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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 6  |  Page : 603-607  

Impact of COVID 19 lockdown on emergency admissions at a large zonal hospital


1 Medical Specialist, MH Kirkee, Pune, India
2 OC SHO Kirkee, Pune, India
3 Anaesthetist MH Kirkee, Pune, India
4 Associate professor, Dept of Community Medicine, AFMC, Pune, India
5 Professor Radiology, MH Kirkee, Pune, India
6 Cl Sol Obs and Gynae, MH Kirkee, Pune, India
7 Sr medical Resident, AFMC, Pune, India

Date of Submission13-Jul-2020
Date of Decision21-Sep-2020
Date of Acceptance21-Sep-2020
Date of Web Publication6-Nov-2020

Correspondence Address:
Arun Yadav
AFMC, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_382_20

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  Abstract 


Introduction: The COVID-19 pandemic along with the measure to control it like complete lockdown has affected the health-care delivery in multiple ways. Resources in the health setup were earmarked for COVID-19. All routine and nonurgent procedures were deferred. There was an overall decrease in the number of patients visiting the emergency department. However, in India, there was no major study conducted on emergency hospital admission at the time of the ongoing COVID-19 pandemic. Materials and Methods: The study was conducted in a zonal hospital as a before-and-after record-based observational study. The hospital admission data for all causes of emergency 2 months prior (i.e., from January 25, 2020, to March 24, 2020) and 2 months into the lockdown (March 25, 2020–May 24, 2020) were studied. The emergency admission during the last 2-year period in the same period was taken as a control for the study. Results: The number of emergencies reported during the year 2018, 2019 and 2020 in January 25 to March 24 were 92, 101, and 119 respectively and in March 25 to May 24 were 93, 107, and 82 respectively. There was no statistically significant difference among age, sex, and socioeconomic status of persons reported as emergencies during the studied period. There was a significant reduction by 31% in emergency hospital admissions two months before and two months after period of lockdown in the year 2020 and it varied as per subject specialty with highest reduction in emergency hospital admissions was found in orthopedic cases by 93% and no reduction in obstetric and newborn emergencies. Conclusion: The COVID-19 lockdown in India had a significant impact on the frequency as well as types of emergency admission to a large zonal hospital. The provisioning of hospital resources may need to be aligned with changing patient workload in view of COVID-19.

Keywords: COVID-19 pandemic, emergency hospital admissions, lockdown


How to cite this article:
Bewal NM, Minhas S, Krishna Prasad G V, Yadav A, Sreedhar C M, Bhasin D, Kumar S. Impact of COVID 19 lockdown on emergency admissions at a large zonal hospital. Med J DY Patil Vidyapeeth 2020;13:603-7

How to cite this URL:
Bewal NM, Minhas S, Krishna Prasad G V, Yadav A, Sreedhar C M, Bhasin D, Kumar S. Impact of COVID 19 lockdown on emergency admissions at a large zonal hospital. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Nov 26];13:603-7. Available from: https://www.mjdrdypv.org/text.asp?2020/13/6/603/300144




  Introduction Top


Severe acute respiratory syndrome coronavirus-2, the novel Coronavirus originated in Wuhan, China in late 2019. It spreads to multiple countries and continent in early 2020 to become a global pandemic.[1] The WHO declared this disease as a pandemic on March 11, 2020.[2] Health-care infrastructure around the world faced the challenge of providing medical care to the community in times of exponentially rising number of cases of COVID-19.

In an attempt to control the spread of the disease, many countries enforced strict lockdown measures,[3] ban on large public gatherings, and forced social distancing. In India, a nationwide lockdown was implemented from March 25, 2020. The pandemic and the measures to control it affected not only the patients but also the health-care system in multiple ways. Hospitals around the globe delivered care for COVID-19 patients by restructuring the available medical resources. COVID-19 emergency, intensive care unit (ICU), non-ICU wards, and non-COVID-19 wards were established in an attempt to provide necessary care to COVID-19 and non-COVID-19 patients both at the same time to ensure that disease spread is curtailed. All routine and nonurgent procedures were deferred. Routine outpatient department (OPD) visits were curtailed, and patients were encouraged to seek telemedicine consultations for nonemergency follow-up care.

In many resource-poor settings, a more conservative approach of management of various emergencies was favored with intent to reduce the possibility of exposing an already overstretched health-care system without compromising the patient care. This changed the demography of patients seeking medical care in emergency and on an OPD basis. There was an overall decrease in patients visiting the emergency department around the globe except at peak time in COVID-19 hotspots.[4] Even at the peak of the pandemic in Europe, the number of non-COVID-19 emergencies including severe trauma, stroke, myocardial infarction, and newly diagnosed malignancy cases, dramatically decreased.[5]

There are no major studies available looking at pattern of emergency hospital admission at this time of the ongoing COVID-19 pandemic. Therefore, we undertook this study to understand the change in pattern of emergency hospitalization, so as to better comprehend the challenges at hand and prepare accordingly.

Aims and objectives

This research was aimed to study the impact of COVID-19 lockdown on frequency and type of emergencies admitted at a large zonal hospital in western Maharashtra. The objectives were to study the difference in frequency of emergencies admitted at that hospital 2 months preceding and during the period of COVID-19 lockdown, as well as to study the difference in types of emergencies admitted there, during the same period.


  Materials and Methods Top


The study was conducted in a zonal hospital. This was a before-and-after record-based observational study. The COVID-19-related nationwide lockdown came into effect in India with effect from March 25, 2020. To study the impact of lockdown on hospital emergency admissions, we studied the hospital admission data for all causes of emergency 2 months prior (i.e., from January 25, 2020, to March 24, 2020, henceforth referred to as 20 A) and 2 months into the lockdown (i.e., from March 25, 2020, to May 24, 2020, henceforth referred to as 20 B). All the emergency hospital admissions during this study period with the name of the main specialty involved were noted from the records in the central registry available in the statistics department of the hospital.

For controls, similar data were collected for the last 2 years from January 25, 2019, to May 25, 2019, as well as from January 25, 2018, to May 25, 2018. Data from the previous 2 years were collected so as to compare the effect in frequency and type of emergencies, as well as seasonal variation, if any.

Inclusion criteria

All patients who were admitted to this hospital as an emergency from January 25, 2020, to March 24, 2020, were included in the study. Besides, all patients who were admitted to this hospital as an emergency from March 25, 2020, to May 24, 2020, were also included. Similar data of hospital emergency admissions in corresponding months in the previous 2 years, i.e., in 2018 and 2019, were also included.

Exclusion criteria

All the other hospital admissions during the above-mentioned period which did not meet the inclusion criteria and not classified as emergency were excluded. Besides, all “found dead” patients brought to the hospital were also excluded.

The ethical clearance was given by the institutional ethics committee vide their letter number IEC/2020/156 dated May 5, 2020.

For data extraction, a case record form was designed. It was pilot tested among ten records. The data were extracted in a case record form by two researchers independently. The data were entered into MS Excel. The data were analyzed using StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX, USA: StataCorp LP. P < 0.05 was taken as statistically significant.


  Results Top


The number of OPD cases and their demographic characteristics are shown in [Table 1]. The number of emergencies reported during the year 2018, 2019 and 2020 in January 25 to March 24 were 92, 101, and 119 respectively and in March 25 to May 24 were 93, 107, and 82 respectively [Figure 1]. The age distribution of the patient is given in [Figure 2]. There was no statistically significant difference among age, sex, and socioeconomic status of persons reported as emergencies during the studied period.
Table 1: Demographic characteristics of patients

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Figure 1: Age distribution of the patients

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Figure 2: Number of patients reported at two periods

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The summary of the entire hospital emergency admissions during the study period is given in [Table 2]. It shows the specialty-wise hospital emergency admissions during the first half of the study period (January 25– March 24 in 2018, 2019, and 2020) and the second half of the study period (March 25 to May 24 in 2018, 2019, and 2020). The before-and-after data were compared in percentage changes. It was observed that while there was no significant difference in frequency of hospital emergency admissions during, before, and after periods in the year 2018 as well as the year 2019, there was a significant reduction by 31% in frequency of emergency hospital admissions 2 months before and 2 months after period of lockdown in the year 2020.
Table 2: Specialty-wise hospital emergency admissions with relative change in frequency during the study period for 2018, 2019, and 2020

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During the same time periods, before and after, for all the 3 years, the difference in specialty-wise hospital emergency admissions was also compared. Two months postlockdown, the highest reduction in emergency admissions was found in orthopedic cases by 93%. This was possibly due to marked reduction in road traffic accidents as an effect of strict lockdown implementation which were the common causes for emergency admissions in orthopedics This difference has been noted across all specialties except gynecology and pediatrics in which there was actually increase in hospital emergency admissions by 28% and 30%, respectively, after the date of lockdown. This increase has been particularly noted, especially 1 month after the lockdown started. This could have been due to unplanned pregnancies/ectopic pregnancies etc., Analysis of medical emergencies before and after lockdown reveals a reduction in common medical emergency admissions such as acute coronary syndrome, stroke, and acute exacerbation of chronic obstructive pulmonary disease (COPD), whereas the emergency medical admissions were found due to uncontrolled blood sugar, uncontrolled hypertension, etc.


  Discussion Top


There was a significant reduction of 31% in total number of hospital emergency admissions observed during 2 months postlockdown as compared to 2 months before lockdown. This may be due to factors like absence of adequate transport facility to hospital, strictness in lockdown measures, markedly reduced road traffic accidents and reduced air pollution. Often, there was a site of clear skies, weather offices in important cities in India as well as worldwide reported improved air quality.[6],[7] Even, a polluted city like Delhi reported markedly reduced levels of pollution. This reduced pollution can be directly attributed to reduced hospitalizations due to respiratory emergencies such as exacerbations of COPD, bronchial asthma, or pneumonias. There were a significant reduction in pediatric asthma admission,[4] reduced stroke admissions,[8] likely due to reduced outdoor activity leading to a reduction in exposure to precipitating factors, and significant improvement in air quality due to strict lockdown measures.[9]

The increased prevalence of the use of mask also modified disease pattern. This leads to a reduction in cases of other seasonal diseases having a similar mode of spread. A study in Taiwan reported a marked decline in invasive pneumococcal disease.[10]

Complete lockdown meant a reduced pace of life. The hectic work schedule was reduced due to closed offices, factories, shops and malls, schools and colleges, and other places of work. This forced people to spend more time at home and work from home. The resultant reduced stress level can be a likely contributory factor in observing overall reduced admissions for cases such as ischemic heart diseases and strokes.[8]

There were reports published where patients deferred care due to fear of viral pandemic leading to delay in care. Another study published from The Netherlands studied the change in care of diabetes in community, where more people adopted telemedicine consultations and shared their glucose monitoring data online rather than routine hospital visits. The fear of virus leads to an increase in self-care and increased compliance with treatment leading to drastic reduction in cases of diabetic ketoacidosis.[11]

A Canadian study reported a significant reduction in emergency code activations for stroke and reduction in stroke referrals, but there was no difference in total stroke-related admissions, likely due to reductions in number of patients seeking emergency care and referrals for mild strokes and transient ischemic attack.[8] This interesting correlation between reduced stress and reduction in certain lifestyle diseases and their emergencies needs to be further studied.

The highest reduction in medical emergencies 2 months postlockdown was seen in orthopedic cases. There was a 0.93% reduction in admissions on account of orthopedic emergencies after the lockdown came into effect. The obvious reason for this is likely to be due to reduced road travel and reduced road traffic accidents. This phenomenon has been noted worldwide.

The significant reduction in trauma cases worldwide was a direct effect of significantly reduced vehicular movement and construction activity due to lockdown enforced by most countries. The overall reduction was also seen in surgical emergencies. However, there was a significant increase in death at home during the pandemic interval. Motterle et al. reported a remarkable absolute reduction in urgent urological consultations.[12] Two major hospitals in the UK reported a significant reduction in emergency visits by children and young adults.[13]

There was an interesting observation of a relative increase in hospitalizations due to obstetric cases as well as newborn emergencies by 28% and 30%, respectively, after the date of lockdown.[14],[15] This was likely due to various factors such as absence of quality care at understaffed peripheral hospitals, people spending more time at home, absence of availability of contraceptive measures like condoms due to closed shops, and absence of adequate transport facility which resulted in delayed visits to gynecologists.

The hospital administrator and planners should be aware of the situation and changing clientele for the hospital in times to come. The changes in emergencies would affect the provisioning of stores and workforce for the hospital. They would need to be aligned with the COVID-19 requirement of the hospital.


  Conclusion Top


The COVID 19 lockdown in India had a significant impact on the frequency as well as types of emergency admission to our large zonal hospital. All-cause emergency admissions were reduced except for obstetric emergencies and newborn emergencies in which there was a relative increase in number of admissions postlockdown. The provisioning of hospital resources may need to be aligned with changing patient workload in view of COVID-19.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wu D, Wu T, Liu Q, Yang Z. The SARS-CoV-2 outbreak: What we know. Int J Infect Dis 2020;94:44-8.  Back to cited text no. 1
    
2.
Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed 2020;91:157-60.  Back to cited text no. 2
    
3.
Mandal I, Pal S. COVID-19 pandemic persuaded lockdown effects on environment over stone quarrying and crushing areas. Sci Total Environ 2020;732:139281.  Back to cited text no. 3
    
4.
Krivec U, Kofol Seliger A, Tursic J. COVID-19 lockdown dropped the rate of paediatric asthma admissions. Arch Dis Child 2020;105:809-10.  Back to cited text no. 4
    
5.
Wu F, Zhao S, Yu B, Chen YM, Wang W, Song ZG, et al. A new coronavirus associated with human respiratory disease in China. Nature 2020;579:265-9.  Back to cited text no. 5
    
6.
Mahato S, Pal S, Ghosh KG. Effect of lockdown amid COVID-19 pandemic on air quality of the megacity Delhi, India. Sci Total Environ 2020;730:139086.  Back to cited text no. 6
    
7.
Gautam S. The influence of COVID-19 on air quality in India: A boon or inutile. Bull Environ Contam Toxicol 2020;104:724-6.  Back to cited text no. 7
    
8.
Bullrich MB, Fridman S, Mandzia JL, Mai LM, Khaw A, Gonzalez JC, et al. COVID-19: Stroke admissions, emergency department visits, and prevention clinic referrals. Can J Neurol Sci 2020;1:1-10.  Back to cited text no. 8
    
9.
Srivastava S, Kumar A, Bauddh K, Gautam AS, Kumar S. 21-day lockdown in India dramatically reduced air pollution indices in Lucknow and New Delhi, India. Bull Environ Contam Toxicol 2020;105:9-17.  Back to cited text no. 9
    
10.
Tsai JR, Yang CJ, Huang WL, Chen YH. Decline in invasive pneumococcus diseases while combating the COVID-19 pandemic in Taiwan. Kaohsiung J Med Sci 2020;36:572-3.  Back to cited text no. 10
    
11.
Tack CC. Would you believe? A virus changes diabetes care. J Diabetes Sci Technol 2020;14:795-6.  Back to cited text no. 11
    
12.
Motterle G, Morlacco A, Iafrate M, Bianco M, Federa G, Xhafka O, Zattoni F, Prayer-Galetti T. (2020). The impact of COVID-19 pandemic on urological emergencies: a single-center experience. World journal of urology, 1–5. Advance online publication. https://doi.org/10.1007/s00345-020-03264-2.  Back to cited text no. 12
    
13.
Isba R, Edge R, Jenner R, Broughton E, Francis N, Butler J. Where have all the children gone? Decreases in paediatric emergency department attendances at the start of the COVID-19 pandemic of 2020. Arch Dis Child 2020;105:704.  Back to cited text no. 13
    
14.
Hansen KA, Stovall DW. Ectopic pregnancy during coronavirus disease 2019 (COVID-19): To operate, or not to operate. Obstet Gynecol 2020;136:288-90.  Back to cited text no. 14
    
15.
Hansen KA, Stovall DW. Ectopic pregnancy during coronavirus disease 2019 (COVID-19): To operate, or not to operate. Obstet Gynecol 2020;136:288-90.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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