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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 69-74

Epidemiological Profiles and Clinical Outcomes of Non-COVID-19 Patients during COVID-19 Pandemic: A Single-Center Experience


1 General Directorate of Data & Research, Saudi Red Crescent Authority, Riyadh, Saudi Arabia
2 College of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Global Centre for Mass Gatherings Medicine, Ministry of Health, Riyadh, Saudi Arabia
4 College of Health and Rehabilitation Sciences, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
5 Disaster Management Unit, King Saud University Medical City, Riyadh, Saudi Arabia
6 Department of Emergency Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission15-Jun-2021
Date of Decision20-Oct-2021
Date of Acceptance13-Jan-2022
Date of Web Publication07-Feb-2022

Correspondence Address:
Trad S Alwakeel
College of Medicine, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsm.jnsm_67_21

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  Abstract 


Background: Coronavirus disease-2019 (COVID-19) pandemic continues to storm internationally. Various essential services in the health systems have failed to meet the standardized health needs for those non-COVID-19 patients. In this single academic center study, we describe the epidemiological profiles and clinical outcomes on non-COVID-19 patients during COVID-19 pandemic to guide decision-makers in maintaining essential health services and building a structured recovery plan by the end of this pandemic. Materials and Methods: This retrospective cross-sectional single academic center study included 718 non-COVID-19 patients in King Saud University Medical City between March and June 2020. Demographic, clinical, laboratory, treatment, and disposition data were extracted from the Hospital Electronic Records, Electronic System for Integrated Health Information database. Results: The highest age group was 26–35 years, representing 28.6% (n = 205), and 56% (n = 402) were females. The most common comorbidity was hypertension by 25.5% (n = 183), and the main route of admission was through Emergency Medicine Department, 76.7% (n = 551), and 87% (n = 624) of the admissions were to wards, 13% (n = 92) were to Intensive Care Unit, and 7% (n = 51) were deceased. Based on International Classification of Diseases, Revision 10 classifications, 33.6% (n = 241) had diseases of the respiratory system, 14.5% (n = 104) were obstetrics, and 10.4% (n = 75) were cardiac cases. Conclusion: In this single-center study, maintaining essential health-care services is critical during COVID-19 pandemics. Attention should be addressed to extreme ages and to those with pulmonary, obstetric, and cardiac diseases. Mapping decisions taken to curb COVID-19 is critical to structure a solid recovery plan.

Keywords: Coronavirus disease-2019, coronavirus, essential health-care services, pandemic


How to cite this article:
Alsofayan YM, Alwakeel TS, Alnasser HA, Alnowaiser MM, Alskait GA, Alotaibi RS, Bashaikh HA, Almuzaini YS, Aburas AS, Nofal AR, Khan AA. Epidemiological Profiles and Clinical Outcomes of Non-COVID-19 Patients during COVID-19 Pandemic: A Single-Center Experience. J Nat Sci Med 2022;5:69-74

How to cite this URL:
Alsofayan YM, Alwakeel TS, Alnasser HA, Alnowaiser MM, Alskait GA, Alotaibi RS, Bashaikh HA, Almuzaini YS, Aburas AS, Nofal AR, Khan AA. Epidemiological Profiles and Clinical Outcomes of Non-COVID-19 Patients during COVID-19 Pandemic: A Single-Center Experience. J Nat Sci Med [serial online] 2022 [cited 2023 Feb 9];5:69-74. Available from: https://www.jnsmonline.org/text.asp?2022/5/1/69/337381




  Introduction Top


Coronavirus disease-2019 (COVID-19) is an emerging infectious disease caused by severe acute respiratory syndrome coronavirus-2 which was first reported in Wuhan, the Republic of China, on December 31, 2019, and was, soon after, declared a pandemic.[1] By the end of April 2021, there have been more than 140 million confirmed COVID-19 cases and over 3 million deaths across the globe.[2] Eventually, there was a rising demand for essential health-care services that had crippled the health-care system and called for an urgent strategic adaptation plan to avert system failures. The World Health Organization (WHO) recommended that each country should identify high-priority categories of essential health-care services that should not be disrupted during the acute phases of the pandemic. Some of these categories are essential prevention and treatment services for communicable diseases, core services for vulnerable populations (infants, older adults, comorbidities, mental health conditions), and management of emergency conditions that require time-sensitive intervention through urgent diagnostic imaging and laboratory tests. Having said that, multiple recommended actions were encouraged by the WHO to address the needs of marginalized populations, identify routine and elective services that can be suspended or relocated to less affected areas, and to create a roadmap for progressive reduction and restoration of services as pressure on the health system surges and recedes.[3]

As of June 1, 2021, 451,687 confirmed COVID-19 cases were recorded in Saudi Arabia that include 7377 deaths and 434,439 recoveries.[4] The Kingdom of Saudi Arabia was one of the first countries that take a series of proactive and precautionary measures to curb COVID-19 in the early phases of the pandemic. These included suspending domestic and international flights, banning gatherings in public areas, imposing curfew measures among many others. In order to maintain essential health-care services, multiple strategies were implemented ranging from providing inhospital care for non-COVID-19 patients, activating virtual clinics and telemedicine services, home delivery of medications, continuity of routine vaccinations, and maintaining remote training for health-care providers.[5] All these actions have led to a successful response to the pandemic in Saudi Arabia.[6]

The aim of our study is to highlight the continuity of health-care services for non-COVID-19 patients in Saudi Arabia during COVID-19 pandemic in a single academic center to proffer crucial recommendations and to guide policymakers in their decisions to minimize the impact of the pandemic on essential health-care services.


  Materials and Methods Top


This is a retrospective cross-sectional study including patients presenting to the emergency department and outpatient clinics with negative COVID-19 results upon initial presentation at King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia, between March and June 2020. All laboratory-confirmed COVID-19 cases at initial presentation to KSUMC were excluded. Health-care providers are required to enter demographic, clinical, laboratory, treatment, and disposition data for all patients in the hospital's electronic health records, Electronic System for Integrated Health Information (e-SiHi).

Demographic, clinical, laboratory, treatment, and disposition data were extracted from e-SiHi by three trained health-care workers and filled into a separate electronic sheet. Any discrepancies were adjusted by a fourth independent reviewer. Data privacy was preserved throughout the study by system-generated passwords and granting access for data collectors after signing confidentiality agreement forms. Diagnosis of COVID-19 was based on the laboratory confirmation tests in accordance with the Saudi Ministry of Health protocols.[7] Ages were classified into categories based on a recent nationwide COVID-19-related study.[8] Comorbidities were based on the International Classification of Diseases, Revision 10 (ICD-10) diagnostic codes, then reported as no comorbidities, one comorbidity, and more than one comorbidity.[9] The main outcome of the study is to describe the essential health-care services provided among non-COVID-19 patients. This study was approved by the Institutional Review Board, College of Medicine, King Saud University (Ref. No. 21/0136/IRB) on 30 January 20201.

Based on Raosoft, the calculated sample size was 550, using a population size of 2382 representing all non-COVID-19 cases, after setting a confidence interval at 99% and a margin of error at 5%.[10] Moreover, the patients were selected from (e-SiHi) randomly via the Stat Trek Electronic System to ensure a proper selection of cases.[11]

Descriptive statistics were used to describe categorical variables presented by counts and percentages. All percentages were rounded to one decimal. The analysis was done using IBM Corp® Statistical Package for the Social Sciences Version 24 (SPSS24), Armonk, NY, United States.


  Results Top


Between March and June 2020, 718 patients were included in the study. The highest age group was 26–35 years, representing 28.6% (n = 205), patients who are ≥66 years representing 18.7% (n = 134), then ≤14 years representing 12.7% (n = 91), and more than a half of the sample were females (56%, n = 402). Citizens represented 80.8% (n = 580) of the cases. As for the preexisting comorbidities, 20.2% (n = 145) had one comorbidity, 38.4% (n = 276) had more than one, while the remaining 41.4% (n = 297) were healthy. Moreover, the most common comorbidities were hypertension, 25.5% (n = 183), followed by diabetes mellitus, 22.3% (n = 160) [Table 1].
Table 1: Demographic data, comorbidities, route of admission, and outcomes of the study population

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The main route of admission was through Emergency Medicine Department (EMD), (76.7%, n = 551), 87% (n = 624) of the admitted patients were in wards, 13% (n = 92) were in intensive care unit (ICU), and 7% (n = 51) were deceased [Table 1].

In [Table 2], demographic data, diagnosis, route, and type of admission according to ICU and death outcomes have been described. The most common illnesses of patients across the study period are presented in [Table 3] based on ICD-10 classifications. About one-third (33.6%, n = 241) had respiratory diseases, while 25.8% (n = 62) of them had acute upper respiratory infections, 25.3% (n = 61) had a diagnosis of Pneumonia, and 34.8% (n = 84) were admitted for COVID-19-screening services. The second most common diagnosis was related to obstetrics (OB), representing 14.5% (n = 104) of the sample patient population. The third most common disease category was related to cardiology with a percentage of 10.4% (n = 75). Of that, 28% (n = 21) had heart failure, 26.7% (n = 20) had ischemic heart diseases, and 16% (n = 12) were having cerebrovascular diseases. The fourth most common diagnosis was neoplasms, with a percentage of 8.7% (n = 63). Moreover, 30.2% (n = 19) were diagnosed with malignant neoplasms of the digestive system, 15.9% (n = 10) were diagnosed with malignant neoplasms stated or presumed to be primary, of lymphoid, hematopoietic, and related tissues, and 9.5% (n = 6) were diagnosed with malignant neoplasms of respiratory and intrathoracic organs.
Table 2: Demographic Data, Diagnosis, Route & Type of admission for Death & ICU patients

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Table 3: Patients' diagnosis based on International Classification of Diseases, Revision.10 across the study period

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Out of all patients presented, the majority received medications (72.6%, n = 521). Among those who received medications, the most common type received was antibiotics (34%, n = 251), followed by intravenous (IV) fluids (18.7%, n = 138), and antiplatelets/anticoagulants (12%, n = 86). Furthermore, 40.1% (n = 288) received specific interventions, including surgeries (36.2%, n = 72), OB services (29.1%, n = 58), and dialysis (12.6%, n = 25) [Table 4].
Table 4: Common medications received by patients across the study period

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During the study period, the mean hospital length of stay (LOS) in days for ICU and ward admission was of 20 and 7 days, respectively. The LOS in patients aged between 56 and 65 years had a mean of 19 days, 12 days for patients aged 66 or more years, and 7 days for patients aged <56. Patients with more than one comorbidity had a mean of 12 days, and patients who were admitted to cardiac diseases recorded a mean of 11 days. The least mean was for patients admitted for OB, with a mean of 4 days [Figure 1].
Figure 1: Mean length of stay (days) according to outcomes, age, comorbidities, and selected illnesses

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  Discussion Top


This is one of the earliest studies in the Middle East to assess the impact of COVID-19 pandemic on essential health-care services. Out of the 718 non-COVID-19 patients in this study, the highest age group category was 26–35 years representing 28.6% of the sample. This is no surprise, as young age groups represent the majority of Saudi Arabia's population.[12] Similarly, this was also evident in a recent study of COVID-19 patients in Saudi Arabia.[13] The gender distribution showed a higher percentage of females, 56%, this could be related to the 14.5% of the study sample visiting KSUMC for OB services. From routine deliveries to emergency cesarean sections, special attention to the risk of vertical transmission of COVID-19 led to strict precautionary measures, especially in the late phases of pregnancy. Previous studies discussed that OB services were rarely disrupted in a significant way during the pandemic, and any disruption of OB and neonatal services could increase the morbidity and mortality of both the mother and newborn.[3],[14],[15] Furthermore, a study done in Ethiopia documented that despite most components of maternal and child health services suffering from a low case flow, delivery services remained relatively stable.[16] The overall prevalence of hypertension is 25.5%, and almost one-fourth of the adult population in Saudi Arabia are affected by diabetes mellitus.[17],[18] Having said that, the two most common comorbidities in our study were hypertension in 25.5% and diabetes Mellitus in 22.3%. Most of the visits to KSUMC were through EMD (76.7%), as certain national decisions to curb COVID-19 included curfew measures and suspending elective surgeries at the early phases of the pandemic. Therefore, the active open channel to receive patients whether for COVID-19 or not was mainly through EMD. Resources were then directed to utilize non-EMD medical staff in engaging them in telemedicine services and virtual clinics.[5] Worrisome enough, COVID-19 pandemic could probably delay the presentation of many urgent cases, as suggested by previous studies.[19] Fortunately, KSUMC applied policies and procedures for visual triage, standard precautions, and quarantine measures following the Saudi Center for Disease Prevention and Control to prevent the spread of the pandemic and ensure the safety of its visitors.[20] About 12.9% of the inhospital admission was in the ICU, patients with age ≥66-year-old represented 41% of them, as the age above 65 was found to be an independent predictor of hospitalization.[21] Those patients admitted to the ICU were mainly admitted for pneumonia 26%, heart failure 12%, and cerebrovascular diseases 7%. Consistent with the characteristics of COVID-19 patients, old age is a known risk factor for ICU admission.[22] The burden of non-COVID-19 cases on ICUs was considered at the beginning of the pandemic on a national level, and surge capacity plans were implemented to ensure maintaining essential services and the availability of crucial equipment's (such as mechanical ventilators) in critical care areas with the support of local factories in the region.[5] Nevertheless, time-sensitive cardiac and stroke diseases were receiving proper management during the pandemic. Advanced cardiac life support for cardiac arrests, percutaneous coronary intervention for myocardial infarctions, and invasive and medical management for strokes were delivered while maintaining personal protective equipment following local protocols.[20] Seven percent of the non-COVID-19 cases died during their presence in the hospital. Czeisler stated that the most probable cause of this increase in death rates was related to delays or avoidance of non–COVID-19 medical care during the pandemic.[23] Again, age was an important factor in reaching these critical outcomes.[22],[24] The main cause of death was related to consequences of malignant neoplasms 11%, pneumonia 10%, and renal failure 7%. In comparison to a study done in London, they reported that the most common cause of death in hospitalized non-COVID-19 patients during 2020 was due to cancers.[25] Furthermore, a study was done in 2006 showed that 31.3% of death in the hospital were due to Malignant tumor diseases, 4.2% for acute or chronic renal diseases, and 3.5% for infectious diseases.[26] Providing care for vulnerable immunocompromised oncology patients was a true challenge during COVID-19. Providing care for vulnerable immunocompromised oncology patients during COVID-19 such as maintaining firm chemotherapy schedules, minimizing exposure to communicable diseases, and ensuring the availability of isolation rooms and ICU beds was a true challenge that triggered the provision of a structural plan to overcome these concerns, as was suggested by a recent study to provide additional hospitals and ICU beds during COVID-19 pandemic.[27] Sepsis was also a leading factor for mortality in the non-COVID-19 population and early management could reduce adverse outcomes.[28] Essential services for renal failure patients were indeed affected by the pandemic waves manifested in the continuous need for urgent and nonurgent dialysis, and if neglected, can lead to a significant increase in both morbidity and mortality. Prioritizing these services and diverting the nonurgent cases to specialized centers is a key solution to ensure the continuity of services. Most frequent medication provided for the non-COVID-19 patient were antibiotics (34%), IV fluids (18.7%), and antiplatelet/anticoagulant (12%). These medications are similar to the most common illnesses diagnosed in this study (pneumonia, cardiac diseases). As mentioned, elective surgeries were suspended, 3.5% of patients received psychiatric evaluation and management as the impact of COVID-19 on mental health is obvious internationally.[29] Telephysiatry solutions were effective in providing these patients with essential diagnoses and treatment plans to avoid unnecessary visits to the hospital.

Inhospital LOS was variable with a mean of 4–20 days. Surprisingly, LOS was higher when compared with a COVID-19 study done during the same period. This difference could be attributed to our study population, especially for ICU LOS that had more elderly patients and more comorbidities.[19] Occupying these beds for a long time necessitates continuous monitoring and preparing surge capacity plans and investing in resources to avoid the bed crises in pandemics.[5]

Maintaining essential health-care services for non-COVID-19 patients is an ongoing challenge during this pandemic. Carefully structuring a surge capacity plan, prioritizing available resources to treat medical and surgical conditions, diverting nonemergent cases, and identification and prioritization of essential services are of utmost importance. Toward the end of the pandemic, building recovery plans of services are crucial to guide decision-makers into proper actions on a national level to rebuild the health system efficiently.

We consent to several limitations in this study being a cross-sectional, retrospective, and single-center study with all its drawbacks. Furthermore, the short time period of the study could not represent the full image of essential services in KSUMC as COVID-19 pandemic continues. Missing variables, including the role of primary care centers in providing essential vaccines, were not captured. Moreover, the provision and maintaining essential training for health-care workers was not captured as well. This study would guide the policymakers in their decisions to reduce the impact during COVID-19 pandemic and emphasize the importance of maintaining essential health-care services. Since there are not many similar studies in the region, we recommend further studies to measure the full-scale image of essential health-care services and mapping national decisions of curfew measures, suspending certain services, and others to curb pandemics and to establish better recommendations.


  Conclusion Top


In this single-center study, maintaining essential health-care services is critical during pandemics. We observed that the elderly, hypertension, and diabetes mellitus are the most frequent to seek hospital services. Respiratory diseases, OB, cardiac diseases, and malignant neoplasms are the most health-care services required. To better understand the impact, we need to map decisions taken on the national levels to curb COVID-19, as this will reveal services affected and guide a solid recovery plan by the end of the pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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