Impact on polytrauma patient prehospital care during the first wave of the COVID-19 pandemic: a cross-sectional study

In December 2019, an infectious outbreak of unknown aetiology was detected in Wuhan, Hubei Province, China. It has been identified as the agent that caused the outbreak of a novel coronavirus, SARS-CoV-2 [1]. On 11 March 2020, the World Health Organization (WHO) declared the outbreak of coronavirus SARS-CoV-2 an international public health emergency affecting more than 4.5 million people, having caused more than 14,510 deaths [2]. By early July 2020, Spain had recorded more than 249,000 cases and 28,000 deaths [3].

The extraordinary health situation caused by the pandemic has changed many routine healthcare criteria, protocols and strategies. The gap between the demand for and the availability of resources, the need for healthcare teams to self-protect and the logistical difficulties resulting from the saturation of the emergency care system have had a major impact on many healthcare processes in emergency departments [4]. The intensity of the outbreak in certain regions and overwhelmed emergency services and critical care units may affect healthcare provided to other pathologies. The system has been under such strain that it has been difficult to offer a similar response to the period prior to the pandemic, even for pathologies with well-established circuits such as the treatment of time-dependent pathologies like acute myocardial infarction [5] or stroke [6].

Difficulties at coordination centres, call overload, patients’ fear of contagion, and the essential use of personal protective equipment, have come to alter some emergency medical system (EMS) procedures [7‐9] including time-dependent pathology circuits: activation codes [10].

Since 2011, in Catalonia attention to severe trauma patients has been regulated by a specific procedure involving prehospital care and emergency departments of hospitals in Catalonia [11, 12]. The process involves a high degree of coordination and communication between the healthcare team, the health coordination centre and the referral hospital. Having identified the severity of the patient, he or she is prioritized according to specific treatment needs and is transferred to the optimum centre to provide a definitive response.

The impact of the pandemic on healthcare for time-dependent pathologies and on the chain of healthcare given to the polytrauma patient is not well established. However, new studies have emerged in recent weeks [13]. Given the declared state of emergency and restricted mobility, it was considered timely, as an objective of the study, to analyse the differences in the epidemiological and clinical profiles of prehospital polytrauma patients between the months of February and May 2020, compared to the same period for the previous year.

The study included 3023 polytrauma patients treated by the EMS in Catalonia. During the 2019 study period, 2045 (67.6%) patients were treated; however, during the pandemic period, 978 (32.4%) patients were treated, representing a 52% decrease (p = 0.002). Figure 1 shows a reduction of patients treated per fortnight that is most pronounced from 15 March 2020 onwards, coinciding with the start of lockdown on 14 March.

Regarding the epidemiological characteristics of the sample, 71.5% were male and the most common age group was 31–50 years (37.7%) with a mean age of 40.3 (SD 18.9 years), as set out in Table 1. Of the entire sample, 8.1% were under 18 years of age. There were no changes in 2020 in terms of mean age or gender. The number of cases was proportional to the regional population, i.e., 60% originated in the Barcelona health region, 10.4% in Girona, 9% in Tarragona, and 4.5% in Lleida.

Road traffic accidents decreased abruptly at the start of lockdown (14 March 2020), falling by 22.7% (61.8% before and 39.1% after lockdown; p < 0,001). However, unlike road traffic accidents, vehicle–pedestrian collisions decreased throughout the pandemic period (p = 0.043). An increase in accidents caused by weapons (p = 0.031) and burns (p = 0.007) was also noted, especially in the home in 2020 (24.3% in 2019 vs 46.1% in 2020; p = 0.016). Finally, a rise in traumatic falls was noted exclusively after the onset of lockdown.

Table 2 shows the types of accident in the total sample and the different periods of the study. The number of traffic accidents decreased from 1211 (59.2%) to 522 (53.4%), and pedestrian-vehicle collisions fell from 249 (12.2%) to 92 (9.4%). Regarding injuries caused by weapons and burns, there was an increase in the percentage of cases [43 (2.1%) vs 41 (4.2%) and 15 (0.7% vs 22 (2.2%), p = 0.002 and p < 0.001, respectively].

The number of polytrauma patients treated in Catalonia decreased significantly during the COVID-19 pandemic. However, the severity of their injuries did not. Even during the post-lockdown period, from May 2020 onwards, the figures did not approach those of the previous year, in line with other studies that describe a fall of up to 44% [14]. Road traffic accidents, including vehicle–pedestrian collisions, decreased significantly due to the mobility restrictions in force during this period [15]. Such a decrease has also been described in the paediatric population in Canada, where injuries due to road traffic accidents virtually disappeared during the COVID period [16]. Despite the decrease in the number of injuries during the initial phase of the pandemic, patient severity increased. This has also been described in Germany [17]. The percentage of more severe physiological variables and critical anatomical areas, identified as priorities 0 and 1, increased.

Series published in the United Kingdom revealed a decline in general traumatology of up to 26%, but without undergoing an increase in the percentage of more severe patients [18]. The increase in the number of severe patients may be related to the greater occurrence of potentially severe injuries, such as injury to the head, pelvis and spine.

No differences are observed in patients’ epidemiological profile, the most frequent patient remaining a middle-aged male involved in a road traffic accident [19].

The first wave of the pandemic posed a challenge to the teams involved in prehospital care, as they had to adapt to the changing typology of the persons notifying and patients. An increase was observed in the allocation of BLS units to trauma patients. ALS units were increasingly occupied with providing home care to patients infected with SARS-CoV-2. This was also described in the research conducted by Laukkanen et al. [20].

There was a notable increase in patients treated for weapon wounds and burns, especially in the home, and an increasing incidence of traumatic falls. This increase in weapons wounds and burns in the home cannot be ruled out as being related to an increase in cases of gender-based violence [21]. Regarding the increase of fall patients during lockdown, its association with suicide attempts cannot be ruled out either [22, 23]. This may be associated with the increase in patients treated with mental health disorders during the study period, and hence further studies will be required. Further studies would require conducting and further evidence is needed.

Diagnoses have changed little for all priorities, with head injury involving loss of consciousness as the leading cause among the most severe patients (Fig. 2).

In respect of healthcare provision times, there were no differences between the two periods, which shows that, despite the complexity of providing healthcare, times attending to patients went unchanged. This key aspect was not observed in the provision of healthcare to time-dependent pathologies, such as stroke, which has undergone increased delays in first aid and increased complications [24]. Other studies on trauma patients focus on the impact of the pandemic on the reorganization undergone by hospitals, without addressing the prehospital phase of the healthcare pathway [25].

The main limitation of this study is that it only includes information supplied by prehospital care (EMS), apart from hospital mortality. We do not dispose of data on hospital length of stay, ICU admissions and hospital diagnoses upon discharge. Moreover, we cannot rule out selection bias, since patient inclusion depends on the implementation of the polytrauma code by the professional attending to the patient. However, its main strength is that we have collected data from all out-of-hospital polytrauma events occurring within Catalonia because the EMS covers the entire territory.

The study allows concluding that the pandemic caused a sharp decline in polytrauma events in our region, especially due to a decrease in the number of road traffic accidents as a result of mobility restrictions, and led to an increase in other types of accidents, mainly violent assaults, burns and falls. The profile of patients has changed as they present with increased severity and injuries to the head-spine and pelvis. Finally, despite the difficulties in attending to time-dependent pathologies, quality standards relating to the delay times throughout the prehospital healthcare pathway were maintained.