What impact have Covid-19 pandemic on number of death occurring at the Emergency Department: A Retrospective Analysis of Mortality in India from January 2019 to May 2021

study results found that largest total number of death occurred in the of private health facility 2021 whereas the least number of deaths (limitation is data availability accredited During the rst year of the pandemic, average mortality per month (Jan2020-Dec2020) the emergency department (ED) of private hospitals in India was 917 per month whereas before the pandemic it was 414 per month while during second year of pandemic i.e. 2021 the average mortality increased to 2405 per month (up to May 2021).

advanced triage system. There exists a lack of proper knowledge and advanced directives in the beginning i.e. December 2019 of the covid-19 pandemic era.

Conclusions
Due to novel disease majority of clinicians have challenging situation as well as Emergency Medicine (EM) teams faced a sudden increase in the number of cases with limited resources. Furthermore, a lack of proper knowledge and directives may have hindered access to proper care, as witnessed in many part of the world and available in various literatures. The authors hope that this study will help global researchers as well as policy makers to promote further research and discussion into preparation methods for such pandemics to reduce patient's risk of death in the ED.

Background
Acute treatment in emergency case management is required for survival and stabilization of critical patients, followed by a shifting to the relevant medical department for further care. However, for the seriously ill critical patients, i.e., when the care provided by the Emergency Department (ED) of the hospital is not enough to enable transfer, death may occur while treatment in the emergency department. This aspect of emergency management is often overlooked, and very few researcher and government is really serious regarding who dies in the ED. This research study is a retrospective analysis of the mortality occurring at the emergency department of public and private hospitals from 1st January 2019 to May31st 2021 with aim to nd out impact of covid-19. The rst case of covid-19 was reported from Wuhan in China during December 2019 and a state of acute emergency is still going on around the globe [1].
For better understanding the impact of the SARS-CoV-2 pandemic on hospital healthcare, I have studied mortality occurring in the emergency department (ED) of rural, urban, public and private hospitals in India during this covid-19 pandemic era and compared it with the period before January 2020 when this pandemic has not accounted for a single documented case in India. The World Health Organization (WHO) declared on March 11, 2020, the novel coronavirus (SARS-CoV-2) outbreak a global pandemic. The rst documented case in India was found in January 2020 hence up to December 2019 mortality in ED I have considered as prepandemic era deaths [1]. India had reported the rst documented death from Covid-19 on 12 March 2020 from the state of Karnataka [2].
Starting from Dec 2019 SARS-CoV-2 caused a global pandemic of disease resulting in substantial excess mortality and major disruption to healthcare. The rst year i.e. 2020 COVID-19 cases in India prompted a national lockdown which had also reduced OPD (out patient department) patients of different noncommunicable diseases [3]. Lockdown measures changed during the second year 2021 of pandemic and covid-19 vaccination programme started countrywide in 2021. During this pandemic, healthcare restructuring and modi cation is going on from local to national levels in anticipation of predicted needs. Reports of reductions in OPD for non-COVID-19 acute illnesses have raised questions that several patients may not have attended hospital for an acute illness. There are several factors in uencing hospital admission during the pandemic such as fear of acquiring COVID-19 infection.
In India, acute hospital care is given to patients reporting directly to the emergency department (ED) of any hospital or if required referred by their primary health centre to higher canters.

Aim And Objective
The aim of my study was to determine the total Mortality occurring in India from 1st January 2019 to 31st May 2021(limitation due to data availability is limited from accredited source) of emergency department admissions of public and private health facilities. The objective is to nd out if there is increase or decrease in mortality during the covid-19 pandemic era by comparing average mortality per month before the pandemic from 1st and 2nd year of pandemic i.e. 2020 and 2021 respectively (also called rst and second wave which author feels a misnomer as the wave de nition and terminology in context of covid-19 is not established and there are also small waves in between as well as different countries have different peak-time of cases and mortality due to covid-19 pandemic).

Methods
This research study is a cross sectional retrospective analysis of the mortality occurring at the emergency department of public and private hospitals from 1st January 2019 to May31st 2021 with aim to nd out impact of covid-19 on average mortality. Website Electronic patient records of HMIS (health management information system) of MoHFW (ministry of health and family welfare), Government of India is collected, observed, analyzed, compared for all patients deaths occurring at Emergency Department (ED) of both public and private health facilities (n = 452102) during the period January 2019 to May 2021.
I have extracted data from the health management information system (HMIS) for all ED patients mortality occurring at the Emergency Department of rural, urban, public and private health facilities in India from January 2019 to May 2021 of all ages and gender (n = 452102). In next version of this research study data for medical admissions from the HMIS for pre and pandemic era will also be included for better epidemiological analysis and understanding.

Statistical analysis
The data for mortality occurring at the Emergency Department of rural, urban, public and private health facilities in India from January 2019 to May 2021 were recorded, calculated and analyzed with Microsoft o ce in this version 2. Stata software will be used in next version if required.

Results
Impact of Covid-19 pandemic on number of death occurring at the Emergency Department of all health facilities cumulative ED mortality increased sharply from August 2020 following the Unlock 2.0: 1 July 2020 -31 July 2020 (31 days). From March 2021 the ED mortality have seen a tremendous rise following Unlock 10.0: 1 March 2021 -march 2020 as listed below and this lockdown has also disrupted many other essential services [4]. The lockdown strategy is found effective to control the covid-19 outbreak but there are several limitations to impose lockdown for longtime [5]. Hence the government of India started unlock as follow [6]: Unlock: The study results found that largest total number of death occurred in the ED during may 2021 whereas the least number of deaths occurred in February 2019 (limitation is data availability up to May 2021 from accredited sources). During the rst year of the pandemic, average cumulative mortality per month (Jan2020-Dec2020) in the emergency department (ED) of rural, urban, public and private hospitals in India was 16067per month whereas before the pandemic it was 12542 per month while during second year of pandemic i.e. 2021 the average mortality increased to 21758 per month (up to May 2021).

Impact of Covid-19 pandemic on number of death occurring at the Emergency Department of rural health facilities
The study results found that largest total number of death occurred in the ED of rural health facility during may 2021 whereas the least number of deaths occurred in July 2020 (limitation is data availability up to may 2021 from accredited sources). During the rst year of the pandemic, average mortality per month (Jan2020-Dec2020) in the emergency department (ED) of rural hospitals in India was 9758 per month whereas before the pandemic it was 10807 per month while during second year of pandemic i.e. 2021 the average mortality reduced to 10121 per month (up to May 2021).
Compared to pre-pandemic era in the rst year of pandemic era the average total number of deaths occurring at Emergency Department of rural health facility reduced by 1.12 times or 1049 per month average decrease is seen see gure 5, Table 1 and 2. Compared to pre-pandemic era in the second year of pandemic era the number of deaths occurring at Emergency Department of rural health facility reduced by 1.07 times or 686 per month average decrease is seen see gure 5, Table 1 and 3. Here it is remarkable to note that compared to pre-pandemic era in the rst year of pandemic era the average total number of deaths occurring at Emergency Department of rural health facility reduced by 1.12 times or 1049 per month average decrease is seen as well as compared to pre-pandemic era in the second year of pandemic era the number of deaths occurring at Emergency Department of rural health facility reduced by 1.07 times or 686 per month average decrease is seen, whereas the urban facilities of healthcare has reported an increase in mortality during covid-19 pandemic years. This may be due to shifting or referral of critical patients to urban higher centers. Still in India it's very unfortunate that urban population is still devoid of higher tertiary centers.
The study results found that largest total number of death occurred in the ED of public health facility during may 2021 whereas the least number of deaths occurred in February 2019 (limitation is data availability from accredited sources). During the rst year of the pandemic, average mortality per month (Jan2020-Dec2020) in the emergency department (ED) of public hospitals in India was 15150 per month whereas before the pandemic it was 12128 per month while during second year of pandemic i.e. 2021 the average mortality increased to 19353 per month (up to May 2021).
Compared to pre-pandemic era in the rst year of pandemic era the total number of deaths occurring at Emergency Department of public health facility increased 1.24 times or 3022 per month average increase is seen see Table 1 and 2. Compared to pre-pandemic era in the second year of pandemic era the number of deaths occurring at Emergency Department of public health facility increased 1.59 times or 7225 per month average increase is seen see Table 1

Study Strengths And Limitations
This is the rst article of its kind in the literature, to my knowledge, that has studied, investigated the impact of covid-19 on the number of death occurring at the Emergency Department of rural, urban, public, private health facilities from COVID-19/SARS-CoV-2 pandemic in 36 states and union territories of India. One of the most peculiar strength is that the research study data were gathered from reliable accredited sources of Government Health Department. I have analyzed the impact of covid-19 on the number of death occurring at the Emergency Department starting from beginning of pandemic. This is exceptional and totally new idea to determine the ED mortality trends during a pandemic. A limitation is that author has not calculated some epidemiological indicators taking into account the health facility population coverage of the different zones.
Another limitation is availability of more data from accredited sources. This limitation will be tried to remove in next version with more data and more epidemiological correlations. The comparison between different health facilities will be added in next version.

Conclusions
Due to novel disease majority of clinicians have challenging situation as well as Emergency Medicine (EM) teams faced a sudden increase in the number of cases with limited resources. Furthermore, a lack of proper knowledge and directives may have hindered access to proper care, as witnessed in many part of the world and available in various literatures. The authors hope that this study will help global researchers as well as policy makers to promote further research and discussion into preparation methods for such pandemics to reduce patient's risk of death in the ED. Less ED mortality in the rst year of the pandemic have given opportunities for reducing ED mortality in the future, but due to delayed or missed care and certainly management failure we have seen rise in mortality during second year of pandemic up to the study period observation. Of course there is limitation to this nding. This research study have identi ed major changes in ED mortality during the pandemic era and highlight the profound impact of a pandemic on emergency care, even for non-pandemic illness. The author is hopeful that this research study will form a foundation for policy makers for planning to minimize the impact in the future. This research is very broad and to reduce the length of article a short description of facts is presented in this version. More information and advanced analysis will be presented in next version by the author. -Ethics approval and consent to participate: Not applicable. This study has not involved any human or animals in real or for experiments. The data on the COVID-19 pandemic were taken from the Health Department available as electronic patient records from HMIS (health management information system) of MoHFW (ministry of health and family welfare), Government of India.

Abbreviations
-Consent for publication: The author provides consent for publication to anyone for increasing and sharing knowledge to people who need it.
-Availability of data and materials: Electronic patient records from HMIS (health management information system) of MoHFW (ministry of health and family welfare), Government of India.
-Con icts of Interest/ Competing Interest: There are no con icts / competing of interest -Funding-Self sponsored. No aid taken from individual or agency etc. Monthly death comparison graph at ED of rural health facilities in India