==== Front Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 2747891110.5144/0256-4947.2016.258asm-4-258Original ArticleEmergency department attendance patterns during Ramadan Butt Taimur aKhan Hameed Ullah aAhmed Israr aEldali Abdelmoneim b a Department of Emergency Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia b Department of Biostatistics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi ArabiaCorrespondence: Dr. Taimur Butt, Chairman, Department of Emergency Medicine, King Faisal Specialist Hospital and Research Centre, PO Box 3354, Riyadh 11211, Saudi Arabia, T: +966-11-4647272, tbutt@kfshrc.edu.sa, ORCID: http://orcid.org/0000-0003-4949-2344Jul-Aug 2016 36 4 258 264 Copyright © 2016, Annals of Saudi Medicine2016This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.BACKGROUND Patient attendance in the emergency department (ED) is inherently variable and unpredictable. Resources might be better allocated if use of the ER could be predicted. During the month of fasting (Ramadan), healthy adult Muslims do not eat or drink from dawn to sunset and in the Middle East, social activities occur mostly during night. There is no published data that has reported changes in local ED attendance pattern during Ramadan. OBJECTIVES Determine if there are differences in tertiary care ED attendance during Ramadan compared to other times of the year. DESIGN Retrospective, using data from the hospital integrated clinical information system. SETTING Tertiary care institution in Riyadh, Saudi Arabia. PATIENTS AND METHODS All ED visits during the Islamic calendar years of 1431–1434 (December 18, 2009–October 13, 2013) were analyzed. MAIN OUTCOME MEASURES Patient volume, acuity, demographics and admission rate variability between Ramadan and other months. RESULTS During the study period of 4 years, of 226 075 ED patients, 129 178 (57.14%) patients were seen during the day shift (07:00 to 18:59). During Ramadan, 10 293 (60%) patients presented during the night shift compared with the day shift (P<.0001). This trend was seen consistently with no statistically significant differences in admissions 7%, triage acuity or when compared with other months. CONCLUSION During Ramadan, ED attendance changes as more patients present during the night shift. In Saudi Arabia and possibly other Muslim countries, appropriate resources should be allocated during Ramadan to manage the nocturnal ED patient surge. LIMITATIONS We believe that the majority of our patients fast, but it is not known how many ED patients were actually fasting during the study period. This study was conducted in a tertiary care hospital and the patient population presenting to our ED is predominantly Muslim; therefore, the results may not be generalized to populations that are not predominantly Muslim. ==== Body Emergency Department (ED ) patient visits have an inherent natural variability through the day and month to month. The demand for services changes due to seasonal and weekly patterns.1 ED patient attendance patterns may change during local community events, school holidays, sudden influxes of visitors in town or a festivity such as Ramadan (Muslim month of fasting). To optimize the quality of patient care, efficient patient flow, shorten waiting times and length of stay, a balance between the supply of emergency resources and demand for services must be maintained. Cost-effective ED staffing plans account for historic patient volumes during peak and trough hours.2 Also, due to a worldwide shortage of trained and qualified emergency staff, physicians, mid-level providers and nurses, appropriate staffing schedules are required for optimal patient outcomes.3 During Ramadan, healthy Muslims do not eat, drink, smoke or have sexual intercourse from dawn to sunset.4 Muslims follow a lunar calendar and Ramadan is the 9th month. Depending on the sighting of the moon, this may be 29 or 30 days. As a lunar calendar is shorter than the Gregorian calendar by 11 days, Ramadan may fall any time of the year. During summer months the fasting period may be 18 hours long in the region. During Ramadan the change in the sleep-wake cycle is associated with changes in meal schedules, increased food consumption during the night, a decrease in daytime alertness and psychomotor performance and an increase in the intensity of certain diseases.5 Islam does not mandate fasting for sick persons, children, elderly, travelers, insane, pregnant or lactating and menstruating women.6,7 However, many of these individuals attempt fasting to fulfill their religious obligations.8 One epidemiologic study indicated that a majority (79%) of patients with type 2 diabetes fasted for at least 15 days during Ramadan and in another study over half (58%) of peritoneal dialysis patients elected to fast.9,10 It is quite conceivable that some of these patients may present to an ED with sickness or injury.11 During Ramadan, social activities like shopping and family recreational activities are more frequent after people have broken their fast and during the night time. This retrospective study is an attempt to find out whether these social, cultural and religious factors during the month of Ramadan impact ED volume, triage acuity, admission rate and patient demographics in a tertiary care hospital in Riyadh, Saudi Arabia. The patient population presenting to this hospital is predominantly Muslim. To our knowledge, such data from Saudi Arabia has not been published before. PATIENTS AND METHODS Electronic data on patient visits to the ED of King Faisal Specialist Hospital and Research Centre in the city of Riyadh, Saudi Arabia were retrospectively collected from the Integrated Clinical Information System (ICIS). Permission from the Research Advisory Council (RAC # 2131 154) was obtained before accessing hospital data. The data from February 15, 2010 to October 6, 2013 corresponding to Islamic Calendar Rabi-al-awal 1, 1431 to Dhu-al-Hijja 30, 1434 were collected and analyzed. All ED visits were included and direct admissions to the hospital were excluded. Descriptive statistics for the continuous variables are reported as mean and standard deviation and categorical variables are summarized as frequencies and percentages. Continuous variables were compared by the independent t test or ANOVA as appropriate, while categorical variables were compared by chi-square test. The level of statistical significance was set at P<.05. The statistical analysis was done by using the software package Statistical Analysis System (SAS version 9.4). RESULTS Data for the Islamic year 1431 comprises of 10 months (15 February to 7 November 2010). During this period, a total of 48 466 patients were seen in the ED. Of this total, 27,195 (56%) were seen during the day shift (07:00 to 18:59) and 21,271 (44%) were seen during the night [a]shift (19:00 to 06:59). This day to night shift variability in patient volume was statistically significant (P<.0001). More patients were seen during the day shift in all months except during Ramadan, when more patients were seen during the night shift. This difference was also statistically significant when compared with all other months as well as when compared with average for the whole year (P<.0001) (Figure 1). No statistically significant difference was noted among other variables studied between Ramadan and the rest of the year. A total of 44 677 (92%) ED patients were discharged home. There were 37,338 (77%) adults (14 years and above) and 11 128 (23%) pediatric. There were 25 435 females (52%) and 23 018 males (48%). No statistically significant differences were noted when Ramadan was compared with the rest of the months and the entire year (Table 1). A similar trend was seen during the year 1432 (7 December 2010 to 23 October 2011) as noted in Figure 2 and Table 2. During the year 1433 (26 November 2011 to 17 October 2012) similar trend was noted (Figure 3, Table 3). For the year 1434 (15 November 2012 to 6 October 2013) the patient presentation pattern is shown by Figure 4 and Table 4. During the study period, 1431–1434 (December 2009 to October 2013), a total of 226,075 patients were seen in the ED, 129,178 (57%) patients were seen during the day shift and 96,897 (43%) were seen during the night shift (P<.0001). However, during the month of Ramadan, more patients presented to the ED during the night shift after breaking their fast, as compared with all other months or the average of the entire year (P<.0001) (Figure 5). A total of 211,217 (93%) ED patients were discharged home. There were 176 120 (78%) adults and 49 955 (22%) pediatrics. Female ED patient visits included 118 562 (52%) while male patients were 107 476 (48%). Among these variables a similar trend continued during Ramadan months. The cumulative results are shown in the Table 5. Patient triage acuity based on Canadian Triage and Acuity Scale (CTAS) was analyzed for Ramadan and the rest of the months through 1431 to 1434. No association was found in the number of category 1 and 2 (emergent) patients, Category 3 (urgent) patient volume was increased while the category 4 (non-urgent) patient volume was noted to have decreased during Ramadan as compared with the rest of the months (Figure 6). DISCUSSION During the months of Ramadan, the majority of the patients presented to the ED during the night shift after breaking their fast. This change corresponds to the nocturnal culture pattern that develops during this month in a Middle Eastern society.12,13 Use of the ED by patients is based upon convenience, inability to access primary care, lack of insurance or patient perception of an urgent medical condition. This study shows a sudden reversal of the ED patient arrival pattern during the month of Ramadan suggesting that social and cultural factors have a strong influence on the use of the ED by the patients. To maintain quality of care, resource allocation must match patient care demands. Accurate predictions of future demand and workload can enable optimal staff scheduling and resource allocation.1 The staff scheduling for the ED shifts can be done by using mathematical calculations, analytical analysis, hospital website activity volume or daily and hourly patient arrival patterns.14 Patient acuity, complexity and often social status may affect physician workload. Whereas sicker patients may take more physician time with procedures and consultations, patients with higher social status might require more time for disease discussion and reassurance. To maintain a balance between resource allocation and quality of care, future staff planning should be based on historic patient arrival patterns, day and night visit variability, number of admissions, patient acuity, variation in gender and adult-to-pediatric visit ratio. ED patient arrival has natural variability while the operating room (OR) schedule has artificial variability. Smoothing the OR schedule can improve ED patient flow.15 It would be interesting to see if a similar variability is present in the scheduling of surgeries during Ramadan. Likewise, other supporting departments like radiology, pathology, respiratory services, admitting services and others must align their staffing to ED patient care demands. During the month of Ramadan, we change the emergency physician schedule for both the fast track and the main department. Shifts are arranged to match the higher incoming patient volume during the night, without actually increasing the total daily hours of coverage. This study supports our practice as the total volume of patients during Ramadan did not change. In our ED, the on-call and back-up staffing is maintained without any change throughout the year. Intermittent fasting during the month of Ramadan has been shown to cause various health effects, including changes in serum glucose, glycosylated hemoglobin, physiological and psychological responses of athletes, LDL cholesterol, electrolyte, seizure frequency and caffeine withdrawal headaches.16–20 These health effects did not increase ED patient volume in our study. Patients who are fasting, usually avoid visiting the ED during the day time, and prefer to visit after breaking their fast because if someone is fasting, taking oral medications and intravenous fluids with calories will break the fast. Intramuscular injections and IV fluids without calories are often permitted by religious authorities, but in our experience are commonly avoided by our patients. As a tertiary hospital, our patient population is quite complex. However, the acuity of illness based on the CTAS did not change significantly during Ramadan. Other variables that did not change significantly included admission rate, discharge rate, gender and age distribution. These findings suggest no significant health effects in our patient population. We believe that the majority of our patients fast but it is not known as to how many ED patients were actually fasting during the study period. This study was conducted in a tertiary care hospital and the patient population presenting to our ED is predominantly Muslim; therefore, the results may not be generalized. In conclusion, despite natural variability, the monthly ED patient volume, age, gender and the admission rate remained constant throughout the years. There was a significant change in the patient presentation pattern during the month of Ramadan, with a greater number of patients presenting to the ED after sunset and through the night shift. This nocturnal arrival pattern may be related to religious, social and cultural factors in the region. EDs and other hospital support services in Saudi Arabia and possibly other Muslim countries in the region should adjust their staff schedules accordingly. Figure 1 Emergency department patient attendance (1431). Figure 2 Emergency department patient attendance (1432). Figure 3 Emergency department patient attendance (1433). Figure 4 Emergency department patient attendance (1434). Figure 5 Emergency department patient attendance (1431–1434). Figure 6 Emergency department triage acuity distribution (1431–1434). Table 1 Patient demographic data, Islamic year 1431. Months Total Arrival time Disposition Age Gender Day Night Home Admit Adult Peds Female Male Rabi-al-awal 5423 3194 2229 5153 270 4084 1339 2796 2623 Rabi-al-thani 5172 2982 2190 4727 445 3885 1287 2681 2489 Jumada-al-awal 4947 2860 2087 4485 462 3840 1107 2622 2325 Jumada-al-Thani 4765 2804 1961 4391 374 3715 1050 2433 2332 Rajab 4327 2448 1879 4017 310 3386 941 2323 2004 Shaaban 3974 2217 1757 3667 307 3204 770 2049 1925 Ramadan 4171 1623 2548 3783 388 3300 871 2231 1938 Shawwal 4651 2551 2100 4200 451 3696 955 2406 2245 Dhu-al-qada 5444 3200 2244 5091 353 4086 1358 2925 2516 Dhu-al-hijja 5592 3316 2276 5163 429 4142 1450 2969 2621 Total 48 466 27 195 21 271 44 677 3789 37 338 11 128 25 435 23 018 Percentage 100 56 44 92 8 77 23 52 48 Table 2 Patient demographic data, Islamic year 1432. Months Total Arrival Time Disposition Age Gender Day Night Home Inpatient Adult Peds Female Male Muharram 5665 3439 2226 5243 423 4123 1542 3047 2617 Safar 4947 2930 2017 4586 361 3747 1200 2614 2332 Rab-al-awal 4804 2877 1927 4440 364 3702 1102 2484 2320 Rab-al-thani 5020 3001 2019 4615 405 3881 1139 2615 2405 Jumada-al-awal 4840 2818 2022 4406 434 3750 1090 2494 2342 Jumada-al-thani 5104 2948 2156 4676 428 3966 1138 2625 2479 Rajab 4506 2496 2010 4109 397 3564 942 2353 2153 Shaaban 4508 2463 2045 4029 479 3633 875 2312 2196 Ramadan 4181 1614 2567 3743 438 3379 802 2172 2009 Shawwal 4865 2766 2099 43147 518 3842 1023 2571 2292 Dhu-al-qada 5293 3223 2070 4842 451 4091 1209 2737 2556 Dhu-al-hijja 5126 3027 2099 4682 444 3873 1253 2684 2441 Total 58 859 33 602 25 257 53 718 5142 45 551 13 315 36 564 28 142 Percentage 100 58 43 91 9 77 23 52 48 Table 3 Patient demographic data, Islamic year 1433. Months Total Arrival time Disposition Age Gender Day Night Home Inpatient Adult Peds Female Male Muharram 5522 3379 2143 5046 476 4195 1327 2829 2693 Safar 5118 3056 2062 4584 534 3813 1305 2614 2332 Rab-al-awal 5068 3075 1993 4545 523 3878 1190 2647 2421 Rab-al-thani 5280 3116 2164 4781 499 4044 1236 1805 2475 Jumada-al-awal 4972 2901 2071 4466 506 3860 1112 2679 2293 Jumada-al-thani 5192 3065 2127 4632 560 4070 1122 2707 2481 Rajab 4634 2616 2018 4132 502 3701 933 2523 2110 Shaaban 4372 2380 1992 3891 481 3508 864 2306 2068 Ramadan 4342 1724 2618 3907 435 3507 835 2323 2019 Shawwal 4600 2612 1988 4119 481 3762 838 2425 2172 Dhu-al-qada 4243 3138 2105 4777 466 4121 1122 2759 2481 Dhu-al-hijja 5041 2955 2086 4542 499 3921 1120 2658 2382 Total 59 384 34 017 25 367 53 422 5962 46 380 13 004 31 417 27 957 Percentage 100 57 43 90 10 78 22 53 47 Table 4 Patient demographic data, Islamic year 1434. Months Total Arrival time Disposition Age Gender Day Night Home Inpatient Adult Peds Female Male Muharram 5308 3225 2083 4762 546 4040 1268 2759 2549 Safar 5250 3198 2052 4715 535 4002 1248 2759 2494 Rabi-al-awal 4671 5746 1925 4164 507 3689 982 2480 2119 Rabi-al-thani 5203 3138 2065 4693 510 4034 1169 2704 2499 Jumada-al-awal 5062 2985 2077 4545 517 3898 1164 2684 2370 Jumada-al-thani 5036 2969 2067 4554 482 3939 1097 2622 2413 Rajab 4970 2894 2076 4463 507 3911 1059 2633 2336 Shaaban 4315 2476 1839 3862 453 3532 783 2225 2090 Ramadan 4406 1846 2560 3943 463 3642 764 2260 2146 Shawwal 4747 2653 2094 4215 532 3928 819 2458 2288 Dhu-al-qada 5082 3052 2030 4572 510 4042 1040 2608 2470 Dhu-al-hijja 5316 3182 2134 4804 512 4194 1122 2806 2509 Total 59 366 34 364 25 002 53 292 6074 46 851 12 515 30 998 28 283 Percentage 100 58 42 90 10 79 21 52 48 Table 5 Patient demographic data, Islamic year 1431–1434. Months Total Arrival Time Disposition Age Gender Day Night Home Inpatient Adult Peds Female Male Muharram 16 495 10 043 6452 15 572 923 12 358 4137 8635 7859 Safar 15 315 9184 6131 14 404 911 11 562 3753 8126 7188 Rabi-al-awal 19 966 11 892 8074 18 794 1172 15 353 4613 10 407 9555 Rabi-al-thani 20 675 12 237 8438 19 316 1359 15 844 4831 10 805 9868 Jumada-al-awal 19 821 11 564 8257 18 403 1418 15 348 4473 10 483 9337 Jumada-al-thani 20 097 11 786 8311 18 728 1369 15 690 4407 10 387 9705 Rajab 18 437 10 454 7983 17 208 1229 14 562 3875 9832 8603 Shaaban 17 169 9536 7633 15 885 1284 13 877 3292 8892 8276 Ramadan 17 100 6807 10 293 15 824 1276 13 828 3272 8986 8112 Shawwal 18 863 10 582 8281 17 394 1469 15 228 3635 9863 8997 Dhu-al-qada 21 062 12 613 8449 19 783 1279 16 340 4722 11 029 10 023 Dhu-al-hijja 21 075 12 480 8595 19 909 1169 16 130 4945 11 117 9953 Total 22 6075 129 178 96 897 211 220 14 858 176 120 49 955 118 562 107 476 Percentage 100 57 43 93 7 78 22 52 48 ==== Refs REFERENCES 1 Jones Spencer S Forecasting daily patient volumes in the emergency department Academic Emergency Medicine 2008 15 2 159 170 18275446 2 Hall Randolph Modeling Patient Flows Through the Health care System Patient Flow Springer US 2013 3 42 3 Kirsch Thomas D The development of international emergency medicine: a role for US emergency physicians and organizations Acad Emer Med 1997 4 10 996 1001 4 Topacoglu H Impact of Ramadan on demographics and frequencies of disease-related visits in the emergency department Int J Clin Pract 2001 5 59 8 900 905 5 Fazel M Medical implications of controlled fasting J Royal Soc Med 1998 91 5 260 6 Azizi F Ann Nutr Metab Islamic fasting and health 2010 56 4 273 82 7 Gomceli Yasemin B Kutlu Gulnihal Cavdar Leyla Inan Levent E Does the seizure frequency increase in Ramadan? Seizure 2008 17 671 676 18468459 8 Jamilian M The Effect of Ramadan Fasting on Outcome of Pregnancy Middle-East Journal of Scientific Research 2015 23 7 1270 1275 9 Wiley-Blackwell, John Wiley & Sons The incidence of hypoglycaemia in Muslim patients with type 2 diabetes treated with sitagliptin or a sulphonylurea during Ramadan: a randomised trial Int J Clin Pract 2011 11 65 11 1132 1140 21951832 10 Al Wakeel J Mitwalli AH Alsuwaida A Al Ghonaim M Usama S Hayat A Shah IH Recommendations for fasting in Ramadan for patients on peritoneal dialysis Perit Dial Int 2013 Jan-Feb 33 1 86 91 23349195 11 Langford EJ Ishaque MA Fothergill J Touquet R The effect of the fast of Ramadan on accident and emergency attendances J R Soc Med 1994 9 87 9 517 518 7932456 12 Fazel M Medical implications of controlled fasting J R Soc Med 1998 5 91 5 260 263 9764079 13 Bogdan A1 Bouchareb B Touitou Y Ramadan fasting alters endocrine and neuroendocrine circadian patterns. Meal-time as a synchronizer in humans? Life Sci 2001 2 23 68 14 1607 15 11263673 BMC Emerg Med 2009 9 1 19178716 14 Sun Yan Forecasting daily attendances at an emergency department to aid resource planning BMC emergency medicine 2009 9 1 15 Eugene Litvak “Optimizing patient flow by managing its variability.” front office to front line: Essential Issues for health care Leaders Oakbrook Terrace, IL Joint Commission Resources 2005 91 111 16 Saada D Ait Effect of Ramadan fasting on glucose, glycosylated haemoglobin, insulin, lipids and proteinous concentrations in women with non-insulin dependent diabetes mellitus African Journal of Biotechnology 2010 9 1 17 Azizi F Rasouli HA Serum glucose, bilirubin, calcium, phosphorus, protein and albumin concentrations during Ramadan MJIRI 1987 1 1 38 41 18 Salehi M Neghab M Effects of fasting and a medium calorie balanced diet during the holy month Ramadan on weight, BMI and some blood parameters of overweight males Pak J Biol Sci 2007 10 6 968 71 19069900 19 Chaouachi A Leiper JB Chtourou H Aziz AR Chamari K The effects of Ramadan intermittent fasting on athletic performance: recommendations for the maintenance of physical fitness J Sports Sci 2012 30 Suppl 1 S53 73 22738880 20 Abu-Salameh Ibrahim Plakht Ygal Ifergane Gal Migraine exacerbation during Ramadan fasting The Journal of Headache and Pain 2010 11 6 513 517 20652352