This study is the first to use secondary collected data by the SMARC system of the KSA to identify epidemiological patterns and trends of ICU patients’ referrals. This system is unique in that it is limited to secondary, tertiary, and specialised healthcare facilities with no primary care involvement. Hence, its ability to capture patterns of critical illness is heightened, especially since the data captures the period in which COVID-19 was highly active and severe cases were at a peak. The current analysis shows variations in the number of ICU requests, reasons for referrals, clinical specialities involved across both the BUs and administrative areas.
4.1 Variations in ICU e-referral characteristics in general
The average age of patients with an ICU referral request was found to be slightly younger than the mean age of ICU admitted patients in the KSA [18]. This difference between admitted cases and cases with referral requests may be due to their clinical nature, the severity of disease and the capacity of management. It may be that referrals are requested for cases where patients’ outcomes are anticipated to be improved. Differences were also seen for sex, where males had almost double the female requests. Considering that this period covers the peak of the pandemic, and the fact that global trends show that males are susceptible to more severe consequences from COVID-19 than females, then it may be that this is reflected in this current analysis [19]. Furthermore, referrals for Saudis were almost triple that of non-Saudis, which is proportional with the Saudi population census. The Saudi government had also announced on the 30th of March of 2020 that non-Saudis including immigrants and illegal residents will enjoy free and unconditional access to healthcare and treatment in public facilities without any financial or legal liabilities during the pandemic response period [20]. It is worthy to note that non-Saudi workers also benefit from accessibility to private healthcare due to insurance coverage by their employers [21].
According to the characteristics of ICU referrals, the “out of scope” category was predominant. ICU care requires a multidisciplinary team, including medical and surgical specialists, to diagnose, treat and monitor different types of critical illnesses, and the shortage of ICU staff is a well-known issue, even before the pandemic, and exists in advanced healthcare systems [22, 23]. Naturally, this issue of shortage of staff was further exacerbated with the increased demand for ICU admissions due to critical cases of COVID-19 [24]. Similarly, resource constraints emerged as the second reason for ICU referral during the pandemic. Treating COVID-19 patients requires sufficient availability of hospital resources including vacant ICU beds, personal protective equipment, and well-trained ICU staff [13]. All of these were overwhelmed during the response period due to the swift and high increase of cases [25]. This resulted in overwhelming public health resources and capacity in public hospitals all over the world [26]. To overcome the high surge in ICU, private sectors had to engage in the response. In the KSA, a strategic approach was implemented whereby patients are referred to private hospitals, with the costs being covered by the Saudi government, regardless of nationality or residential status. A further policy addition was the designation of specific healthcare facilities as reference centers, as well as the development of a system for daily monitoring of isolation bed occupancy in order to facilitate timely decisions for bed expansions or patient transfers to neighboring facilities [27]. This policy is designed to manage ICU capacity effectively, ensuring that there is sufficient space available in these critical care units during this crisis and any future crisis. By leveraging the resources of private healthcare facilities, the government aims to maintain a buffer in ICU occupancy, thus enhancing the healthcare system's preparedness for potential emergencies.
During the pandemic, a variety of supplies are critical for providing life-saving care to patients. The shortage of ventilators and medical staff is significant, but the scarcity of other resources like personal protective equipment, monitors, intravenous supplies, and medications also critically affects patient outcomes and limits the capacity for delivering effective critical care [28]. The Saudi pandemic response focused on equipment availability by forming a national committee for critical care equipment, tasked with determining the types and quantities of equipment needed for a worst-case scenario of 10,500 simultaneous critical COVID-19 cases [29]. This planning guided the acquisition of critical care hardware, consumables, and medications. This systematic approach ensured preparedness for escalating ICU demands.
4.2 Variations of ICU e-referral requests according to BUs and regions
This study found that Eastern BUs had the highest proportion of ICU e-referral requests due to unavailable beds. According to the MoH statistical yearbook for 2022, the ICU had the least number of ICU beds compared to other regions [30]. However, this region ranks third in terms of population size [31]. Hence, our results show disproportionate allocation of ICU beds specifically for this region. This study also showed that referrals due to unavailable equipment and machines were the highest in the Northern and Southern BUs. These disparities offer insights into the regional variations in healthcare resource allocation. In a previously published study that had examined the rate of confirmed COVID-19 ICU admissions as a quality indicator between the five BUs, they found that the highest odds of admission were in the Northern and Western BUs [32]. The conclusion was that patients’ clinical characteristics and resource allocation were potential reasons for these variations. This study further emphasises that healthcare resource management is of vital importance.
Adjusting for population size is critical in understanding the demand for services. For example, although the results show that the highest proportion of requests was observed in the Western BUs, it showed a referral rate of 14.88 per 10,000 of the population which ranks as the third. However, when further investigating administrative areas shows that Albaha area which belongs to the Western BU had an extremely high ICU referral request rate (49.41 per 10,000). The relatively smaller population residing in this area may indicate a higher severity of ICU cases, or an extreme shortage of resources.
Medical specialty accounted for almost two thirds of the specialties requested. This is not surprising since this data covers specifically the time in which COVID-19 started to spread. The fact that both the Western BU had the highest proportion of e-referral requests reflects the previously reported number of mortality due to COVID-19 which was also found to be highest in this region [1]. With regards to oncology, the highest proportion of requests was seen in the Northern BU. According to the MoH statistical book, there is no oncology centre in the North [33]. However, there are four fully equipped oncology centres in the KSA regulated by the MoH, two of which are located in Central region and the other two in the Eastern and Western regions [33]. This centralization approach is a known healthcare strategy to improve outcomes of patients experiencing specific critical conditions including oncology and is followed in the UK to allow for swift access to multidisciplinary teams and expert professionals [34, 35]. Nevertheless, the absence of such a centre in the North naturally meant that the referral requests would be high.
4.3 Patterns of ICU e-referral requests over time
The pattern of monthly ICU referral requests during the two-year period showed two main waves where the requests were high. This pattern was significantly influenced by the spread of COVID-19 cases across the country. The first wave of ICU referral requests reached its peak in July 2020 and ended by February 2021, which mirrored the patterns of COVID-19 deaths and critical cases where the number of deaths reached its peak in July 2020 with 58 daily deaths, then began its decline until February 2021 with 6 daily deaths [36]. Likewise, the number of critical COVID-19 cases reached the peak in July 2020 with 2,295 cases, then started to decline towards the end of January 2021 [36]. These patterns are in line with the fact that the ICU admissions and referrals increased with the increasing number of COVID-19 cases across the globe during the pandemic [37, 38]. It is worthy to note that this patten of incline and decline found in this data may also be affected by the national strategies put forth by the government to mitigate the surge in critical cases. In addition to the suspension of flights, the shift to online education, suspension of social and religious gathering as well as quarantine, the introduction of the vaccination program has also played a vital role strategy [39, 40]. The decline of the second ICU referral request wave in June 2021 mirrored the progress of the COVID-19 vaccination plan, when 50% of the Saudi population (aged ≥ 12 years) received the first vaccination dose and this decline was sharper towards August 2021 when 50% of the population had received the second dose. Vaccinations have been proven to reduce severe levels of infections, and deaths due to the disease [41].
4.4 Strengths and limitations
This study uses a large and comprehensive dataset of e-referral requests for ICU admissions across the KSA, providing a broad and representative picture of ICU demand during the pandemic. It covers two years, allowing for analyses of trends over time. The findings of this study could provide valuable insights for policymakers on healthcare resource allocation, regional disparities, and preparedness for future pandemics. However, there are limitations to consider. The study focuses solely on ICU referrals, which might not fully capture the broader healthcare dynamics during the pandemic, particularly in outpatient and non-ICU settings. Also, while this study provides insight into the actions taken for capacity building and collaboration between governmental and private healthcare sectors, it is specific to the KSA’s unique healthcare system. Therefore, even though there are transferable policies, the context of the country should be taken into consideration before direct application elsewhere.