The Role of Telemedicine Services in Reducing Emergency Department Overload in Saudi Arabia

Department of Research and Development, General Directorate of Medical Consultations, Ministry of Health, Riyadh, Saudi Arabia General Director Office, General Directorate of School Health, Ministry of Health, Riyadh, Saudi Arabia Department of Health Statistics, General Directorate of Primary Health Centers, Ministry of Health, Riyadh, Saudi Arabia Research Department, Assistant Deputy Minister for Primary Healthcare, Ministry of Health, Riyadh, Saudi Arabia


Introduction
ED overcrowding is described as one of the main issues in emergency departments (EDs) of any hospital ]2[ . ED overcrowding is defined as a condition occurred when healthcare providers' loss the capability to provide medical care service within short time ]1[ .
In general, there are many reasons leading to ED overcrowding, and these reasons could be related to manpower and non-manpower deficiency. The deficiency of manpower resources includes nursing staff, specialist physicians, administrative staff, or other staff related to different departments in hospitals could cause ED overload. The non-manpower deficiency includes beds, medications, diagnostic tools or machines may also lead to ED overload ]3[ . However, there is another important reason for ED overload which is related to increased non and less-urgent patients presenting at ED. This issue is usually due to lack of patients' education or/and lack of telemedicine services ]4[ . Patients categorized as less-or non-urgent illness are highly distributed in every district of any city, therefore, presenting of these kind of patients in ED will lead to ED overcrowding, and may delay or reduce of healthcare efficacy in treating patients with very serious illness; which usually need resuscitation, emergent or/and urgent medical intervention. In addition, ED overcrowding may lead to reduce satisfaction of patients, and . In Saudi Arabia, the ministry of health applied new telemedicine technology to serve patients by using the mobile application which include Sehha application and 937 medical call center. These telemedicine applications support patients that unable to visit the clinics or living in remote areas far away from cities, help to reduce costs consumed without any significant needs and decrease overload at secondary and tertiary care facilities. Also, patients living in Saudi Arabia were showing high satisfaction rates after using the implemented telemedicine services.
The main aim of this study is to determine the role of different telemedicine services in reducing non-urgent visits to EDs in Saudi Arabia.

Study design and patients' recruitment:
A cross-section study was conducted during August 2020 -May 2021 among 319 patients were using two telemedicine services in Saudi Arabia, including medical call center, and Sehha smart phone application. A systematic random sampling method with a sample interval of 1:15 was used to collect the patients from each of the two telemedicine services to determine their role in reducing less-and non-urgent visits to EDs in Saudi Arabia. The study excluded patient that already visited an ED before consulting the telemedicine services, and patients diagnosed with schizophrenia, bipolar, dementia, or any defects in cognitive skills that may interfere their participation in this study.

Data collection
The data were obtained from a previous survey designed by the Saudi Ministry of Health. The survey's data reflecting the patients' socio-demographic characteristics, chief complaint, type of consultation, time to reach the nearest ED, intention to visit ED, and ED visits within 24 hours of using telemedicine services.

Endpoints
The primary endpoint of this study aims to determine the role of different telemedicine services in reducing non-urgent visits to EDs in Saudi Arabia. The secondary endpoint is to compare between medical call center and Sehha application concerning their efficacy in decreasing the ED overload.

Statistical analysis:
For the analysis of the results, student T-test, fisher exact, and chi-square tests were used. The data were saved, organized and graphed by using Microsoft excel 2010 program. The level of significance was considered when the p-value was less than 0.05.

Ethical consideration:
The study proposal was reviewed and approved by an ethics review committee (the Central Institutional review board committee) in the Saudi Ministry of Health. The approval letter for this study was given in June 2020 with the central IRB log number: 20-96M.

Results
This study analyzed the data from 319 patients who completed the survey provided by the Saudi Ministry of Health that concerning on information related to their health status, and ED visits. The Almost 50% of the included patients had the intention to visit the ED before contacting the telemedicine services, and most of them need less than 30 minutes to reach the nearest ED.
Besides, physicians working in the telemedicine services had categorized the severity of patients' medical status based on CTAS system, which revealed that 7.2%, 13.5%, and 79.3% of total patients were classified as CTAS level III, level IV, and level V, respectively (p-value < 0.05).
Besides, more than 70% of the enrolled patients need 30 minutes or less to reach the nearest ED (see table.2).
Among patients that had the intention to visit the ED (N=159), 53 of them did not go to EDs after using telemedicine services (p-value < 0.01) (see figure.2). Regarding medical call center and Sehha application, 9.6% and 24.4%, respectively of the patients used these telemedicine services had changed their mind concerning visiting ED after taking the medical advice (p-values < 0.01) (see figure.3 and figure.4).
Respecting the patients who already visited an ED after contacting telemedicine services, the majority of them (>66%) were visiting governmental hospitals, not having medical insurance for private hospitals, and not willing to pay for medical charges at the ED (see table.3 and table.4).

Discussion
Patients categorized as less-or non-urgent illness are commonly presented in ED of any hospital globally. The existing of these kind of patients in ED could lead to ED overcrowding, and may delay or reduce of healthcare efficacy in treating patients with very serious illness, which usually need resuscitation, emergent and urgent medical intervention. Morover, ED overcrowding may lead to lower satisfaction rates among patients, and could increase the risk of delaying critical interventions ]8[ .
In this study, the researchers were trying to found the role of applying telemedicine services in Saudi Arabia (medical call center and Sehha application) in reducing the ED overload by patients classified as CTAS level IV and level V, and to revealed the differences between the two telemedicine services regarding this issue.
Most of the included patients were young adults living in the central and western regions. The results of the study showed that the applied telemedicine services in Saudi Arabia had a role in avoiding ED overload by significantly decreasing the patients' visits to the hospitals for less-and non-urgent medical issues. Moreover, the researchers figured out that Sehha application had more significant effect in reducing ED visits by patients compared to medical call center.
On the other hand, this research suggesting that lacking of medical insurance for private hospitals and unwilling of people to pay for medical charges could be main factors for the ED overload in the governmental hospitals in Saudi Arabia.
Globally, few studies were assessing the impact of telehealth services on emergency visits. Some studies were determining the efficacy of telemedicine in reducing ED crowding in United Kingdom (UK), however, these studies did not show significant difference in decreasing number of less-or non-urgent patients in ED after applying telemedicine services ]9-14 [ . However, a previous study was revealed that 24 hours-walk-in clinics in the UK had the ability to decrease the overload of ED services and showed high satisfaction reflects from the patients [15].

Limitations of the study
The cross-sectional design, small sample size, and data based on self-report were the most drawbacks of this studies. In addition, due to coronavirus disease of 2019 (COVID-19) pandemic, some patients claiming that they didn't visit ED because their fear of SARS-CoV-2 infection, however, the number of those patients were significantly few compared to patients had declared that they got benefit of the telemedicine services.

Conclusion and recommendation
The implemented telemedicine services in Saudi Arabia, namely Sehha application and medical call center showed to be effective in reducing ED overload by providing medical advices to lessand non-urgent patients and deal with their minor medical issues. The researchers recommending further studies concerning on the number of ED visitors before and after the telemedicine era in Saudi Arabia.

Conflicting interest:
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.