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Coronavirus disease 2019 (COVID-19) has placed unprecedented demand on healthcare services around the world. In some countries, surges in infection rates have overwhelmed the capacity of hospitals. Reported rates of intensive care unit (ICU) admission among patients with COVID-19 disease have varied widely from 3% to 100%.1 Although the true rate of ICU admission among patients with COVID-19 is not certain, it is clear that many patients who are admitted to the ICU require prolonged periods of invasive mechanical ventilation. Because such specialised care can only safely be provided by trained ICU staff in an ICU environment, ICU capacity is an important issue to consider in relation to the readiness of hospital systems to deal with surges in infection rates. New Zealand has among the lowest level of ICU beds per capita in the OECD at four per 100,000 population.2 This compares to Australia at nine, France at 16 and Germany at 34.2 During business as usual, the degree of capacity constraint is such that in 2018, 17% of all New Zealand elective surgical operations that required planned post-operative admission to an ICU had to be postponed because of the lack of an available ICU bed.3 The comparable rate for Australian ICUs over the same time period was 1.7%.3 Accordingly, during the COVID-19 epidemic, ICU capacity is a potential point of particular vulnerability in the New Zealand healthcare system. While plans to mitigate the critical lack of ICU capacity by purchasing ventilators and other respiratory equipment, using non-ICU areas and non-ICU staff to care for ICU patients, have been developed, the most important component of New Zealand’s COVID-19 response to date has been the public health response. New Zealand’s five-week restrictive Alert Level 4 lockdown and subsequent two-week Alert Level 3 lockdown phase resulted in prolonged elimination of COVID-19 from New Zealand. The association between these interventions and the unplanned (emergency) admissions to the ICU have not been reported. This information is important because the degree to which lockdowns can effect unplanned ICU admissions is a relevant consideration in determining the risk of ICU capacity being overwhelmed in subsequent COVID-19 surges where lockdowns are imposed. Accordingly, we undertook a retrospective study to evaluate rates of unplanned ICU admissions before, during, and after New Zealand’s COVID-19 Alert Level 4/3 lockdown. We also sought to describe the characteristics and outcomes of patients admitted to Wellington ICU during lockdown in comparison to historical controls.

Method

Study design, setting and oversight

We conducted a retrospective cohort study using data from the Wellington Hospital ICU database, which contains information on all admissions to the ICU. Wellington ICU is a 24-bed facility providing tertiary services to a population of 1.1 million New Zealanders from 10 hospitals across seven other District Health Boards in the lower North Island and upper South Island.

The study was approved by the New Zealand Health and Disability Ethics Committee (Ref 20/NTB/219). As the study involved retrospective review of deidentified data, requirements for informed consent were waived.

Study population

Patients were eligible for inclusion if they had an unplanned admission to Wellington ICU during the first 35 weeks of the year in any year from 2015 to 2020 inclusive. Unplanned ICU admissions were defined as all admissions except for those that were planned to occur following elective surgery.

For the purposes of comparing the characteristics and outcomes of patients admitted during COVID-19 lockdown we focused on the period from 25 March until 12 May inclusive, which corresponded to the five weeks of New Zealand’s Alert Level Four and the subsequent two weeks of Alert Level Three.4 Patients admitted in 2020 were defined as the COVID-19 lockdown cohort. Those patients admitted from 2015 to 2019 were defined as the historical controls.

Exposures and variables of interest

The primary exposure of interest was the 2020 COVID-19 lockdown. The primary variable of interest was the rate of unplanned ICU admission. However, we also sought to describe the demographics, illness severity, reasons for ICU admission, ICU admission duration, ICU mortality and hospital outcomes of patients with unplanned admissions to ICU during the 2020 COVID-19 lockdown compared to historical controls.

Recorded data

Age, gender and ethnicity were recorded. Ethnicity was categorised using the New Zealand Ministry of Health’s ethnic group priority order with each person assigned to a single ethnic group.5 We recorded the source of ICU admission divided into the following categories: (i) operating theatre following emergency surgery; (ii) emergency department; (iii) hospital ward; (iv) transfer from another hospital (except for from another ICU); and (v) transfer from another ICU. We recorded the illness severity using the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score. The APACHE-II score is calculated based on the presence of comorbidities and the most deranged physiological variables from the first 24 hours in the ICU. The APACHE-II score can range from 0 to 71, with a higher score indicating more severe disease and a higher risk of death. ICU admission diagnoses were aggregated by body system using APACHE-II diagnostic categories. We recorded the ICU length of stay, the ICU mortality, and the discharge destination from Wellington Hospital, where the ICU is situated.

Statistical analyses

The principal comparison was of the unplanned daily ICU admission rates in the pre-lockdown, lockdown and post-lockdown periods with admission rates in 2020 compared to historical controls based on the average admission rates obtained from equivalent weeks of the year from 2015 to 2019 inclusive.

We compared the demographics, ICU admission characteristics, illness severity, ICU admission durations, ICU mortality and hospital outcomes of patients admitted during the lockdown compared with historical controls. To provide further information, we reported the ICU admission diagnoses by body system for 2020 and for each of the preceding five years.

Comparisons between groups were performed using chi-square tests for proportions, Student’s t tests for normally distributed data and Wilcoxon rank-sum tests otherwise with results reported as an n with percentages, means±SDs, or median (interquartile range), respectively.

All analyses were performed using Microsoft Excel 2010. A two-sided p value of less than 0.05 was used to indicate statistical significance.

Results

The number of ICU admissions per month during the first 35 weeks of 2020 compared to the historical average based on ICU admission rates in the equivalent weeks from the prior five years are shown in Figure 1. In the 13 weeks of 2020 prior to lockdown there were an average of 2.41±1.40 unplanned ICU admissions per day compared to the historical average of 2.61±1.40 unplanned ICU admissions per day (P=0.23). During the five weeks of Alert Level Four, and the subsequent two weeks of Alert Level Three, the number of unplanned ICU admissions per day fell to 1.65±1.52 compared to a historical average of 2.56±1.52 ICU unplanned ICU admissions per day (P<0.0001). Since the end of Alert Level 3 in Wellington there have been 2.60±1.52 unplanned ICU admissions per day compared to a historical average of 2.79±1.51 unplanned ICU admissions per day (P=0.29).

The characteristics and outcomes of patients with an unplanned admission to Wellington ICU during New Zealand’s COVID-19 lockdown and of the patients admitted in the equivalent weeks of the year from the prior five years were similar and are shown in Table 1. Additional data on the breakdown of the COVID-19 and historical control admissions by ethnicity are shown in Table 2.

A breakdown of ICU admission diagnoses categorised by body system during the 2020 lockdown dates and during the preceding five years is shown in Figure 2. The number of admissions in the cardiovascular, gastrointestinal, sepsis, trauma and metabolic categories was lower than any of the preceding five years. The greatest number of admissions was in the neurologic category where admission rates were just above the median of the prior 5 years (Table 3).

Table 1: Characteristics and outcomes of unplanned admissions to Wellington ICU during New Zealand’s COVID-19 Alert Level 3 and Alert Level 4 lockdown compared with historical controls.*

*Unplanned ICU admissions were defined as all ICU admissions except for those that were booked to occur after elective surgery. Data for historical controls were obtained from the equivalent dates to the 2020 COVID-19 lockdown but from the 2015 to 2019 inclusive. †P value calculated using X2 disregarding cells with a frequency less than five. ‡Residual categories includes “don’t know”; “refused to answer”; “response unidentifiable”; “not stated”. ¶Scores on the APACHE II range from 0 to 71, with higher scores indicating more severe disease and a higher risk of death. Abbreviations: APACHE: Acute Physiology and Chronic Health Evaluation; ICU: Intensive Care Unit; OT: operating theatre.

Table 2: Detailed breakdown of unplanned ICU admissions by ethnic group.*

*For people who identified as belonged to more than one ethnic group, the following ethnic group priority order was used to allocate each person to a single category: NZ Māori, Tokelauan, Fijian, Niuean, Tongan, Cook Island Maori, Samoan, Pacific people not further defined, South East Asian, Indian, Chinese, Other Asian, Asian not further defined, Latin American/Hispanic, African, Middle Eastern, Other ethnicity, Other European, European not further defined, NZ European, don’t know, refuse to answer, response unidentifiable, not stated.

Figure 1: Unplanned admissions to Wellington ICU by week before, during and after COVID-19 Alert Levels 3 and 4.*

*Red shading corresponds to the dates of Alert Level 4 (from 25 March until 26 April); orange shading corresponds to the dates of Alert Level 3 (from 27 April until 13 May). Historical averages were calculated using ICU admission data for equivalent weeks of the year 2015 to 2019 inclusive with error bars representing the standard deviation; only positive error bars are shown.

Table 3: Unplanned ICU admissions by body system.

Figure 2: Unplanned admissions to Wellington ICU from 25 March until 13 May by year categorised by body system.*

*In 2020 these dates correspond to Alert Level 4 (from 25 March until 26 April) and Alert Level 3 (from 27 April until 13 May). Abbreviations: ICU: intensive care unit.

Discussion

In this single-centre retrospective cohort study conducted at Wellington Hospital ICU we observed a highly statistically significant reduction in unplanned ICU admissions associated with New Zealand’s COVID-19 lockdown. The number of unplanned ICU admissions decreased by just over a third compared to historical controls, with the reduction in admissions appearing to begin in the first week of Alert Level 4. The observed reduction in ICU admission rates appeared to occur for most categories of ICU admission diagnosis because, except for patients with neurologic disorders, observed unplanned ICU admission rates were low by historical standards. Unplanned ICU admission rates quickly returned to historical levels in the post-lockdown period.

One potential concern with the lockdown is that patients with potentially life-threatening diseases may not have presented to hospital. Our data do not preclude this possibility; however, we observed that the characteristics and outcomes of patients who had unplanned admissions to Wellington ICU during the COVID-19 lockdown where broadly similar to historical controls. In particular, the breakdown of patients with unplanned admissions by ethnic group does not support the hypothesis that access to ICU during COVID-19 differed by ethnic group.

Our findings are consistent with prior studies evaluating the association between COVID-19 lockdowns and hospital presentations. These include a New Zealand study which reported a 43% reduction in injury-related presentations to level one trauma centre during lockdown.6 International studies have shown a consistent and significant reduction in acute heart failure presentations in Italy,7 paediatric emergency department presentations in Italy,8 tertiary-care ophthalmology presentations in India,9 and oral and maxillofacial trauma presentations to a central London hospital.10 To our knowledge this is the first study to evaluate the association between a COVID-19-related lockdown and unplanned ICU admission rates. Only one patient with COVID-19 was admitted to Wellington ICU during the COVID-19 lockdown. As a consequence, the data presented here largely reflect the association between lockdown and ICU admissions that are unrelated to COVID-19. The observation that unplanned ICU admission rates fell concurrently with the start of Alert Level 4 and that the number of unplanned ICU admissions per day was just over a third lower than historical levels has potential implications to New Zealand’s planning for future surges in infections. If these findings are confirmed in other New Zealand ICUs this would suggest that the available ICU capacity freed up by a lockdown, will substantially exceed the amount of ICU capacity that would be freed up by simply cancelling elective operations that require patients to receive post-operative ICU care.

While our study provides comprehensive data on a highly statistically significant association between New Zealand’s COVID-19 lockdown and a reduction in unplanned admissions to Wellington Hospital ICU, it has several limitations. Firstly, our sample size is small and true differences between the characteristics of the COVID-19 cohort and historical controls may not have been evident in our analyses due to a lack of statistical power to detect such differences. Secondly, our retrospective design does not allow us to attribute a causal link between the period of lockdown and observed unplanned admission rates. Accordingly, we cannot be certain that similar reductions an unplanned ICU admission rates would be observed in future lockdowns. Thirdly, it is unclear whether or not our findings are generalisable to hospitals outside of New Zealand or, indeed, whether they even apply to other New Zealand hospitals. Finally, our observation that rates of unplanned ICU admissions in all categories except for those in patients with neurologic disorders were low by historical standards is based on a small number of events and may have occurred due to the play of chance. We cannot preclude the possibility that the drop in unplanned ICU admissions associated with lockdown is attributable to reductions in admissions in a more limited number of diagnostic categories.

Our findings should prompt further research evaluating the association between the COVID-19 lockdown and unplanned ICU admission rates in other New Zealand hospitals and comparative studies that evaluate whether the association between lockdowns and unplanned ICU admissions differed in other countries that took a less restrictive approach to lockdown.

Conclusions

In this study, we observed a reduction in unplanned admissions to Wellington Hospital ICU associated with New Zealand’s initial COVID-19 lockdown. There were no significant differences in the characteristics of patients who had an unplanned admission to Wellington ICU during the COVID-19 lockdown compared with historical controls.

Summary

Abstract

Aim

To evaluate rates of unplanned ICU admissions before, during and after New Zealand’s COVID-19 Alert Level 4/3 lockdown, and to describe the characteristics and outcomes of patients admitted to Wellington ICU during lockdown in comparison to historical controls.

Method

We conducted a retrospective cohort study using the Wellington Hospital ICU database and included patients with an unplanned ICU admission during the first 35 weeks of the year from 2015 to 2020 inclusive. The primary variable of interest was the rate of unplanned ICU admission in 2020 compared with historical controls. We also described the characteristics and outcomes of patients with unplanned admissions to ICU during the 2020 COVID-19 lockdown compared to historical controls.

Results

During the five weeks of Alert Level Four, and the subsequent two weeks of Alert Level Three, the number of unplanned ICU admissions per day fell to 1.65±1.52 compared to a historical average of 2.56±1.52 ICU unplanned ICU admissions per day (P<0.0001). The observed reduction in ICU admission rates appeared to occur for most categories of ICU admission diagnosis but was not evident for patients with neurologic disorders. The characteristics and outcomes of patients who had unplanned admissions to Wellington ICU during the COVID-19 lockdown were broadly similar to historical controls. The rate of unplanned ICU admissions in 2020 before and after the lockdown period were similar to historical controls.

Conclusion

In this study, we observed a reduction in unplanned admissions to Wellington Hospital ICU associated with New Zealand’s initial COVID-19 lockdown.

Author Information

Paul J Young, Co-Clinical Leader, Intensive Care Unit, Wellington Hospital, Wellington; Deputy Director, Medical Research Institute of New Zealand, Wellington; Benjamin Gladwin, Intensive Care Registrar, John Hunter Hospital, Newcastle, New South Wales, Australia; Alex Psirides, Co-Clinical Leader, Intensive Care Unit, Wellington Hospital, Wellington; Alice Reid, Research Fellow, Medical Research Institute of New Zealand, Wellington.

Acknowledgements

This research was conducted during the tenure of a Health Research Council of New Zealand Clinical Practitioner Research Fellowship held by Paul Young. The Medical Research Institute of New Zealand is supported by Independent Research Organisation funding from the Health Research Council of New Zealand.

Correspondence

Dr Paul Young, Intensive Care Unit, Wellington Hospital, Private Bag 7902, Wellington South.

Correspondence Email

paul.young@ccdhb.org.nz

Competing Interests

Nil.

1. Abate SM, Ahmed Ali S, Mantfardo B, Basu B. Rate of Intensive Care Unit admission and outcomes among patients with coronavirus: A systematic review and Meta-analysis. PLoS One. 2020; 15:e0235653.

2. http://www.oecd.org/coronavirus/en/data-insights/intensive-care-beds-capacity (Accessed 10th September 2020)

3. http://www.anzics.com.au/wp-content/uploads/2020/08/2018_19-CCR-Activity-Report.docx.pdf (Accessed 10th September 2020)

4. http://covid19.govt.nz/alert-system/alert-system-overview/ (Accessed 10th September 2020)

5. http://www.health.govt.nz/nz-health-statistics/data-references/code-tables/common-code-tables/ethnicity-code-tables (Accessed 10th September 2020)

6. Christey 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; 133:81–8.

7. Colivicchi F, Di Fusco SA, Magnanti M, Cipriani M, Imperoli G. The Impact of the Coronavirus Disease-2019 Pandemic and Italian Lockdown Measures on Clinical Presentation and Management of Acute Heart Failure. J Card Fail. 2020; 26:464–5.

8. Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Delayed access or provision of care in Italy resulting from fear of COVID-19. Lancet Child Adolesc Health. 2020; 4:e10–e1.

9. Babu N, Kohli P, Mishra C, et al. To evaluate the effect of COVID-19 pandemic and national lockdown on patient care at a tertiary-care ophthalmology institute. Indian J Ophthalmol. 2020; 68:1540–4.

10. Yeung E, Bradsma DS, Karst FW, Smith C, Fan KFM. The Influence of 2020 Coronavirus Lockdown on Presentation of Oral and Maxillofacial Trauma to a central London hospital. Br J Oral Maxillofac Surg. 2020.

Contact diana@nzma.org.nz
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Coronavirus disease 2019 (COVID-19) has placed unprecedented demand on healthcare services around the world. In some countries, surges in infection rates have overwhelmed the capacity of hospitals. Reported rates of intensive care unit (ICU) admission among patients with COVID-19 disease have varied widely from 3% to 100%.1 Although the true rate of ICU admission among patients with COVID-19 is not certain, it is clear that many patients who are admitted to the ICU require prolonged periods of invasive mechanical ventilation. Because such specialised care can only safely be provided by trained ICU staff in an ICU environment, ICU capacity is an important issue to consider in relation to the readiness of hospital systems to deal with surges in infection rates. New Zealand has among the lowest level of ICU beds per capita in the OECD at four per 100,000 population.2 This compares to Australia at nine, France at 16 and Germany at 34.2 During business as usual, the degree of capacity constraint is such that in 2018, 17% of all New Zealand elective surgical operations that required planned post-operative admission to an ICU had to be postponed because of the lack of an available ICU bed.3 The comparable rate for Australian ICUs over the same time period was 1.7%.3 Accordingly, during the COVID-19 epidemic, ICU capacity is a potential point of particular vulnerability in the New Zealand healthcare system. While plans to mitigate the critical lack of ICU capacity by purchasing ventilators and other respiratory equipment, using non-ICU areas and non-ICU staff to care for ICU patients, have been developed, the most important component of New Zealand’s COVID-19 response to date has been the public health response. New Zealand’s five-week restrictive Alert Level 4 lockdown and subsequent two-week Alert Level 3 lockdown phase resulted in prolonged elimination of COVID-19 from New Zealand. The association between these interventions and the unplanned (emergency) admissions to the ICU have not been reported. This information is important because the degree to which lockdowns can effect unplanned ICU admissions is a relevant consideration in determining the risk of ICU capacity being overwhelmed in subsequent COVID-19 surges where lockdowns are imposed. Accordingly, we undertook a retrospective study to evaluate rates of unplanned ICU admissions before, during, and after New Zealand’s COVID-19 Alert Level 4/3 lockdown. We also sought to describe the characteristics and outcomes of patients admitted to Wellington ICU during lockdown in comparison to historical controls.

Method

Study design, setting and oversight

We conducted a retrospective cohort study using data from the Wellington Hospital ICU database, which contains information on all admissions to the ICU. Wellington ICU is a 24-bed facility providing tertiary services to a population of 1.1 million New Zealanders from 10 hospitals across seven other District Health Boards in the lower North Island and upper South Island.

The study was approved by the New Zealand Health and Disability Ethics Committee (Ref 20/NTB/219). As the study involved retrospective review of deidentified data, requirements for informed consent were waived.

Study population

Patients were eligible for inclusion if they had an unplanned admission to Wellington ICU during the first 35 weeks of the year in any year from 2015 to 2020 inclusive. Unplanned ICU admissions were defined as all admissions except for those that were planned to occur following elective surgery.

For the purposes of comparing the characteristics and outcomes of patients admitted during COVID-19 lockdown we focused on the period from 25 March until 12 May inclusive, which corresponded to the five weeks of New Zealand’s Alert Level Four and the subsequent two weeks of Alert Level Three.4 Patients admitted in 2020 were defined as the COVID-19 lockdown cohort. Those patients admitted from 2015 to 2019 were defined as the historical controls.

Exposures and variables of interest

The primary exposure of interest was the 2020 COVID-19 lockdown. The primary variable of interest was the rate of unplanned ICU admission. However, we also sought to describe the demographics, illness severity, reasons for ICU admission, ICU admission duration, ICU mortality and hospital outcomes of patients with unplanned admissions to ICU during the 2020 COVID-19 lockdown compared to historical controls.

Recorded data

Age, gender and ethnicity were recorded. Ethnicity was categorised using the New Zealand Ministry of Health’s ethnic group priority order with each person assigned to a single ethnic group.5 We recorded the source of ICU admission divided into the following categories: (i) operating theatre following emergency surgery; (ii) emergency department; (iii) hospital ward; (iv) transfer from another hospital (except for from another ICU); and (v) transfer from another ICU. We recorded the illness severity using the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score. The APACHE-II score is calculated based on the presence of comorbidities and the most deranged physiological variables from the first 24 hours in the ICU. The APACHE-II score can range from 0 to 71, with a higher score indicating more severe disease and a higher risk of death. ICU admission diagnoses were aggregated by body system using APACHE-II diagnostic categories. We recorded the ICU length of stay, the ICU mortality, and the discharge destination from Wellington Hospital, where the ICU is situated.

Statistical analyses

The principal comparison was of the unplanned daily ICU admission rates in the pre-lockdown, lockdown and post-lockdown periods with admission rates in 2020 compared to historical controls based on the average admission rates obtained from equivalent weeks of the year from 2015 to 2019 inclusive.

We compared the demographics, ICU admission characteristics, illness severity, ICU admission durations, ICU mortality and hospital outcomes of patients admitted during the lockdown compared with historical controls. To provide further information, we reported the ICU admission diagnoses by body system for 2020 and for each of the preceding five years.

Comparisons between groups were performed using chi-square tests for proportions, Student’s t tests for normally distributed data and Wilcoxon rank-sum tests otherwise with results reported as an n with percentages, means±SDs, or median (interquartile range), respectively.

All analyses were performed using Microsoft Excel 2010. A two-sided p value of less than 0.05 was used to indicate statistical significance.

Results

The number of ICU admissions per month during the first 35 weeks of 2020 compared to the historical average based on ICU admission rates in the equivalent weeks from the prior five years are shown in Figure 1. In the 13 weeks of 2020 prior to lockdown there were an average of 2.41±1.40 unplanned ICU admissions per day compared to the historical average of 2.61±1.40 unplanned ICU admissions per day (P=0.23). During the five weeks of Alert Level Four, and the subsequent two weeks of Alert Level Three, the number of unplanned ICU admissions per day fell to 1.65±1.52 compared to a historical average of 2.56±1.52 ICU unplanned ICU admissions per day (P<0.0001). Since the end of Alert Level 3 in Wellington there have been 2.60±1.52 unplanned ICU admissions per day compared to a historical average of 2.79±1.51 unplanned ICU admissions per day (P=0.29).

The characteristics and outcomes of patients with an unplanned admission to Wellington ICU during New Zealand’s COVID-19 lockdown and of the patients admitted in the equivalent weeks of the year from the prior five years were similar and are shown in Table 1. Additional data on the breakdown of the COVID-19 and historical control admissions by ethnicity are shown in Table 2.

A breakdown of ICU admission diagnoses categorised by body system during the 2020 lockdown dates and during the preceding five years is shown in Figure 2. The number of admissions in the cardiovascular, gastrointestinal, sepsis, trauma and metabolic categories was lower than any of the preceding five years. The greatest number of admissions was in the neurologic category where admission rates were just above the median of the prior 5 years (Table 3).

Table 1: Characteristics and outcomes of unplanned admissions to Wellington ICU during New Zealand’s COVID-19 Alert Level 3 and Alert Level 4 lockdown compared with historical controls.*

*Unplanned ICU admissions were defined as all ICU admissions except for those that were booked to occur after elective surgery. Data for historical controls were obtained from the equivalent dates to the 2020 COVID-19 lockdown but from the 2015 to 2019 inclusive. †P value calculated using X2 disregarding cells with a frequency less than five. ‡Residual categories includes “don’t know”; “refused to answer”; “response unidentifiable”; “not stated”. ¶Scores on the APACHE II range from 0 to 71, with higher scores indicating more severe disease and a higher risk of death. Abbreviations: APACHE: Acute Physiology and Chronic Health Evaluation; ICU: Intensive Care Unit; OT: operating theatre.

Table 2: Detailed breakdown of unplanned ICU admissions by ethnic group.*

*For people who identified as belonged to more than one ethnic group, the following ethnic group priority order was used to allocate each person to a single category: NZ Māori, Tokelauan, Fijian, Niuean, Tongan, Cook Island Maori, Samoan, Pacific people not further defined, South East Asian, Indian, Chinese, Other Asian, Asian not further defined, Latin American/Hispanic, African, Middle Eastern, Other ethnicity, Other European, European not further defined, NZ European, don’t know, refuse to answer, response unidentifiable, not stated.

Figure 1: Unplanned admissions to Wellington ICU by week before, during and after COVID-19 Alert Levels 3 and 4.*

*Red shading corresponds to the dates of Alert Level 4 (from 25 March until 26 April); orange shading corresponds to the dates of Alert Level 3 (from 27 April until 13 May). Historical averages were calculated using ICU admission data for equivalent weeks of the year 2015 to 2019 inclusive with error bars representing the standard deviation; only positive error bars are shown.

Table 3: Unplanned ICU admissions by body system.

Figure 2: Unplanned admissions to Wellington ICU from 25 March until 13 May by year categorised by body system.*

*In 2020 these dates correspond to Alert Level 4 (from 25 March until 26 April) and Alert Level 3 (from 27 April until 13 May). Abbreviations: ICU: intensive care unit.

Discussion

In this single-centre retrospective cohort study conducted at Wellington Hospital ICU we observed a highly statistically significant reduction in unplanned ICU admissions associated with New Zealand’s COVID-19 lockdown. The number of unplanned ICU admissions decreased by just over a third compared to historical controls, with the reduction in admissions appearing to begin in the first week of Alert Level 4. The observed reduction in ICU admission rates appeared to occur for most categories of ICU admission diagnosis because, except for patients with neurologic disorders, observed unplanned ICU admission rates were low by historical standards. Unplanned ICU admission rates quickly returned to historical levels in the post-lockdown period.

One potential concern with the lockdown is that patients with potentially life-threatening diseases may not have presented to hospital. Our data do not preclude this possibility; however, we observed that the characteristics and outcomes of patients who had unplanned admissions to Wellington ICU during the COVID-19 lockdown where broadly similar to historical controls. In particular, the breakdown of patients with unplanned admissions by ethnic group does not support the hypothesis that access to ICU during COVID-19 differed by ethnic group.

Our findings are consistent with prior studies evaluating the association between COVID-19 lockdowns and hospital presentations. These include a New Zealand study which reported a 43% reduction in injury-related presentations to level one trauma centre during lockdown.6 International studies have shown a consistent and significant reduction in acute heart failure presentations in Italy,7 paediatric emergency department presentations in Italy,8 tertiary-care ophthalmology presentations in India,9 and oral and maxillofacial trauma presentations to a central London hospital.10 To our knowledge this is the first study to evaluate the association between a COVID-19-related lockdown and unplanned ICU admission rates. Only one patient with COVID-19 was admitted to Wellington ICU during the COVID-19 lockdown. As a consequence, the data presented here largely reflect the association between lockdown and ICU admissions that are unrelated to COVID-19. The observation that unplanned ICU admission rates fell concurrently with the start of Alert Level 4 and that the number of unplanned ICU admissions per day was just over a third lower than historical levels has potential implications to New Zealand’s planning for future surges in infections. If these findings are confirmed in other New Zealand ICUs this would suggest that the available ICU capacity freed up by a lockdown, will substantially exceed the amount of ICU capacity that would be freed up by simply cancelling elective operations that require patients to receive post-operative ICU care.

While our study provides comprehensive data on a highly statistically significant association between New Zealand’s COVID-19 lockdown and a reduction in unplanned admissions to Wellington Hospital ICU, it has several limitations. Firstly, our sample size is small and true differences between the characteristics of the COVID-19 cohort and historical controls may not have been evident in our analyses due to a lack of statistical power to detect such differences. Secondly, our retrospective design does not allow us to attribute a causal link between the period of lockdown and observed unplanned admission rates. Accordingly, we cannot be certain that similar reductions an unplanned ICU admission rates would be observed in future lockdowns. Thirdly, it is unclear whether or not our findings are generalisable to hospitals outside of New Zealand or, indeed, whether they even apply to other New Zealand hospitals. Finally, our observation that rates of unplanned ICU admissions in all categories except for those in patients with neurologic disorders were low by historical standards is based on a small number of events and may have occurred due to the play of chance. We cannot preclude the possibility that the drop in unplanned ICU admissions associated with lockdown is attributable to reductions in admissions in a more limited number of diagnostic categories.

Our findings should prompt further research evaluating the association between the COVID-19 lockdown and unplanned ICU admission rates in other New Zealand hospitals and comparative studies that evaluate whether the association between lockdowns and unplanned ICU admissions differed in other countries that took a less restrictive approach to lockdown.

Conclusions

In this study, we observed a reduction in unplanned admissions to Wellington Hospital ICU associated with New Zealand’s initial COVID-19 lockdown. There were no significant differences in the characteristics of patients who had an unplanned admission to Wellington ICU during the COVID-19 lockdown compared with historical controls.

Summary

Abstract

Aim

To evaluate rates of unplanned ICU admissions before, during and after New Zealand’s COVID-19 Alert Level 4/3 lockdown, and to describe the characteristics and outcomes of patients admitted to Wellington ICU during lockdown in comparison to historical controls.

Method

We conducted a retrospective cohort study using the Wellington Hospital ICU database and included patients with an unplanned ICU admission during the first 35 weeks of the year from 2015 to 2020 inclusive. The primary variable of interest was the rate of unplanned ICU admission in 2020 compared with historical controls. We also described the characteristics and outcomes of patients with unplanned admissions to ICU during the 2020 COVID-19 lockdown compared to historical controls.

Results

During the five weeks of Alert Level Four, and the subsequent two weeks of Alert Level Three, the number of unplanned ICU admissions per day fell to 1.65±1.52 compared to a historical average of 2.56±1.52 ICU unplanned ICU admissions per day (P<0.0001). The observed reduction in ICU admission rates appeared to occur for most categories of ICU admission diagnosis but was not evident for patients with neurologic disorders. The characteristics and outcomes of patients who had unplanned admissions to Wellington ICU during the COVID-19 lockdown were broadly similar to historical controls. The rate of unplanned ICU admissions in 2020 before and after the lockdown period were similar to historical controls.

Conclusion

In this study, we observed a reduction in unplanned admissions to Wellington Hospital ICU associated with New Zealand’s initial COVID-19 lockdown.

Author Information

Paul J Young, Co-Clinical Leader, Intensive Care Unit, Wellington Hospital, Wellington; Deputy Director, Medical Research Institute of New Zealand, Wellington; Benjamin Gladwin, Intensive Care Registrar, John Hunter Hospital, Newcastle, New South Wales, Australia; Alex Psirides, Co-Clinical Leader, Intensive Care Unit, Wellington Hospital, Wellington; Alice Reid, Research Fellow, Medical Research Institute of New Zealand, Wellington.

Acknowledgements

This research was conducted during the tenure of a Health Research Council of New Zealand Clinical Practitioner Research Fellowship held by Paul Young. The Medical Research Institute of New Zealand is supported by Independent Research Organisation funding from the Health Research Council of New Zealand.

Correspondence

Dr Paul Young, Intensive Care Unit, Wellington Hospital, Private Bag 7902, Wellington South.

Correspondence Email

paul.young@ccdhb.org.nz

Competing Interests

Nil.

1. Abate SM, Ahmed Ali S, Mantfardo B, Basu B. Rate of Intensive Care Unit admission and outcomes among patients with coronavirus: A systematic review and Meta-analysis. PLoS One. 2020; 15:e0235653.

2. http://www.oecd.org/coronavirus/en/data-insights/intensive-care-beds-capacity (Accessed 10th September 2020)

3. http://www.anzics.com.au/wp-content/uploads/2020/08/2018_19-CCR-Activity-Report.docx.pdf (Accessed 10th September 2020)

4. http://covid19.govt.nz/alert-system/alert-system-overview/ (Accessed 10th September 2020)

5. http://www.health.govt.nz/nz-health-statistics/data-references/code-tables/common-code-tables/ethnicity-code-tables (Accessed 10th September 2020)

6. Christey 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; 133:81–8.

7. Colivicchi F, Di Fusco SA, Magnanti M, Cipriani M, Imperoli G. The Impact of the Coronavirus Disease-2019 Pandemic and Italian Lockdown Measures on Clinical Presentation and Management of Acute Heart Failure. J Card Fail. 2020; 26:464–5.

8. Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Delayed access or provision of care in Italy resulting from fear of COVID-19. Lancet Child Adolesc Health. 2020; 4:e10–e1.

9. Babu N, Kohli P, Mishra C, et al. To evaluate the effect of COVID-19 pandemic and national lockdown on patient care at a tertiary-care ophthalmology institute. Indian J Ophthalmol. 2020; 68:1540–4.

10. Yeung E, Bradsma DS, Karst FW, Smith C, Fan KFM. The Influence of 2020 Coronavirus Lockdown on Presentation of Oral and Maxillofacial Trauma to a central London hospital. Br J Oral Maxillofac Surg. 2020.

Contact diana@nzma.org.nz
for the PDF of this article

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Coronavirus disease 2019 (COVID-19) has placed unprecedented demand on healthcare services around the world. In some countries, surges in infection rates have overwhelmed the capacity of hospitals. Reported rates of intensive care unit (ICU) admission among patients with COVID-19 disease have varied widely from 3% to 100%.1 Although the true rate of ICU admission among patients with COVID-19 is not certain, it is clear that many patients who are admitted to the ICU require prolonged periods of invasive mechanical ventilation. Because such specialised care can only safely be provided by trained ICU staff in an ICU environment, ICU capacity is an important issue to consider in relation to the readiness of hospital systems to deal with surges in infection rates. New Zealand has among the lowest level of ICU beds per capita in the OECD at four per 100,000 population.2 This compares to Australia at nine, France at 16 and Germany at 34.2 During business as usual, the degree of capacity constraint is such that in 2018, 17% of all New Zealand elective surgical operations that required planned post-operative admission to an ICU had to be postponed because of the lack of an available ICU bed.3 The comparable rate for Australian ICUs over the same time period was 1.7%.3 Accordingly, during the COVID-19 epidemic, ICU capacity is a potential point of particular vulnerability in the New Zealand healthcare system. While plans to mitigate the critical lack of ICU capacity by purchasing ventilators and other respiratory equipment, using non-ICU areas and non-ICU staff to care for ICU patients, have been developed, the most important component of New Zealand’s COVID-19 response to date has been the public health response. New Zealand’s five-week restrictive Alert Level 4 lockdown and subsequent two-week Alert Level 3 lockdown phase resulted in prolonged elimination of COVID-19 from New Zealand. The association between these interventions and the unplanned (emergency) admissions to the ICU have not been reported. This information is important because the degree to which lockdowns can effect unplanned ICU admissions is a relevant consideration in determining the risk of ICU capacity being overwhelmed in subsequent COVID-19 surges where lockdowns are imposed. Accordingly, we undertook a retrospective study to evaluate rates of unplanned ICU admissions before, during, and after New Zealand’s COVID-19 Alert Level 4/3 lockdown. We also sought to describe the characteristics and outcomes of patients admitted to Wellington ICU during lockdown in comparison to historical controls.

Method

Study design, setting and oversight

We conducted a retrospective cohort study using data from the Wellington Hospital ICU database, which contains information on all admissions to the ICU. Wellington ICU is a 24-bed facility providing tertiary services to a population of 1.1 million New Zealanders from 10 hospitals across seven other District Health Boards in the lower North Island and upper South Island.

The study was approved by the New Zealand Health and Disability Ethics Committee (Ref 20/NTB/219). As the study involved retrospective review of deidentified data, requirements for informed consent were waived.

Study population

Patients were eligible for inclusion if they had an unplanned admission to Wellington ICU during the first 35 weeks of the year in any year from 2015 to 2020 inclusive. Unplanned ICU admissions were defined as all admissions except for those that were planned to occur following elective surgery.

For the purposes of comparing the characteristics and outcomes of patients admitted during COVID-19 lockdown we focused on the period from 25 March until 12 May inclusive, which corresponded to the five weeks of New Zealand’s Alert Level Four and the subsequent two weeks of Alert Level Three.4 Patients admitted in 2020 were defined as the COVID-19 lockdown cohort. Those patients admitted from 2015 to 2019 were defined as the historical controls.

Exposures and variables of interest

The primary exposure of interest was the 2020 COVID-19 lockdown. The primary variable of interest was the rate of unplanned ICU admission. However, we also sought to describe the demographics, illness severity, reasons for ICU admission, ICU admission duration, ICU mortality and hospital outcomes of patients with unplanned admissions to ICU during the 2020 COVID-19 lockdown compared to historical controls.

Recorded data

Age, gender and ethnicity were recorded. Ethnicity was categorised using the New Zealand Ministry of Health’s ethnic group priority order with each person assigned to a single ethnic group.5 We recorded the source of ICU admission divided into the following categories: (i) operating theatre following emergency surgery; (ii) emergency department; (iii) hospital ward; (iv) transfer from another hospital (except for from another ICU); and (v) transfer from another ICU. We recorded the illness severity using the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score. The APACHE-II score is calculated based on the presence of comorbidities and the most deranged physiological variables from the first 24 hours in the ICU. The APACHE-II score can range from 0 to 71, with a higher score indicating more severe disease and a higher risk of death. ICU admission diagnoses were aggregated by body system using APACHE-II diagnostic categories. We recorded the ICU length of stay, the ICU mortality, and the discharge destination from Wellington Hospital, where the ICU is situated.

Statistical analyses

The principal comparison was of the unplanned daily ICU admission rates in the pre-lockdown, lockdown and post-lockdown periods with admission rates in 2020 compared to historical controls based on the average admission rates obtained from equivalent weeks of the year from 2015 to 2019 inclusive.

We compared the demographics, ICU admission characteristics, illness severity, ICU admission durations, ICU mortality and hospital outcomes of patients admitted during the lockdown compared with historical controls. To provide further information, we reported the ICU admission diagnoses by body system for 2020 and for each of the preceding five years.

Comparisons between groups were performed using chi-square tests for proportions, Student’s t tests for normally distributed data and Wilcoxon rank-sum tests otherwise with results reported as an n with percentages, means±SDs, or median (interquartile range), respectively.

All analyses were performed using Microsoft Excel 2010. A two-sided p value of less than 0.05 was used to indicate statistical significance.

Results

The number of ICU admissions per month during the first 35 weeks of 2020 compared to the historical average based on ICU admission rates in the equivalent weeks from the prior five years are shown in Figure 1. In the 13 weeks of 2020 prior to lockdown there were an average of 2.41±1.40 unplanned ICU admissions per day compared to the historical average of 2.61±1.40 unplanned ICU admissions per day (P=0.23). During the five weeks of Alert Level Four, and the subsequent two weeks of Alert Level Three, the number of unplanned ICU admissions per day fell to 1.65±1.52 compared to a historical average of 2.56±1.52 ICU unplanned ICU admissions per day (P<0.0001). Since the end of Alert Level 3 in Wellington there have been 2.60±1.52 unplanned ICU admissions per day compared to a historical average of 2.79±1.51 unplanned ICU admissions per day (P=0.29).

The characteristics and outcomes of patients with an unplanned admission to Wellington ICU during New Zealand’s COVID-19 lockdown and of the patients admitted in the equivalent weeks of the year from the prior five years were similar and are shown in Table 1. Additional data on the breakdown of the COVID-19 and historical control admissions by ethnicity are shown in Table 2.

A breakdown of ICU admission diagnoses categorised by body system during the 2020 lockdown dates and during the preceding five years is shown in Figure 2. The number of admissions in the cardiovascular, gastrointestinal, sepsis, trauma and metabolic categories was lower than any of the preceding five years. The greatest number of admissions was in the neurologic category where admission rates were just above the median of the prior 5 years (Table 3).

Table 1: Characteristics and outcomes of unplanned admissions to Wellington ICU during New Zealand’s COVID-19 Alert Level 3 and Alert Level 4 lockdown compared with historical controls.*

*Unplanned ICU admissions were defined as all ICU admissions except for those that were booked to occur after elective surgery. Data for historical controls were obtained from the equivalent dates to the 2020 COVID-19 lockdown but from the 2015 to 2019 inclusive. †P value calculated using X2 disregarding cells with a frequency less than five. ‡Residual categories includes “don’t know”; “refused to answer”; “response unidentifiable”; “not stated”. ¶Scores on the APACHE II range from 0 to 71, with higher scores indicating more severe disease and a higher risk of death. Abbreviations: APACHE: Acute Physiology and Chronic Health Evaluation; ICU: Intensive Care Unit; OT: operating theatre.

Table 2: Detailed breakdown of unplanned ICU admissions by ethnic group.*

*For people who identified as belonged to more than one ethnic group, the following ethnic group priority order was used to allocate each person to a single category: NZ Māori, Tokelauan, Fijian, Niuean, Tongan, Cook Island Maori, Samoan, Pacific people not further defined, South East Asian, Indian, Chinese, Other Asian, Asian not further defined, Latin American/Hispanic, African, Middle Eastern, Other ethnicity, Other European, European not further defined, NZ European, don’t know, refuse to answer, response unidentifiable, not stated.

Figure 1: Unplanned admissions to Wellington ICU by week before, during and after COVID-19 Alert Levels 3 and 4.*

*Red shading corresponds to the dates of Alert Level 4 (from 25 March until 26 April); orange shading corresponds to the dates of Alert Level 3 (from 27 April until 13 May). Historical averages were calculated using ICU admission data for equivalent weeks of the year 2015 to 2019 inclusive with error bars representing the standard deviation; only positive error bars are shown.

Table 3: Unplanned ICU admissions by body system.

Figure 2: Unplanned admissions to Wellington ICU from 25 March until 13 May by year categorised by body system.*

*In 2020 these dates correspond to Alert Level 4 (from 25 March until 26 April) and Alert Level 3 (from 27 April until 13 May). Abbreviations: ICU: intensive care unit.

Discussion

In this single-centre retrospective cohort study conducted at Wellington Hospital ICU we observed a highly statistically significant reduction in unplanned ICU admissions associated with New Zealand’s COVID-19 lockdown. The number of unplanned ICU admissions decreased by just over a third compared to historical controls, with the reduction in admissions appearing to begin in the first week of Alert Level 4. The observed reduction in ICU admission rates appeared to occur for most categories of ICU admission diagnosis because, except for patients with neurologic disorders, observed unplanned ICU admission rates were low by historical standards. Unplanned ICU admission rates quickly returned to historical levels in the post-lockdown period.

One potential concern with the lockdown is that patients with potentially life-threatening diseases may not have presented to hospital. Our data do not preclude this possibility; however, we observed that the characteristics and outcomes of patients who had unplanned admissions to Wellington ICU during the COVID-19 lockdown where broadly similar to historical controls. In particular, the breakdown of patients with unplanned admissions by ethnic group does not support the hypothesis that access to ICU during COVID-19 differed by ethnic group.

Our findings are consistent with prior studies evaluating the association between COVID-19 lockdowns and hospital presentations. These include a New Zealand study which reported a 43% reduction in injury-related presentations to level one trauma centre during lockdown.6 International studies have shown a consistent and significant reduction in acute heart failure presentations in Italy,7 paediatric emergency department presentations in Italy,8 tertiary-care ophthalmology presentations in India,9 and oral and maxillofacial trauma presentations to a central London hospital.10 To our knowledge this is the first study to evaluate the association between a COVID-19-related lockdown and unplanned ICU admission rates. Only one patient with COVID-19 was admitted to Wellington ICU during the COVID-19 lockdown. As a consequence, the data presented here largely reflect the association between lockdown and ICU admissions that are unrelated to COVID-19. The observation that unplanned ICU admission rates fell concurrently with the start of Alert Level 4 and that the number of unplanned ICU admissions per day was just over a third lower than historical levels has potential implications to New Zealand’s planning for future surges in infections. If these findings are confirmed in other New Zealand ICUs this would suggest that the available ICU capacity freed up by a lockdown, will substantially exceed the amount of ICU capacity that would be freed up by simply cancelling elective operations that require patients to receive post-operative ICU care.

While our study provides comprehensive data on a highly statistically significant association between New Zealand’s COVID-19 lockdown and a reduction in unplanned admissions to Wellington Hospital ICU, it has several limitations. Firstly, our sample size is small and true differences between the characteristics of the COVID-19 cohort and historical controls may not have been evident in our analyses due to a lack of statistical power to detect such differences. Secondly, our retrospective design does not allow us to attribute a causal link between the period of lockdown and observed unplanned admission rates. Accordingly, we cannot be certain that similar reductions an unplanned ICU admission rates would be observed in future lockdowns. Thirdly, it is unclear whether or not our findings are generalisable to hospitals outside of New Zealand or, indeed, whether they even apply to other New Zealand hospitals. Finally, our observation that rates of unplanned ICU admissions in all categories except for those in patients with neurologic disorders were low by historical standards is based on a small number of events and may have occurred due to the play of chance. We cannot preclude the possibility that the drop in unplanned ICU admissions associated with lockdown is attributable to reductions in admissions in a more limited number of diagnostic categories.

Our findings should prompt further research evaluating the association between the COVID-19 lockdown and unplanned ICU admission rates in other New Zealand hospitals and comparative studies that evaluate whether the association between lockdowns and unplanned ICU admissions differed in other countries that took a less restrictive approach to lockdown.

Conclusions

In this study, we observed a reduction in unplanned admissions to Wellington Hospital ICU associated with New Zealand’s initial COVID-19 lockdown. There were no significant differences in the characteristics of patients who had an unplanned admission to Wellington ICU during the COVID-19 lockdown compared with historical controls.

Summary

Abstract

Aim

To evaluate rates of unplanned ICU admissions before, during and after New Zealand’s COVID-19 Alert Level 4/3 lockdown, and to describe the characteristics and outcomes of patients admitted to Wellington ICU during lockdown in comparison to historical controls.

Method

We conducted a retrospective cohort study using the Wellington Hospital ICU database and included patients with an unplanned ICU admission during the first 35 weeks of the year from 2015 to 2020 inclusive. The primary variable of interest was the rate of unplanned ICU admission in 2020 compared with historical controls. We also described the characteristics and outcomes of patients with unplanned admissions to ICU during the 2020 COVID-19 lockdown compared to historical controls.

Results

During the five weeks of Alert Level Four, and the subsequent two weeks of Alert Level Three, the number of unplanned ICU admissions per day fell to 1.65±1.52 compared to a historical average of 2.56±1.52 ICU unplanned ICU admissions per day (P<0.0001). The observed reduction in ICU admission rates appeared to occur for most categories of ICU admission diagnosis but was not evident for patients with neurologic disorders. The characteristics and outcomes of patients who had unplanned admissions to Wellington ICU during the COVID-19 lockdown were broadly similar to historical controls. The rate of unplanned ICU admissions in 2020 before and after the lockdown period were similar to historical controls.

Conclusion

In this study, we observed a reduction in unplanned admissions to Wellington Hospital ICU associated with New Zealand’s initial COVID-19 lockdown.

Author Information

Paul J Young, Co-Clinical Leader, Intensive Care Unit, Wellington Hospital, Wellington; Deputy Director, Medical Research Institute of New Zealand, Wellington; Benjamin Gladwin, Intensive Care Registrar, John Hunter Hospital, Newcastle, New South Wales, Australia; Alex Psirides, Co-Clinical Leader, Intensive Care Unit, Wellington Hospital, Wellington; Alice Reid, Research Fellow, Medical Research Institute of New Zealand, Wellington.

Acknowledgements

This research was conducted during the tenure of a Health Research Council of New Zealand Clinical Practitioner Research Fellowship held by Paul Young. The Medical Research Institute of New Zealand is supported by Independent Research Organisation funding from the Health Research Council of New Zealand.

Correspondence

Dr Paul Young, Intensive Care Unit, Wellington Hospital, Private Bag 7902, Wellington South.

Correspondence Email

paul.young@ccdhb.org.nz

Competing Interests

Nil.

1. Abate SM, Ahmed Ali S, Mantfardo B, Basu B. Rate of Intensive Care Unit admission and outcomes among patients with coronavirus: A systematic review and Meta-analysis. PLoS One. 2020; 15:e0235653.

2. http://www.oecd.org/coronavirus/en/data-insights/intensive-care-beds-capacity (Accessed 10th September 2020)

3. http://www.anzics.com.au/wp-content/uploads/2020/08/2018_19-CCR-Activity-Report.docx.pdf (Accessed 10th September 2020)

4. http://covid19.govt.nz/alert-system/alert-system-overview/ (Accessed 10th September 2020)

5. http://www.health.govt.nz/nz-health-statistics/data-references/code-tables/common-code-tables/ethnicity-code-tables (Accessed 10th September 2020)

6. Christey 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; 133:81–8.

7. Colivicchi F, Di Fusco SA, Magnanti M, Cipriani M, Imperoli G. The Impact of the Coronavirus Disease-2019 Pandemic and Italian Lockdown Measures on Clinical Presentation and Management of Acute Heart Failure. J Card Fail. 2020; 26:464–5.

8. Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Delayed access or provision of care in Italy resulting from fear of COVID-19. Lancet Child Adolesc Health. 2020; 4:e10–e1.

9. Babu N, Kohli P, Mishra C, et al. To evaluate the effect of COVID-19 pandemic and national lockdown on patient care at a tertiary-care ophthalmology institute. Indian J Ophthalmol. 2020; 68:1540–4.

10. Yeung E, Bradsma DS, Karst FW, Smith C, Fan KFM. The Influence of 2020 Coronavirus Lockdown on Presentation of Oral and Maxillofacial Trauma to a central London hospital. Br J Oral Maxillofac Surg. 2020.

Contact diana@nzma.org.nz
for the PDF of this article

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