The efficacy and value of emergency medicine: a supportive literature review

The status of emergency medicine in the state of Kuwait

BACKGROUND AND OBJECTIVE OF THE REVIEW

There is limited literature on the emergency medicine (EM) specialty in Kuwait, and this paper evaluated the development status of the specialty under Arnold's classification.

DISCUSSION

In Kuwait, the EM specialty is recognized with an existing professional society and structured residency training program with post post-board-certification exam. The emergency departments are directed by board-certified emergency physicians with existing emergency medical services and transfer systems. However, there is still a huge demand for trained emergency physicians and a further need to advance the existing trauma system. The academic EM in the country needs further progress in research and developing a specialty journal, databases, and subspecialty training. The management systems within the emergency departments are well developed.

CONCLUSION

The EM status is its way to reaching maturity if we overcome a few deficits and challenges in the system. Lastly, two great achievements were made through the establishment of 'the Kuwait Poison Control Center' and the simulation training in EM.

Key factors for sustainable working conditions in emergency departments: an EUSEM-initiated, Europe-wide consensus survey

BACKGROUND AND IMPORTANCE

Modern emergency medicine (EM) is a complex, demanding, and occasionally stressful field of work. Working conditions, provider well-being, and associated health and performance outcomes are key factors influencing the establishment of a sustainable emergency department (ED) working environment.

OBJECTIVES

This multinational European Delphi survey aimed to identify unequivocal major factors for good and poor ED working conditions and their possible effects on health care provider well-being.

DESIGN/SETTING AND PARTICIPANTS

A total of 18 experts from six European countries (Belgium, Finland, Germany, Italy, Romania, and the UK) covering three different hospital sizes (small, medium, and large) in their respective countries participated in the two-round Delphi survey. All panelists held leadership roles in EM.

OUTCOME MEASURES AND ANALYSIS

The first step involved conducting an extensive literature search on ED working conditions. The second step involved the first Delphi round, which consisted of structured interviews with the panelists. The survey was designed to obtain information concerning important working conditions, comments regarding work-life factors identified from the literature, and ratings of their importance. Interviews were transcribed and analyzed following a standardized protocol. In the second Delphi round, experts rated the relevance of items consolidated from the first Delphi round (classified into ED work system factors, provider health outcomes, and ED work-life intervention approaches).

RESULTS

A nearly unequivocal consensus was obtained in four ED work condition categories, including positive (e.g. job challenges, personal motivation, and case complexities) and negative (e.g. overcrowding, workflow interruptions/multitasking, medical errors) ED work conditions. The highly relevant adverse personal health events identified included physical fatigue, exhaustion, and burnout. Concerning intervention practices, the panelists offered a wide spectrum of opportunities with less consensus.

CONCLUSION

Work system conditions exert positive and negative effects on the work life of ED providers across Europe. Although most European countries have varying health care systems, the expert-based survey results presented herein strongly suggest that improvement strategies should focus on system-related external stressors common in various countries. Our findings lay the scientific groundwork for future intervention studies at the local and systemic levels to improve ED provider work life.

Establishing a 'Virtual' model of emergency care in Melbourne's southeast

Digital technologies, specifically those required to facilitate telehealth via an audiovisual medium, are now at a standard that allows them to reliably assess patients with acute complaints within their homes. The coronavirus disease 2019 (COVID-19) pandemic forced innovation and led to an increased acceptance of telehealth from both clinicians and patients and presented an opportunity to incorporate telehealth into emergency medicine practice. With inpatient capacity strain exacerbated by the pandemic, three hospital networks within Melbourne's geographical southeast collaborated with Ambulance Victoria (AV) to set up a virtual emergency department (VED) service in January 2022. This service aimed to allow certain patients to receive care in the more convenient setting of their homes. Referrals were made directly by AV personnel at the home while they were attending to these patients. Consultation with a VED clinician was initiated through a secure audiovisual platform, 'Healthdirect'. Following this consultation, care could be facilitated at home through the VED clinician providing advice regarding treatment that paramedics could administer or through linkage into one of the various outreach services provided by the organisations. The VED represents part of the initial integration of telehealth into our organisations. We hope our initial framework might be built upon through greater integration with community services and incorporating more digital technologies. The ongoing graded expansion of telehealth services within our organisations will likely see more and more patients managed in their own homes.

Practice Patterns and Management Protocols in Trauma across Indian Settings: A Nationwide Cross-sectional Survey

Background

Trauma is the leading cause of death in India resulting in a significant public health burden. Indian Society of Critical Care Medicine (ISCCM) has established a trauma network committee to understand current practices and identify the gaps and challenges in trauma management in Indian settings.

Material and methods

An online survey-based, cross-sectional, descriptive study was conducted with high-priority research questions based on hospital profile, resource availability, and trauma management protocols.

Results

Data from 483 centers were analyzed. A significant difference was observed in infrastructure, resource utilization, and management protocols in different types of hospitals and between small and big size hospitals across different tier cities in India (p < 0.05). The advanced trauma life support (ATLS)-trained emergency room (ER) physician had a significant impact on infrastructure organization and trauma management protocols (p < 0.05). On multivariate analysis, the highest impact of ATLS-trained ER physicians was on the use of extended focused assessment with sonography in trauma (eFAST) (2.909 times), followed by hospital trauma code (2.778 times), dedicated trauma team (1.952 times), and following trauma scores (1.651 times).

Conclusion

We found that majority of the centers are well equipped with optimal infrastructure, ATLS-trained physician, and management protocols. Still many aspects of trauma management need to be prioritized. There should be proactive involvement at an organizational level to manage trauma patients with a multidisciplinary approach. This survey gives us a deep insight into the current scenario of trauma care and can guide to strengthen across the country.

How to cite this article

Sodhi K, Khasne RW, Chanchalani G, Jagathkar G, Kola VR, Mishra M et al. Practice Patterns and Management Protocols in Trauma across Indian Settings: A Nationwide Cross-sectional Survey. Indian J Crit Care Med 2023;27(1):38-51.

Experiences of Transgender Participants in Emergency Departments: Findings from the OutLook Study

Purpose: Even in cases of medical emergency, mistreatment and negative experiences in life or in medical settings can deter trans patients from seeking necessary care. The purpose of this study was to identify factors associated with trans persons' emergency department (ED) avoidance in the mixed urban-rural Region of Waterloo, Ontario, Canada. Methods: The OutLook Study was a community-based partnership that created an online, cross-sectional questionnaire for lesbian, gay, bisexual, transgender, and other sexual and gender minority community members. Participants in this analysis were 16 years of age or older, lived, worked, or attended school in Waterloo Region, and identified as trans (n=112). Binary logistic regression was used to test associations between sociodemographic, resilience, and risk variables, and ED avoidance. Sociodemographic variables statistically significant at p<0.05 at the bivariate level were included as controls to explore different combinations of resilience and risk factor in multivariable models. Results: Participants reporting complete or partially complete medical transitions were more likely to report ED avoidance, compared to those who had not initiated medical transition. Elevated transphobia was associated with greater likelihood of avoidance. However, increasing levels of social support decreased the likelihood of avoidance. In multivariable models, social support, support from a special person, and transphobia were always significant, regardless of controlled variables. Conclusion: Transphobia-enacted in the contexts of everyday life and health care-can deter patients from seeking care. Patient-centered care requires careful attention to trans identity and health needs, especially in emergency settings. In the absence of structural changes, providers can take steps to mitigate the erasure and discrimination trans patients experience and anticipate when accessing EDs.

Emergency medicine as a career: Knowledge, attitudes and predictors in Nigerian medical students

INTRODUCTION

Despite the high burden of deaths from emergency conditions in Nigeria, there are no formal emergency medicine (EM) residency programs in the country. Due to the absence of training programs in the country, we hypothesised that there may be a lack of awareness of these benefits of specialised emergency care among medical students and also a lack of interest in it. In this study, we assessed the knowledge and attitude of Nigerian medical students towards EM specialty and their willingness to undergo EM training.

METHODS

Online surveys were shared among medical students in six selected medical schools, one in each of the six geo-political zones in Nigeria. The surveys were designed to assess the knowledge of, attitude towards, and interest in EM residency programs. A total of 439 responses were received and analysed using Epi Info 7 analytical software.

RESULTS

Among the 439 respondents, the average knowledge score was 27.5%. Thirty-three percent (CI 28%-37%) of all the respondents had good knowledge about the availability of and opportunities in EM. Good knowledge was determined by a score of >50% on the knowledge portion of the survey, 97%% (CI 96%-99%) of the respondents felt that EM training program should be established in Nigeria and 20.5% % (CI 17%-25%) of the respondents were interested in pursuing EM as a specialty of choice.

CONCLUSION

Our research showed that there is a low level of knowledge about EM residency training programs among Nigerian medical students. This is likely secondary to the current absence of these programs in Nigeria. Almost all of the respondents felt that an EM training program should be established and a substantial number of medical students indicated an interest in pursuing the specialty.

Emergency physicians' role in telemedicine care during the coronavirus disease pandemic: Experiences from Taiwan

Taiwan's response to the coronavirus disease pandemic received international recognition. Among various epidemic control measures, telemedicine services are provided for people under home quarantine. Although this service presents no policy, cost or equipment problems, the medical needs of people under home quarantine are diverse. Further, there are no clear guidelines regarding which specialists should be included in a multidisciplinary team. Moreover, many physicians are unwilling to participate in telemedicine, creating a big challenge for hospitals providing these services. Emergency physicians (EPs) have unique experiences in crisis management and can provide a number of effective public health measures. We advocate that EPs should be the first specialists to contact patients in a multidisciplinary team. Currently, there is a lack of literature on this subject, and Taiwan's epidemic control experience is used as an example to prove our viewpoint and provide recommendations for future EPs.

The views and experiences of Zambia's emergency medicine registrars in South Africa: Lessons for the development of emergency care in Zambia

Introduction

Although low- and middle-income countries (LMICs) are beginning to integrate emergency medicine (EM) specialist physicians into their healthcare systems, they must often send these trainees to other countries with established registrar programmes. Given that retention of foreign-trained EM specialist physicians is low following repatriation, there is interest in understanding their expectations and intentions when they return. This study aimed to describe the expectations of Zambia's EM registrars regarding the development of various aspects of emergency care in Zambia.

Methods

In this qualitative, descriptive study, individual telephonic interviews were conducted with current Zambian EM registrars using a semi-structured interview schedule. Recorded interviews were transcribed verbatim, validated by participants, and subjected to inductive content analysis.

Results

Four interviews were completed, representing the entire population of interest. Two key categories emerged from these discussions: that the state of emergency care in Zambia was inadequate, and that there were numerous priority areas for further developing the emergency care system. A lack of recognition of EM as a specialty, resource and training constraints in emergency units, and the lack of a formal prehospital emergency care system were prominently identified as challenges. Priority aspects that registrars hoped to focus on when developing emergency care included expanding local training and knowledge, improving the supply chain for essential medications and equipment, increasing interprofessional collaborative practice, and advocating for emergency care.

Conclusion

Zambian EM registrars characterised the nascent emergency care system by challenges that are common in many LMICs and align with previous in-country assessments of emergency care. In order to ensure that registrars' strategies are ultimately implemented upon their return to Zambia, it is imperative they are communicated with stakeholders in-country. From there, mutual planning can occur between future EM specialists and government stakeholders, to ensure that there are mechanisms in place to facilitate dissemination.

Critical emergency medicine and the resuscitative care unit

Critical emergency medicine is the medical field concerned with management of critically ill patients in the emergency department (ED). Increased ED stay due to intensive care unit (ICU) overcrowding has a negative impact on patient care and outcome. It has been proposed that implementation of critical care services in the ED can negate this effect. Two main Critical Emergency Medicine models have been proposed, the "resource intensivist" and "ED-ICU" models. The resource intensivist model is based on constant presence of an intensivist in the traditional ED setting, while the ED-ICU model encompasses the notion of a separate ED-based unit, with monitoring and therapeutic capabilities similar to those of an ICU. Critical emergency medicine has the potential to improve patient care and outcome; however, establishment of evidence-based protocols and a multidisciplinary approach in patient management are of major importance.

Emergency medicine - A great career field for the anaesthesiologist!

Emergency Medicine (EM) is a fast upcoming medical speciality wherein patients presenting with emergent life-saving medical and surgical problems are managed. Emergency physicians are first-line providers of emergency care. They diagnose important clinical conditions even before completing patient assessment, order investigations, interventions, resuscitation and treatment for life-threatening acute conditions. There are several interesting sub-specialisations of EM like trauma care, disaster medicine, toxicology, ultrasonography, critical care medicine, hyperbaric medicine, etc. In some countries, the speciality of EM is a popular choice among medical students; whereas in some other countries, the speciality is now evolving. In India, the speciality is growing fast; Nonetheless, the National Medical Commission has made the existence of the department of EM compulsory in all medical colleges in India from the session of 2022-23. Anaesthesiologists suit the speciality of EM because they have quick decision making skills and swift reflexes as well as diverse knowledge and skills in the fields of critical care, resuscitation and pain management. This article written by anaesthesiologists working in the field of EM, attempts to guide the postgraduate students wanting to take up a career in EM.

Who provides what care? An analysis of clinical focus among the national emergency care workforce

OBJECTIVE

Clinician expertise has been associated with improved patient outcomes, yet ED clinicians often work in various clinical settings beyond the ED and, therefore, may risk expertise by having less clinical focus. We sought to describe clinical focus among the emergency care workforce nationally.

METHODS

Using the 2017 Medicare Public Use Files (PUF), we performed a cross-sectional analysis of clinicians receiving reimbursement for emergency care Evaluation & Management (E/M) services from Medicare fee-for-service Part B. Clinicians were categorized by type as EM physicians, non-EM physicians, and advanced practice providers (APPs). The primary outcome was the clinical focus of the individual clinician, defined as the proportion of E/M services within the ED setting relative to a clinician's total E/M services across all practice settings.

RESULTS

Of 65,710 unique clinicians providing care to Medicare fee-for-service beneficiaries in the ED setting, 39,016 (59.4%) were classified as EM physicians, 8123 (12.4%) as non-EM physicians, and 18,571 (28.5%) as APPs. The individual clinician median focus was 92.8% (interquartile range [IQR]: 87.0, 100.0) for EM physicians, 45.2% (IQR: 5.1, 97.0) for non-EM physicians, and 100.0% (IQR: 96.3, 100.0) for APPs.

CONCLUSION

EM physicians have twice as much clinical focus in comparison to non-EM physicians providing emergency care to Medicare fee-for-service beneficiaries. These findings underscore the importance of diverse training and certification programs to ensure access to clinically focused ED clinicians.

Collaboration with non-emergency care specialists and other emergency care providers: A research primer for low- and middle-income countries

As emergency and acute care systems develop, the ability to broadly engage key stakeholders becomes paramount for success. Collaborating with emergency medicine clinicians as well as other providers who have already developed their specialties, administrative leadership, as well as networking locally and regionally would maximise the success of developing a sustainable emergency care system.

Emergency medicine in Norway: The road to specialty recognition

Emergency medicine (EM) in most of Europe is a much newer specialty than in the United States. Until recently, emergency departments (EDs) in Norway were staffed with unsupervised interns, leading to a government report in 2008 that called for change. From the establishment of the Norwegian Society for Emergency Medicine in 2010 to the creation of the specialty in 2017 and the approval of the first emergency physician in Norway in 2019, our review article describes how a small group of physicians were able to work with politicians and the media to get an emergency medicine specialty approved despite resistance from a much larger group of existing specialists. Norway faced many of the same obstacles as the United States did with implementing the specialty 60 years ago. This article serves as a review of the conflict that may ensue when enacting a change in public policy and a resource to those countries that have yet to implement an emergency medicine specialty.

Status, role, and performance of emergency medicine specialists in Iran: A qualitative study

INTRODUCTION

The performance of the emergency department (ED) as one of the main parts of hospitals, have a great impact on the performance of the whole-hospital. In Iran, the official education program of this discipline was started in 2001 and has expanded in most medical universities. Given the unprecedentedness of emergency medicine (EM), there are limited studies about this specialty. Thus, this study aims to explore the status, role, and performance of Iranian EM specialists.

MATERIALS AND METHODS

This qualitative study was conducted using content analysis of 19 semi-structured interviews with EM specialists and key informant. Purposive sampling was conducted, and some teaching and nonstate hospitals in different geographic regions of Tehran city were selected. Conducting interviews continued until reaching the data saturation. Thematic analysis was employed. Extracted themes were reviewed and confirmed by some of the participants.

RESULTS

The study results were categorized within five main themes; included the role of ED from EM specialists' viewpoint, EM specialists' viewpoint on their discipline, performance of EM specialists (including medical, managerial, and economic performance), and role of EM specialists in patient satisfaction; and opportunities and challenges of EM specialists.

CONCLUSION

Overall, the study findings highlighted the effectiveness and positive medical, managerial and economic impacts of EM in Iran, inside and beyond hospitals. However, the study addressed significant opportunities some solvable challenges in educational, professional and economic domains, and interdisciplinary relationships. Further studies are recommended for comprehensive exploring viewpoint of other disciplines and stakeholders.

Snapshot of emergency departments in Jakarta, Indonesia

OBJECTIVE

EDs in Indonesia face an unprecedented increase in patient influx after the expansion of national health insurance system coverage. The present study aims to describe EDs' characteristics and capabilities utilisation in Jakarta.

METHODS

An ED inventory was created from the Jakarta Provincial Health Office and the Indonesian Hospital Association registries. The EDs that were accessible to the general public 24/7 were surveyed about their characteristics during the calendar year 2017. For further ED analysis, we stratified the hospitals into four types (A, B, C and D) based on their size and capabilities, with type A being the largest.

RESULTS

From the 118 (81%) out of 146 EDs that responded, there were 2 million ED visits or 202 per 1000 people. The median annual visit volume was 11 200 (interquartile range 4233-18 000). Further stratification highlights the annual visit difference among hospital types where type A hospitals reported the most with 32 000 (interquartile range 13 459-38 873). Almost half of the EDs (47%) answered that ≥60% of the inpatient census came from the ED. Less than half of the EDs (44%) can manage psychiatry, oral-maxillofacial and plastic surgery cases. Consultant coverage varied across hospitals and by hospital type (P < 0.05), except for general surgery and obstetrics and gynaecology consultants who were available in most hospitals (74%).

CONCLUSION

Physicians with limited experience and EDs with heterogeneous emergency care capabilities likely threatened the consistency of quality emergency care, particularly for time-sensitive conditions. Our study provides a benchmark for future improvements in emergency care.

Postgraduate Diploma in Emergency Medicine in India

BACKGROUND

In India, and other low- and middle-income countries (LMICs), the majority of emergency care is provided by frontline providers without specialty training in emergency medicine. In order to fill this need, we developed the Indian Postgraduate Diploma in Emergency Medicine (PGDEM), a 1-year skills-focused course for practicing doctors. This article describes the curriculum development and implementation as well as the follow-up survey conducted to gauge the impact of the course.

METHODS

Programme graduates were surveyed via e-mail. All participation was voluntary and survey data remained anonymous.

RESULTS

A total of 98.1% of graduates reported that the skills and knowledge they gained during the programme were important to their current job; 94.7% reported using their training from the course on a regular basis. Graduates reported an improvement in confidence performing all procedures taught during the course. Respondents work in a variety of medical specialties, including emergency medicine (50.0%), cardiology (5.8%), internal medicine (11.5%) and family medicine (23.1%).

DISCUSSION

PGDEM graduates overwhelmingly view the knowledge and skills they learned as essential training that they use on a regular basis and practice in a variety of medical specialties after completing the course. The PGDEM represents a unique model to provide training in emergency medicine and acute care to the frontline doctors who are frequently responsible for providing emergency care in LMICs. The PGDEM training model can be scaled up rapidly, with the potential to increase capacity in developing emergency care systems.

Impact of emergency medicine training implementation on mortality outcomes in Kigali, Rwanda: An interrupted time-series study

INTRODUCTION

Although emergency medicine (EM) training programmes have begun to be introduced in low- and middle-income countries (LMICs), minimal data exist on their effects on patient-centered outcomes in such settings. This study evaluated the impact of EM training and associated systems implementation on mortality among patients treated at the University Teaching Hospital-Kigali (UTH-K).

METHODS

At UTH-K an EM post-graduate diploma programme was initiated in October 2013, followed by a residency-training programme in August 2015. Prior to October 2013, care was provided exclusively by general practice physicians (GPs); subsequently, care has been provided through mutually exclusive shifts allocated between GPs and EM trainees. Patients seeking Emergency Centre (EC) care during November 2012-October 2013 (pre-training) and August 2015-July 2016 (post-training) were eligible for inclusion. Data were abstracted from a random sample of records using a structured protocol. The primary outcomes were EC and overall hospital mortality. Mortality prevalence and risk differences (RD) were compared pre- and post-training. Magnitudes of effects were quantified using regression models to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

From 43,213 encounters, 3609 cases were assessed. The median age was 32 years with a male predominance (60.7%). Pre-training EC mortality was 6.3% (95% CI 5.3-7.5%), while post-training EC mortality was 1.2% (95% CI 0.7-1.8%), constituting a significant decrease in adjusted analysis (aOR = 0.07, 95% CI 0.03-0.17; p < 0.001). Pre-training overall hospital mortality was 12.2% (95% CI 10.9-13.8%). Post-training overall hospital mortality was 8.2% (95% CI 6.9-9.6%), resulting in a 43% reduction in mortality likelihood (aOR = 0.57, 95% CI 0.36-0.94; p = 0.016).

DISCUSSION

In the studied population, EM training and systems implementation was associated with significant mortality reductions demonstrating the potential patient-centered benefits of EM development in resource-limited settings.

Trend analysis of emergency department malpractice claims in the Netherlands: a retrospective cohort analysis

BACKGROUND

Over the past two decades, several quality improvement projects have been implemented in emergency departments (EDs) in the Netherlands, one of these being the training and deployment of emergency physicians. In this study we aim to perform a trend analysis of ED quality of care in Dutch hospitals, as measured by the incidence of medical malpractice claims.

PATIENTS AND METHODS

We performed a multicentre retrospective cohort study of malpractice claims in five Dutch EDs over the period 1998-2014. Incidence risk ratios were calculated to demonstrate any relation of specific quality improvement initiatives with the primary outcome, defined as the number of claims per 10 000 ED visits per year.

RESULTS

During the study period, the cumulative number of ED visits increased significantly from 99 145 in 1998 to 162 490 in 2014 (P < 0.01). In total, 228 of 2 348 417 ED visits (0.97 per 10 000) resulted in a malpractice claim. At the same time, the yearly number of ED claims filed decreased with 0.07 (0.03-0.10) per 10 000 each year. The claim rate was higher in the period before emergency physicians were employed in the ED [1.18 (0.98-1.41) claims per 10 000 visits] compared with the period after they were employed [0.81 (0.67-0.97), incidence risk ratio 0.69 (0.53-0.89), P < 0.01].

CONCLUSION

Even though the number of ED visits increased significantly over the past two decades, the number of malpractice claims filed after an ED visit decreased. Various quality improvement initiatives, including the training and employment of emergency physicians, may have contributed to the observed decrease in claims.

Emergency Medicine in the Kingdom of Bahrain

It has been more than a decade since emergency medicine became recognized as a specialty in the Kingdom of Bahrain. In the last fifteen years emergency medicine has widely established itself and developed rapidly in the Kingdom. The three main emergency departments are: Salmanyia Medical Complex (SMC), Royal Medical Services of Bahrain Defence Force (RMS-BDF) and King Hamad University Hospital (KHUH) are now fully equipped and operated by a majority of board certified emergency physicians.

Standardized protocols, and the Central National Ambulance will be established in the near future, and the ambulances will offer both basic and advanced life support by trained nurses and paramedics.

Emergency Medicine residency training programs were established in the main three hospitals in Bahrain for the Arab Board Certification initially, while currently only two hospitals, BDF hospital and KHUH are recognized as training centers for the Saudi Board Residency Program.

This article will focus on many aspects related to emergency medicine in the Kingdom of Bahrain including: history of health care systems in Bahrain, hospitals and primary care, disaster management, Emergency medical services (EMS), hospital-based emergency care, training in emergency medicine and universities. We aim to present Bahrain’s past and existing emergency medicine experience, our perspective about the existing challenges faced by the specialty, and the future plans for the advancement of emergency medicine in the Kingdom.

Dedication increases productivity: an analysis of the implementation of a dedicated medical team in the emergency department

Background

In several European countries, emergency departments (EDs) now employ a dedicated team of full-time emergency medicine (EM) physicians, with a distinct leadership and bed-side emergency training, in all similar to other hospital departments. In Portugal, however, there are still two very different models for staffing EDs: a classic model, where EDs are mostly staffed with young inexperienced physicians from different medical departments who take turns in the ED in 12-h shifts and a dedicated model, recently implemented in some hospitals, where the ED is staffed by a team of doctors with specific medical competencies in emergency medicine that work full-time in the ED.

Our study assesses the effect of an intervention in a large academic hospital ED in Portugal in 2002, and it is the first to test the hypothesis that implementing a dedicated team of doctors with EM expertise increases the productivity and reduces costs in the ED, maintaining the quality of care provided to patients.

Methods

A pre–post design was used for comparing the change on the organisational model of delivering care in our medical ED. All emergency medical admissions were tracked in 2002 (classic model with 12-h shift in the ED) and 2005/2006 (dedicated team with full-time EM physicians), and productivity, costs with medical human resources and quality of care measures were compared.

Results

We found that medical productivity (number of patients treated per hour of medical work) increased dramatically after the creation of the dedicated team (X²_KW = 31.135; N = 36; p < 0.001) and costs with ED medical work reduced both in regular hours and overtime. Moreover, hospitalisation rates decreased and the length of stay in the ED increased significantly after the creation of the dedicated team.

Conclusions

Implementing a dedicated team of doctors increased the medical productivity and reduced costs in our ED. Our findings have straightforward implication for Portuguese policymakers aiming at reducing hospital costs while coping with increased ED demand.

Studying the Variability in Patient Inflow and Staffing Trends on Sundays versus Other Days in the Academic Emergency Department

Background:

Resource limitation, staff deficiency, and variability in patient inflow contribute to emergency department (ED) overcrowding, associated with delayed care, poor care, and poor patient outcomes. This study seeks to describe and analyze patient inflow variability and staffing trends on Sundays versus other days in a tertiary academic ED from South India.

Methods:

Patient inflow and staffing data for 2 years were collected from hospital records, cross-checked, and statistically analyzed using Epi Info 7.0.

Results:

Significant increase in patient inflow (45.6%) was noted on Sundays compared to other days (155.9 [95% confidence interval (CI): 152.75–159.05] vs. 107.1 [95% CI: 105.98–108.22]; P < 0.001), with higher inflow in the morning shifts (67.4 [95% CI: 65.41–69.45] vs. 32.1 [95% CI: 31.45–32.70]; P < 0.001). All categories of ED staff were deficient across all shifts (2.1 [95% CI: 2.05–2.15] tier-2 physicians, 4.9 [95% CI: 4.86–4.94] nurses, and 1.9 [95% CI: 1.88–1.92] nurse assistants on an average), especially tier-1 physicians (0.3 [95% CI: 0.24–0.36] on Sundays and 0.5 [95% CI: 0.48–0.52] on other days; P < 0.001). Patient-per-hour (PPH)-per-provider based on patient arrival rate was generally high. PPH per tier-1 physician was the highest, being 10.6 (95% CI: 9.95–11.14) versus 5.4 (95% CI: 5.26–5.59; P < 0.001) in the morning and 7.2 (95% CI: 6.95–7.45) versus 6.6 (95% CI: 6.43–6.74; P = 0.08) in the evening shifts on Sundays and other days, respectively.

Conclusions:

There were deficiencies in all categories of ED staff on all days, and this was pronounced on Sundays due to significantly higher patient inflow. Inadequate ED staffing, especially due to a significant dearth of tier-1 physicians is a pointer toward quality compromise in developing EDs. Authors recommend adequate staff deployment in developing EDs for optimum quality care. This should be implemented such that staffing is based on expected patient inflow so that a PPH-per-provider goal of 2.5 is targeted across all shifts.

Selection of quality indicators for hospital-based emergency care in Denmark, informed by a modified-Delphi process

Background

In 2013, Danish policy-makers on a nationwide level decided to set up a national quality of care database for hospital-based emergency care in Denmark including the selection of quality indicators. The aim of the study was to describe the Delphi process that contributed to the selection of quality indicators for a new national database of hospital-based emergency care in Denmark.

Methods

The process comprised a literature review followed by a modified-Delphi survey process, involving a panel of 54 experts (senior clinicians, researchers and administrators from the emergency area and collaborating specialties). Based on the literature review, we identified 43 potential indicators, of which eight were time-critical conditions. We then consulted the Expert panel in two consecutive rounds. The Expert panel was asked to what extent each indicator would be a good measure of hospital-based emergency care in Denmark. In each round, the Expert panel participants scored each indicator on a Likert scale ranging from one (=disagree completely) through to six (=agree completely). Consensus for a quality indicator was reached if the median was greater than or equal to five (=agree). The Delphi process was followed by final selection by the steering group for the new database.

Results

Following round two of the Expert panel, consensus was reached on 32 quality indicators, including three time-critical conditions. Subsequently, the database steering group chose a set of nine quality indicators for the initial version of the national database for hospital-based emergency care.

Conclusions

The two-round modified Delphi process contributed to the selection of an initial set of nine quality indicators for a new a national database for hospital-based emergency care in Denmark. Final selection was made by the database steering group informed by the Delphi process.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-016-0203-x) contains supplementary material, which is available to authorized users.

Emergency medicine as a specialty in Asia

Aim

We aim to examine the similarities and differences in areas of EM development, workload, workforce, and capabilities and support in the Asia region. Emerging challenges faced by our EM community are also discussed.

Methods

The National Societies for Emergency Medicine of Hong Kong, India, Japan, Malaysia, Philippines, Singapore, South Korea, Taiwan, Thailand and Turkey participated in the joint Japanese Association of Acute Medicine (JAAM) and Asian Conference of Emergency Medicine (ACEM) Special Symposium held in October 2013 at Tokyo, Japan. The findings are reviewed in this paper.

Results

Emergency medicine (EM) has over the years evolved into a distinct and recognized medical discipline requiring a unique set of cognitive, administrative and technical skills for managing all types of patients with acute illness or injury. EM has contributed to healthcare by providing effective, safe, efficient and cost-effective patient care. Integrated systems have developed to allow continuity of emergency care from the community into emergency departments. Structured training curriculum for undergraduates, and specialty training programs for postgraduates are in place to equip trainees with the knowledge and skills required for the unique practice of EM.

Conclusion

The practice of EM still varies among the Asian countries. However, as a region, we strive to continue in our efforts to develop the specialty and improve the delivery of EM.

Postgraduate Emergency Medicine Training in India: An Educational Partnership with the Private Sector

BACKGROUND

Emergency medicine (EM) is a recently recognized specialty in India, still in its infancy. Local training programs are developing, but remain very limited. Private, for-profit hospitals are an important provider of graduate medical education (GME) in India, and are partnering with United States (US) universities in EM to expand training opportunities.

OBJECTIVE

Our aim was to describe current private-sector programs affiliated with a US university providing postgraduate EM training in India, the evolution and structure of these programs, and successes and challenges of program implementation.

DISCUSSION

Programs have been established in seven cities in India in partnership with a US academic institution. Full-time trainees have required didactics, clinical rotations, research, and annual examinations. Faculty members affiliated with the US institution visit each program monthly. Regular evaluations have informed program modifications, and a local faculty development program has been implemented. Currently, 240 trainees are enrolled in the EM postgraduate program, and 141 physicians have graduated. A pilot survey conducted in 2012 revealed that 93% of graduates are currently practicing EM, 82% of those in India; 71% are involved in teaching, and 32% in research. Further investigation into programmatic impacts is necessary. Challenges include issues of formal program recognition both in India and abroad.

CONCLUSIONS

This unique partnership is playing a major early role in EM GME in India. Future steps include official program recognition, expanded numbers of training sites, and a gradual transition of training and education to local faculty. Similar partnership programs may be effective in other settings outside of India.

Improvement of clinical quality indicators through reorganization of the acute care by establishing an emergency department-a register study based on data from national indicators

Background

The Emergency Departments (EDs) reorganization process in Denmark began in 2007 and includes creating a single entrance for all emergency patients, establishing triage, having a specialist in the front and introducing the use of electronic overview boards and electronic patient files. The aim of this study was to investigate the quality of acute care in a re-organized ED based on national indicator project data in a pre and post reorganizational setting.

Methods

Quasi experimental design was used to examine the effect of the health care quality in relation to the reorganization of an ED. Patients admitted at Nykøbing Falster Hospital in 2008 or 2012 were included in the study and data reports from the national databases (RKKP) regarding stroke, COPD, heart failure, bleeding and perforated ulcer or hip fracture were analysed. Holbæk Hospital works as a control hospital.

Chi-square test was used for analysing significant differences from pre-and post intervention and Z-test to compare the experimental groups to the control group (HOL). P < 0.05 was considered statistically significant.

Results

We assessed 4584 patient cases from RKKP. A significant positive change was seen in all of the additional eight indicators related to stroke at NFS (P < 0.001); however, COPD indicators were unchanged in both hospitals. In NFS two of eight heart failure indicators were significantly improved after the reorganization (p < 0.01). In patients admitted with a bleeding ulcer 2 of 5 indicators were significantly improved after the reorganization in NFS and HOL (p < 0.01). Both compared hospitals showed significant improvements in the two indicators concerning hip fracture (p < 0.001). Significant reductions in the 30 day-mortality in patients admitted with stroke were seen when the pre- and the post-intervention data were compared for both NFS and HOL (p = 0.024).

Conclusions

During the organisation of the new EDs, several of the indicators improved and the overall 30 days mortality decreased in the five diseases. The development of a common set of indicators for monitoring acute treatment at EDs in Denmark is recommended.

Development of an emergency nursing training curriculum in Ghana

The formal provision of emergency health care is a developing specialty in many sub-Saharan African countries, including Ghana. While emergency medicine training programs for physicians are on the rise, there are few established training programs for emergency nurses. The results of a unique collaboration are described between a university in the United States, a Ghanaian university and a Ghanaian teaching hospital that has developed an emergency nursing diploma program. The expected outcomes of this training program include: (a) an innovative, interdisciplinary, team-based clinical training model, (b) a unique and low-resource emergency nursing curriculum and (c) a comprehensive and sustainable training program to increase in-country retention of nurses.

Emergency care and health systems: consensus-based recommendations and future research priorities

The theme of the 14th annual Academic Emergency Medicine consensus conference was "Global Health and Emergency Care: A Research Agenda." The goal of the conference was to create a robust and measurable research agenda for evaluating emergency health care delivery systems. The concept of health systems includes the organizations, institutions, and resources whose primary purpose is to promote, restore, and/or maintain health. This article further conceptualizes the vertical and horizontal delivery of acute and emergency care in low-resource settings by defining specific terminology for emergency care platforms and discussing how they fit into broader health systems models. This was accomplished through discussion surrounding four principal questions touching upon the interplay between health systems and acute and emergency care. This research agenda is intended to assist countries that are in the early stages of integrating emergency services into their health systems and are looking for guidance to maximize their development and health systems planning efforts.

State of Emergency Medicine in Switzerland: a national profile of emergency departments in 2006

Background

Emergency departments (EDs) are an essential component of any developed health care system. There is, however, no national description of EDs in Switzerland. Our objective was to establish the number and location of EDs, patient visits and flow, medical staff and organization, and capabilities in 2006, as a benchmark before emergency medicine became a subspecialty in Switzerland.

Methods

In 2007, we started to create an inventory of all hospital-based EDs with a preliminary list from the Swiss Society of Emergency and Rescue Medicine that was improved with input from ED physicians nationwide. EDs were eligible if they offered acute care 24 h per day, 7 days per week. Our goal was to have 2006 data from at least 80% of all EDs. The survey was initiated in 2007 and the 80% threshold reached in 2012.

Results

In 2006, Switzerland had a total of 138 hospital-based EDs. The number of ED visits was 1.475 million visits or 20 visits per 100 inhabitants. The median number of visits was 8,806 per year; 25% of EDs admitted 5,000 patients or less, 31% 5,001-10,000 patients, 26% 10,001-20,000 patients, and 17% >20,000 patients per year. Crowding was reported by 84% of EDs with >20,000 visits/year. Residents with limited experience provided care for 77% of visits. Imaging was not immediately available for all patients: standard X-ray within 15 min (70%), non-contrast head CT scan within 15 min (38%), and focused sonography for trauma (70%); 67% of EDs had an intensive care unit within the hospital, and 87% had an operating room always available.

Conclusions

Swiss EDs were significant providers of health care in 2006. Crowding, physicians with limited experience, and the heterogeneity of emergency care capabilities were likely threats to the ubiquitous and consistent delivery of quality emergency care, particularly for time-sensitive conditions. Our survey establishes a benchmark to better understand future improvements in Swiss emergency care.

Development of emergency medicine in Europe

Emergency medicine (EM) is emerging worldwide. Its development as a recognized specialty is proceeding at difference rates in different countries. Europe is a region with complex political affiliations and is composed of countries both within and outside the European Union (EU). Europe is seeking greater standardization (harmonization) for mutually improved economic development. Medicine in general, and EM in particular, is no exception. In Europe, as in other regions, EM is struggling for acceptance as a valid field of specialization. The European Union of Medical Specialists requires that once two-fifths of countries acknowledge a specialty, all EU countries must address the question. EM had achieved the needed majority by 2011. This article briefly describes the European road to specialty acceptance.

Emergency departments in The Netherlands: is there a difference in emergency departments with and without emergency physicians? a cross-sectional web-based survey

BACKGROUND

There is a growing interest in emergency departments (EDs) and the development of emergency medicine in The Netherlands. In the last decade several policy reports have stated that the quality of emergency care should be improved and that emergency physicians (EPs) play a large role in the quality improvement. The Netherlands Society of Emergency Physicians (NVSHA) has developed an emergency medicine training program, which has been nationally recognized since 2009. Nevertheless, not all EDs are staffed with EPs yet. This study aimed to explore differences between Dutch EDs with EPs and those without EPs.

METHODS

A cross-sectional web-based survey was performed on data over the year 2008 or 2009 in all 105 Dutch hospitals with an emergency department. We documented which ED-specific courses were attended by physicians working in the ED (list of 3 courses) and which clinical audit activities were implemented (list of 6 activities). The choice of courses and clinical audits was based on those mentioned in published quality reports and in national debates on emergency care. We compared EDs with and without EPs. The final analysis was based on a linear regression analysis, controlling for ED size and having an EP training program. We considered P < 0.05 significant.

RESULTS

Our survey's response rate was 67%. EPs worked significantly more often in larger EDs. The linear regression analysis shows that the total number of courses attended by physicians was on average 0.51 higher (P = 0.000) in EDs with EPs than in EDs without EPs, and the total number of implemented clinical audits was on average 0.49 higher (P = 0.008). After controlling for potential confounders, the effect of both the composite number of courses attended (P = 0.001) and the composite number of implemented clinical activities (P = 0.032) remained significant.

CONCLUSION

This study shows that EPs are significantly more present in larger EDs and in EDs where there is more continuing professional education and where there are more clinical audit activities. Our findings suggest that the presence of emergency physicians is positively associated with the quality of emergency care, but prospective research is required to examine causality.

Physician-led team triage based on lean principles may be superior for efficiency and quality? A comparison of three emergency departments with different triage models

Background

The management of emergency departments (EDs) principally involves maintaining effective patient flow and care. Different triage models are used today to achieve these two goals. The aim of this study was to compare the performance of different triage models used in three Swedish EDs. Using efficiency and quality indicators, we compared the following triage models: physician-led team triage, nurse first/emergency physician second, and nurse first/junior physician second.

Methods

All data of patients arriving at the three EDs between 08:00- and 21:00 throughout 2008 were collected and merged into a database. The following efficiency indicators were measured: length of stay (LOS) including time to physician, time from physician to discharge, and 4-hour turnover rate. The following quality indicators were measured: rate of patients left before treatment was completed, unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days.

Results

Data from 147,579 patients were analysed. The median length of stay was 158 minutes for physician-led team triage, compared with 243 and 197 minutes for nurse/emergency physician and nurse/junior physician triage, respectively (p < 0.001). The rate of patients left before treatment was completed was 3.1% for physician-led team triage, 5.3% for nurse/emergency physician, and 9.6% for nurse/junior physician triage (p < 0.001). Further, the rates of unscheduled return within 24 hours were significantly lower for physician-led team triage, 1.0%, compared with 2.1%, and 2.5% for nurse/emergency physician, and nurse/junior physician, respectively (p < 0.001). The mortality rate within 7 days was 0.8% for physician-led team triage and 1.0% for the two other triage models (p < 0.001).

Conclusions

Physician-led team triage seemed advantageous, both expressed as efficiency and quality indicators, compared with the two other models.

World Health Assembly Resolution 60.22 and its importance as a health care policy tool for improving emergency care access and availability globally

The recent adoption of World Health Assembly Resolution 60.22, titled "Health Systems: Emergency Care Systems," has established an important health care policy tool for improving emergency care access and availability globally. The resolution highlights the role that strengthened emergency care systems can play in reducing the increasing burden of disease from acute illness and injury in populations across the socioeconomic spectrum and calls on governments and the World Health Organization to take specific and concrete actions to make this happen. This resolution constitutes recognition by the World Health Assembly of the growing public health role of emergency care systems and is the highest level of international attention ever devoted to emergency care systems worldwide. Emergency care systems for secondary prevention of acute illnesses and injury remain inadequately developed in many low- and middle-income countries, despite evidence that basic strategies for improving emergency care systems can reduce preventable mortality and morbidity and can in many cases also be cost-effective. Emergency care providers and their professional organizations have used their comprehensive expertise to strengthen emergency care systems worldwide through the development of tools for emergency medicine education, systems assessment, quality improvement, and evidence-based clinical practice. World Health Assembly 60.22 represents a unique opportunity for emergency care providers and other advocates for improved emergency care to engage with national and local health care officials and policymakers, as well as with the World Health Organization, and leverage the expertise within the international emergency medicine community to make substantial improvements in emergency care delivery in places where it is most needed.