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 insitution maintain high operational readiness should a second wave of critically ill patients with coronavirus disease 2019 be admitted.

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.”

No abstract

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.

Introduction Pediatric Early Warning Scores (PEWS) facilitate the identification of non-ICU pediatric patients at risk for deterioration. Limited studies exist to describe the utility of Burn specific PEWS (bPEWS) in the early identification of clinical vulnerability. The purpose of this retrospective chart review was to associate a bPEWS assessment value with a need for elevation to an ICU level of care for the burn-injured child. Methods A retrospective chart review of all non-mechanically ventilated (nMV) pediatric patients admitted to the burn service from July 2013 to May 2016 (n=709). Data included bPEWS scores, age, total body surface area (TBSA) burn and hospital length of stay (LOS). A pediatric level of care (PLC) designation, instituted as a model of care delivery following this study, utilizes bPEWS to categorize patients by acuity. Patients are grouped by their highest bPEWS: a) unstable (bPEWS &gt; 8; b) watchers (bPEWS 5–7); and c) stable (bPEWS &lt; 5). This study retroactively utilizes this framework. Results 709 patient charts yielded 12,642 bPEWS data points. 37 patients (0.53%) scored &gt; 8 during their hospital stay. Patient age was not statistically significant, a=2.4 years, b=3.25, and c=2.3(F=0.64, p = 0.53). More secondary diagnoses were present in the a) unstable cohort (59%) than either the b) (26. 6%) or c) (20%); (c2 = 6.3, p = 0.02 and p &lt; 0.01). There was a statistically significant difference in the number of patients in the unstable cohort versus the watcher and stable cohorts combined (c2 = 13.21, p &lt; 0.01). Patient transfer to the pediatric ICU (PICU) occurred in 10.8% of the a) unstable group and none of the watcher or the stable cohorts (b, c), (p=0.02). Pediatric critical intensivist consults occurred in 19% of the a) unstable patients but not in either the watcher or the stable patients (p &lt; 0.01). The average LOS was 18.1 days in the a) unstable group, 9.41 days in the b) watcher group, and 6.06 days for the c) stable group, (F=19.20, p &lt; 0.01). TBSA burn was larger for the unstable group (12.5%), versus 5.74% for watcher patients, and 2.5 % for stable patients, (F=9.70, p &lt; 0.01). On average, the peak bPEWS scores occurred hospital day 3.27 in the unstable group, 2.58 in the watcher group, and day 1.88 in the stable status group, (NS) (F=0.88, p = 0.42). There were no mortalities. Conclusions This retrospective review captures the infrequent experience of significant clinical deterioration in the nMV pediatric burn population reflected through the bPEWS lens. There appears to be a relationship between high bPEWS scores, burn size, presence of a secondary diagnosis, and increasing LOS. This study supports the designation of these patients to higher levels of care. This bPEWS driven paradigm presently results in adjusted nursing staffing ratios, frequency of assessment, and mandated collaborative medical practice patterns. Applicability of Research to Practice Directly Applicable.

October l Nursing2021 l 33 MULTISYSTEM INFLAMMATORY SYNDROME in children (MIS-C) is a previously unrecognized and potentially catastrophic illness that appears in children who have been exposed to or diagnosed with COVID-19. In the US as of September 1, 2021, there have been approximately 40,000,000 identified COVID-19 cases related to exposure to the SARS-CoV-2 virus and nearly 640,000 deaths. 1 However, the actual number of cases of COVID-19, particularly early in the pandemic, may not have captured the magnitude of infection because of limited testing that was directed at people who presented with more significant illness. 2 Children appeared to tolerate infection with COVID-19 well, but in late spring 2020, a hyperinflammatory process in children similar to Kawasaki disease (KD) began to emerge in the United Kingdom and several other European nations. 3 In mid-May 2020, New York State formulated an interim case definition of MIS-C. Soon after that, the CDC began tracking reports of children meeting the criteria of this novel syndrome.As of September 1, 2021, 4,044 cases of MIS-C have been identified in the US, resulting in 37 deaths. 4 Waves of new infection are sweeping through the world, heightening concern about people of all ages, including children. In the US, 22% of the population is made up of infants,

Introduction Central line-associated bloodstream infections (CLABSI) remains a high risk for burn patients due to their compromised integumentary system. Additionally, identifying bloodstream infections secondary to a burn infection versus a central line remains a challenge. Literature review suggests multidisciplinary CLABSI bundles (MCB) demonstrate reduction of CLABSIs. This research looks at the use of a MCB compared to the application of the standard CLABSI bundle alone reduce CLABSI incidence and standardized infection ratios over the past two years in the Burn Center. We hypothesize a MCB will have sustained CLABSI SIR and incidence reduction over time. Methods Infection Prevention & Control CLABSI data collection on all burn patients pre-intervention (2017-2018) and post-intervention (2019-2020) were performed as a quality improvement project; IRB was not obtained. In addition to the CLABSI Bundle (optimal site, aseptic insertion, aseptic maintenance, timely removal, & education), MCB was also implemented in Qtr. 1, 2019. MCB includes necessity of line discussion during daily and multidisciplinary rounds, strategic blood culture collection upon admission/transfers for patients with existing central line, improved nursing and provider documentation of burn infection per CDC definitions, integration of CLABSI reviews in tiered Burn Quality Improvement Program, and universal zero CLABSI goal setting for RNs. Two-sample t-test will be used to compare results pre-intervention (2017-18) & post-intervention (2019-20). CLABSI incidence and standardized Infection ratio will be illustrated per year. Results The post-intervention CLABSI SIR data (M= 0.08, SD=0.11) significantly improved when compared to the pre-intervention CLABSI SIR data (M= 0.77, SD= 0.169), t(2)=4.72, p=0.02. The post-intervention CLABSI incidence data (M=0.5, SD=0.70) significantly improved when compared to the pre-intervention CLABSI incidence data (M=4.5, SD= 0.70), t(2)= 5.65, p= 0.01 Conclusions The combination of the CLABSI bundle with the MCB demonstrated favorable CLABSI SIR and incidence reduction, as literature suggests. Implementing multimodal, multidisciplinary interventions must be a priority for sustained CLABSI reduction. Considerations for future studies should measure length of catheter days, incidence of positive blood cultures on admission/transfers for patients with existing central lines, and incidence of burn infection rates with positive blood culture and an existing central line.

ATI,4' Afp;IC44 7QURN4. [Oct. 5.t 187, regularly every four hours a tablespoonful of liquor acetatis ammoniae with five grains of carbonate of ammonia added, and had champagne, with or without soda-water, at the rate of a bottle every twenty-four hours. I may mention that this treatment and the washing out the vagina and uterus were continued throughout. Next day, the skin was completely covered with the eruption, the tongue taking on the typical strawberry appearance, and the fauces being very much inflamed and painful. The pulse remained about I20, and the temperature ranged from Ioi deg. to I04 deg. Altogether, the case was one of pure unmixed scarlatina. I say pure, for from first to last there was not a single local puerperal symptom. On the third and fourth nights of the fever, there were some delirium and restlessness, but not more than one sees in even moderately mild cases of scarlatina. The case went on well; desquamation began on the eighth day, and was completed before the end of a month. The patient sat up in a chair in a fortnight from her delivery, and was outof-doors in a month. Now here is a case in which a sharp attack of undoubted scarlatina, setting in thirty-two hours after delivery, does not modify in any way the puerperal condition. There never was the slightest abdominal tenderness, or tympanites, or suppression of the lochial discharge; the