key: cord-0712517-0qy4cxyi
authors: Erturk, Ahmet; Demir, Sabri; Oztorun, Can İhsan; Erten, Elif Emel; Guney, Dogus; Bostanci, Suleyman Arif; Sahin, Vildan Selin; Kiris, Atike Gulsah; Bay, Hatice Kübra; Bedir Demirdag, Tugba; Keskin, Gulsen; Azili, Mujdem Nur; Senel, Emrah
title: Management of a pediatric burn center during the covid-19 pandemic
date: 2021-07-27
journal: J Burn Care Res
DOI: 10.1093/jbcr/irab137
sha: 8739a7553ff4d74fe30707647fcc599d5ea46d87
doc_id: 712517
cord_uid: 0qy4cxyi

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, total body surface area (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=0.042), 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.

The global coronavirus disease-2019 (COVID-19) pandemic is having a devastating impact all around the world and is overwhelming health systems in many countries. The disease originated in China in December 2019 and rapidly developed into a global pandemic. It is causing a significant death toll and is still not under control. The mortality rate has been reported to be around 2% of all cases. 1 As there are still no effective medical treatments, prevention of transmission is currently the most effective way of dealing with this outbreak.

Most nations have developed their own individual nationwide protocols to combat the pandemic. 2, 3 Burns are common in children globally and constitute a significant cause of accidental childhood deaths in underdeveloped and developing countries. 4 American Burn Association (ABA) guidelines suggest that children with moderate burns can be managed in peripheral burn units, but children with major burns should be transferred to tertiary burn centers. 5 Our hospital is the biggest hospital complex in Turkey, with over 3,700 beds in total and 600 beds for children. It serves as a pandemic hospital for both adults and children. The Pediatric Burn Center (PBC) of our hospital is a tertiary referral center that serves children with major burns in our country as well as from neighboring countries. During the pandemic, our PBC remained operational and continued to serve all children with major burns regardless of the pandemic and the patient's infectious condition.

In children, the disease process of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is usually mild or asymptomatic. 6 As cellular and humoral immunity are A c c e p t e d M a n u s c r i p t compromised in children with burns, various infections may be more lethal than they would be in unaffected children. 7 In addition to the other infections that arise secondary to burns, additional infection with COVID-19 may increase the morbidity and even mortality in these patients. 8 Due to these concerns, prevention of COVID-19 transmission becomes more critical in children with burns, and identification and isolation of burn patients infected with COVID-19 may improve outcomes and reduce mortality.

Driven by the above-mentioned concerns, we created an algorithm to help prevent COVID-19 transmission and to improve the management of pediatric burn patients during the pandemic. The aim of this study was to evaluate the results of our approach and clinical outcomes.

All patients under 18 years of age who were admitted to the PBC between May 2020 and November 2020 were enrolled in the study. The study was designed as a prospective study, and local ethical committee approval was obtained (Nu:E1-20-956). The study was carried out by adhering to the principles of the Helsinki Declaration. An informed consent was obtained from the parents or legal guardian of each patients. A detailed history was obtained at the time of admission regarding the presence of symptoms of COVID-19 infection (including fever, cough, and diarrhea), suspicious contagious contact history, and travel abroad before the burn. Additionally, epidemiological data, cause of burn, depth of burn, TBSA, total hospitalization days, polymerase chain reaction (PCR) test results (at admission and during the treatment process), and presence of lung involvement in patients with positive PCR test results were extracted from patient records.

A nationwide action plan was organized by the Ministry of Health in 2012, and a systematic algorithm was created to organize a homogenous distribution of sufficient number and quality A c c e p t e d M a n u s c r i p t of burn units and centers to provide effective transport and management of burn patients. 9 Thanks to the algorithm, a burn patient who is admitted to any health facility can be transported to a burn unit/center in an average of two hours after initial resuscitation and management is performed. In this context, 55 burn units and 16 burn centers with a total of about 1100 patient rooms are available nationwide. Our hospital and PBU are located in the capital city of Turkey, and the PBU a referral center for pediatric burn cases.

A WhatsApp group was formed by the physicians who are in charge of the burn units/centers all around Turkey. When a burn case is admitted to a health facility, medical data and images of the burned areas are delivered to the staff of the burn unit/center. After a quick evaluation (around two hours) of the patient using telemedicine, a decision is made for the most convenient burn unit/center for the patient to be transported to. Also, the means of transport (by land or air) is decided on depending on the clinical condition of the patient and the distance to the referral center. This algorithm is also useful during natural or manmade disasters to coordinate convenient transport of patients with multiple trauma. With the emergence of the pandemic, information about the patient's COVID-19 test results, suspicious contact history, presence of symptoms, and travel history abroad are also included in the algorithm to ensure that all necessary precautions are taken before the patient arrives at the burn center. The algorithm we employed during admittance and management of pediatric burn cases in our center is presented in Figure 1 . A c c e p t e d M a n u s c r i p t During the initial evaluation and management of the patients in Group 1, a surgical mask, apron, and gloves were used in the standard fashion during wound care and medical treatments. N95 masks, protection glasses, face shields, surgical suits, surgical gloves, and boots were used in the standard fashion during the care of patients in Group 2 ( Figure 2 ).

There are 12 patient rooms in our center, and all are designed as intensive care unit rooms.

All rooms are single, and two have negative pressure systems. This arrangement enabled the isolation of patients and their companions. One asymptomatic parent without a suspicious contact history was allowed to accompany the child, and meals were served in patients' rooms.

All interventions were suspended if possible and if deemed "not urgent" until PCR results were obtained. PCR results were usually available within four to six hours. Urgent interventions (initial wound care, urgent escharotomy/fasciotomy) were performed as a bedside procedure in the patient's room under necessary precautions depending on the patient's risk group, and sedoanalgesia/anesthesia was performed when necessary. All further surgical procedures (fascial excision, grafting) were suspended until the PCR results were obtained.

If early surgery was not anticipated, wound care products that do not require frequent replacement, such as Therabond TM (Silverlon, Argentum Medical LLC, Geneva, IL, USA ), Aquacel TM (ConvaTec Inc., Flintshire, UK) and Acticoat TM (Smith & Nephew Co. Ltd., UK), were preferred for initial wound care. If the patient's PCR test result was negative, then surgical interventions and consecutive wound care were performed in the operation room reserved for burn patients, which is located in the burn center. If the PCR test result was positive, routine wound care was performed as a bedside procedure under sedoanalgesia/anesthesia in the patient's room. Other surgical interventions were performed A c c e p t e d M a n u s c r i p t in another operating room that was reserved for COVID-19 positive patients in the general hospital block with all the recommended precautions for COVID-19. All staff without symptoms underwent routine tests weekly, and staff with symptoms tested immediately.

The Although statistical analyses for burn depth, history of travel abroad, presence of symptoms, and suspicious contact history could not be performed as there were insufficient cases, the depth of burn appeared to be deeper in Group 1. Detailed statistical analyses are presented in Table 2 .

Among the four patients with a positive PCR test, only one patient in Group 1 (admitted with a 50% TBSA flame burn) demonstrated signs of severe infection. This patient was isolated due to a positive PCR test. A lung x-ray obtained for respiratory distress during follow-up revealed pulmonary involvement, and treatment for COVID-19 was initiated. The PCR test became negative on follow-up, and his/her isolation was terminated. Details about the other three patients are presented in Table 3 . A c c e p t e d M a n u s c r i p t

Although the overall rate of hospital admittance decreased during the COVID-19 pandemic, the rate of admittance to burn units and centers did not reduce significantly. [10] [11] [12] No significant change in the number of hospitalized patients (98 patients vs 101 patients) were observed in our center, too. Maintaining the health service provided to patients with burn injuries during the pandemic presented additional risks for patients and health care professionals. During the COVID-19 pandemic, it has commonly been observed that more rapid spread and even outbreaks can emerge when proper precautions are not taken during patient admittance because transmission from asymptomatic patients to other patients and healthcare staff can occur. 13 Because of this concern, various precautions are recommended 2, 14 . Therefore, in accordance with the recommendations of the Infection Control Committee of our hospital, each admitted patient is regarded as a "possible case" and isolated until the PCR test result is obtained.

Asymptomatic COVID-19 infections are much more common in children than adults and have been reported to be between 4.4% and 53%. [15] [16] [17] [18] [19] [20] Accordingly, asymptomatic children are regarded as potential "super-spreaders" because the high rate of asymptomatic disease in children can cause the disease to spread more rapidly. The course of COVID-19 infection is more severe in patients with coexisting diseases, in immunosuppressed individuals, and in the elderly. Patients with burn injuries are also included in this high-risk group as they have a coexisting burn injury. 21 The rate of asymptomatic infection at admission was 4.0% in our cohort of patients. Although this rate may appear low, it is significant because patients treated in burn units/centers are in a high-risk group. During the study period, no patient-to-staff transmission of COVID-19 was demonstrated.

A c c e p t e d M a n u s c r i p t Due to the rapid rate of spread of COVID-19, rigorous precautions should be taken in order to prevent transmission between patients and staff. 13 Azzena et al. reported successful prevention of spread by performing COVID-19 tests at the time of admission for all patients, which is consistent with our study. 21 Others have also reported successful prevention of transmission by performing similar precautions. 2, 22 Nevertheless, these precautions are not sufficient alone when not accompanied by other additional measures. Physical distancing, mask use, and hygiene principles should be strictly followed to prevent COVID-19 and other infections because the most common cause of death in burn patients is still infections. 23, 24 Prevention of transmission is still the best way to confront the COVID-19 pandemic since there are no effective drug treatments, and the success of vaccination programs, which have been initiated more recently, is unclear. 25 This is more pronounced for intensive care units and burn centers where nosocomial transmission may be faster and more lethal. 26 M a n u s c r i p t 

Coronavirus Update (Live): 90,199,834 Cases and 1

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Effects on mortality of changing trends in the management of burned children in Turkey: Eight years' experience

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Viral Infections in Burns

COVID-19 infection in children

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An outbreak of Covid-19 in a Burn Unit: The impact on the health system and management strategies for infected patients

Burn center function during the COVID-19 pandemic: An international multi-center report of strategy and experience

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Clinical features of children with SARS-CoV-2 infection: An analysis of 115 cases

Epidemiology of COVID-19 among children in China

Clinical analysis of 25 COVID-19 infections in children

Proportion of asymptomatic coronavirus disease 2019: A systematic review and meta-analysis

Burn Unit admission and management protocol during COVID-19 pandemic

Protective measures for burn care professionals during the coronavirus disease 2019 pandemic: Systematic review. Ann Burns Fire Disasters

Predicting and managing sepsis in burn patients: Current perspectives. Ther Clin Risk Manag

Contribution of bacterial and viral infections to attributable mortality in patients with severe burns: An autopsy series

Managing a tertiary-level NICU in the time of COVID-19: Lessons learned from a high-risk zone

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Infection control practices in children during COVID-19 pandemic: Differences from adults

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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