Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID- 19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. burns 46 (2020) 1021 1035 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/burns Burn center function during the COVID-19 pandemic: An international multi-center report of strategy and experience Juan P. Barret a, Si Jack Chong b, Nadia Depetris c , Mark D. Fisher d, * , Gaoxing Luo e , Naiem Moiemen f , Tam Pham g, Liang Qiao h , Lucy Wibbenmeyer i , Hajime Matsumura j a Department of Plastic Surgery and Burns, Hospital Universitari Vall d’Hebron, Department of Surgery, School of Medicine, Universitat Autonoma de Barcelona, Passeig de la Vall d’Hebron 119-129, 08035 Barcelona, Spain b Department of Plastic Reconstructive and Aesthetic surgery, Singapore General Hospital, Academia 20 College Road, Singapore 169856, Singapore c Anaesthesia and Intensive Care, Città della Salute di Torino, corso Bramante, 88 10126, Torino, Italy d Division of Plastics and Reconstructive Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52240 USA e Institute of Burn Research, Southwest Hospital Army (Third Military) Medical University, Chongqing 400038, China f University Hospitals Birmingham Foundation Trust, (Heritage Building) Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK g Harborview Medical Center, 325 Ninth Ave, Box 359796, Seattle, WA, USA h Department of Burn and Plastic Surgery, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, 197 Ruijin Er Road, Shanghai 200025, China i Division of Acute Care Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, USA j Department of Plastic and Reconstructive Surgery, Tokyo Medical University, 6-7-1 Nishishinjyuku, Shinjukuku, Tokyo, 160-0023, JAPAN article info abstract Article history: The novel coronavirus, SARS-CO V2 responsible for COVID-19 pandemic is rapidly escalating across Accepted 6 April 2020 the globe. Burn centers gearing for the pandemic must strike a balance between contributing to the pandemic response and preserving ongoing burn care in a safe and ethical fashion. The authors of the present communication represent seven burn centers from China, Singapore, Japan, Italy, Spain,theUnitedKingdom(UK), andtheUnitedStates(US).Eachcenterislocatedatadifferentpoint Keywords: along the pandemic curve and serves different patient populations withintheir healthcare systems. COVID-19 We review our experience with the virus to date, our strategic approach to burn center function SARS-COV2 under these circumstances, and lessons learned. The purpose of this communication is to share Austere conditions experiences that will assist with continued preparations to help burn centers advocate for optimum Burn surgery burn care and overcome challenges as this pandemic continues. Critical care © 2020 Elsevier Ltd and ISBI. All rights reserved. * Corresponding author. E-mail addresses: jpbarret@vhebron.net (J.P. Barret), chong_si_jack@hotmail.com (S.J. Chong), nadia.depetris@gmail.com (N. Depetris) , mark-d-fisher@uiowa.edu (M.D. Fisher), logxw@yahoo.com (G. Luo), nmoiemen@aol.com (N. Moiemen), tpham94@uw.edu (T. Pham), ql10727@rjh.com.cn (L. Qiao), lucy-wibbenmeyer@uiowa.edu (L. Wibbenmeyer), hmatsu-tki@umin.ac.jp (H. Matsumura). https://doi.org/10.1016/j.burns.2020.04.003 0305-4179/© 2020 Elsevier Ltd and ISBI. All rights reserved. 1022 burns 46 (2020) 1021 1035 traveled from Wuhan city [1]. As of today, Shanghai has had 1. Introduction 451 confirmed cases. Among them, 108 are in stable condition, 6 remain in critical condition, 2 are in severe condition, five The world has watched the COVID-19 pandemic unfold as it patients have died, and 330 have recovered [2]. The first wave began in the province of Wuhan, China in the end of 2019 and of COVID-19 patients in Shanghai occurred in February. But a has inexorably marched across the globe. At the beginning of second wave of disease is being observed due to the large flow April, at the time of the publication of this report, the world is of people back to Shanghai returning from abroad. Today all united in apprehension about the future. Like a slow-motion people coming from abroad are screened with nucleic acid car accident, we have all contemplated what coming weeks tests. will bring to our communities. Reports have taught us that the disease brings high 2.2. Shanghai strategic approach to burns during COVID- volumes of critically ill patients in a surge that can be 19 overwhelming. The lines of defense for the critically ill start with the medical intensive care units, followed by the surgical The Shanghai Center for Disease Control has directed the flow intensive care units, leaving the burn intensive care units of care across the city throughout the outbreak. Ruijin Hospital shielded at first. is the largest hospital in the city including a dedicated acute But the burn service as a whole is a working unit of great burn hospital on the campus. After Wuhan was locked down resilience able to handle the arduous care of the sickest patients on January 23, our burn hospital was directed not to treat any with the largest and most complex wounds. As a result, the burn patients with fevers. Careful screening has been performed to service represents an important component of the response to keep COVID-19 positive patients out of the burn hospital. All the COVID-19 surge, as has been demonstrated repeatedly. burn patients with fever were directed to specialized clinics for As burn leaders anticipate the surge in their own cities in testing for COVID-19. coming weeks, the strategic approach will vary depending on Since the second week of January, we have been screening numerous local factors. As the following reports demonstrate, people first by phone and again at the door for travel history, key tasks include strategic coordination of services, reasoned presence of family members from epidemic areas, presence allocation of burn resources to the surge, and maintenance of of fever and any respiratory symptoms in the last 2 weeks. residual burn capacity. We present the strategy and experience to The only patients who can be admitted to the burn hospital date of seven burn centers in China, Singapore, Japan, Italy, Spain, must be negative for travel risk factors in the last 2 weeks and the UK, and the US. These centers are located across the full range be afebrile. Even then, asymptomatic patients undergo chest chronologically: before, in the midst of, and status post the peak of computed tomography (CT) prior to admission. To date, no new cases (Fig. 1). We anticipate a follow-up report when the COVID-19 patients have been admitted at Ruijin Burn pandemic threat has receded and hope our collective experience Hospital. will be useful. Indeed, we must find ways to become stronger, more responsive and agile, before the next challenge comes. 2.3. Burn workforce management during the pandemic We have 22 physicians and 74 nurses in the burn hospital. Since 2. Shanghai experience the second week of January, we have modified the call schedule to maintain physicians in reserve in case of illness. One team has 2.1. Course of COVID-19 in Shanghai been dispatched from the burn hospital to assist the fight against the disease in Wuhan, Hubei province. The team included The first case reported in Shanghai was on January 20, 2020 at 2 physicians and 3 nurses. Telehealth has also been incorporated the start of the outbreak in China (Fig. 2). The patient had into the practice of therapists, nurses, and Physicians/NPs/PAs. Fig. 1 – The centers are located across the full range of the surge timeline. burns 46 (2020) 1021 1035 1023 Fig. 2 – New COVID-19 cases: China. 2.4. Workforce safety and surveillance 2.5. Burn hospital ED practice Hospital staff are regularly screened for the possibility of ED evaluations are conducted with one person per consulta- COVID-19. A color coded QR health code is used to identify and tion room (Fig. 3). Family accompaniment is minimized, and direct workers by risk level [3]. Staff complete a screening febrile patients are screened and directed to the nearest fever application and are assigned a code accordingly. The identical clinic. Even without fever or other high-risk factors, PPE is used system is used with patients and serves as a passport system in all ED encounters including masks, shields, gloves, and for movement through the hospital for all. gowns. Fig. 3 – Shanghai Ruijin Burn Hospital Screening Algorithm. 1024 burns 46 (2020) 1021 1035 2.6. Inpatient burn practice Educating all the personnel about the protection and control of COVID-19, all the personnel should pass the tests Constant surveillance for fever or other risk factors for online, paperwork, and practice. COVID-19 is performed after admission. On the ward, PPE is used during patient care and social distancing principles are 3.2. Staff travel restrictions emphasized. Inpatients who develop respiratory symptoms or fever undergo Reverse Transcriptase-Polymerase Chain Reac- Local and hospital administrators have been carefully direct- tion (RT-PCR) and chest CT. On discharge, principles of COVID- ing staff to limit risk of COVID-19 to our hospital. Those who 19 prevention are emphasized and follow-up is done through traveled to Hubei province or other regions outside Chongqing telemedicine as much as possible. Also, the messages of cannot return without clearance. Hospital staff must also prevention, first aid, treatment, and rehabilitation are pro- receive clearance from the president of the hospital to leave moted as much as possible during the pandemic. downtown Chongqing. A fever clinic was established for the evaluation of individuals with symptoms such as fever, cough, sore throat, dyspnea. Asymptomatic staff with known unpro- 3. Chongqing experience tected contact with a suspected COVID-19 patient are quarantined for 14 days. Chongqing is one of the four municipalities in China with a population of 32 million, adjacent to Hubei province. COVID-19 3.3. Protection of staff at the burn center was first diagnosed in January and then escalated starting January 20th. Total cases to date are 579 with 6 deaths. Only The temperature of all staff is measured on entrance and exit three additional cases have been identified in Chongqing in from the center and only necessary staff are permitted to March, all of them came from overseas. All the domestic enter. Staff food must only be from home or from the hospital patients have been discharged at the time of recovery. There canteen and meals should be consumed in isolation. We avoid have been no suspected or confirmed COVID-19 burn patients unnecessary meetings. Necessary meetings are minimized to so far. During the last two months, our burn volume has no more than 15min in well-ventilated places. Finally, staffing substantially diminished, which we attribute to alterations in is adjusted fluidly matching the number of staff in the hospital population activity (Fig. 4). Our center has 96 burn inpatients to the need. Staff are sent home when possible. Staff are also on March 30. One doctor and four nurses from BICU of our encouraged to use private transportation to and from the center are still working to rescue the severe patients of hospital. Those who must use public transportation wear COVID-19 in Wuhan since January 22. mask, glove, and face shield, maintaining 1.5 2m distance from others. 3.1. Chongqing burn strategy during COVID-19 3.4. Burn patient screening during COVID-19 Fortunately, we have not experienced an overwhelming burden of disease. But we have developed detailed practices Enhanced precautions when evaluating new patients include to protect and maintain burn system function through the heighted PPE use and careful screening for COVID-19 risk pandemic. factors. In addition, all new admissions require prior Fig. 4 – COVID-19 in Chongqing, China. burns 46 (2020) 1021 1035 1025 notification of the director and head nurse of the ward. only for life-threatening causes. PPE enhanced to the Suspected and confirmed COVID-19 patients do not go on to secondary or tertiary level in these circumstances. Emergen- further burn care without infectious disease consultation. cy procedures in patients of unknown status should be Suspected patients are screened by nucleic acid tests and chest preceded by a CT scan and enhanced PPE is used. During the CT. We continue to remain vigilant for evidence of COVID- height of the outbreak in Chongqing, follow-ups and 19 after admission as well, ready to escalate precautions for rehabilitation visits were minimized and conducted via any patient who develop suspicious new findings. Regardless telehealth when possible. of status, each patient should be set in a single room. 3.7. PPE and sanitation equipment 3.5. Patient cohorting It is incumbent of each ward to establish a system to register Our burn center consists of 6 clinical floors with 4 wards and and manage PPE and disinfection supplies. Usage and supply 150 burn beds and 4 research floors. New severe burn are calculated every day. patients are admitted to BICU on the fifth floor with no visitors. New, lower severity inpatients are admitted to the second floor for the first 14 days of the admission. There, first 4. Singapore experience level PPE are maintained, and patients are housed in individual rooms with no more than one caregiver. Pediatric 4.1. Course of COVID-19 in Singapore patients are allowed two caregivers. The temperature of both patients and caregivers are checked twice daily. Patients and Singapore is a city state that has a population of 5.5 million and caregivers are also not permitted to leave the ward. This is served by a single burn unit, Singapore General Hospital emotional impact of this isolation is mitigated via remote (SGH). COVID-19 was first diagnosed in the city on January 2nd video for family. and a slow increase has been developing since that time (Fig. 5). In Singapore we have had more than 850 COVID- 3.6. Burn surgery during COVID-19 19 patients total with 19 currently in the ICU, 3 deaths, and 250 who are status post discharge. Currently most of the Our strategy during the outbreak is to abstain from elective patients are imported cases from returning Singaporeans. The operations on COVID-19 positive patients, reserving surgery rate of infection in the city is steadily accelerating, with an Fig. 5 – New COVID-19 cases: Singapore. 1026 burns 46 (2020) 1021 1035 inflection point that has just become apparent in late March. Fortunately, no burn patients with the virus have been 5. Tokyo experience encountered so far. 5.1. Course of COVID-19 in Tokyo 4.2. Singapore COVID-19 strategy Tokyo is the largest city in Japan with a dense population of Burden of COVID-19 has not yet necessitated extensive 13.85 million. The first COVID-19 patient was diagnosed on January round the clock cohorting of staff and no impact on burn 30. The patient was a female in her 30s working as a tour conductor capacity has been experienced so far. Burn personnel have in Wuhan. She entered Japan on January 20th and became been contributing to the virus effort. Junior staff have all symptomatic four days later followed by pneumonia. Since that been deployed to the emergency department and to the time 299 patients are COVID-19 positive, 253 are hospitalized, isolation wards. Senior staff may start to be deployed to 13 are critically ill, 6 have died, and 40 have been discharged (Fig. 6). contribute to the overall efforts. Foreign patients which used Tokyo has observed a dramatic rise in cases in March prompting to account for most of our major burn patients have now the Governor of Tokyo to say, “we are at the point where we can been restricted. deter the explosion of infection” calling for a lockdown. We are preparing for a surge of infections across the city. 4.3. Physical plant Burn services in Tokyo are provided by 14 Burn/Trauma units which comprise the Tokyo Burn Unit Association. So far Of note, our previous experience with SARS, Nipah Virus, H1N1, none of these units have treated a burn patient suspicious and MDROs has resulted in considerable physical plant elements for COVID-19. Consequently, burn services are running within the hospital designed for occasions such as this. In 2019, normally at this time. the burns unit at SGH created a separate isolation wing which can function independently. The capacity of the 8 isolation-capable 5.2. Effect of the pandemic on burn center resources ICU rooms (all with ante-room), separate operating theater and support rooms to facilitate cohorting, change and disposal. The Across the 14 Tokyo burn centers, we have not yet experienced isolation wing can independent cater to the normal workload of a surge in patients. But there is concern for limitations in burn patients while the 34 bed burn center is catered for mass numbers of negative pressure rooms, staffing, and PPE. One casualty scenarios. hospital is beginning to restrict access to outpatient care. Fig. 6 – New COVID-19 cases: Japan. burns 46 (2020) 1021 1035 1027 5.3. Tokyo burn center plan of the burn patients, either adults or children, who were admitted to both centers had confirmed COVID-19, until now. Burn patients suspicious by history or clinical findings will be Only one child, who was admitted before the outbreak, had a screened with chest x-ray (CXR) and chest CT, followed by PCR family contact with a suspected COVID-19 individual but if the diagnosis is unclear. Patients with suspected infection consequently tested negative. will be evaluated in a dedicated room. At this time, we do not have plans to change technique of burn care, either surgical or 6.2. Birmingham strategy during COVID-19 pandemic at the bedside. We have not instituted cohorting of the staff yet. The Tokyo burn system has not yet been stressed by the 6.2.1. University hospitals Birmingham COVID-19 pandemic yet but we anticipate the imminent and A UK wide lockdown was issued on Monday 23 March, however rapid escalation of disease. Infected patients with trauma, University Hospitals Birmingham Executive team on March burns, and other acute illnesses will soon arise, and there will 10th, asked all hospital staff not to travel outside the be an urgent need to address these. There is likewise an urgent Birmingham area and banned all hospital “professional” visits. need to simulate situations that the burn unit will face. On March 20th, the hospital preparedness was ramped up in order to create a regional hub COVID-19. All routine surgeries were canceled, and out-patient clinics were converted to 6. Birmingham experience “virtual” consultations, with all required IT support put in place. Visiting to in-patients is canceled except in exceptional 6.1. Course of COVID-19 in Birmingham circumstances and footfall to the hospital site is tightly monitored and controlled. Meetings are conducted via video Birmingham city is the second largest in UK with a population conference wherever possible and social distancing is encour- of 1.1 million and a wider metropolis population of 2.4 million. aged amongst staff members whilst at work. The current 36 University Hospitals Birmingham has 2700 beds and covers all theaters, on Queen Elizabeth Hospital Site, are now prepared to medical and surgical specialties, with 100 Critical care beds on support the existing critical care bed and only 3 theaters were the main site of Queen Elizabeth Hospital, hosts the Regional designated for emergencies including Burns. Adult Burn Center with 18 beds (3 Intensive care, 7 High On Burns, we lost 3 critical care beds as they were within the dependency, and 5 isolation rooms and 4 low dependency general critical care cohort that was designated to support beds). Birmingham Children Hospital, Specialized Pediatric COVID-19 patients. As part of the strategic resilience all 7 high Hospital hosts the Regional Pediatric Burn Center with11 beds dependency rooms at the burn center were upgraded to fully (2 burn pediatric intensive care, 2 high dependency, 3 isolation equipped intensive care rooms and from now ventilated burn rooms and 4 low dependency beds. patients can be cared for at the burn center rather than the Although the first 2 cases of COVID-19 patients in UK were general ICU. reported on January 31, 2020, the first patient in Birmingham with COVID-19 was not reported till March 9th, 2020 (Fig. 7). [4] 6.2.2. Birmingham children hospital As of March 29, 2020, there are 513 patients with confirmed The numbers of hospitalized children with COVID-19 is very COVID-19 reported by Public Health England in Birmingham. As small, however there was some strategic shift to respond to the for the March 30th the Queen Elizabeth Hospital site have more local and national pressures on burn care. An agreement was than 260 patients with suspected or confirmed COVID-19. None set in place to accommodate young adults within the children Fig. 7 – The numbers of COVID-19 individuals in the West Midland Region. 1028 burns 46 (2020) 1021 1035 hospital, if required. Furthermore, there was a national national guidelines on the care of burn patients due to be agreement between clinicians, commissioners and NHS published shortly of patients with revised Baux score >90, England, to designate Birmingham as a National Burn Center patients with Canadian frailty score >5 and suspected or during the pandemic confirmed positive COVID-19 patients. 6.3. Changes in the patients pathways 7. Barcelona, Spain experience All available consultants at the Queen Elizabeth Hospital site had extra training on the basic Critical care management as 7.1. Course of COVID-19 in Barcelona relevant to COVID-19 patients to support the critical care team. All medical staff are changed to a full shift rota pattern and The COVID-19 outbreak in Spain started in February. The first daily assessments are made of minimal staff numbers imported cases appeared in the Canary Islands and the required to maintain a safe service. Any members of staff Island of Mallorca. Following that, the next imported cases considered surplus to this requirement are redeployed to other appeared in different cities around the country. These were areas such as dedicated teams for proning ventilated patients imported cases from the North of Italy before mandatory or inserting intravenous access. All planned rotations of junior confinement of that population was instituted. Community medical staff are postponed. Daily meetings are held to brief spread of the virus in Spain then began in the first two weeks the senior medical staff about any relevant organizational or of March (Fig. 9) [5]. This was also the point at which the clinical issues to be disseminated to the rest of the medical inflection point in the rate of spread was observed. The most team. severely affected regions early on were Madrid, La Rioja, and Minor burns <10% TBSA are not routinely admitted and the Basque Country. The situation of the whole of Spain at during the period of the pandemic lockdown, patients, parents the time of this report includes 85,195 confirmed cases and carers were taught to do their own dressing at home and (accounting to an incidence of 1828 cases/1,000,000 people), provided with adequate supply of dressings. Telemedicine are 5231 in intensive care, 6528 deaths, and 16,780 cases used to monitor these patients in a structured “virtual” burn recovered and cured. wound dressing clinics. Moderate burns were admitted only The first case in our hospital came on March 2nd. On March after consultant burn surgeon review of that patient in the 11th we had 21 cases (Fig. 8). A State of Emergency was emergency room. Major Burns care pathway was also adapted declared on the 13th with mandatory confinement. But an to accommodate to the new hospital strategic shift. Access to exponential rate of admissions has been observed, nonethe- theater on admission as per original protocol is still main- less. At the time of this report (March 30th), there are now tained, however, further theater access requires prioritization, 685 cases of pneumonia admitted in the hospital and 147 in competing with other emergencies. Immediate access for ICU. Forty additional cases have been transferred to nearby burns at the Children Hospital is still maintained. private hospital which has been subsumed under University We are following national guidelines for PPE and patients Hospital control. Fifteen cases have been housed in a nearby testing for COVID-19. We can only test patients with fever or hotel which has been medicalized and the nearby sports symptoms. There was criticism of the limited testing in UK pavilion has been transformed in a campaign hospital to house compared to other European countries. Furthermore, there is 22 additional patients [6]. Fig. 8 – Evolution of admitted cases at the Vall d’Hebron Hospital Campus. burns 46 (2020) 1021 1035 1029 All health professionals have been mobilized except for COVID-19 admissions in the General ICU, the Burn Center has minimal staff to maintain the function of specialized units started to admit non-COVID polytrauma and non-COVID Neuro- including the Burn Center. Surgery is reserved only for life ICU patients. All anaesthesiologists and intensive care physicians threatening conditions, including severe burn cases. have been mobilized for COVID-19-related work. As a conse- quence, the center has been forced to decrease its OR capacity to 7.2. Barcelona burn function during COVID-19 life-threatening conditions only. ICU capacity has been doubled by converting non-essential wards to ICUs. Currently, the Our Burn Center is a 26-bed facility with our own burns hospital has a capacity of more than 200 ICU beds for adult operating theater, outpatient department, rehabilitation area patients. Since March 26th, the Burn Center has been converted to and dedicated burn ER. The Center treats both adults and a non-Covid ICU, being the last area of the Trauma Hospital children and serves a catchment population of 8 million COVID-free besides the Regional Spinal Cord Injury Unit. As of people. Average burn admissions are 550 per year and 3000 March 27th, the only area of the Hospital campus that is entirely burn emergencies per year. non-COVID is the Children's &Women hospital. Eight patients with suspected COVID-19 infection have been examined so far. Of those, 3 positive cases have been confirmed. 7.4. Staff management during the COVID-19 surge One of the cases died after developing pneumonia. The patient was 84 years old with a 5% full thickness burn on the back of the Until March 26th, the physician workforce was divided into thighs. There have been no problems with supplies and access two cohorts which rotated through 2-week shifts. The off-duty to the operating room as burn services are considered essential. physicians remained at home, not on call. But the surge of The center maintained full capacity until March 23rd. Following cases has forced more aggressive staff deployment. Since that day, the center started to admit non-Covid19 critical March 26th all surgical staff have been mobilized to staff patients and had to decrease the OR capacity. Burn emergencies COVID-19 ICUs except for a minimal staff to maintain essential and admissions have also decreased due to the confinement of surgical services. Nurses remain divided into three cohorts the population and the decrease of industrial activity. rotating 1 week on and home for 2 weeks. 7.3. Workforce management during COVID-19 surge 7.5. Staff COVID-19 infections March 26th has been somewhat of a watershed with considerable Our first burn staff COVID-19 infections occurred the week of intensification of work after that time. Due to the pressure of March 23rd including a head-nurse with respiratory Fig. 9 – New COVID-19 cases: Spain. 1030 burns 46 (2020) 1021 1035 symptoms and fever. One burn intensivist is now admitted 7.7. Inpatient burn care with COVID-19 pneumonia. Unprotected exposure of personnel to positive patients are COVID-19-positive patients are preferentially treated with reported to the Occupational Risk Prevention Department for multi-day dressings (48 72h). Nonetheless, more frequent investigation. If the contact is at risk personnel is confined at dressing changes are performed when required. home. 7.6. Patient COVID-19 screening and disposition 8. Turin, Italy Experience If a burn patient presents to the ER with a suspicious history 8.1. Course of COVID-19 in Turin and clinical exam, pharyngeal sputum RT-PCR and chest X-ray are performed. Turin, in Northwestern Italy, has a population of 875,000 and is Patients requiring admission have a chest X-ray regardless located in the Piedmont region. This is adjacent to Lombardy, the of symptoms. After admission, burn patients who develops Italian epicenter of COVID-19. The surge in Turin began in early symptoms are isolated and undergo sputum PCR and chest March with nearly 10,000 cases in the Piedmont region by the end X-ray. Isolation is maintained until definitive results return. of the month. This is in the larger context 105,792 cases nationally The final disposition of a COVID-19 Positive Burn Patient is and 12,428 deaths to date (Fig. 10). As the burden of disease has as follows: mounted in the city, ICU capacity in the seven hospitals has been doubled, and in some cases tripled. Nonetheless hospitals are  Non-critical burn: transfer to surgical COVID Ward with extremely full. The Orthopedic and Trauma Center (CTO) of the nursing by a cohort of burn nurses for COVID patients. Città della Salute Hospital had been reserved from COVID-19 to  Critical Burn patient: transfer to the COVID-19 Positive maintain trauma and burn capacity. But at the time of the present Trauma ICU which is located next to the non-COVID Burn/ report, even this hospital has 6 critically ill, and 20 ward COVID- Trauma ICU. 19 patients. Overall incidence of burn injuries is diminished, but some unusual burns relating to efforts to disinfect with alcohol The Burn Center works with continue positive pressure in have been observed. The surge of cases in Turin has required a the Burn ER, Burns Theater and the Burn-ICU rooms. radical redistribution of burn workforce into the COVID-19 effort. Therefore, no COVID-19 positive patients may be treated in Indeed, the present intensity of the effort has made it difficult these areas [7]. even to draft this communication. Fig. 10 – New COVID-19 cases: Italy. burns 46 (2020) 1021 1035 1031 8.2. Strategies from Turin University of Washington Medicine (UW Medicine), 73 patients are currently hospitalized among the 4 main hospitals (UW Several important strategies should be emphasized based on Medicine-Montlake, UW Medicine-Northwest, Harborview our experience. The speed and severity of the crisis must not be Medical Center, and Valley Medical Center). With rapid underestimated. As resources will be in high demand, be ready ramp-up of testing, we have tested over 34,000 samples in to regionally centralize severe burn patients so that other burn our region. Our region is witnessing a sudden change in the centers can care for COVID-19 patients. Regional hospitals rate of positivity (from 6 7% to 14%) in the most recent should be ready to increase critical care capacity. Defensive samples, suggesting that we may be at an inflection point in measures to prevent the spread of the virus within hospitals the incidence curve. must be started immediately. Invasive procedures raise the risk of transmission by several mechanisms from proximity to 9.2. Seattle COVID-19 strategic plan airway manipulation. This can lead to new lines of transmis- sion in and outside the hospital. Therefore, great prudence This evolving pandemic has already had a larger impact on our must be exercised in performing procedures. region's healthcare system than any other event in our lifetime. Harborview Medical Center (HMC) activated the incident command system one month ago (late February 9. Seattle, USA experience 2020) to prepare personnel, resources and processes for a projected large influx of confirmed and presumptive infection 9.1. Course of COVID-19 in Seattle cases. The burn center participates in the planning organized within HMC, the UW health system, as well as the Northwest On January 21, 2020, the Washington State Department of Healthcare Response Network (NHRN). The University public Health announced that an individual tested positive for the COVID-19 resource page is: https://covid-19.uwmedicine.org/ SARS-CoV2 virus, the first confirmed case of COVID-19 in the where plans and protocols are disseminated [8]. US. Over the last two months, the Seattle region has become an epicenter of the infection (Fig. 11). The federal government 9.3. Inpatient hospital organization declared Washington a major disaster area on March 22nd and pledged federal assistance to our State. As of March 24, there Within the hospital, COVID-19 patients are cohorted on are 2469 confirmed cases and 123 deaths in Washington. At the 2 separate floors (1 ICU and 1 acute care floor). Geographic Fig. 11 – New COVID-19 cases: USA. 1032 burns 46 (2020) 1021 1035 separation offers the advantages of using specialized ICU possible. If patients require immediate transfer in for evalua- rooms with negative pressure and maintenance of strict tion, strict screening protocols are in place to detect symptoms infection control practices in those units. As the number of and cohort on arrival patients. Upon discharge, patients are COVID-19 patients surge, additional space will be located instructed in wound care and therapy. They are provided sequentially in the trauma surgical ICU, the post-anesthesia sufficient dressing and medication supplies to support tele- care unit (PACU), then burn/pediatric ICU. Providers can health follow-up. Burn center outpatient in-person appoint- maintain droplet precautions in these expansion spaces, but ments have been reduced by 90%, by reschedule engineering challenges limit how many can be converted to a (reconstruction, late burn effects) and tele-visits (mostly negative pressure environment in a short period. through pictures, with some video-visits). Burn providers can now be off-site, conducting telehealth follow-ups coordi- 9.4. Conservation of resources nated by the clinic. To conserve equipment resources, all elective procedures 9.8. Inpatient burn team redeployment throughout the health system are canceled, with reappraisal planned in 6 weeks. Total operating room capacity has been The burn team workforce also has an impending need to re- intentionally reduced by 1/3 so far, with strict rules to conserve deploy: (1) to oversee the care of burn patients if they are PPE, specifically surgical masks and gowns. The inpatient burn cohorted in COVID units, and (2) to augment the critical care units are implementing reusable cloth gowns and repeat use of capabilities of the institution. Currently, one burn ICU nurse surgical masks. This implementation has an estimated per shift is deployed to the COVID-19 ICU for 12h for savings are more than 200 disposable gowns and masks per onboarding. N95 testing, training to properly don and doff day from the burn ICU and acute care inpatient units alone. isolation PPE are underway for all burn personnel. Multiple health systems have engaged the community in the region to help fabricate additional surgical masks and donate 9.9. Burn care adaptation PPE that individuals may have purchased. Overall burn treatment strategies have not changed thus far, 9.5. Protection of personnel but we are preparing for the possibility that altered standards of care may need to be implemented soon. We adhere to the All healthcare personnel have the immediate need to preserve principle that such activation must occur in conjunction with their health, in order to reduce infection risk and be ready to our regional partners, as critical care capabilities must substitute in case of exposure. As such, part of the provider consider all conditions, not just COVID-19 vs. other specialized staff is now working from home (attending physicians, fellows, patient populations. Urgent reallocation of resources is often advanced practice providers and residents). The UW Health possible with improved regional awareness, for instance, System has suspended all clinical rotations for medical when ventilators are scarce in one facility but available in students and other clinical trainees. Nursing and therapy another. Another regional consideration is blood supply. services have not yet adopted this off-site work arrangement. Currently, our region's blood supply is at 60% of normal given On-site personnel perform an attestation of having no blood drive event cancelations and regional stay-at-home respiratory symptoms before beginning their daily work. orders. Scoring the severity of illness across conditions, Healthcare workers with respiratory symptoms must stay although an imperfect system, allows for proper allocation home and undergo testing as indicated. Online town halls are of resources and most importantly upholds the principle of held at least weekly, and more resources are made available distributive justice in an overwhelmed healthcare system. In daily to improve situational awareness and the resilience of the meantime, our burn center is reducing the needs for healthcare workers. All new clinical research enrollment is daily dressing changes for inpatients, through silver- suspended whereas ongoing research activities have been impregnated dressings and ointment reapplications on greasy converted to remote access. The entire administrative support gauze. Updated protocols are already in place for procedures staff is working remotely. that generate aerosolized particles (airway procedures,- cardiopulmonary resuscitation, bronchoscopy). Previous ef- 9.6. Burn service strategies forts to convert in-hospital visits, and team meetings to video format have also accelerated because of the need to imple- The overriding principle for the burn service line in this ment in-hospital distancing. pandemic is to reduce our current footprint within the hospital, while advocating for the needs of the acute burn patients. 10. Iowa City, USA experience 9.7. Outpatient burn care 10.1. Course of COVID-19 in Iowa City In the outpatient phase, we have increased our recommen- Iowa City is small college town in the rural Midwest of the dations for acute burn patients to receive local wound care and United States. As such it has been shielded from the earlier follow video instructions for therapy exercises (available free, waves of COVID-19 that have hit the coastal US. The University online) for acute burn referrals. The burn clinic contacts each of Iowa Hospital and Clinics (UIHC) is an 811 bed with annual referred patient to offer telehealth follow-ups whenever inpatient admissions of 37,000. The hospital serves a local burns 46 (2020) 1021 1035 1033 population of 147, 001 whereas the Burn Center serves the state team and surgical intensive care workforce, developed a new of Iowa and surrounding environs bringing the burn popula- schedule (March 24). With the cancelation of elective surgeries, tion served to 3.1 million. emergency general surgery and trauma services were com- Nonetheless, we have witnessed the remarkable reach of bined. One surgeon was assigned to both services for a 4-day COVID-19 as infected patients accumulate with mounting period with a daily back up. In the anticipation of the need for speed even in Iowa (Fig. 12). The first case came to our area on intensivists, a list of available general surgery faculty was March 8th with community spread reported by March 15th. At created to cover the ACS team. The resident schedule was the time of this report, we anticipate entering the steep phase adjusted to a 5-day rotating schedule to accommodate services of the curve in our area over the next two weeks. As of March with more needs and provide time off (March 26). 27, the state of Iowa had 235 positive residents, 50 of whom were hospitalized and 3 deaths. The number of positive cases 10.4. University of Iowa burn service planning of coronavirus has been increasing at an average rate of 5.9 new cases a day since testing became more available on 10.4.1. Adaptation in communication March 20 [9]. There have been no suspected or confirmed The burn unit, in many regards, was well positioned to adjust to COVID-19 burn patients have presented so far. the new guidelines. Already with a well-functioning interdisci- plinary team, the burn team was able to adjust to electronic 10.2. University of Iowa COVID-19 strategic plan communication platforms for rounds and communication. Telemedicine was already an active way to communicate with The University of Iowa Hospitals and Clinics (UIHC) had both clinic and outside referral hospitals. For clinic stream- already benefitted from the experience of many other cities lining, the team was able to effectively communicate via phone and countries in preparations for COVID-19 when the first and the patient web portal. For referral hospitals, an optional positive residents were announced in early March. Multiple picture upload to a privacy-protected email was made manda- steps were instituted sequentially. Conservation of PPE (March tory (Health Insurance Portability and Accountability Act, 1996). 9) and orders for reusable gowns and cloth hats were placed. Per protocol charge nurses were able to continue to manage The Emergency Command of the hospital was activated, and potential transfers with house officer or advanced practice daily meetings instituted (March 10). The daily census was provider input when necessary. pruned by cancelation and conversion of clinic visits to telemedicine visits (March 14) and elective surgeries were 10.4.2. Wound care adaptations canceled (March 17). The flow of visitors was restricted (March Wounds were preferentially placed in long term dressings for 13) and entrances were secured and monitored (March 15). both in and outpatients. Discharged patients were instructed Remote work was offered to staff on March 16. The hospital set on future wound care per the discharging nurse and videos up an online site to manage in-kind donations from the that had been previously created. Finally, our disaster community and one for employee ideas on the crisis preparedness dressing supply list was reviewed with the management. These actions have seen a reduction in the hospital to ensure that we had enough supplies and did not hospital census from near capacity on March 8 to 72% on March have to adjust our daily routines. 26. 10.4.3. Changes in burn care algorithm 10.3. Reorganization of workforce Projections of the coming surge of critically ill COVID- 19 patients in the state of Iowa suggest we will face shortages In anticipation of workforce realignments and absences, the in ventilators and ICU capacity in two weeks. Our present Acute Care Surgery Division (ACS), which included the burn stance is aimed to conserve resources as much as possible. We Fig. 12 – COVID-19 cases: Iowa. 1034 burns 46 (2020) 1021 1035 are currently formalizing an austere conditions allocation 11.5. Engagement in regional strategic planning scheme for critical care resources in case of severe burns. An effective regional response to the pandemic will include a centralized strategic command to coordinate clinical units. 11. Discussion Burn center leadership should be engaged with this process, including the reorganization of critical care and re-allocation 11.1. Key lessons from centers at the tail end of the epidemic of other resources within their hospital and regional emer- surge gency/disaster preparedness network. Regional critical care coordination is of utmost importance, as altered and crisis Chongqing and Shanghai are cities of the largest scale, standards of care may need to be implemented in specific positioned relatively close to Hubei and are now well past circumstances. The allocation of scarce resources (such as the main surge of infections. The most important lessons from ventilator access) for burn patients will need to be considered their experience are on the subject of big picture coordination together with needs of all other critical care patients in the and discipline in prevention. Their remarkable success in region. Burn center leaders must leverage existing regional containment should motivate other centers to carefully study collaboration and continue to communicate with other burn their approach. leaders regionally, nationally and internationally to fast-track Both cities had a centralized command structure for the the dissemination of best practices and lessons learned. response to the virus which was able to direct the population and coordinate city-wide clinical strategy. 11.6. Conservation of resources Even though COVID-positive patients were kept out of the burn service, both burn centers maintained intense and Burn personnel should also lead in conservation strategies to meticulous precautions with great discipline. Consequently, preserve resources. Burn patients are inherently susceptible to neither of these exceptionally large burn centers had a single infections. Given the shortage of PPE, burn personnel have case of a COVID positive patient in their main units, preserving adapted to new policies that have included limited access to burn center function. And importantly, burn patients who gowns and reduction of health care provider-patient exposure. were COVID-positive were successfully managed as part of the This has led to the adoption of multi-day dressings to obviate COVID-positive cohort. daily wound care. Some centers choose to avoid multi-day dressings for outpatients as these specialized dressings may 11.2. Key lessons from centers currently in the middle of the require return clinic visits for changes. In many cases, simple surge daily dressings done at home are a viable option. Barcelona is a large city with an advanced healthcare system. 11.7. Maintenance of burn workforce And yet the surge of life-threatening COVID-19 has forced the city to engage in a heroic defensive action. A key lesson to be Preservation of the burn workforce is essential to maintaining learned is that the COVID-19 surge can reach a scale and burn competency and can be achieved through institution of intensity that few of us have ever experienced. As the surge strict infection control protocols and instituting strategies to intensifies, a continuous reallocation of healthcare resources accommodate remote work. Many of the centers have rotated may be required. This is a challenging task that should be work forces to accommodate days off, these include teams of vigorously planned now. Likewise, burn center resources will nurses, residents, and physicians. Few reports of burn person- be increasingly directed to the COVID-19 response. This will nel infections have been reported. This is most likely secondary result in a de facto austere situation vis-à-vis burns. Hence to strict infection screenings and visitor restrictions instituted austere condition burn algorithms should be titrated as the at hospitals and burn centers. The most stringent of these have scale of the COVID-19 threat rises. occurred in Asia including reporting exposures to Occupational Health, hospitals lockdown and either using private modes of 11.3. Key lessons from centers at the start of their surge transportation, or requiring PPE if using mass transportation. The remaining centers in this report are included to demonstrate 11.8. The importance of cohorting the approach of centers with different circumstances, systems, and patient populations but who all have had the advantage of Geographic cohorting of burn patients helps to maintain non- advanced warning. In a follow up report, we will review the infectious status at the same time providing proximity to enable performance of our respective strategies in coping with the wound care as well as interprofessional team care. Burn centers, coming threat. especially those in Asia, have maintained burn units as COVID- free units, screening with RT-PCR, chest radiographs and chest 11.4. Principles of burn center management during the CT scans, and requiring admission permission from hospital pandemic administration. Physical plant permitting, a burn center may be able to be divided into modular isolation units to care for burn The clinical treatment of burn patients with COVID-19 infec- patients or other patients with COVID-19. If the floor plan of the tion itself is beyond the scope of this report. But there are key unit does not allow for this, the burn team will have to adapt to concepts that are specific to burn service organization as travel to other units to offer care to burn patients with COVID-19. follows. This is the situation currently in Barcelona. Finally, with the burns 46 (2020) 1021 1035 1035 continued spread of infected patients, many burn units have REFERENCES been re-purposed into general intensive care units, taking on trauma and other specialty populations. When the regional needs exceed these capabilities, burn [1] Report of COVID 19 in Shanghai City. Shanghai, China. center providers can expect to be re-deployed and have Shanghai Municipal Health Commission. http://wsjkw.sh.gov. expanded roles as necessary to assist in the care of surge cn/xwfb/20200121/5b01c1a678df4faab338d9ed1efdc958. html2020. patients, such as intensivist deployments in Shanghai and [2] Report of COVID 19 in Shanghai City. Shanghai, China. Singapore. Shanghai Municipal Health Commission. http://wsjkw.sh.gov. cn/xwfb/20200325/baaaa2bb956e4c1693861cf80e11305c. 11.9. Technique of burn care under pandemic conditions html2020. [3] QR health code is used to identify. In: Commission SMH, editor. As resources become scarce, a de facto austere condition http://wsjkw.sh.gov.cn/fkdt/20200217/ emerges. Burn units should be ready to titrate strategies to the aa2cce7311dd47efa9a1d8536d2baf24.html. [4] Public Health England Historic Dashboard. https://www. degree of austerity using existing instruments such as the arcgis.com/apps/opsdashboard/index.html#/ American Burn Association Austere Conditions Guidelines f94c3c90da5b4e9f9a0b19484dd4bb142020 [Accessed 31 March [10]. That being said, no center has yet reported the need to 2020]. change burn surgery or bedside technique per se other than [5] Legido-Quigley H, Mateos-Garcia JT, Campos VR, Gea-Sanchez heightened PPE precautions when indicated. M, Muntaner C, McKee M. The resilience of the Spanish health system against the COVID-19 pandemic. Lancet Public Health; 2020. [6] Pla de contingència de Vall d’Hebron per fer front a l’epidèmia 12. Conclusion del SARS-CoV-2. Comitè de Direcció de l’Hospital Universitari Vall d’Hebron; 2020. The shocking speed with which the COVID-19 pandemic has [7] Protocol d’actuacions a tenir en compte davant de possibles exploded, and the scale of strategic planning required to cope casos d’infecció per Coronavirus SARS-CoV-2. https:// make it very difficult for systems to prepare adequately. In many intranet.vallhebron.com/sites/default/files/2020-03/Protocol- places, the critical care demand will create sudden scarcity Vall-Hebron-COVID-19.pdf2020. [8] UW Medicine COVID-19 Resource Site. https://covid-19. which will impact the capacity to provide critical care for burns. uwmedicine.org/Pages/default.aspx2020. This obligates each burn center to prepare for burn care under [9] Jin B. The COVID tracking project. https://covidtracking. austere conditions. In cases of massive COVID-19 disease, the com2020. burn center will become an important cache of personnel, space, [10] Young AW, Graves C, Kowalske KJ, Perry DA, Ryan CM, and equipment. Burn center leadership should actively engage Sheridan RL, et al. Guideline for burn care under austere in the local and regional strategic planning. Importantly, the conditions: special care topics. J Burn Care Res 2017;38: burn community should seek ways to help one another through e497 509. the coming challenge. The present collection of experiences FURTHER READING (ADDITIONAL RECOMMENDED aims to achieve the goal of early communication among burn RESOURCES ) leaders in order to disseminate knowledge rapidly and fast-track best practices for the burn community. [11] UW Harborview burn center videos for home burn care. https://www.youtube.com/playlist?list=PLFEMTIzjmLeUC- Conflict of interest tONmpxadXa_7rusm_B6. [12] Disaster response resources from the ABA during the COVID- None declared. 19 crisis. http://ameriburn.org/quality-care/disaster- response/. Author Contribution It was the wish of the authors to share equal credit. This is why the authors have been listed in alphabetical order.