Abstract
Background
The coronavirus disease 19 (COVID-19) pandemic is reported to have changed injury patterns, prevalence, and outcomes across multiple institutions in the United States. Interpretation of aggregate data is difficult because injury patterns vary between urban and rural hospitals and the implementation of locoregional public health policies and guidelines in response to COVID-19 differed. To prepare our trauma system for future societal shutdowns, we compared injury patterns and outcomes of injured children and adolescents at a single pediatric trauma center before and during the first two years of the COVID-19 pandemic.
Material and Methods
We abstracted demographic, injury, and outcome data for injured children and adolescents (age <15 years) who required admission using our hospital trauma registry and the electronic medical record. We compared differences prior to and during the COVID-19 pandemic using univariate analysis. To address confounding variables, we also analyzed in-hospital mortality using a multivariable regression.
Results
We observed an increase in the number of injured children requiring admission during the first year of the COVID-19 pandemic compared to the pre-pandemic era. Among injury types sustained, we observed an increase in firearm and non-firearm related penetrating injuries (p < 0.001) during the first year, but not the second year, of the COVID-19 pandemic. Controlling for several confounding variables, we also observed an increase in in-hospital mortality (p = 0.04) during the first year of the COVID-19 pandemic.
Conclusions
The psychosocial and socioeconomic burden of the COVID-19 pandemic may have contributed to the rise in penetrating injuries and the odds of in-hospital mortality among a cohort of children and adolescents who were admitted to our hospital following injury. This data may be used to prepare our trauma system for future societal shutdowns through data informed resource utilization.
Key Words: Pediatrics, COVID-19, Wounds and Injuries
INTRODUCTION
In March 2020, the United States implemented public health stay-at-home (SAH) orders to limit the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, including the closure of non-essential businesses, schools, and daycares. Similar to the 2008 Global Economic Crisis, the coronavirus disease 19 (COVID-19) pandemic has been associated with a negative impact on the mental and physical wellbeing of children and adults likely because of the unusual and widespread social isolation that occurred [1,2]. Several retrospective studies observed shifts in injury patterns and severity during the onset of the COVID-19 pandemic, including an increase in penetrating injuries, drug abuse, domestic violence, and mortality among injured children, adolescents, and adults [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13]. Despite the removal of SAH orders, the burden of the COVID-19 pandemic-related restrictions was particularly prolonged among children, adolescents, and their parents because of limited vaccine availability and continued governmental and private sector COVID-19 policies and guidelines [14,15].
While several retrospective multi-institutional studies detail injury patterns and outcomes among children and adolescents during the COVID-19 pandemic, the interpretability and generalizability of these studies is difficult for several reasons [1,5,6,15]. First, the implementation and timeline of public health policies differed on the county, state, and federal level during the pandemic. Second, the prevalence of injury types often differs between rural and urban hospitals and between American College of Surgeons (ACS) or state-based equivalent trauma center designatory levels [16]. To help prepare our trauma system for future societal shutdown or major events (e.g., natural disaster, pandemics, etc.), we examined the pattern of injury types and outcomes among injured children and adolescents who presented to our institution during the COVID-19 pandemic. We hypothesize that our institution managed a greater number of children with penetrating injuries and witnessed a decrease in the number of children with blunt injuries who required hospital admission during the COVID-19 pandemic, without an increase in mortality.
METHODS
Selection of Subjects
Children’s Hospital of Richmond at Virginia Commonwealth University is an ACS Level I designated pediatric trauma and burn center and about 550 injured children are admitted for management of their injuries each year. We obtained data for injured children and adolescents (age < 15) who required admission from March 1, 2018, through February 28, 2022, using the hospital trauma registry and the electronic medical record. Because our trauma registry excluded patients who were discharged home from the emergency department prior to 2020, we excluded all patients who were discharged home from the emergency department. We also excluded children who died in the emergency department to limit our study to children who were admitted to the hospital following injury. Our Institutional Review Board approved this study as an exempt protocol.
Data Collection
We obtained patient, injury, resuscitation, and outcome characteristics, including age, sex, race, the initial emergency department systolic blood pressure, heart rate, Glasgow Coma Score (GCS), injury type, mechanism of injury, presence of confirmed or suspected child physical abuse, injury severity score (ISS), Abbreviated Injury Scale (AIS) severity score for four body regions (head, chest, abdomen and pelvis, and extremities), hospital length of stay, and in-hospital mortality. We defined race as white, black, and other. To standardize blood pressure and heart rate across age groups, we used z-scores. We defined hypotension as a z-score less than negative two. We defined tachycardia as a z-score greater than two and bradycardia as less than negative two. We consolidated the mechanism of injuries into 12 categories: motor vehicle crash, fall, pedestrian struck, struck by or against, burn, penetrating by firearm, penetrating by non-firearm, drowning, hanging, suffocation, poisoning, and unknown. We defined injury type as blunt, penetrating, burn, and ‘other.’ We defined ‘other’ as drowning, hanging, suffocation, poisoning, and found down or unknown. Using the motor component of GCS (GCSm) and ISS, we defined moderate or severe injury as a GCSm score <6 or an ISS 15 [17,18]. We defined severe injury to body regions as an AIS severity score . To identify patients with suspected or confirmed child physical abuse, we reviewed all International Classification of Diseases -10th edition (ICD-10) diagnoses codes within our trauma registry study cohort. We identified the following diagnosis codes: T74.02XA, T74.12XA, T74.22XA, T76.12XA, Y07.01, Y07.03, Y07.11, Y07.12, Y07.50, Y07.511, Y07.59, Y07.9, Y07.410, Y07.432, Y07.499, and Y07.510. We defined the pre-COVID era from March 1, 2018 through February 29, 2020, COVID-year 1 from March 1, 2020 through February 28, 2021, and COVID-year 2 from March 1, 2021 through February 28, 2022.
Statistical Analysis
The primary outcome assessed was the comparison of injury types between the pre-COVID era and the first and second year of the COVID-19 pandemic. Because the pre-COVID era consisted of two years, we performed univariate comparison of all data metrics abstracted from the trauma registry and electronic health record during these years. Metrics that were statistically different were excluded from further analysis. As a secondary outcome, we analyzed mortality outcomes during the first and second years of the COVID-19 pandemic and compared to the pre-COVID era using univariate analysis and a multivariable logistic regression. Variables were selected for inclusion in the multivariable analysis based on univariate comparisons and clinical knowledge and included the presence of hypotension upon arrival, tachycardia or bradycardia upon arrival, injury severity, injury type, and suspected or confirmed child physical abuse. Because these metrics were missing in between 0% and 14.6% of patients in this analysis, we imputed 10 data sets under the assumption of a missing at random pattern and combined results using standard techniques. In addition to the variables included in the multivariable model, the imputation model also included age, sex, race, ISS, GCS score, and mortality.
We tested continuous data for normality and reported as median with interquartile range (IQR) for non-normally distributed data and as average with standard deviation (SD) for normally distributed data. For univariate comparisons, we performed Chi Square, Fisher’s Exact, T-test, and Mann-Whitney testing as appropriate. We tested our multivariable model for collinearity and did not observe collinearity between co-variates. We defined significance at p < 0.05 using two-sided tests. We performed statistical analysis using GraphPad PRISM (San Diego, CA) and SAS 9.4 (Cary, NC).
RESULTS
Characteristics of Study Patients
At our institution, 2,217 pediatric patients were treated in the emergency department for injuries requiring admission during the study period (Table 1 ). The median age of all children was 5.2 years (interquartile range [IQR] 1.8, 10.2). Most patients had blunt injuries (n = 1483, 66.9%), followed by burn (n = 573, 25.8%), penetrating (n =109, 4.9%), and other (n = 51, 2.3%). We observed a total of 103 (4.6%) cases of confirmed or suspected child physical abuse throughout the study period. The median ISS was 4 (IQR 1, 9) and the median hospital length of stay was 2 days (IQR 1, 3). We observed that children who presented in the first year of the pre-COVID era had a longer hospital length of stay compared to the second year of the pre-COVID era (2 days [IQR 1, 4] vs. 1 day [IQR 1, 3]; p = 0.004). All other metrics included in this study were similar between these years. When compared to the pre-COVID era, we observed an increase in the number of injured children requiring admission during COVID-year 1 (p = 0.01), but not during COVID-year 2 (Table 1). We also observed an increase in the number missing initial physiological values during the first and second year of the COVID-19 pandemic compared to the pre-COVID era, including systolic blood pressure, heart rate, and GCS scores.
Table 1.
Summary Characteristics
| Variable | Pre-COVID era (n = 989) | COVID-year 1 (n = 629)∗ | COVID-year 2 (n = 599) |
|---|---|---|---|
| Age (years, median [IQR]) | 5.3 (1.9, 10.3) | 5.7 (1.9, 10.4) | 5.0 (1.8, 10.0) |
| Sex, n (%) | |||
| Male | 613 (62.0) | 402 (63.9) | 380 (63.4) |
| Female | 376 (38.0) | 227 (36.1) | 219 (36.6) |
| Race, n (%) | |||
| White | 327 (33.1) | 222 (35.3) | 212 (35.4) |
| Black | 642 (64.9) | 388 (61.7) | 368 (61.4) |
| Other | 20 (2.0) | 19 (3.0) | 19 (3.2) |
| Initial arrival physiology | |||
| Hypotensive, n (%) | 18 (1.8) | 5 (0.8) | 9 (1.5) |
| Tachycardic or Bradycardic, n (%) | 205 (20.7) | 117 (18.6) | 105 (17.5) |
| GCS motor < 6, n (%) | 51 (5.1) | 35 (5.6) | 30 (5.0) |
| ISS, median (IQR) | 4 (1, 9) | 4 (1, 9) | 4 (1, 9) |
| Moderate or severe injury, n (%) | 119 (12.0) | 63 (10.0) | 89 (14.9) |
| Injury type, n (%) | |||
| Blunt | 653 (66.0) | 412 (65.5) | 418 (59.8) |
| Burn | 275 (27.9) | 151 (24.0) | 147 (24.5) |
| Penetrating | - | - | - |
| Firearm | 25 (2.5) | 27 (4.3)∗ | 13 (2.2) |
| Non-firearm | 6 (0.6) | 26 (4.1)∗ | 6 (1.0) |
| Other | 28 (2.8) | 13 (2.1) | 10 (1.7) |
| Hospital LOS (days, median [IQR])# | 2 (1, 3) | 1 (1, 3)∗ | 1 (1, 2)∗ |
| Mortality, n (%) | 15 (1.5) | 14 (2.2) | 10 (1.7) |
| Child Physical Abuse, n (%) | 39 (3.9) | 36 (5.7) | 28 (4.7) |
IQR: interquartile range; GCS: Glasgow Coma Scale; ISS: Injury Severity Score; Moderate or severe injury: ISS or GCS motor < 6; LOS: length of stay; Pre-COVID: March 1, 2018 through February 28, 2020; COVID-year 1: March 1, 2020 through February 28, 2021; COVID-year 2: March 1, 2021 through February 28, 2022
p < 0.05 when compared to the Pre-COVID era
The median hospital length of stay was statistically different between the two Pre-COVID years. All other metrics were similar between these years
Injury Characteristic Comparisons
During the first year of the COVID-19 pandemic, we observed an increase in both firearm-related (n = 27, 4.3% vs. n = 25, 2.5%; p = 0.05) and non-firearm-related (n = 26, 4.1% vs. n = 6, 0.6%; p < 0.001) penetrating injuries requiring admission (Table 1). The number of children admitted with blunt, burn, or ‘other’ injury types and those with confirmed or suspected child physical abuse did not differ in the first or second year of the COVID-19 pandemic compared to the pre-COVID era (Table 1). Despite an increase in penetrating injuries, injury severity was similar during the COVID-19 pandemic compared to before (Table 1).
Mortality Comparisons
During the study period, 39 (1.8%) children and adolescents died in the hospital (Table 1). These children were more likely to present with hypotension and abnormal heart rates, have moderate or severe injuries, and be injured by different injury types than children who survived to hospital discharge (Supplementary Table 1). We did not observe an increase in overall mortality during the first or second year of the COVID-19 pandemic compared to pre-COVID era on univariate analysis (Table 1). When adjusted for hemodynamic instability upon arrival, injury severity, injury type, and confirmed or suspected child physical abuse, in-hospital mortality at our institution was higher (odds ratio [OR] = 2.7, 95% CI 1.0, 7.4; p = 0.04) during the first year of the COVID-19 pandemic (Table 2 ).
Table 2.
Odds of Mortality During the COVID-19 Pandemic Determined by Multivariable Logistic Regression
| Variable | Odds ratio (95% CI) | p-value |
|---|---|---|
| Hypotensive upon arrival | 14.1 (3.3, 60.9) | <0.001 |
| Tachycardic/Bradycardic upon arrival | 0.7 (0.3, 1.7) | 0.47 |
| Moderate/Severe injury | 24.5 (11.6, 73.4) | <0.001 |
| Injury type | ||
| Blunt | -- | -- |
| Burn | 0.6 (0.1, 2.5) | 0.56 |
| Penetrating | 3.9 (1.2, 11.6) | 0.02 |
| Other | 18.3 (6.3, 53.1) | <0.001 |
| Child physical abuse | 1.6 (0.4, 5.1) | 0.46 |
| Time era | ||
| Pre-COVID | -- | -- |
| COVID-year 1 | 2.7 (1.0, 7.4) | 0.04 |
| COVID-year 2 | 2.3 (0.9, 6.3) | 0.09 |
Area under the ROC curve: 0.96; Hosmer-Lemeshow p value = 0.91
Moderate/Severe Injury: Injury severity score 15 or GCSm < 6
Pre-COVID: March 1, 2018 through February 28, 2020; COVID-year 1: March 1, 2020 through February 28, 2021; COVID-year 2: March 1, 2021 through February 28, 2022
Among the children who died in the hospital, most children died of ‘other’ injuries (n = 18, 46.2%), followed by blunt (n = 17, 43.6%), penetrating (n = 3, 7.7%), and burn (n = 1, 2.6%) injury types (Supplementary Table 1). We did not observe any difference in age, the time to death, injury severity score, severity of body regions injured, physiological derangements on arrival, and the mechanism of injury during the first or second year of the COVID-19 pandemic compared to the pre-COVID era (Table 3 ).
Table 3.
Demographic, Injury, and Physiological Characteristics Among Patients Who Died Following Admission
| Metric | Pre-COVID (n = 15) | COVID-year 1 (n = 14) | p-value | COVID-year 2 (n = 10) | p-value |
|---|---|---|---|---|---|
| Age, years [median (IQR)] | 3.5 (1.4, 6.4) | 3.8 (2.1, 11) | 0.48 | 8.3 (0.3, 11) | 0.81 |
| Time to death, days [median (IQR)] | 1.5 (1.0, 2.0) | 2 (1.0, 2.8) | 0.54 | 1.0 (0.0, 4.5) | 0.79 |
| Injury severity score [median (IQR)] | 26.5 (21.3, 30.0) | 26.0 (1.8, 38.3) | 0.73 | 25.2 (18.0, 32.3) | 0.53 |
| Hypotensive, n (%) | 4 (26.7) | 2 (14.3) | 0.65 | 2 (20.0) | >0.99 |
| Tachycardia, n (%) | 5 (33.3) | 3 (21.4) | 0.68 | 5 (50.0) | 0.44 |
| GCS, n (%) | |||||
| 13-15 | 0 (0.0) | 3 (21.4) | 0.09 | 1 (10.0) | 0.43 |
| 9-12 | 1 (6.7) | 0 (0.0) | 1 (10.0) | ||
| 3-8 | 14 (93.3) | 9 (64.3) | 8 (80.0) | ||
| Mechanism of injury, n (%) | |||||
| Motor vehicle crash | 3 (20.0) | 3 (21.4) | 0.90 | 3 (30.0) | 0.97 |
| Fall | 1 (6.7) | 1 (7.1) | 0 (0.0) | ||
| Pedestrian struck | 0 (0.0) | 2 (14.3) | 0 (0.0) | ||
| Struck by, against | 2 (13.3) | 0 (0.0) | 2 (20.0) | ||
| Burn | 0 (0.0) | 0 (0.0) | 1 (10.0) | ||
| Penetrating - firearm | 1 (6.7) | 1 (7.1) | 1 (10.0) | ||
| Penetrating – non-firearm | 0 (0.0) | 0 (0.0) | 0 (0.0) | ||
| Drowning | 3 (20.0) | 2 (14.3) | 0 (0.0) | ||
| Hanging | 0 (0.0) | 2 (14.3) | 0 (0.0) | ||
| Suffocation | |||||
| Poisoning | 0 (0.0) | 0 (0.0) | 0 (0.0) | ||
| Unknown | 5 (33.3) | 3 (21.4) | 3 (30.0) | ||
| AIS score , n (%) | |||||
| Head | 9 (60.0) | 10 (71.4) | 0.76 | 7 (70.0) | 0.81 |
| Chest | 3 (20.0) | 6 (42.9) | 3 (30.0) | ||
| Abdomen/pelvis | 2 (13.3) | 2 (14.3) | 3 (30.0) | ||
| Extremities | 0 (0.0) | 0 (0.0) | 0 (0.0) | ||
IQR: interquartile range; AIS: Abbreviated injury severity score; Pre-COVID: March 1, 2018 through February 28, 2020; COVID-year 1: March 1, 2020 through February 28, 2021; COVID-year 2: March 1, 2021 through February 28, 2022
DISCUSSION
In this single-institution study, we compared patient demographic, injury, and outcome characteristics of injured children and adolescents at our institution before and during the first two years of the COVID-19 pandemic. The number of injured children and adolescents who presented to our institution requiring admission decreased during the onset of the COVID-19 pandemic but was overall increased during the first year of the COVID-19 pandemic compared to the pre-COVID era. We observed a transient increase in the number of children who presented with firearm-related and non-firearm-related penetrating injuries during the first year of the COVID-19 pandemic. After adjusting for several patient and injury characteristics, we also observed an increase in in-hospital mortality during the first year of the COVID-19 pandemic.
Unintentional injury is the leading cause of death for children and adolescents age 1 to 19 years over the last 20 years [19]. From 1999 to 2020, the leading cause of death among all mechanisms of injury was motor vehicle crashes followed by firearms [20,21]. Since 2016, the gap between these mechanisms of injury has progressively narrowed, and in 2020, firearm injuries surpassed motor vehicle crashes as the leading cause of death in children [22,23]. Several factors may explain this finding. First, public health initiatives and improved safety technology in motor vehicles has been shown to improve survival among children and adolescents involved in a motor vehicle crash [22, 23, 24]. Second, during the onset of the COVID-19 pandemic, air pollutants produced by vehicle emissions decreased throughout the United States and the world suggesting a reduction in transportation volumes [25]. Finally, firearms have been observed to be present in one out of three households with children and are often not stored in a secure location [26]. In addition, 39% of parents who reported that their children were unaware of the firearm’s location and 22% of parents who reported that their children had never handled the household gun were contradicted by their child in a survey of 201 households [27]. While this study was conducted in 2002, the recent rise in firearm injuries prior to and during the COVID-19 pandemic may be partially attributed to increased knowledge and access to the location of household firearms coupled with increased opportunity as a function of more time spent at home.
The COVID-19 pandemic impacted the health and economy of populations worldwide as a direct and indirect consequence of the virus. Children and adolescents were unusually isolated throughout the pandemic due to public health preventative measures [1,2]. Because vaccine availability was initially limited to adults, school and daycare shutdowns were prolonged and exposure quarantines persisted among children and adolescents despite the re-opening of schools and daycares. As a consequence, parents and their children may have been prone to prolonged financial and psychological stressors, reduced support, and increased exposure to abusive relationships [14,15]. Likely as a result of these societal changes, injury patterns changed among adults and children, including an increase in penetrating and burn injuries, drug abuse, child physical abuse, and a decrease in blunt injuries [1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 28]. In our single-institutional study, we similarly observed an increase in penetrating injuries in the first year of the COVID-19 pandemic. Despite similarities between our institutional study and others, our study did contradict several other single- and multi-institutional pediatric studies likely because injury patterns and how patterns respond to societal change differ among various demographics, counties, states, and countries [1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 13, 14, 15, 28, 29]. We did not observe a change in injury types other than penetrating injuries or in child physical abuse. Several reasons may explain this, including our intentional exclusion of children who did not meet or survive long enough to be admitted and the inherit heterogeneity associated with locoregional trauma centers. Although multi-institutional studies have several benefits compared to single-institution studies, their validity requires all centers to obtain similar results among similar patients with each center having access to comparable equipment and technical expertise [30]. Because prospective multicenter trials are difficult, if not impossible, to analyze trends in injury patterns and outcomes for future societal shutdowns, retrospective multicenter studies should attempt to control for locoregional injury pattern and public health policy discrepancies through balancing methods like propensity score matching [30].
Similar to discrepancies in injury pattern presentations during the COVID-19 pandemic, outcomes also varied among several studies, including hospital length of stay and mortality [1, 2, 3, 4, 5, 6, 7, 8, 14, 15]. During the COVID-19 pandemic, many human resources, medical supplies, and equipment were reallocated or depleted because of staffing shortages and industrial plant closures [31]. As a result, providing optimal care for trauma patients was challenging across many United States hospitals. At our institution, we observed an increase in in-hospital mortality during the first year of the COVID-19 pandemic when controlling for several initial injury characteristics. Although we did not capture longitudinal hospital characteristics, we did not observe any difference in age, injury severity, arrival physiology, mechanism of injury, and body regions with severe injury among children who died during the first year of the pandemic compared to before. Our finding suggests that the burden the COVID-19 pandemic placed upon our institution may have contributed to worse outcomes following injury but requires further analysis. Identifying and controlling for survivability of injuries and the in-hospital procedures and events that lead to mortality in this cohort of children may nullify our observation, but this type of review was beyond the scope of this study. Understanding how the COVID-19 pandemic altered injury patterns and factors associated with outcomes of injured children and adolescents may assist trauma systems in optimization and allocation of resources, development of injury prevention programs, and improving burnout, emotional exhaustion, and moral distress among providers that were well documented throughout the pandemic for future catastrophes [16, 32, 33].
Our study has several limitations. First, our study consisted only of hospitalized injured patients and did not account for patients who died before hospital arrival, in the emergency department, or were discharged home from the emergency department. Injury patterns and severity likely differ between patients who die prior to or shortly after arrival, those who are discharged home, and for those who are hospitalized. Second, our study was retrospective and only consisted of metrics included in our institutional trauma registry. Although prospectively collected data is preferred, identification of future societal ‘shutdowns’ are difficult to predict and study prospectively. Third, we observed a difference in the amount of missing data during the COVID-19 pandemic compared to before. Despite addressing the missing data through multiple imputation, validation of our findings is necessary. Third, our multivariable analysis only accounted for the initial physiological and injury characteristics and did not account for residual confounding variables, including events and procedures that occurred during the entire hospitalization. Validation of our findings should account for trends in physiological values over time and in-hospital procedures and events. Fourth, we did not perform a review or analysis to determine the survivability of injuries among patients who died. Future validation of our findings should account for survivability of injuries. Finally, we only captured injured children at an urban Level 1 pediatric trauma. This cohort of injured children and adolescents may not reflect injury patterns as a whole.
The COVID-19 pandemic brought unprecedented changes to healthcare systems worldwide as a direct and indirect consequence of the virus. Although the effects of the pandemic on trauma systems likely vary, the results of our study should be used to support our locoregional trauma system and trauma systems with similar patient and injury characteristics to prepare for future events with particular regard to prevention and appropriate resource utilization.
AUTHOR CONTRIBUTIONS
TMS, DS and LB performed literature search, study design, data collection, data analysis, data interpretation, writing, and critical revision of the manuscript. EJ and ZPM performed data collection and critical revision of the manuscript. JH performed data analysis and critical revision of the manuscript.
The authors report no conflicts of interest.
Supplementary data
REFERENCES
- 1.Yeates E.O., Grigorian A., Schellenberg M., et al. Effects of the COVID-19 pandemic on pediatric trauma in Southern California. Pediatr Surg Int. 2022;38(2):307–315. doi: 10.1007/s00383-021-05050-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Sethuraman U., Kannikeswaran N., Singer A., et al. Trauma Visits to a Pediatric Emergency Department During the COVID-19 Quarantine and "Stay at Home" Period. Am Surg. 2021 doi: 10.1177/00031348211047497. [DOI] [PubMed] [Google Scholar]
- 3.Leichtle S.W., Rodas E.B., Procter L., et al. The influence of a statewide "Stay-at-Home" order on trauma volume and patterns at a level 1 trauma center in the united states. Injury. 2020;51(11):2437–2441. doi: 10.1016/j.injury.2020.08.014. https://doi.og/10.1016/j.injury.2020.08.014 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.DiFazio L.T., Curran T., Bilaniuk J.W., et al. The Impact of the COVID-19 Pandemic on Hospital Admissions for Trauma and Acute Care Surgery. Am Surg. 2020;86(8):901–903. doi: 10.1177/0003134820939904. [DOI] [PubMed] [Google Scholar]
- 5.Forrester J.D., Liou R., Knowlton L.M., et al. Impact of shelter-in-place order for COVID-19 on trauma activations: Santa Clara County, California, March 2020. Trauma Surg Acute Care Open. 2020;5(1) doi: 10.1136/tsaco-2020-000505. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Russell K.W., Acker S.N., Ignacio R.C., et al. Child physical abuse and COVID-19: Trends from nine pediatric trauma centers. J Pediatr Surg. 2022;57(2):297–301. doi: 10.1016/j.jpedsurg.2021.09.050. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Shaw K.G., Salton R.L., Carry P., et al. Multi-day delay to care identified in pediatric trauma cases during COVID-19. J Pediatr Orthop B. 2022;31(1):e56–e64. doi: 10.1097/BPB.0000000000000910. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Chaudhari P.P., Anderson M., Ourshalimian S., et al. Epidemiology of pediatric trauma during the coronavirus disease-2019 pandemic. J Pediatr Surg. 2022;57(2):284–290. doi: 10.1016/j.jpedsurg.2021.09.054. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Donnelly M.R., Grigorian A., Swentek L., et al. Firearm violence against children in the United States: Trends in the wake of the COVID-19 pandemic. J Trauma Acute Care Surg. 2022;92(1):65–68. doi: 10.1097/TA.0000000000003347. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Cohen J.S., Donnelly K., Patel S.J., et al. Firearms injuries involving young children in the United States during the COVID-19 pandemic. Pediatrics. 2021;148(1) doi: 10.1542/peds.2020-042697. [DOI] [PubMed] [Google Scholar]
- 11.Sanford E.L., Zagory J., Blackwell J.M., Szmuk P., Ryan M., Ambardekar A. Changes in Pediatric Trauma During Covid-19 Stay-at-Home Epoch at a Tertiary Pediatric Hospital. J Pediatr Surg. 2021;56(5):918–922. doi: 10.1016/j.jpedsurg.2021.01.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Bessoff K.E., Han R.W., Cho M., et al. Epidemiology of Pediatric Trauma During the Covid-19 Pandemic Shelter in Place. Surg Open Sci. 2021;6:5–9. doi: 10.1016/j.sopen.2021.06.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Wells J.M., Rodean J., Cook L., et al. Injury-Related Pediatric Emergency Department Visits in the First Year of Covid-19. Pediatrics. 2022;150(4) doi: 10.1542/peds.2021-054545. https://doi.og/10.1542/peds.2021-054545 [DOI] [PubMed] [Google Scholar]
- 14.Kovler M.L., Ziegfeld S., Ryan L.M., et al. Increased proportion of physical child abuse injuries at a level I pediatric trauma center during the Covid-19 pandemic. Child Abuse Negl. 2021;116(Pt 2) doi: 10.1016/j.chiabu.2020.104756. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Collings A.T., Farazi M., Van Arendonk K., et al. Impact of "Stay-at-Home" orders on non accidental trauma: A multi-institutional study. J Pediatr Surg. 2022;57(6):1062–1066. doi: 10.1016/j.jpedsurg.2022.01.056. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Wieck M.M., Silva T., Kohler J.E. Changing Patterns of Pediatric Trauma During the Covid-19 Pandemic. Pediatr Ann. 2022;51(7):e286–e290. doi: 10.3928/19382359-20220504-07. [DOI] [PubMed] [Google Scholar]
- 17.Meyer D.E., Vincent L.E., Fox E.E., et al. Every minute counts: Time to delivery of initial massive transfusion cooler and its impact on mortality. J Trauma Acute Care Surg. 2017;83(1):19–24. doi: 10.1097/TA.0000000000001531. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Palmer C. Major trauma and the injury severity score--where should we set the bar? Annu Proc Assoc Adv Automot Med. 2007;51:13–29. [PMC free article] [PubMed] [Google Scholar]
- 19.Centers for Disease Control and Prevention - National Center for Injury Prevention and Control. Fatal Injury and Violence Data. 2001-2020. https://www.cdc.gov/injury/wisqars/fatal.html
- 20.Goldstick J.E., Cunningham R.M., Carter P.M. Current Causes of Death in Children and Adolescents in the United States. N Engl J Med. 2022;386(20):1955–1956. doi: 10.1056/NEJMc2201761. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Stevens J., Pickett K., Reppucci M.L., et al. National trends in pediatric firearm and automobile fatalities. J Pediatr Surg. 2022 doi: 10.1016/j.jpedsurg.2022.09.028. [DOI] [PubMed] [Google Scholar]
- 22.Cunningham R.M., Walton M.A., Carter P.M. The Major Causes of Death in Children and Adolescents in the United States. N Engl J Med. 2018;379(25):2468–2475. doi: 10.1056/NEJMsr1804754. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Simons-Morton B.G., J L.H., Leaf W.A., Preusser D.F. The effect on teen driving outcomes of the Checkpoints Program in a state-wide trial. Accid Anal Prev. 2006;38(5):907–912. doi: 10.1016/j.aap.2006.03.001. [DOI] [PubMed] [Google Scholar]
- 24.Zakrajsek J.S., Shope J.T., Greenspan A.I., et al. Effectiveness of a brief parent-directed teen driver safety intervention (Checkpoints) delivered by driver education instructors. J Adolesc Health. 2013;53(1):27–33. doi: 10.1016/j.jadohealth.2012.12.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Heintzelman A FG, Lulla V. Substantial Decreases in U.S. Cities’ Ground-Based NO2 Concentrations during COVID-19 from Reduced Transportation. Sustainability.13(9030). 10.3390/su13169030. [DOI]
- 26.Schuster M.A., Franke T.M., Bastian A.M., et al. Firearm storage patterns in US homes with children. Am J Public Health. 2000;90(4):588–594. doi: 10.2105/ajph.90.4.588. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Baxley F., Miller M. Parental misperceptions about children and firearms. Arch Pediatr Adolesc Med. 2006;160(5):542–547. doi: 10.1001/archpedi.160.5.542. [DOI] [PubMed] [Google Scholar]
- 28.Pines N., Bala M., Gross I., et al. Changes in Pediatric Major Trauma Epidemiology, Injury Patterns, and Outcome During Covid-19-Associated Lockdown. Trauma. 2023;25(1):62–66. doi: 10.1177/14604086211045359. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Matthay Z.A., Kornblith A.E., Matthay E.C., et al. The DISTANCE study: Determining the impact of social distancing on trauma epidemiology during the COVID-19 epidemic-An interrupted time-series analysis. J Trauma Acute Care Surg. 2021;90(4):700–707. doi: 10.1097/TA.0000000000003044. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Sox H, Stern S, Owens D, et al. Assessment of Diagnostic Technology in Health Care: Rationale, Methods, Problems, and Directions: Monograph of the Council on Health Care Technology. Washington (DC)1989. 10.17226/1432. [DOI] [PubMed]
- 31.Liveris A., Stone M.E., Jr., Markel H., et al. When New York City was the COVID-19 pandemic epicenter: The impact on trauma care. J Trauma Acute Care Surg. 2022;93(2):247–255. doi: 10.1097/TA.0000000000003460. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Duncan T.K., Weaver J.L., Zakrison T.L., et al. Domestic violence and safe storage of firearms in the COVID-19 era. Ann Surg. 2020;272(2):e55–e57. doi: 10.1097/SLA.0000000000004088. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Hatchimonji J.S., Swendiman R.A., Seamon M.J., et al. Trauma does not quarantine: Violence during the COVID-19 pandemic. Ann Surg. 2020;2072(2):e53–e54. doi: 10.1097/SLA.0000000000003996. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.