Effect of the COVID-19 Pandemic on Trauma Volume and Transport Time at a Level I Trauma Center

Introduction: Baystate Medical Center is the only Level I Trauma Center in Western, MA. The COVID-19 pandemic has had varying effects on Trauma Centers in regards to volume. Initial studies showed an increase in volume during the lockdown phase, but there has been no evidence of trends after lockdown. Method(s): Retrospective, review of trauma registry data pre- COVID (1/2016-2/2020) and during COVID-19 pandemic (3/2020-12/2021). Comparisons between time periods performed using T-Test. Result(s): Mean total traumas per month were significantly increased during the pandemic (191.3 v. 110.3 patients per month, p <0.001). Both blunt (174.2 v. 100.4, p <0.001) and penetrating (17.1 v 9.9, p <0.001) traumas increased during the COVID pandemic. There was a significant increase in both scene calls (105.0 v 73.8, p<0.001) and interfacility transfers (IFT) (42.7 v 36.0 P = 0.004) during the pandemic. There was no change in injury severity score (11.0 v 11.2, p = 0.498) during the pandemic. Ground interfacility transport times (34.13 min v 28.60 min, p = 0.036) increased significantly during COVID. Other transport times were not changed. Conclusion(s): During the COVID-19 pandemic, Baystate Medical Center saw a statistically significant increase in trauma volume across multiple dimensions that continued even after the end of the lockdown period. In addition, IFT ground transport times increased suggesting that patients were being transported from facilities farther away likely due to the strain on the regional health system from the pandemic.

Trauma: a stress during pandemic?

Introduction: Coronavirus disease 2019 pandemic significantly impacted on trauma systems, since emergency departments (ED) suddenly were overwhelmed by patients requiring intensive care unit (ICU) admission. Once, trauma volume was supposed to decrease due to lockdown policies, we aimed to describe ICU trauma admissions during this period. Method(s): Retrospective observational study of all trauma patients admitted to the ICU of a Portuguese Trauma Center between January 2020 and December 2021. Data were collected from clinical hospital records. Result(s): 437 trauma patients (15% of all admissions), mostly male (71%), with a median age of 59 years-old (42-74) were included. At least one comorbidity was present in 71% of the patients. Median severity scores were: SAPS II 26 (19-38), SOFA 3 (1-6), ISS 13 (9-22), RTS 8 (6-8) and TRISS 96,75 (81.1-98.6). The most frequent mechanisms of injury were falls (59%) and road traffic accidents (25%). The majority consisted of blunt trauma (88%), 65% of brain trauma and 35% of musculoeskeletal trauma. Trauma Team assessment was started in < 3 min in all cases and median length of stay (LOS) in the ED was 261 min (154-418). Surgical intervention was performed in < 4 h in 56% of surgical brain trauma injuries, in < 6 h in 67% of extremity open fractures and in < 1 h in 6% of a penetrating trauma. Shock, mainly hemorrhagic, was present in 8% of the patients on hospital admission. 38% were submitted to invasive mechanical ventilation and 34% to vasopressors. The most common complication was nosocomial infection (18%). The median LOS in the UCI was 12 days (5-24). Only 8% of the patients died in the ICU and 11% in the hospital. Conclusion(s): During pandemic, trauma persisted a major health problem with a significant consumption of time and critical care resources. The high influx of patients may have influenced the LOS in the ED before ICU admission and the time until the surgical intervention. Despite it, mortality remained low.

Effect of COVID-19 Pandemic on Major Trauma Treated at a Level I Trauma Centre.

PURPOSE OF THE STUDY The paper aims to evaluate the effect of COVID-19 pandemic on a change in the number of major trauma cases, their mechanism and length of hospital stay as seen by a Level I Trauma Centre. MATERIAL AND METHODS The retrospective study included a total of 755 major trauma patients (ISS >= 16) treated at our Level I Trauma Centre in the period 2018-2019 ("pre-COVID-19 time") and 2020-2021 ("COVID-19 time"). The effect of COVID-19 infection on the change in the number and nature of major trauma, mechanism of injury, length of treatment during prehospital care, length of hospital stay, and mortality. RESULTS Of the total number of 755 patients with major trauma, in the "pre-COVID-19 time" 399 patients were treated, while in the "COVID-19 time" it was 356 patients (p = 0.10). The mechanism of major trauma did not change, road traffic accidents prevailed (61% vs. 56%, p = 0.25), the proportion of injuries due to falls from height increased (25% vs. 32.5%, p = 0.08), a significant decrease was observed in the category of severe skiing injuries (7 vs. 2, p = 0.003). The severity of injuries evaluated by Injury Severity Score remained unchanged (25 vs. 25, p = 0.08), but an increased number of patients with trau-matic brain injury (TBI) marked by the Abbreviate Injury Score (AIS) >= 4 was observed (38 vs. 56, p = 0.03). The total length of a hospital stay shortened (18 vs. 15 days, p = 0.04), but the mortality rate spiked (52 vs. 73 patients, p = 0.08). DISCUSSION In the "COVID-19 time", the total number of major trauma cases dropped just like in the other European countries. Despite restrictive measures imposing mobility restrictions, no change was reported in the mechanism of injury, with traffic accidents still prevalent, except for skiing injuries. Unlike the US, we did not see an increase in penetrating injuries due to interpersonal violence or suicidal behaviour. However, there was an increase in the percentage of patients with an isolated TBI as a result of a fall from height. An increase in mortality was reported due to an increase in severe TBI. The length of hospital stay was reduced as a result of efforts to maintain hospital bed availability. CONCLUSIONS During the COVID-19 pandemic, compared to the two years immediately preceding, no significant decrease in the number of major trauma cases was reported, despite the introduction of restrictive measures. The proportion of road traffic injuries remained the same, whereas the number of falls from height slightly increased, which consequently led to an increase in the number of severe TBI. The number of penetrating injuries due to acts of violence did not increase, but due to the lockdown there was a significant decrease in severe skiing-related injuries. The anti-epidemic measures in place did not prolong the pre-hospital care for severely injured patients.Copyright © 2022, Galen s.r.o.. All rights reserved.

Acute Isolated Diastolic Hypotension and History of Substance Abuse in the Development of Delirium

INTRODUCTION: In a prior analysis, delirium was seen more often in patients with at least one incident of IDH in the first 48 hours compared to those who remained normotensive (8.1 vs 3.0%). Here we explored events over the entire hospital stay and focused on a subpopulation of patients with a history of substance abuse (SA). Their treatment would include a narcotic or benzodiazepine, as potential vasodilators they could increase the likelihood of IDH. METHOD(S): We performed Aa retrospective chart review of patients >18 years with blunt trauma, Glascow Coma Scale >= 14 and head/neck Abbreviated Injury Score <= 1 admitted to our Level I trauma center from 8/1/16 to 4/1/20, to avoid potential confounding from COVID-19., was doneperformed. This study focused on two groups: normotensive (systolic blood pressure (SBP) >100 and diastolic blood pressure (DBP) >60) throughout their stay and IDH (SBP > 100 and DBP < 60) at any point during their admission. We compared them these two groups on the occurrence of delirium after an IDH episode using. The statistical comparisons were done using chi-square tests and logistic regressions, which included other patient characteristics associated with IDH and delirium. RESULT(S): A total of 1656 patients met inclusion criteria and were assessed for delirium (613 normotensive and 1043 IDH). As hypothesized, delirium was significantly more likely in the IDH than in the normotensive group (5.1 vs 1.5%;p < 0.001). As predicted patients with SA history were more likely to have IDH (62.2 vs 56.0%) and were more likely to develop delirium (6.2% vs. 3.4%) although these differences were not statistically significant. The IDH effect on delirium was significant only for patients without SA history and SA history was significant for delirium only in the normotensive group (both p <.0.001). The effect of IDH and its interaction with SA remained significant in multivariate analysis. Age also remained an independent risk factor for delirium. CONCLUSION(S): These results confirm our prior work on the association of IDH and delirium and suggest that SA has an impact on IDH. Surprisingly, these two factors do not appear to compound each other. This pattern remains significant in a multivariate approach. More exploration of the interaction of substance abuse on IDH and other factors is needed.

Alcohol use and trauma in Alberta after COVID-19 lockdown: Overrepresentation and undertreatment are opportunities for improvement

Background: Alcohol is a major factor in traumatic injuries. Accreditation bodies recommend alcohol screening and intervention programs as trauma quality indicators. Previous research in Alberta reported increasing alcohol use prevalence in major trauma. The COVID-19 pandemic has also been linked to increased alcohol consumption. Our objective was to characterize injury characteristics and their relationship to alcohol use during the summer trauma season after the COVID-19 lockdown, and compliance with alcohol misuse screening, at a level 1 trauma centre in Edmonton, Alberta. Method(s): We conducted a retrospective chart audit for trauma patients aged 18-64 years who were admitted to the University of Alberta Hospital Trauma Service from June 1 to Aug. 31, 2020. Variables included demographics, injury characteristics, ethanol level on presentation, history of substance use and screening or intervention. Tertiary surveys as well as psychiatry and addictions consultations were reviewed to assess compliance with screening and intervention. Frequencies and basic descriptives were calculated. Logistic regression was performed to identify relationships between alcohol use and injury patterns. Result(s): A total of 176 patients met the inclusion criteria. The mean age was 40 (standard deviation [SD] 13.8) years, and 128 (72.7%) were male. Blunt injuries were most common (144 patients [81.8%] had a blunt injury, 27 [15.3%] had a penetrating injury and 3 [1.7%] had a burn), with average Injury Severity Score 13 (1-45) and average length of stay 10.6 (SD 14.6) days. Motor vehicle crashes (MVCs) predominated (66 patients, 37.5%) followed by falls (33 patients, 18.8%), sport-related injuries (30 patients, 17.1%) and stabbings (17 patients, 9.7%). A total of 156 patients (88.6%) had an ethanol level drawn on presentation;50 (32%) were positive, and 33 of these (66%) were legally intoxicated. Forty-five patients (25.6%) had a documented addiction history with alcohol use disorder, 29 of whom presented with a positive ethanol level. Of the 50 patients with elevated ethanol level on presentation, the average age was 36 (SD 12.1) years and the mean ethanol level was 36.9 (SD 23.3) mmol/L. MVCs were the most common mechanism (18 patients, 36%). Screening for alcohol use disorder was performed in 39 (78%) of these 50 patients who presented with a positive ethanol level (unclear documentation in the remainder). Addiction services were offered to 10 of 50 patients (20%). Positive ethanol level was associated with younger age (36 v. 41 yr, p = 0.02). Logistic regression revealed that positive ethanol level was significantly associated with stab mechanism of injury (odds ratio [OR] 3.75, 96% confidence interval [CI] 1.1-11.6, p < 0.05);intoxication further increased association with stab injury (OR 4.4, 95% CI 1.4-15, p < 0.01). Conclusion(s): The prevalence of positive ethanol level in trauma patients is rising: 32% currently, compared with 24% from Alberta 2010 data. Over one-quarter of MVC patients had a positive ethanol level, and intoxication increased the odds of stab injury. Compliance with alcohol misuse screening was 78% with only 20% of patients offered intervention, despite 58% having alcohol use disorder. Interventions to reduce preventable injuries and alcohol misuse at the population and hospital levels are needed..

The Impact of the COVID-19 Pandemic on Pediatric Non-accidental Trauma

Background: Non-accidental trauma (NAT) is a global health issue and is responsible for 50,000 deaths worldwide and 1,800 deaths in the United States annually. Established risk factors for NAT include lower socioeconomic status and ethnic minority status. Memphis, TN has the nation's second poorest metropolitan area, with greater than one-third of children living in poverty and a disproportionate number of those being ethnic minority children. The COVID-19 Pandemic, in addition to direct health effects, has brought with it increased financial and social hardship, possibly exacerbating the factors leading to violence against children. We sought to explore what impact the COVID19 Pandemic had on the incidence of NAT within an already atrisk population. Methods: Retrospective registry data was obtained for patients with suspected and confirmed NAT admitted through the Pediatric Emergency Department at our Level 1 Pediatric Trauma Center from 2011-2020. We compared the NAT rates before and during the COVID-19 Pandemic, designated as year 2020, using risk ratios and Chi-squared test. We conducted interrupted time series analysis to examine the impact of COVID-19 and time on the rate of NAT. A P-value ≤ 0.05 was considered statistically significant. Results: The year 2020 showed an increase risk of NAT compared to prior years since 2011, both individually and as a whole. Interrupted time series analysis revealed a steady rise in NAT admissions over the last decade, but this rise was eight-fold above expected rates in the time of the COVID-19 Pandemic, RR 8.64 (95% CI: 3.3-13.9;p 0.006). There was decrease in emergency department encounters by 35.5% during the COVID-19 Pandemic compared to the average over the prior nine years. Patient demographics of NAT admissions prior to the COVID-19 pandemic and during the Pandemic did not significantly change. Injury Severity Score showed a decrease during the pandemic compared to the decade prior to the pandemic (p 0.002). Total hospital days were unaffected but total ICU days showed a decrease from 5.7 to 1.5 days (p <0.001). Conclusion: Our study found a disproportionate increase in incidence of hospitalized NAT cases despite overall decreased volume of emergency department encounters during the COVID-19 Pandemic. Additionally, there was a decrease in injury severity and ICU length of stay, suggesting the increase in hospitalized NAT cases did not result in more critical injury, but rather increased frequency of mild-to-moderate severity of injury. We hypothesize the added social stress and financial impact of the COVID-19 Pandemic has resulted in heightened external stress on families, therefore increasing the risk of NAT in the pediatric population. Further evaluation on a national level, including non-hospitalized children, will need to be conducted. Our study supports the need for increased community awareness of NAT for at-risk children during times of social disruption and financial crisis.

DID THE COVID-19 PANDEMIC AFFECT PSYCHOLOGICAL READINESS TO RETURN-TOSPORT IN YOUNG ATHLETES UNDERGOING ACL RECONSTRUCTION?

Background: Return-to-sport (RTS) following anterior cruciate ligament reconstruction (ACLR) is influenced by multiple physical and psychological variables. Psychological readiness has been associated with improved patient reported outcomes as well as RTS rates in young athletes. The COVID-19 pandemic may have altered the typical recovery process for patients undergoing ACLR. Hypothesis/Purpose: To compare 6-month postoperative levels of psychological readiness to RTS in ACLR patients before and during the pandemic. Methods: Patients were prospectively enrolled 6 months after primary ACLR at a single academic sports medicine practice, from December 2018 until May 2021. Patients were categorized into pre-COVID (enrollment prior to March 13, 2020) and COVID groups (March 13, 2020 - May 26, 2021). Demographic information, outcomes scores including the ACL-Return to Sport after Injury Scale (RSI) and PROMIS Psychological Stress Experiences (PROMIS-PSE), and physician RTS clearance were obtained and compared for both groups. Comparisons were performed utilizing Chi-square, Student's t-tests and linear regression. A matched analysis was conducted between groups controlling for age, sex, and graft type. Results: 231 patients were included in the present study (89 males, 142 females;mean age 16.9 years), with 76% (176/231) in the pre-COVID group and 24% (55/231) in the COVID group. There were no significant differences in age and sex between the two population cohorts. There was a significant difference in time from surgery to enrollment in the COVID group compared to the pre- COVID group (7.1 vs 6.2 months, p<0.001). In the matched cohort (n=126, 37/126 COVID group), the COVID group was cleared earlier by their physician to RTS compared to the pre-COVID group (6.9 months vs 8.5 months, p<0.001). While there was no significant difference between groups in 6 month ACL-RSI scores (63.8 pre-COVID vs 66.6 COVID, p=0.48), both groups yielded globally low scores. There were no significant associations between matched groups in PROMIS-PSE (p=0.71), IKDC (p=0.55), Pedi-IKDC (p=0.15), and Pedi-FABS (p=0.77) scores (Table 1). Conclusion: Young athletes demonstrated similar levels of psychological readiness to RTS at 6 months following ACLR prior to and during the COVID-19 pandemic. Patient-reported outcome scores were similar in pre-COVID and COVID ACLR patients, suggesting that the pandemic may not have played a detrimental role in perceptions of recovery. Psychological readiness may not be fully optimized at 6 months post-ACLR and young athletes may benefit from additional time and training for progressive confidence, muscle strength, and performance.

Epidemiology of major trauma in New Zealand: a systematic review

Background: Physical injuries are one of the major causes of disability and death worldwide and have an immense impact on population health. In New Zealand, an estimated 8% of total health loss from all causes is attributed to injuries. aim: To describe the incidence and characteristics of major trauma in New Zealand. methods: A systematic review based on a MEDLINE search strategy was performed using the databases PubMed, EMBASE, CINAHL and Scopus. Search terms included: “Wounds and Injuries,” “Fatal Injuries,” “Injury Severity Score,” “Major Trauma,” “Severe Trauma,” “Injury Scale,” “Epidemiology,” “Incidence,” “Prevalence” and “Mortality.” Studies published in English up to September 2021 reporting the incidence of major trauma in New Zealand were included. The quality of studies was assessed using the GATE LITETM tool. results: Thirty-nine studies fulfilled the inclusion criteria. The majority of studies were descriptive observational studies (n=37). The incidence of fatal trauma was highest among those injured from motor vehicle crashes (MVCs) or falls, Māori males and those sustaining head injuries. The incidence of non-fatal major trauma was highest among young Māori males. MVCs and falls were the most common mechanism of injury among trauma patients across all age groups. Length of hospital stay was greatest in patients with the highest Injury Severity Scores. conclusions: The incidence of major trauma varies by age, sex and ethnicity. This review highlights the need for further analytical studies that can explore factors that may impact survival from major trauma.

High social vulnerability affects survival of pediatric patients with abusive head trauma: Comparison during COVID-19

Background: Abusive Head Trauma (AHT) is a syndrome of life-threatening intracranial injuries. The COVID-19 pandemic imposed new stresses upon socially vulnerable populations, but the relationships between social vulnerability, COVID-19 and AHT outcomes are not known. We investigated whether patient or social factors predicted survival after AHT and whether these factors and outcomes were modified during COVID-19. Methods: A single-institution database was queried for all admissions of children with a confirmed diagnosis of AHT from 2018-2021. Clinical information, radiographs and clinic follow-up data were reviewed. Social vulnerability index (SVI) was calculated based on published methods (atsdr.cdc.gov). Univariate and multivariate analyses were performed. Results: One hundred and three cases of AHT were reviewed. Median age at presentation was 4 months (IQR 2-10) in the overall cohort, males outnumbered females overall (76 males, 27 females). 18 patients died (17.5%), higher than previously reported rates. Nonsurvivors had higher social vulnerability index (.867 vs .719, p=0.004);71% had high social vulnerability compared to 39% of survivors. There was no difference in fatality rate before (19%) or during (15%) COVID-19. All nonsurvivors were intubated on admission, compared to 36% of survivors (p<0.001) and all nonsurvivors were comatose compared to 29% of survivors (p<0.001);61% of nonsurvivors had cardiac arrest on admission compared to 3% of survivors (p<0.001). The injury severity score of nonsurvivors was higher than that of survivors (27 vs 17, p=0.02 in univariate analysis). Nonsurvivors were less likely to have multiple fractures (11% vs. 43%, p=0.01). Nonsurvivors were more likely to have bilateral hypoxic ischemic injury (HII, 89% vs 29%, p< 0.001, Crude OR for survival 0.33, p<0.001, p=0.017 in multivariate analysis). There was no difference in rates or types of neurosurgical intervention, intracranial hemorrhage location, or presence of spinal hemorrhage between nonsurvivors and survivors. Discussion: Mortality from AHT in our series was higher than previously reported: more than one out of six children in our series did not survive. Although nonsurvivors were more likely to live in highly vulnerable social settings, COVID-19 did not change survival rate. Nonsurvivors are more likely to present in coma requiring intubation and in cardiac arrest. Subdural hematomas are seen in survivors and non-survivors but surgical mass lesions are rare and surgery does not improve survival. We identify a strong association between completed bilateral HII on admission and fatality in AHT. The high mortality of AHT in association with HII, and the low efficacy of intervention after completed HII supports a public health effort towards treatment and prevention focusing on socially vulnerable communities.

The effect of trauma admission on adverse outcomes and progression of frailty

INTRODUCTION/HYPOTHESIS: Frailty is recognized as a predictor of complications and poor outcomes in the geriatric patient population. Our aim was to study the prevalence of frailty and outcomes in patients following trauma admission to a critical care unit. We hypothesize the presence of admission frailty will be an independent predictor of higher mortality, increased length of stay, and will progress as a result of traumatic injuries post hospitalization within all age groups older than 24years old. METHODS: A prospective observational study was performed over a 3-month period on trauma patients in a trauma critical care unit. An admission frailty and at 6 weeks post-discharge frailty was determine using the 5-item FRAIL Scale. The study was approved by the Institutional Review Board Ethics Committee. All comparisons were performed at a level of significance of p ≤ 0.05. RESULTS: Of the 110 patients admitted to the Trauma ICU from January to March 2021, 25% were considered frail vs. 20% pre-frail vs. 55% non-frail. Mean age of frailty was 70 years old, the youngest age being 48 years old. Pre-frail patients with a mean age of 58 years old, a minimum age of 31years old. Comparing frail vs. non-frail patients', the frail patients had a higher mortality rate (57.1 vs 42.86% p- 0.16);Covid positivity (80 vs 20%, p- 0.03);ETOH (75 vs 25%, p-0.08);sepsis diagnosis (100% vs 0 p-0.09). No statistical significance in ICU LOS (p-0.16) and injury severity score (p-0.43). Statistical significance was achieved between the groups for HTN (p-< 0.0001) and DM (p-0.03). At 6-week post discharge frailty assessment of 67 patients demonstrated statistical significance between admission and post discharge frailty (p-< 0.0001). 25% of the admitted non-frail patients progress to frail state on post-discharge evaluation. 21% of the admitted non-frail patients progress to a pre-frail state. 19% percent of the admitted pre-frail patients progress to a frail state. CONCLUSIONS: Although statistical significance was not achieved in mortality and LOS, both groups trended in the direction towards significance, calling for a larger randomized control trial. We did, however, demonstrate that trauma admission increases frailty scores in all groups. This trend was most revealing in the non-geriatric group.

Effect of alternatives to opiates program on discharge opioid prescribing in trauma patients

INTRODUCTION: Opioid overdose deaths increased over two decades, with the incidence accelerated further during the COVID-19 pandemic. While opioids remain mainstay for trauma-related pain management, organizations are focused on reducing use. This study aimed to determine if a hospitalwide Alternatives to Opiates (ALTO) program reduced opioid prescribing at discharge after trauma. METHODS: A single-center, retrospective analysis of patients ≥18 years old admitted for ≥24 hours with primary diagnosis of traumatic injury between August 1, 2018 - October 31, 2019 was performed. Admissions before July 1, 2019, represent the control group, whereas admissions on/after represent the ALTO group. Patients with alcohol or polysubstance abuse, chronic opioid use, or in-hospital mortality were excluded. The primary outcome was incidence of opioid prescribing at discharge. Secondary outcomes were percent with in-hospital non-opioid and multimodal analgesia, and hospital and intensive care unit (ICU) length of stay (LOS). A sample size of 129 patients was needed to observe a 30% reduction in primary outcome and maintain 80% power to detect a statistically significant difference using alpha < 0.05. RESULTS: A total of 703 patients were included, 471 in the control and 232 in the ALTO groups. Mean age was 59±22 years and 58.7% were male. Mean initial Injury Severity Score (ISS) was 9.1±7.7 and Charlson Comorbidity Index (CCI) was 2.7±2.7. In-hospital opioid prescribing was higher (70.4% vs. 87.5%, p< 0.0001), and opioid discontinuation at hospital discharge occurred less frequently (60.5% vs. 56.2%, p=0.1237) after ALTO implementation. Surgical intervention, lack of ICU admission, ISS ≥9 and CCI ≤1 was associated with lower incidence of opioid discontinuation at discharge in both groups. Most patients received nonopioid (93.6 vs. 98.7%, p=0.0051) and multimodal analgesia (84.3% vs. 87.5%, p=0.3083) during hospitalization. Median hospital LOS [5(3-9) vs. 4(3-7), p=0.3427] and ICU LOS [2(0-4) vs. 3(2-5), p=0.3461] were similar. CONCLUSIONS: Opioids remain mainstay for traumarelated pain management. In our study, ALTO was not associated with a reduction in in-hospital opioid prescribing or at discharge. Identification and implementation of strategies to further reduce opioid prescribing at discharge in trauma patients are needed.