The impact of COVID-19 pandemic on the indications of non-COVID … – Nature.com

The official worldwide deaths from COVID-19 pandemic surpassed 6 million, and it is still far from over3. The restrictions and global full or partial lockdowns have been initiated to slow down the spread of the virus and flatten the curve of the pandemic14,15. However, these measures had negative impacts in different strata of life, including the changes in accessibility and structure of health care delivery. From the time of early pandemic declared by WHO on March 2020, a moratorium on every kind of elective surgeries was placed to preserve the critical care resources. Since the high influx of patients with severe disease after the outbreak made the available medical staff and equipments insufficient to meet the needs of all patients, admission decisions to ICUs become more important. Therefore, the effects of COVID-19 outbreak on case volumes and ICU bed utilization have changed the traditional indications for admissions, disease control methods, demographics and overall outcomes in both COVID-19 and non-COVID-19 patients16,17. Health care utilization was affected by this major public health emergency, with elective high risk procedures and treatment for non-urgent conditions significantly cancelled or postponed18,19. The largest decrease was seen in preventive and primary care visits for common chronic conditions18. Furthermore, previous investigations have shown that even patients with life-threatening conditions may have avoided hospital admissions, possibly due to concerns regarding the exposure to SARS-CoV-220. Substantial reductions in admissions and treatments for carcinoma, stroke and myocardial infarction were also reported21,22. A prolonged pandemic may also continue to exacerbate growing gender, social and economic inequalities with devastating consequences for those most at risk, since it has disproportionately impacted women, from reduced economic opportunities and decreased access to reproductive and maternal health care, especially in developing countries.

Although there are many post-pandemic publications on the change in demographics, treatment algorithms and outcomes of surgical patients admitted to both COVID and non-COVID wards and ICUs, our knowledge on OGAs only consists of clinical experience since OG patients constitute only 5 to 10% of general ICU population12,16,17. These studies reveal that there is over 90% reduction from baseline in the number of elective surgeries performed allowing 70 to 80% of surgical ICU beds to be available for COVID-19 positive patients23,24. In the present study, we analysed the patients admitted to ICU for non-COVID-19 OG pathologies as our hospital was not announced as a COVID-hospital in metropolitan Istanbul area, but we still had to be careful in reserving bed capacity in case of other COVID hospitals may overflow with patients. To our knowledge, this is the first study investigating the impact of COVID-19 outbreak on non-COVID-19 OGAs to ICUs, and according to our findings, our ICU admitted 38% fewer OG inpatients after March 2020.

Hemorrhage, hypertensive disorders of pregnancy, sepsis and malignancy are among the most common indications for the OGAs to ICUs8,9. However, preexisting medical conditions, cardiac diseases, respiratory disorders, and complicated operations are usually followed up in ICUs, as well. In a pre-pandemic study of Heinonen et al.25, published in 2002, the authors report that the most common diagnoses at ICU admission for the gynecological patients were postoperative haemorrhage (43%), infection (39%) and cardiovascular disease (30%). The mean duration of their stay in the ICU was 4.97days and the mortality in the ICU was 0%.Other pre-pandemic studies of Sailaja et al.26 and Richa et al.27, published in 2019 and 2008, respectively, confirmed hypertensive disorders (24.2% vs 26%) and obstetric hemorrhage (23.1% vs 20%) as the most common obstetric admissions. In Richa et al. s 27 study, sepsis (26.7%) and preexisting medical problems (6.65%) were also ranked among the indications. According to our pre-pandemic admission indications; hemorrhage, hypertension and placental pathology in obstetric (60% vs 41% vs 29%, respectively), and postoperative complications and hemorrhage (57% vs 19%, respectively) in gynecological patients were detected as the leading causes. Sepsis and cardiopulmonary diseases (4.5% vs 2.7%, respectively) were also among the indications of OGAs to ICU, and the main disease groups were similar to the pre-pandemic literature, even the percentages differ probably due to regional population factors.

Since there is no similar study in our PubMed research of the English-written literature, we could compare the post-COVID-19 results with our own pre-outbreak data. The most important findings in the present study were the change in indications after outbreak as significant increases in admission ratios of pregnancy-induced hypertension and placental pathologies (36% and 58%, respectively) in obstetric, and postoperative complications and sepsis (69% and 12%, respectively) in gynecological patients. Significant decrease in admissions for hemorrhage in obstetric patients (from 60 to 36%) was also another interesting finding in the present study. In our opinion, priority given to oncological operations might explain the increase in postoperative complications seen in gynecologic patients. Since oncology patients were older, their APACHE-II scores were also higher. However, there were no important changes in their acute physiology scores and chronic health points. Similarly, we explain the decrease in hemorrhage in obstetric patients and in obstetric admissions to ICU partly by a result of the improvement in maternal and fetal care lately. Another contributing factor can be the effective use of postanesthesia care unit (PACU) and secondary care units located in the surgical wards, since most of the patients formerly admitted to ICUs were followed up in these units. Most importantly, the procedure of selecting priority patients by gynecologists and intensive care specialists in cooperation, and meticulous implementation of the rule of only accepting patients with strict indications may help to interpret the changes in OGAs during the outbreak. This has been achieved by changes in triage with denying ICU admissions to less-ill patients in order to accomodate those with postoperative complications and sepsis. This may also explain why bleeding patients are less well-represented since bleeding can typically be dealt with outside the ICU, but sepsis or ventilator dependency cannot.

The primary goal in ICU is to resuscitate patients and save their lives, and one of the most important secondary goals is to decrease the length of stay in order to improve the quality of medical care and reduce cost. However, prolongation of hospital stay in ICUs due to life-threatening diseases are increasing in the world28. According to literature, the mean length of stay in ICUs ranges from 1 to 28days for most of the diseases including gynecological pathologies29,30. However, it is well known that elderly oncology patients with multiple comorbidities stay longer in ICUs31,32. In our study, comparatively shorter duration of stay in ICU was remarkable. It was on average only 3days, even most of them underwent oncologic surgery. Because they were transferred to their OG wards as soon as their intensive care treatment ends.

The major limitation of our study is its retrospective design, which may cause difficulties in controlling for potential confounding bias. Moreover, we could not compare our single-center data with the literature since there was no similar articles in our web search. However, the present study investigating the impact of COVID-19 pandemic on the indications of non-COVID-19 OGAs to ICU will contribute to the current literature, since these findings remind the health professionals of the primary role of ICUs; admitting patients who really needs to be there. We also believe that our findings will question the accuracy of wider indications for OGAs to ICUs in pre-pandemic period, and help in planning the policy for future post-pandemic days.

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