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Brief Clinical Report

The Effect of California’s Stay-at-Home Order on Trauma Patient Volume During the Coronavirus Disease 2019 Pandemic

Beyer, Carl A. MD*; Hopper, Leslie D. MD*; French, Casey E. DO*; Galante, Joseph M. MD*; Callcut, Rachel A. MD*

Author Information
doi: 10.1097/AS9.0000000000000005
  • Open


Novel coronavirus disease 2019 (COVID-19) was first identified in December 2019.1 The subsequent pandemic has challenged governments and health systems around the world. In an effort to curb transmission, many localities have enacted strict control measures, including banning nonessential travel, conducting symptom screening, and enacting quarantine for suspected cases.2 California was the first US state to issue a stay-at-home order on March 19, 2020, which remains in effect over 6 weeks later.3 These restrictions, reducing travel and social interaction, may impact trauma patient volume, but there has been no long-term quantitative research examining this effect. We hypothesized that the weekly volume of trauma activations would be lower in the 6 weeks following California’s stay-at-home order, compared with the same timeframe during the 2 previous years.


This study was considered exempt by the Institutional Review Board. Our hospital is an American College of Surgeons-verified adult and pediatric level 1 trauma center in Northern California covering a region with roughly 6 million people spread across 65,000 square miles. The weekly summary data for all trauma activations were recorded for the 6-week period from March 19 through April 29 during the years 2018 to 2020. No changes to the standard of care were implemented, nor were trauma center resources redirected at our center in response to the pandemic. Data collected included the total number of activations, the number of activations at each acuity level (level 1, level 2, and level 3), and the number of pediatric traumas. The activation acuity is determined by the emergency department internal triage officer using an algorithm. This algorithm includes vital signs, patient age, and specific mechanisms of injury (Table 1). Activations for those younger than 14 years of age were classified as pediatric traumas.

Table 1.
Table 1.:
Algorithm to Determine Level of Trauma Activation Used by the Emergency Department Internal Triage Officer

Student t test was used to compare the mean number of activations during the years before the stay-at-home order to the current year. Data are presented as mean (standard deviation). An analysis of variance (ANOVA) with repeated measures was used to compare the trends in weekly activations between years. Statistical significance was set at <0.05. Statistical analyses were performed using Stata version 16 (Stata Corp., College Station, TX).


There were 2299 trauma activations during the 18 weeks of this study. In the period after the stay-at-home order, there was a significant reduction in the mean weekly number of total trauma activations (141.3 [15.9] vs 100.5 [11.9]; P < 0.001), level 2 activations (53.9 [7.4] vs 34.7 [5.6]; P < 0.001), and level 3 activations (56.0 [9.5] vs 32.7 [5.2]; P < 0.001). There was no difference in the mean weekly number of level 1 activations (24.1 [6.8] vs 26.0 [7]; P = 0.584) or pediatric trauma activations (16.8 [5.8] vs 11.8 [4.2]; P = 0.086) in the period after the stay-at-home order when compared with the same time periods during the prior 2 years. On ANOVA, there was a significant difference in the weekly trends in total activations (Fig. 1), level 2 activations, and level 3 activations (all P < 0.001). There was no significant difference in the weekly trends for level 1 (P = 0.782) or pediatric (P = 0.118) trauma activations.

Total weekly trauma activations at a level 1 trauma center during the 6 weeks following California’s stay-at-home order and during the same timeframe in the previous 2 years.


This study is the first to evaluate the longer-term effects of government restrictions in response to the COVID-19 pandemic, and it shows that total trauma volume was decreased in the 6 weeks following the enactment of California’s stay-at-home order. As health systems have shifted focus to caring for COVID-19 patients, they have drawn on the expertise of all specialties, including trauma surgeons, to assist overwhelmed medical intensive care units. Although the surgical workforce is a resource, it is also important to consider what is needed for those requiring non-COVID-related surgical care, including for trauma. Trauma is the leading cause of death for those 1 to 44 years old, and trauma patient volume is an important indicator for resource allocation.4 A recent small study from New Zealand demonstrated lower trauma volumes in the 14 days following a shelter-in-place order.5 Similarly, another study showed a 4.8-fold decrease in total trauma volume in the immediate 15 days after the enactment of a stay-at-home order.6 In contrast, some authors have suggested that a similar order in Philadelphia actually led to an increase in firearm violence, although this was not quantified.7 Although total trauma volume in this study was lower, our data showed that level 1 trauma activations and pediatric traumas were unchanged from the same timeframe in prior years. Future studies should include individual patient outcomes data, ideally from multiple centers, to better understand the effects of COVID-19-related restrictions. As organizations consider how to redeploy resources for additional waves of COVID-19 patients, trauma care capacity must be maintained for seriously injured adults and children.


1. Zhu N, Zhang D, Wang W, et al.; China Novel Coronavirus Investigating and Research Team. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 2020; 382:727–733
2. Cheng H, Jian S, Liu D, et al. Contact tracing assessment of COVID-19 transmission dynamics in Taiwan and risk at different exposure periods before and after symptom onset. JAMA Intern Med. 2020. [Epub ahead of print]
3. Executive Order N-33-20. Executive Department, State of California. Available at: Accessed May 4, 2020.
4. Stonko DP, Dennis BM, Callcut RA, et al. Identifying temporal patterns in trauma admissions: Informing resource allocation. PLoS One. 2018; 13:e0207766
5. Christen G, Amey J, Campbell A, Smith A. Variation in volumes and characteristics of trauma patients admitted to a level one trauma centre during national level 4 lockdown for COVID-19 in New Zealand. N Z Med J. 2020; 133:81–88
6. Forrester JD, Liou R, Knowlton LM, et al. Impact of shelter-in-place order for COVID-19 on trauma activations: Santa Clara County, California, March 2020. Trauma Surg Acute Care Open. 2020; 5:e505
7. Hatchimonjii JS, Swendiman RA, Seamon MJ, Nance ML. Trauma does not quarantine: violence during the COVID-19 pandemic. Ann Surg. 2020; 272:e53–e54
Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.