Geriatric Burn Injuries Presenting to the Emergency Department of a Major Burn Center: Clinical Characteristics and Outcomes.

BACKGROUND: Burn injuries in geriatric patients are common and may have significant associated morbidity and mortality. Most research has focused on the care of hospitalized patients after admission to burn units. Little is known about the clinical characteristics of geriatric burn victims who present to the emergency department (ED) and their ED assessment and management. OBJECTIVE: Our aim was to describe the clinical characteristics and outcomes of geriatric patients presenting to the ED with burn injuries. METHODS: We performed a comprehensive retrospective chart review on all patients 60 years and older with a burn injury presenting from January 2011 through September 2015 to a large, urban, academic ED in a hospital with a 20-bed burn center. RESULTS: A total of 459 patients 60 years and older were treated for burn injuries during the study period. Median age of burn patients was 71 years, 23.7% were 80 years and older, and 56.6% were female. The most common burn types were hot water scalds (43.6%) and flame burns (23.1%). Median burn size was 3% total body surface area (TBSA), 17.1% had burns > 10% TBSA, and 7.8% of patients had inhalation injuries. After initial evaluation, 46.4% of patients were discharged from the ED. Among patients discharged from the ED, only 1.9% were re-admitted for any reason within 30 days. Of the patients intubated in the ED, 7.1% were extubated during the first 2 days of admission, and 64.3% contracted ventilator-associated pneumonia. CONCLUSIONS: Better understanding of ED care for geriatric burn injuries may identify areas in which to improve emergency care for these vulnerable patients.

Skin Failure Among Critically Ill Patients Afflicted with Coronavirus Disease 2019 (COVID-19).

Objective: To characterize skin integrity among coronavirus disease 2019 (COVID-19) patients treated in the intensive care unit (ICU), and identify risk factors for skin failure (SF) in these patients. Design: The characteristic, profound pro-inflammatory, hypercoagulable state of COVID-19 is manifested by the high severity of illness and extensive organ dysfunction observed in these patients. SF in critically ill patients, although described previously, exhibits a uniquely complex pathogenesis in this population. Patients: Retrospective review of all COVID-19 patients (confirmed positive for severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) admitted to a single surgical ICU for at least 48 hours between March-June 2020. Interventions: Data were extracted from a COVID-19 institutional data repository that harvested data from electronic health records and other clinical data sources. Demographics; coagulation/inflammation biomarkers; number, location, and stage of SF lesions; resource utilization; and outcomes were captured. Measurements and Main Results: 64 patients met inclusion criteria; 51 (80%) developed SF (SF+ ). Forty-three (85%) developed stage 3 or higher SF (χ2 = 22.66, P < .0001). Thirty-nine of 51 (76%) SF+ patients developed more than one SF lesion (χ2 = 13.26, P = .0003). SF+ patients manifested a profound pro-inflammatory, hypercoagulable phenotype (lower serum albumin and higher ferritin, interleukin [IL]-6 and D-dimer concentrations [all, P < .001]). Durations of mechanical ventilation, vasopressor therapy, and ICU length of stay were significantly longer (all, P < .05) in the SF + patients. Conclusions: The unique characteristics of COVID-19 dermatopathology and the strong correlation between markers of inflammation and development of SF reflect COVID-19-related organ dysfunction and its deleterious effects on the microcirculation. Considering that skin is invaded directly by SARS-CoV-2 and affected by COVID-19-related immune complex deposition and microthrombosis, SF may reflect disease as opposed to pressure injuries related to processes of care. In the context of COVID-19 critical illness, SF should not be considered a "never event."

Multisystem inflammatory syndrome in children: A complication of COVID-19.

ABSTRACT: Multisystem inflammatory syndrome in children is a previously unrecognized and potentially catastrophic illness that appears in children who have been exposed to or diagnosed with COVID-19. As healthcare agents and members of the community, nurses are positioned to assist in identifying children who may experience previously unrecognized complications of infection from the SARS-CoV-2 virus.

Rapid Critical Care Training for Nurses Deployed to Intensive Care Units During the COVID-19 Surge.

BACKGROUND: During the first COVID-19 pandemic wave, non-intensive care unit (non-ICU) nurses were deployed to temporary ICUs to provide critical care for the patient surge. A rapid critical care training program was designed to prepare them to care for patients in either temporary or permanent ICUs. OBJECTIVE: To evaluate the effectiveness of this training program in preparing non-ICU nurses to provide critical care for COVID-19 patients in temporary ICUs. METHODS: A survey was used to evaluate the impact of rapid critical care training on nurses' critical care skills and compare the experiences of nurses deployed to temporary versus permanent ICUs. Data were analyzed with χ2 and Spearman ρ tests with α = .05. RESULTS: Compared with nurses in other locations, nurses deployed to temporary ICUs were less likely to report improved capability in managing mechanical ventilation; infusions of sedative, vasoactive, and paralytic agents; and continuous renal replacement therapy. Nurses in temporary ICUs also reported being less prepared to care for critically ill patients (all P < .05). CONCLUSIONS: The rapid training program provided basic critical care knowledge for nurses in temporary ICUs, but experiences differed significantly between those deployed to temporary versus permanent ICUs. Although participants believed they provided safe care, nurses with no critical care experience cannot be expected to learn comprehensive critical care from expedited instruction; more formal clinical support is needed for nurses in temporary ICUs. Rapid critical care training can meet emergency needs for nurses capable of providing critical care.

Rapid Critical Care Training of Nurses in the Surge Response to the Coronavirus Pandemic.

BACKGROUND: In response to the coronavirus pandemic, New York State mandated that all hospitals double the capacity of their adult intensive care units In this facility, resources were mobilized to increase from 104 to 283 beds. OBJECTIVE: To create and implement a 3-hour curriculum to prepare several hundred non-critical care staff nurses to manage critically ill patients with coronavirus disease 2019. METHODS: Critical care nursing leaders and staff developed and implemented a flexible critical care nursing curriculum tailored to the diverse experience, expertise, and learning needs of non-critical care nursing staff who were being redeployed to critical care units during the surge response to the pandemic. Curricular elements included respiratory failure and ventilator management, shock and hemodynamics, pharmacotherapy for critical illnesses, and renal replacement therapy. A skills station allowed hands-on practice with common critical care equipment. RESULTS: A total of 413 nurses completed training within 10 days. As of June 2020, 151 patients with coronavirus disease 2019 still required mechanical ventilation at our institution, and 7 of 10 temporary intensive care units remained operational. Thus most of the nurses who received this training continued to practice critical care. A unique feature of this curriculum was the tailored instruction, adapted to learners' needs, which improved the efficiency of content delivery. CONCLUSIONS: Program evaluation is ongoing. As recovery and restoration proceed and normal operations resume, detailed feedback from program participants and patient care managers will help the institution maintain high operational readiness should a second wave of critically ill patients with coronavirus disease 2019 be admitted.

A Pilot Study to Validate the Burn Center Pediatric Early Warning Score Tool in Clinical Practice.

The pediatric early warning score (PEWS) tool helps providers to detect subtle clinical deterioration in non-intensive care unit pediatric patients and intervene early to prevent significant adverse outcomes. Although widely used in general pediatrics, limited studies report on its validation; none report on use with burn-injured patients. New York-Presbyterian/Weill Cornell Medical Center modified a general PEWS system to a burn-specific PEWS and integrated its use into standard practice. This study investigated the external validity of the PEWS process in clinical practice. Fifty cases of patients aged 0 to 15.9 years admitted between January 2012 and June 2013, whose length of stay (LOS) more than 3 days were selected for review from this cohort of n equal to 187. Demographics, total PEWS and score changes, and compliance with PEWS documentation and with resultant interventions were reviewed. Continuous variables are presented as mean ± SD, P less than 0.05. Mean age, burn size, and LOS were 3.2 ± 3.3 years, 4.8 ± 5.7%, and 9.8 ± 7.0 days; 26% required grafting, and 50% were male. No mortalities occurred. One thousand six hundred and twelve PEWS from 1745 opportunities were documented (92.4%). For all PEWS (n = 1612) and PEWS greater than 0 (n = 912), means were 0.9 ± 1.2 and 1.6 ± 1.2, respectively. Among the 162 PEWS increase events, intake (54.1%) and output (4.5%) parameters increased most commonly. Of these, 129 PEWS increases (79.6%) were followed by an intervention that most commonly included text notation of score increase (93.7%), physician/physician assistant notification (70.5%), and feeding-tube insertion (25.6%). Patients with PEWS greater than 0 had similar age, LOS, and larger burn size (5.2% vs 1.4%, P < 0.05) than those with PEWS equal to 0. Compliance with PEWS performance and resultant actions based on score increases are high. Data support that even small changes in burn-injury specific PEWS stimulate provider discussion and intervention and support its validation; further studies on its effect on practice are warranted.