Impact of the COVID-19 lockdown on trauma team activations in a single major Lithuanian trauma center: A retrospective single-center study.

Background: As a result of the coronavirus disease 2019 (COVID-19) pandemic and national quarantine, different levels of social and movement restrictions, and stay-at-home requests, trauma trends have changed. The aim of the present study was to determine the impact of lockdown on patients treated by the trauma team (TT) at a single major Lithuanian trauma center during the COVID-19 pandemic.
Methods: This is a retrospective, descriptive study of adult (≥18 years old) trauma patients (for whom the TT was activated). Consequently, we analyzed the national lockdown periods from 16 March to 15 May 2020 and from 16 December 2020 to 28 February 2021, compared with the corresponding period of the previous year.
Results: There was a 10% reduction in TT activations during the national lockdown period. No significant differences were noted in patient demographics. In the COVID-19 cohort, patients had higher Injury Severity Score (14 [IQR 6-21] vs. 9 [IQR 3-18], P = 0.025) and longer time to computed tomography scan (33 [IQR 25-43] vs. 23 [IQR 20-31] min, P < 0.001). Moreover, in the COVID-19 cohort, three times more patients were transferred from the emergency department (ED) straight to the operating room (n = 12 [19%] vs. n = 4 [5.7%], P = 0.018, Cramer's V = 0.21).
Conclusion: Patients were more severely injured, and more patients required emergent surgery during the lockdown. In addition, it took longer to transfer patients to the ED and to perform a computed tomography scan. Copyright:

INTRODUCTION

The coronavirus disease 2019 (COVID-19) has spread across the world since December 2019, when it was first mentioned in Wuhan, Hubei province, China; it has changed the normal work processes in health-care systems worldwide.[1] The first coronavirus case in the Republic of Lithuania was confirmed on February 28, 2020, and a national lockdown was announced throughout the territory beginning March 16, 2020. A gradual reduction of restrictions started on May 15, 2020, and the national lockdown was canceled on June 16, 2020. The second wave started with 133 cases on September 9, 2020, and rose to 1972 cases on November 7, 2020. Due to this escalation of positive cases, a lockdown was announced in some municipalities and various restrictions were reinstated around the country, but without a stay-at-home order. On December 16, 2020, the restrictions were tightened to a national lockdown [Figure 1].

Figure 1

Lockdown periods

As a result of the COVID-19 pandemic and the national lockdown, different levels of social and movement restrictions, and stay-at-home requests, trauma trends have changed. Only a few studies have reported the impact of the pandemic on trauma bay activity.[234567] The data also vary from country to country regarding the type and mechanism of injury as well as injury severity.[891011] Trauma remains among the top ten leading causes of death in low- and middle-income countries.[12] In the European Union, Lithuania has the highest suicide rate (25.8 cases/100,000 inhabitants) and is among the top three countries with regard to the death rate due to road traffic accidents.[13] Our aim was to determine the impact of lockdown on patients treated by the trauma team (TT) at a single major Lithuanian trauma center during the COVID-19 pandemic.

METHODS

We conducted a retrospective, descriptive study of adult (≥18 years old) trauma patients (for whom the TT was activated) presenting to the Level 1 trauma center hospital of the Lithuanian University of Health Sciences Kauno Klinikos (LSMUL KK) emergency department (ED). Patients who died in the ED were excluded from the study. LSMUL KK is a major trauma center, seeing patients from a region with a population of 564,000; it has 63,000 emergency visits annually, of whom 22% are due to trauma.

We analyzed two time periods when full national lockdowns were announced: March16−May 15, 2020 and December 16, 2020 to February 28, 2021. We compared the above--mentioned lockdown periods to the corresponding periods of the previous year.

LSMUL KK uses a two-tiered TT activation model: yellow and red [Table 1]. The yellow team includes an intensive care doctor or emergency medicine physician, a senior and a junior surgical resident, a trauma resident, a radiology resident, and two nurses. The red team includes the same as the yellow team plus surgical and trauma attendings. The characteristics of the TT have been described in our previous study.[14] We have analyzed all TT activations. TT activations for severely injured patients (Injury Severity Score [ISS] >15) were analyzed in a subgroup analysis.

Table 1

Trauma team activation criteria

Red trauma team activation criteria

Glasgow Coma Scale <9

Respiratory rate <8 or >30 breaths per min

Blood pressure <90 mmHg

Oxygen saturation <90%

Heart rate >120 beats per minute

Stridor

Two broken long bones or pelvic fracture

Penetrating injury on the neck, chest or waist

Suspected internal hemorrhage

Flail chest

Airway burned or >18% of THE body surface burned

Limb amputation higher than THE palms and feet

Yellow team activation criteria

No red team activation criteria and one of the following:

Patient is a pedestrian, cyclist, motorcyclist, or diver

Patient was injured during an explosion or shootout

Patient fell from >3 m

Other emergency services were needed to extract the patient

The variables analyzed included age, gender, arrival time of day, ISS, EMS time from alert to scene, EMS time from alert to hospital, time from arrival to trauma bay to computed tomography (CT) scan, in-hospital length of stay (LOS), LOS in intensive care unit (ICU LOS), intention of injury, type of injury, mechanism of injury, type of TT activation, survival status, and number of patients who were transferred straight to the operating theater (OR). Only diagnostic tests that were performed within 1 hour were included in the present study. We chose this time frame because of the “golden hour” concept and because studies performed later during the observation period in the ED would distort the actual time needed to diagnose life-threatening injuries.

During the lockdown, the ED zoned itself into two parts: a clean ED and a dirty ED for patients with fever or respiratory symptoms. TT patients were triaged to the clean ED, which had the advantage of containing the usual trauma resuscitation bays and a computerized tomographic (CT) scanner next to it. Basically, the logistics of these patients or TT itself were not impacted by the pandemic.

All data were analyzed using descriptive analysis with IBM® SPSS® statistics, version 21 (IBM Corp., Armonk, NY, USA). A Mann−Whitney U-test was used for nonparametric data. Categorical variables were compared using Pearson's Chi-square test of proportion; in categories with n <5, Fisher's exact test was used. Cramer's V strength test was used to test the data when a significant Chi-square result was obtained. A difference was considered significant if P < 0.05. For missing data, the last observation carried forward method was used.

RESULTS

Patient demographics and severity or type of injury did not differ between the two lockdown periods. Consequently, we analyzed all the cases from the above-mentioned full national lockdown periods compared to cases from the corresponding periods of the previous year.

We observed a 10% reduction in TT activations during the lockdown period (63 vs. 70; P = 0.12), and one patient during lockdown was excluded from the study due to death in the ED. No statistically significant differences were noted in patient demographics or in the level of activation [Table 2].

Table 2

Patient characteristics and outcome

	Lockdown (n=63)	Control (n=70)	P
Red TT activation, n (%)	25 (39.7)	21 (30)	0.219
Age (years) (IQR)	39 (29-54)	45 (31-62)	0.287
Male, n (%)	47 (74.6)	51 (71.8)	0.718
Time of arrival category, n (%)
Morning 00:00-08:00	8 (12.3)	14 (19.7)	0.354
Day 08:00-16:00	18 (28.6)	31 (43.7)	0.061
Evening 16:00-24:00	37 (58.7)	27 (38)	0.017
EMS time to scene (min) (IQR)	9 (5-16) n=59	10 (7-16) n=59	0.422
EMS time to hospital (min) (IQR)	48 (33-65) n=59	37 (24-60) n=59	0.04
ISS (IQR)	14 (6-21)	9 (3-18)	0.025
Time to CT (min) (IQR)	33 (25-43) n=49	23 (20-31) n=55	0.0001
Patients’ outcome
Transferred to OR, n (%)	12 (19)	4 (5.7)	0.018
ICU LOS (days) (IQR)	3 (1-7)	4 (1-10)	0.609
LOS (days) (IQR)	6 (1-15)	4 (0-15)	0.151
Mortality, n (%)	2 (3.2)	1 (1.4)	0.49

TT: Trauma team, IQR: Interquartile range, EMS: Emergency medical services, ISS: Injury Severity Score, CT: Computed tomography, OR: Operating theatER, ICU: Intensive care unit, LOS: Length of stay

There was no difference in EMS arrival time to the scene, but it took 11 min longer to transfer patients to the hospital during the lockdown (48 [IQR 33−65] vs. 37 [IQR 24−60], P = 0.04). In arrival time analysis, there was a moderate correlation in that during the lockdown more patients tended to arrive during evening hours (58.7% vs. 38%, P = 0.017, Cramer's V = 0.21). Furthermore, patients were more severely injured in the COVID-19 cohort (ISS 14 [IQR 6−21] vs. 9 [IQR 3−18], P = 0.025). Eleven EMS data sheets were missing in the control cohort and four in the lockdown cohort; these patients were excluded from EMS times.

We were unable to identify any differences in type of injury, intention of injury, or mechanism of injury [Table 3]. However, we observed significantly longer times to CT scan during the COVID-19 period (33 [IQR 25−43] vs. 23 [IQR 20−31], P = 0.0001). Moreover, more patients were transferred to the OR straight from the ED during the lockdown (n = 12 [19%] vs. n = 4 [5.7%], P = 0.018, Cramer's V = 0.21). Despite there being more severely injured patients during the lockdown, there were no statistically significant differences in LOS, ICU LOS, or mortality [Table 2].

Table 3

Injury characteristics

	Lockdown (n=63), n (%)	Control (n=70), n (%)	P
Penetrating injuries	12 (19)	8 (11.3)	0.207
Intention of injury
Accident	49 (77.8)	60 (84.5)	0.318
Self-inflicted	4 (6.3)	5 (7)	0.873
Violence	10 (15.9)	6 (8.5)	0.186
Mechanism of injury
MVC	19 (30.2)	19 (26.8)	0.663
MBC	4 (6.3)	2 (2.8)	0.324
Cyclist	3 (4.8)	3 (4.2)	0.881
Pedestrian versus car	6 (9.5)	9 (12.7)	0.564
Fall <3 m	4 (6.3)	10 (14.1)	0.144
Fall ≥3 m	9 (14.3)	11 (15.5)	0.845
Struck by object (falling tree, other heavy machinery)	4 (6.3)	3 (4.2)	0.581
Stabbed	10 (15.9)	7 (9.9)	0.296
Other***	4 (6.3)	5 (7)	0.873

***Beaten, burned, electrical injury. MVC: Motor vehicle collision, MBC: Motorcycle collision

Analysis of severely injured patients

There were more severely injured patients (ISS > 15) during the lockdown (30 [47.6%] vs. 21 [30%], P = 0.032). More of these patients were transferred straight to the OR (9 [30%] vs. 3 [14.3%], P = 0.036), and we observed longer time to CT scan in the lockdown group (36 [IQR 28−45] vs. 25 [IQR 19-31], P = 0.003). Other variables were not significantly different.

During the lockdown, the median LOS in days was longer for more severely injured patients (14 [IQR 7-22] vs. one [IQR 1−5]; P = 0.0001), and more patients were transferred to the OR (n = 9 [30%] vs. n = 3 [9.1%], P = 0.036) than those with ISS ≤15. Similar data of severely injured patients were observed in the control group: median LOS was 12 (IQR 2−26) vs. 3 (IQR 1−13) days (P = 0.022); three (14.3%) severely injured patients were transferred straight to the OR vs. one (2%) with ISS <15 (P = 0.045).

DISCUSSION

Our findings of a 10% reduction in TT activations during the COVID-19 lockdown are consistent with those of two other studies performed in the USA and one from Hong Kong.[21115] This is a logical finding and has a couple of possible explanations. One reason would be the stay-at-home order with closure of nonessential shops and businesses, entertainment venues, schools, and public events. Collectively, this resulted in a decrease in vehicle and pedestrian traffic, as well as gatherings both during the workday and after hours.[16] However, the difference of seven TT activations over a short analyzed period, could be a normal variation. Interestingly, Jacob et al. reported no difference in the number of TT activations in Australia during the lockdown.[17]

Some studies have reported a reduction in patient age during lockdown as well as an 8%−9.1% increase in male patients.[12345678910111213141516181920] In the present study, these changes were not statistically significant, supporting the published data from other studies.[610111821] Another important observation during the COVID-19 pandemic was a significantly prolonged time for patients to be transferred to the hospital. This could be due to increased concern for prehospital staff safety and the use of personal protective equipment (PPE). From clinical practice, it is obvious that the use of PPE impacts the work of all levels of staff from doctors to cleaners. Protective suits limit movement, double gloves make hands numb, and it becomes difficult to handle small objects, and eye protection is constantly fogging and distorts vision. However, our study revealed no change in patient outcomes, supporting data from other studies.[202122] We observed a significantly increased time from admission to ED to CT scan; Halvachizadeh et al. reported a similar finding.[4] This prolongation might be due to more febrile or COVID-19 patients requiring a CT scan and more time is needed for disinfecting the CT room after these patients. Another reason could be that more severely injured patients needed more time to be stabilized prior to CT scan.

We observed a significant increase in trauma severity during the lockdown. The majority of published studies have reported no change or a decrease in trauma severity,[2356791116171821] while a study by Chang et al. and WȨhnert et al. supports our data demonstrating an increase in trauma severity.[1023] Despite increased trauma severity, the LOS, ICU LOS, and mortality were not significantly differ between the study periods. We hypothesize that the moral and system pressure to have free space in the wards, just in case the pandemic situation escalates, forced the entire hospital system to function more quickly and more efficiently. To explain this phenomenon in more detail, a case-by-case analysis should be initiated.

We were unable to identify any significant changes in type, intention, or mechanism of injury. Blunt, accidental MVC remained the most common reason to be treated in the trauma bay. During the stay-at-home order, traffic was lighter in urban and suburban locations, and patrolling police officers were also reduced. Those were perfect conditions for breaking the law and exceeding speed limits. We do not have up-to-date data from the authorities, but there have been several announcements over the public news channels about this issue. This could be one of the reasons why we treated more seriously injured patients.

This study has several limitations. This was a single-center study with a limited time span of investigation and the results may not be broadly applicable to different regions with different population dynamics, particularly areas with different responses to COVID-19. Nevertheless, our hospital is a trauma center and a referral hospital for the central region of Lithuania, and we do not have a significant population of severely injured patients. Despite that our findings were supported by some authors, the possibility exists that, due to the small sample size, these results may be normal variations between time periods. The study is also retrospective, which limits further investigation into the mechanisms behind the observed changes.

CONCLUSION

Patients were more severely injured and more patients required emergent surgery during the lockdown. In addition, it took longer to transfer patients to the ED and to perform a CT scan. However, the LOS, ICU LOS, and mortality did not differ between the study periods.

Research quality and ethics statement

This study was approved by the Institutional Review Board/Ethics Committee at the Lithuanian University of Health Sciences (Approval #BEC-LSMU®-29; Approval date: January 4, 2017). The authors followed the applicable EQUATOR Network (http://www.equator-network.org/) guidelines, specifically the STROBE Guidelines, during the conduct of this research project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.