BURN CARE AND PREVENTION JOURNAL

OBJECTIVES: Although hospital admissions and elective surgeries were recommended to be reduced during the COVID-19 pandemic period, the same could not be done for burn patients. It is vital that burn treatment starts immediately and continues without interruption. With this in mind, burn centers should take added precautions during this pandemic. In the present study, we present our experiences in our burn center during the pandemic period.

MATERIALS AND METHODS: From March 2020 to February 2021, 457 patients were successfully treated at our center. We implemented training immediately for all hospital staff, with all staff provided with personal protective equipment. We minimized the risk of contamination by completely isolating burn patients and reducing the number of beds. We determined a 3-degree protection protocol according to the general condition of the patients and the diagnosis of COVID-19. During the pandemic period, we continued to treat burn patients by adhering to our protection protocols.

RESULTS: During pandemic period, 381 patients (83.4%) were treated as outpatients and 76 patients (16.6%) were hospitalized. The most common cause of burns was scalding, with 172 adult patients (61.4%) and 152 pediatric patients (85.8%). Mean total burn surface area of hospitalized patients was 25.34% in adult patients and 9.95% in pediatric patients. During the treatment process, only 2 patients were diagnosed with COVID-19, and burn treatments were successfully completed, with patients discharged without any problems.

CONCLUSIONS: Ensuring isolation among patients in our burn center and determining protection protocols for burn center health care workers played key roles in the continuity of uninterrupted care during the pandemic period.

KEY WORDS: Burn, Isolation, Pandemics

In December 2019, the novel 2019 coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detected for the first time in China, which quickly spread globally.¹ During its global spread, COVID-19 has shown devastating effects in both patients and health care providers, especially in older patients, patients with comorbidities, trauma patients, transplant patients, and immunosuppressed patients.² According to the World Health Organization (WHO), nearly 40 million confirmed cases of COVID-19 and more than 1 million deaths have been reported.³

With the declaration of COVID-19 as a pandemic by the WHO, targeted precautions are required in the field of health, as in other areas. Recent studies have indicated that hospitalizations should be reduced and elective surgeries should be postponed as much as possible.^4,5 However, these recommendations are not valid for burn patients. Burns are an acute care condition, and the treatment of patients with extensive burns poses a race against time.⁶ For this reason, treatment should be continued but with necessary precautions and with specific policies for burn centers. In the present study, we describe our experiences in our burn center during the pandemic period.

MATERIALS AND METHODS

The first burn center in our country was established in July 1975 by our team at Hacettepe University. The Başkent University Burn Center was established in 1993 by the same team, and many burn patients have been successfully treated as outpatients and inpatients (Figure 1). Our Burn Center consists of 3 areas: (1) an outpatient clinic; (2) a semi-sterile area, which includes 4 rooms for burn patients, with each room having 2 beds and all rooms having intensive care availability; and (3) a sterile area that includes an operating room and 4 isolated intensive care unit (ICU) beds, with 1 in an isolated room. During the pandemic period between March 2020 and February 2021, 457 patients were treated as outpatients or were hospitalized in our center.

Protection of burn center staff members
With the onset of the pandemic period, all staff, including the doctors and nurses working in our burn center, were given training on hand hygiene and general prevention measures. In addition, required personal protective equipment was provided for the entire team. Body temperature of all hospital staff was checked daily. Asymptomatic staff members with known unprotected contact with any COVID-19 patients were isolated for 14 days.

We developed a specific policy in our burn center, which required 3 degrees of protection. The first-degree protection consists of hand hygiene, surgeon cap, operating mask, medical rubber gloves, scrubs, and isolation clothes when performing bedside procedures (wound dressing, central line catheter placement). First-degree protection is used for outpatients and patients who are hospitalized with no suspicion for COVID-19 and total burn surface area (TBSA) of less than 25%.

Second-degree protection consists of hand hygiene, surgeon cap, N-95 face masks, medical rubber gloves, protective goggle, scrubs, and isolation clothes if necessary. Second-degree protection is used for patients without suspected COVID-19 who have greater than 25% TBSA.

Third-degree protection consists of hand hygiene, special protective coverall, surgeon cap, N-95 face masks, double medical rubber gloves, and protective goggle. Third-degree protection is used throughout treatment for patients who are suspected or are diagnosed with COVID-19 (Figure 2).

Specific precautions in burn center areas
Outpatient clinic
During examination in our outpatient clinic, patients with any suspicion for COVID-19 are directed to the COVID-19 unit, with all necessary precautions taken with third-degree protection in a specially provided isolated area. The isolated area is given fresh air for at least 10 minutes after each examination, and all equipment is disinfected with 5.25% sodium hypochlorite at a 1/100 concentration. For patients with no suspicion of COVID-19, patients are routinely examined with first-degree protection. Control examinations of patients are performed with as long intervals as possible, depending on the severity of the wound.

Semi-sterile areas
In the semi-sterile areas, the number of beds in all rooms has been reduced by half, allowing hospitalized patients to be completely isolated from each other during their treatment period. A COVID-19 polymerase chain reaction (PCR) test and, if possible, thorax computed tomography (CT) are performed for all patients before hospitalization. At 24 hours after hospitalization, a second PCR test is performed, with staff members maintaining third-degree protection until the diagnosis of COVID-19 is completely ruled out. During this period, we conduct surgical rounds with the minimum number of personnel. The number of team members who enter a patient’s room for examinations and encounters is also limited. In addition, we restrict multidisciplinary rounds of dietary, pharmacy, social work, and care coordination staff as much as possible. Visitors are not permitted in the semi-sterile area.

Sterile areas
The number of beds in the sterile area has also been reduced by half, thus ensuring a safe distance between patients. In patients to be hospitalized in a sterile area, a COVID-19 PCR test is performed twice within a 24-hour interval (Figure 3). In addition, thorax CT is applied to clinically stable patients during admission and to unstable patients after stabilization. The treatment of patients continue in an isolated ICU room until the COVID-19 diagnosis is excluded, with third-degree protection maintained by hospital staff (Figure 4). If a diagnosis of COVID-19 is ruled out, the patient is transferred to the other ICU beds. Patients diagnosed with COVID-19 continue to be hospitalized in isolated rooms, with antiviral treatment initiated after consultation with the infectious disease department.

Our surgical strategy during the pandemic period was similar to that of burn centers in other countries.7 COVID-19 PCR test is given to patients 24 hours before all elective surgeries, and thorax CT is performed when necessary. In cases when COVID-19 is diagnosed or clinically suspected, elective surgeries are postponed as much as possible. In life-threatening situations of patients who are diagnosed with COVID-19 or whose condition is uncertain, third-degree protection precautions are taken and surgery is performed.
With these measures taken in all 3 areas, we did not make any changes to our treatment strategies and burn care techniques for any patients.

Statistical analyses
Quantitative variables are expressed as mean ± SD, whereas qualitative variables are presented as frequencies. The chi-square or Fisher exact test was used for data analysis. P < .05 was considered statistically significant.

During the pandemic period (between March 2020 and February 2021), 457 burn patients were successfully treated in our burn center. Of these patients, 199 were male patients (43.5%) and 258 were female patients (56.5%); 381 (83.4%) were treated as outpatients and 76 (16.6%) were hospitalized. Of the outpatients, 227 (59.5%) were adult patients and 154 (40.5%) were pediatric patients. Of the 76 hospitalized patients, 53 (69.7%) were adult patients and 23 (30.3%) were pediatric patients. Mean age of the pediatric patients was 4.35 ± 0.34 years, and mean age of adult patients was 41.77 ± 1.08 years. For adults, mean length of hospital stay was 15.7 days, whereas it was 5.4 days for pediatric patients. Demographic characteristics of patients are summarized in Table 1.

The mean TBSA of outpatients was 4.31% in adult and 1.97% in pediatric patients. In hospitalized patients, mean TBSA was 25.34% in adult patients and 9.95% in pediatric patients. Causes of burn injuries in adult patients were scald in 172 patients (61.4%), flame in 40 patients (14.2%), contact in 23 patients (8.2%), chemicals in 19 patients (6.7%), steam in 9 patients (3.2%), electrical in 5 patients (1.7%), cold-frozen in 2 patients (0.7%), explosion in 1 patient (0.3%), and other causes in 9 patients (3.2%). In pediatric patients, causes of burn injuries were scald in 152 patients (85.8%), contact in 16 patients (9%), explosion in 1 patient (0.5%), and other causes in 8 patients (4.5%) (Table 2).

During the pandemic period, we performed 109 burn surgeries (92 adult, 17 pediatric). We performed debridement surgery to all pediatric patients. In adult patients, we performed 38 debridement, 26 graft surgery, 16 escharotomy, 8 fasciotomy, 2 flap surgery, and 2 amputation procedures.

During the pandemic period, 2 of our patients were diagnosed with COVID-19. The first patient, a 57-year-old male patient with cause of burn injury of flame, had a TBSA of 35%. COVID-19 diagnosis was confirmed by bronchoscopy; the patient had no inhalation injury. The patient was transferred to us from a state hospital and was intubated and sedated. As soon as the patient was admitted, he was taken to the isolated ICU room, third-degree protection was performed by the staff members, and COVID-19 PCR test was performed. After the patient was monitored and replacement treatments were performed, escharotomy was performed under sedation. After 24 hours, a repeat COVID-19 PCR test was performed. In addition, a thorax CT was performed. The patient’s body temperature was 38.7 ºC after being extubated at the end of 24 hours. Although the patient’s PCR tests were negative, the clinical and thorax CT results showed findings similar to COVID-19 findings. Favipiravir treatment was given after consultation with the infectious disease department. The patient underwent debridement and flap surgery 2 times under isolation conditions. The patient’s treatment was successfully completed at the end of day 47, and he was discharged.

The second patient, a 30-year-old male patient with burn injury from explosion, had TBSA of 53%. Third-degree protection was performed by staff members, COVID-19 PCR test was performed, and resuscitation treatment of the patient was started immediately. We performed escharotomy under anesthesia. On day 2, the patient had a repeat PCR test and thorax CT was performed. The patient’s body temperature was between 38.4 and 38.8 ºC for 3 days. Both PCR tests were negative; however, clinical and thorax CT findings were consistent with COVID-19. Therefore, favipiravir treatment was given to the patient in addition to burn treatment. Third-degree protection was used throughout his treatment. We performed repeated debridement and dressing; at the end of day 30, the patient was successfully discharged.

The COVID-19 outbreak has made it necessary to take specific precautions in the field of health. Although studies have recommended that patients avoid admission to the hospital and that surgeons postpone elective surgical procedures,^8,9 this is not possible in burn centers, as burns should be treated immediately.¹⁰ In the present study, we showed that, if necessary precautions are taken, burn care services can be provided successfully and without delay.

Burn patients need emergency treatment at early stages. Treatment is needed for not only the burn wound itself but also for systemic effects, especially with burns wider than 20% of TBSA. There can also be additional systemic problems due to the mechanism of burn injury, such as inhalation injury in indoor burns. arrhythmias after electric burns, and additional traumas from falls, explosions, and impactions.^7,11

COVID-19 is an extremely infectious disease. So far, effective treatments are still unclear.¹² In this current situation, the most important thing is to prevent disease transmission. Close contact is a route of disease transmission for COVID-19. Because health care givers are in close contact during patient examinations, venous access procedures, conventional dressing procedures, and surgeries, one way to decrease transmission is via medical personal protective measures. Caregivers should protect themselves and their patients. For this reason, in our burn center, we provide training and educate all team members on self and patient protection and provide all necessary personal protective equipment. In addition, isolation between patients is an important method to reduce the spread of the disease.¹³ In our center, we treat only 1 patient in each room and use sterile materials separately for each patient. In addition, after each dressing or surgical procedure, the entire team replace their personal protective equipment with new ones.

We can see some similarities in burn patients versus COVID-19 patients,^14,15 with difficulties in differential diagnoses in large burn and COVID-19 patients. Fever is common for both large burn and COVID-19 patients. Lung injury, together with inhalation injury, can be encountered in patients with burns. Burn patients are prone to pulmonary edema because of systemic inflammatory responses and resuscitation with large fluid volumes. Radiography examinations of the chest may show similarities in patients with large burns versus patients with early-stage COVID-19. In our center, we performed COVID-19 PCR test and thorax CT twice for all patients to allow differential diagnosis of burns with COVID-19.

Although COVID-19 has a high spread rate and high mortality, burn patients should continue their treatment without interruption during this pandemic. With necessary precautions, including providing isolation conditions and training all hospital personnel, the treatment of patients can be continued successfully and without undesirable consequences.

Volume: 1 Issue: 1 March 2021

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