Original Article

Effect of Ramadan on Emergency Department Attendances: A Retrospective Study


  • Perihan Şimşek
  • Metin Yadigaroğlu
  • Burak Katipoğlu
  • Aynur Şahin
  • Murat Topbaş
  • Abdülkadir Gündüz

Received Date: 03.07.2019 Accepted Date: 30.08.2019 Eurasian J Emerg Med 2021;20(4):219-223


Changes in diet and lifestyle are often observed during Ramadan. These changes may affect visits to the emergency department (ED). However, it remains unclear how exactly visits to the ED are affected. Thus, this study aimed to investigate the effect of Ramadan on visits to the ED.

Materials and Methods:

Hospital records and files of patients aged >17 years who visited a university hospital ED just before, during and immediately after Ramadan from 2014 through 2016 were retrospectively reviewed.


A total of 44146 ED visits were evaluated. It was found that ED visits were lower during Ramadan than during other months (p<0.001). Further, during Ramadan, there was a significant increase in ED visits one hour after iftar and one hour before sahur (p<0.001). The number of forensic cases significantly decreased during Ramadan (p<0.001).


During Ramadan, the number of ED visits decreased and the timing of the ED visits was altered. There was a significant increase in visits one hour after iftar and one hour before sahur.

Keywords: Emergency department, iftar, ramadan


During Ramadan, Muslims perform fasting. Fasting requires abstaining from many activities such as eating, drinking, sexual activity, drug use and smoking from sunrise to sunset (1). This worship affects health by inducing changes in the life rhythm and physiological processes (2).

Due to limitations of many requirements during the day, excessive consumption after the sunset, and changes in sleep patterns, irritability and anxiety can develop in fasting individuals (3). However, the spiritual effect of Ramadan fasting may remove people from violence (4). On the other hand, Ramadan fasting can cause changes in water electrolyte balance, serum total cholesterol, blood glucose level, systolic and diastolic blood pressure (5). Along with the psychological and physiological effects of fasting, changes in diet and lifestyle brought by the Ramadan month can affect emergency department (ED) attendances (6,7).

The analysis of the effect on the need for ED services in Ramadan is of great importance in terms of enabling emergency health service delivery in this month. The study aimed to investigate the effect of Ramadan on causes of ED attendances and time period of ED attendances.

Materials and Methods

The study was planned according to the descriptive research method. The Study conducted in a University Hospital Emergency Department. The Emergency Department have 38 bed capacity and average 250 attendances in 24 hours have been made to the department. In the study, in the three-years period covering the years 2014-2016, the ED attendances during the Ramadan months and as a control group just before and immediately after the Ramadan months were assessed and compared with each other. In the evaluation, between the dates of May 7 to August 4, 2016; May 18 to August 16, 2015; May 28 to August 27, 2014 hospital records of all attendances made by individuals 18 years of age and older were retrospectively reviewed. In the review, the data of the patients who underwent ethanol testing and the consultation notes of the patients who required toxicology consultation were evaluated separately. The research was carried out after the approval of the University Clinical Research Ethics Committee (date: 20/03/2017, decision no: 2017-30).In this study causes of ED attendances were divided into four groups. These groups are traffic accidents, work accidents, forensic cases (except from traffic and work accidents) and other emergency cases. Attendances which made for prescribed injections and dressing were not included in the study.

Statistical Analysis

The data obtained in the study were analyzed in IBM Statistical Package for the Social Science (IBM SPSS; Armonk, NY, USA) for Windows v23.0software. Qualitative data were assessed by chi-square test. Normality of distribution was determined using Kolmogorov-Smirnov test. Parametric tests were used for the analysis of normally distributed data, nonparametric tests were used for the analysis of the data that did not normally distribute. The effect of the Ramadan months on the attendance time was examined by using ANOVA tests with repetitive measurements. Qualitative data were presented by number and percentage (%), and quantitative data by arithmetic mean ± standard deviation formula. Statistically, p<0.05 was considered significant.


During the study period 44,146 ED attendances were made. In this period, the average age of the ED attendants was 42.1 years (min=18, max=104). 50.3% of patients were male and 49.7% of them were female. 27.5% (n=12,139) of the attendances were made in Ramadan month, of 38.3% (n=16,902) before the Ramadan and of 34.2% (n=15,105) after the Ramadan. The median number of daily attendances during Ramadan (median=137), was lower than the months just before the Ramadan (median=190) and immediately after the Ramadan (median=166) months. This difference between the months was statistically significant (p<0.001) (Table 1).

It was found that during the months of Ramadan, there was a decrease in the number of attendances for all hours of the day in general. It was seen that the decrease was more prominent especially about one hour before the iftar. However, about an hour after iftar (during the research period, iftar hours changed between 07.53 p.m.-08.07 p.m.), the attendances increased rapidly, and it was determined that the number of attendances exceeded the number of attendances made before and after Ramadan at the same time (Figure 1). It was also determined that the attendances to the ED increased significantly one hour before sahur and during the sahur hours compared to the attendances were made at the same time in the previous and next months (during the survey period, the hours of sahur changed from 02.39 a.m. to 03.16 a.m.). This change in the attendance hours during Ramadan was statistically significant (p<0.001). 

It was determined that forensic cases accounted for 1.8% of all attendances during Ramadan. This rate was significantly lower than before and after Ramadan (p<0.001). In addition to traffic accidents constitute 1.3% of all attendances before Ramadan, 1.6% of during and after Ramadan (Table 2). Increase in the traffic accidents in Ramadan months was found to be statistically significant compared to the months just before Ramadan months (p=0.025).

In the study alcohol use related ED attendances were evaluated. During the study period, blood ethanol levels of 538 patients were examined. It was found that the attendances of individuals with high ethanol level were significantly lower in the month of Ramadan than the other months (p<0.001) (Table 3). Causes of attendance of patients with high blood ethanol level were examined. 34.2% (n=13) of these patients admitted to the ED due to traffic accident and 52.6% (n=20) of them were forensic cases. 

During the study period, toxicology evaluation of 157 patients was performed. When the attendance periods of these patients were examined, it was seen that the number of attendances related to substance use was lower in Ramadan (18.4%) compared to just before (36.7%) and immediately after (44.9%) the Ramadan months. The blood substance levels were examined according to the attendance periods of the patients (Table 4). There was a significant difference between the months of Ramadan and the months after Ramadan in the blood Tetrahydrocannabinol level (p=0.016). It was detected that the frequency of positive results was found to be lower in Ramadan compared to before and after Ramadan. However, this difference was not statistically significant (p=0.752).


It was seen that in the month of Ramadan, ED attendances declined in general. While the ED attendances evidently decreased about an hour before iftar, there was sharply increase in the ED attendances approximately one hour after iftar. There was also significant increase in one hour before sahur in the ED attendances. In the study it was detected that there was a significant increase in traffic accidents compared to the month before Ramadan. On the other hand, there was a significant decrease in the number of forensic cases forensic cases in Ramadan. In addition, attendances of individuals with high blood ethanol level were significantly lower in the month of Ramadan.

Ramadan causes changes in nutrition, medication use and social life. Lifestyle and socio-cultural characteristics are known to influence the use of ED (8). However, a limited number of studies have been conducted on how the Ramadan month affects the use of ED. It was found that the daily attendances in the Ramadan are similar to the other months in terms of number and diagnosis (9,10). In the study of Pekdemir et al. (11), it was determined that the average number of attendances per day in Ramadan was significantly higher than that of the next month. In our study, it was determined that the number of ED attendances decreased significantly in Ramadan compared to before and after Ramadan. The difference from other publications in the literature may be related to the fasting rate in the regions where the studies were conducted.

According to the results of the studies, there are some changes in the ED attendance times in Ramadan. Kayipmaz et al. (12) detected that ED admissions made during the fasting period in Ramadan was significantly higher than the other times of the day. In the study of Butt et al. (6) it was determined that during Ramadan, night-time attendances (07:00 p.m.-06:59 a.m.) were more compared to day-time attendances (07:00 a.m.-18:59 p.m.). In the study of Pekdemir et al. (11), it was found that the ED attendances in Ramadan concentrated during the first four hours (04:00 p.m.-08:00 p.m.) after iftar. In the study of Balhara et al. (9), The pattern of ED attendances in Ramadan changed significantly compared to the other months than Ramadan; it was determined that the number of ED attendances was lowest at the time of iftar and that the number of the attendances increased rapidly increased rapidly within one and a half-hour afterward. These results were in parallel with findings from our study.

In the study of Khammas et al. (13), it was determined that there is no difference in the number, seriousness and time of traffic accidents of fasting and non-fasting people in Ramadan. However, Kalafat et al. (14), and Tahir et al. (15), found that the traffic accidents in Ramadan were significantly higher than the other months. Similarly, in the current study it was determined that traffic accidents increased in the month of Ramadan compared to the just before months of Ramadan. A survey showed that people felt more nervous in traffic during Ramadan (16). In addition, fasting individuals may develop insomnia, fatigue, inattention and such factors can lead to an increase in traffic accidents (17).

Mohseni et al. (18), reported that violence related ED attendances such as gunshot and knife injuries decreased significantly in Ramadan. Findings of this study support Mohseni et al.’s (18). We detected that forensic cases caused by violence significantly decreased in Ramadan compared to the other months. In Ramadan month, which is called as “patience month”, cooperation and solidarity increase among people. Our findings are thought to be related to the spiritual effect of the month of Ramadan.

Literature about ED attendances related to substance use was not accessed. In this study, it was determined that the number of ED attendances related to substance use decreased during the month of Ramadan. This result is thought to be associated with Muslims trying to abandon the harmful habits in the month of Ramadan.

Study Limitations

Patient files and hospital records were investigated retrospectively in the study. In the analyzed period, during Ramadan months, the fact that the rate of fasting and not fasting persons among patients is unknown is the limitation of this study.


Findings obtained from this study showed that the number of ED attendances decreased during the month of Ramadan and the time period of the ED attendances changed. There was a noticeable increase in ED attendances an hour after iftar, and an hour before sahur. Significant decrease was seen in ED attendances due to forensic incidents.


Ethics Committee Approval: The research was carried out after the approval of the University Clinical Research Ethics Committee (date: 20/03/2017, decision no: 2017-30).

Informed Consent: Retrospective study.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: P.Ş., M.Y., B.K., A.Ş., M.T., A.G., Design: P.Ş., M.Y., B.K., A.Ş., M.T., A.G., Data Collection and/or Processing: P.Ş., M.Y., Analysis and/or Interpretation: P.Ş., M.Y., B.K., A.G., Literature Search: P.Ş., M.Y., B.K., A.Ş., Writing: P.Ş., A.Ş., M.T., A.G.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

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