The impact of COVID-19 on burn referrals received via telemedicine

BackgroundBurn referrals make up a significant proportion of the referrals received by the on-call Plastics surgery team at University Hospital Plymouth (UHP). UHP is a burns facility that takes referrals that are< 10% total body surface area (TBSA) in adults and< 5% in children. Since switching to a telemedicine service in 2018, this has had the benefit of not needing to see the patient face-to-face. It allows for direct advice given over the phone enabling immediate treatment to be administered. In addition it prevents unnecessary referrals. The COVID-19 pandemic has meant that more people are spending time at home and this study aims to see if this has had an impact on the number of referrals received.MethodsData was collected retrospectively over 2 years 2019 and 2020 from MDSAS telemedicine service. The outcome of each referral was recorded as advice given, seen in outpatients or patient admitted. The total for each year was calculated and compared. Also recorded was the age of the patient, the referring unit, the type of burn and the TBSA.ResultsA 19.3% increase in referrals received during the year of 2020. The most common age group for a burn referral was the 0–5 years age group; the number of referrals increased by 8.4% in this age group in the year of lockdown. Scalds and contact burns remained the highest mechanism of injury. TBSA of 0.5% was the most common TBSA over both years. Over 47% of referrals travelled from over 30 miles away. The majority of referrals were either seen in outpatients or given advice only. Burn referrals were most commonly over-estimated, 23.2% of burn referrals in 2019 and 20.9% in 2020 were over estimated by> 1% TBSA. 5.5% of referrals were under-estimated.ConclusionThere was an increase in the number of referrals during COVID-19. Overall there were a very low number of inappropriate referrals. The telemedicine system has impacted positively in time efficiency especially during COVID-19. It has meant that advice can be given without seeing the patient directly leading to both benefits for the patient and the department.     

Aspergilosis pulmonar invasiva en pacientes con síndrome de distrés respiratorio por COVID-19

Patients with COVID-19 who are admitted to intensive care unit (ICU) are at high risk of developing secondary infections, including invasive fungal infections such as invasive pulmonary aspergillosis (IPA). The main purpose was to analyse the putative COVID-19 Associated Pulmonary Aspergillosis (CAPA) patients in our setting. In these patients, we performed mycological culture in bronchoalveolar lavage (BAL) for isolation of Aspergillus sp. We followed the AspICU algorithm to diagnose putative IPA. Moreover, we considered relevant the positivity of galactomannan in BAL. We diagnosed putative IPA in 3 patients. The common features of these 3 patients were: more than 21 days of stay in ICU, severe acute respiratory distress syndrome (ARDS) and treatment with steroids (1 mg/kg per day). Therefore, CAPA has to be systematically considered although a new algorithm to diagnose it is needed to treat patients in early stages in order to avoid catastrophic outcomes.     

COVID-19 and surgery: A thematic analysis of unintended consequences on performance,practice and surgical training

PurposeThe shift in the national focus and allocation of resources to the management of COVID19 has led to significant changes to surgical practice including the delay of elective surgery. The aim of this study was to explore the implications of such changes on surgeons.MethodUsing a qualitative study design, semi-structured interviews were conducted with general surgery consultants and non-consultant hospital doctors from a major tertiary hospital in the Dublin region between March–May 2020. Data collection proceeded iteratively using a thematic analysis approach with quality controls such as memoing and collaborative analysis.ResultsFourteen surgeons (8 male, 6 female) were interviewed. The majority (n = 11, 78.6%) were NCHDs. Significant themes determined included ‘impacts’ on a variety of constructs such as performance, self-reported fatigue and wellbeing. Training themes elucidated included the effects of the cancellation of elective admissions on reduced operative exposure for trainees. Senior surgical staff were particularly focused on increased complexity in patient management. New policy requirements such as personal protective equipment use and novel rotas have had implications for aspects of work engagement. The pandemic and subsequent national restrictions imposed has afforded opportunities for improved well-being but also resulted in greater solitude in surgeons.ConclusionsRhetoric surrounding fatigue management and virus control dominates the conversation on the relationship between COVID-19 and surgery. Tipping the balance back to parity of fatigue management with service delivery in surgery will be key for sustainability of the surgical workforce.     

A systematic review of the evidence for telemedicine in burn care: with a UK perspective

A comprehensive systematic review of telemedicine in burn care was carried out. Studies published between 1993 and 2010 were included. The main outcome measures were the level of evidence, technical feasibility, clinical feasibility, clinical management and cost effectiveness. The search strategy yielded 24 studies, none of which were randomised. There were only five studies with a control group, and in three of these the patients act as their own controls. Four studies performed quantitative cost analysis, and five more provide qualitative cost analysis. All studies demonstrate technical and clinical feasibility. If the significant potentials of telemedicine to assist in the acute triage, management guidance and outpatient care are to be realised, then research needs to be undertaken to provide evidence for such investment.     

The management of major burns – a surgical perspective

In the UK, 1000 patients per year will need resuscitation and inpatient treatment for burns. The mortality has improved significantly over the last 50 years but over three hundred people die each year. A greater understanding of the pathophysiology together with improvements in resuscitation, critical care and surgical techniques have all contributed to survival. For larger burns (greater than 25% total body surface area) there is a profound release of cytokines and chemokines. This results in a marked systemic inflammatory response syndrome, leading to edema, effects on multiple organ systems, a hypermetabolic response and suppression of the immune system. Early surgical care is based around the ABCD philosophy (as guided by Advanced Trauma Life Support and also Emergency Management of Severe Burns). An assessment system based on depth is vital for clinical decision making and prognosis. Many centers now aim for early excision and grafting of burns. Early excision modifies the host responses by removing devitalized tissue that might otherwise invoke deleterious effects, but its removal in itself may also provide a major insult. Several variations in approach are possible to modify the impact of excision and an approach tailored to the individual is appropriate. Covering the excised burn area can be achieved with wide range of materials from allograft to synthetic skin substitutes. Key to successful burn care is a directed multi-disciplinary model for providing appropriate expertise on individual sites, together with the development of burn care networks to facilitate effective delivery of burns services across an entire region.     

St Andrew’s COVID-19 surgery safety (StACS) study: The Burns Centre experience

BackgroundThe COVID-19 pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has the potential to significantly impact burns patients both directly through infective complications of an immunocompromised cohort, and indirectly through disruption of care pathways and resource limitations. The pandemic presents new challenges that must be overcome to maintain patient safety; in particular, the potential increased risks of surgical intervention, anaesthesia and ventilation. This study comprehensively reviews the measures implemented to adapt referral pathways and mitigate the risk posed by COVID-19 during the height of the pandemic, within a large Burns Centre.MethodsA prospective cohort study was designed to assess patients treated at the Burns Centre during the UK COVID-19 pandemic peak (April–May 2020), following implementation of new safety measures. All patients were analysed for 30-day mortality. In addition, a prospective controlled cohort study was undertaken on all inpatients and a random sample of outpatients with telephone follow-up at 30 days. These patients were divided into three groups (operative inpatients, non-operative inpatients, outpatients). COVID-19 related data collected included test results, contact with proven cases, isolation status and symptoms. The implemented departmental service COVID-19 safety adaptations are described.ResultsOf 323 patients treated at the Burns Centre during the study period, no 30-day COVID-19 related deaths occurred (0/323). Of the 80 patients analysed in the prospective controlled cohort section of the study, 51 underwent COVID-19 testing, 3.9% (2/51) were positive. Both cases were in the operative group, however in comparison to the non-operative and outpatient groups, there was no significant increase in COVID-19 incidence in operative patients.ConclusionsWe found no COVID-19 related mortality during the study period. With appropriate precautions, burns patients were not exposed to an increased COVID-19 risk. Similarly, burns patients undergoing operative management were not at a significantly increased risk of contracting COVID-19 in comparison to non-operative groups.