We observed a 10.3% reduction in call volume and a corresponding reduction in the total number of ambulances dispatched with lights and sirens in the Region of Southern Denmark during the first wave of the COVID-19 epidemic compared with the year before the pandemic. The time spent at the scene treating patients that were released following treatment increased by approximately 20% during the COVID-19 epidemic compared with the year before. The time spent at the scene in patients transported to hospitals also increased but only by 10% compared with the year before. These changes did not cause any changes in the response times.
Like our findings, a reduction in the number of EMS missions during the COVID-19 pandemic (and correspondingly in the number of visits to the emergency departments) has been described by other authors [3,4,5,6,7]. Many different explanations have been proposed: Lifestyle changes brought about by the imposed lockdown may have influenced the propensity to become injured in driving accidents or other recreational activities [15,16,17,18,19]. It is also possible that the fear of contagion of SARS-CoV-2 has reduced the incentive to call for emergency medical assistance [6]. It has even been reported that patients have refrained from calling on the health care system for fear of “disturbing” the system during the pandemic [20]. The decrease in EMS activations is likely not entirely explained by societal changes implemented in response to COVID-19, but also in the public’s perception of the workload within the hospitals, which may have led to behavioural changes. The observed decrease in the present study may be explained by the shutting down of almost all of the Danish society that in itself might have led to a reduction in the number of traffic accidents, a reduction in the number of domestic accidents, and a reduction in the number of incidents related to the gathering of people. Other possible reasons may be that patients could be avoiding the EMS for fear of acquiring a SARS-CoV-2 infection.
In contrast to the present study and other related studies, a study from New York reported a significant increase in demands on the EMS resources of 60% compared with the same period the year before the pandemic. The majority of this increase was the result of an increase in calls regarding respiratory or cardiovascular cases [21].
The differences between the findings in our study and similar studies and the findings in the study by Prezant et al. [21] may reflect organisational differences in the public’s factual or perceived access to acute health care. In Denmark, health care is funded by taxes and is without immediate costs to the patient. This applies to both visits at the general practitioner and acute hospital care. Thus, in general, there probably is overall confidence that sufficient emergency and non-emergency services exist and alternative resources for low acuity conditions (primary care physicians, other healthcare clinicians) are trusted even during a pandemic. Thus, it is probable that in Denmark, the emergency medical dispatch system was not used as a first choice in low-acuity situations.
The overall findings that the on-scene time was prolonged have been reported by other ambulance services during the COVID-19 pandemic [22,23,24]. The interim guidelines issued by the World Health Organization in March 2020 stated that personal protective equipment (medical masks, gowns, gloves, and eye protection) (PPE) should be applied when transporting suspected COVID-19 patients to the hospital [25]. In the Region of Southern Denmark, these guidelines were adopted by the ambulance services and consequently, the time spent applying PPE necessarily was added to the patient access interval or the on-scene time. The increase in patients released at the scene and the longer time spent at the scene for these patients was probably the result of a deliberate assignment of increased competencies to the ambulance personnel in evaluating patients and deciding who might be released at the scene following prehospital treatment. Thus, to reduce crowding at the emergency departments, specific prehospital units manned with experienced paramedics were established with the aim of performing an in-depth evaluation of the patient followed by consultations with in-hospital physicians or prehospital physicians regarding the appropriateness of leaving some patients at home. Similar systems were developed in other emergency medical systems resulting in an increased number of prehospital patients that could be released at the scene following treatment [5].
In contrast with other studies that reported prolonged response times during the COVID-19 epidemic [21, 24, 26], the EMS in the Region of Southern Denmark managed to retain a normal response time for ambulances during the first wave of the COVID-19 pandemic.
The number of ambulances available in the Region of Southern Denmark did not change between the two periods. Nor did the dispatch practices change. Thus, in all other respects than increased competencies of the paramedics and the incentives made for the prehospital personnel to either release patients at the scene based on the examinations and tests performed by the paramedics or based on consultations with in-hospital or prehospital physicians, the system remained static during the two observational periods.
Should the EMS have had less buffering capacity, an increased workload in an otherwise static system would lead to increased response times. The fact that no increase in response times was observed despite an increase in on-scene time may thus be attributed to a combination of the reduced demand for ambulances combined with the existence of a system with an acceptable buffering capacity.
Limitations
One major limitation in this study is that only operational data were analysed. No person-identifiable data were investigated. As such, no measures of the distribution of diagnoses can be made, just as no discussion regarding mortality within specific ICD-10 classification diagnosis chapters can be made. Thus, the study does not address the nature of the missions nor the individual events that led to a citizen requesting an ambulance. In contrast to the data regarding ambulance runs, the data on call volume could not be obtained on a weekly basis rather were collected monthly. Thus, data on call volumes are slightly less accurate than data on ambulance runs.
A further limitation to this study is that it did not investigate the impact of the COVID-pandemic on the emergency departments. This has, however, been done previously on a Danish national basis, where the governmental national ‘shelter at home’ order was associated with a marked reduction in unplanned hospital attendances [27].
Strengths
The strengths of this study lie in the organisation of the prehospital services in the Region of Southern Denmark. The dispatch of all the ambulances in the region is carried out from one dispatch centre. As no ambulances can be dispatched in the region unless dispatched by the emergency medical dispatch centre, data completeness is assured.