Skip to main content

Main menu

  • Latest content
    • Latest content
  • Archive
  • About the journal
    • About the journal
    • Editorial board
    • Information for authors
    • FAQs
    • Thank you to our reviewers
    • The American Association for the Surgery of Trauma
  • Submit a paper
    • Online submission site
    • Information for authors
  • Email alerts
    • Email alerts
  • Help
    • Contact us
    • Feedback form
    • Reprints
    • Permissions
    • Advertising
  • BMJ Journals

User menu

  • Login

Search

  • Advanced search
  • BMJ Journals
  • Login
  • Facebook
  • Twitter
TSACO

Advanced Search

  • Latest content
    • Latest content
  • Archive
  • About the journal
    • About the journal
    • Editorial board
    • Information for authors
    • FAQs
    • Thank you to our reviewers
    • The American Association for the Surgery of Trauma
  • Submit a paper
    • Online submission site
    • Information for authors
  • Email alerts
    • Email alerts
  • Help
    • Contact us
    • Feedback form
    • Reprints
    • Permissions
    • Advertising
Open Access

Impact of shelter-in-place order for COVID-19 on trauma activations: Santa Clara County, California, March 2020

Joseph D Forrester, Raymond Liou, Lisa M Knowlton, Ronald M Jou, David A Spain
DOI: 10.1136/tsaco-2020-000505 Published 7 May 2020
Joseph D Forrester
1 Department of Surgery, Stanford University, Stanford, California, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Raymond Liou
1 Department of Surgery, Stanford University, Stanford, California, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Lisa M Knowlton
1 Department of Surgery, Stanford University, Stanford, California, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ronald M Jou
2 Department of Surgery, Santa Clara Valley Medical Center, San Jose, California, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
David A Spain
1 Department of Surgery, Stanford University, Stanford, California, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF
Loading

Abstract

Introduction The shelter-in-place order for Santa Clara County, California on 16 March was the first of its kind in the USA. It was unknown what impact this order would have on trauma activations.

Methods We performed a retrospective analysis of institutional trauma registries among the two American College of Surgeons Level 1 trauma centers serving Santa Clara County, California. Trauma activation volumes at the trauma centers from January to March 2020 were compared with month-matched historical cohorts from 2018 to 2019.

Results Only 81 (3%) patients were trauma activations at the trauma centers in the 15 days after the shelter-in-place order went into effect on 16 March 2020, compared with 389 activations during the same time period in 2018 and 2019 (p<0.0001). There were no other statistically significant changes to the epidemiology of trauma activations. Only one trauma activation had a positive COVID-19 test.

Discussion Overall trauma activations decreased 4.8-fold after the shelter-in-place order went into effect in Santa Clara County on 16 March 2020, with no other effect on the epidemiology of persons presenting after traumatic injury.

Conclusion Shelter-in-place orders may reduce strain on healthcare systems by diminishing hospital admissions from trauma, in addition to reducing virus transmission.

Introduction

The novel corona virus, severe acute respiratory syndrome coronavirus 2 (COVID-19), was identified in December 2019 in Wuhan, China.1 The first cases of COVID-19 were reported in Santa Clara County, California, on 31 January and 2 February 2020.2 Over concern for community transmission of COVID-19, on 16 March 2020 the Santa Clara County Public Health Department issued a shelter-in-place order to improve social distancing.3 4 There are two verified Level 1 trauma centers that provide trauma care to 70%–80% of the 1.938 million residents of Santa Clara County, and it was not known how this proactive public health intervention would impact trauma volume. Our objective to was assess how the shelter-in-place order would impact trauma activation volume at our two centers.

Methods

We compared trauma activation volumes at the trauma centers from January to March 2020 to month-matched historical cohorts of trauma activations from 2018 to 2019. Patients were identified using institutional trauma registries. Epidemiologic variables assessed included age, sex, admission to the hospital or an intensive care unit (ICU), injury severity score (ISS) and mechanism of injury. Minor and major trauma activations were grouped according to pre-existing trauma center-specific definitions. Patients were considered positive for alcohol if they had a blood alcohol level ≥0.08. Any drug identified on urine toxicology screen not administered during initial trauma assessment was considered a positive. Missing values were not included in the analysis, and variables with missing values are reported as such. Fisher’s exact and Wilcoxon rank sum test were used to compare categorical and numerical variables respectively. P<0.05 was considered significant. This study was exempted by the Institutional Review Boards of both institutions.

Results

Between January and March 2018, 2019 and 2020, there were a total of 3057 trauma activations. There were 1170 (38%) activations in 2018, 974 (32%) activations in 2019 and 913 (30%) activations in 2020. Median age was 38 (range: <1–103) years and 1995 (65%) were male. Two thousand five hundred and seventy-five (84%) activations were minor traumas and 482 (16%) were major traumas. Nine hundred and sixty (31%) activations occurred on the weekend. There were 397 (19%) patients positive for alcohol and 226 (11%) positive for drugs, among patients with this information available. Median ISS was 5 (range: 1–75). Blunt mechanisms were reported for most trauma activations (n=2866, 94%). A total of 1523 (50%) trauma activations required admission to the hospital. Of these, 484 (16% of all activations) resulted in ICU admissions. There were 11 (0.4%) patients who died in the trauma bay.

Only 81 (3%) patients were trauma activations at the trauma centers in the 15 days after the shelter-in-place order went into effect on 16 March 2020, compared with 389 activations during the same time period in 2018 and 2019 (p<0.0001) (figure 1). While fewer patients were admitted on weekend days after the shelter-in-place order went into effect (14% vs 31%, p<0.0001), there were no other statistically significant changes to the epidemiology of trauma activations. Only one trauma activation had a positive COVID-19 test.

Figure 1
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1

Trauma activations in Santa Clara County, California – January–March, 2018–2020. Upper graph represents trauma activations during 2018 and 2019. Lower graph represents trauma activations in 2020. Dotted line is 3-day running average with the upper and lower bounds of the SD with solid lines. Cardinal star marks 16 March.

Discussion

Overall trauma activations decreased 4.8-fold after the shelter-in-place order went into effect in Santa Clara County on 16 March 2020. There was otherwise no change to the epidemiology of the traumatically injured patients presenting to these two institutions. To our knowledge, no trauma-specific assessments have occurred with prior infectious disease outbreaks where quarantine or shelter-in-place order was enforced. However, with both the severe acute respiratory syndrome outbreak in 2003 and the Ebola virus disease outbreak in West Africa in 2014 and 2015, similar drops in inpatient hospital admissions were identified.5 6 While the observed decrease in trauma activations inherently makes sense as there are fewer motor vehicles in use, the impact on interpersonal violence and mental health is not as clear.7 It is important to note, therefore, that our two centers have a high frequency of blunt traumatic injury; the reduction in trauma activations we observed may not be reflective of the experience in other locales, particularly those in large metropolitan areas with higher frequencies of penetrating trauma.

Conclusion

Shelter-in-place orders may help reduce the strain on healthcare systems by diminishing hospital admissions from trauma, in addition to reducing virus transmission. Further longitudinal research is needed to assess if the decrease in number of trauma activations remain sustained over time.

Footnotes

  • Contributors JDF: data acquisition, manuscript preparation and editing; RL and RMJ: data acquisition and manuscript preparation; LMK and DS: manuscript preparation and editing.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

References

  1. ↵
    1. Huang C ,
    2. Wang Y ,
    3. Li X ,
    4. Ren L ,
    5. Zhao J ,
    6. Hu Y ,
    7. Zhang L ,
    8. Fan G ,
    9. Xu J ,
    10. Gu X , et al
    . Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497–506.doi:10.1016/S0140-6736(20)30183-5 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31986264
    OpenUrlCrossRefPubMed
  2. ↵
    1. Cody SH
    . Letter from the Health Officer - February 3, 2020: Santa Clara County Department of Public Health, 2020.
  3. ↵
    1. Zwald ML ,
    2. Lin W ,
    3. Sondermeyer Cooksey GL ,
    4. Weiss C ,
    5. Suarez A ,
    6. Fischer M ,
    7. Bonin BJ ,
    8. Jain S ,
    9. Langley GE ,
    10. Park BJ , et al
    . Rapid Sentinel Surveillance for COVID-19 - Santa Clara County, California, March 2020. MMWR Morb Mortal Wkly Rep 2020;69:419–21.doi:10.15585/mmwr.mm6914e3 pmid:http://www.ncbi.nlm.nih.gov/pubmed/32271724
    OpenUrlPubMed
  4. ↵
    1. Cody SH
    . Order of the health officer of the County of Santa Clara: Santa Clara County Department of Public Health, 2020.
  5. ↵
    1. Schull MJ ,
    2. Stukel TA ,
    3. Vermeulen MJ ,
    4. Zwarenstein M ,
    5. Alter DA ,
    6. Manuel DG ,
    7. Guttmann A ,
    8. Laupacis A ,
    9. Schwartz B
    . Effect of widespread restrictions on the use of hospital services during an outbreak of severe acute respiratory syndrome. CMAJ 2007;176:1827–32.doi:10.1503/cmaj.061174 pmid:http://www.ncbi.nlm.nih.gov/pubmed/17576979
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Bolkan HA ,
    2. van Duinen A ,
    3. Samai M ,
    4. Bash-Taqi DA ,
    5. Gassama I ,
    6. Waalewijn B ,
    7. Wibe A ,
    8. von Schreeb J
    . Admissions and surgery as indicators of hospital functions in Sierra Leone during the west-African Ebola outbreak. BMC Health Serv Res 2018;18:846.doi:10.1186/s12913-018-3666-9 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30413159
    OpenUrlPubMed
  7. ↵
    1. Dailey SF ,
    2. Kaplan D
    . Shelter-in-place and mental health: an analogue study of well-being and distress. J Emerg Manag 2014;12:121–31.doi:10.5055/jem.2014.0166 pmid:http://www.ncbi.nlm.nih.gov/pubmed/24828908
    OpenUrlPubMed
PreviousNext
Back to top
Email

Thank you for your interest in spreading the word on TSACO.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Impact of shelter-in-place order for COVID-19 on trauma activations: Santa Clara County, California, March 2020
(Your Name) has sent you a message from TSACO
(Your Name) thought you would like to see the TSACO web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Alerts
Sign In to Email Alerts with your Email Address
Citation Tools
Impact of shelter-in-place order for COVID-19 on trauma activations: Santa Clara County, California, March 2020
Joseph D Forrester, Raymond Liou, Lisa M Knowlton, Ronald M Jou, David A Spain
Trauma Surg Acute Care Open May 2020, 5 (1) e000505; DOI: 10.1136/tsaco-2020-000505

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Cite This
  • APA
  • Chicago
  • Endnote
  • MLA
Loading
Impact of shelter-in-place order for COVID-19 on trauma activations: Santa Clara County, California, March 2020
Joseph D Forrester, Raymond Liou, Lisa M Knowlton, Ronald M Jou, David A Spain
Trauma Surg Acute Care Open May 2020, 5 (1) e000505; DOI: 10.1136/tsaco-2020-000505
Download PDF

Share
Impact of shelter-in-place order for COVID-19 on trauma activations: Santa Clara County, California, March 2020
Joseph D Forrester, Raymond Liou, Lisa M Knowlton, Ronald M Jou, David A Spain
Trauma Surgery & Acute Care Open May 2020, 5 (1) e000505; DOI: 10.1136/tsaco-2020-000505
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
Respond to this article
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Article
    • Abstract
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Footnotes
    • References
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF

Related Articles

Cited By...

More in this TOC Section

  • Examining trends in gun violence injuries before and during the COVID-19 pandemic across six trauma centers
  • Acute appendicitis severity during the early COVID-19 pandemic period
  • Predictors of first pass success without hypoxemia in trauma patients requiring emergent rapid sequence intubation
Show more Brief report

Similar Articles

 
 

CONTENT

  • Latest content
  • Archive
  • eLetters
  • Sign up for email alerts
  • RSS

JOURNAL

  • About the journal
  • Editorial board
  • Thank you to our reviewers
  • The American Association for the Surgery of Trauma

AUTHORS

  • Information for authors
  • Submit a paper
  • Track your article
  • Open Access at BMJ

HELP

  • Contact us
  • Reprints
  • Permissions
  • Advertising
  • Feedback form

©Copyright 2022 The American Association for the Surgery of Trauma