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Injury 51 (2020) 1414–1418 Contents lists available at ScienceDirect Injury journal homepage: www.elsevier.com/locate/injury Impact of the COVID-19 Pandemic on an Emergency Traumatology Service: Experience at a Tertiary Trauma Centre in Spain ✩ Jorge H. Nuñez a,b,c,∗, Andrea Sallent a,b, Kushal Lakhani a,b, Ernesto Guerra-Farfan a,b, Nuria Vidal a,b, Seper Ekhtiari d, Joan Minguell a,b a Department of Traumatology and Orthopedic Surgery, University Hospital of Vall d’Hebron. Barcelona, Passeig de la Vall d’Hebron, 119-129, 08035 Barcelona, Spain b Universitat Autónoma de Barcelona. Barcelona, Passeig de la Vall d’Hebron, 119-129, 08035 Barcelona, Spain c Department of Traumatology and Orthopedic Surgery, Mutua de Terrassa Hospital. Terrassa, Plaça del Doctor Robert, 5, 08221 Terrassa, Barcelona, Spain d Division of Orthopaedic Surgery, Department of Surgery, Mc Master University, Hamilton, Ontario, Canada a r t i c l e i n f o a b s t r a c t Article history: Introduction: The severe disruptions caused by the SARS-CoV-2 coronavirus have necessitated a redistri- Accepted 9 May 2020 bution of resources to meet hospitals’ current service needs during this pandemic. The aim of this study was to provide an overview of the impact of the pandemic, and its corresponding State of Emergency, on Keywords: a tertiary traumatology emergency service. Pandemic Methods: An observational study was performed at a tertiary hospital within the Spanish National Health trauma System. Four different periods were studied, including the first 20 days of Spain’s current State of Emer- hip fractures COVID-19 gency, from March 14 to April 02, 2020 (Period 4). This period was compared to the 20-day period prior to the State of Emergency (Period 3), and to matching periods in the two previous years (Periods 1 and 2). A total of 6,565 patient visits were analyzed: 1909 in Period 1 (29.1%), 2161 in Period 2 (32.9%), 1983 in Period 3 (30.2%), and 512 in Period 4 (7.8%). Variables collected included patient age and sex, insurance type, discharge destination and reason for hospital admission. Results: The patients’ mean age was 55.1 years old (Standard Deviation (SD): 22.1), and 51.8% were women (3495/6565). During the COVID-19 pandemic, there were significant reductions in total visits to the trauma emergency department, workplace accidents, traffic accidents and number of hospital ad- missions, particularly during Period 4. However, no statistically-significant differences were found in the number of osteoporotic hip fractures admitted between the four periods. The numbers of hospital admis- sions for osteoporotic hip fracture were 42 during Period 1, 41 during Period 2, 43 during Period 3 and 36 during Period 4. Conclusions: While most traumatological presentations decreased in frequency over the course of the outbreak, the number of osteoporotic hip fractures remained stable. Thus, contingency plans in times of crisis need to be carefully targeted, and to keep in mind certain public health issues that do not decrease, despite a State of Emergency, like osteoporotic hip fractures. © 2020 Elsevier Ltd. All rights reserved. Introduction emergency on January 20, 2020 by the World Health Organiza- tion (WHO) and a public health emergency by the United States Coronavirus disease 2019 (COVID-19), which began as an epi- of America (USA) on January 31, 2020. On March 11, 2020, the demic centered in Wuhan, China, was declared a public health WHO declared COVID-19 a pandemic, marking the first pandemic declaration since H1N1 in 2009. The early reported mortality rate, which was between 0.4 and 4.3%, appeared lower than that ✩ Despite reductions in the number of trauma emergency visits, workplace ac- of Severe Acute Respiratory Syndrome (SARS) and Middle East cidents, traffic accidents and number of hospital admission, the number of osteo- Respiratory Syndrome (MERS) [1,2]. Current estimates of mortal- porotic hip fractures remains stable. ity rate for COVID-19 are believed to be inaccurate, however, ∗ Corresponding author. with some believing they are underestimates, since most con- E-mail addresses: hassan2803med@gmail.com, j.nunez@vhebron.net (J.H. Nuñez). firmed patients remain as inpatients, and others believing they https://doi.org/10.1016/j.injury.2020.05.016 0020-1383/© 2020 Elsevier Ltd. All rights reserved. J.H. Nuñez, A. Sallent and K. Lakhani et al. / Injury 51 (2020) 1414–1418 1415 are overestimates, because mild and asymptomatic cases are not Statistical methods being included in the denominator [1,3]. Many different strate- gies have been proposed and implemented worldwide in an at- General descriptive analysis was conducted, overall and by pe- tempt to contain this pandemic, some more successful than oth- riod, including measures of central tendency for quantitative vari- ers. In Spain, the number of COVID-19 cases is growing exponen- ables. Continuous variables were reported using means and stan- tially [4]. Unfortunately, as in many countries, radical measures dard deviations (SD) if they followed a normal distribution; oth- were undertaken in a reactive rather than proactive manner: not erwise, the median and range were used. Absolute frequencies and until March 14, 2020, was a State of Emergency (implementation proportions were used to summarize categorical variables. To com- of stringent lock-down measures for the population) declared in pare the four different time periods, analysis of variance (ANOVA) Spain [5]. and Pearson chi-square analysis were employed for all variables of The spread of COVID-19 has been severely disruptive, and a re- interest, and results further depicted in graphs. For all analyses, the distribution of manpower and resources has been required to meet statistical package IBM SPSS version 25.0 (IBM Corp., Armonk, New the current and anticipated hospital service needs during the out- York, USA) was used. break. As per recommendations from various sources, including specific guidance in orthopaedics [6], there has been a reduction Results in elective clinics and surgeries to shift manpower towards acute specialties combatting COVID-19 and maximize the hospital beds A total of 6565 emergency traumatology visits were analyzed: and resources available. This rapid change in clinic provisions and 1909 visits during Period 1 (29.1%), 2161 during Period 2 (32.9%), the rescheduling of patients causes substantial inconvenience to 1983 during Period 3 (30.2%) and 512 during Period 4 (7.8%). The patients and potentially poses a risk, due to delayed assessments mean age of the patients was 55.1 years old (Standard Deviation and treatment, but is a necessity given the gravity of the current (SD): 22.1) and 51.8% (3495/6565) were women. No statistically- situation [7]. By limiting surgeries and clinics to emergent indica- significant differences were found in age or sex between the four tions only, unnecessary exposure and contamination are limited for analyzed time periods. both patients and healthcare workers. However, this also results in Comparing the four periods for emergency trauma visits, a sig- delayed assessments for many patients, and ultimately adds to the nificant reduction in the number of emergency trauma visits were healthcare burden, as some may not receive care until their dis- identified in Period 4, which had approximately one-fourth as ease is more advanced and potentially requiring hospital admission many trauma admissions as any other period. Emergency trauma [6,8]. Trauma and orthopaedics may not seem to be in the front- visits during Period 4 accounted for just 7.8% of all the admis- line with coronavirus, but we do play a key role, and this must be sions (Fig. 1). No statistically-significant differences were found in planned for. the category of visits, when we compared the different periods The aim of the current study was to provide an overview of the (p = 0.2), though decreases in labor and traffic accidents were ob- impact of a State of Emergency on a traumatology emergency ser- served in Period 4. vice, in order to identify areas for improvement and future plan- There was a statistically-significant difference (p = 0.001) in pa- ning. Preparation for the continuing progression of this COVID- tients’ discharge destinations, with an increase in the rate of hos- 19 pandemic, and preparation for future pandemics, which may pital admissions in Period 4 (Table 1). The rate of hospital admis- be even deadlier and more difficult to contain, is crucial. To our sions was 7.6% in Period 1, 6.3% in Period 2, 8.2% in Period 3, and knowledge, this is the first study to analyze how the pandemic has 12.9% in Period 4. In all the four periods, osteoporotic hip fracture affected a traumatology emergency service. was the most common reason for hospital admissions. Moreover, the number of hospital admissions for osteoporotic hip fracture re- mained relatively stable throughout the four periods: 42 patients Materials and Methods in Period 1, 41 in Period 2, 43 in Period 3 and 36 in Period 4 (p = 0.06) (Fig. 2). An observational study was performed at a tertiary hospital Among the 36 hip fracture patients admitted during the State within the Spanish National Health System. of Emergency, 13 patients were diagnosed with COVID-19 (7 pa- Our university hospital is one of the referral trauma cen- tients confirmed at admission and 6 diagnosed post-operatively). ters in Spain, and is located in the city of Barcelona, in the Among these 13 patients, three died prior to undergoing surgery, autonomous community of Catalonia. The hospital covers a one died after surgery, four were discharged home, and five re- catchment area of more than 550,0 0 0 inhabitants. Four different main alive in the hospital. The remain 23 patients, who were periods were studied, including the first 20 days of the Spain COVID-19 free, were discharged home. Though in-hospital mortal- State of Emergency (March 14 to April 02, 2020, hereafter re- ity appeared somewhat higher in Period 4 (11.1%), no statistically- ferred to as Period 4). The other periods analyzed were the 20 significant difference versus the other periods was found (p = 0.7). days immediately before the state of Emergency (February 23 to The pre-operative mortality rate was statically different, however March 13 2020, hereafter referred to as Period 3), as well as (p = 0.01), the only cases of pre-operative death occurring in Pe- the same periods as Period 4 from the past two years (March riod 4. 16 to April 04, 2019: Period 2, and March 17 to April 05, 2018: Period 1). The inclusion criteria for patients were: 1) presenting to trau- Discussion matology emergency services, and 2) age 15 years or older. If the same patient visited the emergency service two or more times dur- The most important finding identified in the current study is ing the same time period, each clinical visit was counted as a dif- that the absolute volume of osteoporotic hip fracture admissions ferent episode. remained stable during Spain’s State of Emergency. This was de- The variables collected were patient age and gender, insurance spite reduced volumes of trauma emergency visits, workplace ac- type (Catalan Health Service, work accident or traffic accident), and cidents, traffic accidents and hospital admissions. The new out- discharge destination (home discharge, hospital admission, flight or break of the respiratory illness known as ‘COVID-19’ has generated abandonment, or voluntary discharge). Likewise, for admitted pa- serious global public health concern [9]. This being said, health- tients, the admitting diagnosis was collected. care systems must nonetheless continue to treat other diseases and 1416 J.H. Nuñez, A. Sallent and K. Lakhani et al. / Injury 51 (2020) 1414–1418 Fig. 1. Number of visits to trauma emergency services throughout the four periods analyzed. Period 1 (blue): from March 17 to April 05, 2018; Period 2 (red): from March 16 to April 04, 2019; Period 3 (green): from February 23 to March 13 2020, the 20 days immediately before Spain’s State of Emergency; Period 4 (orange): from March 14 to April 02, 2020, the first 20 days of Spain’s State of Emergency. Table 1 General characteristics of the study participants. PERIODS ANALYZED DURING OUR STUDY Period 1 Period 2 Period 3 Period 4 TOTAL P value Age. Median (SD) 56.6 (21.6) 54.5 (21.8) 54.6 (22.5) 57.5 (22.5) 55.1 (22.1) 0.08 Sex Men (%) 908 (47.6) 967 (44.7) 948 (47.8) 247 (50.9) 3070 (48.2) 0.14 Women (%) 1001 (52.4) 1194 (55.3) 1035 (52.2) 265 (49.1) 3495 (51.8) Discharge Destination Home discharge (%) 1736 (90.9) 1977 (91.5) 1762 (88.9) 436 (85.2) 5911 (90.3) 0.001 Hospital admission (%) 146 (7.6) 137 (6.3) 162 (8.2) 66 (12.9) 511 (7.6) Flight or abandonment (%) 23 (1.3) 42 (1.9) 54 (2.7) 9 (1.8) 128 (1.9) Voluntary discharge (%) 4 (0.2) 5 (0.2) 5 (0.3) 1 (0.2) 15 (0.2) Insurance Type Catalan health service (%) 1809 (94.8) 2033 (94.1) 1852 (93.4) 483 (94.3) 6177 (94.0) 0.2 Workplace accident (%) 17 (0.9) 36 (1.6) 47 (2.4) 11 (2.1) 111 (1.7) Traffic accident (%) 83 (4.3) 92 (4.3) 84 (4.2) 18 (3.5) 277 (4.3) Hospital admission Osteoporotic Hip Fracture (%) 42 (28.8) 41 (29.9) 43 (26.6) 36 (54.5) 160 (31.3) 0.06 Non-Osteoporotic Hip Fracture (%) 104 (71.2) 96 (70.1) 119 (73.4) 30 (45.5) 351 (68.7) Age. Median for Hip Fractures (SD) 86.4 (6.4) 86•4 (6.3) 86•2 (7.8) 88•4 (9.2) 86•9 (7.5) 0.1 In-hospital Mortality of Hip Fractures (%) 2 (4.8) 3 (7.3) 3 (7.0) 4 (11.1) 12 (7.4) 0.7 SD: Standard deviation; %: percentage; Period 1: from March 17 to April 05, 2018, Period 2: from March 16 to April 04, 2019; Period 3: from February 23 to March 13, 2020, the 20 days immediately before Spain’s State of Emergency; Period 4: from March 14 to April 02, 2020, the first 20 days of Spain’s State of Emergency. public health problems that continue to occur regularly, like osteo- [11]. With the population being encouraged and/or mandated to porotic hip fractures [10]. When planning for the remaining course stay at home, there are lower risks of traffic and workplace acci- of the current pandemic, as well as future pandemics and other dents. Currently in many countries, only essential work is being global emergencies, it is important to understand which presen- performed on site, the majority of the work being performed re- tations are less common during a State of Emergency, and which motely, even involving certain medical specialties [5,12]. This re- presentations occur with the same or even increased frequency. duction in service visits, accidents and hospital admissions also Significant reductions in visits to the emergency trauma ser- might be explained by there being an understandable fear of visit- vice, workplace accidents, traffic accidents and number of hospi- ing hospitals among the public. This fear can be expected to exist tal admission were found. This is likely because, like many coun- to a greater degree in areas where COVID-19 is more prevalent. At tries around the world, the Spanish government has imposed quar- the time of this writing, on April 02, 2020 in Spain, there had been antines and travel bans on an unprecedented scale. Flattening the 102,136 cases of COVID-19 confirmed, with 9,053 deaths [4]. curve — slowing the spread of COVID-19 across space and time — The number of osteoporotic hip fractures remained stable over is critical, because no healthcare system can sustain a massive in- the first twenty days of the State of Emergency. Thirty-six patients flux of infectious cases to emergency departments and hospitals (22.6% of all the osteoporotic hip fractures studied) were admitted J.H. Nuñez, A. Sallent and K. Lakhani et al. / Injury 51 (2020) 1414–1418 1417 Fig. 2. Reasons for hospital admission for trauma emergencies throughout the four periods analyzed. Blue: osteoporotic hip fractures; Red: all other diagnoses. during Period 4. Hip fractures are devastating injuries that often result in long-term disability and may lead to premature death, es- pecially in the elderly [13]. Due to the rapidly-expanding elderly population, these fractures are one of the most challenging and fastest-growing public health concerns [14]. This problem will con- tinue to grow in the future. It is expected that, worldwide by 2040, Spain will be the country in which the elderly comprise the high- est percentage of the overall population [15]. Another interesting finding of our study is that all 23 hip frac- ture patients who remained COVID-19 free were discharge homed during this pandemic outbreak. Another four hip fracture patients with COVID-19 were discharged home, while five currently remain alive in the hospital. Due to the State of Emergency, there has been a suspension in elective clinics and surgeries, as recommended. We agree with this plan, as it limits the capacity of COVID-19 to spread. Given that essential emergency surgeries are still proceeding as usual, however, contingency plans are needed to maintain these services even as the pandemic worsens. A systematic review of 257,367 patients demonstrated that operative delays beyond 48 hours af- ter admission may increase the odds of 30-day all-cause mortality in hip fracture patients [16]. Similarly, Nyholm et al, in an anal- ysis of 3,517 hip fracture surgeries, found that a surgical delay of more than twelve hours significantly increased thirty-day mortal- ity [17]. Recent studies also have demonstrated that older patients with medical comorbidities are more adversely affected by COVID- 19 infections, owing to their diminished functional reserves and weakened immune systems [18]. This is important to consider in the hip-fracture population, the majority of whom are older and have multiple medical co-morbidities (in our study, the mean age of these patients was 86.9 years old). During this type of pandemic, which most adversely affects this exact population, these patients may need to be prioritized for early surgery even more so than Fig. 3. Current algorithm, as of April 02, 2020, for the treatment of osteoporotic hip fractures during the pandemic caused by the SARS-CoV-2 coronavirus. normal, which may help to reduce their length of stay and, thus, their probability of acquiring a nosocomial infection like COVID-19. In the largest randomized controlled trial to assess hip fracture pa- tients, published recently, an accelerated care pathway was found 19.4% were COVID-19 positive at admission. Given this rate of posi- to be associated with a significantly shorter length of hospital stay tive tests, a routine COVID-19 test at admission for all patients with [19]. Because of the risk of infection and deaths among hip fracture osteoporotic hip fracture was performed, which also may help to patients with COVID-19, at our center we have developed an algo- protect healthcare personal. rithm for caring for these patients during the pandemic, which is Among the limitations of the current study are its retrospective initiated at patient admission (Fig. 3). Among the osteoporotic hip observational design and single-centered nature. Strengths of the fracture patients analyzed during the Spanish State of Emergency, study are that it is the first of its kind at a time of global crisis, 1418 J.H. Nuñez, A. Sallent and K. Lakhani et al. / Injury 51 (2020) 1414–1418 and that the center of interest is a large tertiary referral center [4] World Health Organization (WHO). Novel Coronavirus (2019- nCoV) sit- within the Spanish National Health Service. uation reports. 2020. https://www.who.int/emergencies/diseases/novel- coronavirus- 2019/situation- reports (02 April 2020, date last accessed). In summary, care must be taken, while developing contingency [5] Spanish Government. Real Decreto 463/2020, de 14 de marzo, por el que se plans for reallocating resources during States of Emergency, not to declara el estado de alarma para la gestión de la situación de crisis san- assume that all trauma presentations will decrease. Health prob- itaria ocasionada por el COVID-19. 2020. https://boe.es/boe/dias/2020/03/11/ pdfs/BOE- A- 2020- 3434.pdf#BOEn (accessed March 15, 2020; in Spanish). lems like osteoporotic hip fractures may, in fact, remain stable [6] Clinical guide for the management of trauma and orthopaedic patients during in incidence during such times. Moreover, given that osteoporotic the coronavirus pandemic. 2020. https://www.england.nhs.uk/coronavirus/ fractures disproportionately affect an elderly population with mul- wp-content/uploads/sites/52/2020/03/specialty-guide-orthopaedic-trauma- and- coronavirus- v1- 16- march- 2020.pdf tiple comorbidities, operative delays may increase the risks of both [7] Rosenbaum L. Facing Covid-19 in Italy - Ethics, Logistics, and Therapeutics on in-hospital mortality and nosocomial infection with the pandemic the Epidemic’s Front Line. N Engl J Med 2020 Mar 18 [Epub ahead of print]. virus. With appropriate monitoring and treatment, hip fracture pa- [8] Chan JYK, Wong EWY, Lam W. Practical Aspects of Otolaryngologic Clinical Ser- vices During the 2019 Novel Coronavirus Epidemic: An Experience in Hong tients with and without COVID-19 can do well during this pan- Kong. JAMA Otolaryngol Head Neck Surg 2020 Mar 20 [Epub ahead of print]. demic outbreak, and ultimately be discharged home. [9] Peeri NC, Shrestha N, Rahman S, Zaki R, Tan Z, Bibi S, et al. The SARS, MERS and novel coronavirus (COVID-19) epidemics, the newest and biggest global health threats: what lessons have we learned? Int J Epidemiol 2020 Feb 22 Funding [Epub ahead of print]. [10] Bhandari M, Swiontkowski M. Management of Acute Hip Fracture. N Engl J Med 2017;377(21):2053–62. This research did not receive any specific grant from funding [11] Parmet WE, Sinha MS. Covid-19 — The Law and Limits of Quarantine. N Engl J agencies in the public, commercial, or not-for-profit sectors. Mar 18 [Epub ahead of print]. [12] Smith AC, Thomas E, Snoswell CL, Haydon H, Mehrotra A, Clemensen J, et al. Telehealth for global emergencies: Implications for coronavirus disease Declaration of Competing Interest 2019 (COVID-19). J Telemed Telecare 2020 Mar 20 [Epub ahead of print]. [13] Hartholt KA, Oudshoorn C, Zielinski SM, Burgers PT, Panneman MJ, van Beeck EF, et al. 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