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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 59  |  Issue : 3  |  Page : 259-264

Triaging of patients and their management during the lockdown period due to COVID-19 pandemic at a tertiary eye center in India


1 Deparment of Vitreoretina, Aditya Birla Sankara Nethralaya (A Unit of Medical Research Foundation), Kolkata, West Bengal, India
2 Deparment of General Ophthalmology and Glaucoma, Aditya Birla Sankara Nethralaya (A Unit of Medical Research Foundation), Kolkata, West Bengal, India
3 Deparment of Orbit Oculoplasty Reconstructive and Aesthetic Services, Aditya Birla Sankara Nethralaya (A Unit of Medical Research Foundation), Kolkata, West Bengal, India
4 Deparment of Uvea, Aditya Birla Sankara Nethralaya (A Unit of Medical Research Foundation), Kolkata, West Bengal, India
5 Bhagwan Mahavir Vitreoretina Services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India

Date of Submission16-Jun-2021
Date of Acceptance07-Jul-2021
Date of Web Publication09-Sep-2021

Correspondence Address:
Dr. Md Shahid Alam
Aditya Birla Sankara Nethralaya (A Unit of Medical Research Foundation), Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_85_21

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  Abstract 


Aim: The aim of the study is to describe the triaging of patients based on their clinical profile and the management offered during the lockdown period due to the COVID-19 pandemic at a tertiary eye center. Methods: A cross-sectional study of patients who visited the emergency department during the lockdown (Phase 1 and Phase 2) from March 3,2020 to May 5, 2020 at a tertiary eye care center and their management was carried out. All the data were collected from the Electronic Medical Record of the hospital. Results: A total of 453 patients presented to the hospital during this period. The mean age of the patients was 42.12 ± 18.12 years (Median 46 and Range 31–54). Maximum numbers of patients were in the adult age group (73.95%) and were male (63.35%). On triaging, 42.83% needed emergency care, 20.75% needed urgent care, and 36.42% of patients were manageable with routine care. The majority of the emergency cases were of trauma (46.91%) followed by vitreoretinal (17.01%) and corneal (11.86%) complaints. Most of the patients were managed medically (94.26%) while few needed surgeries (5.74%). The patients being attended during the lockdown period was 1.9% of the total patients (23,121) seen during the same time period in the year 2019. Conclusion: There was a drastic fall in the number of patients visiting the hospital during the lockdown period. The majority of the visiting patients needed emergency care and a handful of patients were managed surgically. Rearranging the clinical and surgical activity with triaging helped us to achieve safe and methodological practice during this pandemic period.

Keywords: COVID-19, lockdown, ophthalmology, pandemic, profile, triage


How to cite this article:
Mistry S, Iqbal A, Alam MS, Das S, Mukherjee S, Kumar A, Rao GS. Triaging of patients and their management during the lockdown period due to COVID-19 pandemic at a tertiary eye center in India. TNOA J Ophthalmic Sci Res 2021;59:259-64

How to cite this URL:
Mistry S, Iqbal A, Alam MS, Das S, Mukherjee S, Kumar A, Rao GS. Triaging of patients and their management during the lockdown period due to COVID-19 pandemic at a tertiary eye center in India. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 Sep 21];59:259-64. Available from: https://www.tnoajosr.com/text.asp?2021/59/3/259/325744




  Introduction Top


It all started in December 2019 in Wuhan (China) when the first case of a new form of pneumonia of unknown origin was notified.[1] On January 7, 2020, the causative organism was isolated from the throat swab and was identified as severe acute respiratory syndrome coronavirus 2 at the Chinese Center of Disease Control. Later, the World Health Organization (WHO) named the disease as COVID-19. In March 2020, the WHO officially declared COVID-19 a pandemic.[2] The first case of COVID-19 in India was reported on January 30, 2020, and looking at the increasing number of cases a countrywide complete lockdown was imposed in India. The lockdown in India started from March 25, 2020 (Phase 1) which limited movement of 1.3 billion people for 21 days, and was extended further on April 14, till of May 3, 2020.[3] Healthcare workers at hospitals serve at the frontline and get exposed to the patients presenting with diverse indistinguishable complaints. Reduced immunity due to long working hours, increasing stress, and limited knowledge of the disease further increase the susceptibility of health workers.[4] Ophthalmologists are considered as a moderate risk category as it involves a lot of physical examination and close contact with the patients. An outbreak in the ophthalmology department has already been reported.[5],[6] Hence, it is of utmost importance to segregate the patients depending on their complaints and manage them accordingly. Guidelines laid for practice include triaging of patients, using personal protective equipment (PPE) kit, altering patient flow in the outpatient department and in surgical room.[7] The present study describes our experience in triaging the patients considering their clinical profile and managing them accordingly during the lockdown period due to the COVID-19 pandemic. The study will not only be helpful for ophthalmologists and institutes facing lockdowns in different parts of the country but will also provide invaluable data pertaining to the management of cases in a pandemic which will be an invaluable helpful resource for the present and future generations.


  Methods Top


It was a cross-sectional study of patients visiting our emergency department during the lockdown Phase 1 and 2 from March 25 to May 3, 2020, and their subsequent management. A total of 453 patients presented to us and were included in the study. All patients underwent compulsory thermal screening at the hospital entrance and were asked regarding different symptoms of COVID-19 (fever, cough, sore throat, diarrhea, loss of taste and smell, etc.) and history of international travel. After hand sanitization, the patients were allowed to enter the hospital premises and were provided with three-ply surgical masks. They were made to wait in the waiting area following waiting hall guidelines. A consent form pertaining COVID-19 pandemic was signed with the patient's contact number and other details, so that if required contact tracing could be done.[6] Patients who were positive for clinical signs and symptoms of COVID-19 were immediately notified to the local or state health care department for further investigations as per the Ministry of Health and Family Welfare (MoHFW) and Indian Council of Medical Research guidelines.[4] The patients were triaged as emergent, urgent and routine cases as per the All India Ophthalmological Society (AIOS) guidelines for the COVID 19 pandemic.[7] While emergency cases are all those cases which pose immediate threat to vision, urgencies are determined by the ophthalmologist's judgment of the potential risk to vision and impact on the quality of life if untreated.[7] Routine cases are those which can be postponed by more than 4 weeks without considerable risk of loss of vision, general health, and functioning.[7] All cases of acute conjunctivitis were seen in a separate isolated room wearing full PPE.[8] All the surgical procedures were performed following the rules laid by MoHFW for infection control and prevention during this period. The clinical data for the study were taken from the electronic medical records system. At the end of the study, data including demographic profile, clinical presentations, diagnosis, and interventional modalities were entered into a Microsoft Excel spreadsheet, and categorical variables were presented in numbers and percentages (%), and continuous variables were presented as mean with standard deviation and mode.


  Results Top


A total of 453 patients were attended during this period. The mean number of patients seen per day was 11.33. The overall number of patients seen during the same time period in the year 2019 was 23,121. The mean number of patients seen per day was 578.02 with a ratio of 55.45:1, far greater than the lockdown period.

The mean age of patients was 42.12 ± 18.12 years (Median 46 and Range 31–54). Fifty-three (11.70%) patients were in the pediatric age group (≤16 years), and 64 (14.12%) were >60 years of age. The adult to the pediatric ratio of patient was 7.39:1. The number of males outnumbered the females (63.35% and 36.6%, respectively). The male-to-female ratio was 1.73:1. The right eye was involved in 66.4% of cases, whereas the left eye in 33.5%. There was not much difference between the number of patients visiting the hospital during the Lockdown 1 (49.22%) and Lockdown 2 (50.78%). The number of new patients (301, 66.44%) was far more as compared to the patients who had already visited the hospital in the past (152, 33.56%) [Table 1]. The patients who had already visited the hospital in the past were either follow-up cases or those with some new complaints. On analyzing the complaints, (excluding the follow-up cases without any complaints) the most common complaint was diminution of vision (n = 102, 22.51%) followed by pain and redness (n = 75, 16.56%) [Table 2]. The cases triaged as emergency, urgent and routine were 194 (42.83%), 94 (20.75%), and 165 (36.42%), respectively.
Table 1: Demographic details of the study population

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Table 2: Presenting complaints of the patients

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Among the cases categorized as emergency majority had a history of trauma (46.91%) which was followed by vitreoretinal (17.01%) and corneal (11.86%) complaints [Table 3] and [Figure 1]. Ninety-four cases (20.75%) were triaged as urgent. Majority of these cases had pathologies pertaining to the cornea (47.87%) followed by glaucoma (18.09%) [Table 4]. A total of 165 patients were triaged as routine cases (36.42%). Among these cases, 53.94% belonged to general ophthalmology, and 23.03% had cataract [Table 5] and [Figure 1]a, [Figure 1]b, [Figure 1]c.
Table 3: Emergency conditions in various subspecialties and their diagnosis

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Table 4: Urgent conditions in various subspecialties and their diagnosis

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Table 5: Routine conditions in various subspecialties and their diagnosis

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Figure 1: Distributions of triaged patients into a) emergency, b) urgency and c) routine cases

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Subspecialty wise out of 37 glaucoma patients, 35.13% of cases were triaged as emergency, 45.95% as urgent, and 18.92% as routine cases. The most common diagnosis among emergent, urgent, and routine cases were blebitis (7, 53.85%), secondary glaucoma (10, 58.82%), and primary open-angle glaucoma (4, 57.14%), respectively [Table 3], [Table 4], [Table 5].

Similarly, out of 70 patients with corneal pathologies, 32.86% were triaged as emergency, 64.29% as urgent, and 2.85% as routine cases. The most common diagnosis among emergent, urgent and routine cases were corneal ulcer (9, 39.13%), corneal epithelial defect (17, 37.78%), and failed corneal graft (2, 100%), respectively. Out of 23 uvea patients, 69.56% were triaged as emergency, 4.35% were as urgent, and 26.09% were as routine cases. The most common diagnosis among emergency, urgent and routine cases were anterior uveitis (15,93.75%) choroiditis (1,100%), and episcleritis (5,83.33%), respectively. Out of 49 vitreoretinal patients, 67.35% were triaged as emergency, 14.28% were as urgent, and 18.37% were as routine cases. The most common diagnosis among emergency, urgent and routine cases were retinal detachment (16,48.48%), status post vitreoretinal surgery (4,57.14%), and vitreous floaters (5,55.56%). Out of 36 oculoplasty patients, none were triaged as emergency, whereas 58.33% were triaged as urgent and 41.67% were as routine cases. The most common diagnosis amongst urgent and routine cases was dacryocystitis (9,42.86%) and external hordeolum (3,20.0%) respectively. Out of 18 pediatrics and neurophthalmology patients, 83.33% were triaged as emergency and 16.67% were as routine cases. The most common diagnosis among emergency and routine cases was retinopathy of prematurity (5,33.33%) and optic atrophy (1,100%). Two out of 3 ocular oncology cases were of retinoblastoma and were triaged as emergency.

The most common trauma cases were of chemical injury (16.17.58%) and corneal injury (10,10.99%), while the most common infectious cases were of acute conjunctivitis (48,52.75%) and endophthalmitis (10,10.99%). Out of 88 general ophthalmology patients, 3.41% were triaged as urgent and 96.59% were as routine cases. All 38 (100%) cataract patients were triaged as routine cases.

A large number of cases (427, 94.26%) were managed medically while 26 cases (5.74%) underwent either surgical or some sort of OPD procedure. Maximum number of surgeries (9, 34.62%) was performed for vitreoretinal issues. Six (23.08%) of these cases had retinal detachment, while 3 (11.54%) had endophthalmitis. Other surgeries performed included globe rupture repair (3, 11.54%), lid tear repair (1,3.85%,) and evisceration (1, 3.85%) [Table 6].
Table 6: Various surgical and outpatient department procedures performed during the lockdown period

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The total number of emergency surgeries performed in the previous year during the same period was 51. The ratio of emergency surgeries performed during the same period in the previous year and that during the lockdown was 1.96:1. Emergency endophthalmitis surgeries performed during the same period in 2019 were 12, with a ratio of 4:1 when compared with the lockdown period. Similarly, the ratio for lid tear/globe rupture repair was 2.5:1 and for emergency evisceration, it was 4:1.


  Discussion Top


The present study describes triaging of the patients visiting a tertiary eye care center and their subsequent management during the lockdown period due to the COVID-19 pandemic. We observed a drastic decrease in the number of patients visiting the hospital when compared to the same duration in the previous year. This fall is attributed mainly to the limitation of transportation facilities and the ongoing fear of the novel coronavirus infection. Majority of the patients were adult males who visited the hospital for the first time. There were large numbers of follow-up patients as their previous follow-up appointments were rescheduled due to the sudden lockdown announcement. These patients visited due to missed follow-ups for their ongoing ocular treatment. Some follow-up patients also presented with new ocular complaints after surgery or ongoing medical treatment. A large number of follow-up cases were managed by teleconsultation as guided by MoHFW during this period,[9],[10] though we have not included those cases in the present study. Because of the constant awareness created by the government, people started understanding the real meaning of emergency care which could be the reason for the significant decline in the numbers of local routine patients. The patients who required emergency medical management were treated on the same day.

Looking at the subspecialty distribution of cases, other than trauma and infections majority of patients were of general ophthalmology, cornea, and vitreoretina followed by glaucoma, oculoplasty, uvea, and pediatric and neurophthalmology. All cases of trauma, infections, and ocular oncology were triaged as emergency cases. The most common ocular oncology cases were retinoblastoma. Likewise, the most common ocular trauma and infectious cases were of chemical and corneal injury, and acute conjunctivitis and endophthalmitis, respectively. The most common emergency cases addressed in different sub-specialties were corneal ulcer, retinal detachment, blebitis, dacryocystitis, anterior uveitis, and retinopathy of prematurity. A large number of cataract patients also visited the hospital and all of them were triaged as routine cases.

The patients who required surgical intervention on an emergency basis were operated on the same day, urgent patients were scheduled as soon as possible and routine elective surgeries were postponed by a minimum of 4 weeks or to the post lockdown period following the guidelines published by AIOS.[7] The most common surgical procedures done during the emergency period were for vitreoretinal issues followed by trauma (lid tear/globe rupture repair). There was gross decline in the number of emergency surgeries compared to the same period during the previous year. While the total number of emergency surgeries dropped down to almost half, the emergency surgeries performed for traumatic ocular injuries (globe rupture and lid tear) dropped down by almost 2.5 times. This is understandable, as the number of road traffic accidents would have come down to minimum because of almost nil transportation and reduced outdoor activities. There was almost a four-fold decline in the number of endophthalmitis surgeries, which can be attributed to lesser number of patients undergoing cataract surgeries and even lesser number of cases of traumatic origin.

It becomes necessary to assess the risk and provide treatment on a need basis during such pandemic. Since majority of the patients having visual complaints have cataracts as a common etiology and most of these patients are elderly with comorbidities, it becomes even more necessary to assess the urgency and act accordingly.

Das and Narayanan did a similar study with almost similar results, although they had a large number of patients and far more emergency surgeries were performed.[11] This difference may be due to more available options for tertiary ophthalmic care in a metropolitan city and surrounding containment zones where the present study was carried out. This could also be attributed to the absolute stoppage of international, interdistrict, and interstate transport during the lockdown. A similar guideline was published in Europe with authors' experience from an epicenter of the COVID-19 outbreak.[12] The present study in addition looks into the number of emergency surgeries performed during the same time period the previous year and compares it with the lockdown period.

While only the emergency service with bare minimum staffs was running during the lockdown, the hospital started functioning fully as soon as the second lockdown was over. During this period in our hospital, we divided our hospital team including all medical and paramedical staffs into three groups, and each team worked for 2 days in a week to reduce the overcrowding in the outpatient department and other premises of hospital. The team was reduced to two with staffs in each group functioning for 3 days a week once the footfall started increasing. We are following the same norm till date. One person from each group was assigned the job to see that all hospital guidelines pertaining to COVID-19 were strictly followed and any breach was identified, reported, and rectified immediately. A COVID care committee was formed consisting of some key members from the hospital infection control committee and administration team, which laid down necessary action plans as the dynamics changed. All the patients who needed emergent and urgent care were called up and were asked to consult at the hospital during the post lockdown period in a graded manner.

These are unpredictable circumstances, where we do not have an idea how the things will unfold, hence all of us need to get used to the new norms. Since the possibility of future lockdowns cannot be ruled out we as ophthalmologists and other medical professions should follow the standard triaging system to increase the productivity of the hospital without compromising on the safety of patients and healthcare workers.

We did not compare the number of patients seen in different subspecialties during the same period in the previous year, and it can be considered a drawback of the study. However, we have compared the number of emergency surgeries performed with the previous year's duration. The present study would be quite helpful in giving an idea regarding the triaging and management of cases, to institutes and private practitioners who are going through different phases of lockdown. We believe that more such studies are needed from different parts of the country, which would be an invaluable resource for the present scenario and also for future generations.


  Conclusion Top


In this article, we share our experience of planning and logistic approach toward the patients as per their emergency requirement and by rules and regulations laid by the government to achieve secured and methodical practice during the COVID 19 pandemic period. It becomes necessary for all ophthalmologists and health workers of other specialties to triage the clinical and surgical activity with due required precautions. We hope that our experiences will serve as pearls for ophthalmologist and other healthcare personnel working in various ophthalmic centers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Lu H, Stratton CW, Tang Y. Outbreak of pneumonia of unknown etiology in Wuhan China: The mistery and the miracle. J Med Virol 2020;92:401-2.  Back to cited text no. 1
    
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”India Most Infected by COVID-19 among Asian Countries, Leaves Turkey Behind”. Hindustan Times; 29 May 2020.Available from: https://www.hindustantimes.com/india-news/india-most-infected-by-covid-19-among-asian-countries-leaves-turkey-behind/story-Jjd0AqIsuL3yjMWg29uJ3I.html. [Last accessed on 2020 May 30].  Back to cited text no. 3
    
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Sengupta S, Honavar SG, Sachdev MS, Sharma N, Kumar A, Ram J, et al. All India Ophthalmological SocietyIndian Journal of Ophthalmology consensus statement on preferred practices during the COVID19 pandemic. Indian J Ophthalmol 2020;68:711-24.  Back to cited text no. 7
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Li JO, Lam DS, Chen Y, Ting DS. Novel Coronavirus disease 2019 (COVID-19): The importance of recognising possible early ocular manifestation and using protective eyewear. Br J Ophthalmol 2020;104:297-8.  Back to cited text no. 8
    
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Das AV, Narayanan R. Demographics and clinical presentation of patients with ocular disorders during the COVID-19 lockdown in India: A report. Indian J Ophthalmol 2020;68:1393-9.  Back to cited text no. 11
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