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In 2020, the coronavirus disease 2019 (COVID-19) pandemic managed to overwhelm many healthcare systems worldwide.  Although such a catastrophe has so far been avoided in New Zealand, largely due to stringent and timely public health measures, the trajectory of the ongoing pandemic is difficult to predict. In view of this, repurposing of health resources has been necessary in order to reduce the potential morbidity and mortality associated with the virus.

However, amid the influx of COVID-19 patients, injuries will continue to occur in the community and trauma patients will continue to arrive at the hospital. While it is imperative to maintain the highest level of care for trauma patients to reduce complications, this may impact on the availability of resources such as ventilators and hospital beds for the severely unwell COVID-19 patients.[[1]] In this complex setting, especially in the event of significant resource constraints, clinicians will have to consider the needs of trauma and COVID-19 patients while ensuring that critical resources are preserved as far as possible.

On 25 March 2020 at 11.59pm, the New Zealand government commenced a nationwide alert level 4 lockdown (Figure 1). In this unprecedented event, people were instructed to stay at home (in their ‘bubble’—with members of the same household) and remain local if exercising or accessing essential services. Public health experts highlighted the need to reduce avoidable pressures on hospitals in order to achieve better resilience for the health system in the face of COVID-19. In particular, emphasis was placed on reducing preventable injuries, including those caused by home accidents, alcohol intoxication and transport-related injuries.[[2]]

Given the novelty of the situation, there is limited evidence examining the pattern of trauma admissions in times of nationwide lockdown and restrictions on movements and activities.[[3–5]] Therefore, the demand for trauma services, and the subsequent impact on scarce hospital resources, was difficult to predict.

This study was conducted with the primary aim of assessing the change in volume and mechanisms of injury of trauma admissions during and after lockdown, with a specific focus on major trauma; and secondarily, to provide information for resource planning and identification of priority areas for injury prevention initiatives.

Methods

A retrospective, descriptive study was conducted on Canterbury District Health Board (CDHB) trauma registry data. Information for the CDHB registry is collected by dedicated trauma nurses at the time of case presentation for contribution to the New Zealand Major Trauma Registry (NZ-MTR). The study population consisted of all patients of all age groups admitted to Christchurch Hospital with major trauma before, during and after alert level 4 lockdown (22 February 2020 to 30 May 2020). The three study groups consisted of major trauma admissions in the 33 days pre-lockdown (which acted as the principal comparison period), during lockdown (a total of 33 days) and in the first 33 days post-lockdown.

Major trauma was defined as having an injury severity score (ISS) ≥13 or death following injury, with a focus on intra-hospital mortality.[[6]] The ISS is a scoring system used to assess trauma severity. It is derived from the Abbreviated Injury Scale (AIS), an internationally used anatomical scoring system that classifies injuries in body regions on a scale from 1 (minor) to 6 (maximal or non-treatable).[[7]]

Patients excluded from the CDHB major trauma registry are those with ISS <13 (non-major injury), delayed admissions more than seven days after injury and admissions for drownings, hangings, poisoning, medical and other surgical emergencies and complicated births. Pre-hospital deaths are also excluded. These exclusions align with criteria used by the NZ-MTR.[[6]] Terms for mechanisms and places of injury were consistent with those used in the annual reports of the New Zealand National Trauma Network.[[6]] Falls were further subcategorised into low falls (≤1 metre in height), high falls (>1 metre in height) and falling down stairs (Table 3). Car, motorcycle, pedal cycle, E-scooter, pedestrian and quad bike/other were grouped into transport-related injuries (including on-road and off-road causes). Alcohol intoxication was defined as either strong clinician suspicion of intoxication and/or a documented blood alcohol level (BAL) greater than the legal driving limit (50mg/100mL) at the time of emergency department (ED) presentation. Outdoor places of injury included public reserves/parks and outdoor sports area (Table 4). Places of injury by urban/rural descriptors were determined using the domicile code where the injury event occurred.

De-identified data were extracted from the CDHB trauma registry and included patient demographics (sex and age), date of ED presentation, ISS, mechanism of injury, place of injury and alcohol intoxication status. Data were compiled and categorised on Excel (Microsoft, version 16.24) and analysed on R. Statistical analysis of associations between patient demographics and admission volumes, mechanisms of injury and places of injury were performed using Chi-squared tests. Ethical approval was granted by the University of Otago Human Ethics Committee (reference number HD20/054).

Figure 1: New Zealand COVID-19 alert levels.[[8]]

Results

Patient demographics and admission volumes

Over the entire study period, a total of 83 patients were admitted with major trauma: 36 in the 33 days pre-lockdown, 21 during lockdown (a total of 33 days) and 26 post-lockdown. The first 33 days post-lockdown is comprised of 16 days in alert level 3 and 17 days in level 2 (Table 1). There was no significant difference in ISS noted between the study periods.

During lockdown, there was a 42% overall reduction in the number of major trauma admissions. Reductions were observed in all subgroups, except in females (no change). The most marked reductions occurred in those under 25 years of age (66% reduction) and males (47% reduction). Post-lockdown, the daily average admissions during level 3 was 0.63/day, which is comparable to 0.64/day during lockdown; and during level 2, the average was 0.94/day, an increase from level 3, albeit still less than 1.09/day pre-lockdown.

Admission volumes were compared with the corresponding time periods in 2018 (Table 2). This showed a noticeable reduction in admissions during lockdown and level 3, although there was a slight increase during level 2. Data from 2019 were not included for comparison due to the Christchurch Mosque Shootings on 15 March 2019.

Table 1: Pre-, during and post-lockdown period major trauma admission volumes at Christchurch Hospital (date range represent 2020 ED presentation dates).

ISS: injury severity score. SD: standard deviation. *Chi-squared test for goodness of fit. **One-way ANOVA. ***Fisher’s exact test.

Table 2: Comparison of major trauma admission volume for same time periods in 2018 and 2020.

Data from 2019 were not included for comparison due to the Christchurch Mosque Shootings in the month of March. n: number of major trauma admissions. *Chi-squared test for independence.

Mechanisms of injury

Pre-lockdown, major trauma admissions were most commonly due to transport-related injuries and falls, which accounted for 50% (n=18) and 31% (n=11) of overall admissions, respectively (Table 3). During lockdown, this was reversed. Falls were the most common injury, accounting for 48% (n=10) of overall admissions, followed by transport-related injuries, which accounted for 38% (n=8). Post-lockdown, transport-related injuries became increasingly more common from level 3 to 2, accounting for 40% (n=4) and 50% (n=8) of admissions in their respective periods. Falls, on the other hand, remained relatively stable, accounting for 30% (n=3) of admissions in level 3 and 31% (n=5) in level 2.

Low falls were the most common type of fall in the pre-lockdown period (n=7). During lockdown, there was an increase in the number of high falls (n=5) compared to pre-lockdown (n=3). High falls occurred in a variety of situations, including falling from ladders, balconies, roofs, trees and construction areas. During level 2, falling down stairs was the most common (n=4), and two of these four cases were related to alcohol intoxication.

Car and motorcycle formed the bulk of transported-related injuries across all periods. Apart from pedal cycle, there was a decrease in all types of transport-related injuries during lockdown.

Aside from mechanisms of injury, injuries associated with alcohol intoxication contributed to 25% (n=9) of admissions pre-lockdown, 33% (n=7) during lockdown and 19% (n=5) post-lockdown with levels 3 and 2 combined (Table 3). Overall, 63% (n=52) of total admissions across the entire study period had a BAL recorded on arrival into hospital. The cases marked ‘unknown’ (Table 3) had neither a BAL or clinician suspicion of alcohol intoxication documented on admission.

Table 3: Pre-, during and post-lockdown period major trauma admission volumes at Christchurch Hospital grouped by mechanism of injury and alcohol intoxication (date range represents 2020 ED presentation dates).

†Falls is the sum of the low falls, high falls and falling down stairs. ‡Transport-related injuries is the sum of car, motorcycle, pedal cycle, E-scooter, pedestrian and quad bike injuries. §Other includes crush, assault, sports-related injuries and deliberate self-harm. ||Alcohol intoxication is defined as either strong clinician suspicion of intoxication and/or documented BAL is greater than the legal driving limit (50mg/100mL) at the time of ED presentation. *Chi-squared test for independence.

Place of injury

The most common places of injury across all periods were on the road and at home (Table 4). During lockdown, a reduction in the volume of admissions from all places of injury was observed, except the footpath, where there was an increase from two to three cases. The most considerable reductions occurred on the road and outdoors, both of which had five fewer cases.

Post-lockdown, specifically during level 2, eight out of 16 admissions were due to road injuries. This represented an appreciable increase in the proportion of admissions attributed to road injuries relative to that observed in any other period.

When place of injury was assessed by urban/rural descriptors, the most marked reductions during lockdown were observed in rural areas (nine cases less) (Table 4). Six out of the 12 cases in rural areas pre-lockdown were transport-related injuries. During lockdown, all rural cases were transport-related, as were one of the two cases in level 3 and three of the four cases in level 2.

Table 4: Pre-, during and post-lockdown period major trauma admission volumes at Christchurch Hospital grouped by place of injury and urban/rural descriptor (date range represents 2020 ED presentation dates).

†Outdoors includes public reserve/park and outdoor sports area. ‡Other includes farm, trade/service area and construction/industrial area.

Discussion

This study assessed the changes in the volume and mechanisms of injury of major trauma admissions to Christchurch Hospital during and after alert level 4 lockdown in New Zealand. The study revealed a 42% overall reduction in major trauma admissions during lockdown. Falls were the most common injury during lockdown, and transport-related injuries post-lockdown. Patterns in major trauma admissions trended towards pre-lockdown levels from level 2 onwards.

In this study, several themes emerged. During lockdown, the greatest reduction in admission volumes was seen in the young age groups and in males. Presumably the non-elderly population were more likely to be on the road, at work, playing sports or engaging in high-risk activities before lockdown. The discrepancy in male and female trauma admissions is not unexpected. In the 2018–2019 annual report by the New Zealand National Trauma Network, 73% of the trauma caseload were males.[[6]] The reason for this discrepancy is likely multifactorial. For instance, higher rates of male employment in occupations that are at increased risk of workplace injuries (including forestry, fishing and construction) [[9]] and more time spent on average participating in sports;[[10]] or this discrepancy may reflect males having an increased intrinsic willingness to engage in risk-taking behaviours.[[11]] Post-lockdown, admission volumes, as indicated by daily average admissions, began to increase only from level 2 onwards. This was somewhat anticipated, as restrictions in level 3 were similar to those during lockdown.[[8]]

Unsurprisingly, admissions due to transport-related injuries fell during lockdown, as may be expected with any decline in road usage secondary to severe travel restrictions. Conversely, admissions due to transport-related injuries increased post-lockdown, particularly from level 2 onwards, when travel restrictions eased and school and workplaces re-opened. Interestingly, the number of admissions due to falls remained largely unchanged during lockdown, despite an overall reduction in admission volumes when compared with the pre-lockdown period. This may be explained by community risk factors for falls that persist even in the presence of lockdown conditions: for instance, elderly age and comorbidities associated with low falls,[[12]] and alcohol intoxication contributing to overall falls. High falls increased slightly during lockdown. Most of these injuries resulted from falling from ladders and trees in the home environment, possibly related to do-it-yourself (DIY) activities.

It is noteworthy that 33% of all injuries leading to major trauma admissions during lockdown were associated with alcohol intoxication—an appreciable increase from the 25% pre-lockdown. In the post-lockdown period, this was 19%. The increase during lockdown may be explained by an increase in alcohol consumption. An online survey by the New Zealand Health Promotion Agency showed that, of 1,190 respondents, 20% increased their alcohol consumption during lockdown, citing stress, boredom and anxiety as key driving factors.[[13]] Of relevance, a number of admissions across all periods were marked ‘unknown’, as no alcohol intoxication status was documented on presentation. Therefore, the actual percentages could be even higher. These findings are consistent with previous research that has demonstrated between 18 to 35% of injury-based ED presentations are alcohol-related.[[14]] Moreover, these findings highlight an ongoing issue: that even during a pandemic, one constant for our already overloaded health system is the avoidable burden created by alcohol-related injuries.

In terms of place of injury, the greatest reductions during lockdown occurred on the road and outdoors, in keeping with restrictions on non-essential movements. On the other hand, there was a small increase in the number of injuries on the footpath, as may be expected under lockdown conditions, when walking and running locally are permitted as forms of exercise. Encouragingly, despite the huge increase in time spent at home by individuals, the number of home injuries during lockdown fell, suggesting that the general public were being more mindful of the potential for injury. In level 2 post-lockdown, there was an increase in the proportion of admissions due to road injuries compared to all other periods. This may be explained, at least in part, by level 2 coinciding with the Queen’s Birthday long weekend, and possibly an element of compensatory behaviour as people sought domestic ‘getaways’ following weeks of travel restrictions.[[15]]

Furthermore, when assessing place of injury by urban/rural descriptors, there was a substantial reduction in injuries from rural areas during lockdown. This paralleled the reduction in transport-related injuries, a finding consistent with previous New Zealand statistics, which show rural residents typically have higher rates of transport-related trauma than urban residents.[[6]]

The findings of this study are comparable to those of Christey et al,[[3]] who reported a 43% reduction in the volume of all injury-related admissions to Waikato Hospital during lockdown, particularly major injuries, with falls being the most common mechanism of injury. In their subsequent follow up study, Christey et al[[16]] reported a “rebound” effect in trauma admissions when COVID-19 restrictions were eased, analogous to the post-lockdown findings observed in this study. In New Zealand and overseas, hospitals have generally reported substantial reductions in overall adult and paediatric trauma admissions during lockdown. Typically, transport-related injuries have reduced most significantly, with the number of falls being generally stable or not decreasing and more injuries occurring in the home environment.[[3–5,16–20]] To date, there is a paucity of evidence examining the pattern of trauma related admissions in the COVID-19 post-lockdown period.[[16]]

In addition to the above, anecdotal evidence from the Accident Compensation Corporation (ACC), New Zealand’s national accidental injury compensation entity, showed that overall claims for injury in the first week of lockdown were down about two thirds compared to the same week in the previous year. The injury with the most overall ACC claims was falls at home.[[21]]

There are several limitations to this study. As a result of a single centre experience, as well as the limited timeframe of lockdown, the absolute number of patients included in the study is small. Data on ethnicity were not included, as no noticeable trends were identifiable to make meaningful comments. Likewise, the small population size precluded meaningful evaluation of mechanisms and places of injury in the context of other variables, such as age, sex and BAL. Furthermore, analysis of statistical significance could not be gained, especially not when involving a number of subgroups. Consequently, strong conclusions cannot be drawn. Ideally, future follow-up studies will include longer timeframes and larger patient numbers, perhaps by combining trauma registry data from multiple major trauma centres across New Zealand.

Despite the stated limitations, this study has contributed data to a growing field of literature. Importantly, this study has identified some key drivers of preventable injuries during and post-lockdown that are immediately amendable to policy changes, namely falls and alcohol- and transport-related injuries. Firstly, mass media campaigns on preventable home injuries may help. Particular emphasis should be placed on avoiding falls in the home environment. The importance of this has been acknowledged by ACC, which has released guidelines on ‘staying safe during bubble life’ that includes advice on reducing the risk of falls and injuries associated with DIY activities. Secondly, public health initiatives aimed at increasing awareness on the dangers of alcohol intoxication may promote responsible purchasing of alcohol, which was an essential item, along with food, during the COVID-19 pandemic. Such initiatives would highlight the general adverse effects of alcohol on health, the increased risk of respiratory complications for those who contract COVID-19, and the long-term sequelae of alcohol-related injuries. Additional alcohol strategies may include changing sales hours or setting a limit to maximum standard drinks per purchase in supermarkets. Lastly, lower speed tolerance and heavier policing may reduce transport-related injuries. Extra cautionary signs should be placed on roads in rural and smaller regional areas.

Conclusion

Major trauma of all age groups will inevitably occur during lockdowns, although at greatly reduced volumes. Post-lockdown, major trauma admissions reverted to pre-lockdown patterns once restrictions were eased. For resource planning, the resurgence in trauma admissions post-lockdown corresponded with the need to catch up on delayed healthcare appointments, putting a noticeable strain on hospitals in the Canterbury region. In terms of injury-prevention initiatives, the focus should be on reducing alcohol- and transport-related injuries, as well as increasing awareness of avoiding falls in the community. Every effort needs to be made to reduce avoidable stressors on hospitals if we are to achieve the best outcome for the greatest number of patients in the clinically challenging times ahead.

Summary

Abstract

Aim

To describe any change in the volume and mechanisms of injury of major trauma admissions during and after COVID-19 lockdown, and in doing so, to provide information for resource planning and identification of priority areas for injury prevention initiatives.

Method

A retrospective, descriptive study conducted on Canterbury District Health Board trauma registry data. The study population consisted of all major trauma patients of all age groups admitted to Christchurch Hospital over three 33-day periods: before, during and after COVID-19 lockdown in New Zealand. Broadly speaking, major trauma is defined as having an injury severity score 13 or death following injury.

Results

There was a 42% reduction in the volume of major trauma admissions during lockdown. Falls were the most common injury during lockdown, and transport-related injuries after lockdown. Alcohol intoxication was associated with 19 to 33% of all injuries across the study periods.

Conclusion

Major trauma inevitably occurred during lockdown, although at considerably lower volumes. After lockdown, once restrictions were eased, major trauma admissions reverted to pre-lockdown patterns. Injury prevention strategies can reduce avoidable pressures on hospitals at a time of pandemic. In New Zealand, focus should be placed on reducing alcohol- and transport-related injuries and increasing community awareness on falls prevention.

Author Information

Dali Fan: House Officer, Canterbury District Health Board. Hannah Scowcroft: Surgical Registrar, Canterbury District Health Board. Andrew McCombie: Statistician, Canterbury District Health Board. Ruth Duncan: Trauma Nurse Coordinator, Canterbury District Health Board. Christopher Wakeman: Consultant General Surgeon, Canterbury District Health Board.

Acknowledgements

Professor Michael Ardagh, who provided invaluable feedback during the write up of the study protocol.

Correspondence

Dr Dali Fan, Department of Surgery, University of Otago, Christchurch, PO Box 4345, Christchurch 8140, New Zealand

Correspondence Email

dali.fan@cdhb.health.nz

Competing Interests

Nil.

1) Royal Australasian College of Surgeons. Maintaining front-line trauma services during the COVID-19 response. http://anzast.org/wp-content/uploads/2020/03/20200330_999999_LTR_Trauma-Group_COVID-Statement_Hospital-CEO.pdf (accessed 26 June 2020).

2) Thomson G, Delany L, Wilson N. Avoidable hospitalisations: Helping our health system get through COVID-19. https://blogs.otago.ac.nz/pubhealthexpert/2020/03/25/avoidable-hospitalisations-helping-our-health-system-get-through-covid-19/ (accessed 26 June 2020).

3) Christey G, Amey J, Campbell A, Smith A. Variation in volumes and characteristics of trauma patients admitted to a level one trauma centre during national level 4 lockdown for COVID-19 in New Zealand. NZMJ. 2020;133 (1513):81-8.

4) McGuinness MJ, Hsee L. Impact of the COVID-19 national lockdown on emergency general surgery: Auckland City Hospital’s experience. ANZ J Surg. 2020;90(11):2254-2258.

5) Hamil JK, Sawyer MC. Reduction of childhood trauma during the COVID-19 level 4 lockdown in New Zealand. ANZ J Surg. 2020;90:1242-3.

6) New Zealand Major Trauma Registry and National Trauma Network. Annual report 2018-2019. https://www.majortrauma.nz/assets/Publication-Resources/Annual-reports/National-Trauma-Network-Annual-Report-2018-19.pdf (accessed 27 June 2020).

7) Palmer CS, Gabbe BJ, Cameron PA. Defining major trauma using the 2008 Abbreviated Injury Scale. Injury. 2016;47(1):109-15

8) Unite Against COVID-19. New Zealand COVID-19 Alert Levels Summary. https://covid19.govt.nz/alert-system/about-the-alert-system/ (accessed 27 June 2020).

9) WorkSafe New Zealand. Data Centre: Injury, Illness and Serious Harm. https://data.worksafe.govt.nz/graph/summary/injuries_serious_harm (accessed 28 June 2020).

10) Sport New Zealand. Active NZ Survey 2018. https://sportnz.org.nz/assets/Uploads/Published-Final-Active-NZ-Main-Report.-The-New-Zealand-Participation-Survey-2018-12-August-2019.pdf (accessed 29 June 2020).

11) Harris CR, Jenkins M, Glaser D. Gender differences in risk assessment: why do women take fewer risks than men? Judgm Decis Mak. 2006;1(1):48-63.

12) Health Quality and Safety Commission New Zealand. Falls in older people: the impacts. https://www.hqsc.govt.nz/assets/Falls/10-Topics/2017_Topic_1_-_Falls_in_older_people_-_the_impacts.pdf (accessed 24 September 2020).

13) Health Promotion Agency. The impact of lockdown on health risk behaviours. https://www.hpa.org.nz/research-library/research-publications/the-impact-of-lockdown-on-health-risk-behaviours (accessed 24 September 2020).

14) Humphrey G, Casswell S, Han DY. Alcohol and injury among attendees at a New Zealand emergency department. NZMJ. 2003;116(1168):U298.

15) Howie C. Covid 19 coronavirus: Travel boom as Kiwis escape for Queen’s Birthday holiday weekend. https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12335954 (accessed 28 June 2020).

16) Christey G, Amey J, Singh N, Denize B, Campbell A. Admission to hospital for injury during COVID-19 alert level restrictions. NZMJ. 2021;134(1531):50-58.

17) Fahy S, Moore J, Kelly M, et al. Analysing the variation in volume and nature of trauma presentations during COVID-19 in Ireland. Bone Jt J. 2020;1(6):261-266.

18) Rajput K, Sud A, Rees M, Rutka O. Epidemiology of trauma presentations to a major trauma centre in the North West of England during the COVID-19 level 4 lockdown. Eur J Trauma Emerg. Surg. 2020;1-6.

19) Jacob S, Mwagiru D, Thakur I, Moghadam A, Oh T, Hsu J. Impact of societal restrictions and lockdown on trauma admissions during the COVID-19 pandemic: a single-centre cross-sectional observational study. ANZ J Surg. 2020;90(11):2227-2231.

20) Morris D, Rogers M, Kissmer N, Preez AD, Dufourq N. Impact of lockdown measures implemented during the COVID-19 pandemic on the burden of trauma presentations to a regional emergency department in Kwa-Zulu Natal, South Africa. Afr J Emerg Med. 2020; 10(4):193-196.

21) Neilson M. Covid 19 coronavirus: thousands of Kiwis still injuring themselves despite lockdown-ACC. https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12324025 (accessed 29 June 2020).

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In 2020, the coronavirus disease 2019 (COVID-19) pandemic managed to overwhelm many healthcare systems worldwide.  Although such a catastrophe has so far been avoided in New Zealand, largely due to stringent and timely public health measures, the trajectory of the ongoing pandemic is difficult to predict. In view of this, repurposing of health resources has been necessary in order to reduce the potential morbidity and mortality associated with the virus.

However, amid the influx of COVID-19 patients, injuries will continue to occur in the community and trauma patients will continue to arrive at the hospital. While it is imperative to maintain the highest level of care for trauma patients to reduce complications, this may impact on the availability of resources such as ventilators and hospital beds for the severely unwell COVID-19 patients.[[1]] In this complex setting, especially in the event of significant resource constraints, clinicians will have to consider the needs of trauma and COVID-19 patients while ensuring that critical resources are preserved as far as possible.

On 25 March 2020 at 11.59pm, the New Zealand government commenced a nationwide alert level 4 lockdown (Figure 1). In this unprecedented event, people were instructed to stay at home (in their ‘bubble’—with members of the same household) and remain local if exercising or accessing essential services. Public health experts highlighted the need to reduce avoidable pressures on hospitals in order to achieve better resilience for the health system in the face of COVID-19. In particular, emphasis was placed on reducing preventable injuries, including those caused by home accidents, alcohol intoxication and transport-related injuries.[[2]]

Given the novelty of the situation, there is limited evidence examining the pattern of trauma admissions in times of nationwide lockdown and restrictions on movements and activities.[[3–5]] Therefore, the demand for trauma services, and the subsequent impact on scarce hospital resources, was difficult to predict.

This study was conducted with the primary aim of assessing the change in volume and mechanisms of injury of trauma admissions during and after lockdown, with a specific focus on major trauma; and secondarily, to provide information for resource planning and identification of priority areas for injury prevention initiatives.

Methods

A retrospective, descriptive study was conducted on Canterbury District Health Board (CDHB) trauma registry data. Information for the CDHB registry is collected by dedicated trauma nurses at the time of case presentation for contribution to the New Zealand Major Trauma Registry (NZ-MTR). The study population consisted of all patients of all age groups admitted to Christchurch Hospital with major trauma before, during and after alert level 4 lockdown (22 February 2020 to 30 May 2020). The three study groups consisted of major trauma admissions in the 33 days pre-lockdown (which acted as the principal comparison period), during lockdown (a total of 33 days) and in the first 33 days post-lockdown.

Major trauma was defined as having an injury severity score (ISS) ≥13 or death following injury, with a focus on intra-hospital mortality.[[6]] The ISS is a scoring system used to assess trauma severity. It is derived from the Abbreviated Injury Scale (AIS), an internationally used anatomical scoring system that classifies injuries in body regions on a scale from 1 (minor) to 6 (maximal or non-treatable).[[7]]

Patients excluded from the CDHB major trauma registry are those with ISS <13 (non-major injury), delayed admissions more than seven days after injury and admissions for drownings, hangings, poisoning, medical and other surgical emergencies and complicated births. Pre-hospital deaths are also excluded. These exclusions align with criteria used by the NZ-MTR.[[6]] Terms for mechanisms and places of injury were consistent with those used in the annual reports of the New Zealand National Trauma Network.[[6]] Falls were further subcategorised into low falls (≤1 metre in height), high falls (>1 metre in height) and falling down stairs (Table 3). Car, motorcycle, pedal cycle, E-scooter, pedestrian and quad bike/other were grouped into transport-related injuries (including on-road and off-road causes). Alcohol intoxication was defined as either strong clinician suspicion of intoxication and/or a documented blood alcohol level (BAL) greater than the legal driving limit (50mg/100mL) at the time of emergency department (ED) presentation. Outdoor places of injury included public reserves/parks and outdoor sports area (Table 4). Places of injury by urban/rural descriptors were determined using the domicile code where the injury event occurred.

De-identified data were extracted from the CDHB trauma registry and included patient demographics (sex and age), date of ED presentation, ISS, mechanism of injury, place of injury and alcohol intoxication status. Data were compiled and categorised on Excel (Microsoft, version 16.24) and analysed on R. Statistical analysis of associations between patient demographics and admission volumes, mechanisms of injury and places of injury were performed using Chi-squared tests. Ethical approval was granted by the University of Otago Human Ethics Committee (reference number HD20/054).

Figure 1: New Zealand COVID-19 alert levels.[[8]]

Results

Patient demographics and admission volumes

Over the entire study period, a total of 83 patients were admitted with major trauma: 36 in the 33 days pre-lockdown, 21 during lockdown (a total of 33 days) and 26 post-lockdown. The first 33 days post-lockdown is comprised of 16 days in alert level 3 and 17 days in level 2 (Table 1). There was no significant difference in ISS noted between the study periods.

During lockdown, there was a 42% overall reduction in the number of major trauma admissions. Reductions were observed in all subgroups, except in females (no change). The most marked reductions occurred in those under 25 years of age (66% reduction) and males (47% reduction). Post-lockdown, the daily average admissions during level 3 was 0.63/day, which is comparable to 0.64/day during lockdown; and during level 2, the average was 0.94/day, an increase from level 3, albeit still less than 1.09/day pre-lockdown.

Admission volumes were compared with the corresponding time periods in 2018 (Table 2). This showed a noticeable reduction in admissions during lockdown and level 3, although there was a slight increase during level 2. Data from 2019 were not included for comparison due to the Christchurch Mosque Shootings on 15 March 2019.

Table 1: Pre-, during and post-lockdown period major trauma admission volumes at Christchurch Hospital (date range represent 2020 ED presentation dates).

ISS: injury severity score. SD: standard deviation. *Chi-squared test for goodness of fit. **One-way ANOVA. ***Fisher’s exact test.

Table 2: Comparison of major trauma admission volume for same time periods in 2018 and 2020.

Data from 2019 were not included for comparison due to the Christchurch Mosque Shootings in the month of March. n: number of major trauma admissions. *Chi-squared test for independence.

Mechanisms of injury

Pre-lockdown, major trauma admissions were most commonly due to transport-related injuries and falls, which accounted for 50% (n=18) and 31% (n=11) of overall admissions, respectively (Table 3). During lockdown, this was reversed. Falls were the most common injury, accounting for 48% (n=10) of overall admissions, followed by transport-related injuries, which accounted for 38% (n=8). Post-lockdown, transport-related injuries became increasingly more common from level 3 to 2, accounting for 40% (n=4) and 50% (n=8) of admissions in their respective periods. Falls, on the other hand, remained relatively stable, accounting for 30% (n=3) of admissions in level 3 and 31% (n=5) in level 2.

Low falls were the most common type of fall in the pre-lockdown period (n=7). During lockdown, there was an increase in the number of high falls (n=5) compared to pre-lockdown (n=3). High falls occurred in a variety of situations, including falling from ladders, balconies, roofs, trees and construction areas. During level 2, falling down stairs was the most common (n=4), and two of these four cases were related to alcohol intoxication.

Car and motorcycle formed the bulk of transported-related injuries across all periods. Apart from pedal cycle, there was a decrease in all types of transport-related injuries during lockdown.

Aside from mechanisms of injury, injuries associated with alcohol intoxication contributed to 25% (n=9) of admissions pre-lockdown, 33% (n=7) during lockdown and 19% (n=5) post-lockdown with levels 3 and 2 combined (Table 3). Overall, 63% (n=52) of total admissions across the entire study period had a BAL recorded on arrival into hospital. The cases marked ‘unknown’ (Table 3) had neither a BAL or clinician suspicion of alcohol intoxication documented on admission.

Table 3: Pre-, during and post-lockdown period major trauma admission volumes at Christchurch Hospital grouped by mechanism of injury and alcohol intoxication (date range represents 2020 ED presentation dates).

†Falls is the sum of the low falls, high falls and falling down stairs. ‡Transport-related injuries is the sum of car, motorcycle, pedal cycle, E-scooter, pedestrian and quad bike injuries. §Other includes crush, assault, sports-related injuries and deliberate self-harm. ||Alcohol intoxication is defined as either strong clinician suspicion of intoxication and/or documented BAL is greater than the legal driving limit (50mg/100mL) at the time of ED presentation. *Chi-squared test for independence.

Place of injury

The most common places of injury across all periods were on the road and at home (Table 4). During lockdown, a reduction in the volume of admissions from all places of injury was observed, except the footpath, where there was an increase from two to three cases. The most considerable reductions occurred on the road and outdoors, both of which had five fewer cases.

Post-lockdown, specifically during level 2, eight out of 16 admissions were due to road injuries. This represented an appreciable increase in the proportion of admissions attributed to road injuries relative to that observed in any other period.

When place of injury was assessed by urban/rural descriptors, the most marked reductions during lockdown were observed in rural areas (nine cases less) (Table 4). Six out of the 12 cases in rural areas pre-lockdown were transport-related injuries. During lockdown, all rural cases were transport-related, as were one of the two cases in level 3 and three of the four cases in level 2.

Table 4: Pre-, during and post-lockdown period major trauma admission volumes at Christchurch Hospital grouped by place of injury and urban/rural descriptor (date range represents 2020 ED presentation dates).

†Outdoors includes public reserve/park and outdoor sports area. ‡Other includes farm, trade/service area and construction/industrial area.

Discussion

This study assessed the changes in the volume and mechanisms of injury of major trauma admissions to Christchurch Hospital during and after alert level 4 lockdown in New Zealand. The study revealed a 42% overall reduction in major trauma admissions during lockdown. Falls were the most common injury during lockdown, and transport-related injuries post-lockdown. Patterns in major trauma admissions trended towards pre-lockdown levels from level 2 onwards.

In this study, several themes emerged. During lockdown, the greatest reduction in admission volumes was seen in the young age groups and in males. Presumably the non-elderly population were more likely to be on the road, at work, playing sports or engaging in high-risk activities before lockdown. The discrepancy in male and female trauma admissions is not unexpected. In the 2018–2019 annual report by the New Zealand National Trauma Network, 73% of the trauma caseload were males.[[6]] The reason for this discrepancy is likely multifactorial. For instance, higher rates of male employment in occupations that are at increased risk of workplace injuries (including forestry, fishing and construction) [[9]] and more time spent on average participating in sports;[[10]] or this discrepancy may reflect males having an increased intrinsic willingness to engage in risk-taking behaviours.[[11]] Post-lockdown, admission volumes, as indicated by daily average admissions, began to increase only from level 2 onwards. This was somewhat anticipated, as restrictions in level 3 were similar to those during lockdown.[[8]]

Unsurprisingly, admissions due to transport-related injuries fell during lockdown, as may be expected with any decline in road usage secondary to severe travel restrictions. Conversely, admissions due to transport-related injuries increased post-lockdown, particularly from level 2 onwards, when travel restrictions eased and school and workplaces re-opened. Interestingly, the number of admissions due to falls remained largely unchanged during lockdown, despite an overall reduction in admission volumes when compared with the pre-lockdown period. This may be explained by community risk factors for falls that persist even in the presence of lockdown conditions: for instance, elderly age and comorbidities associated with low falls,[[12]] and alcohol intoxication contributing to overall falls. High falls increased slightly during lockdown. Most of these injuries resulted from falling from ladders and trees in the home environment, possibly related to do-it-yourself (DIY) activities.

It is noteworthy that 33% of all injuries leading to major trauma admissions during lockdown were associated with alcohol intoxication—an appreciable increase from the 25% pre-lockdown. In the post-lockdown period, this was 19%. The increase during lockdown may be explained by an increase in alcohol consumption. An online survey by the New Zealand Health Promotion Agency showed that, of 1,190 respondents, 20% increased their alcohol consumption during lockdown, citing stress, boredom and anxiety as key driving factors.[[13]] Of relevance, a number of admissions across all periods were marked ‘unknown’, as no alcohol intoxication status was documented on presentation. Therefore, the actual percentages could be even higher. These findings are consistent with previous research that has demonstrated between 18 to 35% of injury-based ED presentations are alcohol-related.[[14]] Moreover, these findings highlight an ongoing issue: that even during a pandemic, one constant for our already overloaded health system is the avoidable burden created by alcohol-related injuries.

In terms of place of injury, the greatest reductions during lockdown occurred on the road and outdoors, in keeping with restrictions on non-essential movements. On the other hand, there was a small increase in the number of injuries on the footpath, as may be expected under lockdown conditions, when walking and running locally are permitted as forms of exercise. Encouragingly, despite the huge increase in time spent at home by individuals, the number of home injuries during lockdown fell, suggesting that the general public were being more mindful of the potential for injury. In level 2 post-lockdown, there was an increase in the proportion of admissions due to road injuries compared to all other periods. This may be explained, at least in part, by level 2 coinciding with the Queen’s Birthday long weekend, and possibly an element of compensatory behaviour as people sought domestic ‘getaways’ following weeks of travel restrictions.[[15]]

Furthermore, when assessing place of injury by urban/rural descriptors, there was a substantial reduction in injuries from rural areas during lockdown. This paralleled the reduction in transport-related injuries, a finding consistent with previous New Zealand statistics, which show rural residents typically have higher rates of transport-related trauma than urban residents.[[6]]

The findings of this study are comparable to those of Christey et al,[[3]] who reported a 43% reduction in the volume of all injury-related admissions to Waikato Hospital during lockdown, particularly major injuries, with falls being the most common mechanism of injury. In their subsequent follow up study, Christey et al[[16]] reported a “rebound” effect in trauma admissions when COVID-19 restrictions were eased, analogous to the post-lockdown findings observed in this study. In New Zealand and overseas, hospitals have generally reported substantial reductions in overall adult and paediatric trauma admissions during lockdown. Typically, transport-related injuries have reduced most significantly, with the number of falls being generally stable or not decreasing and more injuries occurring in the home environment.[[3–5,16–20]] To date, there is a paucity of evidence examining the pattern of trauma related admissions in the COVID-19 post-lockdown period.[[16]]

In addition to the above, anecdotal evidence from the Accident Compensation Corporation (ACC), New Zealand’s national accidental injury compensation entity, showed that overall claims for injury in the first week of lockdown were down about two thirds compared to the same week in the previous year. The injury with the most overall ACC claims was falls at home.[[21]]

There are several limitations to this study. As a result of a single centre experience, as well as the limited timeframe of lockdown, the absolute number of patients included in the study is small. Data on ethnicity were not included, as no noticeable trends were identifiable to make meaningful comments. Likewise, the small population size precluded meaningful evaluation of mechanisms and places of injury in the context of other variables, such as age, sex and BAL. Furthermore, analysis of statistical significance could not be gained, especially not when involving a number of subgroups. Consequently, strong conclusions cannot be drawn. Ideally, future follow-up studies will include longer timeframes and larger patient numbers, perhaps by combining trauma registry data from multiple major trauma centres across New Zealand.

Despite the stated limitations, this study has contributed data to a growing field of literature. Importantly, this study has identified some key drivers of preventable injuries during and post-lockdown that are immediately amendable to policy changes, namely falls and alcohol- and transport-related injuries. Firstly, mass media campaigns on preventable home injuries may help. Particular emphasis should be placed on avoiding falls in the home environment. The importance of this has been acknowledged by ACC, which has released guidelines on ‘staying safe during bubble life’ that includes advice on reducing the risk of falls and injuries associated with DIY activities. Secondly, public health initiatives aimed at increasing awareness on the dangers of alcohol intoxication may promote responsible purchasing of alcohol, which was an essential item, along with food, during the COVID-19 pandemic. Such initiatives would highlight the general adverse effects of alcohol on health, the increased risk of respiratory complications for those who contract COVID-19, and the long-term sequelae of alcohol-related injuries. Additional alcohol strategies may include changing sales hours or setting a limit to maximum standard drinks per purchase in supermarkets. Lastly, lower speed tolerance and heavier policing may reduce transport-related injuries. Extra cautionary signs should be placed on roads in rural and smaller regional areas.

Conclusion

Major trauma of all age groups will inevitably occur during lockdowns, although at greatly reduced volumes. Post-lockdown, major trauma admissions reverted to pre-lockdown patterns once restrictions were eased. For resource planning, the resurgence in trauma admissions post-lockdown corresponded with the need to catch up on delayed healthcare appointments, putting a noticeable strain on hospitals in the Canterbury region. In terms of injury-prevention initiatives, the focus should be on reducing alcohol- and transport-related injuries, as well as increasing awareness of avoiding falls in the community. Every effort needs to be made to reduce avoidable stressors on hospitals if we are to achieve the best outcome for the greatest number of patients in the clinically challenging times ahead.

Summary

Abstract

Aim

To describe any change in the volume and mechanisms of injury of major trauma admissions during and after COVID-19 lockdown, and in doing so, to provide information for resource planning and identification of priority areas for injury prevention initiatives.

Method

A retrospective, descriptive study conducted on Canterbury District Health Board trauma registry data. The study population consisted of all major trauma patients of all age groups admitted to Christchurch Hospital over three 33-day periods: before, during and after COVID-19 lockdown in New Zealand. Broadly speaking, major trauma is defined as having an injury severity score 13 or death following injury.

Results

There was a 42% reduction in the volume of major trauma admissions during lockdown. Falls were the most common injury during lockdown, and transport-related injuries after lockdown. Alcohol intoxication was associated with 19 to 33% of all injuries across the study periods.

Conclusion

Major trauma inevitably occurred during lockdown, although at considerably lower volumes. After lockdown, once restrictions were eased, major trauma admissions reverted to pre-lockdown patterns. Injury prevention strategies can reduce avoidable pressures on hospitals at a time of pandemic. In New Zealand, focus should be placed on reducing alcohol- and transport-related injuries and increasing community awareness on falls prevention.

Author Information

Dali Fan: House Officer, Canterbury District Health Board. Hannah Scowcroft: Surgical Registrar, Canterbury District Health Board. Andrew McCombie: Statistician, Canterbury District Health Board. Ruth Duncan: Trauma Nurse Coordinator, Canterbury District Health Board. Christopher Wakeman: Consultant General Surgeon, Canterbury District Health Board.

Acknowledgements

Professor Michael Ardagh, who provided invaluable feedback during the write up of the study protocol.

Correspondence

Dr Dali Fan, Department of Surgery, University of Otago, Christchurch, PO Box 4345, Christchurch 8140, New Zealand

Correspondence Email

dali.fan@cdhb.health.nz

Competing Interests

Nil.

1) Royal Australasian College of Surgeons. Maintaining front-line trauma services during the COVID-19 response. http://anzast.org/wp-content/uploads/2020/03/20200330_999999_LTR_Trauma-Group_COVID-Statement_Hospital-CEO.pdf (accessed 26 June 2020).

2) Thomson G, Delany L, Wilson N. Avoidable hospitalisations: Helping our health system get through COVID-19. https://blogs.otago.ac.nz/pubhealthexpert/2020/03/25/avoidable-hospitalisations-helping-our-health-system-get-through-covid-19/ (accessed 26 June 2020).

3) Christey G, Amey J, Campbell A, Smith A. Variation in volumes and characteristics of trauma patients admitted to a level one trauma centre during national level 4 lockdown for COVID-19 in New Zealand. NZMJ. 2020;133 (1513):81-8.

4) McGuinness MJ, Hsee L. Impact of the COVID-19 national lockdown on emergency general surgery: Auckland City Hospital’s experience. ANZ J Surg. 2020;90(11):2254-2258.

5) Hamil JK, Sawyer MC. Reduction of childhood trauma during the COVID-19 level 4 lockdown in New Zealand. ANZ J Surg. 2020;90:1242-3.

6) New Zealand Major Trauma Registry and National Trauma Network. Annual report 2018-2019. https://www.majortrauma.nz/assets/Publication-Resources/Annual-reports/National-Trauma-Network-Annual-Report-2018-19.pdf (accessed 27 June 2020).

7) Palmer CS, Gabbe BJ, Cameron PA. Defining major trauma using the 2008 Abbreviated Injury Scale. Injury. 2016;47(1):109-15

8) Unite Against COVID-19. New Zealand COVID-19 Alert Levels Summary. https://covid19.govt.nz/alert-system/about-the-alert-system/ (accessed 27 June 2020).

9) WorkSafe New Zealand. Data Centre: Injury, Illness and Serious Harm. https://data.worksafe.govt.nz/graph/summary/injuries_serious_harm (accessed 28 June 2020).

10) Sport New Zealand. Active NZ Survey 2018. https://sportnz.org.nz/assets/Uploads/Published-Final-Active-NZ-Main-Report.-The-New-Zealand-Participation-Survey-2018-12-August-2019.pdf (accessed 29 June 2020).

11) Harris CR, Jenkins M, Glaser D. Gender differences in risk assessment: why do women take fewer risks than men? Judgm Decis Mak. 2006;1(1):48-63.

12) Health Quality and Safety Commission New Zealand. Falls in older people: the impacts. https://www.hqsc.govt.nz/assets/Falls/10-Topics/2017_Topic_1_-_Falls_in_older_people_-_the_impacts.pdf (accessed 24 September 2020).

13) Health Promotion Agency. The impact of lockdown on health risk behaviours. https://www.hpa.org.nz/research-library/research-publications/the-impact-of-lockdown-on-health-risk-behaviours (accessed 24 September 2020).

14) Humphrey G, Casswell S, Han DY. Alcohol and injury among attendees at a New Zealand emergency department. NZMJ. 2003;116(1168):U298.

15) Howie C. Covid 19 coronavirus: Travel boom as Kiwis escape for Queen’s Birthday holiday weekend. https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12335954 (accessed 28 June 2020).

16) Christey G, Amey J, Singh N, Denize B, Campbell A. Admission to hospital for injury during COVID-19 alert level restrictions. NZMJ. 2021;134(1531):50-58.

17) Fahy S, Moore J, Kelly M, et al. Analysing the variation in volume and nature of trauma presentations during COVID-19 in Ireland. Bone Jt J. 2020;1(6):261-266.

18) Rajput K, Sud A, Rees M, Rutka O. Epidemiology of trauma presentations to a major trauma centre in the North West of England during the COVID-19 level 4 lockdown. Eur J Trauma Emerg. Surg. 2020;1-6.

19) Jacob S, Mwagiru D, Thakur I, Moghadam A, Oh T, Hsu J. Impact of societal restrictions and lockdown on trauma admissions during the COVID-19 pandemic: a single-centre cross-sectional observational study. ANZ J Surg. 2020;90(11):2227-2231.

20) Morris D, Rogers M, Kissmer N, Preez AD, Dufourq N. Impact of lockdown measures implemented during the COVID-19 pandemic on the burden of trauma presentations to a regional emergency department in Kwa-Zulu Natal, South Africa. Afr J Emerg Med. 2020; 10(4):193-196.

21) Neilson M. Covid 19 coronavirus: thousands of Kiwis still injuring themselves despite lockdown-ACC. https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12324025 (accessed 29 June 2020).

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In 2020, the coronavirus disease 2019 (COVID-19) pandemic managed to overwhelm many healthcare systems worldwide.  Although such a catastrophe has so far been avoided in New Zealand, largely due to stringent and timely public health measures, the trajectory of the ongoing pandemic is difficult to predict. In view of this, repurposing of health resources has been necessary in order to reduce the potential morbidity and mortality associated with the virus.

However, amid the influx of COVID-19 patients, injuries will continue to occur in the community and trauma patients will continue to arrive at the hospital. While it is imperative to maintain the highest level of care for trauma patients to reduce complications, this may impact on the availability of resources such as ventilators and hospital beds for the severely unwell COVID-19 patients.[[1]] In this complex setting, especially in the event of significant resource constraints, clinicians will have to consider the needs of trauma and COVID-19 patients while ensuring that critical resources are preserved as far as possible.

On 25 March 2020 at 11.59pm, the New Zealand government commenced a nationwide alert level 4 lockdown (Figure 1). In this unprecedented event, people were instructed to stay at home (in their ‘bubble’—with members of the same household) and remain local if exercising or accessing essential services. Public health experts highlighted the need to reduce avoidable pressures on hospitals in order to achieve better resilience for the health system in the face of COVID-19. In particular, emphasis was placed on reducing preventable injuries, including those caused by home accidents, alcohol intoxication and transport-related injuries.[[2]]

Given the novelty of the situation, there is limited evidence examining the pattern of trauma admissions in times of nationwide lockdown and restrictions on movements and activities.[[3–5]] Therefore, the demand for trauma services, and the subsequent impact on scarce hospital resources, was difficult to predict.

This study was conducted with the primary aim of assessing the change in volume and mechanisms of injury of trauma admissions during and after lockdown, with a specific focus on major trauma; and secondarily, to provide information for resource planning and identification of priority areas for injury prevention initiatives.

Methods

A retrospective, descriptive study was conducted on Canterbury District Health Board (CDHB) trauma registry data. Information for the CDHB registry is collected by dedicated trauma nurses at the time of case presentation for contribution to the New Zealand Major Trauma Registry (NZ-MTR). The study population consisted of all patients of all age groups admitted to Christchurch Hospital with major trauma before, during and after alert level 4 lockdown (22 February 2020 to 30 May 2020). The three study groups consisted of major trauma admissions in the 33 days pre-lockdown (which acted as the principal comparison period), during lockdown (a total of 33 days) and in the first 33 days post-lockdown.

Major trauma was defined as having an injury severity score (ISS) ≥13 or death following injury, with a focus on intra-hospital mortality.[[6]] The ISS is a scoring system used to assess trauma severity. It is derived from the Abbreviated Injury Scale (AIS), an internationally used anatomical scoring system that classifies injuries in body regions on a scale from 1 (minor) to 6 (maximal or non-treatable).[[7]]

Patients excluded from the CDHB major trauma registry are those with ISS <13 (non-major injury), delayed admissions more than seven days after injury and admissions for drownings, hangings, poisoning, medical and other surgical emergencies and complicated births. Pre-hospital deaths are also excluded. These exclusions align with criteria used by the NZ-MTR.[[6]] Terms for mechanisms and places of injury were consistent with those used in the annual reports of the New Zealand National Trauma Network.[[6]] Falls were further subcategorised into low falls (≤1 metre in height), high falls (>1 metre in height) and falling down stairs (Table 3). Car, motorcycle, pedal cycle, E-scooter, pedestrian and quad bike/other were grouped into transport-related injuries (including on-road and off-road causes). Alcohol intoxication was defined as either strong clinician suspicion of intoxication and/or a documented blood alcohol level (BAL) greater than the legal driving limit (50mg/100mL) at the time of emergency department (ED) presentation. Outdoor places of injury included public reserves/parks and outdoor sports area (Table 4). Places of injury by urban/rural descriptors were determined using the domicile code where the injury event occurred.

De-identified data were extracted from the CDHB trauma registry and included patient demographics (sex and age), date of ED presentation, ISS, mechanism of injury, place of injury and alcohol intoxication status. Data were compiled and categorised on Excel (Microsoft, version 16.24) and analysed on R. Statistical analysis of associations between patient demographics and admission volumes, mechanisms of injury and places of injury were performed using Chi-squared tests. Ethical approval was granted by the University of Otago Human Ethics Committee (reference number HD20/054).

Figure 1: New Zealand COVID-19 alert levels.[[8]]

Results

Patient demographics and admission volumes

Over the entire study period, a total of 83 patients were admitted with major trauma: 36 in the 33 days pre-lockdown, 21 during lockdown (a total of 33 days) and 26 post-lockdown. The first 33 days post-lockdown is comprised of 16 days in alert level 3 and 17 days in level 2 (Table 1). There was no significant difference in ISS noted between the study periods.

During lockdown, there was a 42% overall reduction in the number of major trauma admissions. Reductions were observed in all subgroups, except in females (no change). The most marked reductions occurred in those under 25 years of age (66% reduction) and males (47% reduction). Post-lockdown, the daily average admissions during level 3 was 0.63/day, which is comparable to 0.64/day during lockdown; and during level 2, the average was 0.94/day, an increase from level 3, albeit still less than 1.09/day pre-lockdown.

Admission volumes were compared with the corresponding time periods in 2018 (Table 2). This showed a noticeable reduction in admissions during lockdown and level 3, although there was a slight increase during level 2. Data from 2019 were not included for comparison due to the Christchurch Mosque Shootings on 15 March 2019.

Table 1: Pre-, during and post-lockdown period major trauma admission volumes at Christchurch Hospital (date range represent 2020 ED presentation dates).

ISS: injury severity score. SD: standard deviation. *Chi-squared test for goodness of fit. **One-way ANOVA. ***Fisher’s exact test.

Table 2: Comparison of major trauma admission volume for same time periods in 2018 and 2020.

Data from 2019 were not included for comparison due to the Christchurch Mosque Shootings in the month of March. n: number of major trauma admissions. *Chi-squared test for independence.

Mechanisms of injury

Pre-lockdown, major trauma admissions were most commonly due to transport-related injuries and falls, which accounted for 50% (n=18) and 31% (n=11) of overall admissions, respectively (Table 3). During lockdown, this was reversed. Falls were the most common injury, accounting for 48% (n=10) of overall admissions, followed by transport-related injuries, which accounted for 38% (n=8). Post-lockdown, transport-related injuries became increasingly more common from level 3 to 2, accounting for 40% (n=4) and 50% (n=8) of admissions in their respective periods. Falls, on the other hand, remained relatively stable, accounting for 30% (n=3) of admissions in level 3 and 31% (n=5) in level 2.

Low falls were the most common type of fall in the pre-lockdown period (n=7). During lockdown, there was an increase in the number of high falls (n=5) compared to pre-lockdown (n=3). High falls occurred in a variety of situations, including falling from ladders, balconies, roofs, trees and construction areas. During level 2, falling down stairs was the most common (n=4), and two of these four cases were related to alcohol intoxication.

Car and motorcycle formed the bulk of transported-related injuries across all periods. Apart from pedal cycle, there was a decrease in all types of transport-related injuries during lockdown.

Aside from mechanisms of injury, injuries associated with alcohol intoxication contributed to 25% (n=9) of admissions pre-lockdown, 33% (n=7) during lockdown and 19% (n=5) post-lockdown with levels 3 and 2 combined (Table 3). Overall, 63% (n=52) of total admissions across the entire study period had a BAL recorded on arrival into hospital. The cases marked ‘unknown’ (Table 3) had neither a BAL or clinician suspicion of alcohol intoxication documented on admission.

Table 3: Pre-, during and post-lockdown period major trauma admission volumes at Christchurch Hospital grouped by mechanism of injury and alcohol intoxication (date range represents 2020 ED presentation dates).

†Falls is the sum of the low falls, high falls and falling down stairs. ‡Transport-related injuries is the sum of car, motorcycle, pedal cycle, E-scooter, pedestrian and quad bike injuries. §Other includes crush, assault, sports-related injuries and deliberate self-harm. ||Alcohol intoxication is defined as either strong clinician suspicion of intoxication and/or documented BAL is greater than the legal driving limit (50mg/100mL) at the time of ED presentation. *Chi-squared test for independence.

Place of injury

The most common places of injury across all periods were on the road and at home (Table 4). During lockdown, a reduction in the volume of admissions from all places of injury was observed, except the footpath, where there was an increase from two to three cases. The most considerable reductions occurred on the road and outdoors, both of which had five fewer cases.

Post-lockdown, specifically during level 2, eight out of 16 admissions were due to road injuries. This represented an appreciable increase in the proportion of admissions attributed to road injuries relative to that observed in any other period.

When place of injury was assessed by urban/rural descriptors, the most marked reductions during lockdown were observed in rural areas (nine cases less) (Table 4). Six out of the 12 cases in rural areas pre-lockdown were transport-related injuries. During lockdown, all rural cases were transport-related, as were one of the two cases in level 3 and three of the four cases in level 2.

Table 4: Pre-, during and post-lockdown period major trauma admission volumes at Christchurch Hospital grouped by place of injury and urban/rural descriptor (date range represents 2020 ED presentation dates).

†Outdoors includes public reserve/park and outdoor sports area. ‡Other includes farm, trade/service area and construction/industrial area.

Discussion

This study assessed the changes in the volume and mechanisms of injury of major trauma admissions to Christchurch Hospital during and after alert level 4 lockdown in New Zealand. The study revealed a 42% overall reduction in major trauma admissions during lockdown. Falls were the most common injury during lockdown, and transport-related injuries post-lockdown. Patterns in major trauma admissions trended towards pre-lockdown levels from level 2 onwards.

In this study, several themes emerged. During lockdown, the greatest reduction in admission volumes was seen in the young age groups and in males. Presumably the non-elderly population were more likely to be on the road, at work, playing sports or engaging in high-risk activities before lockdown. The discrepancy in male and female trauma admissions is not unexpected. In the 2018–2019 annual report by the New Zealand National Trauma Network, 73% of the trauma caseload were males.[[6]] The reason for this discrepancy is likely multifactorial. For instance, higher rates of male employment in occupations that are at increased risk of workplace injuries (including forestry, fishing and construction) [[9]] and more time spent on average participating in sports;[[10]] or this discrepancy may reflect males having an increased intrinsic willingness to engage in risk-taking behaviours.[[11]] Post-lockdown, admission volumes, as indicated by daily average admissions, began to increase only from level 2 onwards. This was somewhat anticipated, as restrictions in level 3 were similar to those during lockdown.[[8]]

Unsurprisingly, admissions due to transport-related injuries fell during lockdown, as may be expected with any decline in road usage secondary to severe travel restrictions. Conversely, admissions due to transport-related injuries increased post-lockdown, particularly from level 2 onwards, when travel restrictions eased and school and workplaces re-opened. Interestingly, the number of admissions due to falls remained largely unchanged during lockdown, despite an overall reduction in admission volumes when compared with the pre-lockdown period. This may be explained by community risk factors for falls that persist even in the presence of lockdown conditions: for instance, elderly age and comorbidities associated with low falls,[[12]] and alcohol intoxication contributing to overall falls. High falls increased slightly during lockdown. Most of these injuries resulted from falling from ladders and trees in the home environment, possibly related to do-it-yourself (DIY) activities.

It is noteworthy that 33% of all injuries leading to major trauma admissions during lockdown were associated with alcohol intoxication—an appreciable increase from the 25% pre-lockdown. In the post-lockdown period, this was 19%. The increase during lockdown may be explained by an increase in alcohol consumption. An online survey by the New Zealand Health Promotion Agency showed that, of 1,190 respondents, 20% increased their alcohol consumption during lockdown, citing stress, boredom and anxiety as key driving factors.[[13]] Of relevance, a number of admissions across all periods were marked ‘unknown’, as no alcohol intoxication status was documented on presentation. Therefore, the actual percentages could be even higher. These findings are consistent with previous research that has demonstrated between 18 to 35% of injury-based ED presentations are alcohol-related.[[14]] Moreover, these findings highlight an ongoing issue: that even during a pandemic, one constant for our already overloaded health system is the avoidable burden created by alcohol-related injuries.

In terms of place of injury, the greatest reductions during lockdown occurred on the road and outdoors, in keeping with restrictions on non-essential movements. On the other hand, there was a small increase in the number of injuries on the footpath, as may be expected under lockdown conditions, when walking and running locally are permitted as forms of exercise. Encouragingly, despite the huge increase in time spent at home by individuals, the number of home injuries during lockdown fell, suggesting that the general public were being more mindful of the potential for injury. In level 2 post-lockdown, there was an increase in the proportion of admissions due to road injuries compared to all other periods. This may be explained, at least in part, by level 2 coinciding with the Queen’s Birthday long weekend, and possibly an element of compensatory behaviour as people sought domestic ‘getaways’ following weeks of travel restrictions.[[15]]

Furthermore, when assessing place of injury by urban/rural descriptors, there was a substantial reduction in injuries from rural areas during lockdown. This paralleled the reduction in transport-related injuries, a finding consistent with previous New Zealand statistics, which show rural residents typically have higher rates of transport-related trauma than urban residents.[[6]]

The findings of this study are comparable to those of Christey et al,[[3]] who reported a 43% reduction in the volume of all injury-related admissions to Waikato Hospital during lockdown, particularly major injuries, with falls being the most common mechanism of injury. In their subsequent follow up study, Christey et al[[16]] reported a “rebound” effect in trauma admissions when COVID-19 restrictions were eased, analogous to the post-lockdown findings observed in this study. In New Zealand and overseas, hospitals have generally reported substantial reductions in overall adult and paediatric trauma admissions during lockdown. Typically, transport-related injuries have reduced most significantly, with the number of falls being generally stable or not decreasing and more injuries occurring in the home environment.[[3–5,16–20]] To date, there is a paucity of evidence examining the pattern of trauma related admissions in the COVID-19 post-lockdown period.[[16]]

In addition to the above, anecdotal evidence from the Accident Compensation Corporation (ACC), New Zealand’s national accidental injury compensation entity, showed that overall claims for injury in the first week of lockdown were down about two thirds compared to the same week in the previous year. The injury with the most overall ACC claims was falls at home.[[21]]

There are several limitations to this study. As a result of a single centre experience, as well as the limited timeframe of lockdown, the absolute number of patients included in the study is small. Data on ethnicity were not included, as no noticeable trends were identifiable to make meaningful comments. Likewise, the small population size precluded meaningful evaluation of mechanisms and places of injury in the context of other variables, such as age, sex and BAL. Furthermore, analysis of statistical significance could not be gained, especially not when involving a number of subgroups. Consequently, strong conclusions cannot be drawn. Ideally, future follow-up studies will include longer timeframes and larger patient numbers, perhaps by combining trauma registry data from multiple major trauma centres across New Zealand.

Despite the stated limitations, this study has contributed data to a growing field of literature. Importantly, this study has identified some key drivers of preventable injuries during and post-lockdown that are immediately amendable to policy changes, namely falls and alcohol- and transport-related injuries. Firstly, mass media campaigns on preventable home injuries may help. Particular emphasis should be placed on avoiding falls in the home environment. The importance of this has been acknowledged by ACC, which has released guidelines on ‘staying safe during bubble life’ that includes advice on reducing the risk of falls and injuries associated with DIY activities. Secondly, public health initiatives aimed at increasing awareness on the dangers of alcohol intoxication may promote responsible purchasing of alcohol, which was an essential item, along with food, during the COVID-19 pandemic. Such initiatives would highlight the general adverse effects of alcohol on health, the increased risk of respiratory complications for those who contract COVID-19, and the long-term sequelae of alcohol-related injuries. Additional alcohol strategies may include changing sales hours or setting a limit to maximum standard drinks per purchase in supermarkets. Lastly, lower speed tolerance and heavier policing may reduce transport-related injuries. Extra cautionary signs should be placed on roads in rural and smaller regional areas.

Conclusion

Major trauma of all age groups will inevitably occur during lockdowns, although at greatly reduced volumes. Post-lockdown, major trauma admissions reverted to pre-lockdown patterns once restrictions were eased. For resource planning, the resurgence in trauma admissions post-lockdown corresponded with the need to catch up on delayed healthcare appointments, putting a noticeable strain on hospitals in the Canterbury region. In terms of injury-prevention initiatives, the focus should be on reducing alcohol- and transport-related injuries, as well as increasing awareness of avoiding falls in the community. Every effort needs to be made to reduce avoidable stressors on hospitals if we are to achieve the best outcome for the greatest number of patients in the clinically challenging times ahead.

Summary

Abstract

Aim

To describe any change in the volume and mechanisms of injury of major trauma admissions during and after COVID-19 lockdown, and in doing so, to provide information for resource planning and identification of priority areas for injury prevention initiatives.

Method

A retrospective, descriptive study conducted on Canterbury District Health Board trauma registry data. The study population consisted of all major trauma patients of all age groups admitted to Christchurch Hospital over three 33-day periods: before, during and after COVID-19 lockdown in New Zealand. Broadly speaking, major trauma is defined as having an injury severity score 13 or death following injury.

Results

There was a 42% reduction in the volume of major trauma admissions during lockdown. Falls were the most common injury during lockdown, and transport-related injuries after lockdown. Alcohol intoxication was associated with 19 to 33% of all injuries across the study periods.

Conclusion

Major trauma inevitably occurred during lockdown, although at considerably lower volumes. After lockdown, once restrictions were eased, major trauma admissions reverted to pre-lockdown patterns. Injury prevention strategies can reduce avoidable pressures on hospitals at a time of pandemic. In New Zealand, focus should be placed on reducing alcohol- and transport-related injuries and increasing community awareness on falls prevention.

Author Information

Dali Fan: House Officer, Canterbury District Health Board. Hannah Scowcroft: Surgical Registrar, Canterbury District Health Board. Andrew McCombie: Statistician, Canterbury District Health Board. Ruth Duncan: Trauma Nurse Coordinator, Canterbury District Health Board. Christopher Wakeman: Consultant General Surgeon, Canterbury District Health Board.

Acknowledgements

Professor Michael Ardagh, who provided invaluable feedback during the write up of the study protocol.

Correspondence

Dr Dali Fan, Department of Surgery, University of Otago, Christchurch, PO Box 4345, Christchurch 8140, New Zealand

Correspondence Email

dali.fan@cdhb.health.nz

Competing Interests

Nil.

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