key: cord-0775605-0p41w344 authors: Park, Jiye; Jung, Kyoungwon; Kwon, Junsik; Moon, Jonghwan; Huh, Yo; Heo, Yun Jung; Kang, Byung Hee title: Changes in the characteristics of trauma patients after the early COVID-19 outbreak: A retrospective study of a regional level 1 trauma center in Republic of Korea date: 2022-01-14 journal: Medicine (Baltimore) DOI: 10.1097/md.0000000000028567 sha: 4563ba4fe6ee7db2c32137af52336fe305fdd3a7 doc_id: 775605 cord_uid: 0p41w344 Gyeonggi-do (Gyeonggi province) has the second highest number of coronavirus disease (COVID-19) cases in the Republic of Korea after Seoul, with approximately 25% of the COVID-19 patients as of January 2021. Our center is a level I trauma center located in south Gyeonggi-do, and we aimed to evaluate whether the characteristics of trauma patients changed after the COVID-19 pandemic. We retrospectively reviewed the trauma patients registered with the Korea Trauma Database of the Center from February 2019 to January 2021. The patients were dichotomized into pre-coronavirus disease (pre-COVID) and coronavirus disease (COVID) groups, and their trauma volumes, injury characteristics, intentionality, and outcomes were compared. A total of 2628 and 2636 patients were included in the pre-COVID and COVID groups, respectively. During the COVID-19 period, motorcycle accidents, bicycle accidents, and penetrating injury cases increased, and pedestrian traffic accidents, slips, and injury by machines decreased. The average daily number of patients in the COVID group was lower in March (5.6 ± 2.6/day vs 7.2 ± 2.4/day, P = .014) and higher in September (9.9 ± 3.2/day vs 7.7 ± 2.0/day, P = .003) compared to the pre-COVID group. The COVID group also had a higher ratio of direct admissions (67.5% vs 57.2%, P < .001), proportion of suicidal patients (4.1% vs 2.7%, P = .005), and injury severity scores (14 [9–22] vs 12 [4–22], P < .001) than the pre-COVID group. The overall mortality (4.7% vs 4.9%, P = .670) and intensive care unit length of stay (2 [0–3] days vs 2 [0–4] days, P = .153) was not different between the 2 groups. Although the total number of patients did not change, the COVID-19 pandemic affected the number of monthly admissions and the injury mechanisms changed. More severely injured patients were admitted directly to the trauma center. After the identification of the first case in Wuhan, China in December 2019, coronavirus disease (COVID-19) affected the whole world, with more than 100 million confirmed cases and 2.5 million deaths. Many governments responded to this catastrophic pandemic with various policies and legal actions, such as quarantines and the lockdown of boundaries. Considering the direct influence of COVID-19 on infected patients and their families, many reports have been published covering the indirect influence of the pandemic in the field of trauma, such as a decrease in motor vehicle crash, [1] an increase in alcoholism [2] and suicide attempts, [3] and changes in trauma volume. [4, 5] Since the first domestic confirmation of COVID-19 on January 20, 2020, the Republic of Korea has been one of the countries with an early inflow and spread of COVID-19. The government has developed various policies to prevent the transmission of the virus, including quarantines and social distancing levels. However, despite various efforts, COVID-19 has spread throughout the country. Gyeonggi-do (Gyeonggi province) is the province with the second highest prevalence of COVID-19 after Seoul, and Ajou University Trauma Center is a level 1 trauma center that covers southern Gyeonggi-do. We hypothesized that the COVID-19 outbreak in Gyeonggi-do may have changed the trauma volume and trends experienced by the trauma center. We also investigate whether COVID-19 affected Editor: Roberto Cirocchi. The study protocol was approved by the Ajou Institutional Review Board (AJIRB-MED-MDB-21-041) and followed the latest Declaration of Helsinki (2013). The authors have no funding and conflicts of interests to disclose. Supplemental Digital Content is available for this article. The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request. the overall performance and primary outcome of the level 1 trauma center. Trauma patients registered with the Korea Trauma Data Bank (KTDB) from February 2019 to January 2021 in Ajou Trauma Center were reviewed retrospectively. The center is a level I regional trauma center located in Suwon, South Gyeonggi-do. The KTDB is utilized by all the regional trauma centers to collect data from all trauma admissions, including prehospital data, demographic information, clinical characteristics, and outcomes. Patients admitted to the outpatient clinic were excluded. In our center, there are 2 entrances for admission: via the trauma bay or the emergency room (ER). Whether a patient should enter via the trauma bay or the ER is decided by an emergency squad following the 4 steps of trauma field triage, which includes physiologic, anatomical, and mechanism criteria and special considerations (Supplemental Digital Content S1, http://links.lww.com/MD/G584). In the trauma bay, the patient is examined initially by the trauma surgeon who plays the role of a gatekeeper. In the ER, the emergency physician examines the patient initially and then refers the patient to the trauma team, if needed ( Fig. 1) . As a consequence of the COVID-19 outbreak, patient triage protocols changed in the ER, but there were no changes in the trauma bay. In the ER, there was an additional screening process for patients with body temperatures higher than 37.5°C or upper respiratory infection symptoms before they met with the emergency medical doctors. In emergency situations, they were moved to isolated units, but the number of these units was limited. The first case of COVID-19 in Republic of Korea was confirmed on January 20, 2020. The daily number of cases was less than a dozen and the influence was not evident in January 2020. However, the first breakout of more than a thousand of confirmed cases occurred in Daegu, a city with a population of more than a million, located 240 km from Seoul in February 2020. Though the number of confirmed cases of COVID-19 was not high, the effect of COVID-19 on the emergency medical system in Republic of Korea was significant from the early stages. Hence, patients were included from February and dichotomized to the pre-COVID group (February 2019-January 2020) and the COVID group (February 2020-January 2021) (Fig. 2) . The study was done conducted in a single level 1 trauma center in Ajou medical center, which is located in southern Gyeonggido, where more than 2500 trauma patients admitted annually. Demographics, initial vital signs, routes of admission, injury intentionality, injury characteristics and patterns, prehospital times, and hospital times to admission were compared between the pre-COVID and COVID groups. The monthly number of patients was compared between the 2 groups and with the national status. Continuous variables are presented as means ± standard deviations or medians [interquartile ranges] and were compared using the Student t test or the Mann-Whitney U test after testing for normality. The categorical variables are presented as numbers (percentiles) and were compared using the Chi-Squared test. All the statistical analyses were performed using SPSS version 25.0 (IBM Corp, Armonk NY, USA). After excluding 17 patients who were admitted to the outpatient clinic, 2628 and 2636 patients were included in the pre-COVID and COVID groups, respectively, indicating that there were 8 more patients than the previous year. The COVID group had a higher proportion of direct admissions, admissions via the trauma bay, and suicidal attempt patients. Among the injury mechanisms, motorcycle accidents, bicycle accidents, penetrating injury cases increased, while pedestrian traffic accidents, slips, and injury by machines statistically decreased. Fall was the most common mechanism of injury in both groups (Table 1) . Compared with the pre-COVID group, the COVID group had a lower daily average number of patients in March 2020 (7.2 ± 2.4 persons/day vs 5.6 ± 2.6 persons/day, P = .014) and a higher number in September 2020 (7.7 ± 2.0 persons/day vs 9.9 ± 3.2 persons/day, P = .003) (Fig. 3 ). The first wave of the COVID-19 pandemic occurred in Gyeongsangbuk-do in March, which was far from our trauma center, and the second wave occurred in late August in Seoul and Gyeonggi-do (Fig. 4) . The third wave of the COVID-19 pandemic started in November around Seoul and Gyeonggi-do and is ongoing. The COVID group had higher injury severity scores but the number of patients with an Abbreviated Injury Scale score of 3 (serious) and higher showed were not different between the pre-COVID and COVID groups except for the thorax. Mortality and intensive care unit (ICU) length of stay (LOS) were not significantly different between the 2 groups (Table 2 ). Among patients who were directly admitted to the trauma bay, prehospital time (from injury to admission) increased in the COVID group compared to the pre-COVID group (44 [32-61] minutes vs 51 [37-67] minutes, P < .001). The median hospital stay duration was not significantly different between the 2 periods; however, the subgroup comparisons showed different results. The stay times in both the trauma bay and ERs increased. Especially in the ER, which increased by approximately 40 minutes during the COVID-19 period (Table 3 ). Admissions to the general ward were excluded because those admissions were confirmed after the COVID-19 test results were obtained. The global COVID-19 pandemic has changed every aspect of our society from daily life to the clinical field. Currently, the burden of COVID-19 is growing rapidly; however, a decrease in trauma volume and trauma team activation has been reported in many countries. [4, 5] While the major reasons may be the voluntary decrease in traffic and the preventive measure policies adopted by governments, [5] this could also be caused by the reluctance of patients without COVID-19 to visit hospitals and emergency departments, although this may be less likely to apply to major trauma patients. [6] Unlike most previous reports, our study revealed that the total number of trauma patients admitted to our center was similar Therefore, ER of local hospitals, without isolation rooms, were instructed to refuse patients who had a fever or any other symptoms that mimicked COVID-19. We could not find any actual evidence of refusals for this study and were only able to conclude this based on the paramedic's statements during the outbreak. In addition, the prehospital time increased for patients who visited the trauma bay directly. This may be interpreted as more trauma patients being centralized to the trauma center bypassing the other hospitals. It was not known whether other hospitals refused to admit patients of unknown COVID-19 status; however, it may have been a burden to examine obtunded or febrile patients in hospitals other than at our center. Since the Injury Severity Score was higher in the COVID group, this phenomenon might have been an unexpected positive effect of COVID-19. Similarly, triage and management did not change at the trauma bay because personal protective equipment was required even before the COVID-19 pandemic, unlike in the ER, where an additional screening process was implemented, resulting in an increase in the number of patients admitted via the trauma bay rather than via the ER. Sometimes, patients who did not satisfy the field triage were admitted via the trauma bay when the isolation unit in the ER was not available. There are 2 separate sections in the trauma bay of our center, which enables us to accommodate 2 new patients simultaneously. Each trauma bay bed has a hepa-filter and a 35 minute disinfection process was performed after any case of unknown contact history or suspicious radiologic findings. If three or more patients came in simultaneously, stable patients were allocated to the observation bay with 4 beds. After the initial resuscitation, the patients were moved to an operating room or ICU. There were 10 isolated beds among 40 trauma ICU beds, and three of the 10 beds had negative pressure ventilation systems. We allocated the patients with no information of contact history, unclear chest xray or computed tomography (CT) scans, or body temperatures higher than 37.5°C to the isolated beds. We allocated patients who had contact history with confirmed cases or showed more suspicious radiologic findings, such as ground glass opacities or pneumonia consolidation, to the negative pressure ventilation system. Our center's internal policy for the confirmed cases was to process emergency operations in an operating room with a separate air conditioning system and transfer patients to the designated public hospital for COVID-19 after stabilizing them; however no confirmed COVID-19 case was found during the study period. Every staff member in our trauma center was obligated to wear 5 kinds of personal protective equipment (gown, glove, hair cap, goggle, mask) until the patients were confirmed negative with a polymerase chain reaction examination (gene TM test, SG medical, Seoul). According to previous studies, the injury mechanisms have changed after COVID-19. Chodos et al reported that penetrating trauma increased significantly during COVID-19, and other mechanisms, including falls and motor vehicle accidents, showed no change during COVID-19 in Washington DC. [7] Sephton et al reported that all the injury patterns were reduced, except for pushbike-related accidents. [8] Maletizke et al also reported that the proportion of household injuries, bicycle accidents, and domestic violence increased during the COVID-19 pandemic. [9] Worldwide systemic reviews covering Asia, the UK, the United States, Europe, Australia, and New Zealand reported that all types of traffic accidents decreased, while interpersonal violence, self-harm, and falls increased. [10] They commonly reported increased penetrating injuries, and our study showed similar results. Motorcycle and bicycle collisions also increased. The Republic of Korea developed delivery services by motorcycles or bicycles, which were fast-growing due to the quarantine and social distancing policies. These changes may have been reflected by the increased motorcycle and bike-related accidents. Pedestrian traffic accidents and slips decreased, which may have been due to the lockdown policy that was introduced on May 6, 2020 and was strengthened or slackened throughout the study period depending on the number of daily confirmed COVID-19 cases, epidemiological links, and community transmission. The government recommended that people refrain from going out and closed some facilities to allow for social distancing. Previous studies demonstrated that there was no significant difference in outcomes after the COVID-19 pandemic. [10, 11] Our study also presented consistent results with mortality and ICU LOS. However, the stay time in the trauma bay and ER increased. The stay time in the ER was increased because of the additional screening process (epidemiological history, chest x-ray and CT scan, body temperature, and COVID test) which lasted for approximately 42 minutes. Ben-Heim et al also reported an increase in the time taken from the door to the intervention for patients with myocardial infarctions, while the total hospital LOS and mortality did not change during the COVID-19 period. [12] Less severe trauma patients who did not satisfy field triage went to the ER to ensure that the delay did not lead to worse primary outcomes in terms of the statistics; however, this does not mean that no harm occurred. Patients who were under-triaged may still have faced danger. Our center consistently requested the emergency department members of our hospital to directly refer the patients who seemed to have been under-triaged before arriving at the selection area. The center director and the trauma coordinator also regularly gave feedback to the Gyeonggi-do fire department after gathering examples of under-triaged cases. However, a more effective method needs to be developed. The evacuation time to the operating room was slightly delayed, which may have been due to the isolation preparations in the operating room. The psychological negative effects of social isolation included increased alcoholic consumption, [13] depression, and anxiety. [14] Many studies and the press have reported a spread of depression and anxiety named "corona blue" or "corona fear" which may have led to an increase in suicidal patients. [15, 16] Our study revealed that the number of suicidal patients significantly increased from 2.7% to 4.1% (P = .005) during the COVID-19 period This study had some limitations. First, this study was based on data from a single level 1 trauma center; therefore, it cannot represent the change or progress for the total trauma patterns of the Republic of Korea during the COVID-19 pandemic. Second, because the data were based only on KTDB, detailed reviews such as those on prehospital data were not possible. Third, there were no COVID-19 confirmed trauma patients. In conclusion, the trauma center volume did not change because the patients were centralized to the trauma center during the COVID-19 pandemic. Regarding the injury mechanisms, penetrating injuries, motorcycle and bicycle collisions, and suicidal patients increased, while pedestrian traffic accidents, slips, and injuries by machines decreased. It can be considered that the changes in habits and lifestyle, following the COVID-19 pandemic, have modified the injury mechanisms. The mortality and ICU LOS did not change, although stay time before admission slightly increased. Thus, further study on the profound effects of COVID-19 on the quality of treatment for trauma patients is required. Impact of COVID-19-19 lockdown policy on homicide, suicide, and motor vehicle deaths in Peru Changes in adult alcohol use and consequences during the COVID-19 pandemic in the US The impact of the COVID-19 pandemic on suicide rates Impact of shelter-in-place order for COVID-19 on trauma activations The influence of a statewide "Stay-at-Home" order on trauma volume and patterns at a level 1 trauma center in the United States The Untold Toll -The pandemic's effects on patients without Covid-19 Impact of COVID-19 pandemic on injury prevalence and pattern in the Washington, DC Metropolitan Region: a multicenter study by the American college of Surgeons Committee on Trauma The effect of COVID-19 on a Major Trauma Network. An analysis of mechanism of injury pattern, referral load and operative case-mix Impact of the COVID-19 shutdown on orthopedic trauma numbers and patterns in an academic Level 1 Trauma Center The global burden of trauma during the COVID-19 pandemic: a scoping review Outcome of trauma and orthepaedic surgery at a UK District General Hospital during the Covid-19 pandemic The pandemic's impacts on patients without Covid-19 on multidisciplinary aspects in emergency medicine care Alcoholism and social isolation Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): a longitudinal mediation analysis Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) Epidemic among the general population in China Anxiety over COVID-19 leads to Phagwara woman's suicide We would like to thank Sora Kim, who managed the KTDB in our center.