The effect of COVID-19 social restrictions on major trauma volumes and resource utilisation at a level 1 trauma centre

The Coronavirus (COVID-19) pandemic has posed a significant challenge for the Australian population, economy and healthcare. In stages from 23/03/2020 the Australian government placed social restrictions, mandatory self-isolation laws and quarantining all overseas travellers. The healthcare response involved re-allocation of resources, increasing intensive care capabilities, staff re-training and cancellation of elective surgery. The local effect of the pandemic on trauma epidemiology is unknown. It has been even speculated that major trauma would disappear and trauma specialist staff could be redirected to the pandemic response. Certain injury mechanisms (self-harm, domestic violence) were expected to increase¹. The purpose of this study was to provide objective data on changes in major trauma volumes to aid future planning. We hypothesised that trauma volumes and associated resource utilisation will decrease.

In this observational study a prospective “COVID-cohort” (March-May 2020) was compared to retrospective control period (March-May 2011-2019). All trauma resuscitation patients’ data from the John Hunter Hospital, required by the New South Wales trauma registry, was utilised. Details regarding statistical analysis is provided in the Supporting Information. This study was granted a waiver from the institutional Ethics Committee.

A total of 3574 patients were included (COVID: 259, Control: 3315). There were no differences in age, sex and injury severity score (ISS). See Table 1 [available in PDF]. Mechanism of injury also remained unchanged (Table 2) [available in PDF]. During the COVID period there was decrease in admissions (368±73 to 259; p=<0.002), severely injured patients (ISS>12) (124±16 to 96; <0.001),  intensive care unit(ICU) admissions (56±10 to 35; p=<0.001), ventilator requirements (35±9.3 to 23; p=0.006), operative cases (142±30 to 106; p=<0.001) and in inpatient mortality (3.1%±1.2% to 1.5%; p=0.004). See Table 1 [available in PDF]. The strictest restrictions were in April and the number of severely injured patients, ventilator requirements and inpatient mortality remained unchanged to the control cohort during this period (Supporting Information) [available in PDF].   

For patients self-presenting to hospital, it is possible that the fear of contracting COVID-19 in the healthcare setting could be a potential barrier however the catchment area for our level-1 trauma centre was not severely affected by COVID-19 cases (total of 279 cases in 3 months from a population of a million with 6 ICU admissions and 4 deaths). Therefore, we can assume that reductions in admissions have largely been due to social restrictions enforced by the government².

Our study shows no significant changes in mechanism of injury. Two similar studies however have shown a significant decrease in traffic, industrial, sports and fall related trauma during periods of social restrictions^3,4.

The limitation of this study is the single-centre nature and it did not cover potential second waves. A strength is that our hospital is the only level-1 trauma centre in the area and receives the majority of trauma patients. We extended the study period to ten years to include a larger control cohort and covered the adjacent months for government restrictions not addressed by previous studies ^­3,4.

Despite a reduction in admissions, the demand for trauma care is still consistent with the requirements of a fully functioning trauma service, which should be taken into account by clinicians and hospital administrators when making resource allocation and utilisation decisions⁵. Severely injured patients require comprehensive early management and the importance of senior experienced trauma clinicians being available for decision making cannot be undervalued^6,7. Task shifting of trauma specialist services to viral pandemic management is unlikely to be warranted based on the first wave of COVID-19 in our trauma system⁸.

Figure 1 (Supporting Information) [available in PDF] depicts total number of admissions per week extending beyond the period of analysis. As social restrictions continue to ease throughout New South Wales it appears that the number of admissions is beginning to increase. In light of this a future longitudinal observational study may be of benefit to monitor future trends as restrictions continue to ease.

References:

1. Balogh ZJ, Way T, Hoswell R. The epidemiology of trauma during a pandemic. Injury. 2020;51(6):1243-1244.
2. NSW Health. Latest COVID-19 updates. 2020 [cited 30 July 2020]. Available from: https://www.health.nsw.gov.au/Infectious/covid-19/Pages/stats-nsw.aspx
3. Him Wong J, Chee Cheung K. Impact of COVID-19 on Orthopaedic and Trauma Service. J Bone Joint Surg Am. 2020;Publish Ahead of Print. doi: 10.2106/JBJS.20.00775.
4. Christey G, Amey J, Campbell A, Smith A. Variation in volumes and characteristics of trauma patients admitted to a level one trauma centre during national level 4 lockdown for COVID-19 in New Zealand. N Z Med J. 2020;133(1513):81-86.
5. Aljuboori Z, Sieg E. The early effects of social distancing resultant from COVID-19 on admissions to a Level 1 trauma center. Injury. 2020;51(10): 2332
6. McCullough A, Haycock J, Forward D, Moran C. Early management of the severely injured major trauma patient. Br J Anaesth. 2014;113(2):234-241.
7. Burrell AJC, Pellegrini B, Salimi F et al. Outcomes of COVID-19 Patients Admitted to Australian Intensive Care Units during the Early Phase of the Pandemic. Med J Aust 2020; https://www.mja.com.au/journal/2020/outcomes-covid-19-patients-admitted-australian-intensive-care-units-during-early-phase  [Preprint, 16 September 2020].
8. Maintaining Trauma Center Access and Care during the COVID-19 Pandemic: Guidance Document for Trauma Medical Directors [Internet]. American College of Surgeons. 2020 [cited 30 July 2020]. Available from: https://www.facs.org/covid-19/clinical-guidance/maintaining-access#:~:text=%20Maintaining%20Trauma%20Center%20Access%20and%20Care%20during,for%20Catastrophic%20Disaster%20Response%2C%20NASEM.%20%20More%20