Management of COVID-19 in burns patients: The experience of a UK burn centre

Dear Editor,

During the onslaught of the SARS-Cov-2 (COVID-19) pandemic, majority of healthcare systems focused their approach towards disease containment. The main strategies involved measures to prevent disease spread through social distancing; shielding and use of personal protective equipment (PPE); testing and quarantine of infected cases; and rationalising health care services to prioritise intensive care (ICU) resources.

These measures have had a significant impact on Burns services worldwide. Instigating infection control measures to protect Burn and non-Burn injured patients as well as healthcare staff, create complex logistical arrangements considering the potential risks of transmitting COVID-19 whilst delivering care on the ward and in theatres amidst shortages of PPE [1,2]. There is a reliance on planning discharge of care and patient isolation (suspected or proven COVID-19 = RED area; unsuspected COVID-19 = GREEN area) based on the outcome of the patients’ test [3]; particularly oro- and nasopharyngeal (ONP) RT-PCR swabs despite uncertainties on the validity of the results.

The authors would like to share their experiences of managing Burns patients with COVID-19 in a Burns Centre from March to April 2020. Through these examples we would like to highlight a key point about the care of our Burn patients amidst uncertainties regarding COVID-19, particularly with regards to disease screening and identification, patient isolation and the use of PPE.

1. Our experiences

1.1. Burn patients can present with symptoms of COVID-19, but have varying test results.

We had two men who presented to the local Accident and Emergency department (A&E) with less than 5% total body surface area (TBSA), deep dermal contact burns after collapsed against a radiator. Both patients had recent travel from Spain and a history of generalised fatigue. They were triaged to the COVID-19 isolation (RED) area in A&E and underwent screening for COVID-19.

The first patient had a chest-Xray (Fig. 1 ) which demonstrated localised changes to the right middle zone with no focal consolidation and ONP swabs which were negative. He had a follow-up chest X-ray (Fig. 1) seven days later after developing worsening breathlessness and pyrexia, which showed progressive changes with ground glass appearances suggestive of COVID-19. The second patient had lactic acidosis, raised inflammatory markers, a chest X-ray (Fig. 2 ) suggestive of COVID-19, lactic acidosis, and ONP swabs which were positive.

Fig. 1.

(left) Chest X-ray on Day 1 in A&E demonstrating ‘’hazy’’ appearance in the right middle zone but no focal consolidation. Fig. 1 (right) Chest X-ray on Day 7 in A&E demonstrating bilateral wide spread changes typically found in COVID-19 patients.

Fig. 2.

(left) Chest X-ray on Day 1 in A&E demonstrating supra-added consolidation on chronic peripheral changes consistent with pneumonia. Fig. 2 (right) Chest X-ray on Day 5 demonstrating worsening consolidation in the peripheries.

Both patients were deemed appropriate for non-surgical treatment with dressings. The first patient was managed in the community with advice to continue with self-isolation, oral antibiotics, and telemedicine follow-up burn wound reviews (2–3 times per week) supported by the community Burns Outreach team. The second patient was admitted to the RED Respiratory ward. His respiratory symptoms worsened and he passed away one week later.

1.2. Burn patients can present initially without symptoms of COVID-19, but then develop symptoms and complications of COVID-19 later on.

We had a woman referred with 50 % TBSA scalds following a prolonged lie whilst intoxicated from alcohol in a hot bath contaminated with faecal matter. Fluid resuscitation was commenced by Parkland formula. Her burns were mixed depth (predominantly mid dermal) and were dressed with cerium nitrate-silver sulphadiazine (Flammacerium). Her admission COVID-19 screening: ONP swabs were negative and chest X-ray (Fig. 3 ) demonstrated no significant changes. She denied any history of cough, feeling unwell prior to her injury and contact with COVID-19 positive patients. The Burns team continued to manage her with full PPE as a precaution. Her first three days on the Burns ward were uneventful; her acute kidney injury resolved within 24 h of admission and her daily blood gases were normal. Her wound showed clinical improvement. However on Day 4 of her admission she developed an acute shortness of breath and profound hypoxia on her blood gases. A panel of blood tests demonstrated significantly raised levels inflammatory markers. Her repeat chest X-ray (Fig. 3) demonstrated a generalised ground glass appearance. She was assessed by the Respiratory physicians and ICU team. She was deemed unsuitable for invasive ventilation in view of her co-morbidities and frailty. She was transferred to the RED Respiratory ward for BiPAP treatment with burn management by the Burns team as an outlier. Her second ONP swab returned as negative. However this time it was noted that the repeat test had been performed inaccurately by a member of staff who assumed it was a routine screen for MRSA and only sent it to the laboratory two days later. The patient developed a swollen, dusky left arm two days later and was diagnosed with an occlusive deep vein thrombosis of her left axillary, subclavian and internal jugular vein. Her respiratory function continued to deteriorate and she was commenced on palliation. She died 24 h later.

Fig. 3.

(left) A routine Chest X-ray on Day 1 of admission to check nasogastric tube position demonstrating no significant changes. Fig. 3 (right) on Day 4 of admission following her respiratory deterioration demonstrating extensive changes bilaterally.

2. Key points: delivering burns care that is safe for both patients and staff: accepting burns admissions on a case-by-case basis following evaluation by the multidisciplinary team and using appropriate PPE

Patients receiving inpatient care without COVID-19 symptoms are admitted to the Burns ward (GREEN) where they will be managed in individual side rooms. Patients suspected of COVID-19 and burn injuries with inpatient care and respiratory support are admitted directly from A&E to RED wards. The standard operating procedure (SOP) for the use of PPE in both GREEN and RED Burns areas include the delivery of care by a limited number of ‘essential-only’ staff wearing standard surgical masks, fluid resistant aprons and gloves for each patient interaction. Exceptions include: for inpatients with suspected COVID-19 (clinical history and symptoms); aerosol generating procedures including all burn wound excisions and skin grafting; and wound dressings in the shower. In these scenarios; FFP-3 fit-tested masks, visors, fluid resistant gowns and gloves are utilised.

These measures allow the team to balance the quality of service provision against available resources during the COVID-19 peaks. Efficient triage of patients led by the Burns team at the point of admission in A&E optimises hospital bed resources. From the outset we maintain an assumption that both staff and patients are at risk of transmitting COVID-19. We therefore utilise PPE for each clinical encounter in order to shield everyone. We automatically isolate and keep burn patients in single side rooms to reduce the risk of cross contamination and avoid repetitive decontamination works.

The authors believe that the presence of a negative COVID-19 test or absence of clinical symptoms of COVID-19 shouldn’t be taken at face value. Current evidence demonstrated sensitivity rates of less than 70 % for all COVID-19 diagnostic tests including RNA RT-PCR, total antibody, IgM and IgG at the first week of symptom onset. In addition, the test-positive result rates of RNA RT-PCR tests (currently the most performed test in the UK) varies depending on the sampling technique (eg. oropharyngeal swab, NP swab, bronchoalveolar lavage) and timing of the test from symptom onset [4,5].

Our experiences clearly illustrate the difficulties in pre-empting COVID-19 patients based on symptoms only and the unreliability of test results. Treating patients based on an initial negative test result and in absence of PPE during the first few days of admission can also subsequently risk unnecessary exposure of COVID-19 to both patients and staff. In view of this, we agree with current views that the significant presence of false negative tests should always be taken into consideration pending the development of validated, highly sensitive and specific tests [6]. Therefore all healthcare workers and patients should attempt to deliver care whilst ensuring protection from disease transmission by any means available. Until the risk factors and mechanism of disease transmission becomes more definite, we recommend that all burns services should anticipate and plan to continue delivering patient care whilst taking social distancing and shielding measures into account.

Funding

None.

Conflict of interest

None.