Major trauma presentations and patient outcomes in English hospitals during the COVID-19 pandemic: An observational cohort study

Abstract

Background: Single-centre studies suggest that successive Coronavirus Disease 2019 (COVID-19)-related "lockdown" restrictions in England may have led to significant changes in the characteristics of major trauma patients. There is also evidence from other countries that diversion of intensive care capacity and other healthcare resources to treating patients with COVID-19 may have impacted on outcomes for major trauma patients. We aimed to assess the impact of the COVID-19 pandemic on the number, characteristics, care pathways, and outcomes of major trauma patients presenting to hospitals in England.

Methods and findings: We completed an observational cohort study and interrupted time series analysis including all patients eligible for inclusion in England in the national clinical audit for major trauma presenting between 1 January 2017 and 31 of August 2021 (354,202 patients). Demographic characteristics (age, sex, physiology, and injury severity) and clinical pathways of major trauma patients in the first lockdown (17,510 patients) and second lockdown (38,262 patients) were compared to pre-COVID-19 periods in 2018 to 2019 (comparator period 1: 22,243 patients; comparator period 2: 18,099 patients). Discontinuities in trends for weekly estimated excess survival rate were estimated when lockdown measures were introduced using segmented linear regression. The first lockdown had a larger associated reduction in numbers of major trauma patients (-4,733 (21%)) compared to the pre-COVID period than the second lockdown (-2,754 (6.7%)). The largest reductions observed were in numbers of people injured in road traffic collisions excepting cyclists where numbers increased. During the second lockdown, there were increases in the numbers of people injured aged 65 and over (665 (3%)) and 85 and over (828 (9.3%)). In the second week of March 2020, there was a reduction in level of major trauma excess survival rate (-1.71%; 95% CI: -2.76% to -0.66%) associated with the first lockdown. This was followed by a weekly trend of improving survival until the lifting of restrictions in July 2020 (0.25; 95% CI: 0.14 to 0.35). Limitations include eligibility criteria for inclusion to the audit and COVID status of patients not being recorded.

Conclusions: This national evaluation of the impact of COVID on major trauma presentations to English hospitals has observed important public health findings: The large reduction in overall numbers injured has been primarily driven by reductions in road traffic collisions, while numbers of older people injured at home increased over the second lockdown. Future research is needed to better understand the initial reduction in likelihood of survival after major trauma observed with the implementation of the first lockdown.

Fig 1. Strobe diagram for inclusion of study population.

Fig 2. Number of major trauma patients over time.

Periods of shading indicate lockdown restrictions. MTC, major trauma centre.

Fig 3. Number of major trauma patients presenting over time.

Periods of shading indicate lockdown restrictions. RTC, road traffic collision.

Fig 4. Number of major trauma patients due to road traffic–related trauma compared to index of moto vehicular traffic in England over time.

(a) Number of major trauma patients presenting due to road traffic injuries over time. (b) Rolling annual indices of road traffic in Great Britain (reproduced from Department of Transport website with permission). Periods of shading indicate lockdown restrictions.

Fig 5. Number of major trauma patients due to intentional injury over time.

Periods of shading indicate lockdown restrictions. NAI, nonaccidental injury.

Fig 6. Interrupted time series analysis assessing the impact of COVID restrictions on likelihood of survival following major trauma.

Segmented regression model (fitted solid lines) predicting the weekly risk adjusted survival with discontinuities tested for at implementation of each lockdown (24 March 2020 and 2 November 2020) and at the time of relaxation of the first lockdown (29 June).