Need an Acute Care System? Start Building It.

Published on October 29, 2015
Building a country’s emergency medicine acute care system need no longer be a shot in the dark. Over 65 countries around the world have developed a functional EM system, and consistent patterns and challenges of development have emerged, providing a clear pathway to any country now that wants to build an EM system. Here’s how to start.

The world is on the cusp of a breakthrough in emergency medicine (EM) development. Until the 1960’s, no country in the world had EM as an official medical specialty or had developed a comprehensive acute care system. Over the next several decades, the rate of national EM specialty development and national acute care systems development progressed steadily. In 2015, there are approximately 65 countries worldwide with EM as an official medical specialty, with 3–5 countries per year adopting EM as a specialty and beginning to develop their own comprehensive EM systems.

There are many social, economic, political, and scientific reasons for this progression of EM and acute care systems development, but perhaps the most important reason is that the world of global emergency medicine is learning from its experiences. Compared to our early experiences in the 1960’s and 1970’s, the world now knows much more about how to build comprehensive EM and acute care systems, on local, national, and regional scales. When emergency physicians, hospitals, universities, or health ministries are seeking solutions for problems with overcrowded emergency rooms, personnel and training shortages in critical care and trauma, and the escalating costs of hospital care (all the normal healthcare problems), they increasingly look to those countries and professional EM societies with established EM and acute care systems, and with histories of collaboration and cooperation. The emerging field of global emergency medicine development has responded to these inquiries and requests, and offers solutions to these common challenges and difficulties that are specific to culture, socioeconomics, and local health care needs and abilities. Instead of offering a one-size-fits-all pathway to EM and acute care systems development, the field of global emergency medicine instead suggests the common endpoints of comprehensive EM and acute care systems, and shares successful pathways to reach these endpoints.

This approach works because of the relative homogeneity of acute care systems around the world. At first glance, the respective EM/acute care systems of three or four countries look very different and distinct. However, after being exposed to 30, 40, or 50 countries’ EM systems, they start to look more similar and alike, despite small differences in language, culture, socioeconomic status, or health care system. Patterns in EM system development begin to emerge, and it becomes apparent that other countries’ experiences and histories in national EM development can be used as templates or road-maps for other emerging EM systems. For example, when sifting through each country’s specific set of challenges and difficulties surrounding EM development, it becomes obvious that approximately 70%–80% of their difficulties are nearly identical across different countries and societies. Therefore, global EM development experiences have shown that—rather than “reinventing the wheel”—each country only needs to reinvent and discover the answers to about 20% of their own country-specific EM development challenges, and they can look outside their borders for ideas and assistance for the majority of their challenges. Only a small minority of EM systems development problems are completely country-specific.

Building a comprehensive EM and acute care system requires far more than training emergency care providers; it requires a multifaceted, multi-professional, multidisciplinary collection of systems-within-systems: patient care systems, education and academic systems, administration and management systems, economic and finance systems, legislative and health policy agendas, and public health and national policy agendas. Each of these systems and subsystems have their own timeline, professionals, nomenclature, and financing and governance, yet each must be developed simultaneously (if possible) and interlinked as much as possible in order for a comprehensive EM and acute care system to emerge.

The ultimate goal of EM systems development is to provide the highest quality, safest, most efficacious and cost-effective emergency care to every person—yet each country goes about this development curve slightly differently. Historically, the development project curve for acute care systems usually starts after a handful of interested care givers work to establish patient care systems and training programs, often resulting in the recognition of EM as an official medical specialty (or its equivalent) in that country. Following the establishment of training programs, steps need to be taken to influence and secure financial support for EM care and EM providers. For example, legislative support to ensure nationwide access, and equality and efficacy of emergency care; and public health and policy support to establish and ensure EM as a national priority of national health care systems and agendas.

How to connect all these unconnected systems? Unlike natural, organic systems that grow and flourish under their own impetus and power, EM systems development has to be influenced, coaxed, and sometimes dragged kicking and screaming through these upper echelons of development—often against considerable political, economic, and systemic resistance. Someone has to build it, and, put simply, that’s really what development is.

Over the past 15–20 years of collective experience of EM systems development in approximately 65+ countries around the world, certain patterns of EM development have emerged. In general, the many hundreds of seemingly unrelated difficulties and challenges appear to fall into a relatively small number of major categories, each of which is connected to and embedded inside the other categories. Roughly speaking, it has been proposed that there are eight major systems that should be completed in order to build a comprehensive acute care system. They can be visualized as an interconnected set of systems and subsystems (similar to a collection of embedded Russian dolls), and are outlined here:

i) Discrete patient care systems—Hospitals, clinics, community clinics, etc.

ii) Education systems—Specialty training for physicians, nurses, EMTs, dispatchers, midwives, community health workers, etc.

iii) Administration and management systems—How do you run an ED? How does it fit into your hospital system? How does your system run 50 EDs?

iv) Economic and finance systems—How does a person pay for their emergency care? How does the hospital pay providers and prepare for emergency care? How does the national health care system and/or insurance system pay for emergency care, if at all?

v) Legislative agenda—Legislation is involved in patient care, education, administration and management (especially larger scale management), and financing/funding. Examples include EMTALA (in the United States), Prudent Layperson’s Rules, Acute Health Care as a Human Right, etc.

vi) Health policy agenda—How to get emergency care on the health policy radar screen of national Ministers of Health? Of Ministers of Economics? For example, is health care defined in a country as a human right (political)? If so, is the government required to fund health care (legislative) and thereby fund acute/emergency care?

vii) Public health agenda—The need for emergency care is ultimately an indicator of a country’s overall dedication to public health. As Rudolph Virchow said, “Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.” Emergency care is a subset of the larger system of public health. Globally, improvements in longevity and quality of life came from public health measures. The emergency physician (EP) working in the ED is contributing their own share to public health; EPs take care of the people who often have no other option for care. Dr. Lewis Goldfrank, an EP, has said, “Every patient who presents to the emergency department represents a failure of the public health system.” Improvements in public health are reflected in a population’s use of the ED, and good emergency care contributes to public health. As the front door to the health care system, EDs are vital for providing first-hand disease surveillance, recognition, treatment and disposition, and the ripples of good emergency care are felt all across the hospital system, the economic system, and the public health system.

viii) Identifying and solving local variations—While most challenges and solutions to newly developing EM systems can be found outside that country, embedded in the history and experiences of the dozens of other countries on similar EM development curves, there are nevertheless local challenges that apply only to one or a few countries. Examples include religious or cultural necessities, region-specific epidemiologic or demographic needs, or locally-defined cultural or socioeconomic issues. It falls to each country to examine and develop local solutions to these local problems, which, again, usually only constitute a small minority of EM developmental issues.

DISCUSSION

These eight categories function as discrete spheres but are necessarily interlinked and connected. The linkage between these discrete yet connected spheres constitutes the entire system. An action or a behavior affecting variables in one sphere is felt, responded to, and compensated for by the rest of the system. The entire system starts to look like an interconnected living organism—each variable is connected to nearly all of the other variables, and small change in one sphere is felt throughout the whole system. When the system is built to strengthen itself and to push forward its own development, we see rapid progression along the EM development curve, and the eventual establishment of a comprehensive system. That’s the goal to keep in mind when starting to build projects in each of these eight categories.

The next step in global EM development may likely prove revolutionary, wherein countries who choose to adopt cheaper and more effective ways to deliver emergency care will influence EM care even in developed systems.

I envision these categories hierarchically, like a set of nested Russian dolls. Step 1 is the innermost doll, with each subsequent subsystem fitting outside the inner subsystems. Each subsystem—care systems, education systems, administration, economics, legislation, public health, health policy—needs to be built individually but with the connections to the other subsystems in mind. None of the individual subsystems can be done overnight and each has its own particular time frame for development, examples of which can be found by looking to other countries’ EM development experiences. Whereas EP training and specialty recognition can be done in 3–5 years, for example, economic and legislative agendas may take 5–10 years, and policy agendas can take 5–15 years, depending on local challenges and priorities. Nevertheless, these EM developmental projects must be undertaken and they can be achieved. In the words of Bill Gates, “We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten. Don’t let yourself be lulled into inaction.”

The field of emergency medicine is approaching 50 years old. The field of global EM development is leaving a top-down, proscriptive model wherein the influence of a few countries is offered and filtered down into the rest of the world. Instead, we are now entering a hybrid model wherein EM developments in the rest of the world are filtering back and influencing the so-called founding countries. The next step in global EM development may likely prove revolutionary, wherein countries who choose to adopt cheaper and more effective ways to deliver emergency care will influence EM care even in developed systems.

It’s an exciting time to be involved in global emergency medicine development. Thirty years ago, the world didn’t really know how to build EM systems, and, thirty years from now, nearly every country in the world will have begun or finished building EM systems. The window of opportunity for global EM development is wide open right now, and the experiences of the 65+ countries now undertaking EM development are ripe with learning opportunities, both positive and negative, by which EM and acute care systems development can progress country by country, region by region, to the benefit of emergency patients all over the world.

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