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Emergency Medicine Australasia (2014) 26, 50–55

doi: 10.1111/1742-6723.12181

EMERGENCY MEDICINE PRACTICE

International emergency medicine: Past and future Peter A Cameron1,2,3 Department of Emergency Medicine, Hamad Medical Corporation, Doha, Qatar, 2Department of Epidemiology and Preventive Medicine, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia, and 3International Federation for Emergency Medicine, Melbourne, Victoria, Australia 1

Much has been written about the development of emergency medicine (EM) and its impact on the medical system as a whole. It is still described as ‘new’ and very much seen as a specialty that is evolving, rather than a static domain of knowledge and skills with rigid boundaries. In reality, the fundamentals of emergency treatment in mitigating the effects of acute illness and injury go back to ancient times.1 This is evidenced by descriptions of the urgent management of acute pain with analgesics, splinting of injured limbs, and more sophisticated procedures, such as the removal of kidney stones and craniotomies. The treatments at that time were limited, but the application of these skills brought relief to many people (and a little pain). The practitioners were generalists and did not limit themselves to emergency treatment alone. Over the past half-century, there has been an acceleration of development in emergency medical treatments and a massive explosion in emergency medical system enhancement. This has resulted in a unique body of knowledge and skills, with the evolution of a new medical specialty specific to the delivery of emergency medical care. It is worth reflecting on the drivers for EM specialisation, where the specialty has come from, and what we can expect as the complexity of medical care increases with technological innovation and social changes associated with increasing connectivity.

Drivers for development of emergency medicine The concept of a specialised workforce in EM started almost simultaneously across the English-speaking world, with the formation of ‘Casualties’ in the UK

and Australia/NZ2 and emergency rooms in North America.3 This development mirrored the changes that were occurring in the delivery of medical care more generally: 1. The rise of hospital-based medicine. Before the 1950s, the majority of acute medical care was delivered in the home and doctors’ surgeries – hospitals were functionally akin to hospices for the poor and terminally ill. It was a family responsibility to look after a sick person and if the family was wealthy, they could afford a home nurse. There were only a few operations that were effective, anaesthesia was risky, there was no intensive care unit and complicated surgery had a very high mortality rate. Home births with midwives were the norm. Doctors went to the patient when the patient was very ill. The changes in healthcare delivery after World War II reflected the technological changes in medical delivery, the politics of democratic governments concerned with equal access for all citizens and funding changes that allowed the majority of the population access to advanced treatments. Centralisation of medical care in hospitals with a large body of doctors and nurses meant that there had to be an entry point to the hospital system for emergency patients. 2. Medical advances. Technological advances in medicine resulted in interventions that saved lives. The use of defibrillation for cardiac arrest became widespread in the 1960s after the first successful clinical defibrillation a decade earlier.4 This was a dramatic emergency treatment that required very short time frames for successful outcomes. However, even simple treatments like antibiotics have only come into existence in the past 100 years. Penicillin was discovered in 1928,5 but widespread use of antibiotics and early, aggressive treatment of serious sepsis,

Peter A Cameron, MBBS, MD, FACEM, Professor, Chair, President. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Emergency Medicine Practice

was not evident until much later. Drugs for anticoagulation, cancer, heart failure and a myriad other diseases were also shown to be effective. Improvements in surgical technique and sterilisation led to effective operative management for many conditions, and emergency operations, including those for vascular disease, bowel obstruction and intracranial pathology, were all shown to save lives. Widespread use of enhanced radiology and pathology for investigating illness also accelerated in the second half of the 20th century with a plethora of new investigative techniques. The ability to diagnose and treat many emergency conditions with time-dependent outcomes completely changed the provision of emergency care. 3. Improved transport. The availability of cars for private transport and ambulance vehicles allowed for centralisation of services to major centres. Aeromedical transport for remote, but severe cases also increased accessibility. Rapid assessment and transport of emergency cases allowed the evolution of a new type of clinician, the paramedic. This clinician was responsible for assessing and stabilising the patient to allow a patient to arrive safely at the right medical facility, in the shortest time. In the non-English speaking world, this specialised workforce took longer to develop and pre-hospital care is predominantly undertaken by doctors in some countries. 4. Specialisation of the medical workforce. The huge increase in medical knowledge and treatments over the past few decades has created a conundrum for our acute patients. The small number of subspecialists in each individual specialty means that there is no possibility of extended hours coverage for certain subspecialists. In addition, a patient with an undifferentiated illness does not know which specialist to see and might end up getting multiple referrals before receiving the correct advice. This means that senior physicians with generalist knowledge must be available to assess, stabilise and refer undifferentiated patients appropriately at all hours. 5. Effective emergency treatments. There is now good evidence that early medical intervention can save lives and decrease disability in certain illnesses. Cardiac arrest, septic shock, trauma and stroke are obvious examples. More importantly, recent evidence has shown that it is not only the individual expert proceduralist who improves survival in these emergency conditions, but also the emergency medical system that supports that treatment.6,7

6. Efficiency and safety drivers. The transfer of knowledge regarding process management from industry to medical care has resulted in process changes in hospitals. Hospitals are now viewed more like factories than charitable hospices. Hospital administrators are looking for more efficient ways to ‘process’ patients (clients). This is most evident in elective surgery, where funding models deliver profits and surpluses to hospitals able to reduce waste. For emergency patients, this has meant that getting emergency assessment and treatments happening early, results in less wasted bed-days. This can only be done with senior specialist presence 24 h a day, 7 days a week. In addition, concepts from industry to minimise defects and maximise efficiency have contributed to the patient safety movement. This has been packaged into products such as Six Sigma, a set of technique and tools for process improvement.8 It is evident that experienced assessment and intervention available every hour of the day, is likely to decrease error and preventable injury. A further consequence of the safety movement has been the realisation that physicians should work safe hours. A lack of senior doctors in hospitals after hours has further necessitated experienced assessment and stabilisation for emergency admissions at the front door. 7. Evidence-based medicine. The explosion of medical treatments and trials to prove the effectiveness of treatments has led to a philosophy that medical practice should now have the highest level of evidence to support it, and that treatment protocols should have permanently moved from ‘eminence’ or expert opinion-based to evidence-based medicine. Ensuring that patients receive evidence-based guidelines requires an expert body of specialist knowledge and its application and evaluation, which have developed and expanded rapidly since the early 1990s.

Spectrum of activity The initial impetus for EM came from perceived deficiencies in the management of cardiac and injury cases, as these were conditions where emergency care made a clear difference to outcome. However, most EDs now see a broad spectrum of activity, and critical cardiac and injury conditions make up a minority of cases. The assessment and management of psychiatric conditions, toxidromes, geriatric syndromes, infectious diseases, gastrointestinal, respiratory and musculoskeletal illness

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are now the mainstay of EM practice. What is it that binds this diverse body of knowledge into a specialty? The International Federation for Emergency Medicine (IFEM) definition of EM care focuses on undifferentiated illness: ‘Emergency medicine is a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of episodic undifferentiated physical and behavioural disorders; it further encompasses an understanding of the development of prehospital and inhospital emergency medical systems and the skills necessary for this development.’9

Countries where emergency medicine has flourished It is interesting to look at where EM has flourished. The major proponents of the specialisation of EM were originally the USA, Canada, UK, Australia and New Zealand. This started in the mid-1960s and became more formalised in the 1970s and 80s.3 Hong Kong and Singapore were also early adopters. It is not clear why these countries were first, but it might partly relate to the early adoption of paramedics pre-hospital. This resulted in patients arriving at hospital without a medical assessment, unlike the Franco-German model.10 It is also likely that experience from war showed that it was better to quickly evacuate casualties from the scene and coordinate the rescue and stabilisation to enable early definitive treatment at the major base. There is little value in a single doctor working in suboptimal circumstances in the field. These precepts are sometimes referred to as ‘Scoop and Run’ versus ‘Stay and Play’.11 In countries with doctors in the field with specialised skills, there is more temptation to spend longer and potentially less need to assess and stabilise on arrival. A further driver for early adoption might have been payment and remuneration systems that encouraged hospitals to optimise income by increasing accessibility.

tries with established medical systems, the emergence of a new group of skilled practitioners with instant 24/7 access would potentially reduce income for established specialties – the ‘power and money’ argument. It might also be that the drivers in the Anglo-American countries such as wartime experience and transfer of industrial process concepts to healthcare might have been less evident. In developing countries, it might just have been a lack of access to available expertise and new technologies to force change in healthcare delivery. Despite the large variation in the speed of development, EM is now a specialty practised in over 50 countries.12

Success of emergency medicine Has the development of a broad-based specialty centred on acute undifferentiated illness resulted in better care for patients? Is it more efficient and is it evidence based? It appears that where EM has flourished, outcomes for many illnesses have improved.13 A comparison of outcomes between regions with advanced trauma systems, cardiac arrest systems, stroke systems and so on show large health gains. Access to early analgesia,14 coordinated care for the elderly15; management of drugaffected, psychiatrically disturbed patients16; and many other disadvantaged groups have improved. Hospital efficiencies have been documented and new models of care developed.17–19 The fact that EM is at the interface between hospital and the community ensures that emergency physicians (EPs) are aware of the importance of coordinated care.20 EPs have also been central to implementing clinical pathways within hospitals.21 Also through the IFEM, there is now international consensus on the curriculum required at undergraduate and postgraduate training levels,22,23 as well as on how EDs are managed and what makes a high-functioning ED.24 International groups are working on making the knowledge necessary to deliver emergency care available internationally through programmes such as ‘ENLIGHTENme’, the hub and knowledge bank electronic learning initiative from the College of Emergency Medicine.25

Countries where emergency medicine has not flourished

Failures of emergency medicine

EM has not flourished in countries concentrated in Europe, Asia and Africa. One explanation is the entrenched hierarchy of medical specialties in some of those countries and the resistance to change. In coun-

In some ways, EM has been a victim of its own success. The provision of round-the-clock available senior, skilled staff has allowed other specialties and primary care to abrogate responsibility. It has also given the

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© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Emergency Medicine Practice

public unrealistic expectations regarding medical access for conditions that do not require emergent treatment. This has resulted in increased attendances and a lack of responsibility by practitioners and the community to ensure that EDs are free to see those patients who most need their services. The general practitioner contract that was fully implemented in the UK by April 2004 is a classic example of policy failure in this area.26 In addition to issues with increased non-urgent conditions, EDs have had to manage overcrowding caused by hospitals creating ‘efficiencies’ (that it capping or reducing costs) by closing beds. Lack of access to an acute bed for admitted emergencies creates absolute dysfunction in patient flow. Overcrowding continues to be an international problem for EM and has resulted in unsafe, substandard care across most emergency systems.27,28 Trainees like EM for the variation offered in clinical cases, unpredictable yet exciting bursts of action, teamwork and the feeling of having performed a worthwhile task. However, many are now deciding not to do EM, because of shift work, poor remuneration, stress and overcrowding. There is a general perception of feeling undervalued by hospital administrators and the community. Worldwide, there is now a shortage of EM physicians that is unlikely to be solved anytime soon. EM has also not thrived academically, with EM journals having low impact factors, and EPs having low overall publication records,29 including low h-index (Hirsch index) scores that measure both productivity and impact. Anecdotally, it is argued that the nature and intensity of emergency work, the personality of physicians attracted to it (‘action people’) as well as poor remuneration might all be responsible – but the fact remains that EM has a poor research and publication record.

Funding models Funding models for emergency care vary internationally. There are two major philosophical approaches – one based on throughput measurement, either per capita or adjusted for casemix, and the other based on the concept of role delineation – emergency response, institution role and availability, with only small adjustments for volume.30 The difficulty with fee for service in EM is that it is possible to generate any number of EM visits to increase revenue. It also does not encourage patients to seek alternative services or other providers to take responsibility. This is especially the case when other health providers charge for services. The ‘fire brigade’

principle for funding emergency medical systems is based on the fact that a certain degree of hospital resources is needed whether one patient or five patients are seen. The facility has to be staffed, run, stocked and cleaned, and associated services provided at all hours. The marginal cost for seeing additional patients is small. A funding model based on these principles might be in the best interests of public EM in the long term. This would ensure that focus is placed on ensuring the right patients get to the right hospital and this hospital responds in an appropriate way. This is as opposed to ‘chasing’ business to reduce established overhead costs. In spite of this, we are currently introducing EM casemix payments in Australia31 and in other countries.

Emergency medicine provision EM in Australasia is mostly focused on hospital care. It is now evident that better outcomes could be provided by better integration with community services and outreach programmes. Although this is beginning to happen, most EPs do not feel that this is their major role. Whether EPs perform this role or other providers do, it is essential that better integration with community services is developed. Poor provision of EM in underdeveloped countries remains a major deficit in medical care globally. Simple emergency treatments are not administered for gastroenteritis and other infectious diseases, trauma, respiratory illness, psychiatric illness and cardiac disease – with devastating results.32 Providing emergency systems that work in these countries and in the rural areas of many developed countries should be prioritised. This will involve the training and oversight of many non-physician providers such as emergency medical technicians and even police and other community workers. It is our role as experts to ensure that basic evidence-based treatments are available to everyone, even though delivery need not involve an EP.

Time-based process measures An acknowledgement by EPs that time to delivery of care and time-based process measures are integral to quality emergency care delivery, has resulted in a major distraction for the specialty of EM. EPs must now focus on the fundamentals of emergency care – ensuring that we have good facilities and sufficient well-trained staff organised in a way that delivers high-quality,

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evidence-based, patient-centred care. The ‘4 hour rule’ and similar time-based targets have been politicised to such an extent that their usefulness as a lever for change has been lost.33,34 Quality care is delivered locally and based on a local culture of total quality management – it does not result from a centrist Stalinist model of imposed targets.

Where to now EM is a specialty for the 21st century. It is based on systems thinking35 and making the best use of available evidence. Technological advances have centralised medical care and moved it out of the home and into large institutions. Further technological advances might enable some shift back to individualised care. Individualised physiological and biochemical monitoring systems for patients at risk will make remote therapeutic interventions possible. The extent to which this affects the role of the EP will be interesting to watch. EM is based on consumer expectations of 24/7 availability with uniform standards of care. The specialty is the ultimate team sport with no individual practitioner owning the knowledge. It is interesting to reflect on the direction of sub-specialisation in EM as it erodes one of the fundamental precepts of EM – the acute generalist. There are many deficiencies in emergency care worldwide, with poor adoption of basic standards of emergency care in underdeveloped countries and rural areas, where it would have the greatest impact. Rapid improvements in technology over the coming decades will lead to an even greater necessity to ensure availability of specialised EM to every part of the globe. EM has already changed the way medical care is delivered in a short period of time. It might no longer be a new specialty; however, it will be at the vanguard of improvements in care for patients in their greatest hour of need.

None declared.

3.

Suter R. Emergency medicine in the United States: a systemic review. World J. Emerg. Med. 2012; 3: 5–10.

4.

Beck CS, Pritchard WH, Feil HS. Ventricular fibrillation of long duration abolished by electric shock. JAMA 1947; 135: 985.

5.

Fleming A. ‘On the antibacterial action of cultures of a penicillium, with special reference to their use in the isolation of B. influenzae’. Br. J. Exp. Pathol. 1929; 10: 226–36.

6.

Stub D, Bernard S, Smith K et al. Do we need cardiac arrest centres in Australia? Int. Med. J. 2012; 42: 1173–9.

7.

Cameron PA, Gabbe BJ, Cooper JD et al. A statewide system of trauma care in Victoria: effect on patient survival. Med. J. Aust. 2008; 189: 546–50.

8.

Lean Six sigma Training. [Cited Nov 2013.] Available from URL: http://www.6sigma.us

9.

International Federation for Emergency Medicine IFEM. Definition of Emergency Medicine. [Cited Nov 2013.] Available from URL: http://www.ifem.cc

10. Dick WF. American vs. Franco-German emergency medical services system. Prehospital Disaster Med. 2003; 18: 29–37. 11. Cooke MW. How much to do at the accident scene? Spend time on essentials, save lives. BMJ 1999; 319: 1150. 12. Hallas P, Ekelund U, Bjørnsen L, Brabrand M. Hoping for a domino effect: a new specialty in Sweden is a breath of fresh air for the development of Scandinavian emergency medicine. Scand. J. Trauma Resusc. Emerg. Med. 2013; 21: 26. 13. Holliman CJ, Mulligan TM, Suter RE et al. The efficacy and value of emergency medicine: a supportive literature review. Int. J. Emerg. Med. 2011; 4: 44. 14. National Institute for Clinical Studies – Final report of the NICS Emergency Department Collaborative 2004. [Cited Nov 2013.] Available from URL: http://www.nhmrc.gov.au/_files _nhmrc/file/nics/programs/Final_Report_of_the_NICS _Emergency_Department_Collaborative.pdf 15. Moss JE, Houghton LM, Flower CL, Moss DL, Nielsen DA, McD Taylor D. A multidisciplinary Care Coordination Team improves emergency department discharge planning practice. Med. J. Aust. 2002; 177: 435–9. 16. Department of Health. Mental Health Care – Framework for Emergency Department Services. 2007. [Cited Nov 2013.] Available from URL: http://www.health.vic.gov.au/mentalhealth/ emergency/framework.pdf

18. Cameron PA, Joseph AP, McCarthy SM. Access block can be managed. Med. J. Aust. 2009; 190: 364–8. 19. Oredsson S, Jonsson H, Rogne J et al. A systematic review of triage-related interventions to improve patient flow in emergency departments. Scand. J. Trauma Resusc. Emerg. Med. 2011; 19: 43.

References

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Australasian College for Emergency Medicine. History of ACEM. [Cited Nov 2013.] Available from URL: http://www .acem.org.au

17. Daly S, Campbell DA, Cameron PA. Short-stay units and observation medicine: a systematic review. Med. J. Aust. 2003; 178: 559–63.

Competing interests

1.

2.

Decker WW, Stead LG. The International Journal of Emergency Medicine: a new journal for a new era. Int. J. Emerg. Med. 2008; 1: 1–2.

20. Koehler BE, Richter KM, Youngblood L et al. Reduction of 30-day post discharge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through

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delivery of a targeted care bundle. J. Hosp. Med. 2009; 4: 211– 18.

28. Graff L. Overcrowding in the ED: an international symptom of health care system failure. Am. J. Emerg. Med. 1999; 17: 208–9.

21. Cameron P, Scown P, Campbell D. Managing access block. Aust. Health Rev. 2002; 25: 59–68.

29. Reynolds JC, Menegazzi JJ, Yealy DM. Emergency medicine journal impact factor and change compared to other medical and surgical specialties. Acad. Emerg. Med. 2012; 19: 1248–54.

22. Hobgood C, Anantharaman V, Bandiera G et al. International Federation for Emergency Medicine model curriculum for medical student education in emergency medicine. Emerg. Med. Australas. 2009; 21: 367–72. 23. Hobgood C, Anantharaman V, Bandiera G et al. International Federation for Emergency Medicine Model Curriculum for Emergency Medicine Specialists. Emerg. Med. Australas. 2011; 23: 541–53. 24. International Federation for Emergency Medicine. Framework for Quality and Safety in the Emergency Department 2012. [Cited Nov 2013.] Available from URL: http://www.ifem.cc 25. College of Emergency Medicine. [Cited Nov 2012.] Available from URL: http://www.enlightenme.org/ 26. House J. What’s causing Englands’s A&E crisis? Lancet 2013; 382: 195–6. 27. Sprivulis PC, Da Silva J, Jacobs IG, Jelinek GA, Frazer A. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med. J. Aust. 2006; 184: 208–12.

30. Duckett SJ, Jackson T. Paying for hospital care under a single payer system. Ann. Emerg. Med. 2001; 37: 309–17. 31. Independent Hospital Pricing Authority. IHPA. Emergency Care Services in Australia. [Cited Nov 2013.] Available fromURL:http://www.ihpa.gov.au/internet/ihpa/publishing.nsf/ Content/emergency-care 32. Razzak J, Kellerman A. Emergency medical care in developing countries; is it worthwhile? Bull. World Health Org. 2002; 80: 900–5. 33. Mason S, Weber EJ, Coster J, Freeman J, Locker T. Time patients spend in the emergency department: England’s 4-hour rule-a case of hitting the target but missing the point? Ann. Emerg. Med. 2012; 59: 341–9. 34. R Francis. The Midstaffordshire foundation trust. Public Enquiry Public report. [Cited Nov 2013.] Available from URL: http://www.midstaffspublicinquiry.com 35. Cameron P. Are we the systems specialists? Emerg. Med. (Fremantle) 2003; 15: 1–3.

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International emergency medicine: past and future.

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