were seen during the pandemic. Burn characteristics and demographic patterns did not differ between the COVID and pre-COVID cohorts. Likewise, demographics did not differ between patients with follow-up and those without. The rate of compliance with 2-week follow-up was also not affected. Burn size, burn depth, and mechanism of injury all were associated with higher compliance to follow up. After adjusting for these variables, there was still no difference in the odds of appropriate follow-up. Despite concerns about decreased access to healthcare during COVID, follow-up rates for pediatric burn patients remained unchanged at our pediatric burn center.

Management of a Pediatric Burn Center During the Covid-19 Pandemic.

The aim of this study was to evaluate the results of an algorithm that was created to prevent coronavirus disease-2019 (COVID-19) transmission during the management of children with burns in a tertiary pediatric burn center. Children admitted to the burn center between May 2020 and November 2020 were prospectively evaluated for cause, burn depth, TBSA, length of stay, symptoms suggesting COVID-19, suspicious contact history, history of travel abroad, and COVID-19 polymerase chain reaction (PCR) test results. Patients were divided into two groups: unsuspected (group 1) and suspected (group 2), depending on any history of suspicious contact, travel abroad, and/or presence of symptoms. A total of 101 patients were enrolled in the study, which included 59 boys (58.4%) and 42 girls (41.6%). Group 1 included 79 (78.2%) patients, and group 2 consisted of 22 (21.8%) patients. The most common cause of the burns was scald injuries (74.2%). The mean age, TBSA, and length of stay were 4.5 years, 12.0%, and 13.2 days, respectively. Four patients (3.9%) had a positive PCR test (two patients in each group). Comparing groups, males were more commonly found in group 2 (P = .042), but no differences were found for the other variables. No patients or burn center staff members developed COVID-19 during the course of hospitalization. In conclusion, every child should be tested for COVID-19 upon admission to a burn unit, and a modified algorithm should be constructed for the handling and management of pediatric burn patients.

Adherence of Burn Outpatient Clinic Referrals to ABA Criteria in a Tertiary Center: Creating Unnecessary Referrals?

Initial assessment and triage of burns are guided by the American Burn Association criteria for referral to a burn center. These criteria are sensitive but not specific and can potentially lead to over-triage and "unnecessary" clinic visits. We are a Level 1 trauma center with burn subspecialty care, and due to the COVID-19 pandemic, referrals to our multidisciplinary outpatient burn clinic required triaging for virtual care appointments. In order to improve the triage process, we retrospectively reviewed our outpatient burn clinic referrals over a 2-year period, 2018 to 2019, for adherence to American Burn Association criteria. We collected data pertaining to patient and burn characteristics, as well as treatment outcome, to characterize referrals not requiring an in-person appointment. Of the 244 patients referred, 73% met the referral criteria, with 45% of these patients being healed at the first visit and 14.6% requiring surgical management. Mean time from injury to first visit was 9.7 days (mode 6), and the average number of visits was 2. Overall, mean burn size was 2%, with the majority of injuries being partial thickness (71%), located in the hand or extremity (77%). There was a fairly equal distribution of contact (36%), flame (21%), and scald (26%) burns. This study highlights the nonspecific nature of the American Burn Association referral criteria. We found that pediatric and hand burns in particular were over-triaged and lead to "unnecessary" appointments. This information is useful to help adjust referral criteria and to guide triaging of appointments with the evolution of telehealth and virtual care.

The Impact of the COVID-19 Pandemic on Burn Admissions at a Major Metropolitan Burn Center.

The impact of the coronavirus disease 2019 (COVID-19) pandemic on admission patterns and outcomes at a burn center is still largely unknown. The aim of this study was to determine how the COVID-19 pandemic affected the epidemiology of burn admissions at a major metropolitan burn center. This retrospective cohort study examined how the COVID-19 pandemic affected burn volumes and time to presentation. All burn admissions were included from January 20 to August 31 for the years 2020, 2019, and 2018. The COVID-19 pandemic group included admissions from January 20, 2020 to August 31, 2020 and was compared to the nonpandemic group comprised of admissions from January 20 to August 31 in 2018 and 2019. Subgroup analysis was performed according to meaningful dates during the COVID-19 pandemic including the first U.S. COVID-19 case, shelter-in-place, and state reopening orders. Admission volumes were 403 patients in the COVID-19 pandemic group compared to a mean of 429 patients in the nonpandemic group, which correlated to a 5.8% decrease in volume during the pandemic. The pandemic group showed an increase in time to presentation of 1 day (P < .0001). Subgroup analysis demonstrated stable admission volumes and an increase in time to presentation of 1 day (P < .0001) at each time point. During shelter-in-place orders, there were higher rates of second/third-degree burns and operative burns (94.7 vs 56.3% and 45.6 vs 27%, P < .0001, P = .013). During the pandemic, there were stable admission volumes, delayed time to admission, and an increase in operative burns during shelter-in-place orders. This reinforces the need to maintain appropriate burn center staffing and resources during the COVID-19 pandemic.

Changes in the epidemiologic profile of burn patients during the lockdown in Catalonia (Spain): A warning call to strengthen prevention strategies in our community.

BACKGROUND: The worldwide coronavirus disease 2019 (COVID-19) epidemic, caused by the SARS-CoV-2 coronavirus, is the defining global health crisis of our time. Spain has had one of the highest burdens of COVID-19 worldwide. During this period, Vall d'Hebron University Hospital Burn Center (Barcelona) has faced a unique challenge: supporting the hospital response against COVID whilst continued offering an optimal care to the burn patient. OBJECTIVE: The aim of this study is to characterize the clinical and epidemiological characteristics of acute burn patients who received urgent health care or admission to the our Burn Center during the mandatory confinement period in Spain forced by the COVID-19 epidemic. METHODS: We analyzed the medical records of burn patients who received urgent care and/or admission to our Burn Center during the mandatory confinement period in Spain (Period 1: from March 14th to May 9th, 2020) and during the same period of the last year (Period 2: from March 14th to May 9th, 2019). Both groups were compared in order to find differences in the epidemiologic profile of burned patients. RESULTS: A total of 350 burns cases were analyzed. A 36% reduction in the number of emergency department visits was identified during Period 1. However, we found an increase in the rate of hospital admissions in Period 1 (20% of the burn cases) compared with Period 2 (13% of the burn cases). Seventy-six burn-related primary admissions were analyzed: 37 patients were admitted during Period 1 and 39 patients during Period 2. No differences were found between the two periods in the proportion of patients that underwent surgical treatment: 59.5% of patients admitted during Period 1 and 61.5% of patients admitted during Period 2. A statistically significant increase was noted in the rate of paediatric (aged 0-16 years old) admissions during Period 1 (40.54%, n = 15) compared to Period 2 (20.5%, n = 8). Among paediatric patients, an increase in the rate of surgical procedures was noted in Period 1 (47% of children), compared with Period 2 (37% of children). Proportion of patients that were admitted to the Intensive Care Unit was higher among burn children admitted during period 1 (46.7%, n = 7) than those admitted during Period 2 (25%, n = 2). Among the 37 patients admitted during the lockdown period, two positive COVID-19 patients were confirmed. CONCLUSIONS: This study gives an overview of the clinical and epidemiologic profile of burned patients during the stringent lockdown in Spain forced by the COVID-19 epidemic. Our data shows a stable trend in the number of burn-related admissions and burn related-surgeries during the confinement period. A significant increase in the rate of burn children admitted and an increase in the severity of injuries in this population is noted. These data must be taken in account in the development of strategies to ensure the maintenance of Burn Centers function in extremely situations such as the current epidemic. A lack of effective burn prevention campaigns in our environment has been noted and the development of focused prevention strategies is a priority.

The Impact of COVID-19 on Adult Burn Management in the United Kingdom: A Regional Center Experience.

In this study, we aim to quantify the impact of COVID-19 on burns provision at an adult regional burn center. Two cohorts of patients were identified for comparison: one during the beginning of the COVID-19 lockdown in April 2020 and a comparator cohort in April 2019. There was a 30% decrease in the incidence of adult burns in 2020. The mean total body surface area (TBSA) was 1.8% and 4.3% in 2019 and 2020, respectively. Scald injuries were the commonest mechanism of burns in both cohorts. Depth of burns was deeper in 2019, with 17.6% of patients presenting with deep burns, compared with 9.6% in 2020. Eight percent of patients in 2019 required theater compared with zero patients in 2020. A similar percentage of patients were admitted in both cohorts. In 2019, admitted patients had an average inpatient stay of 0.57 days per TBSA. In 2020, the average stay per TBSA in all patients was 0.6 days and 1.5 days in survivors. In the lockdown period, 54% of patients were followed up by telemedicine. This difficult period has taught us how important a functioning healthcare system is and how we can be better prepared in the future.

The impact and lessons learnt from the COVID-19 pandemic on a UK Burns Centre.

The COVID-19 pandemic has dramatically impacted healthcare provision in the UK and burns services have had to adapt to ensure the continuity of a safe care. As we return to "normality" we reflect on lessons learnt from our response to this pandemic. A service evaluation was performed from patient notes between March 23rd and May 8th 2020 and an anonymous survey given to patients attending outpatient appointments. 258 patients were referred to our burns service and 148 patients completed the survey. Eleven burns were caused by treatment or prevention of COVID-19. Patients delayed seeking medical attention due to concern of catching COVID-19 (36% adults, 8% children). There was a delay in referral of 17 patients despite them fulfilling the referral criteria. Infection rates were higher following delayed presentation (21% vs 6%). The majority of burns were managed conservatively (237/258). Dressing changes were performed at home by 32% of patients. The outreach team treated 22 patients. During the pandemic telemedicine has improved the efficiency of outpatient burn care and outreach nurses have enabled treatment of vulnerable patients. More must be done to raise public awareness of preventable causes of burn injury and to reassure them to seek help when burns occur.