We found a significant reduction in the number of patients referred to the Emergency Department early in the epidemic. A similar situation was reported during the first two weeks of the epidemic in Italy (5) and in China, where a sharp reduction was seen in the number of patients seeking emergency dental treatment (6). However, there are no studies that describe this trend in more detail. We saw a general reduction in the number of patients coming to the Emergency Department from week 11 already, without any medical disciplines standing out. Other European countries such as Belgium, France and Germany refer to unpublished data on a general reduction in the number of patients coming to the Emergency Department, particularly patients with conditions assumed to be less serious (7).
Our study revealed a similar reduction in the number of patients with low urgency and patients whose treatment would normally be fully dealt with in the Emergency Department. In Norway this may be because the Norwegian primary health service has largely dealt with these issues itself, or because the threshold for referring patients to the Emergency Department has risen now in a time of crisis. The primary health service makes sound clinical judgements that limit the inflow of patients. The fact that the inflow of patients is almost unchanged at the weekend, when GP offices are closed, provides support for this statement (Fig. 2).
An explanatory model for the pronounced fall that is greater cause for concern is that patients are delaying contacting their GP or phoning the emergency number for fear of becoming infected or of being an unnecessary burden on the health service. This fear is shared by emergency doctors in Belgium, the UK and France, among others. From Germany there are reports of a reduction in stroke and heart attack cases in the Emergency Department (7), and there have been similar anecdotal reports in Trondheim, Norway. Possibly in order to avoid being a burden on the health system, or for fear of infection, patients have suffered both stroke and heart attacks without seeking help within treatment time window.
It is crucial that the primary health service acts as gatekeeper and filter for the specialist health service. At the same time, the message must be communicated to the public that people must seek medical assistance as early as possible in the event of symptoms of what may be a serious illness.
The aim during the pandemic is for all patients to have safe, high quality assessment and treatment at the Emergency Department, no matter what the situation. This is challenging, as assessment and treatment of isolated patients takes longer and requires more resources. A rapid test for COVID-19 in the Emergency Department would probably reduce clarification time in the Emergency Department. The greatest potential challenge, however, is to have a sufficient number of health personnel (2). Although no Emergency Department staff are in quarantine at present, there is a high risk of health personnel becoming unavailable. It is the calm before the storm in Trondheim, and the Emergency Department is preparing for a large influx of patients with suspected COVID-19.