ABSTRACT
Objective:
This study examines the characteristics of patients with trauma who presented to the emergency department before and after the novel coronavirus disease-2019 (COVID-19) pandemic and analyze the effects on the traumatic injuries.
Methods:
In this study, medical records of patients who presented to the emergency departments of seven hospitals operating as tertiary level hospitals in İstanbul between March-June 2018, March-June 2019, and March-June 2020 are due to trauma were retrospectively analyzed. The clinical and demographic characteristics of traumatic injuries before and after the pandemic were compared.
Results:
In our study, 4088 trauma patients’ data were reviewed: 1279 in March-June 2018, 1684 in March-June 2019, and 1125 in March-June 2020. When the total number of patients was examined, it was noticed that the number of patients decreased significantly during the COVID-19 pandemic. No significant difference was found between the periods regarding the sex and trauma mechanisms of the patients. The mean age was higher in patients admitted in 2020 compared to previous years. In our study, incidences of intracranial hemorrhage, femur fracture, lung injuries, and mortality rates were higher in March-June 2020 compared to previous years.
Conclusion:
In March-June 2020, compared to the previous year, there was a 34% decrease in trauma cases admitted to the emergency department. Albeit no difference was found between the periods regarding trauma mechanisms, the higher mortality in the March-June 2020 period indicates that trauma continues to be one of the major causes of death despite the pandemic.
INTRODUCTION
Despite increased trauma prevention measures and advances in post-trauma care, trauma-related deaths remain one of the main causes of mortality worldwide (1). Likewise, it has been reported that roughly 3% of all deaths in our country are due to trauma, and the most common cause of these deaths is motor vehicle accidents (2).
The coronavirus disease-2019 (COVID-19) pandemic, which broke out in December 2019 and spread worldwide in a short time, still continues to affect millions of people. Morbidity and mortality are attempted to be prevented through treatment strategies and widespread vaccination. Upon the declaration of COVID-19 as a pandemic by the World Health Organization, measures, such as lockdown, social isolation, or restriction of crowded organizations, were taken in many countries. Although the measures were reduced from time to time, these measures were repeated at the peak times of the outbreak. Social restrictions also decreased hospital admissions due to non-COVID-19 causes (3,4). In the literature, it has been reported that there is a decrease in acute coronary syndrome (5), stroke (6), orthopedic (7,8), and pediatric trauma (9) cases during the pandemic.
Similarly, in our country, it was seen that outpatient clinic applications other than COVID-19 decreased, and elective surgeries were postponed due to social isolation measures (3,10). However, the patient profile of the emergency departments diversified with the addition of COVID-19 cases. Although studies for certain disease prevalence have been revealed in the literature in this process, our study compares the demographic characteristics of patients with trauma who presented to seven different hospitals before and after the COVID-19 pandemic.
METHODS
This was a retrospective, multicenter, cross-sectional study, including 4088 patients with trauma who were admitted to University of Health Sciences Turkey, İstanbul Gaziosmanpaşa Training and Research Hospital, Haydarpaşa Numune Training and Research Hospital, Kanuni Sultan Süleyman Training and Research Hospital, İstanbul Haseki Training and Research Hospital, Şişli Hamidiye Etfal Training and Research Hospital, Sancaktepe Şehit Prof. Dr. İlhan Varank Training and Research Hospital, and Kartal Dr. Lütfi Kırdar City Hospital Emergency Department. These seven centers where data was collected were tertiary trauma centers in İstanbul, the most populous city of Turkey, to which all age groups applied. Before conducting this study, ethical approval was obtained from the University of Health Sciences Turkey, Kanuni Sultan Süleyman Training and Research Hospital Clinical Research Ethics Committee (decision no: 133, date: 08.07.2020).
In our study, the period before and during the pandemic was divided into three periods as March-June 2018, March-June 2019, and March-June 2020. March-June 2018 and 2019 were the period when COVID-19 cases were not yet identified worldwide, while March-June 2020 was the period when a pandemic was declared worldwide and our country went into total closure. The medical records of the patients admitted to the above-mentioned centers due to trauma on these dates were reviewed retrospectively. Our inclusion criterion was to applied to the emergency department after having acute trauma in any age group. If the same patient presented to the emergency department more than once in the specified date range, only the first admission was taken into consideration. Patients who were transferred from another hospital to surgery, orthopedics, or another branch due to trauma were excluded from this study.
Age, sex, trauma mechanism, discharge, or hospitalization, and traumatic injuries of the patients were noted down from the hospital records, and the changes in trauma admissions during the pandemic were analyzed.
The primary outcome of our study was to analyze the effects of the COVID-19 pandemic on patients with trauma presented to the emergency department and its effects on trauma-related injuries. Our secondary outcome was to investigate the effects of the pandemic on traumatic deaths and discharges.
Statistical Analysis
Continuous data were presented with mean ± standard deviation and with frequency (n) and percentage (%) for the categorical data. The normality assumptions were controlled by the Shapiro-Wilk test. The association between categorical data was determined by Pearson chi-square and Fisher’s Exact test. One-Way ANOVA was used to compare age among study groups, and the Tukey' s HSD (honestly significant difference) test was used as a post-hoc test for significant cases. Statistical analysis was conducted using the software of IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY). A two-sided p-value less than 0.05 was considered statistically significant.
RESULTS
In our study, the data of 4088 patients with trauma, 2963 in the pre-COVID-19 period and 1125 in the March-June 2020 period, were analyzed. The mean age of patients who presented in March-June 2018 was 42.6±25.9 years, while it was 41.4±25.7 years for those in March-June 2019, and 44.1±25.1 years for those who applied in March-June 2020. The mean age of the patients who presented in 2020 was significantly higher than in 2019 (p=0.021) (Table 1). When we examined the number of trauma patients in the March-June periods of 2018, 2019, and 2020, it was noticed that the number of cases during the pandemic decreased by 34% compared to 2019. No significant difference was determined regarding the sex distribution of the patients by years (p=0.282). When we examined the trauma mechanisms according to 2018, 2019, and 2020, no significant difference was found between the trauma mechanisms of the patients who were admitted to the hospital in the same months before and during the pandemic (Table 2).
The incidence of finger amputation in 2020 (1.2%) was higher than in 2019 (0.4%) (p=0.034), whereas the incidence of shoulder dislocation in 2020 (0.5%) was higher than in 2018 (0%) (p=0.022), and the incidence of other joint dislocations in 2018 (0.6%) was significantly higher than in 2020 (0%) (p=0.014). Motor accident (p=0.056), occupational accidents (p=0.095), and foot sprain (p=0.073) incidences were higher in 2020, and the incidences of falling off a bicycle (p=0.072) in 2019 were higher, yet the difference was not significant.
In our study, the incidence of intracranial hemorrhage in 2020 (13%) was higher than in 2018 (9.7%) (p=0.021), whereas the incidence of lumbar vertebral fracture in 2019 (2.8%) was higher than in 2020 (1.4%) (p=0.049). The incidence of hemothorax in 2020 (3.1%) was higher than that in 2018 (1.6%) and 2019 (1.8%) (p=0.026). The lung contusion incidence in 2020 was 5.6%, which was higher than in 2018 (1.3%) and 2019 (2.6%) (p<0.001). The incidence of intestinal perforation (1.3%) was significantly higher in 2018 than 2019 (0.1%) and 2020 (0.4%) (p<0.001). While the incidence of urinary bladder injury in 2020 (0.7%) was higher than in 2018 (0.1%) (p=0.033), the incidence of intra-abdominal fluid in 2020 (4.1%) was higher than in 2018 (2.1%) and 2019 (2%) (p=0.001), the soft tissue injury rate in 2018 (15.8%) was higher (p=0.021) than in 2019 (12.4%), and the incidence of simple cuts or abrasions (17.9%) in 2020 was higher than in 2018 (12.2%) and 2019 (12.5%) (p<0.001). When the distribution of fracture types by years was analyzed, the incidence of costal fracture (3.6%) in 2019 and 2020 was higher (p<0.001) than in 2018 (p<0.001), whereas the rate of radius fracture and hand phalanx fracture (8.6% and 3.6%) in 2019 were higher (p=0.005 and p=0.030, respectively) than in 2020 (5.5% and 2%). The incidence of femoral fractures in 2020 (22%) was higher than in 2019 (17.5%) (p=0.009). The incidence of muscle tears in 2019 (3.1%) was significantly higher than in 2018 (1.6%), whereas the rate of other tears in 2018 (9.4%) was significantly higher than in 2019 (5.5%) and 2020 (6%) (p=0.011 and p<0.001) (Table 3). The rate of patients who died in 2020 (4.3%) was significantly higher than in 2018 (2.1%) and 2019 (2.4%) (p=0.003). In 4052 patients who were negative for COVID-19, the exitus rate (3.6%) in 2020 was higher than in 2018 (2.1%) (p=0.037). While 72.2% of the 36 patients with COVID-19 polymerase chain reaction (PCR) positive were discharged and 2.8% were referred, 25% were exitus (Table 4).
DISCUSSION
In our study, we determined that there was a 34% decrease in trauma cases admitted to the emergency department in the March-June 2020 period compared to the previous year. Besides, no significant difference was determined between the mentioned periods regarding trauma mechanisms. However, we found a higher post-traumatic death rate during the pandemic.
The decrease in trauma cases during the pandemic period may be due to the decrease in traumatic injuries because of the social restrictions and lockdown mandates, or because patients after minor trauma did not apply to hospitals for fear of COVID-19 contamination. Similar to our study, Hartnett et al. (11) compared March 29-April 25, 2020 with March 31-April 27, 2019, and found that there was a 42% decrease in the department of emergency admissions. İlhan et al. (12), in their single-center study, revealed a 60% decrease in trauma admissions during the pandemic. In another study compared before and after lockdown, it was shown that post-traumatic hospitalization decreased by 30.9% during the lockdown period (13). In another study conducted with 618 patients, it was stated that the need for open surgery increased in the pandemic period compared with the pre-pandemic period, although a 25% decrease was detected in the patients who applied to the emergency department for surgical reasons during the pandemic period (10). In the study investigating the injury-related hospitalization of 21 hospitals between March 15-April 30, 2016-2020, it was shown that hospitalization decreased by 26% during the lockdown period (14).
Regarding the trauma mechanisms, Chiba et al. (15) found a 38.7% reduction in motorcycle accidents, a 42.5% reduction in auto versus pedestrian accidents, and a 28.4% reduction in bicycle accidents. However, they did not report a significant reduction in motor vehicle accidents during the pandemic (15). Besides, DiFazio et al. (16) reported a 75% reduction in motor vehicle accidents and a 28.9% reduction in falls, along with a 44.9% reduction in trauma admissions during the lockdown period of the pandemic. Moreover, İlhan et al. (12) detected a significant decrease in pedestrian injuries during the pandemic. On the other hand, in our study, unlike these studies, the trauma mechanism was similar in the specified periods of all three years. Albeit a significant decrease in traumatic injuries was an expected finding during the pandemic, it was remarkable for us that the trauma mechanism did not change. The reason for this may be that although there are social restrictions and lockdown, a substantial group, such as people with special work permits or motor couriers, is exempt from these bans. Additionally, although the decrease in the number of vehicles on the road relieves Istanbul traffic, the trauma mechanism may not change compared to previous years due to the use of vehicles at higher speeds on relatively empty roads. When we examined the traumatic injuries in our study, the fact that intracranial bleeding, hemothorax, lung contusion, intestinal perforation, urinary system injury, free fluid in the abdomen, soft tissue injury, rib fracture, and femur fracture were detected more frequently in the March-June 2020 period compared to previous years support the exposure to high-energy trauma during the pandemic period. Hence, we consider that the enforcement of traffic rules and raising public awareness about traumas are of considerable importance even during lockdown periods.
Chiba et al. (15) revealed that mortality decreased during the lockdown period compared with the previous year. On the other hand, Yasin et al. (17) showed that mortality was higher during the pandemic period in their study, in which they included 750 road traffic collision patients during the pre-COVID-19 period and 499 road traffic collision patients during the COVID-19 period. Likewise, when we looked at the post-traumatic death rates in our study, there was a significant increase in the death rate in 2020. The reason for this may be the occurrence and mortality of high-energy traumatic injuries at higher speeds in reduced traffic. Furthermore, a more elective approach to the patients due to the pandemic and the waiting for the PCR results for the operation during the pandemic might increase the mortality.
Study Limitations
The current study has some limitations. First, it was a retrospective study and therefore, some data were not available. Trauma scores could not be calculated due to missing data. Although we showed that some injuries were more common in the COVID-19 period in our study, we could not compare the trauma scores with the pre- and post-COVID-19 periods. Second, although we conducted a multicenter study, regional studies with larger participation are needed to analyze the effects of the COVID-19 pandemic and social isolation on trauma.
CONCLUSION
In line with the literature, lockdown and social isolation measures mandated in many countries due to the pandemic resulted in a remarkable decrease in the number of traumas admitted to hospitals in our country. However, when we examined the trauma mechanism during the lockdown, there was no significant change compared with the previous years, but the mortality rate was higher, especially with intracranial hemorrhage, femur fracture, and lung injuries. These findings indicate that trauma remains one of the major causes of death despite the pandemic. Thus, it supports the significance of planning trauma care and necessary measurements in today’s peak day of COVID-19 and a likely new lockdown period to prevent mortality.
Ethics Committee Approval: Before conducting this study, ethical approval was obtained from the University of Health Sciences Turkey, Kanuni Sultan Süleyman Training and Research Hospital Clinical Research Ethics Committee (decision no: 133, date: 08.07.2020).
Informed Consent: Retrospective study.
Peer-review: Externally and internally peer-reviewed.
Author Contributions: Concept - M.Ç., B.G.Y., R.G.; Design - M.Ç., R.G.; Data Collection and/or Processing - M.Ç., D.S., B.G.Y., R.G., Ş.Ç., Ö.S., İ.A., E.A., İ.T., N.M.H., G.E., T.A.; Analysis and/or Interpretation - D.S., B.G.Y., R.G., İ.T.; Literature Search - M.Ç., B.G.Y.; Writing - B.G.Y., Ş.Ç., E.A.
Conflict of Interest: The authors have no conflict of interest to declare.
Financial Disclosure: The authors declared that this study has received no financial support.