1427 The effect of the COVID-19 pandemic on major trauma presentations and patient outcomes in English hospitals
Authors: Marincowitz Carl , Bouamra Omar , Coates Tim , Kumar Dhushy , Lockey David , Newcombe Virginia , Mason Lyndon , Yates David , Thompson Julian , Lecky Fiona 
Published: December 2022

Aims, Objectives and Background

There is evidence that COVID-19 ‘lockdowns’ may have contributed to increased non-accidental injury, domestic violence and self-harm related to deteriorating mental health. Internationally, there is also evidence that the diversion of health care resources may led to worse outcomes for patients presenting with major trauma. There has been no previous national evaluation of ‘lockdown’ measures impact on the characteristics, treatment pathways and outcomes of trauma patients in England

We aimed to assess the impact of successive lockdowns on the volume, demographics, injury mechanism, severity, treatment and outcomes of major trauma in England.

Method and Design

Demographic characteristics and clinical pathways of TARN eligible patients in the first lockdown (24th March to 3rd July 2020 inclusive) and second lock down (1st November 2020 to 16th May 2021 inclusive) were compared to equivalent pre-COVID-19 periods in 2018–2019.

A segmented regression model predicting the weekly risk adjusted survival was estimated and a discontinuity in the gradient (trend) or intercept (level) of the fitted model was tested for at the weekly time point of implementation of each lockdown.

Abstract 1427 Figure 1

Strobe diagram for inclusion of study population

Abstract 1427 Figure 2

Interrupted time series analysis assessing the impact of COVID restrictions on likelihood of survival (red horizontal lines indicate introduction and relaxation of ‘lockdown’ measures)

Abstract 1427 Table 1

Comparison of demographics ‘lockdown’ and pre-COVID periods

PeriodPeriod24Mar19 – 03Jul19 (comparator)24Mar20 – 03Jul20 (lockdown 1)Absolute change [percentage point change (95%CI)] p-value01Nov18 – 16May19 (comparator)01Nov20 – 16May21 (lockdown 1)Absolute change [percentage point change (95%CI)] p-valueTotal2224317510-4733 (-21%)p<0.0001‡41016382622754 (–6.7%)p<0.0001‡Age (years), Median (IQR)67.6 (46.5–83.1)70.9 (50.3–84.2)3.3 (2.4 to 4.2)p<0.000169.1 (48.7–83.6)73.1 (53.3–85.1)4 (3.5 to 4.2)<0.0001Age bands, n(%)Age< 1138 (0.6%)130 (0.7%)-8 [0.1(-0.04 to 0.030)] p=0.14281 (0.7%)234 (0.6%)-47 [0.1 (-0.2 to 0.04)]p=0.1979Age <16942 (4.2%)674 (3.8%)-268 [-0.4 (-0.8 to 0]p=0.05311444 (3.5%)1218 (3.2%)-226 [-0.3(-0.6 to – 0.1)p=0.0084Age 16 – 649561 (43%)6974 (39.8%)-2587 [-3.2(-4.1 to -2.2)P<0.000117173 (41.9%)13980 (36.5%)-3193 [-5.3(-6 to -5)]p<0.0001Age 65 and over11740 (52.8%)9862 (56.3%)-1878 [3.5 (2.5 to 4.5)]p<0.000122399 (54.6%)23064 (60.3%)665 [5.7(5 to 6.3)]P<0.0001Age 85 and over4610 (20.7%)4047 (23.1%)-563 [2.4(1.6 to 3.2)]p<0.00018903 (21.7%)9731 (25.4%)828 [3.7 (3.1 to 4.3)]p<0.0001Male, n(%)12316 (55.4%)9512 (54.3%)-2804 [-1 (-2 to -0.6)]p=0.037322146 (54%)19769 (51.7%)-2377 [-2.3 (-3 to -1.6)]<0.0001CCI*, n(%)CCI 09359 (42.1%)6220 (35.5%)-3139 [ -6.5 (-7.5 to -5.6)] p<0.000116665 (40.6%)12806 (33.5%)-3859 [-7.1(-7.8 to -6.5)]p<0.0001CCI 1 – 58538 (38.4%)6896 (39.4%)-1642 [1 (0.3 to 2)]p=0.042615899 (38.8%)15667 (40.9%)-232 [2.2 (1.5 to 2.9)]p<0.0001CCI 6 – 103032 (13.6%)3061 (17.5%)29 [3.8 (3.2 to 4.6)]p<0.00015987 (14.6%)6863 (17.9%)876 [3.3(2.8 to 3.8)]p<0.0001CCI > 10927 (4.2%)1024 (5.8%)97 [1.7(1.2 to 2.1)]p<0.00011648 (4%)2410 (6.3%)762 [2.3(2 to 2.6)]p<0.0001Not recorded387 (1.7%)309 (1.8%)-88 [0.2 (-0.2 to 0.3)]p=0.8513817 (2%)516 (1.3%)-301 [-0.6(-0.8 to -0.5)]p<0.0001MOI**: RTC, n(%)Car occupant1247 (30.7%)551 (20.4%)-696 [-10.4(-12.4 to -8.2)]p<0.00012485 (35.2%)1551 (31.3%)-934 [-3.9(-5.6 to -2.2)]p<0.0001Pedestrian661 (16.3%)288 (10.6%)-373 [-5.6 (-7.2 to -4)]p<0.00011629 (23.1%)962 (19.4%)-667 [-3.7(-5.1 to -2.2)]p<0.0001Motorcycles1196 (29.4%)711 (26.3%)-485 [-3.2(-5.3 to -1)]p<0.00011524 (21.6%)976 (19.7%)-548[ -1.9(-3.3 to -0.4)]p<0.0001Cyclist912 (22.4%)1139 (42.1%)227 [19.6(17.4 to 21.9)]p<0.00011315 (18.6%)1396 (28.2%)81 [9.5(8 to 11.1)]p<0.0001Other11 (0.3%)<9 ()-10 [ -0.2(-0.4 to -0.06)p=0.025131 (0.4%)10 (0.2%)-21 [-0.23(-0.4 to -0.04)]p=0.0281MOI: Intentional, n(%)Intentional assault130 (0.6%)88 (0.5%)-42 [-0.08 (-0.2 to 0.06)]p=0.2724227 (0.6%)175 (0.5%)-52 [-0.1(-0.2 to 0.002)]P=0.0570Self harm276 (1.2%)284 (1.6%)8 [0.4 (0.1 to 0.6)]p=0.0014525 (1.3%)562 (1.5%)37 [0.2 (0.02 to 0.3)]p=0.0223NAI63 (0.3%)27 (0.2%)-36 [-0.1(-0.2 to -0.03)]p=0.007297 (0.2%)90 (0.2%)-7 [-0.001(-0.07 to 0.07)]p=0.9701Shooting34 (0.2%)40 (0.2%)6 [0.08(-0.01 to 0.2)]p=0.082680 (0.2%)56 (0.1%)-24 [ -0.05(-0.1 to 0.001)]p=0.0979Stabbing450 (2%)312 (1.8%)-138 [-0.2(-0.5 to 0.03)]p=0.0816791 (1.9%)589 (1.5%)-202 [-0.4 (-0.6 to -0.2)]p<0.0001Blows1174 (5.3%)647 (3.7%)-527 [-1.6(-1.9 to -1.2)]p<0.00012059 (5%)1299 (3.4%)-760 [-1.6(-1.9 to -1.3)]p<0.0001Unintentional, n(%)Falls>2m2055 (9.2%)1757 (10%)-298 [0.8(0.2 to 1.4)]P=0.00753740 (9,1%)3528 (9.2%)-212 [0.1(-0.3 to 0.5)]p=0.6181Falls<2m13384 (60.2%)11314 (64.6%)-2070 [4.4 (3.5 to 5.4)]p<0.000125505 (62.2%)26203 (65.8%)698 [6.3 (5.6 to 6.9)]p<0.0001Sport449 (2%)320 (1.8%)-129 [-0.2 (-0.5 to 0.01]p=0.1697615 (1.5%)489 (1.3%)-126 [-0.2 (-0.4 to -0.006)]p=0.0079GCS bands , n(%)Mild19609 (88.2%)15449 (88.2%)4160 [0.1 (-0.6 to 0.7)]p=0.826435831 (87.4%)34051 (89%)-1780 [1.6 (1.2 to 2.1)]p<0.0001Moderate689 (3.1%)625 (3.6%)-64 [0.5(0.1 to 0.8)]p=0.00901333 (3.2%)1127 (2.9%)-206 [-0.3 (-0.5 to -0.06)]p=0.0135Severe955 (4.3%)765 (4.4%)-190 [0.1 (-0.3 to 0.5)]p=0.71361886 (4.6%)1464 (3.8%)-422 [-0.8(-1 to -0.5)]p<0.0001Not recorded990 (4.5%)671 (3.8%)-319 [ -0.6(-1 to -0.2)]p=0.00221966 (4.8%)1620 (4.2%)-346 [-0.6(-0.8 to -0.3)]p=0.0002ISS***, median (IQR)9 (9–18)9 (9–18)09 (9–18)9 (9–17)0ISS bands, n(%)ISS 1 – 84545 (20.4%)3062 (17.5%)-1483 [-3 (-4 to -2)]p=<0.00018266 (20.2%)7838 (20.5%)-428 [0.3(-0.2 to 0.9)]p=0.2457ISS 9 – 159290 (41.8%)7728 (44.1%)-1562 [2.4(1.4 to 3.3)]p<0.000117207 (42%)16969 (44.3%)-233 [2.4(1.7 to 3.1)]p<0.0001ISS >158408 (37.8%)6720 (38.4%)-1688 [5.6(-0.4 to 1.5)]p=0.239115543 (37.9%)13455 (35.2%)-2088 [-2.7 (-3.4 to -2)]p<0.0001ISS >253995 (18%)3127 (17.9%)-868 [-0.1(-0.9 to 0.7 )]p=0.79217521 (18.3%)6201 (16.2%)-1320 [-2.1(-2.6 to -1.6)]p<0.0001Body regions, n(%)Head AIS 3+5911 (26.6%)4670 (26.7%)-1241 [0.1 (-0.8 to 1)]p=0.830111128 (27.1%)9629 (25.2%)-1499 [ -2(-2.6 to -1.3)]p<0.0001Face AIS 3+63 (0.3%)41 (0.2%)-22 [-0.05 (-0.1 to 0.05)]p=0.341699 (0.2%)69 (0.2%)-30 [-0.06 (-0.1 to 0)]p=0.0618Chest AIS 3+4787 (21.5%)3915 (22.4%)-872 [8.3 (0.2 to 1.6)]<0.04508515 (20.8%)8075 (21.1%)-440 [0.3 (-0.2 to 0.9)]p=0.2337Abdomen AIS 3+872 (3.9%)690 (3.9%)-182 [0.02 (-0.3 to 0.4)]p=0.91771465 (3.6%)1179 (3.1%)-286 [-0.5 (-0.7 to -0.2)]p=0.0001Spine AIS 3+1985 (8.9%)1561 (8.9%)-424 [-0.01(-0.6 to 0.5)]p=0.97443784 (9.2%)3459 (9%)-325 [-0.2(-0.6 to 0.2)]p=0.3654Pelvis AIS 3+758 (3.4%)600 (3.4%)-158 [0.02(-0.3 to 0.4)]p=0.91841501 (3.7%)1386 (3.6%)-115 [-0.04(-0.3 to 0.2)]p=0.7802Limb AIS 3+5707 (25.7%)4892 (27.9%)-815 [2.3 (1.4 to 3.2)]p<0.000110719 (26.1%)10122 (26.5%)-597 [0.3(-0.3 to 0.9)]p=0.3053Other AIS 3+217 (1%)199 (1.1%)-18 [0.2 (-0.04 to 0.3)]p=0.1176375 (0.9%)396 (1%)21 [0.1 (-0.01 to 0.2]p=0.0836Polytrauma1622 (7.3%)1350 (7.7%)-272 [0.4 (-0.1 to 0.9)]p=0.11602984 (7.3%)2429 (6.3%)-555 [-0.9(-1.2 to 0.6)]p<0.0001

*CCI Charlson Comorbidity Index

**MOI Mechanism of injury

***ISS Injury Severity Score

‡chi square test for uniform distribution

Abstract 1427 Table 2

Comparison care pathways ‘lockdown’ and pre-COVID periods

PeriodPeriod24Mar19 – 03Jul19 (comparator)24Mar20 – 03Jul20 (lockdown 1)Absolute Change01Nov18 – 16May19 (comparator)01Nov20 – 16May21 (lockdown 2)Absolute Change1stHospital MTC9908 (44.5%)7376 (42.1%)-2532 [-2.4 (-3.4 to -1.4)]p<0.000118099 (44.1%)15928 (41.6%)-2171 [-2.5 (-3.2 to -1.8)]p<0.0001Treated at MTC11176 (50.2%)8256 (47.2%)-2920 [-3 (-4 to -2)]p<0.000120395 (49.7%)17852 (46.7%)-2543[-3 (-4 to -2.4)]p<0.0001Consultant ED8140 (36.6%)5562 (31.8%)-2578 [-4.8(-5.8 to -3.9)]p<0.000114779 (36%)12577 (32.9%)-2202 [-3.2 (-3.8 to -2.5)]p<0.0001CT within 1 hr5062 (31.9%)3992 (30.9%)-1070 [-0.9(-2 to 0.1)]p=0.09449203 (31.6%)7776 (27.1%)-1427 [-4(-5 to -3.7)]p<0.0001Whole body CT3348 (15.1%)3210 (18.3%)-138 [3 (2 to 4)]p<0.00016040 (14.7%)6417 (16.8%)377 [2 (1.5 to 2.5)]p<0.0001ICU stay3092 (13.9%)2208 (12.6%)-884 [-1.3(-1.9 to -0.6) ]p=0.00025591 (13.6%)3850 (10.1%)-1741 [-3.6(-4 to -3)]p<0.0001Mortality*1417 (7.1%)1316 (8.3%)-101 [1.2 (0.6 to 1.7)]p<0.00012916 (7.9%)2858 (8.1%)-58 [0.2 (-0.1 to 0.6)] p=0.2040Discharge destination, n(%)Home (own)13800 (62%)10484 (59.9%)-3316 [-2(-3.1 to -1.2)]p<0.000124961 (60.9%)23368 (61.1%)-1593 [-0.7 (-1.4 to -0.05)]p=0.0340Home (relative/carer)473 (2.1%)372 (2.1%)-101 [0 (-0.3 to 0.3)]p=0.9890974 (2.4%)852 (2.2%)-122 [-0.1(-0.4 to 0.06)]p=0.1653Mortuary*1501 (6.7%)1323 (7.6%)-178 [0.8(0.3 to 1.3)]p=0.00193086 (7.5%)2977 (7.8%)-109 [0.1 (-0.3 to 0.5)]p=0.5113No fixed abode75 (0.3%)47 (0.3%)-28 (-37.3%)107 (0.3%)87 (0.2%)-20 (-18.7%)Not Known87 (0.4%)39 (0.2%)-48 (-55.2%)101 (0.2%)95 (0.2%)-6 (-5.9%)Nursing Home1190 (5.3%)1063 (6.1%)-127 [0.7(0.3 to 1.2)]p=0.00202448 (6%)2231 (5.8%)-217 [-0.2(-0.6 to 0.1)]p=0.1620Other Acute hospital2425 (10.9%)1736 (9.9%)-689 [-0.1(-1.6 to -0.4)]p=0.00144346 (10.6%)3313 (8.7%)-1033 [-0.1(-0.5 to 0.2)]p=0.4115Other institution526 (2.4%)516 (2.9%)-10 [0.6 (0.3 to 0.9)]p=0.0003980 (2.4%)870 (2.3%)-110 [-0.1 (-0.3 to 0.1)]p=0.2817Rehabilitation2077 (9.3%)1871 (10.7%)-206 [1.3(0.7 to 1.9)]p<0.00013851 (9.4%)4274 (11.2%)423 [ 1.7(1.3 to 2.2)]p<0.0001Social care63 (0.3%)50 (0.3%)-13 [0 (-0.1 to 0.1)]p=0.9657121 (0.3%)103 (0.3%)-18 [-0.2(-0.1 to 0.5)]p=0.4939

*These totals do not correspond as mortality includes deaths in the community and is censored at 30 days

Results and Conclusion

The first ‘lockdown’ had a larger associated reduction in total trauma volume (-21%) compared to the pre-COVID period than the second ‘lockdown’ (-6.7%). Trauma volume increased for those 65 and over (3%) and 85 and over (9.3%) during the second ‘lockdown’.

There was a reduction in likelihood of survival (-1.71; 95% CI:-2.76 to -0.66) associated with the immediate introduction of the first ‘lockdown’. However, this was followed by a trend of improving survival (0.25; 95% CI: 0.14 to 0.35) and likelihood of survival returned to pre-pandemic levels by the end of the first ‘lockdown’ period.

Future research is needed understand the initial reduction in likelihood of survival after major trauma observed with the implementation of the first ‘lockdown’ to prevent this occurring if measures re-introduced.