A survey of emergency medicine in 36 countries (page ii)

International EM

CJEM 2001;3(2):109-118

At least some of the physicians who provided emergency care had Advanced Cardiac Life Support (ACLS) training in 28 countries (78%) and Advanced Trauma Life Support (ATLS) training in 24 (67%). EPs performed rapid sequence intubation (RSI) in 27 countries (75%). In countries where EPs utilized RSI, they had access to a variety of agents: succinylcholine (100%), nondepolarizing neuromuscular blockers (96%), midazolam (100%), ketamine (89%), thiopental (85%), fentanyl (81%), etomidate (73%) and propofol (73%). EPs initiated thrombolysis for myocardial infarction in 24 countries (67%), perform thrombolysis for acute ischemic stroke in 4 countries (12%), and performed ultrasonographic examinations in 9 countries (25%). Ultrasonography was most often used by EPs for trauma (n = 9), abdominal pain (n = 5), cardiac (n = 4) and obstetric/gynecologic (n = 3) evaluations. 

Information and management systems

EPs had access to emergency patient medical records through a paper chart in 32 countries (89%) and an electronic chart in 20 countries (56%). Medical records were available within 30 minutes in the EDs of 21 respondents (58%). The estimated time to access medical records ranged from a "few minutes" (Finland, Latvia) to 3 hours (Croatia, Zimbabwe). EPs had access to the Internet in the EDs of 21 countries (58%), but only 9 (25%) had access while actually taking care of patients. 

Respondents were surveyed about the existence of various management systems of EM in their respective EDs (Table 7). Formal systems for peer review were reported by 27 (75%). Systems for quality assurance were reported by 20 of 35 (57%); 18 of 35 (51%) reported systems for quality improvement. Systems for consumer satisfaction were cited by 18 (50%), risk management by 13 (36%), follow-up laboratory result variance by 15 (42%) and follow-up radiology result variance by 12 (33%). Only 13 (36%) reported ED systems for provision of cost-effective EM care.

Future of EM

Participants were asked to rate the obstacles to the future development of EM in their countries (Table 8). A lack of funding was felt to pose a moderate or great barrier in 28 countries (80%). Lack of infrastructure was seen as a moderate or great obstacle in 22 (63%); lack of government support a moderate or great obstacle in 20 (59%). A lack of public support was felt to pose little or no barrier to development in 21 countries (64%), whereas 23 of 34 participants (68%) felt that a lack of support from the physicians who practise EM posed little or no barrier.

Discussion

This survey describes the systems of EM in 36 countries, spanning 6 continents and comprising 66% of the world's population. A precise description of international EM systems would require reliable information from more respondents in more countries, but these data provide an important first "snapshot" of the current global status of EM.

What may surprise many is how developed EM now appears to be in much of the world. Throughout the world, many of the components of EM systems taken for granted in more advanced countries are in place in at least one centre in the majority of the countries surveyed. By determining the minimum presence of the various systems components of EM in countries, we gain our first organized glimpse of the status of EM in the world.

The most ubiquitous system for emergency patient care worldwide is the hospital-based ED (often with independent status within the hospital). The designation of a place in a hospital where the most acutely ill or injured patients are cared for appears to be a universal feature of emergency care.

Systems for prehospital emergency care exist worldwide as well. Of the countries surveyed, 89% had EMS systems and 86% had a national phone number through which the public accessed EMS. Despite this commonality, the actual phone number varied considerably from country to country. As globalization leads to increased public expectations from EM systems, it will be increasingly important for international health care policymakers to consider the merits of a "universal" phone number through which EMS can be activated worldwide.

Most respondents also reported that EDs in their countries had "formal" systems for the emergency care of children (81%) and trauma patients (69%) (Table 6). Formal systems for providing care to patients with toxicological emergencies were reported less often (56%). The factors underlying these differences are unclear and warrant further investigation.

Only 4 respondents reported that their countries had fellowship training in pediatric EM. Since pediatric EM will become an increasingly important concern as EM continues to develop worldwide, it will be helpful to understand how physicians providing emergency care to children are being trained throughout the world.

RSI appears widespread in the EP armamentarium for airway management (75%). In contrast, EP ultrasonography did is not used in many countries (25%) but was relatively common in more economically developed Asia, where surgeons have taken the lead in EM development (Japan, Hong Kong, South Korea and Taiwan). Although 67% of the countries surveyed reported that EPs could initiate thrombolysis for acute myocardial infarction, only 4 countries reported that EPs could initiate thrombolysis for acute ischemic stroke. For those seeking to promote this therapy on an international level, it may be worth investigating which factors underlie this apparent lack of acceptance, such as cost, unavailability of timely neuroimaging or therapeutic skepticism.

Educational systems for EM are well established in the countries surveyed. EM is taught in medical schools throughout the world (83%) and the time-honoured tradition of doctors in training seeing emergency patients existed in most countries surveyed (92%). The majority of respondents also reported that research in EM was performed in their countries. Half of the countries reported having EM residency training programs and EM journals. The majority of respondents also reported that at least some of the physicians who practise EM in their countries received training in ACLS (78%) and ATLS (67%).

What role does EM specialty recognition play in the development of EM? Whereas half of the countries reported official specialty recognition of EM, more than two-thirds reported the existence of advanced academic systems (EM research) and patient care systems (EMS, trauma care), suggesting that more mature systems do develop in some countries even in the absence of officially recognized EP specialists. As seen in the development of EM in the US,¹ the specialty status of EM may be as much a consequence of development as it is a cause of development.

The availability of patient medical records has been cited as an essential component in the development of emergency care systems.³⁹ Most respondents (89%) reported that EPs have access to paper medical records, and 56% reported access to electronic medical records in their EDs. Only 25% of the respondents reported that EPs had access to the Internet while taking care of patients, suggesting that online resources have yet to replace textbooks on the shelves of the world's EDs.

Although systems for quality assurance and quality improvement existed in the EDs of the majority of the respondents surveyed, EM databases were conspicuously underdeveloped throughout the world (17%). The development of national EM databases appears to remain a genuine frontier in the development of EM throughout the world.

What role does cost play in the development of EM in the world? On one hand, the respondents overall felt that a lack of funding was the greatest barrier to the development of EM in their countries. On the other hand, only 36% reported any system for providing cost-effective emergency care to their patients. It is also worth noting that in the 27 countries where EPs performed RSI, they had access to relatively expensive induction agents (i.e., midazolam, etomidate, propofol) at rates comparable to less expensive agents (i.e., ketamine, thiopental, fentanyl). Although local costs may vary and percentage availability does not mean percentage utilized, access to more expensive medications also suggests that cost-containment was not yet considered a pressing issue in many countries. This has important implications for those involved in developing EM internationally. Although it is unlikely that those involved in international assistance can persuade government officials and health care financiers in other countries to fund emergency care systems at greater levels, they can readily introduce cost-sensitive and cost-effective approaches to emergency care to their colleagues in other countries.

Most of the respondents reported that their EDs did not have systems for risk management (64%), systems for follow-up radiology report variance (67%), or systems for following up laboratory report variance (58%), suggesting that EM malpractice was not a major concern in most of the world.

Overall, the respondents felt that the physicians practising EM in their countries presented a smaller obstacle to the future development of EM than did hospital administrators and other physicians. They also felt that a lack of public support was a smaller barrier than a lack of government support. For those interested in international EM development, this underscores the need to educate government policymakers, hospital administrators and other physician specialists of the many benefits of improved EMS. It also suggests that in many countries, an appreciative public awaits the improved emergency medical care that an enthusiastic core of EPs hopes to provide.

This survey also begins to establish a methodology by which an international database of information about EM throughout the world can be accumulated. A more accurate description of the status of EM in the world awaits the consensus participation of experts and agencies in international EM and the establishment of definitions and constructs that are accepted worldwide. A definitive survey will require the application of more sophisticated and widespread survey and sampling techniques. It also awaits the availability of more efficient means of locating and communicating with local EM experts in even the most remote regions of the world.

Establishing such a database will have multiple obvious benefits and can be expanded multidirectionally to include all types of information about EM throughout the world, including workforce, cost and patient outcome data. This information will also be essential for future analysis and comparison of different systems of emergency care delivery, which in turn may assist the establishment of international standards of emergency medical care.

This study demonstrates that the development of EM as a specialty is an international phenomenon that transcends political, economic, cultural and geographic barriers. It also suggests that the overall development of EM may be more advanced in the world than intuitively expected from multiple recently published reports from individual countries.^5-35 Perhaps most importantly it suggests that the kernel for future EM development already exists worldwide.

This survey had a number of important limitations. Many of the terms used in the survey lack internationally accepted definitions. Even terms like "emergency physician" and "EMS" may be subject to different interpretations from country to country. To one respondent, a "system for trauma care" may mean that the physician on duty merely calls a surgeon, whereas to another it may mean a trauma team response according to American College of Surgeons criteria. Still, the significance of the respondent's answers lies not in whether countries have equivalent systems, but in whether the respondent perceived that any system exists at all.

Another limitation was that this study only ascertained the minimum existence of each single system component of EM. No data were collected regarding the frequency of any of the components surveyed. For example, we were unable to report how often EPs served as ED directors or how frequently RSI was performed. Furthermore, the survey did not provide any information about where these system components were located or how they were distributed in a country. Importantly, this study did not report any information about the quality of emergency care provided in the countries studied, which depends instead on outcome data.

The inability to internally validate a single respondent's responses by comparing them with other responses from the same country was another problem. In countries with regional EM variation, a single respondent could unknowingly misrepresent the status of EM elsewhere in the country. In addition, it is possible that some respondents might embellish their description of EM systems in a country to create a "better" appearance to the outside world.

Furthermore, because participants were primarily recruited from international EM conferences, potential participants from many underdeveloped and developing countries were not included in the study, owing to their financial inability to participate in international EM conferences. Finally, because of the need to communicate in English, the study may not adequately represent countries where English is not in common use. Despite this limitation, the study presents data from a large number of countries, including several that have not been previously reported in English language EM literature.

Conclusions

This survey offers a snapshot of the development of EM in the world today. The most common component of emergency medical care systems worldwide was the hospital-based ED. Almost as widespread were EMS systems, followed closely by the EP, often with specialized training (ACLS, ATLS) and the ability to perform life-saving procedures, such as RSI or thrombolysis. The specialty systems components of EM were also in place in many countries, including national EM
specialty organizations, residency training, official specialty recognition and certification boards. Many academic systems of EM existed throughout the world, including medical education in EM, EM residency training, the performance of EM research, and the publication of EM journals. All of these systems components provide the foundation upon which EM can grow locally, regionally and internationally.

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