Impact of lockdown on medical emergency visits during the COVID-19 pandemic in India

After emerging from Wuhan, China, in December 2019 and spreading within a short period of a few weeks, COVID-19 had resulted in one of the worst pandemics in history, with global deaths of over three and a half million. Social distancing and masking in public, lockdown, advancement in diagnosis and management and improved infection control measures were used to flatten the epidemic curve. While there is an undeniable role of lockdown (ie, ban on public assembly and restriction of most travel) in curbing the spread of COVID-19, the impact on other services, including chronic illnesses and emergency services, remains unknown. India declared a lockdown which was starting from 25 March 2020 to 30 May 2020 and gradually relaxed after that. There was a significant reduction in the growth rate of cases. It also helped increase the duration in the doubling of patients. Few studies have reported the impact of lockdown on various essential services. Knowing the effect of lockdowns on hospital services is essential to plan for future pandemics and disasters. Further, with each country experiencing more than one wave, lockdowns (either nationwide or region wise) would be required in the ensuing years. While some data are available from developed nations, data from low/middleincome countries (LMICs) are lacking. We planned to study the impact of lockdown on the trends and mortality among emergency medical admissions and document the difference between the number of emergency visits of the last 4 years and the current year. We conducted a retrospective study in a large tertiary care centre of Northern India (Post Graduate Institute of Medical Education and Research, Chandigarh, India). The data were collected for the first 6 months of the year 2020, which included the ‘prelockdown period’ (from 1 January 2020 to 31 March 2020), lockdown period (1 April 2020 to 31 May 2020) and the postlockdown period (1 June 2020 till 30 June 2021). Data were also collected regarding monthly visits and corresponding mortality for the past 4 years from the central records department. All consecutive patients visiting the medical emergency during the study period were enrolled. We obtained monthly visits and corresponding mortality data from our central records department from January 2016 to June 2020. We also retrieved the information on subjects requiring hospitalisation for ≥24 hours for 2020 from the data registers maintained at the emergency observational units. The sociodemographic profile and the diagnosis (classified as per the IICnternational Classification of Diseases-10 system) were documented. Descriptive statistics were used for summarising the characteristics of study groups. Categorical variables were presented as numbers (%) and continuous variables as mean±SD. Differences in the pattern of diagnosis between the three groups were tested by χ test and analysis of variance for categorical and continuous variables, respectively. The p value for significance was set at <0.05. We calculated the percentage difference in admissions during January and February 2020 (when no COVID-19 cases were reported in our region) compared with the previous 4year average (January and February of 2016–2019). For example, the percentage difference in January 2020 was derived as: ((the number of visits in January 2020−average visits in January 2016–2019)/average visits in January 2016 to 2019)*100. Then we used the percentage difference to estimate the expected number of visits from March to June 2020. Finally, the percentage decline in emergency visits was then calculated as follows: percentage decline=(((estimated number of visits–the actual number of visits)/the estimated number of visits)*100). A total of 22 267 emergency visits was observed during the study period (January to June 2020). Figure 1 shows the difference between the monthly visits between the previous 4 years and the study period (online supplemental table 1). Hospital visits have been increasing over the years. There was a 27% increase in admissions during January and February 2020 compared with the average of the previous 4 years. There was a decline in emergency visits by 54% (expected—10 151, actual— 4681) during the lockdown period, which recovered to 31.6% (expected—4991, actual—3415) during the postlockdown period. Twelve thousand six hundred and ninetyone (57.0%) patients were admitted to the medical emergency from January to June 2020. Of these, 8965 (70.6%), 2310 (18.2%) and 1416 (11.2%) patients were admitted during the prelockdown, lockdown and postlockdown period, respectively. All patients visiting the emergency were tested for COVID-19 by the reverse transcriptasePCR technique. No COVID-19 patient was encountered during the prelockdown period, with the lockdown and postlockdown periods showing a total of 417 (11.2%) and 40