A survey of emergency medicine in 36 countries

International EM

CJEM 2001;3(2):109-118

Abstract

Résumé

Introduction

Although multiple reports on the status of emergency medicine (EM) in individual countries have been published in recent years, little information is available comparing EM systems globally.^1-4 It is difficult to gather information from countries with diverse geographic, political, cultural, linguistic, historical and medical environments, but it is important to do so as a first step toward understanding the development of our specialty around the world.

Describing the status of EM systems worldwide provides a baseline for comparing EM among countries and defines a benchmark against which future development can be measured. It also provides a context for comparing EM by nation groupings (e.g., those with similar geography, population, economic productivity, political systems or cultural composition). It may also help to guide intervention efforts and to allocate limited resources in developing countries. Such information could play a role in the future establishment of international standards of emergency care.

Our objective was to describe the components of EM systems in as many countries as possible, including specialty, academic, patient care, information and management systems.

Methods

A survey of 36 EM professionals from 36 countries was performed by one of the authors (J.L.A.), during the 3 months from Aug. 25 to Nov. 24, 1998. Survey subjects
met the following criteria: 1) a medical professional working in an EM-related field; 2) attended 1 of 4 international EM conferences during the study period (30) or referred into the survey by a previous respondent (6); and 3) able to communicate in English.

Direct one-on-one interviews were conducted with 27 delegates attending 1 of 4 consecutive international EM conferences held during 1998. These conferences included the 4th Pan-European Conference on Emergency Medical Systems (Opatija, Croatia, Aug. 25-29), the 4th Asian-Pacific Conference on Disaster Medicine (Sapporo, Japan, Sept. 2-4), the Emergency Medicine and Prehospital Care Conference (Johannesburg, South Africa, Oct. 7-9) and the American College of Emergency Physicians Scientific Assembly (San Diego, Calif., Oct. 11-14). Potential interviewees were identified from rosters of the conference participants made available by conference organizers. Direct interviews were conducted with a laptop computer screen facing the subject so that the questions could be read in English as they were simultaneously being read aloud in English. Responses were entered immediately by the author in the presence of the respondents to assure correct interpretation and data entry.

Email surveys were conducted with 3 attendees after the conference and with the 6 others who were referred into the study. Participants were asked 95 questions about the existence of various EM specialty, academic, patient care, information and management systems and 8 questions about the future of EM in their countries. When available, the respondents' answers were corroborated by a review of the international EM literature.^5-35

This study was exempt from institutional board review. Repsondents provided their consent to participate in the survey at the time their participation was solicited.

Results

Table 1 lists the professional or academic positions held by survey participants at the time of the study. Twenty-five survey respondents (69%) gave presentations on EM topics at one of the conferences. Three potential participants, from Bangladesh, Bosnia and Herzegovina, and Bulgaria were initially identified but excluded because of language barriers. Five potential participants, from Argentina, France, Israel, Poland and Russia were surveyed but did not respond within the study period and were excluded. The overall study response rate was 88%.

Table 2 lists the per capita gross domestic product, life expectancy and population in the countries represented in the survey.^36-38 The estimated total population of the countries surveyed is 3.9 billion, representing about 66% of the total world population (5.9 billion).^36,38

National EM organizations were identified in 28 (78%) of the 36 countries (Tables 3, 4). Of these, 15 were established in the past 10 years. Recognition of EM as an independent medical specialty was reported in 18 countries (Table 3). Official recognizing bodies included national medical associations, colleges of medicine and government ministries of health. Board certification or similar credentialing for EPs was reported by 13 countries (36%), 9 of these had established board certification in the past 10 years.

Academic systems

Emergency medicine is taught in the medical schools of 30 countries (83%) (Table 3). In 20 countries (56%), EPs teach EM. EM is taught through clinical rotations for medical students in 29 countries (81%) and by formal lecture in 27 (75%). EM residency programs (or equivalent) are present in 18 countries, and at least 10 of these countries established their residency training programs within the past decade. Programs ranged in length from 3 years (Peru, Taiwan, US) to 6 years (Hong Kong, Italy). Only 4 respondents (11%) reported EM fellowships (Canada, Singapore, UK, US), which included pediatric EM, research and epidemiology, trauma, toxicology, cardiac care and emergency medical services (EMS).

EM research was reported in 27 countries (75%), basic science research in 22 (61%) and clinical EM research in 26 (72%). Seventeen respondents (47%) reported that their country had at least one EM journal (Table 5). Six (17%) reported that their country had a national EM database (Austria, Indonesia, New Zealand, Singapore, Slovenia, UK).

Patient care systems

EMS systems were reported in 32 countries (89%). The estimated percentage of patients presenting to hospitals with medical emergencies who arrived by EMS, ranged from 2% (Tunisia) to "almost all" (Germany). A national emergency phone number for public activation of EMS was identified in 31 countries (86%). Most European Union countries reported using "112", Japan, Korea and Taiwan use "119", and the US and Canada use "911". EMS activation numbers elsewhere in the world varied greatly.

Hospital-based EDs were reported in 35 countries (97%), of which 26 (72%) had independent department status within the hospital. In 19 countries (53%), the ED director may be, but was not necessarily, an EP.

EM residents provided some emergency care in 17 countries (47%) (Table 6), as did residents from other specialties in 33 countries (92%). EPs provided emergency care in 27 countries (75%), and in 30 countries (83%) other specialists also provided emergency care. The same physician provided emergency care to both medical and surgical patients in 31 countries (86%). Medical and surgical care was integrated into one physical area within the EDs of 24 respondents (67%). 

Formal systems for pediatric emergency care were identified in the EDs of 29 respondents (81%). The presence of interfacility transfer was reported in 27 (75%), trauma care in 25 (69%), triage in 24 (67%) and toxicological emergency care in 20 (56%). Systems for psychiatric emergency care were reported by 23 of 35 respondents; 22 of 35 reported systems for obstetric and gynecologic emergency care.

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