Major trauma presentations and patient outcomes in English hospitals during the COVID-19 pandemic: An observational cohort study

Carl Marincowitz , Omar Bouamra, Tim Coats, Dhushy Kumar, David Lockey, Lyndon Mason, Virginia Newcombe, Julian Thompson, Antoinette Edwards, Fiona Lecky


Single-centre studies suggest that successive Coronavirus Disease 2019 (COVID-19)-related “lockdown” restrictions in England may have led to significant changes in the characteristics of major trauma patients. There is also evidence from other countries that diversion of intensive care capacity and other healthcare resources to treating patients with COVID-19 may have impacted on outcomes for major trauma patients. We aimed to assess the impact of the COVID-19 pandemic on the number, characteristics, care pathways, and outcomes of major trauma patients presenting to hospitals in England.


To control transmission of the Coronavirus Disease 2019 (COVID-19) during the pandemic, the United Kingdom government implemented successive lockdown measures in England [1]. The first lockdown was announced on 23 March 2020, and, following a period of relaxation, a second lockdown was announced on 30 October due to the emergence of the Alpha variant. By September 2021, there was a 16% reduction in road traffic from prepandemic levels [2]. This presents a unique opportunity to assess the impact of potential road traffic reducing public health measures on major trauma [3].

There is some evidence that restrictions associated with lockdowns may have contributed to increased nonaccidental injury, domestic violence, and self-harm related to deteriorating mental health [4–6]. Internationally, there is also evidence that the diversion of healthcare resources to treating patients with COVID-19, particularly intensive care capacity, may have led to worse outcomes for patients presenting with major trauma [7].

Materials and method

We conducted an observational cohort study and interrupted time series (ITS) analysis to test that hypothesis that disruption of care due to COVID restrictions reduced likelihood of survival following major trauma. The protocol and prespecified analysis are publicly available and included in S1 Appendix [13]. All analyses were conducted in accordance the prespecified plan with no additional exploratory analysis. This study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline (S1 Checklist).


Fig 1 shows the identification of the study cohort and subgroups across the time period (January 2017 to September 2021) of the time series analysis including the comparative analysis during the 2 lockdowns (Period 1: 24 March 2020 to 3 July 2020; Period 2: 1 November 2020 to 16 May 2022) and equivalent prelockdown periods.


We have conducted a national cohort study using trauma registry data to assess the impact of successive lockdowns on trauma presentations and treatment pathways in England. The first lockdown had a larger associated reduction in total trauma volume (−21%) compared to the pre-COVID period than the second lockdown (−6.7%). There were large reductions in trauma related to car occupant and pedestrian road traffic accidents associated with both lockdowns but an increase in cyclist-related trauma, particularly during the first lockdown (Fig 4A and Table 1). Both lockdowns were associated with an increase in the average age of trauma patients compared to the pre-COVID comparator periods (Table 1). Smaller reductions in trauma were observed for those 85 and over (−12.2%) with the first lockdown and trauma volume increased for those 65 and over (3%) and 85 and over (9.3%) during the second lockdown, with corresponding increases in comorbidity (Table 1).


In the first evaluation of the impact of COVID restrictions on major trauma presentations, care pathways, and outcomes in England, large reductions in overall trauma volume were observed particularly in interpersonal violence and both occupant- and pedestrian-related road traffic collisions. Future research is needed to better understand the initial reduction in likelihood of survival after major trauma observed with the implementation of the first lockdown to prevent this occurring if similar measures are introduced again.

Citation: Marincowitz C, Bouamra O, Coats T, Kumar D, Lockey D, Mason L, et al. (2023) Major trauma presentations and patient outcomes in English hospitals during the COVID-19 pandemic: An observational cohort study. PLoS Med 20(6): e1004243.

Academic Editor: Martin Schreiber, Oregon Health and Science University, UNITED STATES

Received: October 25, 2022; Accepted: May 19, 2023; Published: June 14, 2023

Copyright: © 2023 Marincowitz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data used for this study were collected by the Trauma Audit and Research Network (TARN), based at the University of Manchester and analysed by the TARN research committee. The data used for this study can be requested from the TARN research committee ( but may require a data sharing agreement and additional ethics approvals.

Funding: This study did not receive any external funding and has been completed by the Trauma Audit and Research Network (TARN) research committee and collaborators.

Competing interests: The authors have declared that no competing interests exist.Abbreviations: COVID-19, Coronavirus Disease 2019; ED, emergency department; ICU, intensive care unit; ISS, Injury Severity Score; ITS, interrupted time series; MTC, major trauma centre; TARN, Trauma Audit and Research Network



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