Design: The Value of In-House Imaging Why EDs in Hong Kong Are So Understaffed How Important is Training Standardization? India’s MVA Problem: Bystander Apathy EMERGENCY PHYSICIANS INTERNATIONAL
ISSUE 11
The GET REAL Changing Polish EMS crews compete in a national “Road Rally” that takes them from Face of rail tunnels to Emergency abandoned mountainside ravines. Medicine As the world’s elderly population continues to grow, the emergency department stands poised to become the hub of geriatric care.
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FALL 2013
. WWW.EPIJOURNAL.COM
Once the beds in Santa Maria were full, it took 92 trips by military aircraft to transport victims of the fire to Porto Alegre.
page 23
global snapshot – Readers share how their EDs handle acute ischemic stroke. Dr. Barbara Hogan on how EuSEM will help Europe face its next medical crisis.
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EDITOR’S DESK
Perception Problems
O
ver the past year reports have emerged from two countries on opposite sides of the world that they are having trouble filling their trainee positions in emergency medicine postgraduate residency programs. This dire situation is apparently due to the perception in these countries that emergency physicians are overworked and under-supported. Which is often true, thanks in no small part to the problem of ED overcrowding. In many places, a decline in inpatient bed availability has collided with an increased emergency department caseload (particularly of elderly patients) and an increased complexity and severity of cases. Add to that a decreased or inadequate response support from other medical specialties and a decline in physical or personnel resources, and the problem seems clear. But ED crowding isn’t just hurting our ability to fill trainee spots. In the August issue of Emergency Physicians Monthly, Dr. Rick Bukata presents an excellent literature review explaining why holding admitted patients in the ED is both bad for business (hurts the hospital’s bottom line) and erodes patient care. The published evidence is very clear that hospital administrators, the other medical specialties and governments should actively support and appropriately resource emergency medicine to combat this problem. This would in turn help resolve the impending trainee crisis. Fortunately, the United States isn’t currently facing a trainee shortage. In fact, despite an increase in the number of U.S. emergency medicine residency positions in the matching program, there was a marked increase in the number of applicants, and a very high “fill rate” with only 3 of 1744 positions unmatched. However, many are predicting a huge increase in U.S. emergency department caseloads as the provisions of the Affordable Care Act come into effect. If this occurs, without increased resource support for U.S. emergency medicine, we could be looking at the same shortages and crowding problems seen around the globe. The problem of overcrowding is just one of many perception issues facing emergency medicine development around the globe. EPI is interested in learning more about the specific issues facing your emergency departments since early course correction is essential – particularly in countries where the specialty of emergency medicine is still young and developing. Seemingly basic hurdles can majorly impede specialty development if not addressed early, and with solid research. The International Federation for Emergency Medicine is starting to form a task force to look at workplace issues. If you are having particular workplace problems in providing emergency care, let us at EPI know so we can hopefully provide support or advice. Hope to see you at one of the upcoming international emergency medicine conferences, from Havana to Tokyo!
In many places, a decline in inpatient bed availability has collided with an increased emergency department caseload (particularly of elderly patients) and an increased complexity and severity of cases. Add to that a decreased or inadequate response support from other medical specialties and a decline in physical or personnel resources, and the problem seems clear.
Design: The Value of In-House Imaging Why EDs in Hong Kong Are So Understaffed How Important is Training Standardization? India’s MVA Problem: Bystander Apathy EMERGENCY PHYSICIANS INTERNATIONAL
ISSUE 11
The GET REAL Changing Polish EMS crews compete in a national “Road Rally” that takes them from Face of abandoned rail tunnels to Emergency mountainside ravines. Medicine As the world’s elderly population continues to grow, the emergency department stands poised to become the hub of geriatric care. page 23
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FALL 2013
. WWW.EPIJOURNAL.COM
Once the beds in Santa Maria were full, it took 92 trips by military aircraft to transport victims of the fire to Porto Alegre.
global snapshot – Readers share how their EDs handle acute ischemic stroke.
C. James Holliman, MD, FACEP, FIFEM editorial director
Dr. Barbara Hogan on how EuSEM will help Europe face its next medical crisis.
ABOUT EPI With a quarterly print and digital distribution and an online network of more than 2,000 members, EPI is the essential hub connecting global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at www.epijournal.com
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LETTER FROM THE PUBLISHER
Lo-Tech, High Yield
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ast April I found myself stepping into a rail tunnel in the Polish countryside which had lain dormant since the Second World War. My cell phone lit my way as I chose careful steps over blue-tinged patches of ice. And then I came upon the scene: a white sedan was lodged impossibly across the path, nose in the air, propped against the tunnel wall. The green lights of multiple cell phones eerily revealed a driver with a bloody bar protruding from his forehead. Then the driver smiled, mugged for the cameras, and it was time for the show to begin. Moments later, simulated explosions pounded through the tunnel and a frantic EMS crew newly on the scene made the decision that the environment was too unstable for an intubation. With a few shouts they hoisted the victim and ran for the nearest exit. Each year the Polish Society of Emergency Medicine hosts a rally in which EMS teams from across the country compete in simulated rescue scenarios over miles of rugged terrain. While the Polish Society is hardly alone in coordinating a large-scale training simulation, they’ve done so within a resource-limited setting – Poland is among the EU countries with the lowest health expenditure per capita. They accomplished this through real places – from stone quarries to collapsing tunnels to mountainside ravines – and real people. The same “victims” tirelessly showed up at each scenario by jeep, always moulaged in a new and frightening way. And the acting: heart-wrenching cries for help felt real enough to jar the nerves of even a street-weary EMS team. This lo-tech, do-it-yourself spirit represents the kind of budget-conscious problem solving that is going to be needed the world over as emergency medicine adapts to a new healthcare paradigm. The patient burden is increasing while budgets wither, and while emergency physicians understand the value of their specialty, much of the rest of the world needs convincing. EPs need to find wallet-friendly ways to provide proofs of concept for extensions of emergency care services. Whether that means proving the value of making the ED the “hub of care” for elderly patients (report on page 23) or of bringing more clinical testing into the department (page 30) it’s time for emergency medicine to think outside of the box. Emergency physicians are some of the most imaginative problem-solvers in the world. It’s time that those skills were put to use figuring out how to do more with less.
Logan Plaster Publisher
executive editors PETER CAMERON, MD TERRY MULLIGAN, DO, MPH LEE WALLIS, MD PROF. V. ANANTHARAMAN publisher LOGAN PLASTER logan@epijournal.com On Twitter @EPIJournal editorial interns DR. RASHMI SHARMA PEREL BERAL TRACI PERRY regional corespondents CONRAD BUCKLE, MD MARCIO RODRIGUES, MD CARLOS RISSA, MD KATRIN HRUSKA, MD SUBROTO DAS, MD MOHAMED AL-ASFOOR, MD JIRAPORN SRI-ON, MD editorial advisors ARIF ALPER CEVIK, MD KATE DOUGLASS, MD HAYWOOD HALL, MD CHAK-WAH KAM, MD GREG LARKIN, MD PROF. DONGPILL LEE SAM-BEOM LEE, MD ALBERTO MACHADO, MD JORGE OTERO, MD print advertising LOGAN PLASTER logan@epijournal.com
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Fall 2013 // Emergency Physicians International
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EVENT CALENDAR 10/13–06/14
14th Annual Conference for the Society For Emergency Medicine in India // Calicut, India
NINE MONTHS OF INTERNATIONAL EM CONFERENCES
November 18-20, 2013 www.emcon2013.com
Asia Pacific Association Of Medical Toxicology 12th International Scientific Congress // Dubai, United Arab Emirates
OCTOBER
November 21–23, 2013 www.apamt2013.com
October 2-6, 2013 www.tatd.org.tr
November 24-29, 2013 www.sapmea.asn.au/conventions/acem2013
Emergency Medicine Association of Turkey (TATKO 2013) // Eskisehir, Turkey
ACEP Scientific Assembly // Seattle, USA October 14 – 17, 2013 www.acep.org
Australasian College of Emergency Medicine // Adelaide, South Australia
2014/JANUARY
Irish Association for EM Annual Meeting // Letterkenny, Ireland
3rd Int’l Conference on Healthcare System Preparedness and Response to Emergencies and Disasters // Tel Aviv, Israel
October 17–19, 2013 www.iaem.ie
January 12-15, 2014 event.pwizard.com/IPRED3
7th Asian Conference on EM // Tokyo, Japan
FEBRUARY
October 23–25, 2013 www2.convention.co.jp/acem2013/index.html
NOVEMBER
Emergency Medicine Society For South Africa Annual Meeting // Cape Town, South Africa November 5, 2013 www.emssa2013.co.za
World Congress On Ultrasound In Emergency And Critical Care // Hong Kong November 6–9, 2013 www.winfocus.org
8th Annual Conference of the German Association for Emergency Medicine // Hong Kong November 7–9, 2013 www.dgina-kongress.de
African Federation of Emergency Medicine Consensus Conference // Cape Town, South Africa November 8, 2013 www.afcem2012.com
Fall 2013 // Emergency Physicians International
www.epijournal.com
03 | Editor’s Letter 04 | Publisher’s Letter
Source 8 | Dispatches How are acute ischemic strokes typically handled in your emergency department?
10 | Norway 11 | Kenya 12 | Sweden 13 | Iceland 14 | African Federation
Departments 16 | Opinion
AAEM’s 20th Annual Scientific Assembly // New York, USA
EuSEM must expand to help European EM face its newest challenges
February 11-15, 2014 www.aaem.org/education/scientific-assembly
18 | News: India
MARCH
International Symposium on Intensive Care and Emergency Medicine // Brussels, Belgium March 18-24, 2014 www.intensive.org
JUNE
International Conference on Emergency Medicine (ICEM) 2014 // Hong Kong
Bystander aid sadly lacking in world’s traffic accident capital
Reports 20 | Journal Scan From Southern Asia to the Congo, a new review by the Global Emergency Medicine Literature Review Group
23 | The Aging World Why the emergency department should become the ‘hub of care’ for the elderly
26 | Manpower in Asia
June 11–14, 2014 icem2014.org
Why are emergency departments in Hong Kong so understaffed?
SEPTEMBER
28 | Photo Essay
EuSEM 2014 // Amsterdam, The Netherlands September 28–October 1, 2014 eusem2014.org
LIST YOUR NEXT INTERNATIONAL EVENT FOR FREE ON THE EPI NETWORK – WWW.EPIJOURNAL.COM/EVENTS 6
IN THIS ISSUE
Serious simulation at a Polish EMS competition.
30 | Design In-ED imaging can improve efficiency, raise quality of care and improve the bottom line.
34 | Grand Rounds The importance of standardization in the formation of great emergency docs.
SOURCE Firsthand reports of EM development around the globe
DISPATCHES 8 NORWAY 10 KENYA 11 SWEDEN 12 ICELAND 13
>> Norway’s dramatic coastline of fjords and archipelagos offers spectacular views for tourists, and innumerable challgenges for EMS crews, who have honed the use of high speed water ambulances.
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SOURCE // DISPATCHES READER-SUBMITTED UPDATES FROM THE FOUR CORNERS
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Q. How are acute ischemic strokes typically handled in your emergency department?? ______________________
01 AUSTRALIA The protocol is to contact the neurologists if the stroke is within the given time frame and allow them to decide to thrombolyse, or not but there is a lot of reluctance to now go ahead with thrombolysis as it seems the risks seriously outweigh the proven benefit. We have almost monthly discussions about this topic and ED doctors seem to want the protocol changed whereas a lot of neurologists still seem to favour thrombolysing. My department is quite against it and feel it does more damage than good. ______________________
02 AUSTRIA TPA if less than 6 hours. Usually Alteplase. Then Hypothermia. ______________________
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patient and decides on next steps. Until 1 year ago I worked in a different city in Canada where it was considered to be the emergency MD responsibility to do all acute stroke management including an expectation of TPA. In that setting it was my responsibility to coordinate everything for the patient, determine the elegibility for TPA, have the discussion and administer TPA. These were both large cities in Canada, so you can see that practice varies. ______________________
04 COLOMBIA I work in a neurology reference center, so for patients in a therapeutic window we use MRI to incluide or exclude for litic therapy (mean venous thrombolisys or endovascular therapy). Acute stroke (ischemic or haemorragic) goes to intensive care unit if have a kind of therapy, or step down unit (special care) if is only for volume and monitoring. Emergency physician rules in or out to activate the stroke team.
CANADA In the setting I currently work in we activate a stroke team who rapidly sees the
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Fall 2013 // Emergency Physicians International
______________________
05 FRANCE The neurologist on duty is called by the medical call-center / or by the EP in the inpatient ward of the ED. They both activate either the CT scan or the MRI. Then, the best way is to bypass the ED if the symptoms onset is < 4.30 h. Because of the lack of NVICU (Neurovascular Unit), some secondary and tertiary hospital treat the patient in the ED with tPA, then organize a transfer by meical unit (SAMU) to the Stroke Center within hours. ______________________
06 INDIA On the basis of onset of symptoms we determine the window period. If it is less than 4.5 hours then we send the patient for immediate CT of head to rule out ICH. If ICH is negative then according to the NIHSS we determine and do the thrombolysis in our ED. In most of the cases our goal is to start the thrombolysis between 30 to 60 mins after arrival of the patient to the ED.
---------CT scan, call neurologist or surgeon, start antiplatelets, plan thrombolysis if appropriate. Arrange for transfer to floor or ICU ______________________
07 ISRAEL Activation of protocol, CT within 25 min, stroke team activation within 5 minutes. ______________________
08 ITALY Coop between EP and stroke unit. ______________________
09 JAPAN We give Edarabon and antiplatelet to them. ______________________
10 JORDAN ABC protocols on arrival...IV access.. Oxygen. Monitor. Urgent brain CT
scan. Urgent Neuro Consultation. Admission to the relevant inpatient service. ( ICU, general ward, ect...) Initiation of therapy by the oncall neurologist or internest. ______________________
11 KENYA We respond as per the AHA/ASA guidelines, but most patients present after the 4.5 hour mark. ______________________
12 LIBYA ABC. Stabilization. Investigations. Oral anti coagulation. ______________________
13 MALAYSIA First depends on time of stroke. If less than three hours we activate stroke protocol with the tthrompolytic team. ______________________
14 THE NETHERLANDS The ambulance calls ahead, so the ED team prepares for the patient. Upon arrival, the neurologist quickly examines the patient. ASAP, but at least <30mins, a headCT is performed. If thrombolysis is possible <4.5 hrs after onset, it’s done in ED. Then the patient is admitted to a stroke unit. ---------We see whether our patients meet the criteria for thrombolysis, and when the criteria are met, they receive thrombolysis. After receiving the medication, they get immediately transferred to the Stroke Care Unit. Mean time in the emergency department is one hour. ______________________
15 NEW ZEALAND We have what is called acute stroke code. It should be activated as soon as pt suspected that he may have acute ischemic stroke. After stabilization of patient and make sure of ABC we contact neurologist on call and send CT scan request at the same time of stabilization of heamodynamic status of the pt. Then we send the pt to CT scan and getting the result on spot with presence of neurologist for possible of what so called reperfusion study. Then we continue our part by giving aspirin and controlling the blood pressure and
discuss with neurologist regarding the thromploysis indication then we arrange admission to MICU and during all of these steps we should make sure of informing the pt and/or relative and also taking the consent. ---------Admitted to ICU or ward bed with admitting physician deciding on thrombolysis or conservative management. ______________________
16 PANAMA From about 1 year ago we began in several hospitals in our country fribrinolitico treatment for stroke, which is having good results. It is carrying out an educational campaign to physicians in emergency care for stroke. It will be carried out as a pilot hospital medical centers for patients with stroke in the capital. ______________________
17 POLAND All strokes and potential strokes brought to the ED cause an automatic response from the stroke team which is a collaboration between neurology and neurosurgery (I am at a full service academic facility which is the largest in the “providence”). ______________________
18 QATAR As the patients come in with the history of stroke it is assesesed whether they are in the time window for thrombolysis and are candidates for it. They are rushed to the CT scan unit. If it’s an ischemic stroke and within the time window for thrombolysis they are refferred to the neurologist who then thrombolyses them. If they are out of the window they are admitted under care of neurology for further scanning, management and rehabilitation. ______________________
19 SINGAPORE 1. Thrombolysis. 2. MERCI ______________________
20 SLOVENIA Stroke recognition in PreHosp. (Usually by MD) or in small “general” ED; initial stabilization/ABCDE; transfer to
Neurology for CT/tPA/admit. ______________________
21 SOUTH AFRICA If within three and a half hours, stroke team is activated to consider lysis. Otherwise control risk factors, aspirin, physio, speech therapy as needed, refer medicine. Ideally should get a bed in the stroke unit but they are always full. ---------Rehabilitation. Aspirin. Medication optimization. ---------No on-site CT scanning so only selected cases get scanned acutely (young, altered mental status etc.). Also, no on-site CT and no on-site neurology service means no thrombolysis. Selected cases will be discussed with the referral center but coordinating transfer, transport etc effectively means thrombolysis never happens. All stroke patients are referred to the medical inpatient service after initial management. ______________________
22 SPAIN There is a “stroke code” that means if the patient has the criteria for thrombolysis and no contraindications for it it’s done. ______________________
23 SUDAN Ischemic strokes in Sudan present usually late because awareness of population about stroke symptoms is very poor. We are on the way to establish stroke unit in emergency department where I work to raise awareness about stroke among health care provider and population as well. Most cases present late and no way for thrombolysis at all. ______________________
24 SWEDEN Thrombolysis if no contraindication until 4.5 hours from start of symptoms. 4.5 - 6 hours neurointervention in large specialized center, even for wake up stroke. More and more stroke patient get acute vascular imaging (CT scan), no perfusion CT yet. Strikt och simple protocol in the ED, from ED to CT, then to ICU. There Thrombolysis. Specialized Stroke neurologist and neuroradiologist (link of the pictures by Internet) on call at university hospital 24/7. Follow up every month, all Thrombolysis cases are
discussed (neurologist, nurses, radiologist, EP consultant). I am working in a little hospital, 33,000 ED visits/year. ______________________
25 TURKEY Some of them take IV thrombolysis, some of them take only aspirin and follow up, rarely some victims go to angiography lab and radiologist remove the clot. ______________________
26 UNITED KINGDOM Within 3 hours of onset of symptoms, thrombolysis. Otherwise general medical admission and transfer to stroke physicians next weekday. ---------Either direct referrals to neurology bypassing ED or stabilised, rapid imaging and transferred to neurology. ---------Immediate CT and thrombolysis in appropriate cases. Most thrombolysis performed on stroke unit; some hospitals bypassed to deliver to specific hyperacute units. This model exists only in major cities in UK at present. ______________________
27 URUGUAY If they are less than 4.5 hours we administer RTPA, intravenous. Malignant stroke: decompressive in younger patients. ______________________
28 USA Called out like an incoming or walk-up trauma patient with a team response and expedited throughput, to determine tPA eligibility. ---------A “Code Stroke” is called on all strokes or possible strokes presenting within 6 hours of symptom onset. “Code Stroke” is also called upon learning of an EMS notification for stroke. Code Stroke activates radiology, neurology, laboratory to expedite care. Neurology typically is making the decision on whether or not to give tPA. To read a complete list of the responses to this survey, go to epijournal.com
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SOURCE
Given Norway’s scattered population, land ambulances are supplemented by fleets of helicopters, like this Westland Sea King.
NORWAY
Norway struggles with tradition to bring its emergency departments into the 21st century by lars petter bjornsen, md
T
he Norwegian healthcare system, like some other healthcare systems in the West, incorporates well-organised primary healthcare and universal health insurance for its county’s population. However the Norwegian model differs from many other well-developed healthcare systems in that emergency departments (EDs) in Norway are not currently deigned to provide primary healthcare to patients, who require referral from a general practitioner (GP) or other physician to the ED unless transported there directly by emergency medical services. GPs, therefore, are traditionally considered to be the ‘gatekeepers’ of the Norwegian healthcare system and the GP on-call in a local urgent care clinic will, if necessary, be required to refer the patient to the ED of a hospital. Unfortunately, emergency medicine is not currently a speciality in Norway and interns, residents and attending physicians from various in-hospital specialist services are still staffing EDs without any curriculum requirements or standardized benchmarks as to the physician’s competence. Indeed, a majority of physicians providing care for acutely ill patients in the ED are interns, with an average experience of just seven months in practice. In 2007, the Norwegian Board of Health Supervision stated that Norwegian EDs suffer from inadequate management and leadership, lack of systems in triage and quality improvement and limited physician competence. Local and national forces, including the Norwegian Society for Emergency medicine (NOSEM), have been working hard to improve physician competence and availability in Norwegian EDs. Inspired by the changes in other Scandinavian countries, Norway’s goal is to establish a national area of competence and subsequently develop emergency medicine as a speciality in the country. Until now, emergency medicine in
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Norway has been considered to be a part of anaesthesiology, and because of this there has been limited focus on physician competence and logistics for the majority of ED patients. Generally, nurses run the EDs with minimal involvement from physicians, who have previously been considered as ‘guests’ from other departments while continuing to perform their clinical duties, and, despite the fact that most EDs have been administered under the department of anaesthesiology, less than three per cent of ED patients actually require immediate care from an anaesthesiologist. Moreover, emergency medicine in Norway has traditionally been considered somewhat of a ‘lights and sirens affair’ – that is, one of prehospital and critical care – a perspective not dissimilar to that encountered by other aspiring emergency medical services worldwide. This blinkered interpretation has unfortunately slowed development initiatives. In order to overcome this misunderstanding, NORSEM has adopted and encouraged the use of the term ‘emergency department medicine’, which it hopes will more accurately describes the current contents of emergency medicine in Norway, facilitate communication with the wider medical community and allow for commitments from departments other than just anaesthesiology. Thankfully, the Directorate of Health has finally accepted the need for improved competence in the ED and a structured framework for education and standards in the field of emergency medicine. Initially an area of competence was proposed similar to that which can be seen in Denmark, however this was later changed and now a speciality is considered to be a more beneficial path for the future. Although some challenges remain as the medical community in Norway holds some reservations in adopting such international ideas and concepts and there is still significant resistance against altering the GP’s traditional role as an important ‘gatekeeper’ within the system, particularly with regards to the unique
Fall 2013 // Emergency Physicians International
Despite the fact that most EDs have been administered under the department of anesthesiology, less than three percent of the ED patients need immediate care from an anesthesiologist.
geographic and smaller community hospitals. Despite this slow progression in the development of EM in Norway there have, luckily, been some local changes including a shift toward more organized and focussed emergency medicine at hospitals surrounding Oslo and Trondheim. Akershus hospital near Oslo, for example, has changed its EDs based on the Australian and American models and emergency physicians trained abroad have been added to the program team that staffs the ED permanently so that they can perform the initial evaluation, diagnostic work-up and treatment. Different specialties will be consulted as needed and patients will, if necessary, be admitted to the appropriate service. There have also been some changes at the University Hospital in Trondheim, a hospital that has created permanent positions for physicians with competence and interest in emergency medicine. Their work description and responsibilities are not yet determined and it is yet to be seen whether these local concepts will spread nationally and be universally accepted by the medical profession. NORSEM has grown over the last couple of years, but as emergency medicine is not yet a specialty, the society is still fighting to be recognized by the Norwegian Medical Association. Despite this lack of official recognition, NORSEM has become an important voice for the concept and cause of emergency medicine in Norway, collaborating with other emergency medicine societies in Europe to reach the goal of specialty development and we are on the path and making progress. However, further lobbying and international pressure will be needed if we are to succeed, and only time will tell how long it will take to give Norwegian patients the emergency care they deserve.
Approximately half of Kenya’s emergency medical technicians attended the first Skills Training Festival and Competition last May.
KENYA
With increased levels of trauma and chronic illness, Kenyan emergency departments sit poised to receive the brunt of a new healthcare crisis. by benjamin w. wachira, md
A
ccording to Article 43-2 of the Constitution of Kenya 2010: ‘A person shall not be denied emergency medical treatment’. Despite this declaration, however, Kenya offers no formal training opportunities in the field of emergency medicine as a speciality, and has no organized national emergency or trauma care system to speak of. As a result of these shortcomings, Kenya falls well within the ‘underdeveloped’ category with regards to its capabilities in emergency medicine. Already plagued by communicable diseases, the growing influence from occidental countries has increased the rates of smoking and obesity in Kenya. Consequently, this has exacerbated the burden of chronic diseases such as hypertension and diabetes within the Kenyan population, and with increased levels trauma and chronic illness, as well as high levels of communicable diseases and maternal and infant mortality, Kenyan emergency departments sit poised to receive the brunt of a new healthcare crisis. Very few patients present to emergency departments by ambulance in Kenya. This is mainly a result of their scarcity of numbers, but also due to the lack of an organized public ambulance service and the absence of a well-connected and reliable centralized dispatch system. Since 2010 the Center for Disease Control – Kenya, the Kenyan Ministry of Health and, from 2012 onwards, Johns Hopkins University, have held annual conferences along with key emergency services stakeholders in the country to identify the many challenges and opportunities associated with developing a unified emergency medical service system. This collaboration has resulted in the development of an ambulance
standard, along with a training curriculum to regulate training for emergency medical services professionals in Kenya. What is more, a governmental ‘white paper’ for standardizing and improving emergency medical services in Kenya, similar to that of the United States publication of 1965, has been drawn up, though it remains in the developmental stages. In May of 2013, Johns Hopkins University and the Kenya Council for Emergency Medical Technicians co-hosted the inaugural Skills Training Festival and Competition for emergency medical services – the first meeting of its kind in Kenya. The event brought together first-line providers of emergency pre-hospital care to improve trauma care, teamwork and gain public support for emergency medical services in Kenya. Approximately half of Kenya’s emergency medical technicians were in attendance, and the 2-day CME event culminated in a competition for best performance in a staged rescue. The symposium resulted in several key consensus recommendations: prioritize the development of an emergency medical services policy that can be presented to the Kenyan Ministry of Health and other stakeholders; establish a single, national, free medical emergency number for use throughout the Kenya; coordinate the dispatch of all emergency services to emergency incidents; standardize curriculums for emergency medical technicians and create a national regulatory body for emergency medical technicians along with a national register for those currently practicing. Most EDs in Kenya are staffed by clinical officers who work independently, or alongside medical officers. Clinical officers are not physicians but healthcare providers who have undergone three years of rigor-
REFERENCES 1. Arnold, JL et al. International emergency medicine and the recent development of emergency medicine worldwide. Ann Emerg Med. 1999;33(1):97-103. 2. EMS for Kenya. Connecting the Dots: Developing a Unified EMS System in Kenya. <http:// www.emsforkenya. com/> 2013 cited 31.07.13 3. Global Emergency Care Collaborative. Emergency Care Practitioners. < http://globalemergencycare.org/ emergency-carepractitioners/> 2011 cited 31.07.13
ous medical training. Like medical officers however, they still lack specific training in the specialty of emergency medicine. Currently none of Kenya’s medical universities or colleges offer emergency medical training programs, although the Global Emergency Care Collaborative has developed a ‘train-the-trainer’ program over the past four years in acute care at a district hospital in rural Uganda. The program is currently seeking a local institution partner in order to offer a one-year post-graduate diploma in emergency medicine to clinical officers. This will allow them to more effectively manage the initial triage and stabilization of patients, provide supervision and direction for emergency medical services systems and coordinate disaster and emergency medical response services at local and national levels as we progress toward the development of emergency medicine residency programs in Kenya. Though training Kenyan physicians to practice as specialised emergency physicians remains the ultimate goal, residency programs are time-comsuming, expensive, and only matriculate a handful of specialists at a time. As an intermediate step, a private medical university is currently looking to develop a post-graduate diploma in emergency care for doctors. By collaborating with local providers of emergency medical services and the national referral hospital in Nairobi, the institution is not only hoping to create a platform to train native practitioners but also offer the opportunity to others from other countries to experience emergency medicine within the developing world. Already an American Heart Association international training center is being established to provide resuscitation training to the surrounding region. In order to meet tomorrow’s emergency medicine challenges, Kenyan emergency practitioners need to move towards a comprehensive, unified solution, as well as seek expertise and mentorship of healthcare professionals and organizations in countries in which emergency medicine is already mature as a specialty.
www.epijournal.com
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SOURCE
Only months after the news that EM would be recognized as a specialty in Sweden, Lund’s ED – one of the best training programs in the country – began to fall apart.
SWEDEN
Specialty recognition is eminent, but peer appreciation within the hosptial system will remain a challenge. by dr. katrin hruska
E To help solve Sweden’s looming healthcare crisis, emergency medicine will need to project a stronger public image. by dr. nicholas aujulay
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mergency medicine has evolved quite a bit over the last decade in Sweden and when you take the long view, things are looking promising. But recent activity in the medical community has cast a pall over these developments as budget cuts and politics loom large. Emergency medicine cutbacks in Uppsala and Lund are worrisome reminders that emergency medicine is still not an established specialty in the Swedish medical system. Although financial constraints are often put forward as the reason for closing down programs, this does not portray the whole truth. There is still a fair amount of hesitation and suspicion towards a new specialty like EM within the medical community. Although EM has now been around for over 10 years there is still no site in Sweden where an emergency department is run 24/7 by emergency physicians. Most EDs have mixed coverage combining emergency medicine residents with on-call physicians from other departments. Thus the true
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quality and effectiveness of emergency medicine is not witnessed by the Swedish medical community. On top of that most EM residents are not getting close supervison and training the way more matured countries can offer. This has a negative impact on EM’s image with the wider medical community. This struggle for our specialty comes at a time when there is a nationwide debate about healthcare policies. Dagens Nyheter, the biggest nationwide liberal newspaper, published a series of articles where the problems of our tax-funded health system were addressed. Poor quality, low productivity and foremost lack of will to design the health care system focusing on patient needs became evident. In this light EM has a chance to thrive. The inherent nature of emergency medicine – where trained physicians care for a wide range of patients simultaneously – should be an appealing solution for those who wish to combine quality and costeffectiveness. However, in order for this to be seen as a viable option, EM awareness needs to grow; it is basically non existent among politicians and the public. In the near future EM needs to evolve fully in a few hospitals in order to set a positive example. Debate over quality and cost in healthcare will continue, but if we look to the global medical community, emergency medicine can rise to the challenge with time-tested solutions to some of Sweden’s most pressing healthcare problems.
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The inherent nature of emergency medicine – where trained physicians care for a wide range of patients simultaneously – should be an appealing solution for those who wish to combine quality and cost-effectiveness.
mergency medicine will be a primary specialty in Sweden. The National Board of Health and Welfare announced its decision in July 2012, and the new regulations will take effect on January 1, 2015. The outcome of this review of all the medical specialties remained uncertain until the very end. The committee even presented a first report where emergency medicine was left out, and the decision on its future status was postponed due to disagreement within the committee. Since emergency medicine has been a recogniced supraspecialty since 2006, one would think that primary specialty recognition was more of a technical issue. But for the Swedish emergency physicians this was a pivotal moment. Actually, several hospitals had already started to offer emergency medicine training programs without the training in another specialty which was mandatory for specialist certification, since the current system was expensive and still did not provide the necessary training in emergency medicine. Status quo would probably mean the end of emergency medicine as a specialty in Sweden. In fact, pending this official review, the University hospital in Uppsala, with a strong profile in emergency medicine education, decided to close down their specialist training program. The CEO of the hospital had never supported reorganizing the emergency department and wanted the internists and surgeons to take care of their respective patients in the ED. The residents who were at the end of their training were allowed to conclude it. The more junior ones, which could be three or four years into their training since double specialization takes at least seven years, could either settle for internal medicine training only, or go elsewhere. Most emergency medicine training programs have started as projects, often with
the objective of reducing costs by replacing other doctors on call. Emergency physicians have just taken over whatever work the junior doctors of other specialties performed earlier, without changing the structure of the emergency department. Upper management has rarely been involved, at least not initially, and few understand the concept of emergency medicine. In the end, this may turn out to be an even bigger obstacle to overcome than specialty recognition. Stockholm South General Hospital was one of the first hospitals to employ emergency physicians. Thirteen years later, the emergency physcians see all surgical patients, but only do occasional shifts in the sections for internal medicine and cardiology. When bringing doctors out to triage, there are three different doctors. This is of course not a sustainable solution, and a poor training environment for emergency medicine residents. It is a sensitive issue and the CEO, when asked, has not been willing to say whether or not the emergency department should be run by emergency physicians. Only months after the positive news in July 2012, the emergency department at the University hospital of Lund started losing doctors, both consultants and residents. There had always been a high turnover of residents, but now the critical threshold was passed. There were no longer enough physicians to staff the department and they had to start hiring locums just to be able to cover all shifts. One of the best training programs in Sweden, which had taken a decade to create, was ruined in only a few months. When the emergency medicine consultants leave, there is no one to replace them but consultants from other specialties. Specialty recognition did not solve the existing problems, but it did create a sounder foundation for the future of emergency medicine in Sweden. Several hospitals are now considering starting training programs and restructuring their emergency departments. These decisions seem to be supported by hospital management and emergency medicine is allowed some space in the organization, rather than squeezed in there by some enthusiasts on the floor. Hopefully this will be the start of a more stable era in EM in Sweden, but it will of course require some patience, a notoriously rare virtue in the emergency department.
ICELAND
Iceland’s ambitious and aspiring emergency medicine field seeks support and collaboration from abroad. by david thorisson, md
Dial 1-2-2 Iceland now uses the European emergency telephone number for all emergencies
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mergency medicine in Iceland has grown beyond all expectations in the last few years. At 103,000 km2, Iceland is around half the size of the UK but it has a far smaller population of just 320,000 people who inhabit a wild, rural landscape of mountains and fjords. As a result, medical consulting to rural clinics, emergency medical services and helicopter emergency medical services (that also serve the Atlantic up to 250 miles offshore) are closely tied to our emergency department (ED) activity and rotating residents often encounter their first emergency medical experience through pre-hospital work – something that has helped to attract them to our program. The University Hospital is situated in the capital, Reykjavik, and has nearly 20 consultants working in the ED with approximately 90,000 patient visits per year, making it by far the busiest ED in the country. All major specialties and most subspecialties are represented, and though the ED is now well supported there was some resistance when the specialty was established 20 years ago. Despite the obvious need for emergency medicine at the time, several other specialties had little interest in working on the floor in addition to work-
ing in the daytime, while others had vested interests in retaining their established positions of power. As a nation of few inhabitants and shorter communicative distances one is more likely to know colleagues working in other departments of the hospital and, as there is only one medical school in Iceland that operates with collegiality, inter-hospital communications are generally positive and problems often resolved without much contention – a climate that made the introduction of emergency medicine much easier. Our relative isolation has also increased the need for communication with colleagues in other countries and for this reason social media as been warmly welcomed by emergency medicine in Iceland. Ten days are set aside each year for continuing medical education and the attendance of conferences in order to establish new relations abroad and generally keep up to date in the field. Jón Baldursson (board-certified 1992) returned from the USA in 1991 having experienced the practice of modern emergency medicine in Cincinnati where the first American EM training program was established back in 1970. With this formal training, patience and excellent personal www.epijournal.com
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SOCIETY NEWS ICELAND (CONT’D)
skills he was able to establish the speciality in Iceland and convince hospital management and the relevant political bodies that EM was the way forward, an impressive feat considering the speciality was practically unheard of in Iceland at the time. A two-year training program was launched in 2002 with the scope to provide physicians with the first half of their required training in the field. With increasing interest in the speciality worldwide and an excellent facility with which to practise in a working academic hospital, a large group of ambitious and eager residents were recruited many of whom are now returning to Iceland having completed training in the USA, UK, Australia, New Zealand and Sweden. As these consultants return with new expertise, the group has now managed to take over almost all lines of acutely sick patients with the exceptions of psychiatry, gynaecology and paediatrics (though we do include pediatric trauma). Being in the Atlantic away from larger, specialised centers we are quite isolated, but this has also created somewhat of a learning utopia for the emergency physician and we see a bright future for emergency medicine in the country. We are large group of young, enthusiastic physicians building up an academic ED with a growing number of patients in a country having just avoided a financial crisis, with a tight budget and a growing need of resources, management welcomes new ideas and solutions to old problems and hopes to create a flourishing environment for young, creative physicians wanting to conduct academic research or improve flow and performance statistics. As all Icelanders learn English at school and a large majority speak the language fluently, we have been able to invite colleagues from abroad who are interested in working in our department and become acquainted with the way we practice emergency medicine as well as experience Iceland as a whole. We invite all interested to follow our blog: emergencymedicineiceland.blogspot.com.
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News from the African Federation of Emergency Medicine (AFEM)
Supporting African EM Just Got a Lot Easier by stevan bruijns, md
Get Involved Author Assist Peer-support program designed to help inexperienced researchers improve their manuscripts afem.info
Adopt-aDelegate
Help emergency physicians from under-resourced regions attend world-class educational conferences. givengain.com
Fall 2013 // Emergency Physicians International
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n the movie Hotel Rwanda there is a moment when the protagonist thanks a foreign journalist for getting footage of the genocide out to the West in the belief that this will result in foreign intervention. The journalist simply replies: “I think if people see this footage, they’ll say oh my God, that’s horrible; and then they’ll go on eating their dinners.” We may know that an intervention is necessary, but it is all too easy to consider it someone else’s responsibility as long as we are comfortable. Even when we are not indifferent to suffering – we may care deeply for a cause – we doubt that our aid will make its way to the source. As a South African, I have seen the struggle over appropriate foreign intervention play out again and again. With well-appearing but totally corrupt African government officials using foreign aid as a means to line their own coffers, many African communities have understandably grown sceptical of their own governments and foreign interventions. Many aid agencies even factor in a standard loss as a result of corruption. And the problem goes even deeper. Some well-intentioned aid agencies, which manage to sidestep the deep African government pockets, may also inadvertently cause harm by upending the local economy by glutting it with free, foreign goods. A better option for foreign aid in Africa is to support local workers and local leaders. The spark is already present, we need only to apply a well-aimed boost to fan a flame. And this is precisely where we find the development of emergency medicine on the continent. Acute care is not new in Africa; it has
existed to some degree for as long as there have been medical emergencies. But the formal development of emergency medicine through organisations like the African Federation for Emergency Care (AFEM) has placed it high on the development agenda in many countries. Today, a mere decade after the first emergency medicine school opened its doors in Cape Town, there are five African countries that recognise emergency medicine as a specialty. Several others are in the process of following suit, leading to the formalising and establishment of emergency medicine specialists, emergency nursing and prehospital care in many more parts of Africa. As exciting as these developments are, it is a drop in the bucket for Africa’s 53 nations, and there is much more work to do. It’s an exciting time to get involved, and yet the question remains: how can foreign physicians help in a way that doesn’t put the locals out of business, but rather improves their opportunity to succeed? It gets even trickier if you prefer your involvement to be at the Western end of an internet connection. Thankfully, these opportunities are proliferating, and they are constantly improving. If you’re an academic, you might give your time to support Author Assist, a novel peer-support program run by the African Journal of Emergency Medicine (Af JEM). The program allows inexperienced researchers free access to a bank of experienced authors to help improve their research manuscripts in order to have a better chance of succeeding at publication. From the very first submissions to Af JEM when it was continued on page 17
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OPINION
EuSEM Must Expand to Help European EM Face Its Newest Challenges With patient volumes increasing in EDs across the continent, European emergency medicine stands at a crossroads. EuSEM must act decisively to guide the specialty in coming years. by dr. barbara hogan, mba
president-elect, european society of emergency medicine
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uropean emergency medicine is now facing some of the greatest challenges in its history as huge numbers of patients seek care in emergency departments. The European Society for Emergency Medicine (EuSEM) can play a key role in helping emergency doctors meet these challenges by further raising professionalism and helping to find international answers to the challenges emergency medicine is facing. Emergency medicine is now being forced to take the role of providing primary medical care in many European countries. The statistics show amazingly large numbers of patients are being treated, with emergency departments taking on a far larger workload than their traditional accident or urgent care. In Germany alone, about 21 million patients are now treated each year in emergency departments. That’s 25 percent of the German population. The statistics are similar elsewhere in Europe. In other words, if patients bring only one relative or friend with them, half of the population in some of Europe’s largest countries visit an emergency department each year. In his history of emergency medicine, Brian Zink excellently described emergency medicine as treating “Anyone, anything, anytime”. In Europe this is increasingly true, often to the hospital’s economic disadvantage. Tighter healthcare spending has channelled more patents towards emergency departments. Family doctors in general practice on tight budgets are no longer providing after-hours care. Cuts in health spending make it difficult to get appointments with
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specialist physicians in many countries. Many people do not want to leave work during the day for an appointment with a doctor and instead go to an emergency department. Europe’s population is getting older, and the number of elderly people needing urgent medical attention is rising enormously. The increase in patients means emergency department waiting times are a top newspaper and television theme in several countries. Many of the problems European societies do not like to face up to appear in the emergency departments as a daily reality. Alcohol and drug abuse among young people continues to rise sharply. Societies are becoming more violent, large numbers of homeless people are brought to us sometimes half frozen from the streets. Society and politicians may ignore these problems: we cannot. Emergency departments are also being increasingly abused by other parts of the health and social care system. Many private hospitals and elderly people’s homes save money by having no physicians on duty in the evening or at weekends. Instead their business plan is to send sick people in their care to an ED. We in EuSEM are in the centre of this storm. And our vision is more important than ever: To help emergency professionals provide the highest quality of emergency care for all patients and establish emergency medicine as a primary medical specialty. EuSEM must continue and intensify its work to achieve the training of the highest standard to enable emergency physicians to provide the best care quality under the enormous pressures they face. We have created a
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A standardised training for all European emergency physicians would also make it possible for emergency physicians to work in any country in Europe, thereby sharing expertise and experience across the continent.
European curriculum for emergency physician training, approved for EU-wide use by the European Union of Medical Specialists (UEMS). More countries must now implement this in their national training programmes to create a standardised, high quality of European training. A standardised training for all European emergency physicians would also make it possible for emergency physicians to work in any country in Europe, thereby sharing expertise and experience across the continent. EuSEM members represent a huge resource of emergency medical expertise. We need to push this expertise further, beyond borders. Our working groups covering specific sectors will expand in future years to find international answers to the challenges in their areas and make the answers available to EuSEM members. Our international congresses must continue their expansion to provide a unique international forum for European emergency professionals. The scientific results of emergency medicine research in Europe and worldwide are published in the European Journal of Emergency Medicine which will continue to raise the reputation of the emergency medicine specialty and intensify the international transfer of knowledge. EuSEM must work to convince governments and other often hostile medical societies of the need for an emergency medical specialty. We must also work to convince politicians, health services and hospital operators of the huge benefits the emergency medical specialty brings by increasing care quality, saving resources and raising efficiency. EuSEM must become the contact partner providing answers to the thousands of questions raised as we treat the ever-rising numbers of patients: Everything from medical subjects to department architecture, equipment, personnel requirements and assessing performance. The EuSEM Internet page must expand its role to be a major contact point for EuSEM members to gain information from EuSEM about standards and recommendations both about medical and management topics. EuSEM will support the countries still fighting for recognition of the emergency medicine specialty, stepping up our efforts to explain and convince politicians, governments and the other medical societies about the need for the emergency medicine specialty. In recent years, EuSEM has launched a
SOCIETY NEWS series of working groups covering a wide range of themes. These must continue to expand their work to achieve their goals and in turn EuSEM’s goals. The Research and Education committees need special support. I wish to support the Young Emergency Medicine Doctors’ Section, as this represents the future of EuSEM. Helping this tree grow will be key to creating the strong branches to support European emergency medicine in the future. The section needs an intensified presence on the internet and in social media. EuSEM’s image must also be improved to strengthen the presence of EuSEM itself and also to provide a greater international forum about European emergency medicine. EuSEM is taking a series of steps to seek the answers to the challenges to emergency medicine in an international context. Often very basic international data on emergency medicine is lacking as the basis for decision making, with each country’s healthcare system essentially working alone. The EuSEM Professional Committee is conducting a survey of emergency departments with the goal of establishing descriptive data about the structure, organisation and number of patients treated in the emergency departments of EuSEM members’ hospitals. The results will help establish an overview of conditions in emergency departments throughout Europe. EuSEM must in the future be able to provide the answers to all the organisational and structural questions raised by everyone in Europe involved in providing or developing emergency medicine. This will include the mechanisms of national funding concepts of emergency care in Europe and assessing the standards and recommendations for improvement of emergency medicine performance. We will also need to look more closely at wider introduction of quality standards throughout Europe. We need to look more at what Europe can learn from the first schemes such as the German quality certification system for emergency departments, DGINA Zert. I salute the work of the past presidents of EuSEM. Much work has been done and much work still needs to be done. The people of Europe are showing they want our emergency departments. EuSEM will help emergency physicians face the challenge of providing the best emergency care for all the people of Europe.
SUPPORTING AFRICAN EM (CONT’D FROM PAGE 14)
In much of Europe, about 25% of the population receives treatment in an ED each year
If patients bring just one person with them, 50% of the population in some of Europe’s largest countries will visit an ED in a year.
launched three years ago, it became apparent that African researchers had extremely good research ideas, but many lacked the writing skills to get published in journals followed by the international community. Since a lot of African research takes a resource-poor angle to research questions, this information has sadly eluded international literature. The result is that for many acute care topics, international recommendations simply do not apply to most African settings. Examples include limited access to acute investigations taken for granted in the West such as CT scanning in trauma. In essence a research protocol from a resource constrained acute care system may look very different from a similar protocol in a developed setting with no loss to relevance. Author Assist has a robust process in place in order to ensure fair peer review. This is achieved by blinding reviewers to author and author affiliation details and blinding section editors to papers in which Author Assist has been employed. As a result submissions that have had Author Assist involvement can fail peer review although this has so far not occurred. From 14 applications received over the last three years, author assistance has already helped six authors to get published in Af JEM. There are currently five open author assist projects. Another armchair support initiative available to interested emergency physicians is the Adopt-a-Delegate programme. This initiative was introduced in 2009 in response to the large number of requests for financial assistance from African delegates to attend the 2007 inaugural ‘Emergency Medicine in the Developing World’ conference. At the time organizers hoped that reduced registration rates would encourage attendance from a representative group of African physicians, but finances were still prohibitive. The Adopt-a-Delegate programme crowd sources financial support for physicians in developing economies so that they can attend medical conferences. Why pay for someone to go to a conference? A regional medical conference provides an international platform from which African issues can be presented and resolved collaboratively. It also provides attendees access to other delegates (many from Africa)
who have already found solutions to issues within their constrained settings which may be adopted in other settings. And finally, conferences provide an obvious educational opportunity for individuals where education is mainly self-directed and where educational resources are few. Conference sponsorship is not new although I’m not aware of any other conferences where the sponsored delegates’ peers are asked to assist financially in their attending. Given the tight budgets with which AFEM runs its conferences (in order to ensure local affordability), there is little left to put towards a corporate sponsorship solution such as offered by many international conferences. The novel approach of sourcing the sponsorships from other delegates at least at present appears unique to AFEM. It has the additional bonus that sponsored delegates get to meet their sponsors at the conference, which makes the whole thing a bit more personal. Travel is not included in the package in order to encourage sponsored delegates to contribute to their own attendance. Effectively Adopt-a-delegate sponsors half the costs to attend one of a few AFEM approved conferences. The process of application is quite rigorous, requiring motivation letters by employers, local government, personal motivation letters and a list of five references which are all checked and crosschecked before a decision is made. Giving is as easy as a single click (afem.givengain.org). These new initiatives continue AFEM’s mission of fostering acute care leadership within African healthcare and research such that they will eventually lead to independent African practice. But this is only the beginning. We’ve begun highlighting supporting initiatives on Twitter under the hashtag #SUDSec (supporting under-developed settings in emergency care) alongside the hashtag #FOAMed (free open access medical education), which has resulted in the sharing of free textbooks and guidelines. International support for both initiatives has been phenomenal to date, but there is much more to do. Whether you’re able to help locally or can only connect online, there’s never been a better time to fan the flame of African emergency medicine development.
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NEWS
India: Bystander Aid Sadly Lacking in World’s Traffic Accident Capital A recent report by Safe Life Foundation suggests that on India’s dangerous roadways, a major contributing factor to motor vehicle accident deaths is a lack of timely assistance from fellow drivers. by bhuvan bagga
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t took a complicated, six-hour-long surgery to take out a five-feet-long and 2-inches wide iron rod that had impaled 23-year-old Supratim Dutta’s body. Coming in through the front dashboard of his speeding car as it hit a barricade on the roadside, the angular rod went through the upper half of his body and came out from his back, just below the chest, narrowly missing his heart. Thanks to the work of some of the most experienced doctors at India’s biggest government hospital – the All India Institute of Medical Sciences’s (AIIMS) Trauma Centre – Dutta survived. His was a ‘rare’ case. In 2012, India had around 500,000 victims of serious road accidents. The death toll from motor vehicle accidents over the same period was 140,000, giving the country the undisputed title of road accident capital of the world. But this number only tells half of the story. As it turns out, about one in two (around 70,000) of these victims could have lived longer. Why? Because common citizens looked the other way. The story behind these numbers has been fleshed out in a recent study by Save Life Foundation (SLF) on impediments to bystander care in the country. As it turns out, 74 percent of Indians will look away instead of helping a road accident victim and this figure is even higher (in fact highest) in the National Capital at 96 percent. These delays – as we look away – don’t just add to the body count but also affect the quality of life of the survivors. As Dr. KT Bhowmik, additional medical superintendent at the Safdarjung Hospital in New
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Delhi says: “Patients reaching us late is an everyday story. We (doctors) discuss it everyday how if a particular patient had been brought to us a little earlier, we would have been able to do even better for him.” Safdarjung is one of the biggest and busiest government-run hospitals in India. On an average it gets 5 to 7 road traffic accident cases every day. As per the SLF study, 80 percent of such patients find it difficult to reach a good healthcare facility within the golden hour of the accident as passersby prefer not getting involved. Why is it that bystanders and witnesses to road accidents become passive, silent spectators? The survey, conducted with around 1,027 people across cities like Delhi, Hyderabad, Kanpur, Ludhiana, Mumbai, Indore and Kolkata, points to a systemic failure that promotes this lethargy. Around 77 percent of the people blamed the hospitals and medical systems for charging money or ‘detaining’ the bystanders who helped bring injured to hospital. An even higher number, 88 percent, were afraid of going through India’s extensive, corrupt and time-consuming legal hassle, involving the courts and the police departments. The point is further supported by another survey question where a mere 36 percent of all bystanders felt their responsibility ended with calling the emergency numbers; 88 percent of the total surveyed wanted a system to aid, assist the ones helping accident victims. So what are these infrastructural, logistical challenges that hinder a quick, effective response to accidents? First, Indian schools or colleges don’t have any history of small
Fall 2013 // Emergency Physicians International
2012 500,000 victims of serious road accidents 140,000 deaths due to road accidents
capsule courses or curriculum telling the young what to do in case of a road emergency. The simple crash course in emergency response can come in handy in those crucial first few minutes after an accident. A successful doctor-turned-politician, Dr. AK Walia, who is Delhi government’s present health minister, said that this was their target for the future. “Having such capsule programmes, demonstrations of dos and don’ts immediately after the road accident for the young, is the way ahead,” he said. With police vehicles also doubling up as ambulances in most parts of India, such training for police staff would also come in handy. At present, there is not much in terms of police training for handling road traffic accident cases, and yet many victims are transported using police vehicles rather than life-support ambulances. The other reason why people don’t come forward to assist is the fear of harassment. It starts the moment one rushes a victim to the hospital. If it’s a public hospital you don’t have to worry about providing money, but private hospitals are often accused of asking for an advance deposit before starting treatment. Ideally, an accident victim is to be treated on an urgent basis. However, in the absence of an insurance policy, most private hospitals simply ‘refer’ the patient to a government-run centre. “We issued directions to hospitals in the past – and even union government too has told the other states – to ensure such people who help accident victims are allowed to leave after giving their names and contact numbers. There shouldn’t be any harassment,” Walia said. But it happens, as Dr. Bhowmik explained. “Even if hospitals don’t bother about detaining a good Samaritan, accidents are medico-legal cases where the cops almost always ask the persons to stay back (for paperwork).” This extensive paperwork and getting involved with India’s overburdened, tiring legal system is something that even the local police officers want to avoid in accident cases. Dr Bhowmik confirmed how doctors and emergency staff often see cops harping on the issue of jurisdiction in such road traffic accident cases. It comes out in the form of cases like the one in January 2012 when a 30-year old man’s body lay unclaimed on a road between the states of Delhi and Uttar Pradesh. It was a suspected case of hit-and-run and police forces of neither of the two states wanted to
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74 percent of Indians will look away instead of helping a road accident victim. This figure is even higher (in fact highest) in the national capital at 96 percent.
take responsibility. It was three days before the unidentified body was ‘retrieved’ and sent for post mortem. In a vast country like India such cases happen routinely. In another case from Pune, in central India, the local cops sparred for three hours before picking up an accident victim’s body on March 29 this year. Ending such displays will require a reexamination of some of our old laws and some systemic corrections by the union government. Dr. MC Misra, the chief of AIIMS trauma centre, who also led the team of doctors who operated on Dutta and hundreds of other such patients in his career spanning nearly three decades, has some reasonable remedies. He divided the accident into an event with three crucial steps: pre-hospital (from the scene of the accident to the hospital), hospital and post hospital (rehabilitation). For him, pre-hospital is the weakest link in the chain in India. “In urban centers response is generally
within 30 minutes while in rural areas or highways one may even have to wait for eight hours,” Misra said. He emphasized the need for a closer coordination between the cops and the medical staff. “They should be aware of all the local facilities and in case of a big event, should almost always scatter the patients to different medical centres for best attention to each patient.” Incidentally, the trauma centre where he is posted sees around 150 patients every 24 hours, most of them victims of road traffic accident, often coming from Delhi and other North Indian states. In the days, weeks and months ahead, India will also have to focus on increasing its net of ambulances, trauma response infrastructure and drilling the most basic traffic sense into its people. For instance, to give way to ambulances and emergency vehicles on the congested stretches of highway. At the very least, one can take solace in the fact that bystander negligence does not
appear to be a class issue. The SLF survey reveals that 78 percent of the poorest people, 72 percent from middle income category and 70 percent of upper income citizens won’t help the trauma victim in the present system. So, we all look the other way, regardless of our origins. While a developing country like India has other pressing issues to handle, the WHO’s label of “most deaths on road” is a dubious distinction and deserves our urgent attention.
Make Your Mark on the World Stage
Now Recruiting Emergency Medicine Physicians Emergency medicine opportunities are available for physicians of emergency medicine to become part of Cleveland Clinic Abu Dhabi, a multispecialty hospital currently under construction in Abu Dhabi, United Arab Emirates. This 364 (expandable to 490) bed facility will be a unique and unparalleled extension to the Cleveland Clinic model of care. Reporting to the Chief of the Emergency Medicine Institute, you will join a world-class team as it establishes a top critical and acute care hospital in the Middle East. In close collaboration with US-based Cleveland Clinic, you will implement the systems, procedures and culture of the Cleveland Clinic when the facility opens its doors. You will have plenty of opportunities for professional growth from frequent clinical and academic interactions between Cleveland Clinic Abu Dhabi and Cleveland Clinic, and you will be exposed to the latest advancements in medicine and surgery. For consideration, please apply directly online with a current curriculum vitae at: www.clevelandclinicabudhabi.ae
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R report
// journal scan
Global Research Review by Torben K. Becker, MD on behalf of the Global Emergency Medicine Literature Review Group
GLOBAL_Standardized prehospital trauma training saves lives in developing countries Henry JA, Reingold AL. Prehospital trauma systems reduce mortality in developing countries: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2012;73:261-268.
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his systemic review and meta-analysis examines the published data on the effectiveness of prehospital trauma systems in emerging and developing countries. Using a comprehensive search strategy, without restrictions on language or study design, the authors identified 14 studies for the qualitative analysis, all comparing a prehospital trauma care intervention to a control group without the intervention. The mean age of the patients was 32.7 years, 77.7% were male, and 79.6% were injured by a blunt trauma mechanism. Eight studies were included in the metaanalysis. Interventions included introduction of Prehospital Trauma Life Support (6 studies), Advanced Trauma Life Support (1 study), and Basic Trauma Life Support (1 study). The interventions were associated with an overall 25% decrease in mortality (the primary outcome), with a slightly greater treatment effect in rural vs. urban settings (29% vs 21% risk reduction, respectively). Though injuries classified as “Severe” and “Critical” (by Injury Severity Scores of 16-24 and 25-75, respectively) accounted for only 23.5% of patients, they represented 96.4% of the reported fatalities.
This well conducted review demonstrates the potential impact of basic prehospital trauma care interventions in emerging and developing countries. However, it should be noted that none of the included studies were randomized controlled trials and the majority (7/8) were rated as “average” study designs. Importantly, while the authors only included studies published in peerreviewed journals, the results of the Funnel plot and Begg’s test did not suggest the presence of publication bias. Despite the limitations, the results are compelling given the significant morbidity and mortality from injuries worldwide. As such, these data should be used to engage stakeholders at the policy level to advocate for development of basic prehospital trauma care systems. -MR, SB
CONGO_Rapid Testing for Cholera Page AL, Alberti KP, Mondonge V, Rauzier J, Quilici ML, Guerin PJ. Evaluation of a Rapid Test for the Diagnosis of Cholera in the Absence of a Gold Standard. PLoS One. 2012;7(5):e37360.
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he global incidence of cholera has been increasing in recent years. Early outbreak identification is essential for rapid implementation of essential interventions. Rapid diagnostic tests (RDT), such as the Crystal VC, offer promise for early cholera confirmation given the limited capacity in most outbreak settings for stool culture, the gold standard for diagnosis. However, as a gold standard, stool culture has limited sensitivity, which when used as a comparison can underestimate RDT specificity. In this study, the authors evaluated the Crystal VC immunochromatographic test using a modified reference standard in an ongoing cholera outbreak in the Democratic Republic of the Congo. Stool samples were collected from 296 patients at two cholera treatment cen-
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ters. The RDT was performed both by a trained laboratory technician and an untrained clinician to simulate outbreak conditions. Three separate methodologies were used as the reference standard: stool culture alone, stool culture with PCR, and Bayesian analysis. PCR was used to resolve discordant results between culture and RDT to increase the sensitivity of this reference standard. Bayesian analysis, which can be used to assess test performance in the absence of a gold standard, utilized known test characteristics and its past performance. In all scenarios, the RDT had good sensitivity but limited specificity (70.6% when used by a lab technician) when compared against stool culture alone. The test specificity increased to 88.6% when compared to culture with PCR and to 85.0% in the Bayesian analysis. Given the limited lab capacity in most cholera outbreak settings, RDTs offer an important tool for early diagnosis. This study demonstrates that some of the concerns about the limited specificity of RDTs are due to the poor sensitivity of the reference test – and not to characteristics of the RDT itself. The results are limited by a small sample size, as the study outbreak waned earlier than expected. However, the conclusions that the Crystal VC has a higher specificity than initially reported are likely still valid. This information is of significant importance to global EM providers involved in the response to potential cholera outbreaks, hastening their ability to implement response measures. -RH, MF
GLOBAL_Who is willing to work during a public health emergency? Devnani M. Factors associated with the willingness of health care personnel to work during an influenza public health emergency: an integrative review. Prehosp Disaster Med. 2012;27(6):551-66.
W
ithin the last decade there have been three major influenza public health emergencies: SARS, avian flu and the H1N1 pandemic influenza. Because an effective public health response to an influenza emergency depends on health care personnel (HCP) continuing to work, it is important to understand the factors that influence HCP’s intent to work during such an emergency. The objective of this integrative review article was to identify factors that influence the willingness of HCP to report to work during an influenza emergency. The author searched the Cochrane, PubMed, EBSCO, and Google Scholar databases for peer-reviewed, quantitative studies in English that were published between January 1, 2001 and June 30, 2010. Thirty-two studies from ten different countries that met predefined criteria were included. Factors associated with a willingness to work during an influenza outbreak include: being male, being a doctor or a nurse, working clinically or in an emergency department, working full-time, prior influenza education and training, prior experience of working during an influenza emergency, the perception of value in response, the belief in duty, the availability of personal protective equipment and confidence in one’s employer. Factors associated with HCP being less willing to work include: being female, holding a supportive staff position, working part-time, the peak phase of the influenza emergency, concern for family and loved ones, and personal obligations. Interventions that increased HCP willingness to work were preferential access to Tamiflu and the provision of a vaccine for HCP
// Basic prehospital trauma systems in developing countries reduce mortality by 25% . . . Structured resuscitation programs improve mortality – regardless of whether or not they are accredited.
and their family.
This review identifies numerous factors that influence the likelihood that HCP will present to work during an influenza emergency. It is the first review article to integrate the recent literature on this topic, making an important contribution to the literature on health sector human resources during infectious emergencies. A variety of factors, both positive and negative, as well as critical interventions, are identified, giving administrators and public health officials better guidance about what to expect and what they can do during such emergencies. However, the meta-analysis is limited by the highly variable quality of the included studies, equal weighting of studies despite such a range in quality, and the inclusion of only English language articles. -JJ, HD
KENYA_Estimating the Weight of Pediatric Patients in a Low-Income Country House DR, Ngetich E, Vreeman RC, Rusyniak DE. Estimating the weight of children in Kenya: do the Broselow tape and age based formulas measure up? Ann Emerg Med. 2013;61(1):1-8.
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"A CONSPICUOUS TOURNIQUET THAT APPLIES THE LOWEST PRESSURE NECESSARY TO ACHIEVE HEMOSTASIS MUST BE USED!" (Lahham, WJEM Nov 2010)
T
his prospective cross-sectional study of all children presenting to an emergency department (ED) in western Kenya sought to determine which methods of pediatric weight estimation were valid in a low-income country. The authors enrolled children (n= 967, age range 2 months to 14 years) presenting to a government referral emergency department in western Kenya. Only children who had conditions that would obviously make height or age based weight estimates inaccurate (i.e. cerebral palsy, dwarfism) were excluded. Each child had an estimated weight calculated using three methods (Broselow Tape, APLS and Nelson’s age based formulas). Bland-Altman analysis was used to determine limits of agreement. Weight estimates were defined a priori as valid if the 95% confidence interval for the mean percent difference between actual weight and estimated weight was < 10%. The Broselow tape provided the most accurate estimation of the child’s weight. In less than 1% of cases was the Broselow estimate off by two “color zones” and in >65% of children, the height correlated to the proper color zone for the actual weight. The APLS method was less accurate, but still met the definition for validity, while the Nelson method was not valid. This study has several strengths. First, the four main clinicians performing the height measurements all measured a percentage of the children at the beginning of the study and there was excellent agreement between their measurements. Additionally, the sample is size is quite large and includes children of various ages, increasing the reliability of the results. The most prominent limitation of the study is its lack of generalizability. The study site charges a fee for care, which may bias the population toward a more affluent (i.e., less likely to have malnourished children) population. Additionally, the study period did not include times of famine, so one cannot assume that any of the methods would be accurate in such settings. Finally, although there is no obvious bias, due to resource limitations, not all patients who presented to the ED were
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// journal scan
enrolled. This article compliments research that has validated the accuracy of the Broselow tape in high-income settings. These data support the use of either the Broselow tape or APLS methods to estimate weight in children presenting to the ED in a low resource setting.
SOUTHERN ASIA_Zinc supplementation for acute lower respiratory tract infection in children does not improve outcomes
-MB, ES
Das RR, Singh M, Shafiq N. Short-term therapeutic role of zinc in children <5 years of age hospitalized for severe acute lower respiratory tract infection. Ped Resp Review. 2012;13:184-191.
GLOBAL_Impact of Structured Resuscitation Training Programs Mosley C, Dewhurst C, Molloy S, Shaw BN. What is the impact of structured resuscitation training on healthcare practitioners, their clients, and the wider service? Med Teach. 2012;34(6):e349-85.
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his review article attempts the first systematic analysis of the results of structured resuscitation training programs (SRT) on participants, institutions, and patient outcomes. It uses an English language literature search surrounding the concepts of resuscitation training, clinical competence, and skill, as well as retention and outcomes. Articles where screened and reviewed by several authors with a consensus model regarding changes in protocol during the evidence gathering process. The article used a modified Kirkpatrick hierarchy (a four level model to evaluate training programs), categorizing results into level 2 (modification of attitudes/perceptions and skills), level 3 (behavioral change), or level 4 (change in organizational practice and benefits in clinical outcomes). Of 3781 articles searched, 105 articles of heterogeneous design were included in the study. Data were compiled and qualitatively reviewed based on study aim, design and sample characteristics, data analysis, and results and conclusions. Results were categorized and presented based on a modified Kirkpatrick hierarchy with divisions for neonatal, pediatric, and adult SRT. The review demonstrated that SRT consistently improves the knowledge and skill of participants and that these levels begin to deteriorate starting at three months after the trainings. In settings where SRT were institutional and no prior trainings existed, a clear improvement in mortality and clinical management was evident, suggesting a group effect. Specific groups to be trained, components of training programs, and whether or not the SRT was accredited did not impact the results. SRT programs are essential but complex, poorly understood and contentious components of global efforts in emergency medicine development. This article represents a robust attempt to systematically review and impart understanding on the heterogeneous and conflicting body of evidence with regard to educational impacts and outcomes. The results are encouraging, demonstrating improvement in knowledge and skills, mortality, and clinical management. The knowledge deterioration and presumed reduction in skills and outcomes suggests the benefits of training refreshers or regular drills, although this was not a direct result of the study. Finally, lack of clear evidence on the benefits of particular training methods or need for use of accredited programs suggests that it is likely all training has some benefit with the added benefits demonstrated when SRT was institution-wide.
-SM, TB
R
outine dietary zinc supplementation has been shown to reduce the frequency of lower respiratory tract infection in children under 5 years of age. The evidence for using zinc in the treatment of acute lower respiratory tract infection (ALRTI) has not been established. This meta-analysis sought to determine whether zinc supplementation in the treatment of ALRTI has an effect in treatment outcomes. The authors describe an extensive search strategy for the selection of articles by multiple authors blinded to each other’s selections. Studies were assessed for methodological quality using standardized assessment forms. Only randomized, blinded, controlled studies utilizing a treatment and placebo group were included in the analysis. Studies were excluded if they did not directly assess the outcomes of objective improvement in respiratory illness, duration of hospitalization, adverse events or change in treatment. Studies were also excluded if they were primarily assessments of particular respiratory illnesses such as HIV or measles-related respiratory illness, or were primarily testing treatment with additional medications such as vitamin A or multiple micronutrients. Discrepancies between authors’ selections were mediated through a defined process. Of 62 studies using the selected search strategy, seven ultimately met the inclusion and exclusion criteria to include a total of 1066 children. Pooled data analysis sought to find a therapeutic effect of zinc supplementation in addition to traditional antibiotics. No statistically significant difference between the placebo and treatment groups was found in either primary or secondary treatment outcomes. This meta-analysis utilized a well-defined search strategy to answer a single research question – whether zinc supplementation improves outcomes for ALRTI. The study question is legitimate. Since zinc supplementation has been shown to reduce incidence of ALRTI, it may be reasonably assumed that zinc treatment may also improve outcomes in ALRTI. However, this study demonstrates that there is no compelling evidence to suggest that this is true. The study is reproducible given the methods described and attempts to limit bias and improve inter-rater reliability are well documented. The utilization of only randomized, blinded, placebo-controlled studies adds to the reliability of the analysis. By excluding studies that assess particular ALRTIs (measles or HIV-related lung infections) as well as studies that assess multiple treatments (multiple micronutrient supplementation) the research question is adequately narrow in focus. Despite this care in study selection, of the 62 eligible studies, only 7 met the inclusion/exclusion criteria. Four of the seven were conducted in India and all were conducted in southern Asia. All but one of the studies were conducted in tertiary or referral hospitals. This geographical bias limits the study’s generalizability to more diverse regions, countries, or treatment settings. Despite the narrow setting and low number of acceptable studies, the conclusion that zinc has no effect on the duration of ALRTI illness or associated symptoms is compelling and should result in further research, even if zinc may ultimately not be a recommended treatment modality for ALRTI.
-BH, TB
editors MR: Michael Runyon, MD SB: Suzanne Bartels, MD, MPH RM: Regan H. Marsh, MD, MPH MF: Mark Foran, MD, MPH 22
Fall 2013 // Emergency Physicians International
JM: Joshua M. Jauregui, MD HD: Herbie Duber, MD, MPH MB: Mark Bisanzo, MD ES: Erika D. Schroeder, MD, MPH
TB: Torben K. Becker, MD SM: Stephen Morris, MD, MPH BH: Braden Hexom, MD
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// the aging world
New Age: Why the World Needs Geriatric Emergency Medicine The world’s elderly population continues to explode, creating both strain and opportunity in the field of emergency medicine. Emergency physicians need to respond by solidifying the ED as the hub of care for the aging patient.
by kathleen walsh do ms, melissa stiles md & chik loon foo mssb
E
dina Petrovic, an 82-year-old retired elementary school teacher, is upset. She does not want to be admitted to the hospital. “I have to take care of my husband and who is going to feed my cat?” Edina’s husband, who has moderate dementia, is sitting next to her, holding her hand and reassuring her he can care for himself for a few days. Mrs. Petrovic fell in her kitchen this morning stating she caught her foot on the rug. She could not get up and her husband called 911. Several neighbors were present and were anxiously talking over one another when EMS arrived. She was getting more agitated about the situation and stated, “I am okay, just get me up and you can all go home.” Her best friend and neighbor convinced her to go to the ED. A cervical collar was placed and she was strapped down to a backboard for transfer. Her only complaint was right hip pain, although EMS crew also noticed a “goose egg” on the back of her head. She denied hitting her head or any other injuries. In the trauma bay, the team quickly moved Edina from the gurney to the exam bed. The EKG leads and pulse ox were attached. An additional 16 gauge IV was placed (after third attempt to find vein). Her blood pressure was checked every 5 minutes. She was focused on the cuff commenting it was “hurting my arm” while the physician quickly ran through the trauma evaluation including a FAST exam. Her clothes were removed, much to her angst. She was then turned onto her side for the spine and rectal exam – which she was not expecting and became visibly upset. When asked to rank her pain, she stated “a lot, now leave me alone”. Off to the radiology suite she went for additional imaging. CXR, pelvis and hip x-rays were negative. The CT head demonstrated a scalp hematoma and CT C/T/L spines were negative. The ED physician recommended admission for observation as she had
difficulty bearing weight on her right leg and concern for the head injury. ************* The percentage of the world’s population over 60 years of age will double from about 11% to 22% between 2000 and 2050. Although more developed countries have the oldest population profiles, the vast majority of older people and rapidly aging populations are in less developed countries. The repercussions of the rapidly aging world population are noticed throughout society, but nowhere are they more evident than in the healthcare system. Policy makers have to make decisions about hospital admissions, costs, social services, and manpower. The
benefits of these changes may not be seen for several years. However, sometimes small and seemingly simple changes focused on the elderly emergency department patient (e.g. follow-up phone call after visit) have been shown to have immediate positive outcomes. ( Jones et al, Poncia et al). This was the subject of two symposia presented by the Society of Academic Emergency Medicine (SAEM) at this year’s International Association of Gerontology and Geriatrics (IAGG) World Congress in Seoul, South Korea. The group from SAEM’s Academy of Geriatric Emergency Medicine spoke on “Building a Geriatric Friendly Emergency Department” and “How to Engage Organized Medicine in Geriatric Education, Research, and Knowledge Translation.” The IAGG was founded in 1950 with the mission of promoting worldwide gerontological research and training through collaboration between international, inter-governmental, and non-governmental organizations. The world congress is held every four years in different countries throughout the world. The main theme for the 2013 conference in Seoul was “Digital Ageing: A New Horizon for Health Care and Active Aging” (e.g. robotics, personal health tracking, data sharing, on-line education). There were over 5,000 conference attendees from more than 90 countries. Symposia topics in biological science, clinical medicine, social and behavioral science and research policy and practice were presented. Emergency departments throughout the world
Fig. 1: The ED as a Hub of Care for the Elderly GEM nurse/ Care Coordinator Geriatric Emergency Review Clinic Primary Health (GP/ Polyclinics) Unit (EDOU)
Admit
Medical Social Worker Physiotherapy
TRST in ED
EDOU Screening
Bladder Protocol
Medication Reconciliation ‘ComPacks’ Day Care – Social/ Rehab/Dementia
Falls Evaluation
Discharge
Observational Unit (EDOU) Stepdown Care (Community Hospitals) Subacute Care
Post Acute Care at Home (PACH) / Virtual Hospital
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// the aging world
are starting to see the influx of the elderly patients and their complex medical needs. This increase is not only due to the aging population, but also to the shrinking primary care pool of physicians (both family medicine and internal medicine) and subsequent lack of access to basic health care assessment and prevention. The team from SAEM presented several new and emerging concepts of care for the geriatric patient in the emergency department. The first key concept is embracing that emergency departments around the world are the “hub of care” for elderly patients (figure 1). Emergency providers need to move beyond the concept of “admit versus discharge” for our elderly patients and think in terms of a continuum of care. Hospital admission rates for the elderly vary significantly throughout the world (figure 2). Research has shown that admission of the elderly patient is not always beneficial as it can lead to deconditioning, DVT/PE’s, nosocomial infections, medication errors, longer LOS and bed blocks. These in turn cause diversions and ED overcrowding. Examples of this “continuum of care” model include the geriatric emergency review clinic, observational and stepdown units, faint and fall clinic, virtual hospitals, palliative care units, and admitto-home programs, just to name a few. (Conroy) In order to establish the emergency department as the hub of care for the elderly, three things must be agreed upon: 1) Education The entire workforce – from EMS to IV/phlebotomist/radiology technicians to medical students – needs to be educated on geriatric physiology, medication management, atypical presentation of disease and cognitive/behavioral disorders. These educational innitiatives can take a variety of forms. When educating EMS, consider providing lectures at local or regional meetings on atypical presentations in the geriatric patient, geriatric trauma, pain management, etc. Take time to engage EMS personnel in “real time” when they arrive with a patient. Expand on the patient’s chief complaint, physical findings, vital signs, EKG, etc... There are also resources available online developed by the American Geriatrics Society and the National Council of State EMS Training Coordinators (www.gemssite.com). When teaching IV/phlebotomists/radiology techs and nurses aids, give short presentations at meetings and bedside teaching to recognize abnormal vital signs and cognitive impairment (delirium and dementia). Take opportunities to observe and report abnormal physical findings such as bruising, petechiae, bleeding, bony deformity, difficulty with gait and balance. When educating the nursing staff, identify nurses who have an interest in geriatric medicine to be leaders and educators for the staff. Encourage these
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Fig. 2: Elderly admission rates across five of the world’s most developed healthcare systems 65% 59% 46%
47%
25%
Canada CIHI 2010
UK
Downing 2005
USA
Strange 1998
leaders to consider joining the Emergency Nursing Association (www.ena.org), which offers a Geriatric Emergency Nursing Education (GENE) online learning module. This newly updated program includes video, images, animation, voice-over narration, and knowledge checks. Since there are simply not enough geriatricians to serve the burgeoning older population, it is essential that emergency medicine physicians have competency in the core geriatric topics and principles. Resources for medical students and residents are available through the Portal of Geriatric Online Education (pogoe.com) as well as all the major professional socities. 2) Targeting and Screening There has been a change in the paradigm of the ED patient we are seeing all over the world. We are moving from the younger patient with a single complaint – acute issue, easier to diagnose and treat with rapid dispositions – to the geriatric patient with multiple problems, acute or subacute or chronic condition. Our new goals are controlling symptoms, maximizing function and maintaining continuity of care. “Targeting” involves identification of those patients by location (e.g. skilled nursing facility, lives alone), condition (e.g. falls, dementia) or risk (e.g. multiple medications, elder abuse), and intervening with structured evaluation and follow-up. Screening elderly patients for conditions known to be detrimental – such as falls, dementia, delerium and elder abuse – helps providers identify and address hidden needs. Any healthcare provider (CNA, technician,
Fall 2013 // Emergency Physicians International
Australia Singapore Lamb 2009
Foo 2009
nurse, physician) can be trained to implement the appropriate screening tool with the goal of quick and appropriate intervention to reduce repeat ED visits and possible hospitalizations. 3) Networking Geriatric emergency care relies heavily on establishing direct and supportive relationships with all of the essential players, from hospital administration to the medical home (transition/urgent care systems), to assisted living and home care organizations. This is the best way to attain the triad of (1) better health care, (2) better health and (3) lower costs for beneficiaries. We aim to improve individual patient experiences of care along the Institute of Medicine’s six domains of quality (Safety, Effectiveness, Patient Centeredness, Timeliness, Efficiency and Equality). We encourage better health for entire populations by addressing causes of poor health, such as physical inactivity, behavioral risk factors, lack of preventative care and poor nutrition. And finally we lower the total cost of care resulting in reduced private and government expenditures by improving care, ultimately enhancing the health care system. (Carpenter) The key to accomplishing these three goals is to have “geriatric friendly” emergency departments, or, better yet, Geriatric Emergency Departments. During the symposia, Dr. Mark Rosenburg discussed the steps that his ED went through to establish what is one of the first Geriatric Emergency Departments in the United States. In the USA, there are now over fifty Geriatric Emergency Departments and work is in progress for developing a certification process for
these departments. Dr. Foo discussed the success of the emergency department observational unit at Tan Took Seng Hospital in Singapore in reducing readmittance to the ED and hospitalizations (Foo et al). As with most global conferences, the rich discussions with international colleagues that followed the lectures were the true highlights. In order for geriatric emergency medicine to thrive, these liasions will need to be maintained and strengthened. There are several professional international geriatric organizations including the IAGG, Japan Geriatrics Society, Australian and New Zealand Society for Geriatric Medicine, European Union Geriatric Medicine Society and the American Geriatric Society. We need to work across specialties, and between organizations to generate high-yield peer reviewed research priorities. For emergency physicians throught the world, there has never been a better time to get started. We are facing the “perfect storm” of an increasing geriatric global population, rising health-care costs and too few geriatric-trained health care professionals. Emergency departments sit at a unique crossroad in the continuum of patient care, overlapping with outpatient, inpatient, prehospital, home, and extended care settings. We need to start addressing how care for the elderly is delivered not only within the ED itself, but also at transitions of care to and from the ED. There are however, concerns raised regarding the geriatric ED. Cost is one of the main issues being addressed. New facilities, additional equipment, and increased staffing are all things that cost money. Many emergency departments operate on very limited budgets and may be unwilling to invest in the geriatric ED at the expense of other aspects of emergency care. Hospitals may also struggle with which patient could benefit from the geriatric services. Healthy, more independent seniors directed to the specialized geriatric areas may find it somewhat offensive. While most physicians would agree that the new design features being implemented in geriatric emergency departments are positive changes, some argue that these changes would be more effective if implemented throughout the ED. One of the main hurdles to overcome is
REFERENCES Carpenter CR. Geriatric Emergency Medicine. Clin Geriatr Med. 2013 Feb;29(1). Conroy SP, Ansari K, Williams M, Laithwaite E, Teasdale B, Dawson J, Mason S, Banerjee J. A controlled evaluation of comprehensive geriatric assessment in the emergency department: the ‘Emergency Frailty Unit’ Age Ageing. 2013 Jul 23.
// Emergency departments sit at a unique crossroad in the continuum of [geriatric] patient care, overlapping with outpatient, inpatient, prehospital, home, and extended care settings.
demonstrating that the geriatric ED can provide better health, improved patient experiences and reduced cost to the healthcare system. To accomplish this, we need to continue to build on well designed health services research focused on the clinical and economic outcomes of the geriatric ED. Emergency medicine has recognized the special needs of children and psychiatric patients. Now is the time to also address the focused needs of older adults within the emergency department setting. ************* To return to the opening patient scenario, if Ms. Petrovic had presented to a Geriatric Emergency Department, her care and disposition would have been managed differently. EMS would have faxed in the EKG (normal) and given a pre-arrival report stating they were concerned about head trauma and possible hip fracture. With her permission, they would have placed her medication bottles into a bag and brought them into in the ED. You could hear the ambulance sirens approaching, but when they arrived the atmosphere in the trauma bay would be jarringly calm. There would be no beeping machines, glaring lights or loud voices talking over one another. Edina would be transferred
Foo CL, Vivian Siu WY, Tan TL, Ding YY, Seow E. Geriatric assessment and intervention in an emergency department observation unit reduced reattendance and hospitalisation rates. Australasian J on Ageing 2012; 31(1): 40-46.
to a thick mattress and additional padding would be arranged for neck and upper back with her noticeable thoracic kyphosis. A senior life specialist volunteer would be present, providing comforting conversation. In this case, the volunteer recognizes one of the patient’s hearing aids is missing and reaches for the amplified headphones. An IV technician obtains US-guided venous access with a single attempt. Clothes are removed after explanation and with a respectful gentleness. The physician talks to her directly during her exam and pauses when needed to answer questions. Her pain is addressed and treated with repositioning, Tylenol and a cool compress. The ED social worker was present when she arrived and located her husband and best friend to bring them back to the trauma bay. The ED pharmacist completed the medication reconciliation. After x-rays were cleared, a physical therapist is consulted who prescribes a front-wheeled walker and arranges for home physical therapy. Edina demonstrates the ability to ambulate with the walker in the ED. The social worker arranges a daily home visit by a visiting nurse to assess fall risk and a follow-up of the head injury. A follow-up visit to her primary care office is also arranged. The emergency department is changing as the world’s population ages; the time is now for emergency medicine to adapt to meet the challenge.
Kathleen Walsh DO, MS is a Assistant Professor of Medicine at the University of Wisconsin School of Medicine and Public Health. She is fellowship trained and board certified in Geriatric Medicine. Melissa Stiles MD is a Professor of Family Medicine with the University of Wisconsin School of Medicine and Public Health. She is also fellowship trained and board certified in Geriatric Medicine and board certified in Palliative Medicine. Chik Loon Foo MBBS is a senior consultant at Tan Tock Seng Hospital (TTSH), whose emergency department is the busiest in Singapore. His special interests are in geriatrics and medical informatics.
Poncia HDM, Ryan J, Carver RM. Next day telephone follow up of the elderly: a needs assessment and critical incident monitoring tool for the accident and emergency department. J Accid Emerg Med 2000; 17: 337-340.
Jones JS, Young MS, LaFleur FA, Brown MD. Effectiveness of an organized follow-up system for elder patients released from the emergency department. Acad Emerg Med 1997; 4(12): 1147-52.
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// manpower in asia
Why Are Hong Kong’s Emergency Departments So Understaffed? Some EDs in Hong Kong have between a half and a quarter of the number of doctors per patient compared with other world-class departments.
by timothy rainer, md
L
ack of medical staff in public emergency departments is in many ways a global phenomenon, so why should Hong Kong’s public emergency departments be singled out for special attention? Anyone who circuits the globe from country to conference and back will hear many similar stories of a critical shortage of emergency trainees and physicians. Hong Kong is not alone, and certainly does not have the worst healthcare statistics in the world. It boasts one of the longest average life expectancies for both males and females, despite spending about 5.2% GDP per annum on healthcare. So not all can be bad. Hong Kong considers itself a ‘world class’ city and arguably has one of the six most developed emergency medicine specialties in the world. Along with the UK, USA, Canada, Australia and Singapore, it leads the world in the development of emergency medicine. The specialty in Hong Kong is now over 15 years old, and has its own College, Society, six-year training programme, 16 fully accredited emergency departments, over 450 specialists and trainees, a three-level examination system, and is sought after by overseas doctors for accreditation and training. So what’s the problem? In the last five years, established physicians and new medical graduates have become increasingly disappointed, disinterested and disenchanted with the specialty. A decreasing number of new graduates are choosing emergency medicine as a career, and an increasing number of trainees and specialists are leaving for greener pastures. In recent years competition for vacant posts has decreased, and in some years up to 20% of training posts are unfilled. Over the last 10 years hospital emergency care has come under increasing pressure. In some hospitals less than two thirds of emergency medicine posts have been filled, more than 60% training posts are vacant, and few, if any, new graduates apply for positions. Junior physicians rotate from
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other specialties for ‘service-training’ and general practitioner locums prop up the service. It is a tragic trend and a sad return to the past. Emergency trainees not uncommonly leave the specialty in their last year of training! Compare this with neighbouring Malaysia where nearly 400 graduates are on the waiting list for 34 national emergency medicine training posts. Food for thought. Where have these emergency physicians gone and why did they leave? The real reasons may never be known but those departing leave the specialty for other careers, for the private sector (despite its poorly developed emergency system), to hospital management, and to general private practice. And why did they leave? The commonest reasons given are the unprotected and excessive workload, long patient waiting times, increasing numbers of critically ill and complicated patients who require complex assessment and management, insufficient resources, unreasonable work expectations, devalued staff, low morale, excessive night duties, overcrowding, severe access block, insufficient and unprotected training opportunities and poor promotion prospects. And there are no signs on the horizon that this situation will improve. Does this sound familiar? More recently, waiting times for a first doctorpatient consultation in emergency departments have exceeded 24 hours, and the maximum number of patients waiting for that first medical consultation has reached 110. Some patients have waited over five days in emergency departments for a hospital bed, and some days up to 75 patients can wait longer than eight hours for a bed. Access block is a major challenge in some emergency departments. In Hong Kong, access block is defined as any patient waiting longer than eight hours for admission to a hospital bed after the decision has been made that admission is required. Compare this with the recent National Health Service Report on Transforming Urgent and Emergency Care Services in England. ‘Recent data shows
Fall 2013 // Emergency Physicians International
that the number of patients waiting more than four hours from the time of arrival at an A&E department to admission or discharge increased from 1.73 per cent to 4.1 per cent between 2009/10 and 2012/13.’ Hospital managers in Hong Kong balk at the thought of a true four-hour emergency department process time in Hong Kong. The average access block in some hospitals in Hong Kong was over 550 patients per month. Table 1 shows a comparison between the medical staff to patient ratio from emergency departments in other international ‘world class’ settings with two leading departments in Hong Kong. This data was culled in 2007 but in the last five years there has been no improvement. Some emergency departments in Hong Kong have between a half and a quarter of the number of doctors per patient attendance compared with ratios other world-class departments. The reasons for this tragic situation are probably not unique to Hong Kong. For example, in some emergency departments in the UK, there is overcrowding, worsening admission block, an increasing complexity of cases being managed in the ED, deteriorating working conditions, lengthening waiting times, decreasing patient satisfaction, staff burn out and fewer new doctors joining and staying in the specialty. In 2012/13, in response to a patient satisfaction survey in the UK, it was considered shocking that ‘thirty-three per cent of respondents said they waited more than half an hour before they were first seen by a doctor or nurse – up from 24 per cent in 2004 and 29 per cent in 2008’! However, in Hong Kong, waiting times to first consultation may last as long as 24 hours. The Way Ahead document jointly prepared in 2003 by the British Association for Emergency Medicine and the Faculty of Accident and Emergency Medicine (UK) provided recommended staffing levels for typical A&E Departments in the UK. For a department with an annual attendance of 100,000 patients, the recommendation was that there should be at least 36 doctors including eight consultants and 28 trainees, which would result in a doctor to patient attendance ratio of 1:2778. Britain and Hong Kong have strong historical connections and similar health services and intended provisions of care. So how does Hong Kong compare with the UK? In a hospital in Hong Kong with an annual attendance of about 150,000 The Way Ahead suggests that about 54 doctors are needed to provide a reasonable service. In fact the number of allocated medical staff is 30 (15 specialist/consultants and 15 trainees), with a comparative shortfall of 55%. This assumes that all posts are filled. Other specialties have well-defined roles, and emergency medicine is no different. The role of emergency medicine is to assess and to treat undif-
Total Annual Emergency Department Attendance
Population served (where known)
Clinical Director, Consultant, Associate Consultants
Number of Specialists
Higher Specialist Trainees (4-6 yrs)
Basic Specialist Trainees (1-3 yrs)
Other Doctors
Total # of Doctors
DoctorPatient ratio
DoctorPopulation ratio
Hospital A, Hong Kong
120,000
500,000
9.5
4
3
8
1
25.5
1:4700
1:19600
Hospital B, Hong Kong
150,000
750,000
8
5
10
5
2
30
1:5000
1:25000
Hospital C, Singapore
115,000
10
31
41
1:2780
Hospital D, UK
100,000
7
11
20
38
1:2630
Hospital E, UK
85,000
450,000
6
8
18
32
1:2650
1:14060
Hospital F, Australia
45,000
500,000
16
8
7
41
1:1100
1:12200
Hospital G, UK
145,000
11.5
14
32
57.5
1:2520
Hospital H, USA
89,300
32
24
24
80
1:1120
Hospital I, India
35000
500,000
1
0
8
4
14
1:2500
1:35720
Hospital J Scotland
100,000
500,000
6.7
10
22
6
45
1:2220
1:11180
ferentiated illness and injury. But unlike most other specialties, emergency medicine has a 24/7 open door policy, which leaves it open to ‘abuse’ from all quarters. Whilst other specialties largely retain their function, emergency medicine undergoes major role changes to meet the needs of society and the hospital. It is not only responsible for managing undifferentiated illness, and for hospital gate keeping, but also often acts as the buffer, pending zone and satellite for other specialties who cannot find a bed for a patient from their clinic. In reality, the pressure on emergency care is a multi-faceted problem, which extends way beyond the emergency department, and apart from those mentioned there may be other reasons why the specialty in Hong Kong is in crisis. The underlying issues are partly historical and partly political. It started during the economic crises of 1997 and 2003 when high level decisions were made to reduce the numbers of students entering medical and nursing schools. This relieved the short-term pain of financial strain but set a course for even greater trouble. Next, the public, in general and understandably, do not want to increase taxes, do not want to pay for emergency care, and do not support a higher percentage of GDP allocated to healthcare. Yet there is an expectation that optimal care should be provided and also with minimal delay. This is not reasonable and not sustainable. The result has been a squeeze on frontline emergency staff from the government and healthcare managers above, from the public below, and from other hospital and university departments alongside. When there is pressure from all sides eventually something must give, the bubble bursts, and
0
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the only perceived solution is to ‘get out’. If things are so bad, then why isn’t anything being done about it? Again, there are many possible reasons. First, those in authority may fear to face the reality and enormity of the problem. The problem is perceived as too large to solve, too politically sensitive and so it may be better not to face it. Second, the shortage of doctors is not unique to emergency medicine but may also apply to many other specialties. Third, there may be a fear from academic sectors that the aging population with its poor prospects of any quality life whatever care they receive will flood the hospital system and affect medical student training, education, research and advancement. Hospitals in Wales have recently been in the headlines as increasing surgical waiting lists give way to a bitter winter of acute and unscheduled medical illness. Fourth, there are fears that an honest and transparent revelation of real and relevant data would discredit the authorities, the government and hospital managers. To voice this out would have an adverse effect on any individual’s hopes of development and promotion. Very few whistle blowers find an honoured place in history. Whilst there is little doubt that this situation adversely affects patient safety, taking the lid off the problem, and collecting and analyzing data, is thought to be too damaging politically. So, what are the answers to these challenges? First, we need to acknowledge that this is a high priority, complex, multisystem problem that is most clearly evident in emergency medicine but actually involves all levels of healthcare and government. The whole hospital system needs to understand its responsibility – that this is a system,
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and not an emergency department problem, which needs rigorous assessment, root cause analysis and a multifactorial approach. Second, politicians need to face these realities with honesty and transparency, adopting a longterm view to addressing the problem. This is not easy when ‘office’ is dependent on short-term appeal and votes. Politically it may be perceived as suicide to address these issues. Third, are working conditions reasonable? Staff need to be valued and rewarded, and their lives and careers enhanced and protected. Job descriptions need to be attractive. Quality training needs to be provided and protected. It is not all about the patient. It is about the staff too. Fourth, do tough decisions need to be made, and in some cases some services cut? It appears that there is a trend, despite insufficient resources, to increase rather than decrease services, and to build new hospitals and to expand specialties. Rather than produce high quality care for all, could this result in diluted, sub-standard and fragmented care for many? There is a need to contract and consolidate high quality care into fewer centres. Patients may have to travel further, but when they get to hospital they will be assured of a high standard of specialist care, 24/7. Fifth, the public need to be continually informed about its responsibility both in their use of services, and payment in taxes. A world-class service is expensive. Sixth, do we need international benchmarking and risk adjusted mortality data on all aspects of care and between different models of provision? It continued on page 33 www.epijournal.com
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// polish ems
P photo
Serious Simulation at Polish EMS Rally On the eve of Central Europe’s largest EM congress, EMS crews compete in a national “Road Rally” that takes them from abandoned rail tunnels to mountainside ravines.
by terrence mulligan, do photos by logan plaster
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very four years, Poland hosts the Central European Emergency Medicine Congress, and 2013 was the largest CEEM Congress yet. In April 2013, the Polish Society of Emergency Medicine hosted the 4th such congress in Wroclaw and Karpacz, Poland. Prof. Juliusz Jakubaszko, president of the Polish Society, welcomed over 750 participants and lecturers from over 30 countries to the series of workshops, lectures and research exhibitions. In the intervening years between each CEEM congress, Prof. Jakubaszko presents a Winter Symposium, which is now in its 22nd year. Every year in the days leading up to the symposium, and again this year before the CEEM 2013, the congress organizes a large national EMS Extreme Rescue competition. Eight Polish EMS teams from around the country compete in a two-day EMS rally that covers over 250 miles of urban, rural and mountainous terrain. Teams race to complete seven EMS disaster, mass casualty and wilderness rescue simulated scenarios. This year, eight teams of 5-10 members consisting of EMTs, paramedics, physicians and other EMS professionals participated in rescuing moulaged patients from mountain ravines, raging waterfalls, snow-covered forests, and from train tun-
01 01 A Polish EMS team rushes
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Fall 2013 // Emergency Physicians International
to the aid of a moulaged victim during a mountain climbing rescue scenario A high angle rescue simulation ends by ferrying the victim over a ravine. A rescue scenario takes EMS crews – and observers – deep into an abandoned rail tunnel. Prof. Juliusz Jakubaszko gets interviewed by the Polish media on the site of a simulation scenario. A moulaged car accident victim waits for rescuers as coordinators prepare a series of simulated explosions.
nels deep underground. EMTs and paramedics were graded and rated according to their adherence to EMS training protocols for safety, efficiency, ingenuity and speed, all under highly realistic conditions and simulated hazards of disaster and wilderness rescue. This yearâ&#x20AC;&#x2122;s CEEM 2013 was the most successful yet, highlighting the continuing excellence of emergency medicine in Central Europe generally, and in Poland specifically. Next year, the Polish Society of Emergency Medicine will host the 23rd Winter Symposium in EM in Karpacz, Poland, a beautiful skiing town in the Karkonosze mountains in southwest Poland. Learn more at epijournal.com/events, or connect with Polish emergency physicians on the EPI Network at network.epijournal.com. 03
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Bringing It In House In-ED imaging can improve efficiency, raise the quality of care and even help the bottom line. Dr. Manuel Hernandez explains how to design it right from the ground up. 05
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s the ED has evolved, the role of advanced diagnostics has exploded in the evaluation and management of our patients. Beginning with simple roentgenograms and basic laboratory analysis, our diagnostic capabilities have expanded to include advanced non-invasive imaging that has largely replaced exploratory surgery and the “wait-and-see” approach commonly used in the absence of diagnostics. The concept of housing imaging within the ED had gained popularity, though at differing rates. The most readily available data from the United States and other advanced systems has shown a steady increase in imaging utilization. For example, data from the United States has demonstrated a five-fold increase in CT studies ordered in paediatric cases from 1995 – 2008 (Larson). Flattening and even declining utilization trends are also beginning to exhibit themselves for adult patients in advanced systems where CT scans have been readily available for many years (Levin, Menoch). Part of what has driven increased use of imaging can be attributed to increased availability and practice in high-liability environments. While there is limited peer-reviewed data to suggest a correlation between availability of imaging in-department and utilization rates, links between liability concerns and utilization have been demonstrated (SmithBindman). The Case for In-ED Imaging Planning for In-ED imaging begins with developing the business case for why investment in such expensive technologies will enhance performance, be it clinical quality, operational efficiency, financial performance or any combination of the three. Table 1 demonstrates the impact of imaging turnaround times on overall ED performance. Looking at the cost of construction of unnecessary capacity and annual staffing costs to support
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fig. 1: ED design with x-ray immediately adjacent to triage
TABLE 1: Treatment Stations Required to Support; Diagnostic Imaging by Imaging Demand ED #1
ED #2
ED #3
Number of Annual Imaging Cases
15,000
15,000
15,000
Imaging Turnaround Time
48 min.
36 min.
20 min.
12,000 hrs.
9,000 hrs.
5,000 hrs.
1.8 stations
1.4 stations
0.8 stations
Total Care Time ED Treatment Stations Required to Support Imaging Demands1
1. Assumes 75% exam room occupancy target patient care, the case for developing design solutions to reduce imaging turnaround times is clear. Building on the information in Table 1, Table 2 further explores the business case for in-ED imaging services. Based on the information presented in Table 2, an investment in an in-ED x-ray unit would break even on the investment within 2-3 years of implementation, while a CT scanner would break even on the investment within 5-7 years, depending on
Fall 2013 // Emergency Physicians International
the technology purchased. Other studies have looked at the cost effectiveness of use of advanced imaging modalities as a part of the ED evaluation phase as a strategy for reducing the overall cost of care. For example, use of coronary CT angiography in the ED as a part of an in-ED cardiac rule-out pathway has been shown to reduce overall length of stay for low-risk chest pain patients while also significantly reducing the total cost of care for the patient encounter (Goehler). In All Images © 2013 Cannon Design
TRIAGE
TREATMENT TREATMENT
TREATMENT
IMAGING TREATMENT
TREATMENT
fig. 2: Imaging Location in High Volume ED
fig. 4: CT Scanner Immediately Adjacent to High-Acuity Zone
TABLE 2: Cost Analysis of Imaging Turnaround Times ED #1
ED #2
ED #3
1.8 stations
1.4 stations
0.8 stations
Average ED Design & Construction Costs
€3,375/m2
€3,375/m2
€3,375/m2
Recommended Treatment Station Size
13.3 m2
13.3 m2
13.3 m2
Costs Attributed to Imaging Turnaround Times
€80,798
€62,843
€35,910
DESIGN & CONSTRUCTION COSTS Stations Required to Support Imaging Costs
STAFFING COSTS
TABLE 3: ED Minimum Imaging Volumes By Modality to Justify In-ED Imaging Investmentd MODALITY
RECOMMENDED TRESHOLD VOLUME
Fixed X-ray
Standard Requirement
Portable X-ray
Standard Requirement
Portable Ultrasound
Standard Requirement
Total Care Time
12,000 hrs
9,000 hrs
5,000 hrs
CT
~ 13,000
Annual Care Hours / RN FTE1
6,240 hrs.
6,240 hrs.
6,240 hrs.
MRI
~ 4,400
RN FTEs Required to Support Imaging Turnaround Time
1.92
1.44
0.80
Annual RN Salary
€70,000
€70,000
€70,000
Annual Nursing Labor Costs Required to Support Imaging Turnaround Time
€134,400
€100,800
€56,000
1. FTE = Full Time Equivalent situations such as this, the investment in an in-ED CT scanner could yield a quick return on the investment in the technology. Imaging Modalities to Consider Selecting the proper imaging technologies can have a direct impact on speed to diagnosis, initia-
tion of definitive management and overall length of stay in the ED. The selection criteria for what imaging to include within the borders of the ED should, at a minimum, include the following: • Annual imaging volumes (by modality) performed in the ED • ED acuity and special patient populations
• Distance of ED from main diagnostic imaging services (immediately adjacent, distant, remote) • Availability of diagnostic imaging staff 24/7 or on-call • Potential impact on total cost of care • Annual ED Imaging Volumes The addition of diagnostic imaging technology in the ED is no small investment. Because of this investment requirement, it is important to consider whether or not the demand for imaging services justifies the investment. While there is no industrywide benchmark for imaging volumes that justify investment in imaging, this author considers the information in Table 3 as a useful guideline. www.epijournal.com
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TABLE 4: ED Minimum Imaging Volumes By Modality to Justify In-ED Imaging Investment SPECIAL PATIENT POPULATION / DESIGNATION
X-RAY
Ultrasound
CT
Paediatrics
X
X
+/-1
Trauma
X
X
X
Acute Stroke
X
X
Chest Pain Center
X
X3
MRI
MRI
+/-2
~ 4,400
1. Frequent use of CT in the paediatric population is a topic of much debase in EM. As of the time of this publication consensus on In-ED CT except for high-volume / high-acuity paediatric centers does not exist. 2. Early studies at advanced academic medical centers are indicating benefit of early MRI in acute stroke patients, As of the time of this publication consensus on the value of in-ED MRI does not exist. 3. Studies investigating use of coronary CT angiography as a part of a rapid â&#x20AC;&#x153;triple rule-outâ&#x20AC;? in low risk patients is showing benefit. This requires advanced CT technology, typically 64-slice dual source scanning capability of better.
ED Acuity and Special Patient Populations As EDs develop more and more specialty services, the speed to diagnosis and definitive management becomes evermore important. Similarly, as patient acuity levels increase in the ED it can be expected that more and more demand for imaging services will develop. With this understanding in mind and based on current and future standards of care, this author considers Table 4 to be a useful guideline for in-ED imaging planning. Distance of ED From Main Diagnostic Imaging Services Studies analyzing the root causes of delayed ED imaging have indicated that order processing and patient transport times, along with imaging location can all impact imaging turnaround times. A study of three urban Canadian EDs demonstrated that turnaround times for plain x-ray studies were shorted in the ED with an imaging unit within ED, while turnaround times were over 50% longer when the x-ray unit was located remote to the ED (Worster). Availability of Diagnostic Imaging Staff 24/7 or On-Call Staffing the imaging areas of the ED is another important consideration for in-ED imaging services. Clearly, a CT scanner in the ED is of no benefit
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if there is no staff to run it. Once an imaging modality is located within the borders of the ED, it is expected the service will be available 24/7 through either an in-house or on-call staffing model. Potential Impact on Cost of Care Throughout this article, examples of how diagnostic imaging has impacted the overall cost of care have been presented. Bending the cost-curve of emergency care and the total cost of care are important considerations that can be meaningfully impacted by careful imaging planning in any ED design. For example, selecting advanced CT technologies with subsequent elimination of oral contrast preparation for abdominal CT scans has shown to reliably decrease length of stay by as much as two hours or more without compromising quality (Levenson, Hopkins, Hlibczuk, Anderson). Designing the ED for Optimal Imaging Services While previous ED designs typically centered on placing in-ED imaging services deep within the ED and clustered together newer designs are experimenting with decentralization of imaging services, placing each modality closest to its area of greatest demand. This said, as illustrated in Figure 2, extremely large EDs (annual census > 100,000 visits) may benefit from centrally locating in-ED imaging relative to all treatment stations by reducing travel distances for patients and staff.
Fall 2013 // Emergency Physicians International
fig. 3: X-ray Immediately Adjacent to Triage
Varying the location of the imaging modalities within the ED can have a significant impact on overall speed to imaging and length of stay for all but the largest EDs. One ED that moved its fixed x-ray unit from deep within the ED to be adjacent to triage noted a 25% reduction in length of stay for patients requiring x-ray studies (Horton). The logic of this design approach is that lower acuity, ambulatory patients tend to rely on the fixed x-ray unit, while higher-acuity patients tend to receive a higher number of portable x-rays in many EDs. Figure 2 demonstrates an ED design depicting a decentralized imaging model with x-ray located proximate to triage and lower acuity areas while CT is located closer to the trauma bays. Figure 1 shows an ED design with x-ray immediately adjacent to triage. This design solution creates a patient flow that, where clinically-acceptable, allows the triage team to identify and order the appropriate imaging study with the patient receiving the x-ray prior to being placed in a treatment station with a resulting decrease in travel distances for the patient and staff. Figure 4 illustrates an ED design with the in-ED CT scanner located immediately across the corridor from the major resuscitation stations, reducing travel distances for the most critically-ill patients receiving care in the ED. Portable imaging technologies have also been shown to add value and should be planned for appropriately. A 2010 Canadian study assessed the impact of a portable CT scanner in rural commuAll Images Š 2012 Cannon Design
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manpower in asia nity hospitals linked to larger referral center via a tele-stroke program resulted in increased ability to deliver thrombolytics to patients presenting with an acute ischemic stroke (Shuaib). When planning for portable imaging modalities, the primary concerns in ED design are proximity and size. First, storage space for the portable units should be in close proximity to the staff using the technology and the patients most frequently requiring the corresponding imaging study. Second, ED treatment stations should be designed large enough to accommodate entry of the portable imaging technology into the room with the ability to easily access the patient from at least three sides. Other important ED design considerations with respect to imaging focus on ensuring imaging staff have adequate workspace in proximity to where imaging services will be performed. Similarly, equipment necessary to process images should be immediately adjacent to where imaging studies will be performed to reduce overall staff travel distances and delays in study turnaround times. Equally important, locations where ED physicians and staff can view images should be readily available throughout the ED. This is most easily accomplished by ensuring adequate viewing monitors or, more recently, through the use of high-resolution portable tables with wireless connection to the imaging viewer. An important non-facility design consideration is how linking EDs across a community can help reduce overall utilization of imaging modalities,
REFERENCES Anderson B, Salem L, Flum D. A systematic review of whether oral contrast is necessary for the computed tomography diagnosis of appendicitis in adults. Am J Surg. 2005;190:474-478. Bailey JE, Pope RA, Elliott EC, Wan JY, Waters TM, Frisse ME. Health information exchange reduces repeated diagnostic imaging for back pain. Ann Emerg Med. 2013 Jul;62(1):16-24. Bamberg F, Marcus RP, Schlett CL, Schoepf UJ, Johnson TR, Nance JW Jr, Hoffmann U, Reiser MF, Nikolaou K. Imaging evaluation of acute chest pain: systematic review of evidence base and cost-effectiveness. J Thorac Imaging. 2012 Sep;27(5):289295. Goehler A, Ollendorf DA, Jaeger M, Ladapo J, Neumann T, Gazelle GS, Pearson SD. A simulation model of clinical and economic outcomes of cardiac CT triage of patients with acute chest pain in the emergency department. AJR Am J Roentgenol. 2011 Apr;196(4):853-61. Hlibczuk V, Dattaro JA, Jin X, et al. Diagnostic accuracy of noncontrast computed tomography for appendicitis in adults: a systematic review. Ann Emerg Med. 2010; 55:51-59. Hopkins CL, Madsen T, Foy Z, Reina M, Barton E.
particularly for patients being seen in multiple EDs or having multiple visits for the same complaint. One community developed a health information exchange that allowed all EDs to access the results of imaging studies performed at other EDs in the community. Access to previously-completed imaging studies resulted in a 64% decrease in repeat imaging studies for patients complaining of back pain (Bailey). Similarly, designing ED imaging services to support image import capabilities for patients being transferred to another ED for ongoing management has been shown to reduce reimaging (Bamberg, Sodickson). This would have the obvious benefit of reducing unnecessary radiation exposure and lowering the total cost of care. Figure 5 illustrates the design of a common imaging view room that can support both in-house and uploaded images. Summary Through careful planning, business case development and design, EDs can be developed to support best-in-class design features while enhancing the standard of care, improving overall efficiency and productivity of the ED, lowering length of stay and reducing the cost of care for multiple patient groups. Facilities planning new, renovated or expanded EDs are wise to carefully consider how diagnostic imaging will evolve and, based on this, what imaging should be considered for inclusion within the physical borders of the ED.
Does limiting oral contrast decrease emergency department length of stay? West J Emerg Med. 2012 Nov;13(5):383-7. Horton E. Personal interview. Apr. 2012. Larson DB, Johnson LW, Schnell BM, Goske MJ, Salisbury SR, Forman HP. Rising use of CT in child visits to the emergency department in the United States, 1995 – 2008. Radiology. 2011;259(3): 793-801. Levin DC, Rao VM, Parker L. The recent downturn in utilization of CT: the start of a new trend? J Am Coll Radiol. 2012 Nov;9(11):795-8. Levenson RB, Camacho MA, Horn E, Saghir A, McGillicuddy D, Sanchez LD. Eliminating routine oral contrast use for CT in the emergency department: impact on patient throughput and diagnosis. Emerg Radiol. 2012 Dec;19(6):513-7. Menoch MJ, Hirsh DA, Khan NS, Simon HK, Sturm JJ. Trends in computed tomography utilization in the pediatric emergency department. Pediatrics. 2012 Mar;129(3):e690-7.
(CONT’D FROM PAGE 27)
is very convenient to say that Hong Kong’s situation is unique and that we should not compare apples and oranges. However, independent scrutiny and advice may bring much-needed direction. Seven, we need more realistic and relevant methods of determining departmental staffing needs. Staff allocation is frequently determined based on number of patients registering annually in an emergency department. But with the changing and increasingly complex roles of emergency physicians, this is an outdated and simplistic concept which needs to be revisited. Should workload be redefined as the number of patient contacts rather than the number of patient attendances? For example, a patient waiting for admission for five days as a result of access block may need an additional five or more patient contacts, but at the moment they are simply counted as one registration. Finally, do systems from other worldclass settings need to be visited and learned from? Other cities less wealthy than Hong Kong provide better working conditions and emergency patient care than does Hong Kong. This needs to be acknowledged. What are these settings doing that we in Hong Kong are not doing? They have accountability, transparency, Smith-Bindman R, McCulloch CE, Ding A,make Quale tough C, benefitrates frontline staff andinpaChu PW. decisions Diagnostictoimaging for head injury the ED and states’ medical tients, and have malpractice a mediumtort to reforms. long-term Am J Emerg Med. 2011 Jul;29(6):656-64. strategy that transcends the lifespan of a Sodickson A, Opraseuth J, Ledbetter S. Outside single government. imaging in emergency department transfer Hong Kong is not a poor city.patients: Surely we CD importcan reduces rates of subsequent imaging do better. utilization. Radiology. 2011 Aug;260(2):408-13.
Worster A, Fernandes Rainer CM, Malcolmson C, Evain K, Professor has worked Simpson D. Identification of root causes for emerHong Kong for 17 years, and is curgency diagnostic imaging delays at three Canadian rently Director of the Accident and hospitals. J Emerg Nurs. 2006 Aug;32(4):276-80.
Emergency Medicine Academic Unit at the Chinese University of Hong Kong and Honorary Consultant at the Emergency Medicine Department at the Prince of Wales Hospital, Hong Kong.
Shuaib A, Khan K, Whittaker T, Amlani S, Crumley P. Introduction of portable computed tomography scanners, in the treatment of acute stroke patients via telemedicine in remote communities. Int J Stroke. 2010 Apr;5(2):62-6.
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Grand Rounds
PETER CAMERON, MD // PRESIDENT OF IFEM
What Makes a Good Emergency Doc? My ED is staffed by physicians of various nationalities and training backgrounds, raising the question: “How important is standardized emergency training?”
L
Living and working in the Middle East with a large number of doctors from very different backgrounds has made me think about what makes a good emergency doctor.
a strong tradition of international engagement, with the Royal Colleges having provided exams for international candidates for many years. More recently, the US organizations have started to explore this with both the ACGME (American Council of Graduate Medical Education) and the ABEM (American Board of Emergency Medicine) developing international arms. Countries such as Qatar, Singapore and United Arab Emirates have been exploring accreditation of training programs and exams using these bodies. The accreditation would be under an international arm of the national body. This accreditation will be expensive and beyond the financial capacity of many countries. Nevertheless there In my department, I have doctors with vastly different training, all of whom have are many benefits for countries developing their emergency systems in having specialist training in emergency medicine. The training programs vary in length, accreditation by an international body. intensity, exposure to clinical conditions and procedures, cultural grounding Accreditation by a credible international authority immediately gives status and supervision. Some of the doctors come from countries with well-established to the discipline at a political and community level. The status of the specialemergency systems while others trained in systems where emergency care is ist group amongst peers is also elevated. In addition, the accreditation process haphazard and poorly developed. There are doctors with only a few years of acts as a powerful tool to force health services to adequately experience post graduation from medical school and other resource training facilities and workforce. Hopefully the doctors who are literally “battle-hardened” from managing accrediting body can also assist with educational resources war injuries and fighting repressive regimes. As the chief of It will be interesting including standardized processes, benchmarking and sharservice, I’ve wondered if any particular group of doctors to see how ing of experience in developing training programs. In the obviously outperforms the others. platforms such future, it might be that graduates from programs that have The International Federation for Emergency Medicine as “EnlightenME” international accreditation are more likely to get jobs in has done a lot of work over the last few years establishing from the College of other countries and may avoid tortuous entry requireconsensus on both undergraduate and postgraduate trainEmergency Medicine ments. ing programs. These are now available on the IFEM webin the UK perform It is often asked why IFEM doesn’t undertake accredisite. The core curriculum content is very similar between when translated tation of training and run exams as well. In theory, this jurisdictions. Two further documents will be available between training is a good idea and could really provide an international soon – one on assessment and another on continuing proprograms. Will benchmark for comparison of training schemes. Additionfessional development, post specialist training. It is clear candidates perform ally, it could allow more free movement of EM physicians from these papers that there is wide variability around the equally well around between countries. Unfortunately the infrastructure reworld with most residency programs being between 3-7 the globe as they quired to do this well is enormous and the process would years post graduation from medical school. Standard rowork through on-line be very expensive. Unless time was volunteered and travel tations through critical care, paediatrics and so forth are material? was donated, the financial risk would be high for IFEM usually mandated. The shorter training programs – such as and ultimately may not be worthwhile. The reality is that those in the USA – have now realized that many aspects of the larger national organizations have processes and infraan emergency physician’s role need further training. So felstructure already in place that can be modified for international sites. It is therelowships have been introduced in many subspecialist areas such as critical care, fore easier for these organizations to trial these forms of accreditation and assessadministration, research, EMS etc. ment. That is not to say that IFEM will never become involved in accreditation During training, both formative in-service evaluations and summative exand assessment – but at this stage, it is beyond our current resources. aminations are undertaken. Log books for skills and procedures, courses such as So, back to my emergency department with a heterogenous group of docATLS, ACLS are also common. Importantly, there is little benchmarking of astors from varying backgrounds. There is no doubt that when I compare the skill sessments between jurisdictions. It will be interesting to see how platforms such levels, there is a bigger variation than in an emergency department in Australia, as “EnlightenME” from the College of Emergency Medicine in the UK (supwhere there is much greater standardization of training. However the biggest ported by IFEM), perform when translated between training programs. Will single determinate of competence and ability is attitude. Given that most doccandidates perform equally well around the globe as they work through on-line tors who complete medical school are intelligent and have some dedication to material? How much will we have to modify content and assessments to match their work, keen young doctors will find the answers to clinical problems in spite needs in each geographic area? of the specifics of their training program. For this to happen easily, there should Some national organizations are now offering international accreditation of be a culture of learning within the department and access to learning resources. training, which should further standardize educational experiences. The UK has
34 Fall July 2013 2012 //// Emergency Emergency Physicians Physicians International International
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The biggest single determinate of competence and ability is attitude. Given that most doctors who complete medical school are intelligent and have some dedication to their work, keen young doctors will find the answers to clinical problems in spite of the specifics of their training program. For this to happen easily, there should be a culture of learning within the department and access to learning resources.
The Morgan Lens for Emergency Ocular Irrigation Patient enters, eyes inflamed.
The Morgan Lens is inserted.
In less than 20 seconds irrigation is underway, and your hands are free to help elsewhere.
OnLy with the MOrgAn LenS:
Clearly the “seniors” within the ED are quite important in providing the right environment. There has to be time for reflective practice and to explore the best treatment options. Given that I have a large variation in training levels, is it better to send everyone back through a “standard residency” or “inculturate” through in-service experience and rectify specific gaps for individuals? The evidence would suggest that in the right environment, specialist doctors will develop to the same level of competence over about 10 years. So it would seem that the most logical approach in a department such as mine is to have a fairly rigorous performance appraisal and feedback system with access to a strong continuous professional development program to fill identified gaps in skills or knowledge. The downside of this for the individuals, is that there is no international recognition of this in-service training and it is only useful to the institution. The global migration of doctors is massive and there is little doubt that it will continue to increase. The conundrum that I face in my department is common in many places around the world. Fortunately I have considerable resources available to manage the situation. In many countries, there are similar issues but no resources. Electronic platforms will help to share skills, educational content and experience cheaply. I think IFEM can also help by expediting the sharing of processes and expertise across national boundaries. Peter Cameron is currently the President of the International Federation for Emergency Medicine and Chair of Emergency Medicine at Hamad Medical Corporation in Qatar.
• “Hands-free” ocular irrigation – frees staff • Effectively removes chemicals or non-embedded foreign bodies • 100% of solution treats the eye – no pooling • Eliminates blinking reflex • Patient may be transported without stopping irrigation • Patient rests comfortably with eyes closed Fast, comfortable, and effective— there’s a reason 95% of the hospitals in the USA use the Morgan Lens.
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Fall 2013 // Emergency Physicians International
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