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.

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.

[Effects of COVID-19 lockdown on the demand for health care of children and adolescents with burns in three specialized outpatient centers in Chile]. / Efectos del confinamiento por COVID-19 en la demanda de atención de niñas, niños y adolescentes con quemaduras en tres centros ambulatorios especializados de Chile.

INTRODUCTION: COVID-19 pandemic has meant adapting to a different reality, with long-term lockdowns that might cause an increase of burns in children at home. OBJECTIVE: To compare the epidemiological situation of patients admitted to the Corporación de Ayuda al Niño Quemado (COANIQUEM) due to out patient burn injuries management at the beginning of COVID-19 lockdown with the same period the year before. PATIENTS AND METHODS: Analytical and cross-sectional study. A population of 2,027 patients under the age of 20, who were admitted to COANIQUEM for the first time with burn inju ries, between April and July of 2019 and 2020 was analyzed. The number of patients admitted each month was registered as well as their demographic, social, and clinical characteristics. The monthly percentage variation was calculated by comparing patient data in both years. RESULTS: During 2020, there was a 48.7% decrease in overall outpatient admissions. There was a relative increase of 10.5% in burns in patients under 5 years old, 18.3% in scalds, 33.1% in the number of burns in 3 or more body locations, and 16.8% in burns occurring at home. These parameters were not influenced by geographic location, sex, or socioeconomic level. CONCLUSIONS: In the first period of the COVID-19 pandemic, with strict lockdown strategies, there was a decrease in the demand for burn care, affecting both outpatients with acute burns and those who were admitted for sequelae rehabilitation, as a result of the effective decrease in the burns incidence and the reduced access to health care.

Does exercise influence burn-induced inflammation: A cross-over randomised controlled feasibility trial.

BACKGROUND: Burn injuries trigger a greater and more persistent inflammatory response than other trauma cases. Exercise has been shown to positively influence inflammation in healthy and diseased populations, however little is known about the latent effect of exercise on chronic inflammation in burn injured patients. The aims of the pilot study were to assess the feasibility of implementing a long duration exercise training program, in burn injured individuals including learnings associated with conducting a clinical trial in COVID-19 pandemic. METHODS: Fifteen participants with a burn injury between 5-20% total body surface area acquired greater than a year ago were randomised in a within-subject designed study, into one of two conditions, exercise-control or control-exercise. The exercise condition consisted of six weeks of resistance and cardiovascular exercises, completed remotely or supervised in a hospital gym. A comprehensive outcome measurement was completed at the initial, mid and end point of each exercise and control condition. To determine the success of implementation, the feasibility indicator for the data completeness across the comprehensive outcome battery was set at 80%. RESULTS: Half (49%) of eligible participants in the timeframe, were recruited and commenced the study. Six participants withdrew prior to completion and a total of 15 participants completed the study. Eight participants were randomised to the exercise-control and seven to the control exercise group. Five participants trained remotely and seven did supervised training. Three participants completed a mix of both supervised and remote training initiated due to COVID restrictions. Outcome measures were completed on 97% of protocolised occasions and 100% of participants completed the exercise training. CONCLUSIONS: Conducting a long duration exercise training study on burn injured individuals is feasible using the described methods. The knowledge gained helps improve the methodology in larger-scale projects. Insights into the impact of COVID-19 on this clinical trial and success enhancing adaptations for the researcher, research practice and the participant, are presented.

The burned patient in times of COVID-19: proposal derived from lessons learned.

COVID-19 is a public health problem, so any burn patient who is managed as an outpatient or requires hospital management is a potential carrier of SARS-CoV-2. Burn patients are susceptible to COVID-19 due to the burn and its immunosuppressive effect, the procedures they undergo and other factors related to the burn, which makes them at high risk of contracting the disease and transmitting it, especially to the healthcare team involved in its management. Therefore, it is important to organize strategies in the services that care for burn patients during the COVID-19 pandemic. The objective of this paper is to present a proposal for response, organizational management and strategic planning in a burns service in times of COVID-19, based on the lessons and experience acquired.

La COVID-19 es un problema de salud pública, por lo que cualquier paciente quemado que se maneje como externo o que requiera manejo hospitalario es un potencial portador del SARS-CoV-2. El paciente quemado es susceptible a la COVID-19 debido a la quemadura y a su efecto inmunodepresor, a los procedimientos a los que es sometido y a otros factores inherentes a la quemadura, lo que le hace un paciente con alto riesgo de contraer la enfermedad y trasmitirla, especialmente al equipo de salud que está involucrado en su manejo. Por lo anterior, es importante organizar estrategias en los servicios que atienden pacientes con quemaduras durante la pandemia de COVID-19. El objetivo de este trabajo es presentar una propuesta para la respuesta, el manejo organizativo y la planeación estratégica en un servicio de quemados en tiempos de COVID-19, basándonos en las lecciones aprendidas y la experiencia adquirida.

The Effects of the COVID-19 Pandemic on Burn Clinic.

The COVID-19 pandemic has led to anxiety and fears for the general public. It is unclear how the behavior of people with acute burns and the services available to them has changed during the pandemic. The aim of our observational study was to evaluate our clinic's experience with patients presenting with burns during the first 10 months of the COVID-19 pandemic and determine if delays in presentation and healthcare delivery exist within our burn population. Patients referred to our clinic from March 1, 2020 to December 15, 2020 were reviewed for time of presentation after injury. We defined a true delay in presentation of >5 days from date of injury to date of referral for patients who were not inpatients at our facility or received initial care elsewhere prior to referral. Of the 246 patients who were referred to our clinic, during this time period, 199 patients (80.89%) attended their appointments. Our in-person clinic volume from referrals increased in July 2020 with a sharp decrease in August 2020. Our total clinic volume decreased in 2020 from 2019 by about 14%. Referrals to our clinic decreased in 2020 from 2019 by about 34%. Video telehealth visits did not account for the decrease in visits. There was low incidence of delays in presentation to our clinic during the pandemic. Additional investigation is necessary to see if the incidence of burn injury decreased. Despite the pandemic, our clinic remained ready and open to serve the burn population.

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.

Pediatric head and neck burns increased during early COVID-19 pandemic.

OBJECTIVE: The purpose of this study was to describe patterns of burns to the head and neck in children during the early COVID-19 pandemic. STUDY DESIGN: This cross-sectional study reviewed pediatric patients in the Burn Care Quality Platform Registry. Patients were included if they were ≤17.9 years old and had sustained burns to the head and neck. Patients were separated into the following groups: March 13 to September 13, 2019 (before COVID-19 pandemic, BC) or March 13 to September 13, 2020 (during the initial 6 months of the COVID-19 pandemic, C19). The study team collected patient-related variables, details regarding burn injury, burn severity, and hospital course. Univariate and bivariate analyses were calculated. The chi-squared test was used for categorical variables. Statistical significance was P < .05. RESULTS: Fifty-five children with head and neck burn injuries were included. There was a 200% increase in burns to the head and neck region in children in April 2021 compared with previous year. Burns to head and neck in White children occurred more often during C19 (P = .03). The study revealed differences in timing of presentation (time of burn injury to emergency department admission) in different racial groups during (White children [P = .05]), and after the pandemic (African American children [P = .02]). CONCLUSIONS: There was a transient increase in burns to the head and neck region in children during the early pandemic compared with the historic cohort.

Adjunctive Nonpharmacologic Interventions for the Management of Burn Pain: A Systematic Review.

BACKGROUND: The conventional way of treating burn victims with mainstream pain control modalities is costly and has many negative side effects. In this study, the authors aim to present the findings from the major clinical trials on three nonpharmacologic interventions-hypnosis, virtual/augmented reality, and yoga-as supplements to conventional pain regimens for burn management. METHODS: A computerized literature search was conducted of the PubMed and ClinicalTrials.gov databases in April of 2020. The online screening process was performed by two independent reviewers with the Covidence tool. The protocol was reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses, and it was registered at the International Prospective Register of Systematic Reviews of the National Institute for Health Research. RESULTS: The search yielded 254 articles from 1955 to 2020. Fifty-eight studies met the authors' inclusion criteria. Yoga reduced cognitive and somatic anxiety in burn survivors, and improved body image. Virtual reality is effective in pain reduction in both the pediatric and the adult burn population, and in faster burn wound reepithelialization. Hypnosis has similar results regarding reducing pain quality and anxiety in burn patients undergoing burn wound care and dressing changes but was not found to significantly accelerate the healing process. CONCLUSIONS: Nonpharmacologic interventions are not a substitute for conventional analgesics; however, they could help patients have better control over their pain, greater self-esteem, and less postburn traumatic experiences. Burn care centers should consider nonpharmacologic interventions to improve patient satisfaction and their participation in the treatment and rehabilitation process.

RSTNCOVID Burns: A multi-centre service evaluation and stakeholder survey of the impact of COVID-19 on burns care in England, Wales and Northern Ireland.

As the UK entered the first wave of the COVID-19 pandemic, the National Health Service published consensus guidance to the UK burns services advising changes to the acute management of burns to allow the continuation of safe care while protecting limited hospital resources. We aimed to describe the demographics of burns service users, changes to clinical pathways and experiences of the burns team during the first wave of the COVID-19 pandemic. All burns services in the UK were invited to participate in a national collaborative, trainee-led study supported by the Reconstructive Surgery Trials Network. The study consisted of (1) a service evaluation of patients receiving burns treatment during the COVID-19 pandemic; (2) a multidisciplinary team survey. Analyses were descriptive and narrative depending on data types. Collaborators from 18 sites contributed data from burns MDT surveys and 512 patients. Patient demographics were consistent with typical burns patterns in the UK. The delayed presentation occurred in 20% of cases, with 24 patients developing complications. MDT surveys indicated substantial adaptations and challenges as a result of the pandemic. Access to theatres and critical care were limited, yet a comprehensive acute burns service was maintained. Telemedicine was utilised heavily to reduce patient footfall. Adaptations in the provision of burns care, including greater outpatient care and telemedicine, have emerged out of necessity with reported success. The impact of reduced scar therapy and psychological interventions for burns patients during the pandemic requires longer-term follow-up. Lessons from the UK experience can be used to strategise for future pandemics.

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.

Burn injury from filling balloons with nitrous oxide.

We present the case of a female teenager who sustained nitrous oxide burns to the medial aspect of both thighs from contact with a nitrous oxide canister being used to fill balloons. There was a delay in presentation as the injury was not initially recognised. These burns were initially assessed as being superficial partial-thickness burns but took a prolonged time to heal despite regular wound care. This was complicated by a lack of adherence to recommended treatment for much of the patient care as well as the patient testing positive for COVID-19 during their management, which prevented surgery and significantly extended time to healing. While small numbers of similar cases have been previously described this is the first reported case outside of the Netherlands and in a child. Being aware of such cases ensures early referral to specialist burn care for appropriate management to give patients the best possible outcome.

Management of burns during coronavirus disease pandemic: Single center experience and outcomes.

BACKGROUND: Prolonged stays and multiple operations in burn management increase the risk of transmission. We would like to discuss our experience in hospitalized burn patients with Coronavirus disease (covid-19) infection. METHODS: In-patient burns with confirmed COVID-19 infection were studied. Age, gender, burned total body surface area (TBSA), number and sort of operations and dressing changes, intensive care unit stay, ward stay, total length of stay, and morbidity and mortality were analyzed. Medical staff observed for infection. RESULTS: The mean age of the 11 positive patients was 51 (±19.37) years and burned TBSA was 34.36% (±21.97%). Six (54.5%) patients presented with negative polymerase chain reaction (PCR) tests; however, symptoms and findings revealed the illness. Patients underwent 85 operations including hydrosurgery. Totally, 475 dressing changes were done. Respiratory failure caused three mortalities without sepsis. Age, TBSA, and deep dermal burn percent of the mortalities showed no difference. None of the staff and hospitalized other patients had hospital acquired COVID-19 infection. CONCLUSION: Healthcare must continue during pandemics. Awareness, proper usage of personal protective equipment, keeping social distance, and strengthened access control to the clinic are important priorities to avoid viral transmission. The difficulty in PCR negative patients was the confusing effect of burns as most of the laboratory and radiologic findings overlaps with the major burns' consequences. Findings, cannot be explained by the clinical course of burn, should indicate COVID infection. Regarding our results, burn patient treatment routines can be applied safely by competence to focused and re-adopted precautions as there were no hospital acquired COVID-19. Patients must trained for cross-contamination. Healthcare's must prioritize their own health under all situations including pandemics. Updating, the preventive cautions and rigid compliance are a must.