COVID-19 is a an infectious disease caused by severe acute respiratory syndrome virus 2 (SARS-CoV-2) (1). The spectrum of the disease ranges from asymptomatic to severe, sometimes requiring prolonged treatment in intensive care unit (ICU). The estimated fatality rate is approximately 1.1% and the proportion of patients that require hospitalization range from 1.1–18.4% with hospitalization and mortality rates sharply increasing in older population (2). COVID-19 puts serious strain on ICU and inpatient capacity of healthcare systems and has been mitigated by suspending non-urgent care (3, 4). Emergency care however has remained fully operational as public health measures against COVID-19 are unlikely to have major effect on incidence of non-infectious emergencies. Even though the progression of COVID-19 pandemic is followed closely, the effect of the pandemic on non-COVID-19 -related emergency care has so far received less attention.
COVID-19 is the third epidemic caused by coronaviruses in the 21st century (5). Serious acute respiratory syndrome (SARS) epidemic emerged in China in 2003 and spread to several countries. Middle East respiratory syndrome virus (MERS) emerged in 2012 in Saudi Arabia and spread to 27 countries (5). The difference between COVID-19 and the previous coronavirus epidemics is that the clinical picture of COVID-19 is in most patients less severe, which makes it easier for the disease to spread as patients with minimal symptom remain active in the society (6). Even though the scale of previous epidemics has been considerably smaller, the literature from heavily affected areas provides valuable information on patient flow dynamics in the face of an epidemic. Reports from SARS outbreak in Taiwan showed a decline of the number of ED patients by approximately 30% while the proportions of different patient segments remained largely unchanged (7). A similar decline was reported in Hong Kong (8). In a Canadian study, SARS outbreak resulted in an overall decrease of ED visits where the reduction was mostly explained by the lower attendance of pediatric patients (9). On the contrary, SARS epidemic in Singapore resulted in an overall increase of ED presentations by about 30%. The increase was explained by increased number of severe patients brought by ambulance and patients seeking help for respiratory symptoms (10).
Although the reduction in emergency department presentations amidst the COVID-19 pandemic has been observed widely, published data has been mostly anecdotal. In a recent report from Northern Italian tertiary center, the number of ED visits decreased by almost 50% compared to the previous year but the overall composition of patient segments seemed largely unchanged. A noteworthy observation is the increased hospitalization rate suggesting a more serious patient profile than usually (11). Recent Portuguese report cited a reduction of 30–50% across emergency and non-emergency presentations (12). A report from Israeli tertiary center reported a reduction of 32% in the volume of surgical patients amidst COVID-19 pandemic and there was a moderate negative correlation in emergency department visits and confirmed COVID-19 cases in Israel (13). United States nationwide report from Centers for Disease Control reported a 42% reduction in emergency department visits. The largest proportional reductions were in musculoskeletal disorders and the highest increases in mental disorders (14).
Finland has not been spared by the impact of COVID-19. Until September 13, 2020 there has been 8,512 confirmed cases and 337 deaths with total of 789,500 tests performed. To protect the population from the consequences of a widespread disease, the Government of Finland declared a national state of emergency on March 16, 2020. In practice this meant closing the schools, closure of nightlife establishments and restaurants, and restricting movement to and from densely populated Helsinki capital area to the rest of the country. In practice this meant closing the schools together with rapid introduction of e-learning, closure of nightlife establishments and restaurants, and restricting movement to and from the most infected and densely populated Helsinki capital area to the rest of the country. The state of emergency was lifted on June 16, 2020, but extensive restrictions to certain areas of life (travel, mass gatherings) are still applied.
The stratification of the urgency of presenting ED patients based on administrative data is not trivial since triage classification differs between institutions and practitioners (15). Direct utilization of ICD-10 classification (16) is also insufficient since many categories contain a wide range of disorders of the organ system ranging from benign to acutely life-threatening. New York University Emergency Department Algorithm (NYU-EDA) was developed to provide a systematic reference for estimation of urgency, preventability and level of care needed for patients with different diagnoses by conducting a full chart review on the Clinical Modification of 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10-CM) based on 3,500 ED records (17). The reference contains statistical estimation of urgency for different diagnoses (e.g. for ICD-10-CM diagnosis R104 Unspecified chest pain, 68% of are deemed to require ED care and 32% of patients are deemed to be treatable by primary care physician).
The goal of this study is to assess the effect of state of emergency and COVID-19 pandemic on quality and quantity of presentations in the Emergency Department of a Finnish secondary care hospital.