Seasonal variation in trauma admissions to a level III trauma unit over 10 years

Effect of the COVID‑19 pandemic on the management and outcomes of patients with traumatic injuries (Review)

During the COVID-19 pandemic, ~10% of the global population was officially affected, resulting in diverse changes, ranging from shopping habits to stringent hospital protocols. This article sought to provide a concise summary of relevant data concerning the interplay between COVID-19 and trauma, encompassing the entire trajectory from presentation to hospital discharge. Throughout the pandemic, there was a noticeable reduction in trauma presentations, while the ranking of injury mechanisms remained largely unchanged. To ensure essential surgical support, protocols were adjusted accordingly. Although there were some less significant changes in injury severity score, hospital length of stay, intensive care unit stay and mortality, the overall patient outcomes appeared to improve. In conclusion, the COVID-19 pandemic led to a decline in trauma cases and an enhancement in patient outcomes. However, regrettably, certain mechanisms of injury saw an increase in frequency. To cope with the epidemiological context, management strategies were adapted, and unutilized resources were redirected to cater to the care of COVID-19 patients.

Influence of COVID-19 Protocols on the Efficiency of Trauma Theater: Retrospective Observational Study

BACKGROUND

The COVID-19 pandemic has influenced health care delivery significantly. Numerous studies have highlighted that trauma theater efficiency has decreased during the COVID-19 pandemic; however, there is limited information as to exactly which stage of the patient theater journey is causing this decreased efficiency and whether efficiency can be improved. In the trauma theater of Warrington Hospital, United Kingdom, we have attempted to maintain trauma theater efficiency despite the requirement for increased infection control.

OBJECTIVE

The aim of this study was to evaluate the effects of additional COVID-19 infection control protocols on trauma theater efficiency in our center, considering the length of time taken for specific theater events, and to find out whether our interventions were successful in maintaining theater efficiency.

METHODS

We compared the efficiency of the trauma theater in a busy unit in December 2019 (pre-COVID-19) and December 2020 (with COVID-19 protocols in place). We collected time logs for different theater events for each patient in December of both years and compared the data.

RESULTS

There was no significant difference in the average number of cases performed per session between the COVID-19 and pre-COVID-19 time periods (P=.17). Theater start time was significantly earlier during the COVID-19 period (P<.001). There was no significant difference between the two periods in transport time, check-in time, preprocedure time, anesthetic time, and the time between cases (P>.05). A significant difference was observed in the check-out time between the two groups in the two time periods, with checking out taking longer during the COVID-19 period (P<.001).

CONCLUSIONS

Our results show that our theater start times were earlier during the COVID-19 pandemic, and the overall theater efficiency was maintained despite the additional COVID-19 infection control protocols that were in place. These findings suggest that well-planned infection control protocols do not need to impede trauma theater efficiency in certain settings.

Seasonal pattern in elderly hospitalized with acute kidney injury: a retrospective nationwide study in Italy

Purpose

Acute kidney injury (AKI) frequently complicates hospitalization and is associated with in-hospital mortality (IHM). It has been reported a seasonal trend in different clinical conditions. The aim of this study was to evaluate the possible relationship between seasons of the year and IHM in elderly hospitalized patients with AKI.

Methods

We selected all admissions complicated by AKI between 2000 and 2015 recorded in the Italian National Hospital Database. ICD-9-CM code 584.xx identified subjects with age ≥ 65 years and age, sex, comorbidity burden, need of dialysis treatment and IHM were compared in hospitalizations recorded during the four seasons. Moreover, we plotted the AKI observed/expected ratio and percentage of mortality during the study period.

Results

We evaluated 759,720 AKI hospitalizations (mean age 80.5 ± 7.8 years, 52.2% males). Patients hospitalized with AKI during winter months had higher age, prevalence of dialysis-dependent AKI, and number of deceased patients. In whole population IHM was higher in winter and lower in summer, while the AKI observed/expected ratio demonstrated two peaks, one in summer and one in winter. Logistic regression analysis demonstrated that parameters such as age, autumn, winter, comorbidity burden were positively associated with IHM.

Conclusion

We conclude that a seasonality exists in AKI, however, relationship between seasons and AKI could vary depending on the aspects considered. Both autumn and winter months are independent risk factors for IHM in patients with AKI regardless of age, sex and comorbidity burden. On the contrary, summer time reduces the risk of death during hospitalizations with AKI.

Does seasonal variation in orthopaedic trauma volume correlate with adverse hospital events and burnout?

INTRODUCTION

Assessing workload and mitigating burnout risk should be a constant goal within training programs. By using work relative value unit (wRVU) data in a non-elective orthopaedic trauma practice, we investigated seasonal variation in workload on an orthopaedic trauma service at a level I trauma centre. We also investigated whether there was a correlation in seasonal preventable adverse patient safety events (PSEs) and resident Epworth Sleepiness Scale (ESS) scores.

MATERIALS AND METHODS

Data on wRVUs were collected over an 8-year period for a single orthopaedic trauma surgeon with a non-elective practice. Monthly wRVU totals were tabulated over this 8-year period and compared with total hospital orthopaedic surgical trauma volume. The total number of wRVUs and surgical cases analysed were 80,955 and 9,928 respectively. A total of 1,560 PSEs and four years of resident ESS scores were analysed. Data on seasonal variations was evaluated for significance utilizing the Kruskal-Wallis test. WRVUs were then compared to total case volume, PSEs, and resident ESS scores using Spearman's correlation coefficients.

RESULTS

We found that wRVUs significantly differed by month (P-value < 0.001) and season (P-value < 0.001) with the highest volume occurring in the summer months. Seasonal variation in wRVUs demonstrated a positive linear correlation with total surgical volume (P-value <0.001) and resident reported ESS scores (P-value = 0.001). PSEs were highest in the summer (P = 0.026), but were not correlated with our findings of seasonal variations in orthopaedic volume (P-value = 0.741).

CONCLUSION

WRVUs of our single surgeon's orthopaedic trauma practice had a seasonal variation with significantly higher volume during the summer. These findings were representative of seasonal variations in total hospital orthopaedic trauma volume and also demonstrated correlation with objective resident sleepiness scores. PSEs were more frequent in the summer but not correlated with seasonal variation in volume. Burnout poses a risk to patient safety and has been shown to be correlated with increased work volume. These topics are important and applicable to various specialties involved in the care of patients with orthopaedic trauma injuries.

Patterns and mechanisms of major trauma injuries during and after the UK Covid-19 Nationwide lockdown: analysis from a UK Major Trauma Centre

PURPOSE

To compare patterns and mechanisms of injuries during and after the UK Nationwide lockdown during the COVID-19 pandemic.

METHODS

This prospective cohort study included all major trauma admissions during the 10-week period of the nationwide lockdown (09/03/2020-18/05/2020), compared with admissions in the 10-weeks following the full lifting of lockdown restrictions (04/07/20-12/09/2020). Differences in the volume, spectrum and mechanism of injuries presenting during and post-lockdown were compared using Fisher's exact and Chi-squared tests as appropriate. The associated risk of 30-day mortality was examined using univariable and multivariable logistic regression.

RESULTS

A total of 692 major trauma admissions were included in this analysis. Of these, 237 patients were admitted during the lockdown and 455 patients were admitted post-lockdown. This represented a twofold increase in trauma admission between the two periods. Characteristically, both cohorts had a higher proportion of male patients (73.84% male during lockdown and 72.5% male post-lockdown). There was a noted shift in age groups between both cohorts with an overall more elderly population during lockdown (p = 0.0292), There was a significant difference in mechanisms of injury between the two cohorts. The 3-commonest mechanisms during the lockdown period were: Road traffic accidents (RTA)-31.22%, Falls of less than 2 m-26.58%, and falls greater than 2 m causing 22.78% of major trauma admissions. However, in the post-lockdown period RTAs represented 46.15% of all trauma admissions with falls greater than 2 m causing 17.80% and falls less than 2 m causing 15.16% of major trauma injuries. With falls in the elderly associated with an increased risk of mortality. In terms of absolute numbers, there was a twofold increase in major trauma injuries due to stabbings and shootings, rising from 25 admitted patients during the lockdown to 53 admitted patients post-lockdown.

CONCLUSIONS

The lifting of lockdown restrictions resulted in a twofold increase in major trauma admissions that was also associated with significant changes in both the demographic and patterns of injuries with RTA's contributing almost half of all injury presentations.

TRIAL REGISTRATION

This study was classed as a service evaluation and registered with the local audit department, registration number: 20-177C.

Wilhelms D. Differentiating properties of occupancy rate and workload to estimate crowding: A Swedish national cross-sectional study

BACKGROUND

Emergency department (ED) crowding causes increased patient morbidity and mortality. ED occupancy rate (OR; patients by treatment beds) is a common measure of crowding, but the comparability of ORs between EDs is unknown. The objective of this investigation was to investigate differences in ORs between EDs using staff-perceived workload as reference.

METHODS

This was a national cross-sectional study in Sweden. EDs provided data on census, treatment beds, staffing, and workload (1-6) at 5 time points. A baseline patient turnover was calculated as the average daily census by treatment beds, denoted turnover per treatment bed (TTB), for each ED. A census ratio (CR), current by daily census, was calculated to adjust for differences in the number of treatment beds.

RESULTS

Data were returned from 37 (51%) EDs. TTB varied considerably (mean = 4, standard deviation = 1.6; range, 2.1-9.2), and the OR was higher in EDs with TTB >4 compared with ≤4, 0.86 versus 0.43 (0.43; 95% confidence interval [CI], 0.27-0.59), but not workload, 2.75 versus 2.52 (0.23; 95% CI, -0.19 to 0.64). After adjusting for confounders, both TTB (k = -0.3; 95% CI, -0.49 to -0.14) and OR (k = 3.4; 95% CI, 1.76-5.03) affected workload. Correlation with workload was better for CR than for OR (r = 0.75 vs 0.60, respectively).

CONCLUSION

OR is affected by patient-to-treatment bed ratios that differ significantly between EDs and should be accounted for when measuring crowding. CR is not affected by baseline treatment beds and is a better comparable measure of crowding compared with OR in this national comparator study.

Universal thermal climate index associations with mortality, hospital admissions, and road accidents in Bavaria

When meteorological conditions deviate from the optimal range for human well-being, the risks of illness, injury, and death increase, and such impacts are feared in particular with more frequent and intense extreme weather conditions resulting from climate change. Thermal indices, such as the universal thermal climate index (UTCI), can better assess human weather-related stresses by integrating multiple weather components. This paper quantifies and compares the seasonal and spatial association of UTCI with mortality, morbidity, and road accidents in the federal state of Bavaria, Germany. Linear regression was applied to seasonally associate daily 56 million hospital admissions and 2.5 million death counts (1995-2015) as well as approximately 930,000 road accidents and 1.7 million people injured (2002-2015) with spatially interpolated same day- and lagged- (up to 14 days) average UTCI values. Additional linear regressions were performed stratifying by age, gender, region, and district. UTCI effects were clear in all three health outcomes studied: Increased UTCI resulted in immediate (1-2 days) rises in morbidity and even more strongly in mortality in summer, and lagged (up to 14 days) decreases in fall, winter, and spring. The strongest UTCI effects were found for road accidents where increasing UTCI led to immediate decreases in daily road accidents in winter but pronounced increases in all other seasons. Differences in UTCI effects were observed e.g. between in warmer north-western regions (Franconia, more districts with heat stress-related mortality, but hospital admissions for lung, heart and external reasons decreasing with summer heat stress), the touristic alpine regions in the south (immediate effect of increasing UTCI on road accidents in summer), and the colder south-eastern regions (increasing hospital admissions for lung, heart and external reasons in winter with UTCI). Districts with high percentages of elderly suffered from higher morbidity and mortality, particularly in winter. The influences of UTCI as well as the spatial and temporal patterns of this influence call for improved infrastructure planning and resource allocation in the health sector.

Effect of weather variables on the incidence of trauma: A retrospective study at a single tertiary hospital center for 4 years

The occurrence of trauma is associated with various factors, including weather. We aimed to elucidate the relationship between local weather factors and the incidence of trauma to effectively manage and treat patients in a community setting. A retrospective study was conducted at a single center from January 2016 to December 2019. The study participants were trauma patients in the Cheongju area where the regional trauma center is located. Weather data including average daily temperature (°C), rainfall duration (hours), amount of rainfall (mm), average relative humidity (%), wind speed (m/s), and total sunlight hours per day were collected. One-way analysis of variance, correlation analysis, and linear regression analysis were performed. The average age of the participants (n = 3352) was 52.69 years. As regards seasonal difference in the incidence of trauma, there were more patients in spring than in winter (2.42/day vs 2.06/day, P = .05). The highest number of average daily trauma incidents occurred from April to June, and the difference between this value and that from January to February was significant (F = 2.20, P = .01). According to the distributed lag nonlinear model (DLnM), the relative risk is greater than 1 when the mean temperature is high (>15°C) compared to when the temperature is low (<15°C). The trauma patient prevalence was the highest at high wind speed (4.5 m/s). When the total amount of sunlight was long (>Ref. 8 hours), the trauma patient prevalence was relatively higher than the median value (lag = 0). DLnM analysis results showed that the relative risk of trauma patients increased as the amount of precipitation increased, and the incidence of trauma increased when the relative humidity was 40% to 50%. Multiple linear regression analysis revealed that high average daily temperatures and long average daily total sunlight hours resulted in an increased incidence of trauma (F = 6.605, P < .001). An increase in temperature, an increase in the daily sunlight hours, an increase in rainfall, high wind speed, and relative humidity of 40% to 50% are associated with a relatively high risk of trauma.

Impact of the COVID-19 pandemic on the treatment of injuries during lockdown in Norway

AIMS

In order to prevent a major outbreak of COVID-19 disease in Norway, a series of lockdown measures was announced on 12 March 2020. The aim of the present paper was to describe the impact of this lockdown on the treatment of injuries.

METHODS

We collected hospital data on injury diagnoses from a national emergency preparedness register established during the pandemic. We identified the number of injured patients per day in the period 1 January-30 June 2020, and analysed the change in patient volumes over two three-week periods before and during the lockdown by sex, age, level of care, level of urgency, type of contact and type of injury.

RESULTS

Compared to pre-lockdown levels, there was an overall reduction of 43% in injured patients during the first three weeks of lockdown. The decrease in patient contacts did not differ by sex, but was most pronounced among young people. Substantial reductions were observed for both acute and elective treatment and across all levels of care and types of contact, with the exception of indirect patient contacts. The change in patient contacts varied considerably by injury type, with the largest reduction observed for dislocations/sprains/strains. The decrease was much lower for burns/corrosions and poisoning.

CONCLUSIONS

A substantial reduction in the treatment of injuries was observed during lockdown in Norway. Possible explanations for this finding include an overall decrease in injury risk, a redistribution of hospital resources and a higher threshold for seeking medical attention as a result of the pandemic.

The ICON Trauma Study: the impact of the COVID-19 lockdown on major trauma workload in the UK

BACKGROUND

The global pandemic caused by SARS-CoV-2 has impacted population health and care delivery worldwide. As information emerges regarding the impact of "lockdown measures" and changes to clinical practice worldwide; there is no comparative information emerging from the United Kingdom with regard to major trauma.

METHODS

This observational study from a UK Major Trauma Centre matched a cohort of patients admitted during a 10-week period of the SARS-CoV-2-pandemic (09/03/2020-18/05/2020) to a historical cohort of patients admitted during a similar time period in 2019 (11/03/2019-20/05/2019). Differences in demographics, Clinical Frailty Scale, SARS-CoV-2 status, mechanism of injury and injury severity were compared using Fisher's exact and Chi-squared tests. Univariable and multivariable logistic regression analyses examined the associated factors that predicted 30-days mortality.

RESULTS

A total of 642 patients were included, with 405 in the 2019 and 237 in the 2020 cohorts, respectively. 4/237(1.69%) of patients in the 2020 cohort tested positive for SARS-CoV-2. There was a 41.5% decrease in the number of trauma admissions in 2020. This cohort was older (median 46 vs 40 years), had more comorbidities and were frail (p < 0.0015). There was a significant difference in mechanism of injury with a decrease in vehicle related trauma, but an increase in falls. There was a twofold increased risk of mortality in the 2020 cohort which in adjusted multivariable models, was explained by injury severity and frailty. A positive SARS-CoV-2 status was not significantly associated with increased mortality when adjusted for other variables.

CONCLUSION

Patients admitted during the COVID-19 pandemic were older, frailer, more co-morbid and had an associated increased risk of mortality.

Musculoskeletal Attendances to a Minor Injury Department During a Pandemic

Introduction: As coronavirus disease 2019 (COVID-19) became a public health emergency of international concern, countries across the globe began to instate strict social distancing restrictions or “lockdowns”. During these times emergency departments in the United Kingdom (UK) recorded a significant drop in patients attending when compared to the same months of previous years. Attendances related to musculoskeletal (MSK) trauma also saw a significant drop in numbers

Objective: The purpose of this retrospective audit was to investigate patterns of injuries attending during the pandemic and more specifically during times of lockdown.

Method: Retrospective audit data was collected from an electronic medical record system (MediTech V6) during the time period of the first lockdown in the UK. Data was collected for patients attending the emergency department at the Queens Hospital Burton site of the University Hospitals of Derby and Burton National Health Service (NHS) Trust. Presenting complaints were recorded for the entire emergency department, and diagnosis on discharge and activity status was recorded for minor injuries only. This data was then compared to the same date from 2019.

Results: Overall attendances in the emergency department decreased by 45.42% during the first lockdown when compared to the same time period in 2019. MSK problems also saw a significant drop as back pain decreased by 58.88%, neck pain fell by 78.52% and limb problems decreased by 59.74%. When comparing data from the minor injury department, limb problems decreased by 20.45%. The number of soft tissue injuries decreased by 24.05% and fractures decreased by 7.96%.

Conclusion: Attendances in the emergency department were greatly reduced during the COVID-19 pandemic, especially during the first lockdown. The rates of fractures and soft tissue injuries within the minors’ area of the emergency department were also reduced but not at the same rate as the overall attendance. A large number of fractures and soft tissue injuries still presented to the emergency department despite reduced national activity. These attendances may be as a result of the increased rate of Do It Yourself (DIY)-related injuries and altered patient/social behaviour due to lockdown, social distancing, and seasons/weather. Further research would be required to investigate the changing patterns of behaviour especially as we enter a second wave of cases.