Patterns of Inpatient Admissions during Hajj: Clinical conditions, length of stay and patient outcomes at an advanced care centre in Makkah, Saudi Arabia

Objectives: This study aimed to describe inpatient clinical conditions at an advanced care facility in Saudi Arabia during the annual Hajj pilgrimage and to determine factors correlating with length of stay (LOS). Methods: This retrospective study was conducted at the King Abdullah Medical City (KAMC), Makkah, Saudi Arabia, and included all inpatients admitted during the annual Hajj pilgrimage between August and October 2015. Demographic, administrative and clinical data were collected from patient charts and analysed. Results: A total of 296 inpatients were included in the study, of which the majority were male (73.6%) and ≥55 years old (77%). Walk-in admissions occurred less frequently than referrals (38.9% versus 61.1%). Most patients (41.6%) were admitted during the peak Hajj period (the 8-13th days of Dhu al-Hijjah). Acute coronary syndrome was the most prevalent provisional diagnosis (65.2%). In terms of outcomes, 89.2% of the inpatients were discharged in a stable condition, with 37.5% discharged within ≤24 hours of admission. However, 39.9% required admission to the Intensive Care Unit (ICU). Overall, LOS was significantly associated with various factors, including the mode of admission, admission period, admitting department, number of comorbidities and ICU admission (P <0.050 each). Conclusion: Most of admissions were referrals, and the main Hajj period witnessed the majority of admissions. The vast majority of inpatients eventually discharged in a stable condition. Determinants of the length of hospital stay were the mode of admission, admission period, admitting department, number of comorbidities and ICU admission.


INTRODUCTION
The annual Hajj pilgrimage is a compulsory requirement for members of the Islamic faith who are physically and financially able to make the journey; it involves travelling to Makkah, the capital of Saudi Arabia, during the month of Dhu al-Hijjah, which is the last month of the Hijri calendar. 1,2 Some pilgrims arrive in Makkah nearly one month before the central rituals of Hajj, which begin officially on the 8-13 th day of Dhu al-Hijjah, and often stay for another month after the pilgrimage ends. The annual Hajj pilgrimage is considered one of the largest annual mass gatherings in the world. 3 Furthermore, the pilgrimage itself involves taking part in an array of physically demanding rituals at specific locations and during short periods of time. 4 The risk of heat exhaustion as well as the spread of communicable diseases is greatly increased during Hajj. [4][5][6] Moreover, people with chronic diseases and the elderly are at greater risk of medical complications. [7][8][9][10] Common diagnoses among hospitalised pilgrims include cardiac conditions and respiratory infections such as pneumonia. 7,10,11 In addition, inpatients also frequently suffer from comorbidities, including hypertension, diabetes mellitus, cardiac conditions and chronic lung diseases. [10][11][12][13] In Makkah, the healthcare system is composed of secondary and tertiary medical centres which provide high-quality care to patients during the Hajj period. A recent study conducted at two medical centres near the Al-Haram Holy Mosque found that 16.5% of pilgrims required further medical treatment in an advanced tertiary healthcare centre. 14 Similarly, another study evaluating hospitalisation and patient admissions in Makkah concluded that about 3% of patients required admission to a tertiary hospital. 15 The Ministry of Health in Saudi Arabia recently established the King Abdullah Medical City (KAMC) in Makkah as a response to increased demands on tertiary healthcare services in the region. Nevertheless, few studies have evaluated patterns of admission or length of stay (LOS) in secondary care hospitals and none has been conducted at the ultimate healthcare facility in the region, KAMC. [10][11][12][13] Thus, the current study aimed to describe admission patterns and inpatient outcomes at the KAMC during the annual Hajj pilgrimage.

METHODS
This retrospective cross-sectional study was conducted at the KAMC and included all inpatients admitted between the 16 th day of Dhu al-Qidah and the fourth day of Muharram, corresponding to 31 August-17 October 2015. This particular Hajj season was divided into three consecutive periods-the pre-ritual period before the 8 th day of Dhu al-Hijjah (21 days), the peak Hajj period between the 8-13 th days of Dhu al-Hijjah (six days) and the post-ritual period after the 13 th day of Dhu al-Hijjah (21 days). The inpatients' demographic (i.e. age, gender and nationality), admission (i.e. the admitting department, admission mode and date and time of admission) and clinical (i.e. provisional diagnostic category, evidence of infection, admission to the Intensive Care Unit [ICU] and the presence of chronic diseases, complications or comorbidities) data were collected from hospital charts using Medica Plus software.
During the study period, admission to the ICU occurred as a result of significant in hospital complications such as cases requiring mechanical ventilation or those suffering from sepsis, shock, acute kidney injuries or severe electrolyte imbalance. Comorbidities were defined as the presence of diabetes mellitus, hypertension, Ischaemic Heart Disease (IHD), hyperlipidaemia or chronic obstructive pulmonary diseases. The overall LOS was calculated from the time of admission until discharge. Inpatients were categorised according to mode of admission as either walk-ins (i.e. those presenting to the emergency room) or referrals (i.e. those transferred to the KAMC from other healthcare centres). Provisional diagnoses were divided into five categories: acute coronary syndrome (ACS), altered levels of consciousness, pulmonary oedema, a heart blockage or other. Patient outcomes were divided into four categories as either improved, deceased, absconded/discharged against medical advice or transferred to their home country.
Data were analysed using the Statistical Package for the Social Sciences (SPSS), Version 16.0 (IBM Corp., Armonk, New York, USA). Binary variables included gender (male or female), mode of admission (walk-in or referral), bacterial blood culture results (positive or negative) and ICU admission (yes or no). Multinomial variables included the inpatient's nationality, number of comorbidities, admitting department, admission period, provisional diagnostic category and outcome. Binary variables were compared using the Mann-Whitney U-test, while a Kruskal-Wallis H-test was used to compare multinomial variables. Age and LOS were treated as categorical variables. A Shapiro-Wilk analysis was conducted to determine if the distribution of the data was normal. Non-parametric data were expressed as medians and Interquartile Ranges (IQRs) at the 25 th and 75 th percentiles. Spearman's correlation coefficient was used to calculate the null hypothesis which stated that there would be no relationship between age and LOS. An alpha level of P <0.050 was considered significant.
Ethical approval to conduct the study was provided by the Institutional Review Board (IRB) of the KAMC prior to data collection.

RESULTS
A total of 306 inpatients were admitted to the KAMC during the study period; however, 10 patients (3.3%) were excluded due to incomplete data. Therefore, a total of 296 inpatients were included in the study. None were of Saudi nationality and the majority were male (73.6%). The male-to-female ratio was approximately 3:1. Patients aged 55-64 years old were most frequently admitted (39.2%), followed by those aged 65-74 years old (26.7%). The median age was 61 years (IQR: 55-69 years old). Most cases were referred from other healthcare facilities (61.1%) and were admitted during the peak Hajj period (41.6%). The most frequent provisional diagnosis was ACS (65.2%), followed by an altered level of consciousness (14.2%). Correspondingly, the majority of patients were admitted to the cardiology department (78.4%).
A total of 72 patients (24.3%) had a single comorbidity, while 67 (22.6%) and 108 (36.5%) patients had two, three or more comorbidities, respectively. There were 118 inpatients (39.9%) admitted to the ICU. According to their bacterial blood culture results, 9.5% of the patients developed an in-hospital infection. The LOS for most inpatients was ≤ 5 days (72.3%), with 37.5% staying ≤ 1 day. In terms of patient outcomes, there were very few deaths (3.7%). The vast majority showed clinical improvement and were subsequently discharged in a stable condition (89.2%) [ Table-I].
The LOS was not found different among different age groups and gender, i.e. p = 0.809 and 0.343, respectively. However, the median LOS for referred cases was significantly higher than that of walk-in cases (median: 3 days, IQR: 1-7 days versus median: 2 days, IQR: 1-6 days; P = 0.014). A significant difference in LOS was also observed between patients admitted to different specialties (P <0.001) and those admitted during different admission periods (P = 0.023) [ Table-II].

DISCUSSION
Currently, there are two main modes of admission at the KAMC during the Hajj period. Referred patients receive customised treatment by highly-qualified physicians while 24-hour emergency services are available on a walk-in basis. In the current study, referrals from other healthcare facilities were found to constitute the majority of hospital admissions; however, walk-in admissions were also fairly common. This is in accordance with previous research conducted at the Al-Noor Specialist Hospital, another advanced healthcare centre in the region. 10 Most secondary healthcare centres located in Makkah and Al-Mashaer are wellequipped for emergency situations and to provide short-term hospitalisation services. Furthermore,  patients admitted to such centres may be transferred to other secondary or tertiary hospitals for longerterm hospitalisation within the last few days of Hajj. Subsequently, patients in stable condition are followed up at secondary care hospitals until they are discharged, whereupon they are seen at the primary healthcare centre located in their respective residential camps. 10,12,13 As per previous research, the findings of the present study indicated that the primary Hajj period (the 8-13 th days of Dhu al-Hijjah) was the time during which most patients sought healthcare. 10 Moreover, the vast majority of patients admitted to the KAMC were ≥45 years of age, with 82.4% aged between 45-75 years old. An earlier study similarly found that 68.6% of admitted patients at the Al-Noor Specialist Hospital were 60 years of age or older. 10 In another study conducted in temporary health facilities in Mina and Arafat, most admitted cases were over 40 years old (79%). 12 As the financial demands of the Hajj pilgrimage are relatively costly, most Hajj visitors are usually elderly because such individuals are more likely to be able to afford such costs. However, another study conducted in two small healthcare centres near the Al-Haram Holy Mosque reported that the ages of Hajj pilgrims were more evenly distributed. 14 As most Hajj visitors are elderly, they are more vulnerable to developing serious medical complications such as IHD; this may explain why the highest proportion of patients in the current study were admitted to the cardiac department and provisionally diagnosed with ACS. In contrast, the findings of two other studies of secondary hospitals in Al-Mashaer and Mina/Arafat revealed that respiratory tract infections such as pneumonia were the leading cause of admission (39.4% and 19.7%, respectively), followed by cardiovascular events like IHD (8.8% and 12.3%, respectively). 13,14 However, the relatively cooler weather during the 2002 and 2003 Hajj pilgrimages-which fell in those years during the month of February-may have played a role as an effect modifier in these cases. In contrast, Hasan et al. found that ACS was the primary cause of admissions among known cases of diabetes during the Hajj period. 16 In terms of clinical outcomes, approximately 40% of inpatients in the current study were transferred to the ICU. These findings were extremely high compared to those reported by  10,12 This variation might be due to the higher proportion of patients in these studies who had been admitted to medical departments, thereby excluding surgical patients. 10,12 Nevertheless, despite the higher rate of admission to the ICU in the current study, there were very few fatalities (3.7%), with almost 90% of patients showing improvement and being discharged in good condition. This suggests that the KAMC provides a high standard of medical care during the Hajj pilgrimage. In contrast, Khan et al. reported a higher incidence of mortality during their study (16.5%). 10 In a previous study of the admission patterns of seven hospitals in Al-Mashaer, including KAMC, Al-Ghamdi et al. reported that 40% of admitted patients were discharged in stable condition, while 59% were transferred to other secondary or tertiary hospitals. 13 Such findings are an indicator that the healthcare facilities in this region are highly standardised and provide both short-and long-term hospitalisation. However, in view of the high proportion of patients who were discharged within the first 24 hours in the current study, further longitudinal studies are recommended to investigate whether some patients are admitted unnecessarily.
In the present study, LOS was found to be strongly associated with various factors, including referral from another healthcare facility, admission during the post-ritual period, admission to the cardiothoracic surgery department, being provisionally diagnosed with an altered level of consciousness, having three or more comorbidities, evidence of bacterial infection and admission to the ICU. On the other hand, age and nationality showed no relationship with LOS.
There are several potential limitations to the current study. First, the data collected was incomplete due to a lack of patient-reported information in the hospital records. Second, the analysis included individuals of diverse backgrounds and characteristics; nevertheless, the findings of the study could be relevant to other healthcare systems that cater to mass gatherings with large numbers of individuals of different nationalities. Lastly, due to the lunar nature of the Hijri calendar, the Islamic year is nearly 11 days shorter than that of the Gregorian calendar which thus signifies that weather conditions during the annual Hajj pilgrimage may vary. This phenomenon partially limits the generalisation of the current findings to other Hajj pilgrimages as well as other rituals based on the Hijri calendar.

CONCLUSION
Referral cases were the preponderance and the majority of admissions occurred during the main hajj period. While most of admitted cases discharged eventually in a stable status, just more than a third of them discharged within the first 24 hours of admission. Admissions of Referral, during post-hajj period, to ICU and cardiothoracic surgery service, with more than two comorbidities, with positive blood culture and altered level of consciousness are associated with relatively longer stay in the hospital. These data may be helpful to hospital administrators and policy-makers in providing cost-effective healthcare to pilgrims.