key: cord-0811901-mym5xi23
authors: Staunton, Peter; Gibbons, John P.; Keogh, Peter; Curtin, Paul; Cashman, James P.; O’Byrne, John
title: Regional Trauma Patterns During the COVID-19 Pandemic
date: 2020-08-13
journal: The Surgeon
DOI: 10.1016/j.surge.2020.08.003
sha: 1f26ba08bd60e62b62cbc46f0632f12633613d17
doc_id: 811901
cord_uid: mym5xi23

Abstract Background The current global pandemic has impacted heavily on health systems, making unprecedented demands on resources, and forcing reconfiguration of services. Trauma and orthopaedic units have cancelled elective surgery, moved to virtual based clinics and have been forced to reconsider the provision of trauma. Our national elective orthopaedic centre has been re-designated as a trauma centre to allow tertiary centres re-direct triaged trauma. Many governments, as part of their COVID-19 management, have significantly restricted activity of the general population. We proposed that trauma patterns would change alongside these changes and maintaining existing standards of treatment would require dedicated planning and structures. Methods Referrals over a six-week period (March 15th – April 30th) were retrospectively reviewed. Data was collected directly from our referral database and a database populated. Analysis was performed to assess trauma volume, aetiology, and changes in trends. Results There were one hundred and fifty-nine referrals from three individual hospitals within the timeframe. Mean age of patient’s referred was 55 (range17-92). Males accounted for 45% of cases. F&A injuries were the most common (32%), followed by H&W (28%), UL (17%), H&F (16%) and K&T (7%). In comparison to the corresponding time-period in 2019, trauma theatre activity reduced by almost one half (45.3%) Conclusion The majority of trauma referred to our Dublin based centre during COVID-19 related population restrictions appears to be home based and trauma volumes have decreased. Significant reductions are apparent in work and sport related injuries suggestive of compliance with COVID-19 activity guidelines. Maintaining existing standards of treatment requires dedicated planning.

The current global pandemic has impacted heavily on health systems, making unprecedented demands on resources, and forcing reconfiguration of services.

Trauma and orthopaedic units have cancelled elective surgery, moved to virtual based clinics and have been forced to reconsider the provision of trauma. Our national elective orthopaedic centre has been re-designated as a trauma centre to allow tertiary centres re-direct triaged trauma. Many governments, as part of their COVID-19 management, have significantly restricted activity of the general population. We proposed that trauma patterns would change alongside these changes and maintaining existing standards of treatment would require dedicated planning and structures.

Referrals over a six-week period (March 15 th -April 30 th ) were retrospectively reviewed. Data was collected directly from our referral database and a database populated. Analysis was performed to assess trauma volume, aetiology, and changes in trends.

There were one hundred and fifty-nine referrals from three individual hospitals within the timeframe. Mean age of patient's referred was 55 (range17-92). Males accounted for 45% of cases. F&A injuries were the most common (32%), followed by H&W (28%), UL (17%), H&F (16%) and K&T (7%). In comparison to the corresponding time-period in 2019, trauma theatre activity reduced by almost one half (45.3%)

The majority of trauma referred to our Dublin based centre during COVID-19 related population restrictions appears to be home based and trauma volumes have decreased. Significant reductions are apparent in work and sport related injuries suggestive of compliance with COVID-19 activity guidelines. Maintaining existing standards of treatment requires dedicated planning.

The current COVID-19 pandemic has impacted on health systems in an unprecedented fashion, producing enormous demands on resources(1). COVID-19

is an abbreviation of coronavirus disease 2019 and refers to the illness arising from infection with the new viral agent SARS-CoV-2. The outbreak which initiated the pandemic originated in Wuhan in the Hubei province of China (2).

Trauma and orthopaedic units, in Ireland amongst others, have cancelled non-urgent elective surgery, moved to virtual based clinics, and made fundamental changes to the provision of trauma(3). This has been in keeping with national and international guidance (4) (5) (6) (7) (8) . The scope of routine trauma management has changed, with services reconfigured to alleviate pressure caused by these resource demands.

Symptomatic of the potential impact on trauma provision, the British Orthopaedic Association have released a pandemic specific BOAST guideline to support practitioners in making difficult treatment decisions during this time(4).

Furthermore, governments across the world, have placed varying restrictions on the activity of populations to limit the spread of COVID-19 (9) . One by-product of these emergency measures is a likely alteration in the volume and type of trauma occurring. The first laboratory confirmed case was recorded in Ireland on February 29 th . Schools and cultural institutions were closed from March 12 th with non-essential businesses closing from March 24 th . A stay-at-home order was issued on March 27 th with brief exercise within two kilometres of the home allowed. This specific stay-athome order was sequentially extended through to May 5 th (10) . The country then J o u r n a l P r e -p r o o f entered its re-opening phase with graduated reintroduction of non-essential activities over the course of the following six weeks (11) .

As an example of reconfiguration undertaken, our national elective orthopaedic unit, based in the Dublin metropolitan area, was re-designated as a trauma unit on March 18th of 2020, with the suspension of all non-urgent elective surgery. The intended purpose was to divert pre-triaged low energy trauma in non COVID-19 patients away from tertiary centres within our metropolitan area. We undertook a review of the pattern of injuries referred to our reconfigured unit during this time. Trauma surgery commenced in our unit on March 18 th .

Our unit acts as a national centre of excellence in adult and paediatric orthopaedic medicine, sports and exercise medicine and rehabilitation medicine, employing over 500 staff and incorporating an on-site radiology service. As a high-volume 159 bed unit, throughput averages 65 overnight cases and 100 day cases per week and more than 1500 primary and revision hip and knee arthroplasties per year. The hospital treats over 24,000 patients annually. Time from referral to surgery was recorded in days. Theatre activity data in the three trauma hospitals was collected for the corresponding time-period in 2019 and 2020 to allow for year on year comparison. χ 2 test was performed to analyse the data using Excel.

There were 159 referrals for surgery from the three north of city hospitals for the time-period given. Females accounted for 55% (82/179) of cases. The mean age of patients was 55 (Range 17-92). The mean Charlson Comorbidity Index was 1 (Range 0-8). The mean time to surgery from referral was 3 days (Range 0-17).

F&A injuries were the most common (32%), followed by H&W (28%), UL (17%), H&F (16%) and K&T (7%). In comparison to the month of April in 2019, trauma theatre activity reduced by almost one half (45.3%), when remaining activity and transferred activity was considered, in the three referring hospitals (Table 1) .

Injuries were sustained at home in 50% of cases. This varied significantly between pre (33%) and post (59%) 'lockdown'. Falls outside of the home happened in 45% of cases pre lockdown and in 36% of cases post lockdown ( Table 2) . Of the 159 referrals; in the pre-lockdown period there were 24 at home and 31 outside home;

during the post-lockdown phase there were 66 at home and 38 outside of home, see post-operatively.

The landscape of orthopaedic practice has changed for the foreseeable future.

Urgent elective cases and trauma will be prioritised while the pandemic continues.

Current restrictions in activity have impacted on the volume of trauma occurring and the type of injuries sustained (12) . Data from our region shows a significant reduction in operative trauma presenting to acute hospitals for this period when compared to 2019. Simple falls at home are the most common mechanism. The data depicts a shift from the pre 'lockdown' period when simple falls outside the home were more common. Compliance with activity restrictions have reduced sporting and workrelated injuries while increasing home improvement and personal exercise injuries, reflected by an increase in medium energy injuries around the home. Pilon type ankle fractures made up 10% of the foot and ankle cases with tri-malleolar fractures making up a further 28%. While our trauma model, in combination with reduced volumes, has allowed trauma to be treated along existing guidelines the expectation is that volumes will increase as work, leisure, and travel activity increases (13) . The ability of trauma systems to cope with those increasing volumes under new working environments presents a challenge unique to these times. Safety of theatre staff, theatre turnover times and J o u r n a l P r e -p r o o f post-operative care capacity are among the aspects that will alter day to day practice (14) . Fracture management needs to be reconsidered in line with the new BOAST guidelines. COVID positive patients have a significant 30-day peri-operative mortality suggesting that only essential surgeries be undertaken in this group(15).

Knowledge also continues to evolve around associated longer term comorbidities in the form of a post COVID-19 syndrome. The musculoskeletal system, as in most viral illnesses, is affected by COVID-19 with a percentage of patient's experience symptoms in the form of myalgias, arthalgias and fatigue. The mechanisms by which the disease produces these symptoms is unknown and an open mind must be given to the possibility of a post COVID-19 syndrome which includes pathology in the musculoskeletal system (16) . Finding a balance in providing an appropriate level of care at a reasonable level of risk to those involved is hugely challenging and consensus statements and algorithms will aid in the optimisation of care (17) .

In the COVID negative cohort, fractures that have a viable delayed treatment, e.g.

later corrective osteotomy in extra-articular distal radius fractures (18) , may need to be de-prioritised to maintain adequate service provision. While making a balanced decision to delay treatment may be required in certain cases, another aspect to consider is the delayed presentation of trauma due to anxieties around attending hospital during a pandemic (19, 20) . The discrepancies in our data between 2019 and 2020 are thought to be based on lower trauma volumes but may be at least partially accounted for by 'hidden trauma'. This phenomenon may place unforeseen demands on reconstructive services at a later date. It is important to acknowledge that the situation will likely remain dynamic through to 2021 and a degree of flexibility in management of trauma systems will be required.

Reduction in elective theatre access will create opportunities for units to re-orient rotas directing specific trauma to the care of more freely available specialists. Our centralised unit created dedicated foot and ankle, hand and wrist, upper limb, hip, and knee lists aimed at ensuring injuries were treated by relevant specialists more frequently compared to pre-COVID-19. This highlights that while significant challenges lie ahead, the current environment will also present opportunities for improvement. We believe that we have created an important blueprint for the reallocation of elective orthopaedic resources for trauma in a crisis environment. We are undoubtedly in a better position to deal with any short-term fluctuations in trauma service demands created by the current pandemic. While we will endeavour to reintroduce elective surgery as expeditiously as possible to our centre to the benefit of thousands of patients awaiting orthopaedic procedures, we will continue to provide an overflow trauma service. Incorporating provisions for a second wave and the continued availability of trauma theatre into the medium term is a key consideration given the short-term unpredictability of the healthcare environment.

Longer term, appropriate foresight around innovations in service provision that are required now can also be used to improve trauma and orthopaedics for the long term.

Trauma and orthopaedic service provision is changing in the face of the COVID-19 pandemic. Consistent with population lockdowns, trauma volumes have dropped and trends in mechanisms have changed. Likewise, volumes and trends will shift once more as countries 're-open' (21) . Jurisdictions must consider how to provide an ( 

Trauma and orthopaedics in the COVID-19 pandemic: breaking every wave

COVID-19: Disease, management, treatment, and social impact

COVID-19 Response in the Global Epicenter: Converting a New York City Level 1 Orthopedic Trauma Service into a Hybrid Orthopedic and Medicine COVID-19 Management Team

BOAST -Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic2020

COVID-19 Guidelines for Triage of Orthopaedic Patients

Intraoperative recommendations when operating on suspected COVID infected patients

Novel Coronavirus COVID-19: Current Evidence and Evolving Strategies

Novel Coronavirus and Orthopaedic Surgery: Early Experiences from Singapore

Italy in lockdown

RTE; 2020

View the measures in Phase 3 which are in place right now

COVID-19 and orthopaedic surgeons: the Indian scenario

CoViD-19 and ortho and trauma surgery: The Italian experience

The COVID-19 outbreak in Italy: perspectives from an orthopaedic hospital

Musculoskeletal symptoms in SARS-CoV-2 (COVID-19) patients

Medically Necessary Orthopaedic Surgery During the COVID-19 Pandemic: Safe Surgical Practices and a Classification to Guide Treatment

Corrective osteotomy after malunited distal radius fractures

Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young

Delayed presentation of acute ischemic strokes during the COVID-19 crisis

After the COVID-19 pandemic: returning to normalcy or returning to a new normal? The Journal of Arthroplasty

The authors would like to acknowledge the contribution of staff to providing the service outlined in the paper.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.