COVID-19 is a novel strain of coronavirus that has a higher mortality rate and is more contagious than influenza [1,2]. The COVID-19 pandemic has been severely disruptive. Strict measures such as travel bans, remote learning, working from home, and social distancing, have been implemented in many countries to reduce spread and ease demand on healthcare systems [2]. In Singapore, heightened safe distancing measures were implemented for 8 weeks (7^th April-31^st May 2020) in anticipation of rising community cases [3]. Members of the public were strongly advised to remain at home, except for essential purchases or urgent medical needs. Subsequently, the safe distancing measures were lifted in three phases as Singapore re-opened its economy: Phase I (1^st–18^th June 2020); Phase II (19^th June–27^th December 2020); Phase III (28^th December 2020) onwards [4]. Trauma care is often time-sensitive and can result in severe life- and limb-threatening injuries if left untreated [5]. Despite the redistribution of manpower and healthcare resources during an outbreak, trauma care cannot be compromised [2,6]. Standard protocols such as contact precautions, donning of personal protective equipment, and screening of contact history and respiratory symptoms in patients, have been established in emergency departments (EDs) [6]. Such protocols ensure minimum contact, the safety of emergency physicians, and timely treatment for all trauma victims [6]. This study evaluates the impact of the COVID-19 pandemic on the epidemiology of trauma-related attendances at an ED in Singapore. Understanding the needs of the trauma unit during a pandemic can improve the preparedness and provision of emergency care during current and future pandemics via adequate resource allocation and contingency planning.

Study Design

A retrospective analysis was conducted on all patients (N=1393) who presented with trauma-related diagnoses at the ED of Tan Tock Seng Hospital (TTSH), an acute tertiary hospital in Singapore, during the pre-COVID-19 (1^st April-31^st August 2019) and COVID-19 (1^st April-31^st August 2020) periods. The following data were retrieved from the trauma registry: patient demographics, mechanism of injuries, Injury Severity Score (ISS), and epidemiology of attendances. This study was conducted in accordance with the Declaration of Helsinki and approved by the National Healthcare Group Institutional Review Board, Singapore (DSRB No. 2021/00133).

Injury Severity Score

The ISS is a standardized anatomical scoring system used to measure injury severity in patients with multiple injuries [7]. An Abbreviated Injury Scale (AIS) score is assigned to injuries at six body regions: Head, Face, Chest, Abdomen, Extremities, and External. Three body regions with the most severe injuries have their AIS score squared and added together to produce the ISS score. The ISS score ranges from one to 75, of which <9=mild; 9-15=moderate; 16-24=severe; ≥25=profound [7].

Statistical Analysis

SPSS version 25 (SPSS, Chicago, IL) was used to perform the statistical analysis. ISS values and mean total ED duration were compared via the Mann-Whitney U test. Associations between categorical variables were assessed using the chi-square test, of which statistical significance was taken at p<0.05.

Characteristics of Trauma-Related Attendances

Overall, the number of trauma-related attendances at the ED in 2019 (N=931) was twice that in 2020 (N=462). The mean age of trauma-related attendees in 2019 (68.91 years, range: 15-100 years) was younger than those seen in 2020 (71.14 years, range: 15-100 years). There was a preponderance of male attendees in 2019 (N=468, 50.3%), while female attendees were more commonly seen in 2020 (N=238, 51.5%). Chinese attendees were most prevalent in 2019 (N=739, N=79.4%) and 2020 (N=391, 84.6%) (Table 1). Trauma-related attendances were most prevalent in August 2019 (N=205, 22.0%) and 2020 (N=136, 29.4%). April 2019 (N=190, 20.4%) had the second highest number of attendances. On the other hand, April 2020 had the lowest number of attendances (N=59, 12.8%). While the majority of attendances occurred during the day (8am-8pm) in both years, a greater proportion of trauma-related attendances occurred in the day in 2020 (N=359, 77.7%) than in 2019 (N=633, 68.0%; p<0.001). 10am was the most common time of arrival in both years (N=65, 7.0%; N= 45, 9.7%). The mean total ED time in 2019 (300.6min, range: 0-1866min) was longer than that in 2020 (258.8min, range: 0-1853min, p<0.01).

Table 1: Characteristics of Trauma-Related Attendances at the Emergency Department.

Characteristics of Trauma-Related Injuries

Falls, vehicular accidents, and injury by tools remain the top three mechanisms of injury in 2019 and 2020. The proportion of falls increased during the COVID-19 period from 77.0% (N=717) to 83.1% (N=384; p<0.05), while the proportion of injuries by tools decreased from 3.2% (N=30) to 1.0% (N=6; p<0.05). There was no significant decrease in the proportion of vehicular accidents from 16.2% (N=151) to 13.6% (N=63, p>0.05). The amount of work-related injuries fell from 46 (4.9%) in 2019 to 18 (3.9%) in 2020 (p>0.05). Of those admitted for falls in 2019, majority (N=391, 54.5%) arrived at the ED via the Emergency Ambulance Service (EAS) provided by the Singapore Civil Defence Force. On the other hand, majority of those admitted for falls in 2020 (N=207, 53.9%) arrived at the ED via their own transport. The proportion of fall cases that were attended to in the resuscitation room in 2019 (N= 219, 30.5%) and 2020 (N=113, 29.4%) were similar (p>0.05). The mean ISS in 2019 (12.49, range: 1-75) and 2020 (12.98, range: 1-54) were similar (p>0.05). Majority of trauma-related attendances were of moderate severity in 2019 (N=703, 75.5%) and 2020 (N=347, 75.1%). Injuries of profound severity were the second most common in 2020 (N=54, 11.7%) compared to injuries of severe severity in 2019 (N=114, 12.2%) (Table 2). The top three places of occurrence for trauma-related events in 2019 and 2020 remained the same: homes (N=451, 48.4%; N=269, 58.2%), public places (N=218, 23.4%; N=86, 18.6%) and roads (N=161, 17.3%; N=65, 14.1%). While the majority of trauma-related events occurred in homes in both years, the proportion of cases increased in 2020 (p<0.05). In 2020, the proportion of cases that occurred at public places (p<0.05) and on roads (p>0.05) decreased.

Table 2: Characteristics of Traumatic Injuries at the Emergency Department.

During an outbreak, trauma-related attendees may vary in infection status and contact history [8]. Despite the uncertainty, emergency physicians must offer optimal and timely care for patients to minimize any morbidity and mortality risk associated with delayed treatment [6]. Understanding the epidemiology of trauma-related ED attendances during a pandemic can enhance the preparedness and response time of emergency care. Strict safety protocols can also be improved upon to allow for effective care without compromising the safety and health of those involved [8]. Similar to many EDs around the world, the number of trauma-related ED attendances fell significantly during the COVID-19 pandemic [2,6,9]. Likewise, ED attendances also declined significantly during the 2003 SARS outbreak in Singapore [10]. This trend may be attributed to the travel bans and quarantine measures imposed by the Singapore government in an attempt to curb the spread of COVID-19 cases [2]. In fact, the two months with the lowest number of attendances correspond to the implementation of the circuit breaker in April and May 2020 [3]. Furthermore, the National Centre for Infectious Disease, co-located across the road from TTSH, handles the bulk of COVID-19 cases during the pandemic. Patients may be fearful of contracting and spreading the disease to family members, or they may not wish to contribute to the work burden of healthcare workers, thereby choosing to avoid or delay visits to the TTSH ED [10]. Falls, vehicular accidents, and injuries by tools remain the top 3 leading causes of injuries in Singapore before and during the COVID-19 pandemic [5]. Consistent with the results of a similar study by Devarakonda et al., majority of trauma-related attendances remain of moderate severity before and during the pandemic [9]. A greater proportion of traumatic events occurred in homes during the pandemic, while such events more commonly occurred outdoors pre-COVID-19. The circuit breaker and phased re-openings could have led to a relative decrease in vehicular accidents as more people stay off the roads and work from home. The lockdown of migrant worker dormitories in response to a surge in COVID-19 transmission among the workers could have contributed to a fall in workplace injuries as well [11]. During a pandemic, EDs should be prepared to address injuries from falls, vehicular accidents, and tools via adequate resource allocation, workflow delegation, and stringent safety protocols, thereby leading to good clinical outcomes for trauma victims. A greater proportion of trauma-related attendances occurred in the day during the pandemic. This may be associated with the prohibition of sales and consumption of alcohol in Phase I, and from 2230 hrs daily in Phase II [10,12]. Members of the public more likely remain at home at night as most food and beverage establishments close early, resulting in reduced night-time ED attendances. The average duration of time spent in the ED also decreased during the pandemic. This may be due to reduced patient load and turnover time as EDs attempt to prevent crowding to minimise any patient-to-patient transmission [13]. During the pandemic, majority of attendances for falls came in on their own rather than via the EAS despite having the same proportion of resuscitation cases. The use of ambulances to transport suspected COVID-19 cases may have led to a stigma against the EAS, of which members of the public would seek alternative forms of transport out of fear of contracting the disease [10].

This study was carried out in a single healthcare institution and may not be representative of all trauma-related attendances in Singapore. However, TTSH trauma unit attends to the largest proportion of trauma patients in Singapore. A study of the national trauma registry can be conducted to allow for a more in-depth understanding of the impact that the COVID-19 pandemic had across the various healthcare institutions in Singapore.

Despite a decrease in trauma-related ED attendances during the pandemic, EDs should still remain well-prepared to attend to patients with injuries from falls, vehicular accidents, and tools. EDs should anticipate traumatic injuries of moderate severity as well. By tailoring the allocation of resources and manpower, and adjusting safety protocols and workflows according to the needs of patients, the capacity and standard of trauma care can be maximised even in the midst of a pandemic.

1. Piroth L, Cottenet J, Mariet A. Comparison of the characteristics, morbidity, and mortality of COVID-19 and seasonal INFLUENZA: A Nationwide, population-based retrospective cohort study. The Lancet Respiratory Medicine. 2021; 9: 251-259.
2. Nunez JH, Sallent A, Lakhani K. Impact of the COVID-19 Pandemic on an Emergency Traumatology Service: Experience at a Tertiary Trauma Centre in Spain. Injury. 2020; 51: 1414-1418.
3. Circuit Breaker to Minimise Further Spread of COVID-19. Retrieved December 2020; 20.
4. Ending circuit breaker: Phased approach to resuming activities safely. Retrieved December. 2020; 20.
5. Lim WW, Goh ES, Ganesh R. Epidemiology of trauma in an acute care hospital in Singapore. Journal of Emergencies, Trauma, and Shock. 2014; 7: 174-179.
6. Sawhney C, Singh Y, Jain K. Trauma care and COVID-19 pandemic. Journal of Anaesthesiology Clinical Pharmacology. 2020; 36: 115-120.
7. Javali RH, Krishnamoorthy, Patil A. Comparison of Injury Severity Score, New Injury Severity Score, Revised Trauma Score and Trauma and Injury Severity Score for Mortality Prediction in Elderly Trauma Patients. Indian J Crit Care Med. 2019; 23: 73-77.
8. Li Y, Zeng L, Li Z. Emergency trauma care during the outbreak of corona virus disease 2019 (COVID-19) in China. World Journal of Emergency Surgery. 2020; 15: 33.
9. Devarakonda AK, Wehrle CJ, Chibane FL.The Effects of the COVID-19 Pandemic on Trauma Presentations in a Level One Trauma Center.The American Surgeon. 2020.
10. Lateef F. The impact of the COVID 19 pandemic on emergency department attendance: What seems to be keeping the patients away? J Emerg Trauma Shock. 2020; 13: 246-51.
11. Measures to Contain the COVID-19 Outbreak in Migrant Worker Dormitories. Retrieved December 2020; 20.
12. Safe Management Measures for F&B Establishments. Retrieved December. 2020; 27.
13. Boyle AA, Henderson K. COVID-19: resetting ED care. Emergency Medicine Journal. 2020; 37: 458-459.