Trends and challenges of emergency and acute care in Chinese mainland:2005–2017

BACKGROUND:Emergency medical service system(EMSS)is essential in providing acute care services for health conditions.However,trends of emergency and acute care in China haven’t been studied systematically.METHODS:Relevant literature was carefully reviewed,including original and review articles,letters,government reports,yearbooks,both in Chinese and in English.Data on the number of emergency visits,physicians and beds in emergency departments(EDs),and the workforce of prehospital emergency care were summarized and analyzed from China Health and Family Planning Statistical Yearbooks(2006–2018).RESULTS:Over the past decade,the number of ED visits tripled from 51.9 million to 166.5 million;and utilization of pre-hospital emergency care increased from 3.2 million to 6.8 million.In response to rapid increases in demand,the number of licensed emergency physicians raised from 20,058 to 59,409;the beds’number increased from 10,783 to 42,367.For pre-hospital emergency care,the volume of health workforce increased from 3,687 to 8,671,with a 109%increase in the number of physicians from 1,774 to 3,712.However,overcrowding,the long length of stay in EDs,poor work environment,and work exhaustion were still the critical challenges faced by China’s EMSS.CONCLUSIONS:The number of emergency visits has grown with continual capability enhancement during the past decade.However,overcrowding,the long length of stay in EDs,poor work environment,and work exhaustion still need to be solved by China’s EMSS.These fi ndings and comparison with the USA could offer experiences and lessons to EMSS development worldwide,especially for developing countries.     

国内外急救医疗服务体系发展的回顾与展望

综述了美、德、法、英等国的急救医疗服务体系发展特点 ;我国急救医疗体系起源与发展、急救模式、急救人员、急救工具、急救网络特点以及我国急救医疗服务体系的发展展望 :提高急诊应急能力 ;建立和完善城市救援系统 ;实现急救装备的现代化 ;加强急救人员培训 ;加强急救医疗服务的区域性协作 ,开展国际交流与合作。     

消防部队现场医疗救助应成为我国现行院前急救模式的拓展和延伸

分析我国现有院前急救管理办法、院前急救现实中存在的不足以及消防部队现场医疗救助的优势,以观察消防现场医疗救助对于院前急救的弥合作用,并提出未来我国院前急救发展前景。应充分利用消防部队的各种优势,把消防的现场医疗急救有机融合到院前急救体系中,并赋予相应的法律权限和职责,能够显著提高我国院前急救水平,缓解急救矛盾,以提高城市应急能力,增加城市安全感。在我国现有院前急救体制下,应充分利用医疗系统以外的社会急救力量,消防部队作为我国现役的一支社会综合救援力量,二者有机结合才能够突破现有急救瓶颈,适应现实社会发展需要,使我国院前急救逐渐与国际接轨。     

Efficiency and cost-effectiveness of advanced EMS in West Germany

A model study was performed by an economist in Lower Frankonia (a mostly rural area of West Germany with several urban centers) to examine the efficiency and cost-effectiveness of the emergency medical service that included prehospital physician presence. To perform this examination about $3.5 million were spent to improve organization and communication within the local emergency medical service, to purchase additional equipment and further emergency vehicles, and to install prehospital emergency physician service. The median response time was lowered to 6 minutes. This report surveys whether these reforms and extra fundings were beneficial and cost-efficient.     

2009年自贡市急救中心院前急救反应能力分析

目的通过客观指标评估2009年自贡市急救中心院前急救反应能力。方法回顾性分析自贡市急救中心2009年所有院前急救数据库,计算接警受理时间、出车准备时间、应急反应时间、急救半径,并与2007年应急反应时间、急救半径比较,分析其可能的影响因素。结果全年院前出诊病例共4588例,接警受理时间为（41.92±10.76）秒,出车准备时间为（2.03±1.11）分钟,白班出车准备时间比夜班短（P（0.05）,急救半径为（10.39±11.24）km;应急反应时间为（20.31±19.61）分钟,与出诊范围、昼夜分布有关（P（0.05）;急救半径及应急反应时间较2007年增加（P（0.05）。结论进一步普及急救知识,提高急诊队伍急救能力,加强急救网络标准化建设,不断提高急救反应能力,方能满足人民群众对急救资源需求的增加。     

黄山山岳型景区院前急救安全隐患分析及对策

针对山岳型景区院前急救中存在的安全隐患进行归纳、分析,并就安全隐患的防范对策作初步探讨,以利于提高山岳型景区院前急救效率和质量,有效规避医疗纠纷的发生.     

Trends in mortality of emergency departments patients in China

BACKGROUND: Emergency medical service system (EMSS) in China is becoming more important. However, studies on mortality of emergency departments (EDs) patients in tertiary hospitals and on the trends in mortality of ED patients all over China are stagnant. The objective of this study was to quantify and describe the trends in mortality of ED patients in China. METHODS: Nine tertiary teaching hospitals were selected from tertiary teaching hospitals in different regions. The annual numbers of ED visits and deaths of these hospitals in 2004, 2009 and 2014 were recorded and analyzed. Chi-square test was used to compare the mortality of the EDs’ visits. Moreover, data on the mortality of ED patients in China from 2005 to 2015 were summarized and analyzed from the China Health and Family Planning Statistical Yearbooks (2006-2016). RESULTS: From 2004 to 2014, the overall annual mortalities in EDs increased among the tertiary hospitals (P<0.001). However, the overall annual mortality in EDs all over China decreased from 0.12% in 2005 to 0.08% in 2015. And the mortalities of EDs patients in the eastern, central and western regions of China all decreased. In addition, the average mortality of EDs patients in northern China was obviously higher than that in southern China (P<0.05). CONCLUSION: The ED mortality was increased in tertiary hospitals while decreased all over China during the past decade, which may be partly caused by some critical challenges faced by China’s EMSS, such as overcrowding and long length of stay in EDs of tertiary hospitals.     

Observational study of prehospital delays in patients with chest pain

Method: A prospective observational study of prehospital times and events was undertaken on a target population of patients presenting with acute chest pain attributable to an acute coronary syndrome over a three month period.

Results: Patients who decided to call the ambulance service were compared with patients who contacted any other service. Most patients who contact non-ambulance services are seen by general practitioners. The prehospital system time for 121 patients who chose to call the ambulance service first was significantly shorter than for 96 patients who chose to call another service (median 57 min v 107 min; p<0.001). Of the 42 patients thrombolysed in the emergency department, those who chose to call the ambulance service had significantly shorter prehospital system times (number 21 v 21; median 44 v 69 min; p<0.001). Overall time from pain onset to initiation of thrombolysis was significantly longer in the group of patients who called a non-ambulance service first (median 130 min v 248 min; p=0.005).

Conclusions: Patient with acute ischaemic chest pain who call their general practice instead of the ambulance service are likely to have delayed thrombolysis. This is likely to result in increased mortality. The most beneficial current approach is for general practices to divert all patients with possible ischaemic chest pain onset within 12 hours direct to the ambulance service.

     

Patient satisfaction with prehospital emergency care following a hip fracture: a prospective questionnaire-based study

Background

Older patients with a hip fracture require specialized emergency care and their first healthcare encounter before arriving at the hospital is often with the ambulance service. Since 2005 there has been a registered nurse on the crew of every ambulance in Sweden in order to provide prehospital emergency care and to prepare the patients for hospitalization. It is important to investigate patient satisfaction with prehospital emergency care following a hip fracture to ensure that their expectations of good care are met.The aim of this study was to investigate patient satisfaction with prehospital emergency care following a hip fracture by comparing two similar emergency care contexts.

Methods

The study was conducted using the Consumer Emergency Care Satisfaction Scale (CECSS) on patients treated for hip fracture in prehospital emergency care. The data were collected within a randomized controlled study for the purpose of comparing prehospital fast track care (PFTC) and the traditional type of transport to an accident and emergency department (A&E).

Results

Questionnaire data from 287 patients, 188 women (66%) and 99 men (34%) with a mean age of 80.9 years, were analysed. More than 80% of the patients selected the most positive response alternatives, but 16% were dissatisfied with the nursing information provided. Patients in PFTC responded more positively on specific caring behaviour than those transported to the A&E department in the traditional way.

Conclusion

Patient satisfaction with prehospital emergency care following a hip fracture is an important outcome and this study highlights the fact that patients expressed a high level of satisfaction with the prehospital emergency care provided by ambulance nurses in both care contexts under study. However, some areas need to be improved in terms of nursing information.

     

Prehospital rapid sequence induction by emergency physicians: Is it safe?

Objectives—To determine if there were differences in practice or intubation mishap rate between anaesthetists and accident and emergency physicians performing rapid sequence induction of anaesthesia (RSI) in the prehospital setting.     

Characteristics and outcome of prehospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians

Aim

To collect data regarding prehospital paediatric tracheal intubation by emergency physicians skilled in advanced airway management.

Methods

A prospective 8-year observational study of a single emergency physician-staffed emergency medical service. Self-reporting by emergency physicians of all children aged 0–14 years who had prehospital tracheal intubation and were attended by either anaesthesia-trained emergency physicians (group 1) or by a mixture of anaesthesia and non-anaesthesia-trained emergency physicians (group 2).

Results

Eighty-two out of 2040 children (4.0%) had prehospital tracheal intubation (58 in group 1). The most common diagnoses were trauma (50%; in school children, 73.0%), convulsions (13.4%) and SIDS (12.2%; in infants, 58.8%). The overall tracheal intubation success rate was 57 out of 58 attempts (98.3%). Compared to older children, infants had a higher number of Cormack–Lehane scores of 3 or 4, “difficult to intubate” status (both 3 out of 13; 23.1%) and a lower first attempt success rate for tracheal intubation (p = 0.04). Among all 82 children 71 (86.6%) survived to hospital admission and 63 (76.8%) to discharge. Of the 63 survivors, 54 (85.7%) demonstrated a favourable or unchanged neurological outcome (PCPC 1–3). The survival and neurological outcomes of infants were inferior compared to older children (p < 0.001). On average an emergency physician performed one prehospital tracheal intubation in 3 years in a child and one in 13 years in an infant.

Conclusions

Anaesthesia-trained emergency physicians working in our system report high success rates for prehospital tracheal intubation in children. Survival and neurological outcomes were considerably better than reported in previous studies.     

Treatment of acute myocardial infarction in Scottish emergency departments: survey of current practice.

INTRODUCTION: Thrombolysis was rarely given in emergency departments in Scotland when last studied in 1996. This study aimed to review the current practice of Scottish emergency departments with respect to thrombolysis for acute myocardial infarction. METHODS: Postal questionnaires were sent to all emergency departments in Scotland staffed by at least one consultant in emergency medicine, assessing the processes used for thrombolysis of acute myocardial infarction in the emergency department. A reminder letter was sent to non-responders after 1 month. All results were anonymized. RESULTS: The response rate was 77% (23 questionnaires from 30 hospitals). Twenty (87%) emergency departments performed thrombolysis according to protocol. In 13 emergency departments, thrombolysis was initiated by the emergency department staff, in six by on-call physicians and one emergency department had nurse-led thrombolysis. Twelve emergency departments occasionally received patients who had been given prehospital thrombolysis. Six hospitals had on-site primary angioplasty but only two hospitals had a 24-h service. Thirteen respondents thought the emergency department was the most appropriate place for thrombolysis, four felt that prehospital thrombolysis was best and one thought that coronary care was optimal. Four respondents felt that prehospital or the emergency department were the best options. CONCLUSION: Most emergency departments in Scotland are now administering thrombolysis for patients with acute myocardial infarction. Thrombolysis, delivered either in the prehospital arena or in the emergency department, is likely to be the primary option for patients with acute myocardial infarction in Scotland in the foreseeable future.     

Medical involvement in prehospital care--a transatlantic comparison.

The role of doctors in prehospital care in the United Kingdom and the USA was compared using information obtained from a visit to the city of Houston emergency medical service (Houston, Texas) and from a review of published reports. The involvement of full time specialist emergency medical services physicians has been crucial to the development of improved standards of practice within American prehospital care. The specialty of accident and emergency medicine should support provision of medical advice to the ambulance services by closer liaison with ambulance service trusts and the formalisation of training in prehospital care to specialist registrars.     

不同院前急救培训方案对社区服务人员的培训效果

目的探讨普及社区服务人员院前急救培训的最佳方法。方法采用方便抽样的方法选取了上海市老西门、外滩两个社区的91名社区服务人员,按随机数字表法将其分配到3个培训模式组中进行院前急救培训。采用红十字会的理论和技能评估工具在培训前、培训后即刻、培训后1个月、培训后3个月对3组学员的培训效果进行评估。结果 3组社区服务人员在培训前的一般情况没有统计学差异(P>0.05)。培训后,3组人员在各评估项目上的差异均有统计学意义(均P<0.05)。结论利用最佳培训方式,注重实效,普及院前急救培训;确立再培训时间,可增强培训效果。     

The Medizinercorps Graz: A 120-Year-Old Institution of Emergency Medicine

Abstract

One year after the establishment of the rescue service of Graz, Austria, in 1889, twelve young medical students were recruited because of the lack of accredited physicians for emergency care, leading to the foundation of the Medizinercorps Graz. This concept of involving medical students in prehospital emergency care has been retained for more than 120 years, and today the Medizinercorps is integrated into the local Red Cross branch, staffing two emergency ambulance vehicles. The responsible medical officer is called Rettungsmediziner and is an advanced medical student with a specialized emergency medical training of more than 3,000 hours, comprising theoretical lectures; in-hospital clerkships in anesthesia, internal medicine, and surgery; manikin training; and hands-on peer-to-peer teaching during assignments. The local emergency medical system provides at least 10 regular basic ambulance vehicles, the two emergency ambulance vehicles, and two emergency physicians on a 24-hours-a-day/seven-days-a-week basis for about 300,000 people. The emergency ambulance vehicles staffed with a Rettungsmediziner respond to all kinds of possibly life-threatening situations and also provide interhospital transfer of intensive care patients. This entirely volunteer-based system enables extremely high-level prehospital emergency care, saves resources and reduces costs, and employs modern training concepts for the continuing advancement of prehospital emergency care.     

Prehospital Emergency Care in Shanghai: Present and Future

Background

In Shanghai, prehospital emergency medical services are provided by the public Ambulance Services. The 60th anniversary of the local Ambulance Services is a good opportunity to provide an overview of the current trends in prehospital emergency medical care in Shanghai.

Objectives

In this report, the features of Shanghai prehospital emergency medical care are described, as well as the Shanghai model of purely prehospital emergency medical care, including the communications and dispatch system, ambulance depots and ambulances, and prehospital rescue teams. Responses to major incidents including public health emergencies and natural disasters are also discussed, with the intention of highlighting future directions in emergency medical services, as well as the influence of international trends in emergency patient care.

Discussion

Although Shanghai has the most advanced dispatch system in China (equipped with a Global Positioning System, Global Information System, and more) and can be expanded quickly in case of mass casualty incidents, there is, as yet, no uniform Emergency Medical Service (EMS) dispatching for the entire city. Nor are there certifications, degrees, or special continuing education programs available for EMS dispatchers. Although there are more and more ambulance depots spread all over Shanghai, the city struggles with inadequate prehospital emergency caregivers, because every ambulance has to be staffed with a qualified Emergency Physician, and there are also recruitment problems for ambulance physicians.

Conclusions

Although faced with many challenges, substantial progress is expected in Shanghai prehospital emergency care.     

体验式教学在急危重症护理学中的应用

目的 探讨在急危重症护理学教学中开展体验式教学的效果.方法 将2008级护理专业本科学生65名分为2个团队,进行突发公共事件急救医疗服务体系体验性演练,并对演练全过程录像.演练结束后回放录像并反思,进行总结汇报,写出心得体会.实验课程结束后,发放调查表了解学生对体验式教学效果的评价.结果 90.6％以上的学生认为体验式教学对巩固理论知识,提高急救意识、急救技能、沟通能力、应变能力、团队协作能力等方面帮助较大或很大.结论 体验式教学有利于激发学生的学习积极性,培养其自主学习的能力及急救综合能力,有助于学生沟通交流、团结协作、人文关怀及应变能力等综合素质的培养.     

Role of rapid sequence induction for intubation in the prehospital setting: helpful or harmful?

Use of rapid sequence induction for intubation was introduced to the prehospital environment in the hope of enhancing patient outcome by improving early definitive airway management. Varying success has been achieved in both air and ground transport emergency medical services systems, but concern persists about the potential to cause patients harm. Individual emergency medical services systems must determine the need for rapid sequence induction for intubation and their ability to implement a rapid sequence induction for intubation protocol effectively with minimal adverse events. Therefore, the value of rapid sequence induction for intubation is dependent on each emergency medical services system design in their ability to establish personnel requirements and ongoing training, expertise in airway management skills, medical direction and supervision, and a quality assurance program. If these principles are strictly adhered to, rapid sequence induction for intubation may be safely used as an advanced airway management technique in the prehospital setting.