The Effects on the Number of Patients Visiting the Emergency Units: Comparison Study Before and During COVID-19 Pandemic in Saudi Arabia

Introduction

In Saudi Arabia and elsewhere, the utilization of emergency departments (EDs) has increased in recent years^1,2 an observation which has been attributed to non-urgent patients comprising approximately 50% of all ED cases.^3,4 In Saudi Arabia, non-urgent patients reported multiple reasons for attending the ED such as convenience and rapid access, and the perception that they will receive better care.⁵ These factors can lead to ED overcrowding with consequences such as increased waiting time, impaired patient-centered care, and disrupted evaluation and treatment.^6,7 The COVID-19 disease outbreak that first surfaced in Wuhan, China, in December 2019, has had a major impact globally, affecting almost every country.⁸ Emergency departments have provided a first point of contact for patients with or without the COVID virus symptoms and have been most heavily impacted by this outbreak. They have played an important role in identifying patients infected with the virus and isolating them for further treatments, highlighting the critical nature of emergency medicine in public health. We studied the volume of patients arriving at an ED in a private hospital in the Kingdom of Saudi Arabia. We found that the number of patients attending the emergency room fell compared to previous years, perhaps due to factors such as the government-imposed curfew, or personal decisions by the public to minimize the chance of infection, based on a perception of any medical facility being a source of such infection. In this paper, we discuss the types of patient that contributed to decreased emergency department attendance during this period and the consequences of this decrease on the community or the patients themselves.

The first indication of the COVID-19 disease outbreak was in the city of Wuhan, Hubei Province, on December 2019 when the Chinese government informed the World Health Organization (WHO) China country office about a cluster of 41 patients with a new respiratory infection. On 11 January 2020, the Chinese authority informed the WHO that this infection was due to a novel coronavirus.⁹ In Saudi Arabia, hospital EDs were prepared to some extent since isolation areas had been created within those departments when the SARS virus outbreak occurred in 2003.^10,11 On a normal day, the ED is manned by three shifts of doctors and nurses over a 24-hr period. The private hospital used in this was therefore prepared to receive a higher number of patients than usual due to the increasing number of COVID-19 infections. Figure 1 shows the number of confirmed cases in the Kingdom of Saudi Arabia since January 2020 (https://www.worldometers.info/coronavirus/).

Figure 1 Daily new cases in Saudi Arabia.

Figure 2 indicates a decline in the number of patients attending the ED between January 2020 and September 2020 compared to the same period in 2018 and 2019.

Figure 2 Number of patients visited the emergency room between 2018 to 2020.

Materials and Methods

Data were collected from an open access source at the private hospital in the capital of Saudi Arabia.¹¹ The data are presented in Figure 2 which shows a significant reduction in the number of patients attending the ED in 2020 compared to the corresponding periods in 2018 and 2019. However, as shown in Table 1, the patient numbers follow similar trends each year, with a peak in the month of February (2020) or March (2018 and 2019). Paired t-tests with a <5% p value were used to define statistical significance.

Table 1 Number of Patients Attending ED in 2018, 2019 and 2020 from January to September

Table 2 presents descriptive statistics for 2018 and 2019 and Table 3 shows estimation for paired difference of the population mean for 2018 and 2019. While Table 4 presents descriptive statistics for 2019 and 2020 and Table 5 shows estimation for paired difference of the population mean for 2019 and 2020. Paired t-tests show no significant difference (p=0.246) between the numbers of patients attending the ED in 2018 and 2019, but a significant difference between attendance in 2019 and 2020 (p<0.001).

Table 2 Descriptive Statistics for 2018 and 2019

Table 3 Estimation for Paired Difference of the Population Mean for 2018 and 2019

Table 4 Descriptive Statistics for 2019 and 2020

Table 5 Estimation for Paired Difference of the Population Mean for 2019 and 2020

Results and Discussion

The private hospital under study classifies ED patients as adults, pediatric or obstetrics and gynecology, and investigations or treatments as shown in Table 6.

Table 6 Patient and Treatment Classifications

Since the number of patients attending the hospital’s ED during the pandemic is statistically lower than the number visited the hospital’s ED in the same period before the pandemic, this situation has several consequences such as an economic impact on the hospital and health impact on the community.⁶ As mentioned, this study will determine the type of patient categories with the greatest reduction in hospital attendance, and the impact, if any, of this reduction on community health. The study therefore aims to compare the characteristics of patients attending the hospital ED before and after the pandemic.

Table 7 shows the number of existing adult hospital patients attending the hospital ED from January to September inclusive in 2019 and 2020. The difference between these attendance numbers was found to be significant based on a paired t test (p=0.011).

Table 7 Shows the Number of Adult Patients with an Existing File Attending the ED

The number of new adult files opened in the same periods in 2020 and 2019 are shown in Table 8. Overall, no significant difference was found between these attendance numbers (p=0.799). However, the table indicates an increase in May 2020 which may reflect COVID-19 virus testing during that month.

Table 8 Shows the Number of New Adult Patients Attending the ED

The numbers of existing pediatric patients attending the ED during 2019 and 2020, during the pandemic, are shown in Table 9. Overall, the numbers were found to the significantly lower in 2020 than in 2019 (p<0.001).

Table 9 Shows the Number of Existing Pediatric Patients Attending the ED

The number of new pediatric new patients attending the ED during these periods are shown in Table 10. A statistically significant difference was found between the attendance numbers in these two years (p<0.001).

Table 10 Shows the Number of New Pediatric Patients Attending the ED

Conclusion

This research has used data reflecting the periods before and during the COVID-19 pandemic to make a comparison of the number of patients attending an ED at a private hospital in the middle eastern region of Saudi Arabia. The data reveal reduced patient attendance at ED during the pandemic. Analysis of the results indicated that there was a difference in the volume of patients’ attendance at the emergency room between the pre- and during-pandemic period. However, the differences in size are limited to a specific type of patient, being apparent in existing patients but not in new patients.

These findings may be explained by existing patients being accustomed to visiting the ED or believing that the risk of visiting the ED is less than that of non-attendance. The lack of significant reduction in new adult patients may indicate that true emergencies necessitated ED attendance for this group of patients.

As a result of this research, it should be clear that each healthcare facility based on its geographical location should evaluate the type of patients who have a difference in size reaching the emergency room.

Healthcare facilities should establish measures to monitor ED attendance by different patient groups in order to determine whether interventions should be introduced to improve access to care. For example, a decrease in the number of children in the category of “injection” or “nebulizer” should trigger contact with their parents to discuss the non-attendance.

In summary, this study indicates that there is a difference between the number of cases attending health facility emergency departments before and after the COVID-19 pandemic, but this difference does not apply to all patient groups. Reasons for non-attendance may include fear of disease transmission within the ED or a tendency not to make non-essential visits to ED. Further research is needed to explore the reasons for ED non-attendance using questionnaire methods to collect data that may lead to changes in state or health facility policy and thus may prevent negative consequences of ED non-attendance.