Traumatology

The impact of SARS and COVID-19 on major trauma in Hong Kong

a b s t r a c t

Background: The coronavirus disease 2019 (COVID-19) pandemic has been enormously disruptive and harmful to people around the world, but its impact on other illnesses and injuries has been more variable. To evaluate the ramification of infectious disease outbreaks on major traumatic injuries, we compared changes in the incidence of major trauma cases during the 2003 severe acute respiratory syndrome (SARS) period with COVID-19 in 2020.

Methods: Data were analyzed from the trauma registry of a major, tertiary-care teaching hospital in Hong Kong. Patients presenting with major traumatic injuries during the first six months of 2001-03 and 2018-20 were re- trieved for analysis. Patient characteristics, injury mechanism, admitting service, and emergency department (ED)/hospital lengths of stay (LOS) were recorded. Raw and adjusted survival rates (using the modified Trauma Injury Severity Score (TRISS)) were recorded.

Results: The number of trauma cases fell dramatically during 2003 and 2020 compared with previous years. In both 2003 and 2020, the number of trauma registry patients fell by 49% in April (compared to the preceding ref- erence years of 2001/02 and 2018/19, respectively). Patient characteristics, treatments, and outcomes were also different during the outbreak years. Comparing 2003 to 2020 relative to their respective reference baselines, the percentages of injuries that happened at home, patients without co-morbidities, and patients’ mean age all in- creased in 2003 but decreased in 2020. Work-place injuries drastically dropped in 2003, but not in 2020. Average ED LOS dropped in 2003 by 36.4 min (95% CI 12.5, 60.3) but declined by only 14.5 min (95% CI -2.9, 32.1) in 2020. Both observed and expected 30-day mortality declined in 2020 vs. 2003 (observed 4.5% vs. 11.7%, p = 0.001, OR 0.352, 95% CI 0.187, 0.661) (expected 4.5% vs 11.6%, p = 0.002, OR 0.358, 95% CI 0.188, 0.684).

Conclusion: Major trauma cases dropped by half during both the peak of the 2003 SARS and 2020 COVID-19 pan- demics in Hong Kong, suggesting a trend for future pandemic planning. If similar findings are seen at other trauma centers, proactive personnel and resource allocations away from trauma towards medical emergency systems may be more appropriate for future pandemics.

(C) 2021

  1. Introduction

The coronavirus disease 2019 (COVID-19) outbreak is a worldwide pandemic, with tens of millions diagnosed with Severe Acute Respira- tory Syndrome Coronavirus Two (SARS-CoV-2) and over a million peo- ple dying [1]. The COVID-19 pandemic has been enormously disruptive

* Corresponding author at: Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, 2/F, Main Clinical Block and trauma centre, Prince of Wales Hospital, Shatin, New Territories, Hong Kong.

E-mail address: [email protected] (J.H. Walline).

1 Joseph Harold Walline and Kevin Kei Ching Hung contributed equally to this work (co-first authors).

and harmful to people around the world, but its impact on rates of other illnesses and injuries has been more variable.

Many have worried about increased rates of domestic violence [2,3] and Mental illness [4,5], but anecdotal evidence suggests that various specialties are experiencing lower than usual caseloads. For example, Baracchini et al. found a lower incidence of acute strokes during the ini- tial Covid-19 outbreak in Italy. But the severity of these cases was higher, likely because concern for SARS-CoV-2 exposure led patients to wait longer before seeking treatment [6]. Likewise, Tam et al. showed that overall rates of ST-segment elevation myocardial infarctions (STEMI) decreased in Hong Kong, although the time needed to care for these patients dramatically increased, suggesting there were ineffi- ciencies in the system created by the response to COVID-19 [7]. We re- cently documented 37% fewer patients seen (year-on-year) in Hong

https://doi.org/10.1016/j.ajem.2021.02.030

0735-6757/(C) 2021

Kong Emergency Departments (EDs) between February and April of 2020 (and 24% fewer overall cases in the first half of 2020 in our own ED), confirming a large reduction in total ED patient volume [8].

Although Balogh et al. have claimed that there are no active practic- ing clinicians with previous pandemic experience and that “the effects of the pandemic on trauma care and injury epidemiology are completely unknown” [9], this is not the case in Hong Kong. Clinicians in Hong Kong experienced the full brunt of the SARS epidemic in 2003, which infected over 8000 individuals in 29 countries with a case fatality rate of nearly 10% [10]. Our institution was hit particularly hard by SARS, treating the city’s first local case in March 2003 which ul- timately infected over 100 hospital staff and students [11]. With a longstanding trauma registry dating from before the SARS epidemic, data from our institution provides a useful comparison for understand- ing the effects of widespread infectious outbreaks on trauma rates. Re- cent studies based on preliminary COVID-19 data have suggested reductions in patient volume at trauma centers in different areas of the world. Leichtle et al. identified a 43% decline in trauma cases at a sin- gle center in the USA in 2020 compared to 2018/19, and also found a higher injury severity score and a shorter length of stay (LOS) [12]. Pintado et al. found an 80% reduction in a Peruvian trauma service at the height of the COVID-19 pandemic in April 2020 (even as overall hos- pital admissions declined only 30%), and noted a non-uniform reduction in certain types of trauma cases (e.g. osteoporotic Hip fractures in- creased as a proportion of overall trauma cases) [13]. Nabian et al. looked at pediatric trauma at a center in Iran during the COVID-19 pan- demic and found a 50% decrease in cases, but no statistically significant change in mechanism [14].

Drawing on evidence from our trauma registry to analyze data dur- ing the COVID-19 pandemic in comparison to SARS, this study provides a more comprehensive, comparative examination of whether and in what ways pandemics have changed rates of major trauma in Hong Kong. We hypothesized that there would be both absolute and relative differences in the numbers of trauma patients presenting in the spring of 2003 and 2020 compared to the two years prior to each pandemic year. By identifying the impacts of COVID-19 and SARS on traumatic in- jury at our trauma center in Hong Kong, we hope to enable better evidence-based predictions for trauma center services and staffing to prepare for future pandemics.

  1. Methods

This was a retrospective study of prospectively collected data from an established trauma registry of a major, tertiary-care teaching hospital and designated trauma center in Hong Kong. We searched for patients presenting with major traumatic injury during the six months between January 1, 2020 and June 30, 2020. January 1, 2020 was the day after the People’s Republic of China informed the World Health Organization of the new virus outbreak in Wuhan, Hubei Province [15]. Although the COVID-19 pandemic has continued through 2020, this comparative paper focuses on the first six-month period of each analysis year in order to align with the 2003 SARS outbreak (which started in Hong Kong in February and tapered off by June of that year). We examined the 2020 trauma registry data in comparison to the corresponding reg- istry data from the same time periods for the previous two years (2018 and 2019). Finally, we compared the 2018-2020 data to corresponding data from 2001 to 2003, which included the spring 2003 outbreak of SARS.

    1. Inclusion criteria

All patients presenting with major traumatic injury to the hospital who were entered into our institution’s trauma registry between Janu- ary 1, 2020 and June 30, 2020 were included in the analysis. Data from the trauma registry during the same six-month period in 2001-2003 and 2018-2019 were also collected for statistical comparison. The

trauma registry only included “major trauma cases,” defined as cases of trauma presenting enough threat to life or limb to warrant activation of the trauma team according to an established set of criteria [16]. Major trauma in this study was not restricted to those with an injury severity score (ISS) of 15 or above; rather, the definition was based on inclusion in the hospital major trauma database.

    1. Data processing and analysis

The primary outcome measure was the absolute number of major trauma patients seen between January 1 and June 30, 2020 compared to the same period in 2001, 2002, 2003, 2018, and 2019. The secondary outcome measures included: injury mechanism (e.g. falls, Motor vehicle collisions), nature of traumatic injury (penetrating vs. blunt trauma), lo- cation of injury (home, work-place injury)), as well as any differences in patient characteristics (e.g. age, gender). We also examined rates of pa- tient comorbidities, body part injured, blood component transfusion history in the first 24-h, admitting specialty, and whether a surgical op- eration was performed. LOS for the ED, intensive care unit (ICU) and hospital, as well as the raw and adjusted mortality for trauma patients were recorded for the period studied. For Expected mortality, we used a modified Trauma Injury Severity Score (TRISS) [17,18] and defined ex- pected mortality as TRISS Ps < 0.5.

    1. Statistical analysis

Chi-square and Fisher’s exact tests were used for categorical data while t-tests were used to compare means of continuous variables. A p-value <0.05 was considered statistically significant. An analysis of the data set was conducted for the six months of data in 2003 and 2020 compared to each other and to the first six months of the two years immediately preceding the year in question (i.e. 2001 and 2002 for 2003; 2018 and 2019 for 2020).

This study was approved by our clinical ethics review board on April 23, 2020.

  1. Results

Unadjusted trauma volume numbers are presented in Table 1, pa- tient and injury characteristics are shown in Table 2, and a visual repre- sentation of trauma cases by month in 2001-2003 and 2018-2020 can be seen in Fig. 1. We see that in both April 2003 and April 2020, there was a 49% decrease in overall trauma cases compared to an average of the preceding two years, respectively. Overall, in the first six months, there was a 14% decrease in major trauma cases in 2003 and a 16% de- crease in 2020.

    1. 200102 vs 2003

Compared to 2001-02, data from 2003 (the SARS outbreak year) demonstrate several statistically significant changes. The mean age of patients increased from 38.8 to 42.2 years (p = 0.037, mean difference 3.4, 95% CI 0.2, 6.6). Median ISS decreased from 8 in 2001-02 to 6 in 2003. There was a statistically significant (p = 0.032) change in the lo- cation of major trauma cases, with cases occurring at home increasing from 17.3% to 21.2%), while road-traffic injuries decreased from 57.6% to 49.8%. Cases involving work-place injuries fell from 16.5% to 5.6% (p < 0.001) OR 0.301, 95% CI 0.164, 0.550. Secondary transfers also de- creased from 17.5% to 10% (p = 0.008) OR 0.522, 95% CI 0.322, 0.848,

and more patients were healthy pre-injury with no co-morbidities (78.0% to 86.3%, p = 0.031). Finally, ED LOS dropped from 144.3 to

107.9 min (p = 0.003, reduction by 36.4 min, 95% CI 12.5, 60.3). There were no other statistically significant differences in causes of trauma, ISS, or injury location.

Table 1

Trauma patient volume, 2001-03 and 2018-20.

Month

2001

2002

2001-02 average

2003

% reduction (2003 vs. 2001-02)

2018

2019

2018-19 average

2020

% reduction (2020 vs. 2018-19)

Jan

43

53

48

51

6%

84

68

76

77

1%

Feb

34

31

32.5

44

35%

64

77

70.5

65

-8%

Mar

36

41

38.5

23

-40%

65

76

70.5

50

-29%

Apr

34

71

52.5

27

-49%

79

89

84

43

-49%

May

38

56

47

44

-6%

77

90

83.5

69

-17%

Jun

45

56

50.5

42

-17%

56

83

69.5

78

12%

Total

230

308

269

231

-14%

425

483

454

382

-16%

Note: numbers are for January 1 to June 30, inclusive, for each year.

    1. 201819 vs 2020

Compared to the same periods in 2018-2019, the first six months of 2020 showed a statistically significant (p = 0.007) increase in percent- age of road-traffic collisions from 44.2% to 51.1% and a decrease in the fraction of incidents at home from 31.3% to 26.2%. There was also a sta- tistically significant drop in the rate of secondary transfer (23.8% vs. 29.3%, p = 0.045) OR 0.755, 95% CI 0.573, 0.994. Only 50.9% (p =

0.007) of trauma patients were healthy pre-injury with no co- morbidities, and the median ISS increased from 9 in the previous two years to 10 in 2020. There were no other statistically differences.

    1. Effect of pandemics on trauma epidemiology

Comparing 2003 to 2020 relative to their 2001-02 and 2018-19 comparisons, we see some noteworthy similarities and differences. The percentage of injuries that happened at home increased in 2003 but decreased in 2020 compared to pre-pandemic years. The percentage of healthy patients without co-morbidities had a statistically significant increase in 2003 but decreased in 2020. Median ISS decreased in 2003 but increased in 2020 (from 6 to 10, p < 0.001).

Other differences were noT inversions, but rather, of degree. There was no statistically significant increase in mean age or percent of pa- tients who were male in 2020 as there was in 2003. Work-place injuries drastically dropped in 2003, but only a non-statistically significant re- duction was seen in 2020. Average ED LOS dropped in 2003 by

36.4 min (95% CI 12.5, 60.3) but declined by only 14.5 min (95% CI

-2.9, 32.1) in 2020.

Looking at the ED and the in-hospital course for major trauma pa- tients, we continue to see statistically significant differences between the pandemic years (see Table 3: ED and Hospital Treatment). In 2003 compared to 2001 and 2002, there was a statistically significant reduc- tion in trauma patients who required an operation (29.9% vs. 38.1%, p = 0.029) OR 0.692, 95% CI 0.497, 0.963. There were no other statisti- cally significant differences in admitting specialty, intensive care unit admission, ICU LOS, or blood transfusion during the first 24 h.

Looking at 2020 compared to 2018 and 2019, there was a non- significant trend towards fewer neurosurgical and more orthopedic ad- missions. There was a statistically significant increase in the percentage of cases needing an operation from 29.6% to 38.7% (p = 0.001) OR 1.502, 95% CI 1.170, 1.930. There was also a statistically significant drop in ICU LOS from 5.1 to 3 days (p = 0.022) mean difference 2.0, 95% CI 0.3, 3.8, and in the use of fresh frozen plasma during a patient’s first 24 h

Table 2

Trauma patient and injury characteristics.

2001-02

n = 538

2003

n = 231

P value

2018-19

n = 908

2020

n = 382

P value

P value

2003 vs. 2020

Age

Mean (SD)

38.8

20.6

42.2

20.6

0.037?

52.4

24.5

53.0

23.9

0.684

<0.001?

Sex

Male

374

69.5%

162

70.1%

0.865

599

66.0%

257

67.3%

0.650

0.462

Injury place

Home

93

17.3%

49

21.2%

0.032?

283

31.3%

99

26.2%

0.007?

<0.001?

Road

310

57.6%

115

49.8%

400

44.2%

193

51.1%

Industrial/construction site

40

7.4%

31

13.4%

108

11.9%

27

7.1%

Parks or sports ground

22

4.1%

11

4.8%

77

8.5%

45

11.9%

Others

73

13.6%

25

10.8%

37

4.1%

14

3.7%

Work-place injury

89.0

16.5%

13

5.6%

<0.001?

171

18.8%

61

16.0%

0.221

<0.001?

Cause

Traffic related

259

48.1%

100

43.3%

0.557

248

27.3%

127

33.2%

0.158

<0.001?

High fall

70

13.0%

36

15.6%

50

5.5%

17

4.5%

Low fall

92

17.1%

43

18.6%

406

44.7%

170

44.5%

Burn

17

3.2%

11

4.8%

68

7.5%

23

6.0%

Others

100

18.6%

41

17.7%

136

15.0%

45

11.8%

Secondary transfer

94

17.5%

23

10.0%

0.008?

266

29.3%

91

23.8%

0.045?

<0.001?

ISS

Median (IQR)

8

16

6

15

0.659

9

17

10

15.5

0.132

<0.001?

Blunt/penetrating/burn

Blunt

494

91.8%

207.0

89.6%

0.447

789

86.9%

345

90.3%

0.182

0.432

Penetrating

28

5.2%

13.0

5.6%

53

5.8%

14

3.7%

Burn

16

3.0%

11.0

4.8%

66

7.3%

23

6.0%

Comorbidity

Healthy

387.0

78.0%

182.0

86.3%

0.031?

482

53.9%

191

50.9%

0.007?

<0.001?

ill non limit

90.0

18.1%

22.0

10.4%

325

36.3%

160

42.7%

ill limit

19.0

3.8%

7.0

3.3%

62

6.9%

23

6.1%

ill severe

0.0

0.0

26

2.9%

1

0.3%

AIS head or neck

3 or more

132.0

24.5%

60.0

26.0%

0.673

358

39.4%

159

42.1%

0.380

<0.001?

AIS face

12

2.2%

5.0

2.2%

0.955

9

1.0%

7

1.9%

0.205

0.788

AIS thorax

73.0

13.6%

29.0

12.6%

0.704

93

10.2%

46

12.2%

0.311

0.888

AIS extremities

96.0

17.8%

32.0

13.9%

0.173

114

12.6%

48

12.7%

0.944

0.682

AIS abdominal

36.0

6.7%

18.0

7.8%

0.584

35

3.9%

15

4.0%

0.923

0.043?

AIS external

19.0

3.5%

10.0

4.3%

0.595

23

2.5%

6

1.6%

0.298

0.040?

ED LOS

Minutes, mean (SD)

144.3

240.9

107.9

95.4

0.003?

156.9

172.5

142.4

132.8

0.102

<0.001?

Fig. 1. Changes in the Number of Trauma Registry Patients by Month (2001-03 and 2018-20).

50

JAN FEB MAR APR MAY JUN

62.7 (45.7-79.6) 52.5 (32.8 – 72.2) 48.5 (28.1 – 68.9) 57.2 (30.1 – 84.2) 62.3 (41.4 – 83.3) 60 (42.2 – 77.8)

MONTH MEAN (95% CI)

56

44

34

31

44

41

36

23

43

34

45

42

38

27

69

56

64

79

71

76

65

83

78

89

77

65

68

53

51

43

90

77

84

77

100

90

80

70

60

50

40

30

20

10

0

2001 2002 2003 2018 2019 2020

from 2.2% to 0.5% (p = 0.033) OR 0.234, 95% CI 0.054, 1.005. There were

no other statistically significant differences in admitting specialty, ICU admission, or blood transfusion during the first 24 h.

The final outcomes for major trauma patients are listed in Table 4: 30-day Mortality and Outcomes. 2003 (relative to 2001-02) saw a sta- tistically significant decrease in overall hospital LOS from 10.4 to

7.4 days (p = 0.022) (mean difference 3.0, 95% CI 0.4, 5.6), but there was no other statistically significant change in 30-day mortality, ex- pected mortality, discharge disposition, discharge GCS, or discharge complication rates.

In 2020, there was a statistically significant change in 30-day outcomes (p = 0.009). Fewer patients were discharged home within 30-days (68.1% vs. 73.6%), while more patients were transferred to a rehabilitation facility (20.4% vs. 13.1%).

    1. Changes between 2001 and 03 and 201820

Both observed and expected 30-day mortality rates declined in 2020 compared to 2003 (4.5% vs. 11.7%, p = 0.001, OR 0.352, 95%

CI 0.187, 0.661). Comparing the absolute numbers of cases between 2001 and 03 and 2018-20, we see that overall numbers of trauma pa- tients increased by 60% over the past 20 years (769 to 1290). Average age increased by 13.6 years (from 38.8 years (2001-02) to

52.4 years (2018-19), p = 0.001, mean difference 13.6, 95% CI 11.1, 16.0). Percent of injuries happening at home almost doubled from 17.3% (2001-02) to 31.3% (2018-19). The percentage of patients who were male did not change over the past 20 years (relatively con- stant around 70%). Although the percentage of all trauma cases caused by road-traffic injuries did decrease, the absolute number of

NUMBER OF TRAUMA CASES

Table 3

ED and hospital treatment.

2001-02

n = 538

2003

n = 231

P value

2018-19

n = 908

2020

n = 382

P value

P value

2003 vs. 2020

Admission specialty

Neurosurgery

168

31.2%

69

29.9%

0.111

360

39.6%

145

38.0%

0.059?

<0.001?

Orthopedics

147

27.3%

75

32.5%

244

26.9%

111

29.1%

Gen Surgery + ENT + PS + urology

80

14.9%

32

13.9%

56

6.2%

26

6.8%

Burns

16

3.0%

8

3.5%

46

5.1%

12

3.1%

Cardiothoracic surgery

14

2.6%

3

1.3%

26

2.9%

15

3.9%

Emergency Medicine

104

19.3%

42

18.2%

154

17.0%

53

13.9%

Others

9

1.7%

0

22

2.4%

20

5.2%

Operation

205

38.1%

69

29.9%

0.029?

269

29.6%

148

38.7%

0.001?

0.026?

ICU

yes

69

12.8%

22

9.5%

0.194

153

16.9%

79

20.7%

0.102

<0.001?

ICU LOS

mean among yes, mean (SD)

6.6

8.8

7.6

13.6

0.681

5.1

8.4

3

5

0.022?

0.138

HDU

Yes

0

3

1.3%

0.008?

86

9.5%

24

6.3%

0.060?

0.004?

HDU LOS

mean among yes, mean (SD)

NA

6

2.6

3.2

3.9

2.5

2.2

0.441

0.019?

24 h RBC

Yes

30

5.6%

12

5.2%

0.831

56

6.2%

19

5.0%

0.403

0.904

mean among used, mean (SD)

8.70

9.2

12.0

14.3

0.379

4.2

5.1

3.3

4.0

0.498

0.063

24 h FFP

Yes

12

2.2%

7

3.0%

0.512

20

2.2%

2

0.5%

0.033?

0.012?

mean among used, mean (SD)

11.2

8.0

16.6

14.6

0.309

7.2

6.1

6.0

0

0.787

0.362

24 h platelet

Yes

9

1.7%

6

2.6%

0.395

26

2.9%

7

1.8%

0.284

0.524

mean among used, mean (SD)

13.2

8.4

15.5

9.2

0.627

7.0

6.6

4.6

2.5

0.350

0.032?

Table 4

30-day mortality and outcomes of trauma patients.

2001-02

n = 538

2003

n = 231

P value

2018-19

n = 908

2020

n = 382

P value

P value

2003 vs. 2020

30-day mortality

Crude

61

11.3%

27

11.7%

0.889

60

6.6%

17

4.5%

0.135

0.001?

Expected (TRISS) Ps < 0.5

57

11.2%

26

11.6%

0.902

53

6.3%

16

4.5%

0.211

0.001?

30-day outcome

Discharged home

368

70.1%

164

71.0%

0.572

668

73.6%

260

68.1%

0.009?

0.005?

Still in hospital

0

0

2

0.2%

0

Transferred to another acute-care hospital

7

1.3%

6

2.6%

19

2.1%

10

2.6%

Transferred to rehabilitation

89

17.0%

34

14.7%

119

13.1%

78

20.4%

Dead

61

11.6%

27

11.7%

71

7.8%

16

4.2%

Hospital LOS

Mean (SD)

10.4

22.8

7.4

13.3

0.022?

10.3

20.6

10.4

39.0

0.963

0.267

Discharge GCS

Median (IQR)

15

0

15

0

0.416

15

0

15

0

0.067

NA

Discharge complication severity scale

Critical

60

11.2%

27

11.7%

0.978

71

7.8%

15

4.0%

0.014?

<0.001?

Severe

1

0.2%

0

11

1.2%

3

0.8%

Serious

10

1.9%

4

1.7%

10

1.1%

4

1.1%

Moderate

12

2.2%

4

1.7%

16

1.8%

8

2.1%

Mild

26

4.8%

10

4.3%

88

9.7%

58

15.5%

None

429

79.7%

186

80.5%

710

78.4%

287

76.5%

* Statistically significant result, p < 0.05.

injuries were nearly identical between the two non-pandemic pe- riods examined (259 (2001-02) vs. 248 (2018-19)). Both the abso- lute number and overall percentage of all trauma caused by high falls (a common method of suicide in Hong Kong) decreased. Per- centages of trauma caused by blunt, penetrating, or burn causes remained relatively constant over time. ED LOS overall was longer in 2018-19 than in 2001-02, and the drop in ED LOS was not statis- tically significant during 2020 compared to 2003.

  1. Discussion

The COVID-19 pandemic, like SARS before it, has had a major impact on trauma cases in Hong Kong. Our study is the first to examine changes in major trauma during both coronavirus outbreaks. Strikingly, we found an identical 49% decrease in major trauma cases in April 2003 and April 2020, which corresponds to peaks in hospitalizations of coronavirus-infected patients during both pandemics in Hong Kong (April 2003 and April 2020) [19]. Overall, there was a 14% and 16% de- crease overall for the first six months of 2003 and 2020, respectively, as compared to a 24% decrease in general ED cases in 2020 [8]. Both raw and adjusted 30-day mortality rates had a statistically significant decline in 2020 compared to 2003 (4.5% vs. 11.7%, p = 0.001), but this is likely a reflection on non-pandemic changes since these mortality rates were in-line (and without a statistically significant difference) from pre-pandemic rates in the two years prior.

In addition to a lower absolute number of major trauma patients during the two pandemic periods, we also found that the percentage of injuries that happened at home increased in 2003 but decreased in 2020 compared to pre-pandemic years. This drop in 2020 is surprising, given the extensive social distancing regulations implemented by the Hong Kong government to control infection transmission, including work from home mandates, school and industry-specific business clo- sures, and restrictions on public gatherings. The higher proportion of major trauma cases occurring outside the home suggests that people in the COVID-19 era may be engaging in more sedentary activities or spending less time at home compared to during the SARS outbreak – which both pose challenges for public health. The percentage of trauma patients with co-morbidities decreased in 2003, but increased in 2020, suggesting that sicker patients overall continued to seek care in 2020. Mean age, number of work-place injuries, and ED LOS did not change in 2020 as it did in 2003. The increase in ED LOS in 2018-2020 may be due to the implementation of ED-based Computed Tomography (CT) scanning beginning in 2004-05; a patient who previously would have transferred out of the ED to obtain a CT before going to the ward or ICU now remained an ED patient for a longer period of time.

Although COVID-19 is still affecting most countries around the world, preliminary studies are beginning to emerge that examine the impact of the pandemic on patient volumes and caseloads in different locations. Articles on trauma care during COVID-19 so far have focused on how to limit viral transmission while still maintaining trauma ser- vices [20]. We documented decreases of over 30% in overall ED patient visits to our hospital and others around Hong Kong during the peak of COVID-19 [8]. Although not to the same degree as Pintado et al. [13] found in Peru, we found that our major trauma cases also dropped more than our overall ED patient volume (49% vs. 34%) in the month fol- lowing the announced pandemic (although this reversed when looking at all six months). Finally, while Boserup et al. found a decrease in the percentage of motor vehicle collisions during COVID-19 in multiple cit- ies in the USA, we found a statistically significant increased percentage of such trauma cases [21].

Looking beyond pandemics, we also identified some intriguing trends for trauma care in Hong Kong that offer important points of com- parison for other urban centers around the world. As our analysis un- covered, mortality rates from our trauma registry have been halved over the past 20 years. This is despite finding that the average age of trauma patients has increased faster than the general population – increasing by 13.6 years between 2001 and 2020 compared to an 8.6- year increase in the median age in Hong Kong during the same time- frame [22]. The reduced mortality is also striking given we also found that more trauma patients had pre-existing co-morbidities (49.1% in 2020 vs. 13.7% in 2003, p < 0.001), which is likely related to the increas- ing average age of Hong Kong trauma patients. The absolute numbers of major trauma caused by road traffic collisions remained nearly un- changed over 20 years, despite a growing and aging population, sug- gesting effective Safety measures have been enacted to improve road safety and stabilize the number of serious cases. Finally, despite their frequency in sensational news coverage [23], high falls (often suicidal) in our trauma registry have decreased over the past 20 years.

  1. Limitations

This was a single-center study of prospectively acquired trauma data. Although the trauma registry is a robust repository for trauma- related data at our institution, it is limited to only major trauma cases. This study did not examine minor traumatic episodes, and so should not be considered representative for all trauma cases at our institution or for Hong Kong. Additionally, this study was limited to the first half of 2020, and broadening the study to examine the full years of 2001-03 and 2018-2020 may change some of the comparative results. However, as our primary interest was in comparing major trauma

during the SARS and COVID pandemics, and SARS was eliminated in Hong Kong by June 2003, we decided to limit this study to the first six months of all years included.

  1. Conclusion

Major trauma cases dropped 49% at the April hospitalization peaks of both the SARS and COVID-19 pandemics in Hong Kong compared to the two years before each pandemic. Both the percentage of injuries that happened at home and the percentage of healthy patients without co- morbidities increased during SARS but decreased during COVID-19.

While COVID-19 and SARS have generated serious public health challenges, the reduction in major traumatic injuries that we docu- mented during both outbreaks in Hong Kong could be considered a ‘sil- ver lining’ for hospital care during pandemics. preliminary reports from other locales during the COVID-19 pandemic have described the shift of surgical trainees and consultants from their base specialties into ICU and COVID-19 wards – for example, Orthopedic surgeons in the U.K. super- vising proning teams for ventilated ICU patients with refractory hypoxia [24]. If more comprehensive trauma registry data from other sites con- firm our findings, proactive personnel redeployment away from trauma towards medical emergency care may be warranted in the face of future pandemics.

Availability of data and materials

Data is available from the corresponding author upon reasonable request.

Informed consent, Ethical approval, and Human rights

The authors affirm that: the study was approved by the Joint Chinese University of Hong Kong – New Territories East Cluster Clinical Research Ethics Committee (CRE Ref. No. 2020.212) on April 23, 2020.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author statement

We confirm that there is no overlap with previous publications, and we confirm that the manuscript, including related data, figures, and ta- bles, has not been published previously and that the manuscript is not under consideration elsewhere. We also confirm that all authors have made substantial contributions to all of the following: (1) the concep- tion and design of the study, or acquisition of data, or analysis and inter- pretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.

CRediT authorship contribution statement

Joseph Harold Walline: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. Kevin Kei Ching Hung: Meth- odology, Formal analysis, Writing – review & editing, Visualization. Janice Hiu Hung Yeung: Data curation, Writing – review & editing. Priscilla P. Song: Writing – review & editing. Nai-Kwong Cheung: Re- sources, Data curation. Colin A. Graham: Writing – review & editing, Supervision.

Declaration of Competing Interest

None.

Acknowledgements

We would like to thank Prof. Marc Ka-Chun Chong for his statistical insights on this project.

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