Original Article
Identifying the Need for Pre-hospital and Emergency Care in the
Developing World : A Case Study in
P Ramanujam, Miriam Aschkenasy
Abstract
Objectives : Increasing industrialization in the developing world
has contributed to an epidemiological transition in disease pattern from
infectious disease as a primary cause of morbidity and mortality, to more
chronic illness such as heart disease and trauma. This study was done in order
to assess the effectiveness of pre-hospital and emergency care as the health
care needs of the population changes and to make recommendations to meet the
growing need for organized emergency services in that community.
Methods :
Results : Data analysis revealed increasing mortality from trauma
and cardiovascular etiologies. Hospital statistics showed that 1/3 of the
annual hospitalizations were from trauma and acute coronary syndromes. Half the
trauma victims had no formal prehospital intervention. Standard of care in the
emergency departments varied considerably with less than half of them carrying
defibrillators and only a third of them carrying defirbillators and only a
third of them carrying intubation equipment.
Conclusion : As developing countries begin to urbanize and grow,
so do their health care needs. The current system does not meet the needs of
increased mortality from trauma and cardiovascular disease. We have suggested
necessary changes for establishment of emergency medical services to meet the
evolving health care needs. ©
Introduction
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s developing countries enter the
twenty first century,
non-communicable diseases are rapidly growing and adding to the existing burden
of communicable diseases. What was once considered a health problem of the west
is already an established epidemic in developing parts of the world. The health
care system needs to reorganize in order to handle the rise in chronic
illnesses and trauma.
Urbanization, better access to health care, improved medical
treatment of infectious disease and health education has lead to longer life
spans, while changes in diet pattern, decreased physical activity and increased
tobacco use predispose this population to development of coronary
atherosclerosis. Current statistics indicate that cardiac diseases and stroke
will be a major cause of death and disability in 2020.1 Adding to
the burden of cardiac diseases is a growing problem from road traffic
accidents. These factors have contributed to the disease transition in
developing countries from communicable diseases to long-term chronic health
problems and trauma. Even though the epidemic is in its very early stages it is
projected to emerge as a major threat to the developing nations.2
In this study we identified the city of
During the year 2001 there were approximately five thousand
road traffic accidents and more than six hundred fatal crashes in the city of
An increasing need for emergency and pre hospital care
combined with strong interest from Sundaram Medical Foundation (SMF) a private
hospital modeled after US community hospitals compelled us to perform a needs
assessment of the system and formulate recommendations for development of an
early pre hospital system in Chennai. We attempted to validate the changing
disease pattern in the community, define the existing emergency and pre
hospital structure and recommend changes to the existing system.
Subjects and Methods
Study Design
This was a retrospective observational study conducted at
SMF, a community hospital in the town of
Setting
SMF is a one hundred and thirty-bed hospital with sixteen
thousand six hundred emergency department visits in the year 2001. The
Emergency department (ED) currently has ten
beds, one resuscitation area and one procedure room. They are the site
for an international Emergency Medicine (EM) elective and work closely with
AAEMI (American Academy for Emergency Medicine in India) a group focused on
development of Emergency Medicine in India.
The data resources were the published results of an Annanagar
health survey, data from trauma and ambulance registries of the hospital, and
unpublished data of a citywide ED survey. We obtained the demographics of the
community and the incidence of communicable and non-communicable diseases in
the community from the Annanagar health survey. Data for trauma and trauma
related visits to the ED, the severity of trauma and pre-hospital care of
trauma patients were obtained from the ED trauma log. Number of ambulance calls
for the month, site of calls, reasons for ambulance calls and time of calls
were obtained from the ambulance log.
ED visits and hospitalization for cardiovascular related
pathology were obtained from the ED admission registry. We also reviewed data
regarding the training level of physicians and equipment availability in
emergency departments across the city, which was obtained from survey results
of the community emergency departments. No patients were enrolled into the
study as subjects. We received an exemption from the IRB (Institutional Review
Board) of our Medical Centre for this study.
Data Analysis
Data was extracted from the various log books by one of the
authors (PR), entered and analyzed using Microsoft Excel.
Results
Demographic data of the community revealed the size of an
average household to be four people, with less than one-fifth of the population
over the age of sixty five. Approximately one tenth of the community were
unskilled or semi-skilled workers. Almost the entire community used modern
medicine for health care needs and more than one-third had health insurance.
Prevalence of hypertension and diabetes in the community were 25% and 16%
respectively. Even though annual incidence of Acute Myocardial Infarction (AMI)
in the community is almost five for every thousand and matches the incidence of
Malaria the annual incidence of stroke was noted to be very low. Trauma had an
annual incidence three times that of Malaria with 50% occurring in the age
group of 16-45 years Trauma accounted for an increasing number of ED visits
from 1% in 1995 to 5 % in 2000. Patients with isolated head injuries were not
included in the trauma log. During the study period, in October 2003, Trauma
was responsible for 70% of all ED visits and 14% of deaths. No formal
pre-hospital care was offered in 85% of the trauma patients.
Chest pain ranked among the top five reasons for ED visits
and about half of the admissions to the ICU (Intensive Care Unit) were from ACS
(Acute Coronary Syndrome). According to the ambulance registry, there was no
documentation of formal pre hospital care offered to these patients.
Data from the ambulance log revealed an average of ³ 3 trips/day for
the single ambulance for emergency calls. This did not account for the critical
care transports by the mobile ICU. One third of ambulance trips were within 5
km of the hospital and another one third of transports were for 5-15 km from
the hospital. Ambulance calls peaked on Thursdays for unclear reasons, and
between 0800- 1400 hours on all days except Sundays. In the majority of cases,
when ambulances were used to transport patients to hospitals, there was no pre
hospital care or treatment offered by qualified personnel. Ambulances were also
commonly used to transport ED patients to outside laboratories or for imaging
purposes with no trained medical staff on board. Call requests for ambulance
were triaged by non-physician staff and ED house staff determined need for
onboard physician.
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Data was reviewed from the citywide survey of emergency
departments performed in January 2000, around the city of Chennai. Trauma
accounted for one fifth of ED visits consistently across all the hospitals.
Although trauma is the most common diagnosis, only one in every eighteen
hospital had their ED medical staff trained in ATLS(Advanced Trauma Life
Support) and three in every eighteen hospitals had ACLS(Advanced Cardiac Life
Support) trained medical staff. Other
physicians were not certified in any other equivalent life support courses.
There was tremendous variability in the availability of medical equipment in
emergency departments. Only a third of hospitals receiving trauma patients had
cervical collars and central line equipment. About three fourths of the
hospitals in the city had resuscitation drugs, only half of them had
defibrillators in the ED and only a third of hospitals had Bag Valve Mask and
paralytics for Rapid Sequence Intubations.
Limitations
There are several limitations to our study. Most critical of
those being it is retrospective in nature there was a large amount of missing
data for pre-hospital care, trauma and acute cardiac care related hospital
visits. There is no mandatory reporting of trauma, head injury was not recorded
in the accident registry and hence the available records may not reflect the
extent of trauma related ED visits. There was no universal definition for the
word “grievous” used to stratify trauma in the registry. This could have
impacted estimating severity of trauma. Also, since there are several trauma
receiving hospitals in the area, the reported hospital data maybe exposing only
a small number of hospital visits. Ambulance registries did not always report
the medical reason for ambulance visits and no documentation of cases requiring
physician for pre hospital care was available. This provides us with almost no
way of estimating the acuity and the need for pre-hospital care in this
community.
There was no registry maintained for Acute Coronary Syndromes
(ACS). It is likely that many cases of
AMI (Acute Myocardial Infarction) during the study period were not captured
leaving us with inadequate information on pre-hospital care in patients with
AMI and out of hospital deaths due to lack of timely intervention.
Finally, demographics of this community may not represent all
other communities. There were no comparable health survey statistics available
from semi urban or rural communities. Statistics in the health survey were
based on patient self–reporting and may not reflect the true level of disease
prevalence in the population.
Discussion
Our study shows that there is morbidity and mortality from
trauma and vascular diseases indicating a compelling need for emergency care
and emergency medical services in developing countries. It is important for
governmental organizations not only to continue public health measures but also
establish emergency care and a pre hospital system. The existing systems are
rudimentary with ambulances being used as transport vehicles. Emergency
departments are staffed by physicians with no formal training. Changes should
be made in stages to this basic system by building components on the existing
infrastructure over time.
We identified the pre-hospital system in Chennai as a model
for a simple pre-hospital system. We have proposed recommendations to the
existing infrastructure to improve care for trauma and cardiovascular patients.
Since these changes should be happening over time, we have stratified them as
early, mid-phase and late phase recommendations. There is no evidence to
support introduction of strategies in the order outlined in our paper. However,
this has been built upon suggestions from physicians who have an extraordinary
knowledge of the system.
Early Phase Recommendations
1. Creating an
Emergency Medical Care Call Center : Sundaram Medical Foundation and a few
other hospitals in Chennai have an emergency number for ambulance call
requests. These numbers should be unified into one standard access number for
ease of use by the community as in western systems which can develop into a
dispatch center in the future.8
2. Levels of Care in trauma systems6 : With
the development of a pre hospital system, it may not be optimal for the
providers to take patients to hospitals not equipped for acute management of
these conditions. Hence, we recommend stratifying hospitals based on the level
of care they can provide to trauma patients. There should be a focus on
creating trauma centres as there is evidence to prove that fewer deaths occur
in seriously injured patients when taken to trauma centre versus a non trauma
centre.9
3. Training ED Physicians and Nurses : In addition to meeting
state requirements for practicing medicine, all physicians, pre hospital
providers and nurses staffing the trauma and cardiac centers should have a
standardized training in acute cardiac life support, pediatric life support and
trauma life support. Physicians and
nurses need higher level of training in handling emergencies to staff emergency
medicine departments. However, recognition of the specialty needs to be done at
a national level.
4. Developing pre hospital system : Ambulances are stationed
at each hospital site or in privately owned sites and are dispatched by the
hospital/company to the site of call.
This can be co-coordinated only if the status of the vehicle when in use
is known to the call center. A system needs to be setup which updates the call
center about the status of the vehicle availability.
Ambulances need to be stationed at locations of high volume
traffic accidents to reduce response times. An ambulance registry needs to be
created to help understand the nature of calls, severity of trauma and pre
hospital care provided to patients. This along with trauma registry will help
obtain prospective data and determine outcomes on patient morbidity and
mortality with implementation of the system.
5. Training First Responders : First responders, being the
front line medical care providers are key elements of any pre-hospital
system. In the present system in
Chennai, there are no defined pre hospital first responders. There are no
defined response times for trauma or acute cardio vascular events in the
system. Sundaram Medical Foundation proposed a novel idea of training the local
motorized rickshaw drivers (auto-rickshaws) as first responders as they are
available in large numbers in the city to provide immediate assistance. We
suggest expansion of this concept to train police officers as first responders
and offer training in first aid, defibrillation, extrication of trauma victims,
immobilization and applying cervical collars and backboards. Since timely
defibrillation and early advanced life support measures has been shown to
improve outcomes in out of hospital cardiac arrest, this needs to be
prioritized during the system development.10-12
Second Phase
The next phase should be on training pre hospital advance
life support providers. Some of the tertiary care hospitals have ambulances
which function as mobile ICUs staffed by physicians and experienced critical
care nurses. Similar training should be given to pre hospital providers and
certification process established. Standards should be established for
equipment carried by ambulance personnel. Curriculum for pre hospital provider
training can be acquired from well developed EMS systems. Concurrently, nurses
can be trained to provide advanced pre-hospital care until the early batch of
providers gain expertise in pre hospital cardiac and trauma care. In the early stages of emergency medicine and
pre-hospital development, knowledge can be gained through distance learning
methodologies and use of telecommunications, particularly for advanced cardiac
life support, trauma life support training in developing countries.13
In the next phase of growth, strong considerations should be
given to development of dispatch centres, communication between dispatch centre
and ambulances, pre-hospital provider and the receiving hospitals.
Communication plays a key role in pre hospital medical care. This helps to
alert the receiving facility about the condition of the patient and mobilize
appropriate resources in trauma and cardiovascular diseases. Once dispatch
centres are created, standardized dispatch protocols and training should be
made available to the dispatchers.
The final stage of development should involve integrating
emergency medical services in medical school curriculum, creation of quality
improvement processes and research centers to help growth of this specialty.
This will help to maintain an Emergency Medical system that will meet the
health needs of the local community.
Conclusions
Developing countries are faced with challenges of handling
increasing morbidity and mortality from vascular diseases and trauma. This has
led to an emerging interest in establishing EMS systems to handle these
emergencies efficiently. As a first step in the development process, we have
proposed short term plans to the existing health care infrastructure. With time
and interest, we hope to see recognition of emergency medicine as a specialty
nation-wide and establishment of EMS systems in the future.
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