INTRODUCTION
On 11 March 2020, the World Health Organization declared the current COVID-19 outbreak a public health emergency of global concern and ultimately a pandemic. Given the magnitude of the coronavirus pandemic and high rate of transmission, various widespread restrictions were imposed, including international travel bans and government-mandated lockdowns in an effort to contain the viral spread.(1)
On 5 March 2020, the first known case of coronavirus was confirmed in South Africa. The subsequent initial increase in the number of cases resulted in a government-enforced lockdown to slow the rate of spread and an attempt to flatten the curve. Anecdotal reports indicated a changing ENT landscape initiated by the pandemic and subsequent lockdown. There have been reports of a decrease in the number of clinic attendees and surgical procedures performed in clinics throughout the world.(2,3) Centres throughout the world initiated telemedicine during the lockdown period; however, this is not possible in public hospitals in South Africa due to constraints in infrastructure and access to technology.(4)
In light of this, we reviewed the services provided by our department, an Otorhinolaryngology, Head and Neck Surgery (ENT) unit at a public teaching hospital in Johannesburg, South Africa over the first 85 days of lockdown.
METHODOLOGY
The study period was from 2 January 2020 to 19 June 2020 which was delineated by the lockdown date of 26 March 2020 into two periods of 85 days for comparative review. Thus, the pre-lockdown phase constituted the period 2 January 2020 to 25 March 2020, and the post-lockdown period as from 26 March 2020 to 19 June 2020.
This was a retrospective review of secondary data obtained from multiple sources (booking centre, the monthly ward, clinic and theatre statistics and the minutes of the weekly morbidity and mortality meetings). A single institution was studied in an attempt to avoid selection bias and to limit the variables in terms of data collection and interpretation.
The ENT Department at the Charlotte Maxeke Johannesburg Academic Hospital, affiliated to the University of the Witwatersrand, continued to function as a quaternary referral centre with the specialist clinics and emergency surgery carrying on during the post-lockdown period (March to June 2020).
DATA EXTRACTED
The data extracted included the number of patients who were booked for the specialist clinics on a weekly basis, the number of patients who attended and the number of procedures that were performed. These procedures included nasopharyngoscopy, ear syringing, suction of the ear with the use of a microscope, nasal cautery, removal of foreign bodies and stroboscopy.
The outpatient clinics studied included the paediatric clinic, the head and neck oncology clinic, the otology and vestibular clinic, the rhinology and skull base clinic and the general ENT clinic (includes the combined multi-disciplinary cleft palate clinic, craniofacial clinic and voice clinic amongst others).
The ward admissions were characterized as either elective or emergency. Inpatient referrals from other disciplines and casualty consultations were included as emergency consultations. Due to the variable nature of telephonic consultations, they were excluded from the study.
Theatre procedures were categorized as elective or emergency procedures.
Descriptive statistics are presented for scheduled appointments within each period, characterizing the number of completed and cancelled visits. Chi-square tests were performed to analyse the differences in appointment completion rates between the two periods.
RESULTS
During the pre-lockdown phase, 2160 patients were booked for the outpatient clinics and 1911 (88.5%) attended in this period (Figure 1). In contrast during the post-lockdown period, 1220 visits were scheduled. Of these, 937 (76.8%) visits were completed. The number of patient visits booked and completed after lockdown declined significantly (P = 0.01). The decrease in attendance rates after the lockdown commenced was also significant (P = 0.0001).
The monthly patient attendances at the outpatient clinics were fairly consistent in the pre-lockdown phase with 31–35 patients seen/day. During the immediate period after lockdown, the patient attendance dropped drastically to 10 patients/day (Table 1).
The breakdown per outpatient clinic is represented in Figure 2, with each clinic showing a decrease in attendance. Using Fisher's exact test, the only significant decrease in comparison to the overall decrease was noted in the General ENT (P = 0.009) and Head and Neck clinics (P = 0.017).
Ward admissions during the pre-lockdown phase included both emergency and elective admissions (patients awaiting surgery and those for medical investigation and non-surgical treatment). The total number of ward admissions for the pre-lockdown period was 380 as opposed to the post-lockdown period of 262, a decline of almost one third (31%).
In total, 416 patients had procedures that were performed in theatre between January and June 2020. During the pre-lockdown phase, 228 patients underwent procedures in theatre, 66 of which were emergencies. There were 46 cancellations. During the post-lockdown phase, 188 surgical procedures were performed (a 21% decrease), none of which were elective cases. There were 14 cancellations. The association between pre- and post-lockdown in terms of the number of theatre procedures performed was insignificant (0.67), but the proportion of cancellations was significant (P = 0.001).
DISCUSSION
The functionality of our unit changed markedly during the initial phases of the lockdown, which was particularly stringent. The data comparisons between the pre- and post-lockdown periods revealed significant decreases in both the number of patients booked and the attendance rates at our specialist out-patient clinics.
Our out-patient clinic attendance rate post-lockdown decreased by almost 25% but not to the same extent in comparison to published data. Kasle et al. conducted a retrospective review within the ENT unit at the Yale School of Medicine during a selected period in the COVID-19 pandemic and compared it to the same period in 2019.(1) Of note, only 12.9% of scheduled visits were completed in the 2020 period with the majority cancelled due to COVID-19. In addition, the majority (55.8%) of their completed visits were via telehealth, an impractical option in our setting. The discrepancy between our clinic non-attendance rates and that of Kasle et al. is consistent with previous suggestions of North American health-care culture and possibly linked to our service being a government sponsored health-care system.(5)
The monthly patient attendance at the outpatient clinics declined drastically from 31–35 patients seen/day during the pre-lockdown phase to 10 patients/day during the post-lockdown phase. At this stage, South Africa was at level 5 lockdown, which entailed a severe curtailment of all activities. The months of May and June saw a steady increase in the number of patients attending the outpatient clinics (15–21 patients/day) with the lockdown levels becoming more relaxed. The rapid initial decline in patient visits mirrors that of Kasle et al. Their subsequent documented increase in completed visits was mainly attributed to telehealth visits.(1)
We observed a decrease in attendance at all our clinics with the General ENT and Head and Neck clinics having the most significant declines in attendance. This finding is consistent with that of Kasle et al. who observed that during the 2020 period, appointment completion rates dropped for all specialities and was highest for head and neck oncology (25.5%).(1) This decline in our unit and elsewhere is most likely is due to a fear of accessing a hospital as it is considered a risky environment.
After the introduction of the lockdown, all elective cases were postponed. However, oncology and emergency cases were still prioritized. This postponement led to a one-third decline in the ward admission rate during the post-lockdown period. The postponement is in-line with measures adopted by comparable departments in Italy, a country which adopted a similar severe lockdown as South Africa.(6) The 21% decrease in the number of surgical procedures performed in theatre during the post-lockdown period in our study was not significant. A study by Ralli et al. in Italy documented a 50.8% decrease in the number of ENT procedures.(7) Their greater reduction in surgical procedures could possibly be explained by the timing of their study which included the period during which Italy experienced their highest rate of COVID-19 infections. Our post-lockdown period included only the initial phase of the COVID-19 infection in South Africa.(8)
The COVID-19 pandemic has resulted in the disruption of ENT and head and neck services throughout the world. The head and neck region has one of the highest concentrations of virus particles and thus there has been a trend to postpone all elective surgery and reschedule out-patient clinics wherever possible.(9) At our institution, we saw a reduction in the number of appointments made at the outpatient clinics; there was still a need for the provision of urgent ENT services throughout the lockdown period with increased numbers in certain areas such as head and neck endoscopy and tracheostomy.
The current study illustrates that despite a lockdown period, there is still an ongoing need for specialist medical and surgical services, and health-care systems need to be tailored to manage all patients such that care is not shifted away from vulnerable groups and solely focused on COVID-19 patients. Unfortunately, clinic non-attendance and rescheduling of elective procedures in a system as constraint as ours is could have long-lasting repercussions on patient health which may be difficult to recover from timeously. A possible long-term solution would be the adoption of telehealth, a trend which would require significant commitment, from both financial and patient perspectives, and health-care education.