Changes in the characteristics of civilian patients admitted to a military hospital before and during the healthcare system crisis: a retrospective cohort study

Background

Since its establishment in April 2022, the military trauma center in Korea has aimed to serve as a definitive treatment facility for military trauma patients, while also working to care for civilian trauma patients. To build the necessary infrastructure and secure a stable workforce, the center established agreements with a university hospital, enabling assistance from experienced civilian doctors. Initially, the number of civilian patients visiting the center was low. However, the center continuously developed its systems and workforce, gradually gaining experience in treating military trauma cases and preparing for an anticipated increase in civilian patients.

In February 2024, the Korean government announced the Essential Medical Care Package Policy, accompanied by a substantial increase in the medical school enrollment quota. This announcement triggered a nationwide wave of mass resignations among medical residents, which disrupted large hospitals that were heavily dependent on resident labor, ultimately causing a healthcare system crisis [1,2]. Consequently, referrals of civilian patients to military hospitals increased and became progressively more frequent. Treating civilian trauma patients is consistent with the trauma center’s founding mission and its duty as a public institution to serve the broader community. For this reason, the center has actively sought to accommodate civilian trauma patients.

Outcomes

The present study was designed to analyze the scale, characteristics, response outcomes, and treatment results of patients who visited the trauma center before and during the healthcare system crisis.

Ethics statement

This study was approved by the Institutional Review Board of Armed Forces Capital Hospital (No. AFCH 2025-02-010). The requirement for informed consent was waived due to the use of deidentified data and the retrospective nature of the study.

Workforce and facilities at the military trauma center

A total of 13 trauma surgeons work at the military hospital's trauma center, including 8 military personnel and 5 civilians dispatched from partner hospitals. The center is part of Korea's largest military hospital, which has 666 beds and 130 physicians (excluding residents). Physicians affiliated with the hospital support the trauma center and include specialists in thoracic surgery, orthopedic surgery, plastic surgery, vascular surgery, hepatobiliary and pancreatic surgery, and neurosurgery, as well as interventional radiologists, anesthesiologists, cardiologists, pulmonologists, neurologists, rehabilitation physicians, and psychiatrists. The trauma center operates independently from the general emergency room (ER) and specializes in trauma patient care. It is equipped with 2 dedicated trauma beds, 2 trauma operating rooms, an 8-bed trauma intensive care unit (ICU), and a 38-bed trauma ward [3].

Study design

This retrospective study reviewed the charts of civilian trauma patients who visited the trauma center during the year preceding the healthcare system crisis (March 2023 to February 2024) and the year following the crisis (March 2024 to February 2025). The factors analyzed included age, sex, type of accident, route of arrival, mode of transportation, time from injury to transfer, injury status, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), ER stay duration, emergency treatment outcomes (admission, transfer, death), ICU stay duration, hospital stay duration, and final treatment outcomes (discharge, transfer, death). Patients with an ISS greater than 15 were classified as severe cases and analyzed separately. Military trauma patients and civilian patients with mild injuries who were treated in the ER and discharged home without hospitalization during the study period were excluded from the analysis.

Statistical analysis

Continuous variables were analyzed using Student t-test and Mann-Whitney U-test. Categorical variables were evaluated with the chi-square test and Fisher exact test. A P-value of less than 0.05 was considered statistically significant. All statistical analyses were performed using IBM SPSS ver. 28.0.1.1 (IBM Corp).

Changes in the number of patients during the healthcare system crisis

During the study period, a total of 828 patients visited the trauma center. The number of military service members who visited remained nearly constant, with 137 patients before the healthcare system crisis and 143 during. Among civilian patients, those with stable vital signs who were alert and had external injuries with an ISS of 1 were either discharged after ER treatment or, in some cases, admitted for observation at the discretion of the trauma surgeon. A total of 103 patients who were discharged after emergency treatment were excluded from the study. The final number of patients included in the analysis was 445 (Fig. 1). Compared to the year prior to the healthcare system crisis (March 2023 to February 2024, group 1, n=81), the number of patients in the year following the crisis (March 2024 to February 2025, group 2, n=364) increased by approximately 4.5 times. The number of patients in March 2024, immediately during the healthcare system crisis, rose to more than three times the number seen in February 2024, and this elevated level of patient visits was sustained after March 2024 (Fig. 2).

Fig. 1.

Flowchart showing the patient selection and exclusion process. ER, emergency room.

Fig. 2.

Monthly visiting civilian patients.

Analysis of the prehospital phase and ER treatment

Table 1 presents an analysis of indicators related to the prehospital phase and ER treatment for all included patients. Both groups had a higher proportion of male patients (51.9% in group 1 and 67.9% in group 2), with group 1 showing a relatively higher proportion of female patients compared to group 2 (P=0.007). The median age was 53 years (interquartile range [IQR], 41.5–61.5 years) for group 1 and 56 years (IQR, 39.3–78.5 years) for group 2. In both groups, patients in their 50s and 60s were predominant (Fig. 3A, B). The majority of patients in both groups arrived directly rather than being transferred from other hospitals (95.1% in group 1 and 87.6% in group 2). The most common transport method was public ambulance in both groups (91.4% and 87.4%, respectively). The transport time from injury to hospital arrival was 56 minutes (IQR, 40–75.5 minutes) in group 1 and 53 minutes (IQR, 41–69 minutes) in group 2. Examining the distribution of transport times, group 1 showed similar proportions of patients arriving within 30–60 and 60–120 minutes, whereas in group 2, the majority arrived within 30–60 minutes (Fig. 3C). After ER treatment, most patients in both groups were admitted for inpatient treatment (96.3% in group 1 and 98.6% in group 2). The ER stay time was 90 minutes (IQR, 63–128.5 minutes) for group 1 and 75 minutes (IQR, 55–101 minutes) for group 2, with group 2 showing a statistically significant shorter stay (P=0.020). Table 2 presents the results for the same indicators as in Table 1, but focuses on patients with severe trauma, defined as an ISS greater than 15. There were 17 severe trauma patients in group 1 and 84 in group 2, with trends similar to those observed for all patients. The ER stay time for severe trauma patients was 103 minutes (IQR, 73.5–142.5 minutes) in group 1 and 76 minutes (IQR, 56.3–106.5 minutes) in group 2, again showing a statistically significant reduction in group 2. The most common ER stay duration for both groups, among all patients and among severe trauma patients, was 60–120 minutes after ER arrival (Fig. 3D).

Table 1.

Analysis of the prehospital phase and ER treatment for all patients (n=445)

Fig. 3.

Proportion of civilian patients between group 1 (before the crisis) and group 2 (during the crisis). Distribution of sex and age in (A) all patients and (B) severe patients. (C) Time taken for transfer after injury. (D) Length of emergency room (ER) stay. (E) Glasgow Coma Scale (GCS) score. (F) Injury Severity Score (ISS). (G) Length of intensive care unit (ICU) stay. (H) Length of hospital stay.

Table 2.

Analysis of the prehospital phase and ER treatment for severe trauma patients with an ISS exceeding 15 (n=101)

Analysis of injury patterns

Table 3 presents the results of analyzing injury patterns for all patients. The most common injury mechanism in both groups was traffic accidents, followed by falls, with no significant differences in injury mechanism indicators (all P>0.05), except for stabbing and cutting (P=0.038). Both groups also had a high proportion of multiple injuries (67.9% in group 1 and 73.6% in group 2). Injury sites were classified according to the Abbreviated Injury Scale (AIS). The proportions of facial injuries and external injuries were significantly higher in group 2 than in group 1 (P=0.043 and P=0.003, respectively).

Table 3.

Analysis of injuries in all patients (n=445)

Severe injury sites were defined as those with AIS scores of 3 or higher. In group 1, the most frequent severe injury sites were chest, pelvis and extremities, and head and neck injuries, while in group 2, the order was pelvis and extremities, chest, and head and neck injuries. There were no significant differences in these variables between the two groups. Similarly, there were no statistical differences in the median ISS or in the proportion of severe trauma patients with ISS greater than 15 between the groups.

Table 4 presents the same indicators from Table 3 applied to severe trauma patients. The injury mechanism distribution was similar to that of all patients, with no significant differences between groups (all P>0.05). For injury type, the proportion of multiple injuries was significantly higher in group 2 than in group 1 (94.0% vs. 76.5%, P=0.041). The proportion of external injuries was also significantly higher in group 2 compared to group 1 (79.8% vs. 52.9%, P=0.030). Severe injury sites with AIS scores of 3 or higher were most frequent in group 1 in the order of chest and head and neck injuries, whereas in group 2, the order was head and neck, chest, and pelvis or extremities. Median ISS values were 20 (17–24.5) in group 1 and 23 (17–33) in group 2, without a statistically significant difference (P=0.202). Fig. 3E and Fig. 3F illustrate the distributions of GCS and ISS in both groups. In both groups, the most common GCS scores were between 13 and 15, while the most common ISS scores were between 1 and 8, followed by scores between 9 and 15.

Table 4.

Analysis of injuries in severe trauma patients with an ISS exceeding 15 (n=101)

Analysis of inpatient treatment

Table 5 presents the results of the inpatient treatment analysis for all patients. The number of patients who received inpatient treatment at the military trauma center was 78 in group 1 and 359 in group 2. Types of admission were categorized as direct ICU admission, ICU admission via the operating room or intervention room, direct admission to the general ward, and general ward admission via the operating room or intervention room. In both groups, the most common type was direct ICU admission, followed by direct general ward admission. Regarding the number of patients treated in the ICU, 42 (53.8%) were in group 1 and 219 (61.0%) were in group 2. The median ICU stay duration was 3 days in both groups, showing no statistically significant difference. The total hospital stay duration was 9.5 days (IQR, 4–30 days) in group 1 and 9 days (IQR, 4–23 days) in group 2, with no significant difference between the groups (P=0.175). After completing inpatient treatment at the military trauma center, 62 patients (79.5%) in group 1 and 285 (79.4%) in group 2 were discharged home, while 16 (20.5%) and 61 (17.0%), respectively, were transferred to other hospitals. There were no deaths in group 1, whereas group 2 had 13 deaths; however, the difference between the two groups was not statistically significant (P=0.138).

Table 5.

Analysis of all patients who underwent inpatient treatment (n=437)

Table 6 shows the results of inpatient treatment for severe trauma patients. In both groups, the most common type of admission was direct ICU admission (50.0% in group 1 and 71.6% in group 2). The number of severe trauma patients receiving ICU care was 12 (75.0%) in group 1 and 75 (92.6%) in group 2, with no statistically significant difference in ICU stay duration between the groups (P=0.571). Hospital stay durations and final treatment outcomes (discharge, transfer to other hospitals, and death) also showed no significant differences between the two groups (all P>0.05). Fig. 3G displays the distributions of ICU stay durations for all patients, with both groups following the sequence of 1–3, 4–7, 8–28, and >28 days. For severe trauma patients, the most common ICU stay duration was between 8 and 28 days in both groups. Fig. 3H shows the distributions of hospital stay durations, with both groups having the highest proportion of patients staying for more than 2 weeks.

Table 6.

Analysis of severe trauma patients with an Injury Severity Score (ISS) exceeding 15 who underwent inpatient treatment (n=97)

Analysis of mortality cases

During the study period, there were a total of 16 deaths. Of these, 3 occurred in the ER and 13 during hospitalization. All deaths occurred during the healthcare system crisis. Among the three patients who died in the ER, two arrived in cardiac arrest, both due to pedestrian traffic accidents. The third patient went into cardiac arrest shortly after arrival, with the mechanism of injury being a fall. These patients could not be evaluated, and the direct cause of death could not be determined.

Table 7 summarizes the cases of patients who died during hospitalization. The most common direct cause of death was brain hemorrhage, which accounted for nine cases. Other causes included liver laceration and major vessel injury. In case 2, the patient, who had been hospitalized at another facility for pneumonia and heart failure, was transferred after sustaining a femoral neck fracture from a slip. This patient died due to worsening pneumonia and heart failure.

Table 7.

Mortality cases

Changes in the number of patients during the healthcare system crisis

The number of trauma patients visiting this military trauma center increased more than fourfold, from 103 before the healthcare system crisis to 445 during the crisis. Since its establishment, the trauma center has aimed to accommodate civilian trauma patients. However, due to limited resources and the prioritization of military trauma cases, it primarily treated civilian patients with extremely severe trauma that other regional trauma centers and medical institutions could not accept, or cases that occurred nearby. Therefore, most of the increase in patient numbers during the healthcare system crisis is presumed to have involved cases that other hospitals were unable to accommodate. The data indeed show a sharp increase in patient numbers from March 2024, immediately following the healthcare system crisis, and this higher level has been sustained since March 2024.

The prehospital phase and ER treatment outcomes

The indicators analyzed in this study were compared with outcomes from Korean regional trauma centers using 2022 and 2023 data from the Korean Trauma Data Bank (KTDB). Following the healthcare system crisis, patient numbers increased, showing patterns similar to those in the KTDB data and in reports from regional trauma centers [4–6]. Regarding aspects that differed from KTDB data, in terms of sex and age distribution, the proportion of female trauma patients in their 80s was higher in the KTDB for 2022 and 2023 (23.5% and 26.9%, respectively). However, this study did not show such a peak. In the KTDB data, the median time from injury to hospital arrival was 96 minutes in 2022, with the highest percentage of trauma patients arriving within 1 to 2 hours (25.9% in 2022 and 25.0% in 2023). For severe trauma patients, the median time to hospital was 72 minutes, and the highest percentage arrived within 30 to 60 minutes (28.6% in 2022 and 30.1% in 2023). In this study, the median time to hospital was shorter than in the KTDB: 56 minutes (IQR, 40–75.5 minutes) before the healthcare system crisis and 53 minutes (IQR, 41–69 minutes) during the crisis for all patients, and 56 minutes (IQR, 30–72.5 minutes) before and 52 minutes (IQR, 37–100 minutes) during the crisis for severe trauma patients. Unlike regional trauma centers, which receive patients from a wide geographic area, this military trauma center primarily receives referrals for patients from relatively close distances, which is presumed to explain the shorter transport times.

Regarding injury sites, this study showed a higher proportion of external injuries than the KTDB data (70.4% in the year before the healthcare system crisis and 84.6% in the year after the crisis started). Only 3 of the 445 patients (0.7%) in this study had external injuries classified as AIS score 3 or higher. Thus, although there were many patients with external injuries, most cases were minor. If the 103 patients (all with an ISS of 1 for external injuries) who were excluded after being treated and discharged from the ER with mild trauma are also considered, it can be inferred that private hospitals had difficulty effectively evaluating and treating mild external injury patients during the healthcare system crisis. In addition, there was a statistically significant increase in patients with facial injuries during the healthcare system crisis. In particular, there were many referrals for facial injuries accompanied by ophthalmologic issues, suggesting that private hospitals became less capable of managing ocular trauma during the crisis.

Comparing the 2022 and 2023 KTDB data, the proportion of patients with ISS exceeding 15 was approximately 25% (25.6% in 2022 and 24.8% in 2023). For the military trauma center, the proportion was 21.0% before the healthcare system crisis and 23.1% during, indicating an increase in severity, although still less than 25%.

As an institution prioritizing both civilian and military trauma patients, this military trauma center emphasizes the importance of distributing medical resources efficiently [7,8]. The military hospital operates both a general ER and a trauma center ER. After the healthcare system crisis, the general ER also began to accept civilian patients. Ideally, mild cases should be treated in the general ER, allowing the trauma center ER to focus on severe trauma patients.

Despite the increase in patient numbers, the shortened ER stay times may reflect improved efficiency resulting from accumulated experience in treating both civilian and military trauma cases. The extremely low transfer rate to other hospitals suggests that the military trauma center can provide specialized trauma care regardless of patient condition [7,9,10].

Inpatient treatment outcomes

The KTDB data did not include information on ICU treatment. The adequacy of ICU care is considered an important criterion for evaluating the capabilities of trauma centers [11–13]. Over the 1-year periods before and during the healthcare system crisis, the proportions of severe trauma patients with ISS exceeding 15 were 20.6% and 22.6%, respectively. However, the proportions of patients receiving ICU care were 53.8% and 61.0%, respectively, indicating a higher rate of ICU admission relative to patient severity [6,14]. This likely reflects the absence of clear ICU admission and discharge criteria, with decisions made at the discretion of the attending physician. It may also indicate an intentional approach to actively monitor and minimize unexpected complications, given the center's relatively limited experience in treating civilian patients [15,16]. Nevertheless, since this military trauma center consistently treats military trauma patients while also accommodating civilian cases, this is an area that requires improvement. For military trauma patients, treatment is generally provided until the patient is ready to return to their unit. For civilian patients, however, it may be more effective to transfer them to civilian hospitals for long-term care and rehabilitation after acute treatment [17]. Activating a medical cooperation team for this purpose is considered necessary.

The trauma team’s response to the surge in civilian patients

As the center is a military institution, it continued to operate under the principle of prioritizing military patients, even after civilian patient admissions began. Following the healthcare system crisis, the surge in civilian patients raised concerns regarding shortages of beds in the ICU and trauma wards, as well as limited resources for patient care, including the availability of surgical staff, operating rooms, intervention teams, and nursing personnel. To address these challenges, daily trauma team discussions were held to manage and allocate resources effectively. During the study period, there were no instances in which military patients were denied admission due to the acceptance of civilian patients. Furthermore, there was no difference in ICU stay durations before and during the healthcare system crisis, a result attributed to the implementation of daily trauma team discussions.

Strengths and limitations

This study is the first to describe the experience of treating civilian patients at this military hospital under the unique circumstances of a healthcare system crisis. It is also the first study to identify areas needing improvement. However, the study has limitations, including a relatively small number of patients, a short study period, and a primary focus on comparisons with KTDB data, which prevented detailed analysis of treatment specifics (e.g., types of surgery, use of mechanical ventilation during ICU care, dialysis, etc.) [5,10,17,18]. Further research is warranted to address these issues. Additionally, as this is a single-center military study, the findings may not be generalizable to other trauma systems.

Conclusions

The sudden healthcare system crisis created a gap in services provided by civilian hospitals, resulting in a surge of referrals of civilian trauma patients to this military trauma center. We believe that the experience of the medical staff at this center is accumulating and that they have the capacity to care for even more civilian trauma patients in the future. Furthermore, during the healthcare system crisis, this center maintained effective cooperation with public emergency medical services and other healthcare institutions. Therefore, we anticipate that requests to transfer civilian trauma patients will continue even after the healthcare system crisis is resolved, and we believe that ongoing reporting on this matter will be necessary.