Hospitals constitute a
very indispensable unit of a community [1]. Apart from provision of primary
healthcare services, referral facilities are also made freely available to the
patients in public sector healthcare settings [2]. Although life expectancy differs
extensively within and across the countries, yet it has substantially been
escalated than that was reported in 1900. Health inequality has considerably
been declined across the world [3]. Health expectancy in the past few decades
has primarily been increased due to advancement in technology and accessibility
to better treatment opportunities [4]. Out-patients services in hospitals of
developing countries are determined to be considerably utilized, even these
services are known to consume about 23% of the budget dispensed to any hospital
for healthcare [5,6]. Laboratory testing of any healthcare center are of
profound significance in making an accurate diagnosis and managing the patients
[7]. The significance of radiological investigations in monitoring the
healthcare and predicting the health outcome cannot be neglected [8].
Radiological and laboratory testing amenities should conveniently be made
available at all levels of healthcare delivery for appropriate diagnosis and
prompt healthcare management of the patients [9]. Medicolegal intricacies
should adequately be known to all doctors as law is equally applicable to
healthcare professionals working in both public and private healthcare settings
[10]. Post-mortem examinations of the dead bodies to verify the cause of death
is also an aspect that is to be sufficiently addressed in tertiary level
healthcare centers by our doctors [11]. The trend of autopsies in developed
nations has substantially been declined due to advanced imaging facilities and
availability of national citizen databases; however underdeveloped nations are
ignorant of their rights to know the cause of death [12,13]. Most
epidemiological studies nowadays begin with mortality statistics as it has
become feasible to retrieve valid data due to Health Management Information
System (HMIS). Being a vital statistic, mortality indictors direct the
attention of policy makers towards prevailing health problems that in turn aids
the regulatory authorities in monitoring and surveillance [14]. The present
study is planned to determine the frequency of outpatient and diagnostic
services made available to the patients in addition to management of
medicolegal cases and conduction of post-mortem during 2020 at DHQ Hospital.
This study apart from assessing the workload of the hospital will also serve as
food for thought to our strategic planners for adequate allocation of
healthcare resources.
Materials and Methods
A cross-sectional
hospital data-based study was done to perceive the frequency of OPD cases managed
along with the investigations (laboratory tests, ultrasounds, X-rays & CT
scans) done at DHQ Hospital during 2020. DHQ Hospital is tertiary care
healthcare facility. It is one of the teaching hospitals affiliated with
Rawalpindi Medical University for facilitation of undergraduate and
postgraduate medical teaching. Being situated in the center of Rawalpindi city,
this hospital also serves as referral center for traumatized patients [15]. In
addition, the data pertinent to mortality, medicolegal cases handled and
autopsies carried out at DHQ hospital was also retrieved from hospital
administrators after getting informed consent. The data was analysed by means
of Microsoft Excel 2010 software.
Results
Trend of cases managed in
General OPD in comparison with Accident & Emergency OPD (Figure 1-6).
Discussion
Delivering the quality
healthcare services is one of the fundamental requisites for universal health
coverage, however availability and accessibility being the principles of
primary health care are also imperative although insufficient to conform the
provision of standard care [16,17]. After managing the highest emergency
patient load during January and February 2020, their maximum propensity was
dealt with in Accident & Emergency OPD in September 2020. On the other
hand, the frequency of the patients treated in General OPD remained almost at
the same pace throughout the year as illustrated in Figure 1.
Emergency departments of
most of the world-wide regions were on high alert on detection of first
COVID-19 case in Wuhan during December 2019. All healthcare professionals being
the frontline warriors were warned for strict adherence to protective measures
for their protection [18]. COVID pandemic has made the role of Emergency
department of healthcare institutes in managing the outbreaks and disasters
quite eminent. Apart from dealing with routine emergency cases, staff of
emergency department working in a tertiary hospital of Singapore handled around
800 COVID-19 cases as well [19]. In addition to increased work load, our health
workforce also faced the risk of getting infected; the dedication of our
healthcare professionals toward their duty and sincerity with the humans for
their well-being is really commendable. The current study revealed the greatest
magnitude of patients catered by Medicine OPD followed by those in Gynecology
& Obstertics and Paediatrics OPD. However, operations at DHQ hospital
seemed to be quite declined or postponed amidst COVID pandemic as portrayed in
Figure 2. Similarly approximately 28 million worldwide elective surgeries were
reported to be deferred during peak emergence of COVID-19 cases during 2020.
Even the resultant backlog was found to take around 45 weeks for settlement
[20]. According to a predictive model, experts estimated the cancellation of
81.7%, 37.7% and 25.4% of operations for benign conditions, malignancies and
elective caesarean sections respectively [21]. Similar study by Metelmann IB et
al to scrutinize the impact of COVID-19 on delay in general, thoracic, vascular
and visceral surgeries in two University hospitals of West did not reveal any
grave health outcomes in response to delay in operation; however postponement
of surgery seemed to arrest the occurrence of hospital acquired infections
among the patients [22]. The patients suffering from benign diseases may most
probably suffer due to further delay in their operations, as even after
resumption of surgical management on reduction in COVID-19 cases the management
of critical patients are most likely to be prioritized for healthcare
provision. The present study manifested the continuation in routine diagnosis
of the patient through X-rays; however occurrence of other investigations among
patients of DHQ hospital amidst COVID pandemic seemed to be at low pace. Only
ultrasonographies were carried out in greatest magnitude during July 2020.
One of the reasons for
reporting diminished investigations during 2020 was restricted admission of
non-critical patients to the hospitals. Likewise, admissions in a University
hospital of Germany were considerably declined with lockdown imposition in
response to COVID-19 and minimal investigations during this interval were
attributed to this globally afflicted scenario [23]. As our healthcare professionals
were confronted with mega challenge of managing the COVID-19 patients due to
novelty of this disease; limiting the access of non-critical patients to the
hospitals during this distressing state was one of the means for protection and
safety of our frontline warriors, patients and the community. The highest
number (145) of deaths in our study was reported during January 2020 that was
before the arrival of coronavirus in Pakistan. However with occurrence of
COVID-19 cases in Pakistan from March 2020, the fatalities did not
significantly surpassed as depicted in Figure 4. The first wave of COVID
pandemic resulted in grave healthcare outcomes particular in United States,
Italy and Spain while prompt diminution in effective Reproduction number to
0.746 in Pakistan was primarily due to strict lockdown imposition in April 2020
and strict compliance to SOPs mainly by our healthcare workforce [24,25].
One of the reasons for
not reporting excessive deaths at DHQ hospital was vigilant instructions to the
gazetted and non-gazetted staff of the medical universities as well as those of
non-medical organizations to attend their offices alternatively and
continuation of their official work at their homes [26,27]. Even the elders
(above 50 years of age) were allowed to work from home amidst COVID pandemic as
they were more prone to infection due to poor immunity. Autopsies and
medicolegal cases were routinely managed at DHQ hospital amidst COVID pandemic.
This was in contrast to other Asian countries where army was called for help
regarding burial of dead bodies [27]. One of the reasons for registration of relatively
minimal deaths at DHQ hospital than those reported worldwide was
non-declaration of DHQ hospital as COVID-19 hospital [28]. In addition to
provide tertiary healthcare services to the populates of inner Rawalpindi, DHQ
Hospital is also designated as teaching hospital for undergraduate as well
postgraduate medical education. These attributes also make this hospital as
playing a pivotal role in healthcare management.
Conclusion and Recommendations
Reporting of routine OPD
cases and continuation of investigations apart from handling of medicolegal
issues at DHQ hospital amidst COVID pandemic was quite normal. The workload on
healthcare services can further be minimized in future also by strict adherence
to precautionary measures.