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Research Article|Articles in Press

Comparison of trauma and burn evaluations in a pediatric emergency department during pre, early and late COVID- 19 pandemic

      Abstract

      Background

      Pediatric trauma epidemiology altered during early COVID-19 pandemic period but the impact of the ongoing pandemic is unknown.

      Objectives

      To compare pediatric trauma epidemiology between the pre, early and late pandemic periods and to evaluate the association of race and ethnicity on injury severity during the pandemic.

      Methods

      We performed a retrospective study of trauma consults for an injury/burn in children ≤ 16 years between January 1, 2019–December 31, 2021. Study period was categorized into pre (January 1, 2019–February 28, 2020), early (March 1, 2020–December 31, 2020), and late (January 1, 2021–December 31, 2021) pandemic. Demographics, etiology, injury/burn severity, interventions and outcomes were noted.

      Results

      A total of 4940 patients underwent trauma evaluation. Compared to pre-pandemic, trauma evaluations for injuries and burns increased during both the early (RR: 2.13, 95% CI: 1.6–2.82 and RR: 2.24, 95% CI: 1.39–3.63 respectively) and late pandemic periods (RR: 1.42, 95% CI: 1.09–1.86 and RR: 2.44, 95% CI: 1.55–3.83 respectively). Severe injuries, hospital admissions, operations and death were higher in the early pandemic but reverted to pre-pandemic levels during late pandemic. Non-Hispanic Blacks had an approximately 40% increase in mean ISS during both pandemic periods though they had lower odds of severe injury during both pandemic periods.

      Conclusions

      Trauma evaluations for injuries and burns increased during the pandemic periods. There was a significant association of race and ethnicity with injury severity which varied with pandemic periods.

      Level of Evidence

      Retrospective comparative study, Level III.

      Keywords

      Abbreviations:

      PED (Pediatric Emergency Department), COVID-19 (Coronavirus Disease 2019), ISS (Injury Severity Score), TBSA (Total Burn Surface Area), CARE (Child At Risk Evaluation)

      Funding/Support

      This study was supported by a grant from the Children’s Hospital of Michigan Foundation. The foundation did not have any role in the study design, data collection, data analysis or preparation of the manuscript.

      Conflicts of Interest

      The authors have no conflicts of interest to disclose.

      Introduction

      Injuries are the leading cause of mortality in children and contribute to significant morbidity [
      • West BA
      • Rudd RA
      • Sauber-Schatz EK
      • et al.
      Unintentional injury deaths in children and youth, 2010-2019.
      ,
      • Finkelhor D
      • Turner HA
      • Shattuck A
      • et al.
      Prevalence of Childhood Exposure to Violence, Crime, and Abuse: Results From the National Survey of Children's Exposure to Violence.
      ,
      • Cunningham RM
      • Walton MA
      • Carter PM
      The Major Causes of Death in Children and Adolescents in the United States.
      ]. Social isolation, increased unemployment rates and disruptions in family, school and child care structure secondary to the coronavirus disease 2019 (COVID-19) pandemic has resulted in significant changes in pediatric trauma epidemiology. Several studies, at the beginning of the pandemic, reported decrease in trauma-related visits to pediatric emergency departments (PED) [
      • DeFazio JR
      • Kahan A
      • Fallon EM
      • et al.
      Development of pediatric surgical decision-making guidelines for COVID-19 in a New York City children’s hospital.
      ,
      • Matthay ZA
      • Kornblith AE
      • Matthay EC
      • et al.
      The DISTANCE study: Determining the impact of social distancing on trauma epidemiology during the COVID-19 epidemic-An interrupted time-series analysis.
      ,
      • Sanford EL
      • Zagory J
      • Blackwell JM
      • et al.
      Changes in pediatric trauma during COVID-19 stay-at-home epoch at a tertiary pediatric hospital.
      ,
      • Bessoff KE
      • Han RW
      • Cho M
      • et al.
      Epidemiology of pediatric trauma during the COVID-19 pandemic shelter in place.
      ] mirroring the decrease in overall PED visits [

      DeLaroche AM, Rodean J, Aronson PL, et al. Pediatric Emergency Departments visits in US children’s hospitals during the COVID-19 pandemic. Pediatrics. 21; 147:e2020039628.

      ]. Further, studies also reported a shift in trauma epidemiology in children with alterations in injury mechanism and types with increases in firearm [
      • Cohen JS
      • Donnelly K
      • Patel SJ
      • Badolato GM
      • Boyle MD
      • McCarter R
      • Goyal MK
      Firearms Injuries Involving Young Children in the United States During the COVID-19 Pandemic.
      ], burn [
      • Charvillat O
      • Plancq MC
      • Haraux E
      • et al.
      Epidemiological analysis of burn injuries in children during the first COVID-19 lockdown, and a comparison with the previous five years.
      ,
      • D’Asta F.
      • Choong J.
      • Thomas C.
      Pediatric burns epidemiology during the COVID-19 pandemic and ‘stay home’ era.
      ,
      • Sethuraman U
      • Stankovic C
      • Singer A
      • et al.
      Burn visits to a pediatric burn center during the COVID-19 pandemic and 'Stay at home' period.
      ], dog bite [
      • Dixon CA
      • Mistry RD
      Dog Bites in Children Surge during Coronavirus Disease-2019: A Case for Enhanced Prevention.
      ], and bicycle injuries [
      • Shack M
      • L Davis A
      • Wj Zhang E
      • et al.
      Bicycle injuries presenting to the emergency department during COVID-19 lockdown.
      ,
      • Wells JM
      • Rodean J
      • Cook L
      • et al.
      Injury-Related Pediatric Emergency Department Visits in the First Year of COVID-19.
      ].
      Studies have shown varying results with respect to impact of the COVID-19 pandemic on all cause injury including child physical abuse and maltreatment severity, hospitalization rates and deaths with some showing an increase and others showing a decrease [
      • Sanford EL
      • Zagory J
      • Blackwell JM
      • et al.
      Changes in pediatric trauma during COVID-19 stay-at-home epoch at a tertiary pediatric hospital.
      ,
      • Wells JM
      • Rodean J
      • Cook L
      • et al.
      Injury-Related Pediatric Emergency Department Visits in the First Year of COVID-19.
      ,
      • Yeates EO
      • Grigorian A
      • Schellenberg M
      • et al.
      Effects of the COVID-19 pandemic on pediatric trauma in Southern California.
      ,
      • Shi Y
      • Kvasnovsky C
      • Khan S
      • et al.
      Impact of the COVID-19 pandemic on trauma activations at a pediatric level 1 trauma center in New York.
      ,
      • Swedo E
      • Idaikkadar N
      • Leemis R
      • et al.
      Trends in U.S. Emergency Department Visits Related to Suspected or Confirmed Child Abuse and Neglect Among Children and Adolescents Aged <18 Years Before and During the COVID-19 Pandemic - United States, January 2019-September 2020.
      ,
      • De Boer C
      • Ghomrawi HM
      • Bouchard ME
      • et al.
      Effect of the COVID-19 pandemic on presentation and severity of traumatic injury due to physical child abuse across US children's hospitals.
      ,
      • Chaiyachati BH
      • Wood JN
      • Carter C
      • et al.
      Emergency Department child abuse evaluations during the COVID-19 pandemic: A multicenter study.
      ]. Most of these studies however, are limited by their evaluation of pediatric trauma-related visits and severity during the early part of the pandemic. The impact of the ongoing pandemic on epidemiology of injuries, severity and outcomes is unknown. Longitudinal surveillance of pediatric trauma epidemiology and severity during the pandemic is essential in order for appropriate prevention strategies to be implemented.
      It has been reported that racial, gender and neighborhood level disparities exist in pediatric trauma care [
      • Dickens H
      • Rao U
      • Sarver D
      • et al.
      Racial, Gender, and Neighborhood-Level Disparities in Pediatric Trauma Care.
      ]. While previous studies have reported racial and ethnic disparities in children with respect to SARS-CoV-2 testing, hospitalization, severity of illness and death [
      • Bailey LC
      • Razzaghi H
      • Burrows EK
      • et al.
      Assessment of 135 794 Pediatric Patients Tested for Severe Acute Respiratory Syndrome Coronavirus 2 Across the United States.
      ,
      • Acosta AM
      • Garg S
      • Pham H
      • et al.
      Racial and Ethnic Disparities in Rates of COVID-19Associated Hospitalization, Intensive Care Unit Admission, and In-Hospital Death in the United States From March 2020 to February 2021.
      ,
      • Javalkar K
      • Robson VK
      • Gaffney L
      • et al.
      Socioeconomic and Racial and/or Ethnic Disparities in Multisystem Inflammatory Syndrome.
      ], there is limited data on the association of race and ethnicity on pediatric trauma and severity during the COVID-19 pandemic.
      Our objectives were to compare trauma evaluations, injury severity and outcomes in children ≤ 16 years of age during the early and late COVID-19 pandemic to the pre-pandemic period in an urban level 1 pediatric trauma center and to evaluate the association of race and ethnicity on injury severity in children during the COVID-19 pandemic.

      Methods

      Study Design and Setting

      This was a retrospective study of children ≤ 16 years of age who were evaluated by our trauma team in the pediatric emergency department (PED) between January 1, 2019–December 31, 2021 for either a trauma or burn related injury. Our PED is an urban, American College of Surgeons verified level 1 pediatric trauma and an American Burn Association verified burn center with approximately 80,000 annual visits. Injury related complaints account for 20% of PED visits and of these, 1.5% meet criteria for trauma activation [

      American College of Surgeons. Resources for Optimal Care of the Injured Patient 2014/Resources Repository. https://www.facs.org/quality-programs/trauma/tqp/center-programs/vrc/resources. Published 2014. Accessed October 1st, 2022

      ]. The entire study period was categorized into the following three time periods: pre-pandemic (January 1, 2019–February 28, 2020), early pandemic (March 1, 2020–December 31, 2020), and late pandemic (January 1, 2021–December 31, 2021). The cut off dates for the early pandemic period were chosen based on pandemic declaration by the World Health Organization and encompassed the stay at home and on-line schooling period. The late pandemic period was chosen to correspond to the hybrid option of either return to in person or continuance of virtual school for children in our state []. This study was approved by our institutional review board (20-05-2238).

      Inclusion and Exclusion Criteria

      Children ≤ 16 years of age who had a trauma team consult and evaluation for their injury or burn were included. We excluded children presenting with (1) medical complaints, (2) ingestions, (3) sexual assaults, and (4) injuries that did not require trauma team evaluation. Eligible children were identified through both the trauma and burn registry maintained by our hospital’s trauma data registrars. This registry includes all patients who either presented directly to our PED or were transferred to our institution for an injury or burn chief complaint that met criteria for trauma activation or required a trauma team evaluation.

      Data Abstraction

      Trained research assistants extracted the following data into a secure online REDCap (version 10.3, Vanderbilt University) database [
      • Harris PA
      • Taylor R
      • Thielke R
      • et al.
      Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support.
      ] from electronic medical records based on guidelines provided by Gilbert et al. [
      • Gilbert EH
      • Lowenstein SR
      • Koziol-McClain J
      Chart reviews in emergency medicine research: Where are the methods?.
      ] for chart review studies: patient demographics, chief complaint category, etiology of injury and burn, total body surface area (TBSA) and injury severity score (ISS) when applicable, interventions performed, PED disposition, need for operative intervention, blood product transfusion, length of hospital stay and death. Independent data verification was performed by the senior author for 25% of included patients to assess for accuracy of data abstraction.
      We categorized gender as a dichotomous variable as male and female. We classified race and ethnicity for the study as: (1) non-Hispanic White, (2) non-Hispanic Black, (3) non-Hispanic other, and (4) Hispanic. Severity of injury was classified using injury severity score (ISS) as follows: minor: ISS of 1–8, moderate: ISS of 9–15, severe: 16–24 and very severe: >25. We abstracted the total burn surface are for burn injuries and any burn with TBSA >15% was classified as severe. Etiology of injury was assigned as secondary to child physical abuse for those children who were evaluated and classified as such by the institution’s Child At Risk Evaluation (CARE) team and included both proven and suspected cases of abuse.

      Statistical Analysis

      Continuous data are presented using median and interquartile range (IQR), with comparison performed using the Kruskal-Wallis test while categorical data are presented as percentages, and compared using Pearson’s Chi-square test. For ISS, mean and standard deviation are also provided to aid in interpretation of the linear regression model. To test whether the number of monthly trauma or burn evaluations were different in each time-period, negative binomial regression was used, with monthly ED volume used as an offset in each of the two models (one for each outcome). Generalized linear modeling was used to determine if ISS varied by period, with log-transformation of ISS used in the model owing to right-skewed data. Regression coefficients are presented after back-transformation, and are interpreted as percentage change in ISS, calculated as [(1-parameter estimate)*100]. Model fit was assessed by visual inspection of residual plots and by comparison of Akaike’s Information Criteria (AIC) amongst candidate models. In addition to study period, covariates in the model were study month (from 1–36), age, biologic sex, and ethnicity (categorized as non-Hispanic White (reference group), non-Hispanic Black, Hispanic, and other (Native American, Pacific Islander, mixed, or unknown). Two- and three-way interactions between study period and other covariates were also assessed. Finally, ordinal logistic regression was used to determine whether there was a difference in injury categories between periods. For the purposes of this model, “mild” injuries were defined as those with an ISS of 1–8, “moderate” injuries as ISS of 9–15, and “severe” injuries as ISS >15 or burns >15% BSA. The same covariates, interactions, and model diagnostics were test/used in these models as in the linear models. The proportional odds assumption was assessed with the Chi-Square test and was upheld (p=0.06). Interpretation of odds ratios (OR) in proportional odds models is the OR of being in a higher versus lower outcome category (in this case, the OR of severe versus minor or moderate or the OR of severe or moderate versus minor). Two-tailed significance was set at alpha < 0.05. Tukey adjustment for multiple comparisons was used for period-ethnicity interactions. Statistical analysis was performed using SAS v9.4 (SAS Institute, Cary, NC).

      Results

      A total of 4,940 patients underwent trauma team evaluation during the study period (pre-pandemic: 1,844, early pandemic: 1,317 and late pandemic: 1,779). After adjusting for monthly PED volume, compared to the pre-pandemic period, there was an increased risk for trauma evaluations in children presenting with injuries during both the early (RR: 2.13, 95% CI: 1.6–2.82) and the late pandemic periods (RR: 1.42, 95% CI: 1.09–1.86). However, this risk decreased in the late when compared to the early pandemic period (RR: 0.67, 95% CI: 0.49–0.89). Similarly, burn consults were greater during both the early (RR: 2.24, 95% CI: 1.39–3.63) and late pandemic periods (RR: 2.44, 95% CI: 1.55–3.83) when compared to the pre-pandemic period. There was no significant difference between the late-versus early-pandemic period (RR: 1.09, 95% CI: 0.66–1.78).
      Table 1 lists the patient demographics, injury type and severity and PED disposition. There was no difference in the median age or gender during the three study periods. However, there were significant differences in the mechanism and type of injury during the three periods. While fall was the most common mechanism of injury during the three study periods, there was an increase in gun shot wounds (GSW) in both the early and late pandemic periods. Burns secondary to hot liquids and contact (direct contact with or touching a hot surface such as iron, radiator, oven/stove surface, muffler on car/motorcycle) were the most common mechanisms of burn injuries during all three study periods. There was an increase in lacerations and a slight increase in fractures during both the pandemic periods. While the majority of injuries noted in our cohort were minor, hospital admissions (45.4%: pre-pandemic vs. 55.1%: early pandemic vs. 51.8%: late pandemic) pediatric intensive care unit (PICU) admissions (6.3%: pre-pandemic vs. 8.9%: early pandemic vs. 6.3%: late pandemic), need for endotracheal intubation (4.2%: pre-pandemic vs. 5.0%: early pandemic vs. 3.1%: late pandemic) operative intervention (24.2%: pre-pandemic vs. 29.7%: early pandemic vs. 29.0%: late pandemic) and death from injuries (0.1 %: pre-pandemic vs. 0.6%: early pandemic vs. 0.3%: late pandemic) tended to be higher during the early pandemic period but reverted to pre-pandemic levels during the late pandemic period. There was no difference in the type of injuries that required operative intervention between the three periods with fracture reduction (approximately 30%) being the most common reason for operative intervention followed by burn debridement (10%) by general surgery and repair of complex lacerations secondary to dog bites (10%) by plastic surgery.
      Table1Demographics, injury characteristics and PED disposition.
      VariablePre-pandemic (n=1844)Early Pandemic (n=1317)Late Pandemic (n=1779)p-value
      Comparisons are between proportion (or median) for each variable between periods; for variables with >1 level, the p-value represents an overall significance test of variable level by period.
      Age in years (median/IQR)5.2 (1.8,10.1)5.6 (2.1,10.0)5.2 (2.0, 10.2)0.1
      Sex (n, %)
       Male1090 (59.3)767 (58.3)1063 (59.8)0.7
      Race/ethnicity (n, %)
      Race and ethnicity missing in 4 study patients.
      <0.001
       Non-Hispanic White253 (13.7)168 (12.8)290 (16.3)
       Non-Hispanic Black494 (26.8)340 (25.8)557 (31.3)
       Non-Hispanic Other976 (53.0)677 (51.4)841 (47.3)
       Hispanic118 (6.4)131 (10.0)91 (5.1)
      Mechanism of injury (n,%)<0.0001
       MVC314 (17.0)231 (17.5)278 (15.6)
       Falls509 (27.6)338 (25.7)456 (25.6)
       GSW16 (0.9)26 (2.0)25 (1.4)
       Animal bites176 (9.5)136 (10.3)137 (7.7)
       Child Physical Abuse87 (4.7)69 (5.2)69 (3.9)
       Burns
      the percentages may be >100 secondary to some children having multiple types of burns and injuries.
      494 (26.8)307 (23.3)484 (27.2)
      • Contact Burns
      • Hot Liquid
      • House fire
      • Electric burns
      162

      307

      15

      12
      98

      191

      17

      1
      156

      311

      19

      7
       Others248 (13.5)210 (16.0)330 (18.6)
      Types of injuries (n, %)
      the percentages may be >100 secondary to some children having multiple types of burns and injuries.
      <0.0001
       Head injury319 (17.3)222 (16.9)394 (22.2)
       Fractures380 (20.6)285 (21.6)394 (22.2)
       Abdominal trauma27 (1.5)21(1.6)53 (3.0)
       Thoracic trauma15 (0.8)14 (1.81)21 (1.2)
       Lacerations289 (15.7)255 (19.4)310 (17.4)
       Eye injuries22 (1.2)24 (1.8)25 (1.4)
       Others213 (11.6)150 (11.4)98 (5.5)
      Severity of injuries
      reported after removing those patients with ISS of 0.
      0.03
       Minor981 (82.6)698 (77.8)908 (79.8)
       Moderate143 (12.0)121 (13.5)164 (14.4)
       Severe32 (2.7)40 (4.5)36 (3.2)
       Very Severe32 (2.7)38 (4.2)30 (2.6)
      ISS – Median, IQR
      After excluding patients with burns and patients whose ISS was 0.
      n=1188

      4 (1,5)
      n=897

      4 (1,5)
      n=1138

      4 (1,5)
      0.01
      TBSA – Median1 (0.5,2.5)1.25 (0.5,3)1 (0.5,2.5)0.108
      Blood requirement27 (1.5)32 (2.4)42 (2.4)0.08
      Need for intubation78 (4.2)66 (5.0)54 (3.1)0.01
      Disposition (n, %)0.0004
       Discharge836 (45.4)519 (39.4)777 (43.7)
       Admit954 (51.8)725 (55.1)919 (51.8)
       Death2 (0.1)8 (0.6)6 (0.3)
       OR from ED52 (2.8)65 (4.9)77 (4.3)
      PICU121 (6.3)122 (8.9)117 (6.3)0.0053
      OR requirement during hospitalization447 (24.2)391 (29.7)516 (29.0)0.0006
      Hospital LOS in days (median/IQR)12.0 (3.4,28.1)15.7 (3.9,35.2)14.0 (4.2,28.3)0.0037
      Abbreviations: PED: pediatric emergency department, MVC: motor vehicle accident, GSW: gun shot wound, ISS: injury severity score, TBSA: total burn surface area, ED: emergency department, OR: operating room, PICU: pediatric intensive care unit, LOS: length of stay.
      1 Race and ethnicity missing in 4 study patients.
      2 After excluding patients with burns and patients whose ISS was 0.
      3 Comparisons are between proportion (or median) for each variable between periods; for variables with >1 level, the p-value represents an overall significance test of variable level by period.
      4 the percentages may be >100 secondary to some children having multiple types of burns and injuries.
      5 reported after removing those patients with ISS of 0.
      When compared to the pre-pandemic period, the proportion of children with severe and very severe injuries nearly doubled during the early pandemic period. While this difference persisted during the late pandemic period for severe injuries, there was return to the pre-pandemic proportions for very severe injuries (Table 1).
      Variables included in the final model for ISS were pandemic period, age, biologic sex, study month, and pandemic period-ethnicity interaction (period*ethnicity). No other two- or three-way interactions involving study period were statistically significant. Each one year increase in age was associated with a 1.27% (95% CI: 0.69–1.86) increase in mean ISS. Female sex was associated with a -5.10% (95% CI: -10.31–0.40) decrease in mean ISS, compared to males. The effect of age and biologic sex however did not differ between the study periods. Overall, the association between race and ethnicity and mean ISS did vary by period (p= 0.01 for period*ethnicity interaction). After adjustment for multiple comparisons, significant differences for effects of individual race and ethnicities on mean ISS between studies periods were found. For non-Hispanic Blacks, there was a 43.5% (95% CI: 17.89–74.77, p <0.001) increase in mean ISS in the early-pandemic versus pre-pandemic period and a 39.9% (95% CI: 5.22–85.86, p=0.02) increase in the late-pandemic versus pre-pandemic period; no difference was found for this group between the early and late-pandemic periods. For the “other” ethnicity group, there was a 36.5% (95% CI: 5.03–77.43, p=0.01) increase in mean ISS in the late-pandemic versus pre-pandemic periods but a decrease of 18.7% (95% CI: -31.12– -4.07, p=0.009) in the early-versus late-pandemic period. No significant differences were found for Hispanic and non-Hispanic Whites (Table 2).
      Table 2Impact of demographics and race and ethnicity on percent change in injury severity score during the three study periods.
      Percent change in ISS95% CIp-value
      Period-ethnicity interactions are Tukey adjusted for multiple comparisons.
      Sex-5.10-10.31 - 0.400.06
      Age1.280.69 - 1.86<0.0001
      Non-Hispanic Black
      Early vs. Pre-Pandemic43.5417.89 - 74.77<0.0001
      Late vs. Pre- Pandemic39.855.22 - 85.860.02
      Early vs. Late Pandemic2.64-15.95 - 25.340.95
      Non-Hispanic Other
      Early vs. Pre-Pandemic10.96-6.53 - 31.740.33
      Late vs. Pre-Pandemic36.515.03 - 77.430.01
      Early vs. Late Pandemic-18.71-31.12 - -4.070.01
      Non-Hispanic White
      Early vs. Pre-Pandemic23.93-3.91 - 59.820.12
      Late vs. Pre-Pandemic21.77-11.34 - 67.240.31
      Early vs. Late Pandemic1.77-20.22 - 29.830.98
      Hispanic
      Early vs. Pre-Pandemic4.46-22.38 - 40.590.94
      Late vs. Pre-Pandemic34.50-9.64 - 100.220.19
      Early vs. Late Pandemic-22.33-43.98 - 7.670.17
      *Significant results are bolded.
      a Period-ethnicity interactions are Tukey adjusted for multiple comparisons.
      In the ordinal logistic regression model for severity of injuries, each one-year increase in age and female sex was associated with greater odds of being in a more severely injured category (age: OR:1.03, 95% CI: 1.01–1.05; female sex: OR: 1.23, 95% CI: 1.03–1.47). However, the effect of age and biologic sex on injury severity category did not differ by study period. Overall, the association between race and ethnicity and injury severity category did vary by pandemic period (p=0.004). For non-Hispanic Blacks, the odds of being in a more severe injury category was lower in both the early (OR: 0.36, 95% CI: 0.21–0.60) and the late-pandemic periods (OR: 0.46, 95% CI: 0.22–0.98) as compared to the pre-pandemic period. There was no difference noted between the early- and late-pandemic periods (Table 3). For Hispanic and non-Hispanic white children, there were no differences in severity of injuries between pandemic and early pandemic periods.
      Table 3Ordinal Logistic Model for Impact of demographics and race and ethnicity on odds ratio of being in a more severe injury category across the three study periods.
      Estimate95% CIP-value
      Period-ethnicity interactions are Tukey adjusted for multiple comparisons.
      Sex1.231.03 – 1.470.024
      Age1.031.01 – 1.050.003
      Non-Hispanic Black
      Early vs. Pre-Pandemic
      Significant results are bolded.
      0.360.21- 0.600.0003
      Late vs. Pre-Pandemic
      Significant results are bolded.
      0.460.22- 0.980.041
      Early vs. Late Pandemic0.770.48 - 1.260.55
      Non-Hispanic Other
      Early vs. Pre-Pandemic0.920.58 - 1.460.93
      Late vs. Pre-Pandemic0.930.47 - 1.850.98
      Early vs. Late Pandemic0.990.64 - 1.530.99
      Non-Hispanic White
      Early vs. Pre-Pandemic0.640.34 - 1.220.36
      Late vs. Pre-Pandemic0.770.33 - 1.780.81
      Early vs. Late Pandemic0.830.45 - 1.520.82
      Hispanic
      Early vs. Pre-Pandemic0.900.40 - 2.040.96
      Late vs. Pre-Pandemic0.440.16 - 1.190.24
      Early vs. Late Pandemic2.070.92 - 4.650.19
      a Significant results are bolded.
      b Period-ethnicity interactions are Tukey adjusted for multiple comparisons.

      Discussion

      Our study results show an increased risk for injury and burn evaluations by the trauma team during the early and late pandemic periods when compared to the pre-pandemic period after adjusting for monthly PED volumes. However, this difference was not sustained when comparing the late pandemic period with the early pandemic period with no difference in the trauma team evaluations for burns and a decrease for traumatic injuries. Further, there was a change in trauma epidemiology with increase in gun shot wounds during both the early and late pandemic periods. While hospitalizations, operative intervention and deaths increased during the early pandemic period, they reverted to pre-pandemic levels during the late pandemic period. Lastly, there was a differential effect of ethnicity on injury severity during the three study periods. Non- Hispanic Blacks had an approximately 40% increase in mean ISS but had a lower odds of severe injury during both the early and late pandemic periods. Non- Hispanic other had an increase in mean ISS during the late pandemic period but a decrease in the early pandemic period.
      Our study results of increased trauma evaluations and increase in severity of these injuries in the early pandemic period are similar to that reported by several other studies which report an increase in burn and injury visits to the Emergency Department, severity and hospital admissions [
      • D’Asta F.
      • Choong J.
      • Thomas C.
      Pediatric burns epidemiology during the COVID-19 pandemic and ‘stay home’ era.
      ,
      • Sethuraman U
      • Stankovic C
      • Singer A
      • et al.
      Burn visits to a pediatric burn center during the COVID-19 pandemic and 'Stay at home' period.
      ,
      • Georgeades CM
      • Collings AT
      • Farazi M
      • et al.
      A multi-institutional study evaluating pediatric burn injuries during the COVID-19 pandemic.
      ,
      • Sethuraman U
      • Kannikeswaran N
      • Singer A
      • et al.
      Trauma visits to a pediatric emergency department during the COVID-19 quarantine and “stay at home” period.
      ,
      • Amin D
      • Manhan AJ
      • Mittal R
      • et al.
      Pediatric head and neck burns increased during early COVID-19 pandemic.
      ,
      • Brewster CT
      • Choong J
      • Thomas C
      • et al.
      Steam inhalation and paediatric burns during the COVID-19 pandemic.
      ,
      • Mann JA
      • Patel N
      • Bragg J
      • et al.
      Did children 'stay safe'? Evaluation of burns presentations to a children's emergency department during the period of COVID-19 school closures.
      ,
      • Kruchevsky D
      • Levanon S
      • Givon A
      • et al.
      Israeli Trauma Group. Burns During COVID-19 Lockdown- A Multi-Center Retrospective Study in Israel.
      ,
      • Williams FN
      • Chrisco L
      • Nizamani R
      • et al.
      COVID-19 related admissions to a regional burn center: the impact of shelter-in-place mandate.
      ,
      • Keays G
      • Friedman D
      • Gagnon I
      Injuries in the time of COVID-19.
      ,
      • Reihanian Z
      • Noori Roodsari N
      • Rimaz S
      • et al.
      Traumatic injuries in children during COVID-19 pandemic: a national report from northern Iran.
      ]. Similar to our study, previous studies have also shown a change in injury type with an increase in penetrating wounds [
      • Sanford EL
      • Zagory J
      • Blackwell JM
      • et al.
      Changes in pediatric trauma during COVID-19 stay-at-home epoch at a tertiary pediatric hospital.
      ] and dog bites [
      • Dixon CA
      • Mistry RD
      Dog Bites in Children Surge during Coronavirus Disease-2019: A Case for Enhanced Prevention.
      ,
      • Plana NM
      • Kalmar CL
      • Cheung L
      • et al.
      Pediatric Dog Bite Injuries: A 5-Year Nationwide Study and Implications of the COVID-19 Pandemic.
      ]. Wells et al. [
      • Wells JM
      • Rodean J
      • Cook L
      • et al.
      Injury-Related Pediatric Emergency Department Visits in the First Year of COVID-19.
      ] studied PED visits for injury at 41 children’s hospitals using the Pediatric Health Information System database and compared the injuries during the pandemic (March 15, 2020–March 14, 2021 divided into early, middle and late pandemic periods) and the pre-pandemic period (March 15–March 14, 2017–2020). While they reported a decline in the overall PED visits for injury, which was largely attributed to decline in visits for minor injuries, they reported a significant increase in serious and critical injury related visits across the pandemic. Similar to our study, they also noted an increase in hospital and PICU admissions as well as mortality secondary to injuries throughout the pandemic periods. Some of the postulated mechanisms for increased injury and severity during the pandemic are school closures and reduced supervision at homes, thus mimicking summer months which have high rates of injury and severity. While Wells study [
      • Wells JM
      • Rodean J
      • Cook L
      • et al.
      Injury-Related Pediatric Emergency Department Visits in the First Year of COVID-19.
      ] evaluated injury related visits only until mid March 2021, ours is the first study to our knowledge to report injury epidemiology and severity in children after a full year of return back to in person school and sports activities during the COVID-19 pandemic. While adding to these early pandemic reports, an interesting finding in our study is that with the ongoing pandemic, injury evaluations and their severity reverted to pre-pandemic levels or reduced even further. We postulate that with the continued in person school attendance by children and the improved social conditions during the ongoing pandemic, the risk of injury has stabilized to pre-pandemic levels.
      The increase in GSW seen in our study has been reported in multiple other studies [
      • Cohen JS
      • Donnelly K
      • Patel SJ
      • Badolato GM
      • Boyle MD
      • McCarter R
      • Goyal MK
      Firearms Injuries Involving Young Children in the United States During the COVID-19 Pandemic.
      ,
      • D’Asta F.
      • Choong J.
      • Thomas C.
      Pediatric burns epidemiology during the COVID-19 pandemic and ‘stay home’ era.
      ,
      • Wells JM
      • Rodean J
      • Cook L
      • et al.
      Injury-Related Pediatric Emergency Department Visits in the First Year of COVID-19.
      ,
      • Donnelly MR
      • Grigorian A
      • Swentek L
      • et al.
      Firearm violence against children in the United States: Trends in the wake of the COVID-19 pandemic.
      ,
      • Gastineau KA
      • Williams DJ
      • Hall M
      • et al.
      Pediatric firearm-related hospital encounters during the SARS-CoV-2 pandemic.
      ] Some of the reasons attributed for this include record gun sales during the pandemic which resulted in an increase in access to guns to children and increased risk taking behavior in children who were bored and unsupervised at home [
      • Donnelly MR
      • Grigorian A
      • Swentek L
      • et al.
      Firearm violence against children in the United States: Trends in the wake of the COVID-19 pandemic.
      ,
      • Hoskins K
      • Beidas RS
      Intersection of Surging Firearm Sales and COVID-19, Psychological Distress, and Health Disparities in the US—A Call for Action.
      ].
      Race and ethnicity demonstrated a differential but significant association with injury severity during the pandemic periods with non- Hispanic Blacks having a higher mean ISS during both the pandemic periods, but with reduced odds of being in more severely injured category during the early and late, compared to pre-pandemic, periods. The reason for increase in mean ISS but not severe injury is unclear. Similarly, the reason for an increase in mean ISS in the non-Hispanic other category during the late pandemic period but a decrease during the early pandemic period is unclear. Cutler et al. [
      • Cutler GJ
      • Zagel AL
      • Spaulding AB
      • et al.
      Emergency Department Visits for Pediatric Firearm Injuries by Trauma Center Type.
      ] reported that nearly 60% of firearm injuries in children involved Blacks with a resultant higher mortality. Irizarry et al. [
      • Irizarry CR
      • Hardigan PC
      • Kenney MGM
      • Holmes G
      • Flores R
      • Benson B
      • Torres AM
      Prevalence and ethnic/racial disparities in the distribution of pediatric injuries in South Florida: implications for the development of community prevention programs.
      ] found that while Hispanics had higher relative risks of falls and motor vehicle injuries than Blacks, the latter had higher risk of gunshot wounds. Banks et al. [
      • Banks KC
      • Mooney CM
      • Borthwell R
      • et al.
      Racial disparities among trauma patients during the COVID-19 pandemic.
      ], evaluating racial disparities among adult trauma patients during the COVID-19 pandemic, found a significant increase in percentage of Black and Hispanic patients presenting to a level one trauma center during the pandemic when compared to the pre-pandemic period. Wells et al. [
      • Wells JM
      • Rodean J
      • Cook L
      • et al.
      Injury-Related Pediatric Emergency Department Visits in the First Year of COVID-19.
      ] reported similar results of larger increases in PED visits for serious and critical injuries among Black, Hispanic and Asian children during the pandemic. We propose that children from socio-economically disadvantaged communities who were amongst the hardest hit with severe COVID-19 illness [
      • Acosta AM
      • Garg S
      • Pham H
      • et al.
      Racial and Ethnic Disparities in Rates of COVID-19Associated Hospitalization, Intensive Care Unit Admission, and In-Hospital Death in the United States From March 2020 to February 2021.
      ] may have experienced decreased supervision secondary to higher proportions of parents being essential workers, fractured family/school structure, and limited access to health care, all of which could account for some of our findings. However, the reason for differential effect during the various time periods of pandemic among different ethnicities is not easily explained. These nuanced differences highlight the need for ongoing surveillance for injury patterns and severity among different race and ethnicities during the pandemic.

      Limitations

      The retrospective nature of the study could have limited the information that was available. However, we reviewed the PED note as well as trauma team notes. This was a single center study conducted at an urban, level 1 trauma and burn center and these results may not be applicable to other settings. Further, we did not evaluate all injury presentations to the PED and analyzed only those patients who were captured by the trauma and burn data registries. Thus, our study does not reflect the epidemiology of all injury presentations to the PED during the COVID-19 pandemic and could have skewed our data against minor injury presentations. Further, we did not study sexual assaults and abuse. Only a minority of our cohort had a severe injury. Further, race and ethnicity information was missing in about one third of patients and 243 patients had an ISS of zero. These could have impacted the results of these associations with severe injury. Given that the pandemic was declared only in March 2020, the time intervals were not equal between the three study periods. This variation in the length of study periods could have resulted in difference in number of subjects during each period and impacted our results.

      Conclusions

      In our institution, there was an increase in trauma evaluations for injuries and burns as well as an increase in proportions of hospital and pediatric intensive care unit admissions and need for operative intervention during the early and late pandemic periods when compared to the pre-pandemic period. Further, there was a significant association of race and ethnicity with injury severity which varied during the different pandemic periods. Continued longitudinal surveillance of injury epidemiology, severity and risk factors for severe injury are needed during the ongoing pandemic so that appropriate prevention and mitigation strategies can be implemented.

      Acknowledgement

      The authors would like to acknowledge Jazmine Ruiz for her help with patient enrollment and data entry for this study.

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