China: Mainland E.M. Takes Strides

Published on October 29, 2015
The emergency department at The University of Hong Kong-Shenzhen Hospital is the first ED in mainland China to meet international standards.

The University of Hong Kong-Shenzhen Hospital first opened its doors for clinical service in July 2012. It aims to reform healthcare in China, as well as bring the best in teaching, training, and research into Shenzhen

Shenzhen is a major city in the southern Province of Guangdong, located immediately north of the Hong Kong Special Administrative Region, and about 30 kilometers north of Hong Kong itself. The Shenzhen area is China’s first Special Economic Zone—and one of its most successful. It covers 2,050 square kilometers and has a total population of more than 14 million.

The University of Hong Kong-Shenzhen Hospital (HKUSZH) is a proud collaboration between the Shenzhen Municipal Government and the University of Hong Kong (HKU). This project, begun in 2012, aims to reform healthcare in China, as well as bring the best in teaching, training, and research into Shenzhen, all of which meet international standards.

BASELINE CHALLENGES

Healthcare reform is a huge task with many challenges and obstacles. The Chief of Service, Dr. Gary Chu, arrived at this hospital in September 2012. The second consultant, Dr. Constantine Au, joined in December 2012. At that time, the Accident and Emergency Department (A&E) consisted of only a small resuscitation room. Two nursing staff members had to deal alone with anything from minor allergic reactions to major trauma, including falls from a construction site next to this hospital. Staff slowly joined the department. At that time, the Medical School in Shenzhen was still new and there were no medical graduates from Shenzhen. All doctors and nurses came from different parts of China. They had different training, different exposure, and different expectations.

Most A&Es in China categorize patients according to specialty. For example, a woman with abdominal pain may be seen by a gynecologist on call. Emergency generalists are rare in China. As the A&E of HKUSZH aimed to follow the Hong Kong system, it introduced generalist care and triage according to severity.

Abuse of CT scan, ESR, and CRP were common. Despite ordering Troponin I for chest pain patients, doctors would order CK-MB as well. However, they seldom ordered h’stix or ECG for indicated patients.

Indicated drug use was different from that of Hong Kong. The law required skin tests for the use of penicillin, tetanus vaccine, and antiserum for snake bite. As a result, cephalosporin became the first choice of many doctors. Abuse of ribavirin was common. Intravenous drip was commonly prescribed to A&E patients in China.

In China, patients keep the A&E records after discharge, and hospitals seldom keep copies. As a result, A&E doctors do not record much on these records, to avoid complaint or litigation.

WHAT DID WE DO?

The A&E of HKUSZH aims to promote evidence-based medicine in order to reduce unnecessary investigations, use of antivirals, and use of IV drugs. Its goal is to become an icon of emergency medicine in China.

We also wanted to inform and educate the public of the concept of A&E HKUSZH, and to manage public expectations. Signage and pamphlets were arranged, and interviews were conducted with local media outlets.

ON-SITE TRAINING

The next step was to offer in-house training and supervision to A&E staff. Doctors and nurses from the A&E departments of Queen Elizabeth Hospital, Alice Ho Miu Ling Nethersole Hospital, United Christian Hospital, Caritas Medical Centre, North Lantau Hospital, and volunteers of the Hong Kong St. John Ambulance Brigade, Hong Kong Red Cross, and other organizations, were invited to Shenzhen to offer in-house training. The training topics included triage systems, resuscitation, infection control, and communication skills. The first Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) of the American Heart Association were conducted in November 2012, in Shenzhen. The first few doctors and nurses of the department joined these courses. When a new target was set, the choice given to the staff was either to achieve it or to leave the department. An audit team, headed by Dr. Innu Li, was put in place to monitor performance and adherence to department protocols.

Dr. Gary Chu and Dr. Constantine Au personally supervised doctors in handling pediatric patients for two months. Each doctor in the department had to undergo pediatric rotation for at least one month. Dr. Robert Yuen, a retired pediatric consultant of Hong Kong, conducted monthly training for doctors and nurses between 2013 and 2014. Rotations to ENT and gynecology were arranged. Each doctor and each nurse had to attend the Airway Workshop. Afterward, doctors had to finish a two-week attachment at the Operating Theatre, and nurses had to finish a three-day attachment. Dr. Tak-Lun Poon, a part-time orthopedic specialist of HKUSZH, started to conduct regular training in trauma, basic surgical skills, and orthopedic skills in mid-2013. Hands-on bedside ultrasound training—rarely practiced by A&E doctors in China—was conducted regularly.

As English is the international language of Western Medicine, English classes were arranged to teach the staff daily English, with separate classes for medical English.

The A&E department is prone to all sorts of complaints, originating from both patients and intra-staff conflict. To enhance the communication skills of the staff, communication workshops began in September 2014. Country and Barrick, a head-hunting company in Hong Kong, conducted the first two workshops. The recent complaint rate has ranged from 0.00% to 0.17% per month.

OFF-SITE TRAINING

In order to raise training exposure, doctors and nurses were sent to training centers in Hong Kong and elsewhere. Clinical observations and visits were conducted at the A&E departments of Queen Elizabeth Hospital, United Christian Hospital, Caritas Medical Centre, and Alice Ho Miu Ling Nethersole Hospital.

With the exception of the first few doctors and nurses who joined the department, all doctors and nurses were sent to the Caritas Medical Centre-Resuscitation Training Centre (CMC-RTC) in Hong Kong to receive further training in BLS, ACLS, and to take the Trauma Course of CMC-RTC. This collaboration began in May 2013. About one-third completed the Pediatric Advanced Life Support (PALS) as well.

The ambulance crew attached to the A&E of HKUSZH received training from the Hong Kong St. John Ambulance Brigade (HKSJB). The instructors of HKSJB came to HKUSZH and conducted some lectures and skill stations in January 2014. Each crewmember was then sent to Hong Kong and had a three-day attachment with HKSJB.

The Hong Kong Poison Information Centre (HKPIC) offered much support to our training program. Two doctors completed the Diploma Course in Clinical Toxicology in 2015. Since mid-2013, many doctors and nurses have taken the Certificate Course in Clinical Toxicology.

Infection control was a hot topic after SARS. Starting in 2013, four doctors went to the University of Hong Kong to take the two-year Certificate of Infectious Disease course, and three nurses took the two-year Infection Control Course. The world-famous Prof. KY Yuen conducted both courses. They completed their courses in July 2015, and another batch will start in November 2015. All staff now wear surgical masks when approaching any patients—another rare practice in China.

Three doctors and two nurses attended the Winfocus Congress, in Hong Kong, in November 2013. They then assisted with in-house training efforts.

Dr. Wei-fu Qiu was the first doctor to attend the Advanced Trauma Life Support (ATLS) of the Queen Mary Hospital, in January 2014. To date, nine of our doctors have passed the examination. The target is to have all doctors trained. In May 2014, three nurses completed the Advanced Trauma Care for Nurses (ATCN), and another three completed the course in May 2015.

Our doctors and nurses have attended many overseas training courses, as well, including the Toxicology Course in Macao, the Toxicology Course in Kaula Lumpar, Malaysia, and the Asian Conference on Emergency Medicine in Tokyo.

In China, “grandfather practice” tends to overrule evidence-based practice. The A&E of HKUSZH is determined to introduce evidence-based practice to China. A group of our doctors and nurses attended the 12th Asia Pacific Evidence-Based Medicine & Nursing Workshop and Conference, in Singapore, in February 2014. Together with the audit team, they saw some successes. For example, the use of IV drugs has been reduced; fewer than ten IV drugs were ordered for ~300 daily patients. The prescription rate of ribavirin has dropped from 300 prescriptions monthly to zero. Abuse of ESR, CRP, CK-MB was stopped. Gastric lavage has only been used three times since our operation; instead, the A&E follows the international standard and uses activated charcoal. At the time of writing, a group of doctors and nurses are taking the Evidence-Based Medicine/Nursing and Literature Appraisal Workshop organized by the Hong Kong College of Emergency Medicine.

To further promote bedside ultrasound, we formed a collaboration with the Australian Institute of Ultrasound (AIU). In October 2014, the first batch of three doctors and two nurses went to AIU in Gold Coast, Australia to learn ultrasound in emergency medicine. The team visited the A&E of the Gold Coast Hospital, as well. Several months later, tutors from AIU came to Shenzhen to teach. Additional courses are scheduled in 2015.

In order to prepare the AED for possible CBRN attack, five doctors and five nurses attended Advanced Hazmat Life Support (AHLS) at the Alice Ho Miu Ling Nethersole Hospital, in Hong Kong, in January 2015. A decontamination chamber is currently under construction at HKUSZH.

MILESTONES

The A&E HKUSZH started her test run in May 2013, with partial services, which were extended to 24 hours a day in September 2013. Unlike other A&E departments in China, patients are prioritized according to their clinical needs, instead of by specialty. The Hong Kong A&E triage system is implemented right from the beginning. As all of the A&E doctors and nurses have formal BLS and ACLS training, the A&E department is responsible for emergency crash calls throughout the hospital, including all the wards and non-clinical areas. A resuscitation record template has been designed to improve and standardize the documentation. These records will be audited by the A&E department to ensure that our hospital maintains its standards, and for CQI. Incidents involving mass casualties and fatalities require strong multidisciplinary collaborations. Thus, in preparing for disasters and outbreaks such as Ebola, we are also working closely with other clinical departments and government departments to conduct drills and set up protocols.

As there were only two full time consultants at the beginning of service, telemedicine was practised. A department WeChat group was set up for 24/7 monitoring and supervision. Working groups have their own WeChat groups, as well.

Other milestones include beginning limited ambulance service in mid-December 2013, which later extended to 24 hours a day. Unmatched Type O Blood was first transfused at the A&E in March 2014, another practice that is seldom conducted in China.

ANTI-VIOLENCE TRAINING

To fight against workplace violence—a serious problem in this locality—the Critical Incident Support Team (CIST) assembled in March 2014. Dr. Shaolong Leng, who holds a medical degree as well as a law degree, leads the CIST. Zero tolerance is the motto. All A&E staff received a personal alarm. The CIST prepared educational materials and a training program on this important issue, and all AED staff, regardless of rank, must complete the Workplace Violence Course. This course aims to minimize incidence, avoid harm, and facilitate police reports. The course was well received and is now extended to staff of other departments. The CIST offers 24/7 support against workplace violence, and it has produced a video to educate the public on this issue.

GRAND OPENING

The official opening was celebrated on June 16, 2014, when the A&E department had finally acquired most of the basic elements of an A&E. We were honored to have Prof. Peter Cameron, Prof. Gautam Bodiwala, Prof. Judith Tintinalli, and Prof. Maaret Castren as our keynote speakers, plus over 50 guest speakers from five continents. The opening coincided with the 2014 Global Emergency Medicine (GEM) meeting, which was granted the National CME of China, as well as CME from most colleges of the Hong Kong Academy of Medicine. Media coverage lasted for two weeks.

The emergency ward opened in August 2014. It started with seven beds, and the ultimate goal is to have 30 beds.

In January 2015, Dr. Fei-lung Lau, the Founding Director of HKPIC, Dr. Man-li Tse, the Consultant of HKPIC and Dr. Yiu-Cheung Chan the Associate Consultant of HKPIC joined the A&E of HKUSZH as part-time consultants. The aim is raise the training and service of clinical toxicology to international standards. Liquid activated charcoal was first used in an intoxicated patient in April 2015. This is not a common decontamination method in China. With their help, a Clinical Toxicology Team was formed, and, as of January 2015, 24/7 phone consultation is available to the A&E doctors and nurses.

INTERNATIONAL ACCREDITATION

The Accreditation Team of the Hong Kong College of Emergency Medicine (HKCEM) visited the A&E department of HKUSZH in December 2014. The findings were favorable. The Council Meeting of HKCEM approved the accreditation in March 2015. On April 9, 2015, the Hong Kong Academy of Medicine officially endorsed this approval. The A&E of HKUSZH is the first training center of HKCEM that lies outside Hong Kong.

HKUSZH is undergoing the accreditation of the Australian Council of Healthcare Standards (ACHS). The A&E is responsible for hospital-wide CPR training, resuscitation audit, and admission flow CQI project. The preliminary comments have been favorable.

COMMUNITY OUTREACH AND RELATIONS

Serving the local community is always our priority. We have conducted a First Aid Promotion Program, visited many schools to promote CPR, and conducted health talks and health checks at a local eldercare center. We formed a Community First Aid Teaching Team, led by two registered nurses, Ms. Meng Yao and Ms. Rong-xiang Shi. This team was given portable CPR mannequins and Automated External Defibrillator trainers, and the team regularly conducts classes with ~20 local participants.

In 2015, we launched the Safe School Shenzhen Project to spread the concept of community first aid to the students of Shenzhen. An Official WeChat Site was set up in May 2015 for the promotion of Emergency Medicine and First Aid to the community. Dr. Innu Li headed this Public Relation Team.

In January 2014, the department hosted the first Sports First Aid Foundation Course in China, in cooperation with the Asian Football-Rugby Union. HKUSZH A&E doctors and nurses have provided standby medical care for international rugby leagues in China, local tennis matches, as well as the Youth Olympics of 2014.

Our main working partner in bringing an international standard of EM to the whole of China is the China Candlelight Education Fund of Hong Kong. This foundation has built over 450 schools in rural China in the past 20 years. Since 2014, it decided to branch out into medical education. Our first joint project began in October 2014, in which instructors of CPR and infectious diseases were sent to rural hospitals in Guangdong Province. This exchange was well received, and the visits are conducted each season. This exchange program will be extended to the Guizhou province in southwest China beginning September 2015.

To date, the daily patient load ranges from 250–450, with weekend surges. Half of these patients are children. In addition to the two full-time and three part-time Consultants from Hong Kong, there are 26 local doctors. Dr. Wei Han, Dr. Huaming Pan, and Dr. Yanli Wang are the Associate Consultants, while the rest are residents. There are 34 nurses, headed by Ms. Jing Zhou. Mr. Xuanji Huang, Ms. Jiangyue Liu, and Ms. Mina Tao are the three Advanced Practice Nurses and the rest are registered nurses.

FUTURE DEVELOPMENT

In addition to improving our current services and projects, we have a long wish-list. The A&E department will expand the number of beds in the emergency ward. An E-ICU will be opened within two years. Dr. Wei-fu Qiu and his team started the Trauma Registry in January 2015, and we will use those data to improve trauma management.

The Clinical Toxicology Team aims to offer consultations to all clinical departments of HKUSZH within two years. With the help of the three Clinical Toxicologists from Hong Kong, the hope is that the A&E of HKUSZH will become a branch of the HKPIC.

In terms of training in the future, HKUSZH has applied to become an International Training Centre (ITC) of the American Heart Association. The A&E department will manage this ITC. Simulation courses in resuscitation, trauma care, and ultrasound will be developed. We shall develop more research projects and submit more publications. More efforts will be spent on promotion of evidence-based medicine and evidence-based nursing.

In terms of community service, we shall increase the number of CPR/AED classes, and will conduct more training exchanges with hospitals in China and Asia.

e.g. Global, Research, or India
e.g. Features, Opinion, or Research
Browse by Category
    Most Popular
      Download Latest Issue
      Issue 19