The DISTANCE study: Determining the impact of social distancing on trauma epidemiology during the COVID-19 epidemic—An interrupted time-series analysis

Abstract

BACKGROUND:The large-scale social distancing efforts to reduce SARS-CoV-2 transmission have dramatically changed human behaviors associated with traumatic injuries. Trauma centers have reported decreases in trauma volume, paralleled by changes in injury mechanisms. We aimed to quantify changes in trauma epidemiology at an urban Level I trauma center in a county that instituted one of the earliest shelter-in-place orders to inform trauma care during future pandemic responses. METHODS:A single-center interrupted time-series analysis was performed to identify associations of shelter-in-place with trauma volume, injury mechanisms, and patient demographics in San Francisco, California. To control for short-term trends in trauma epidemiology, weekly level data were analyzed 6 months before shelter-in-place. To control for long-term trends, monthly level data were analyzed 5 years before shelter-in-place. RESULTS:Trauma volume decreased by 50% in the week following shelter-in-place (p < 0.01), followed by a linear increase each successive week (p < 0.01). Despite this, trauma volume for each month (March-June 2020) remained lower compared with corresponding months for all previous 5 years (2015-2019). Pediatric trauma volume showed similar trends with initial decreases (p = 0.02) followed by steady increases (p = 0.05). Reductions in trauma volumes were due entirely to changes in nonviolent injury mechanisms, while violence-related injury mechanisms remained unchanged (p < 0.01). CONCLUSION:Although the shelter-in-place order was associated with an overall decline in trauma volume, violence-related injuries persisted. Delineating and addressing underlying factors driving persistent violence-related injuries during shelter-in-place orders should be a focus of public health efforts in preparation for future pandemic responses.

Epidemiology of pediatric trauma during the coronavirus disease-2019 pandemic

“…Although some reports have described decreases in pediatric trauma volumes during the COVID-19 pandemic,[ [6] , [7] , [8] , [9] , 15 ] we found overall rates of pediatric trauma activations in LA County did not change significantly compared to the pre-pandemic period. After the California statewide stay-at-home order on March 19 th , 2020, in LA County there were 3 additional dates in 2020 when pandemic control measures were substantially changed.…”

Impact of the COVID-19 Pandemic on Trauma Encounters

“…Many other studies regarding trauma have found similar increases in penetrating trauma. Southern California 24 penetrating trauma increased from 10.3% to 13.0%, A Los Angeles County study 20 separately identified increase in penetrating trauma 15.4% to 15.7%, Philadelphia 19 penetrating trauma increased 17.5% to 23.7%, and San Francisco 16 violence related injuries increased 17% to 46%. This study identified a concurrent decrease in blunt trauma accompanying the increased proportions of penetrating trauma which is similar to previous studies.…”

Violent trauma as an indirect impact of the COVID-19 pandemic: A systematic review of hospital reported trauma

“…Notably, Philadelphia, a major urban city with high pre-COVID rates of violence and which was reported on by three studies, reflected a consistent increase in the proportion of violent trauma regardless of duration at two weeks 19 or 119 days 22 (of note: the third study, with duration of 41 days, found no change in violent trauma when assessment was limited to non-accidental pediatric trauma). 37 It was beyond the scope of this work to establish and assess, per city included in this study, a rating of "high" versus "low" pre-COVID violent trauma burden.…”

“…Of these two, one study was limited to examination of cases of pediatric non-accidental trauma. 37 Of the four remaining US-based studies, ranging from 71 -181 days, three found no change in violent trauma 22,32,39 and one found increased incidence. 27 Among the nine studies that statistically examined changes in violent trauma (duration 13 -90 days), only the longest study, Salzano and colleagues, noted a decrease in violent trauma.…”

“…Neither study assessed changes in violent trauma statistically. 35,36 The majority of studies were based in urban locations, with heavy bias towards high-income countries, including the United States (n=14), [17][18][19]22,[27][28][29][30][31][32][33][37][38][39] Australia (n=2), 23,34 and Western Europe (n=18). 20,21,24,26,[40][41][42][43][44][45][46][47][48][49][50][51][52][53] Records were examined visually via placement of study results onto a world map.…”