Abstract
Background
During the months between April through June 2020 when we experienced the largest number of COVID-19 patients in our hospital, the volume of patients in the Emergency Department (ED) was decreased by more than 30%. In contrast to most early reports we did not notice a decrease in trauma volume during this time period.
Materials and Methods
We compared trauma patients presenting to our Level III Trauma Center, between April 2019 through June 2019 to those presenting from April 2020 through June 2020, the initial surge in COVID-19 patients. We compared ground level falls (GLF), motor vehicle crashes (MVC), bicycle and skateboard crashes, assault, and other.
Results
There was a 13% increase in trauma patients presenting during the study period in 2020 as compared to 2019, and the total number of trauma patients as a percentage of total ED patients also increased 269/9235 (2.9%) to 308/6216 (5.0%), P < 0.0001. There was no significant difference in demographics or outcome data between the trauma patients presenting during the two time periods. Although traffic decreased by more than 40%, the number of MVC's was similar.
Conclusion
The volume of patients presenting to our Trauma Center as compared to the total ED volume increased during the time period from April through June 2020 versus the year just prior to the COVID-19 pandemic. Despite the fact that the total traffic volume decreased more than 40 percent between these two time periods, the actual number of motor vehicle crashes remained similar.
Keywords: Trauma volume, COVID-19 pandemic, Ground level falls, Motor vehicle crashes, Bicycle crashes
Introduction
The recent COVID-19 Pandemic has been the most significant event in the history of medicine since the Spanish Flu. Healthcare workers have had to rapidly change the way medicine is practiced and administered and the changes are ongoing. In particular, the preparedness for the Emergency Department (ED) and hospital surges is a process in evolution. During the H1N1 Pandemic, most hospitals reported a significant increase in the number of ED visits [1], [2], [3]. This increase was especially true for children. During the initial wave of COVID-19 pandemic, most EDs in the United States and Internationally reported a significant decrease ED volume [4], [5], [6]. The volume changes reported varied from a 13% decrease in China [6] to as high as a 49% decrease in the Northeast region of the United States [4]. Different from the H1N1 pandemic, the number of children presenting was particularly decreased [4]. While the number of admissions decreased, the severity of admissions increased [4,6], and the number of less severe illness presentations such as hypertension, nausea and vomiting, and superficial injuries decreased [6]. Because of the increase in severity of illnesses presenting to the Emergency Departments, particularly COVID-19 related illnesses, the number of hospital beds and ICU beds were rapidly depleted [7,8]. In addition to the decreasing number of Emergency Department visits most early reports from Trauma Centers reported a decrease in trauma volume [9], [10], [11], [12], [13], [14], [15], [16]. In particular, the number of motor vehicle crashes reported decreased [[9], [10], [11],13,14]. California was early to institute preventative measures in an effort to control the spread of infections. On February 28, 2020 the state secured COVID-19 tests. On March 4, 2020, the state ordered a State of Emergency. On Monday, March 16 2020, San Francisco and the other Bay Area counties issued shelter-in-place orders in response to the Covid-19 pandemic that served as a model for the statewide stay-at-home order issued by the Governor on Thursday March 19, 2020. The order was extended indefinitely in late April. On March 11, 2020, the State ordered mass gatherings to be canceled or postponed.
The first case relating to COVID-19 in California was confirmed on January 26, 2020. Despite the early and aggressive response from California State leadership, by November 15, 2020, there were 1,019,345 confirmed cases and 18,253 deaths in California. During the surge of COVID-19 related illnesses in the spring of 2020, we also noted a decrease in Emergency Department patient visits in our hospital, from April to June of 2020. This was the time when we experienced the first large volume of COVID-19 inpatients. In contrast to other trauma center reports, we did not see a decrease in trauma volume during the initial wave of COVID-19 patients. We evaluated our database to understand the categories of trauma patients and identify any changes in the pattern of trauma patients that presented to our trauma center during the initial surge of the COVID-19 pandemic.
Materials and methods
Our Trauma Center is an American College of Surgeons verified Level III Trauma Center, and the only Trauma Center in Marin County, a county of 258,826 in 2019. The patients were entered into a relational database. We compared trauma patients in our database presenting to our Level III Trauma Center, between April 2019 through June 2019, to those presenting from April 2020 through June 2020. We compared ground level falls (GLF), motor vehicle crashes including motorcycle (MVC), bicycle or skateboard crashes (Bike/Skate), assault (Assault), and Other. We evaluated demographic data including the total number of trauma patients, and the number of trauma patients as a percentage of total ED visits. We also compared the volume of patients in each of the four major categories, and demographic data including Injury Severity Score (ISS), number of admissions in each category, length of stay for hospital ward, step-down care and ICU admissions. Transferred patients were either patients under the age of 18, or complex pelvic fractures. These patients were not included in our admitted patients although the numbers in each of these categories were small. The number of patients seen at our trauma center with penetrating injuries is small. In order to understand if there were any differences in penetrating trauma due to the pandemic, we compared demographic and outcome data for penetrating trauma during the two years preceding the pandemic, 2018–2019, and the two years of the pandemic, 2020–2021. Comparisons were made using Chi-Square and Unpaired Students t-test. Differences were considered significant for P ≤ 0.05. The study was approved by our Institutional Review Board.
Results
There was a 13% increase in trauma patients presenting in 2020 as compared to the same time period in 2019, 308 versus 269, although this difference was not statistically significant, see Table 1 . The number of ED visits (non-trauma patients) from April through June 2019 was 9235. During the same period in 2020, the number of ED visits decreased to 5908, a 36% decrease. The percentage of trauma patients as compared to ED patients increased significantly during the initial pandemic surge, 269/9235 (2.9%) versus 308/5908 [(5.0%), P < 0.0001]. The most common injury seen in our Trauma Center is ground level fall. The next most common injury is bicycle and skateboard crash. Motor vehicle including motor cycle crashes make up the third largest category of trauma patients. There was a slight increase in assaults, 13/309 (4.2%) versus 8/269 [(2.9%), 2020 versus 2019] although this difference was not significant. There was also a five-fold increase in self-harm, 5 versus 1 (2020 versus 2019) although this difference was also not significant. Assaults made up for 3% and 4% of the total trauma patients in 2019 versus 2020 respectively. There were no significant differences in demographic data between 2019 and 2020, see Table 1. Interestingly, there was no significant decrease seen in patients from MVC's between the two time periods. In the spring of 2019, all patients entered into the database from MVCs were single patient crashes, so there were no trauma patients during this time as multiple casualties from a single vehicle crash. In 2020, there were three instances involving multiple casualties from a single vehicle crash so the number of patients (n = 32) was greater than the number of vehicle crashes (n = 24), see Table 1. The traffic across the Golden Gate Bridge is recorded going from Marin into San Francisco due to the toll charges going southbound. From April through June 2019, the number of vehicles crossing southbound was 5,121,295 and in 2020 during the same period there were 2,268,350 vehicles recorded (Golden Gate Bridge Authority, public data), a 44% decrease. If we use traffic on the Golden Gate Bridge as a surrogate for traffic in Marin County the number of crashes per vehicle on the roadway between April 2019 and June 2019 was one for every 6.64 × 10−6 vehicles, (34/5,121,295). During the same time period from April 2020 through June 2020, the number of crashes per vehicle on the roadways in Marin (using the bridge traffic as surrogate) was one for every 1.05 × 10−5 vehicles, (24/2,268,350) a 37% increase in car crashes per traffic vehicle between April through June 2020 as compared to 2019. There were also no significant differences in outcome data during these two time periods, see Table 2 . In particular, there were no differences in the mean ages of patients in each of the four categories, or in the women as compared to men. In addition, the ISS, the number of patients admitted, and the length of stay for the admitted patients were similar between the two comparison groups. When we compared penetrating trauma in the pre-pandemic period to the pandemic period there was an increase in penetrating trauma from 46 total patients to 66 total patients, although the total trauma volume increased during this time as well. There were no differences in the demographics of the patients with penetrating injuries, see Table 3 . However, the mechanism of penetrating injury did change during pandemic. In the two years’ pre-pandemic the number of patients with gunshot wounds was 7/46 (15%) as compared to 24/66 (36%), P = 0.014. The remainder of penetrating injuries were stab wounds. There were no differences in penetrating injuries from self-harm during our initial pandemic surge.
Table 1.
Demographic data for the three most common trauma encounters from April through June 2019, as compared to the same months in 2020, (when we experienced the first surge of COVID-19 patients). These data show that there was no significant difference in the demographic data in trauma patients evaluated at our Level III trauma center between the study periods in 2019 and 2020. There was an increase in trauma patients as compared to total ED patients in 2020 as compared to 2019.
| 2019 | 2020 | P-Value | |
|---|---|---|---|
| Total Trauma patients | 269 | 308 | NS |
| Total ED patients | 9504 | 6216 | NS |
| Trauma vs ED patients | 269/9235 (2.9%) | 308/5908 (5.0%) | ≤0.0001 |
| GLF-number | 185/269 (69%) | 201/308 (65%) | NS |
| MVC-patients | 34/269 (13%) | 32/308 (10%) | NS |
| MVC vehicle crashes | 34/269 (13%) | 24/308 (8%) | NS |
| Bicycle-Skate-number | 38/269 (14%) | 54/308 (18%) | NS |
| GLF-age | 75 ± 18.7 | 72 ± 20.0 | NS |
| MVC- age | 51.6 ± 22.3 | 43.3 ± 23.4 | NS |
| Bicycle-Skate-age | 49.0 ± 16.5 | 45.4 ± 19.2 | NS |
| GLF-women | 49% | 49% | NS |
| MVC women | 41% | 31% | NS |
| Bicycle-Skate-women | 16% | 22% | NS |
Total ED patients includes trauma patients.
GLF-Ground Level Fall.
MVC-Motor Vehicle Crash (includes motorcycle). During the 2020 study period there were three multi-victim car crashes as opposed to the 2019 study period when there were only single victim crashes.
Bicycle-Skate includes bicycle and skate board injuries.
Table 2.
Outcome data for the three most common trauma admission categories from April 2019 through June 2019 as compared to the same three months in 2020.
| 2019 | 2020 | P-Value | |
|---|---|---|---|
| GLF-ISS | 7.0 ± 6.1 | 6.0 ± 5.6 | NS |
| MVC-ISS | 8.2 ± 8.3 | 7.1 ± 7.6 | NS |
| Bicycle-Skate-ISS | 6.8 ± 5.6 | 7.3 ± 5.5 | NS |
| GLF-admitted | 65% | 62% | NS |
| MVC- admitted | 53% | 60% | NS |
| Bicycle-Skate-admitted | 42% | 39% | NS |
| GLF-LOS (days) | 6.6 ± 6.8 | 5.3 ± 5.6 | NS |
| MVC-LOS (days) | 4.8 ± 3.1 | 5.7 ± 3.7 | NS |
| Bicycle-Skate-LOS (days) | 4.3 ± 2.8 | 4.9 ± 4.9 | NS |
ISS- Injury Severity Score.
GLF-Ground Level Fall.
MVC-Motor Vehicle Crash (includes motorcycle).
Bicycle-Skate includes bicycle and skate board injuries.
LOS-Length of stay for admitted patients includes admissions to the ICU, Step-Down Care, and regular ward admissions. Transferred patients were not recorded as admitted or discharged home.
Table 3.
We compared demographic and outcome data for patients with penetrating injuries during the two years preceding the pandemic, 2018–2019 to the two pandemic years, 2020–2021.
| 2018–2019 | 2020–2021 | P-Value | |
|---|---|---|---|
| Total penetrating trauma | 46 | 66 | |
| GSW (versus total) | 7/46 (15%) | 24/66 (36%) | 0.014 |
| Age (years) | 38.7 ± 14.5 | 34.5 ± 13.9 | NS |
| Men | 40/46 (87%) | 60/66 (90%) | NS |
| Self-inflicted | 7/46 (15%) | 9/66 (14%) | NS |
| Expired | 1/46 (2%) | 5/66 (8%) | NS |
GSW – gunshot wound.
Discussion
Several recent studies evaluating trauma volume have demonstrated a decrease in total trauma patients in 2020 after the onset of the COVID-19 Pandemic [9], [10], [11], [12], [13], [14], [15], [16]. Most reports relate this decrease to an associated decrease in Emergency Department visits. The total number of trauma patients seen at our Trauma Center remained consistent, between April through June 2019 and 2020, during the time when we saw the largest number of admissions for COVID-19 related illness associated with the initial wave of infections. During this time period we saw a thirty-six percent decrease in Emergency Department visits. There was a slight increase in total trauma patients between April and June 2019 as compared to 2020 although this difference was not significant in any specific trauma category. The percentage of trauma patients as compared to total Emergency Department patients did significantly increase during April through June of 2020, with trauma patients making 5 percent of total ED visits in 2020 as compared to less than 3 percent in 2019. Because the traffic volume decreased during these two time periods we were surprised to see a similar number of motor vehicle crashes between the two time periods. One other study demonstrated a similar number of traffic crashes during the initial COVID-19 Pandemic [15], although most studies demonstrated a decrease in MVCs, as much as seventy-five to eighty percent [10,14]. Recent data from the US Department of Transportation/National Highway Traffic Safety Administration demonstrated a significant change in driving patterns and behavior during the first six months of 2020 [17]. These behaviors included speeding, driving while under the influence, and failure to wear seat belts. Additionally, two thirds of those tested were positive for alcohol, marijuana, or opioids, and the use doubled after March. As the pandemic progressed there were an increasing number of people staying at home and fewer driving.
In a report from a Northern California Kaiser Level II Trauma Center, they noted an increase in pediatric patients injured in MVCs after schools were closed although not in increase in total MVCs [16]. We used traffic across the Golden Gate Bridge as a surrogate for traffic volume as the traffic is recorded daily from toll charges. This is an excellent surrogate for the daily traffic volume in Marin County as the tolls only charge going southbound from Marin. The number of vehicles recorded crossing the Golden Gate Bridge decreased by forty-four percent from April through June 2020 as compared to the same months in 2019, after a stay at home order had been issued in California. The number of crashes per vehicle on the roadways between April and June of 2020 as compared to 2019 increased by 37%. Data from the NHTSA would suggest that this is due to riskier driving behavior [17]. This is supported by a large study from Pennsylvania where the authors found that there was a 16% increase in MVC injury severity after the stay at home orders during the COVID-19 pandemic [18].
One study from Philadelphia demonstrated a significant increase in gun violence during their surge in COVID-19 infections [15]. Another study from the D.C area using data from March through May of 2020 demonstrated a 22% decrease in trauma during the first wave of the COVID-19 pandemic. There was no change in the demographics although there was an increase in penetrating trauma. Firearm related injuries increased from 6.8% to 11.8% and stab wounds from 6.9% to 9.2% pre-pandemic to post-pandemic [19]. A recent international study from Cape Town South Africa evaluated trauma after the initial lockdown period from February-June 2020 and noted a 53% decrease in total trauma patients with a 15% decrease seen in firearm related injuries and a 74% decrease in MVC injuries [20]. An intriguing study from Mexico City evaluating crime in the pre-pandemic year, 2019 as compared to the first year of the pandemic 2020 found that there was a decrease in “conventional crime” during the pandemic including domestic violence, burglary, and vehicle theft [21]. Interestingly, they reported an increase in Cartel related crime (“organized crime”) during the pandemic including robbery, kidnapping, and homicide leading the authors to conclude that “Drug lords don't stay at home”. Our Level III Trauma Center evaluates few penetrating injuries. However, our data showed a similar number of penetrating injuries between the pre-pandemic period, 2018–2019 and the pandemic period, 2020–2021 although there was a significant increase in firearm related injuries as compared to stab wounds. Our penetrating trauma, while small in number, parallels larger series. A series of more than 2300 patients from Boston comparing pre-pandemic versus pandemic penetrating trauma demonstrated that the mean age of patients in their series was 29.5 years, and 85% of victims of penetrating injuries were men [22]. Additionally, the increase in penetrating trauma was from gunshot wounds as the number of stab wounds did not increase.
Understanding trauma and ED volume and demographics during a pandemic or other crisis is important to appropriately allocate resources. As an example, if a laboratory technician is shifted away from the ED during a time of decreased volume, that decision could adversely affect the trauma program. If the laboratory technician that is responsible for responding to trauma alerts is occupied elsewhere in the hospital during a trauma activation, then the trauma team would not be recorded as complete. This not only affects patient safety with a delay in blood draw, but also charge capture. In addition to appropriate hospital resource allocation, appropriate public health resource allocation during a pandemic is also reliant on understanding the impact of societal restrictions on firearm related violence and other injures [22]. We believe resource allocation during crisis like the current pandemic necessitates accurate data analysis and good communication between all stakeholders.
Conclusions
The volume of patients presenting to our Trauma Center as compared to the total volume of ED patients increased during the time from April through June 2020 as compared to 2019, the year just prior to the COVID-19 Pandemic. There was no difference in the types and percentages of injuries seen. One reasonable explanation is that the largest percentage of patients we see is from ground level falls in and around the patient's living area and we would not expect that to change from a stay at home order. Additionally, the number of bicycle crashes would also likely be similar after a stay at home order as this type of activity would be considered within the frame of social distancing. Despite the fact that traffic volume decreased by almost fifty percent between these two time periods, the actual number of motor vehicle crashes remained constant. It is beyond the scope of our study to identify the reasons for the increase in motor vehicle crashes per vehicle on the roadways, although data from the NHTSA clearly demonstrated riskier driving behavior during the pandemic.
Authors contributions
Authors Carroll, Tracy, and Pajari contributed to the data collection. Authors Bason-Mitchell and J. Alfrey performed data analysis, background research, and manuscript revision. Authors Maa and Minnis provided valuable assistance in manuscript preparation and writing.
Declaration of Competing Interest
Disclosures: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this manuscript.
Footnotes
Presented at the 17th Annual Academic Surgical Congress, Orlando FL, February 1, 2022
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