key: cord-0982771-9sw22reg
authors: Padubidri, Anokha A.; Rushing, Amy; Ochenjele, George; Sontich, John; Napora, Joshua; Osborne, Ashli; Delozier, Sarah; Wetzel, Robert
title: Increase in gunshot wounds at a level 1 trauma center following the COVID19 pandemic
date: 2021-11-17
journal: OTA Int
DOI: 10.1097/oi9.0000000000000159
sha: c8c3ac6888c37ca372d866c65ddde67e83c5ef16
doc_id: 982771
cord_uid: 9sw22reg

OBJECTIVES: To compare the number of patients with gunshot wounds presenting to our level 1 trauma center before and during the COVID-19 pandemic with a focus on volume trends after the lifting of stay-at-home directives through August 2020. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Seven hundred six gunshot wound patients between 2016 and 2020 (months March to September only). INTERVENTION: COVID-19 pandemic and resultant stay at home directives. MAIN OUTCOME MEASUREMENTS: Number of patients presenting with gunshot wounds per time period. RESULTS: The number of patients with gunshot wounds presenting to our institution increased by 11.7% in March–April 2020 and by 67% in May–August 2020 when compared to previous years. Length of stay significantly decreased in 2020 compared to 2018 and 2019. In 2020, significantly fewer patients had orthopaedic procedures than in 2018. CONCLUSIONS: Patients presenting with gunshot wounds increased during the initial “stay-at-home” portion of the pandemic in March to April and increased significantly more after the restrictions were relaxed during May to August. Level of Evidence: Therapeutic Level III

The SARS-CoV-2 (COVID- 19) pandemic has led to worldwide implications. Social distancing and stay-at-home directives began in the United States in March 2020. These restrictions have had various documented effects on health care systems and emergency room visits. One study showed a decrease in all trauma admissions at a level 1 trauma center by 43% during the "stay-at-home" period between March and April. [1] Another study documented a decrease in orthopaedic consultations at a single level 1 trauma center despite an increase in gunshot wound injuries during the same time period. [2] Conversely, a level 2 trauma center published their experience during the early phase of the pandemic by reporting a 58.8% decrease in high-severity injuries with associated fractures and a 42.9% decrease in lowseverity injuries. [3] While these preliminary studies give providers a glimpse into the pandemic's impact on trauma volumes, there is limited data describing its effect on orthopaedic trauma, particularly in the months following the stay-at-home mandate.

During the COVID-19 pandemic, gun violence increased in multiple cities including New York City, Chicago, and Baltimore. [4] This increase in gun violence can be attributed to multiple factors including the significant rise in unemployment as well as the growing social unrest that seized the nation following multiple publicized shootings across the country. [5] Additionally, government restrictions have compelled families to remain at home for school and work. With dramatically reduced community outlets, at-risk families remained in homes where domestic disputes were prevalent leading to an increase in the incidence of domestic violence and abuse. [6, 7] In parallel with increasing socioeconomic stressors, there has been a dramatic increase in the number of firearm background checks as reported by the Federal Bureau of Investigation. From January to August 2020, the number of background checks increased 68% when compared with the same time period in 2019. [8] Notably, between March 8 and April 11, 2020, there was a 158% increase in gun preparation Google searches. [9] These observations not only reflect signs of a strained society, but they portend the potential surge of trauma volumes for verified centers.

The objective of this study is to compare the number of patients with gunshot wounds presenting to our level 1 trauma center before and during the COVID-19 pandemic with a focus on volume trends after the lifting of stay-at-home directives through August 2020. We hypothesize there was an increase in these injuries during the COVID-19 pandemic. We intend to further delineate this phenomenon with the hopes of increasing awareness and preparedness for injury management.

After institutional review board approval, a retrospective investigation was conducted evaluating all trauma activations at an urban, academic level 1 trauma center from January 1, 2016 to August 31, 2020, months March to September only. Patients were identified via review of the trauma registry, which is a prospectively collected database consisting of all patients presenting as a trauma activation. All adult patients ages 18 years and older presenting with a gunshot wound during the defined time period were included in the study. Patients younger than 18 years of age were excluded. The primary outcome was number of patients presenting with gunshot wounds per time period. Secondary outcomes included orthopaedic injuries, operative orthopaedic procedures performed, and hospital length of stay. The dates were selected based on the state of Ohio social distancing and stay-at-home directives during the COVID-19 pandemic. Ohio public schools were closed on March 12, 2020. Since initial public-school closings, the availability of in-person education has remained variable throughout the state. On March 22, 2020, the stay-at-home order went into effect limiting access to essential services and retailers. Most businesses, including gyms, pools, indoor restaurants/bars, and childcare facilities, were able to reopen between May 15-31. [10] Demographic data and pertinent medical history were collected via trauma registry review including age, sex, and ethnicity. The following injury characteristics and clinical data were collected: orthopaedic injuries, operative orthopaedic procedures, Injury Severity Score (ISS), and hospital length of stay.

Continuous data are reported as means and standard deviations; categorical data are reported using frequencies and percentages. Differences between groups are reported using independent t tests for continuous variables, and chi-square or Fisher exact tests for categorical variables. All tests are 2-tailed and P < .05 is considered statistically significant. GSWs per month. The same time period in 2020 revealed an increase to a monthly average of 20 GSWs, an 11.7% increase overall. Demographic data for previous years were compared to 2020 ( Table 1 ). The only statistically significant differences between 2020 and prior years were found between 2020 and 2018. In 2020, patients were significantly older than in 2018 (35.2 ± 14.4 vs. 28.3 ± 7.8, P = .039). When looking at clinical variables, significantly fewer patients in 2020 underwent orthopaedic procedures compared to those in 2018 (15% vs. 43%, P = .028). In addition, there was a higher incidence of mortality in 2020 compared to patients in 2018. (18% vs. 0%, P = .041) (Tables 2-3).

During the May-August period, the monthly average occurrence of GSWs was 26.5 in 2016, 22.5 in 2017, 19 in 2018, and 18.8 in 2019 for a 4-year previous historical average of 26.2 GSWs per month, compared to the average of 44 GSWs per month in 2020, a 67.9% increase in GSW occurrences. Statistically significant differences between 2020 and prior years were found for 2016, 2018, and 2019. Patients in 2020 were significantly older than in 2016 (30.7 ± 10.3 vs. 28.1 ± 9.8, P = .035), and significantly younger than in 2018 (30.7 ± 10.3 vs. 33.8 ± 12.3, P = .042). In 2020, a significantly higher proportion of patients were African American than in 2018 (98% vs. 88%), P = .003. Hospital length of stay in 2020 was significantly shorter than in 2018 (4.3 ± 5.4 vs. 6.3 ± 10.6, P = .048), and 2019 (4.3 ± 5.4 vs. 6.6 ± 9.3, P = .015). There was a significantly higher rate of distal femur fractures that occurred in May to September 2016 (9.4%, P < .001, compared to 0% in later years). Thoracic vertebra fractures occurred at an increased rate in 2017 (15.1% vs. 1.9% in 2016, 3.8% in 2018, 4.5% in 2019, and 1.6% in 2020, P = .005). Scapula fractures occurred at an increased rate in 2019 (9.1% vs. 1.9% in 2016, 0% in 2017, 1.9% in 2018, and 0.8% in 2020, P = .27). There were no other significant differences in injuries sustained throughout the years.

This study demonstrated an increase in the number of gunshot wounds presenting to our institution during the COVID-19 lockdown period between March and April by 11.7% with a subsequent rise in GSWs after the reopening of the state in May through August by 67.9%. Overall, 2020 yielded an unprecedented number of GSW patients compared to previous years.

Between March and April 2020, there was a significant decrease in the percentage of patients undergoing operative orthopaedic procedures for gunshot wounds when compared to 2018 (15% vs. 43%; P = .028). It is difficult to draw conclusions as to the reason behind this finding although one may consider Padubidri et al OTA International (2021) e159 www.otainternational.org (4.3 ± 5.4 vs. 6.3 ± 10.6 and 6.6 ± 9.3, respectively, P = .048 and .015). Due to the pandemic, there was a push to expedite discharge when patients were medically ready, which could possibly explain this decrease. This was similar to other studies that reported on length of stay in trauma patients during the pandemic. [1, 11] Other significant findings included a higher proportion of African American patients in 2020 compared to 2018 and older patients in 2020 when compared to 2016 and 2018. The reasons for these findings are unknown. The COVID-19 pandemic has had many unexpected effects on the nation and health care system. Nationally and globally, many emergency departments documented a decrease in volume; however, this may not be the case for urban trauma centers in the United States. [12, 13] While some institutions have documented a decrease in all trauma admissions, our institution saw a large increase in gunshot wounds. This is consistent with the rest of the city of Cleveland which, as of June 2020, has seen a 55% increase in gunshot wounds when compared to the same time period in 2019. [14] In Cleveland, there have been more homicides in 2020 than any year since 1991. [15] There have been few other studies looking at the trend of gunshot wounds following the COVID-19 outbreak. Most recent studies did not examine the trends in traumatic injuries following the relaxation of social distancing during the summer of 2020. This is the period of time where we saw the largest increase in gunshot wounds. Conversely, a study from the United Kingdom revealed a decrease in the number of cases of penetrating trauma by 35% with a concomitant increase in the proportion of selfharm cases by 16%. [6] A study conducted in Philadelphia documented a 62.4% increase in gunshot wounds during the post-stay at home period (March 16 to May 30, 2020) when compared to previous years. [16] Yeates et al [11] studied penetrating trauma after the onset of the COVID-19 pandemic in California, and reported an increased rate of gunshot wounds after the stay at home orders, but no difference in suicide or domestic violence rates.

Other studies have looked at the impact of COVID-19 on orthopaedic practices. Lubbe et al performed a retrospective review on all trauma consultations from March 17, 2020, to April 30, 2020 at a Level 1 Trauma Center in Las Vegas. During this period, the number of patients presenting after motor vehicle and motorcycle collisions remained constant; however, there was an increase of automobile versus pedestrian accidents and patients presenting with GSWs during the COVID-19 period.

The beginning of the COVID-19 pandemic resulted in a 3-fold increase in unemployment in Ohio-from 5.4% in March 2020 to 17.3% in April 2020. [17] One month later, the publicized death of George Floyd in Minneapolis resulted in a period of social unrest requiring city-wide curfews and mobilization of the National Guard across the country. [17, 18] These observations depict a population under substantial socioeconomic stress and likely contributed to the rise in shootings during this time period.

Another consequence of a society under strain is the rise in domestic abuse and family violence that has occurred during the COVID-19 pandemic. [18] Some states have shown a greater than 20% increase in domestic violence during the pandemic when compared to previous years. [19] There has been concern that these cases are increasing due to stay-at-home orders and social distancing requiring the victim to quarantine with their abusive partner or family member. [7, 20] There are limitations of this study. This is a retrospective review of data collected from a single institution's trauma registry. There may be confounding factors that affected the described outcomes in the study that were not addressed: the incidence of crime, prevalence of mental illness, and the impact of substance abuse on the overall increase in interpersonal violence during the defined timeframes. Data such as location of shooting and type of weapon used was not collected. In addition, surgeon bias was likely present as it was the individual surgeon's preference whether to treat a patient nonoperatively or to proceed with operative fixation for each injury that occurred.

The findings show gunshot wounds have increased at our institution since the onset of COVID-19, and likely escalated during the defined period of social unrest and lift of the "stay at home" orders during the summer of 2020. Despite the increased number of patient presentations, the total number of operative orthopaedic cases and hospital length of stay did not increase. This study emphasizes the importance of having the appropriate trauma expertise available during an unprecedented epidemic as societal stressors can lead to interpersonal violence and injury. Further studies should follow the trend to see if these numbers decline to pre-COVID-19 levels after the pandemic ceases. .005 * Thumb phalanx fracture 1 (1.9) 0 (0) 0 (0) 0 (0) 0 (0) .616 Tibia fracture 5 (9.4) 6 (11.3) 12 (23) 3 (6.8) 20 (15.9) .159 Tibial pilon fracture 1 (1.9) 0 (0) 0 (0) 0 (0) 0 (0) .616 Tibial plateau fracture 1 (1.9) 1 (1.9) 0 (0) 0 (0) 0 (0) .379 Toe phalanx fracture 1 (1.9) 0 (0) 0 (0) 0 (0) 3 (2.4) .707 Traumatic MCP amputation 0 (0) 1 (1.9) 0 (0) 0 (0) 0 (0) .616 Traumatic metacarpophalangeal amputation 0 (0) 0 (0) 0 (0) 1 (2.2) 0 (0) .134 Triquetrum fracture 0 (0) 0 (0) 0 (0) 0 (0) 1 (0.8) 1.000 Ulna fracture 3 (5.7) 2 (3.8) 2 (3.8) 2 (4.5) 4 (3.2) .957 Vertebra fracture 0 (0) 0 (0) 0 (0) 0 (0) 1 (0.8) 1.000

Padubidri et al OTA International (2021) e159 www.otainternational.org

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