In this study, there is no significant correlation between frequency of ER visits and various demographic and clinical factors. A comparative study on the effect of Ramadan on ER visits during and 30 days after the said lunar month revealed significantly higher number of patients admitted during Ramadan, in comparison to the succeeding lunar month. In terms of demographic and clinical features, there is no statistical significance between the two periods. Likewise, there is no significant variation in terms of clinical characteristics of patients as well as the admission frequency for injuries, neurological and respiratory diseases during Ramadan . Categorical variables of various diabetic ER patients were assessed in this study, as shown in Tables 3, 4 and 5. Chi-square test of these variables showed substantial variation among several variables such as type of antidiabetic medications, diabetes type, arrival time at ER, and precipitating factors. However, clinical presentation and final decision in the ER do not statistically vary during these lunar months (Table 3). Despite the lowering number of admissions from before until after Ramadan, more insulin-dependent patients were admitted as Ramadan passes, 77.5% of patients were admitted in Ramadan whereas 82% were in Shawal. The fact that patients were on insulin reflect that they are either type 1 or uncontrolled type 2 diabetes mellitus. Most patients in the study were hyperglycemic and majority were insulin dependent (Table 3). In addition, more patients (around 40%) were admitted at daytime during Ramadan as fasting occurs. This means that patients could not withstand fasting during the day. Infections was predominant contributing factor for ER visits with uncontrolled diabetes which was noticed in Shawal (62.5%) and Ramadan (33.3%). On the other hand, few ER cases were represented as nonadherence in Ramadan, 10% missed insulin doses and 5% had missed a meal. Furthermore, over than 20% of patients have reported no obvious cause or precipitated factor that contribute to ER visits in the whole 3 months. A related study on analyzing ER patients flow in a tertiary hospital in Abu Dhabi, United Arab Emirates (UAE) during Ramadan in comparison to non-Ramadan days from 2014 to 2016 [ 8]. With 45,116 ER patient visits, increased visits were recorded during non-Ramadan days. During Ramadan, more than half of the patients (53%) were present during fasting period, which is significantly different from that of non-fasting period (47%). Another study evaluated the arrival patterns as well as characteristics of patients admitted in a pediatric and adult ER in UAE during Ramadan from 2010 to 2013. There is statistical significance for the admission pattern during both Ramadan and non-Ramadan days . ER visits are intrinsically variable and unpredictable. As such, better allocation of resources can be established by predicting ER usage. However, there is limited data on variation in local ER visit pattern during Ramadan. For a 4-year period, majority of the ER visits (57.14%) happened during day shift. However, about 3 in every 5 patients visited ER at night shift during Ramadan. As such, proper allocation of resources during Ramadan is necessary among Muslim countries for efficient management of surge of ER patients at night shift . However, results of this study showed higher number of visits among diabetics during day shift, mostly those with type 2 diabetes. Elbarsha and colleagues determined the impact of fasting on diabetic patients admitted at hospitals and their final outcomes during Ramadan in comparison to the 11th lunar month, which is a non-fasting period. With about 60% of admitted patients fasting during Ramadan, significantly higher incidence of acute coronary syndrome was obtained for fasting patients. However, non-fasting patients had statistically significant in-hospital mortality, as they had more complications that made them ineligible for fasting . Decline in ER visits were also observed from Shaban until Shawal. In Beirut, Lebanon, a study on ER visits, emergency incidences clinical outcomes during Ramadan was determined in a tertiary care center. Mean daily ER admission during non-Ramadan months was higher as compared to Ramadan period, whereas longer hospital stay period was recorded during Ramadan. Although most data are comparable, lower admission rates were observed for patients with stroke or acute coronary syndrome during Ramadan. Furthermore, both ER bounce-back rates and death at ER discharge were amplified during Ramadan. During Ramadan, the following conditions might be experienced by ERs: longer stay in period, decline in admissions, as well as possible worse outcomes. Fluctuations in ER visits connected with common conditions are not anticipated . The results of this research project a different trend as shorter length of stay in hospital were recorded during Ramadan (Table 6). For insulin-dependent fasting diabetics, Gad and others revealed no substantial variation in terms of glycemic control (HbA1c) between multiple daily injections (MDI) and continuous subcutaneous insulin infusion (CSII). However, incidence of DKA and hypoglycemia as well as glucose profile were not assessed due to insufficient data . Similar trend was observed as no significant difference was observed in plasma glucose levels from Shaaban until Shawal. A different study revealed glucose level increments during Ramadan compared to pre-Ramadan level for Type 2 diabetes patients followed by significant decline in terms of glucose level after Ramadan. For triglyceride and cholesterol levels, a similar trend was observed although the difference was not statistically substantial. This study revealed that glucose, triglyceride, and cholesterol levels return to pre-fasting levels after Ramadan . Similarly, results showed an increase in glucose levels during Ramadan, with a corresponding return to pre-fasting levels in Shawal. Hassanein and others evaluated the fasting participants, fasting period, hypoglycemic event rate, glycemic control, and lifestyle patterns among type 2diabetes Middle Eastern and North African participants during Ramadan 2016. The average fasting period lasted for 27.7 ± 5.0 days, with almost 60% of the participants fasted during the whole Ramadan period. Substantial development in FPG, HbA1c, and PPG was observed after Ramadan. Confirmed hypoglycemia amplified substantially until Ramadan period, which was found to depend on treatment regimen used. Incidence of severe hypoglycemia also increased significantly up until Ramadan period. Lifestyle changes were reported by majority of the participants during Ramadan .Fasting during Ramadan period can also impact medication adherence among diabetes patients. A certain research evaluated the patient-guided modifications, either twice or once daily, of OAC medication and its possible consequences, as compared to scheduled regular intake. More than half of the participants (53.1%) changed their intake schedule during Ramadan. Likewise, majority of the patients took the medication twice daily. Around 10% of diabetic patients were admitted during Ramadan, which made patient-guided modification a significant variable for hospital admission. During Ramadan, OAC intake with patient-guided amendment is generally observed and accompanied with heightened risk of admission in hospitals. Patient education and effective OAC intake arrangement are deemed advisable during Ramadan . Alkandari and colleagues stated that most of health-specific results associated with Ramadan fasting are mixed. These variations could be indicated by the various factors, such as number of smoking patients, daily fasting period, food, and lifestyle variations, as well as intake of oral medications and intravenous fluids. Meals taken during nighttime before dawn, together with liver glycogen storage, maintains glucose homeostasis during Ramadan. On the other hand, physical activity, body weight changes, as well as the quantity and quality of food intake determines the variation in serum lipids. According to them, Ramadan fasting may be observed by type 2 diabetes patients who are well-controlled and compliant. Healthy individuals can observe Ramadan fasting, but consultation with physicians is required for those with diseases . Lipid profile, glycemic control, dietary intake and weight can significantly be affected by deviations in sleeping patterns, daily physical activities, as well as dietary habits during Ramadan. Hui and Devendra have suggested pre-Ramadan assessment among patients to evaluate the risks associated with fasting. In addition, timing and dosage adjustments with respect to insulin intake, as well as several hypoglycemic agents, it might be necessary during Ramadan with consultation form medical experts .
This study was conducted in only one setting, a tertiary military hospital (National Guard Hospital) in Jeddah. Therefore, patients’ access was restricted to those who have the eligibility in their health care. Accordingly, the sample size of the study was very small (n = 133), when considering the high prevalence of diabetes mellitus and the high number of patients with diabetes that visited the ER in different hospitals in Saudi Arabia.