Global Trauma and injury burden and its impact on the health systems of the country and economic progress have become a major health topic in the recent past. With the recent National Surgical Obstetrics and Anesthesia Plan (NSOAP) emphasis on universal health coverage and health system strengthening worldwide, there is renewed interest in improving trauma care delivery as a major component of surgical services.[1–3]
The Standardized System of care has been proven to improve outcomes following severe trauma since its inception in North America in 1970s.[4–6] Current trauma system architecture in North America and European countries consists of integrated prehospital, institutional and rehabilitative components. Establishing a prototype trauma system needs careful policy and structural planning, financing, constructing, monitoring, and sustenance through a higher level of governmental support. Availability of standardized prehospital services is an integral and essential part of an effective trauma system but is lacking in most low- and middle-income countries (LMIC).[8,9]
Countries in Asia have diverse geographical, environmental, demographic, and economic parameters as well as different healthcare systems and disease burdens. Particularly, organizational structure and amount and type of resources vary enormously in prehospital care systems: some countries mobilize physicians for prehospital care whereas other countries have no formal systems. Furthermore, differences in trauma etiology also matter: Asia being the most populous continent and hub of economic development with world's busiest roads, traffic injuries are the most common in some Asia countries, whereas gunshot wounds are in other countries. This means that neither introducing prehospital care systems, standardized in high-income countries (HICs) as they are nor creating a single standardized system that can fit all LMICs is feasible. In Asian context, trauma is a common cause of hospitalization with the need for a tailor-made system of trauma care catering to varied contextual parameters.
There is a lack of high-quality research that compares different trauma systems in Asia, especially prehospital emergency care, identifies their advantages and disadvantages, and explores the best way forward for each country. We advocate for analyzing diversities of 7 emergency medical systems (EMS) in Asia, identify advantages, disadvantages, and future challenges in each system using the World Health Organization (WHO) trauma system maturity Index, and discuss how we can utilize such comparisons to identify issues common to all and individual direction that each country should follow. This will further identify the focus areas where further in-depth research is needed for future advancement of trauma systems and to inform the Asian health sector policymakers.
Towards aforementioned objectives we created a multinational collaborative research team to analyze EMS in Asia as a pilot project.
Variety of EMS systems
Our research team consists of experts in emergency medicine from 7 Asian countries (China, India, Japan, Sri Lanka, Thailand, The Philippines, and Vietnam). They summarized the EMS systems in these countries as shown below. Obviously, the systems differ considerably from country to country.
In China, EMS is supervised by the National Health Committee and implemented by Provincial and Municipal Health Committee. EMS provides paid services under the supervision of the National, Provincial and Municipal Health Committee. Each municipality has a command control center for EMS, usually one general command center and several sub-centers. The general center is directly supervised by the municipal health committee and the sub-center is stationed in provincial or municipal hospitals, which receives calls from the nationally uniform number of 1-2-0; the EMS and its phone number are well known to people. An ambulance team consists of 3 personnel: usually 2 emergency life support physicians and nurses certified to provide advanced life support procedures (advanced airway management, intravenous line placement, and adrenaline administration) and 1 driver who can provide basic life support procedures. Ambulance teams usually select a suitable hospital according to the patient's conditions in the vicinity, but the patients’ or relatives’ preferences often dictate the destinations. The EMS personnel are permitted to transport patients without notifying the destination hospitals; the hospitals have to accept and admit all such patients regardless of their treatment ability and bed capacities. Although EMS personnel are authorized to declare death and do not resuscitate patients at the scene; in most cases, patient's families request to transport the patients to hospital to be treated or declared dead.
India's EMS system does not have a central organization to govern the system nationwide and consists of various types of providers, such as governments, volunteer organizations, and private hospitals. Therefore, it lacks uniform services, standardized protocol or training, and coordination. Currently, public-private partnership mechanisms cover a large proportion of emergencies. The Dial 1-1-2 is a Pan-India single emergency response number to address all kinds of distress calls such as police, fire, and ambulance, etc., which recently started as a national project by the name of “Emergency Response Support System”. Likewise, Centralized Accident and Trauma Services, funded by the Delhi government, provide EMS responding to calls from numbers of 1-0-2 and 1-0-9-9. People's awareness of these systems and phone numbers seems very low. Private ambulance services by private hospitals exist with a large variety of prehospital care capacities, but their services are costly and unaffordable to most people. While the standardization of training is insufficient with variabilities, some government-recognized training courses exist for 3 levels following the US system (Emergency Medical Technician [EMT]-Basic, EMT-Advanced, and Paramedic levels). Prehospital Trauma Technician training course is also available. Nurses and midwives are also allowed to provide prehospital care as EMS personnel.
In Japan, municipal governments provide free-of-charge EMS under the supervision of the Fire and Disaster Management Agency, an external agency of the Ministry of Internal Affairs and Communications serving as the national lead agency of the EMS system. The municipal fire departments are in charge of ambulance disbatch responding to calls to the nationally uniform number (1-1-9); the EMS and its phone number are well known to people. An ambulance team consists of 3 personnel: usually an emergency life support technicians (ELSTs) who can provide advanced life support procedures (advanced airway management, intravenous line placement, and adrenaline administration) and 2 emergency medical technicians who can provide basic life support procedures. Ambulances with physicians are not routinely used. The ELSTs have to receive on-line physician instructions when performing the advanced life-support procedures. All EMS personnel can perform defibrillation using an automated defibrillator without on-line instruction. EMS personnel are not allowed to declare death at the scene and all out-of-hospital cardiac arrest patients are transported to hospital. EMS personnel should perform triage at the scene, select a hospital suited for the patient's conditions, and inquire whether it can accept the patient. Since hospitals reserve the discretion to decline admission requests based on their capacity, this process sometimes takes a long time.
In Sri Lanka, 1990 Suwa Seriya Foundation is the national lead agency for EMS under Primary Health Care, Epidemics, and COVID Disease Control State Ministry (Indian government supported the system development). The Foundation operates with 297 ambulances, 678 EMTs, and 583 pilots and a single emergency command and control center at Colombo to provide nationwide free-of-charge emergency medical services since its establishment in 2016. Currently, the average response time is 15.5 minutes. The ambulance teams are stationed in and dispatched from police stations. The nationally unified phone number for EMS call is 1-9-9-0; any person in Sri Lanka requiring prehospital emergency case may call this number when needed. Public awareness of this new service has been promoted through various media and via blanket texts from the major cellular telephone companies. The state-of-the-art central command and control center located in Colombo monitors and coordinates all ambulance activities throughout the country: vehicles can be tracked throughout the course of a transport; trained physicians at the center provide medical control and advice.
In Thailand, National Institute for Emergency Medicine is the national lead agency that formulates policies, allocates budget, develops human resources, and standardizes care practices. Each province has a command control center for EMS, usually stationed in provincial hospitals, which receives calls from the nationally uniform number of 1-6-6-9 and manages ambulance dispatch to provide free-of-charge services. Thai EMS consists of various levels of ambulance units operated by various organizations: advanced and intermediate level units staffed with physicians, nurses, paramedics, and EMTs are usually stationed at public hospitals; basic level units staffed with emergency responders with 40-hour training are stationed at sub-district offices; ambulance teams of private hospitals (advanced-level) and charity foundations (basic level) are formally integrated into the system after training and registration. When the patient's conditions are critical, 2-tier dispatch protocol is activated: a basic-level unit from the nearest station and an advance-level unit from a hospital will be dispatched simultaneously. The control centers monitor and coordinate the EMS activities including destination hospital selection. In some areas including Bangkok, Khon Kaen Province, and Sonkla Province, physicians stationed at the center provide medical advice and instructions to the EMS personnel.
In the Philippines, a national EMS system does not exist. Local government units in some big urban areas have established their own EMS systems which may or may not be working in coordination with private EMS groups. Geographically isolated and disadvantaged areas have little to no access to formal EMS. Recently, the National Patient Navigation and Referral System was created to make emergency care services more accessible to a larger population by coordinating the transfer of patients from the community to health facilities as well as interhospital transfers. The system evolved from the Hospital Operations Command Center that was established by the national government, with the Department of Health as the lead agency, to facilitate patient transfer in the coronavirus disease 2019 (COVID-19) pandemic. The Philippines has a number of schools that provide formal training of EMTs. It also has a national organization of emergency medicine specialists, the Philippine College of Emergency Medicine, which seeks to promote and professionalize the practice and provision of emergency care. A bill is presently pending in the national legislative body which aims to establish a national EMS system and professionalize the practice of emergency care providers.
In Vietnam, provincial/municipal health departments are responsible for operating its EMS center under the supervision of the Ministry of Health as the national lead agency for the EMS. EMS centers are operated in 10 provinces and 63 cities using nationwide unified number of 1-1-5 to receive calls. In some provinces, EMS is outsourced to private sectors, such as transportation service companies. Following the French system, an ambulance unit consists of a physician, a nurse, and a driver. The physicians and nurses can perform advanced life support procedures in the field including advanced airway management, drug administration, and defibrillation; however, defibrillators are usually not equipped in the ambulances. The drivers are not trained for patient care. Ambulance teams select a hospital that is suitable for the patient's condition but very often have to follow the request of the patient's family based on their preferences. The EMS personnel transport patients without notifying the destination hospitals. Hospitals have no discretion to refuse treatments and hospitalization of such cases regardless of their treatment ability and bed capacities. EMS personnel are allowed to declare death and stop resuscitation at the scene; however, most patient's families wish to transport the patients to hospital to be treated or declared dead.
All countries have some form of EMS, albeit of different coverage and care quality. Some countries have nationwide coverage whereas others have patchy coverage. Some countries mobilize physicians and paramedics as ambulance personnel whereas other countries depend on volunteers. Some countries have the Ministry of Health as the national lead agency for EMS whereas other countries have different types of lead agencies. Some have nationally uniform systems, which is not feasible for large countries (eg, India). Although their systems are modeled after Western countries, they are not exactly the same. For example, Vietnam follows the French system, but there is no unified training to ensure quality.
When the experts assessed the maturity of each country's trauma system focusing on prehospital care and human resource development using the WHO trauma system maturity Index, except for 1 participating system (India), all others recorded a higher maturity index (3 or 4) to contend (Table 1). Systems that fail to reach full maturity (the Philippines and Vietnam) indicate a lack of standardization, certification, and accreditation of the human resources, sufficient system assets, and nationwide equitable service coverage. In India, no defined EMS organizations or standardized training exist, which means its EMS system is still in its infancy.
Table 1 -
Evaluation of the current EMS system and future perspectives.
|WHO Standard of EMS
|Reasons for Selecting the Status
||• Formal EMS under the supervision of the National Health Committee.• Nationally universal phone number for EMS call (120) exists.• Legislations exist to standardize EMS. The EMS providers also have a formal education program for each level of providers.• Standardized training curriculum exists for EMS.• Prehospital trauma care guidelines are available.
||• There is no defined prehospital care system. There is the presence of a universal access number, but it is for all emergencies and more work like a notification and mostly used to provide transportation from the site to a nearby hospital.• No structured training for the primary trauma care providers.
||• Formal EMS under the supervision of the Fire and Disaster Management Agency as the national lead agency.• Nationally universal phone number for EMS call (119) exists.• Legislations exist to standardize • EMS.• Compulsory health insurance system exists to cover all medical services (EMS not included but EMS is free of charge).• Standardized training curriculum exist for EMS personnel.• Prehospital trauma care guidelines are available.
||• 1990 Suwa Seriya is the government's free-of-charge prehospital emergency care service with 1990 as the 24/7 reachout number established under SUWASERIYA foundation Act and governed under SUWASERIYA foundation with 7 board directors.• Recruitment and training standards were laid down but yet established a formal licensing and appraisal system.
||• The formal EMS system is operated by multi-agencies including ministry of health, ministry of internal affair and NGO. The national institute of emergency medicine system (NIEMS) is a lead agency. 1669 is a single medical emergency number.• The EMS providers also have a formal education program for each level of providers.• The regular renewing of the work license is under the supervision of NIEMS.
||• There is no centralized national EMS system. The big, cities have their own organized EMS systems. Some form of coordination between public and private services exist. Geographically isolated and disadvantaged areas (GIDA), have little to no access to formal EMS.• A national hotline has not been fully functioning.• Training is available for prehospital and in-hospital trauma care. However, many of well-trained personnel get jobs abroad.• The National Patient Navigation and Referral System helps coordination in emergency care.
||• Formal EMS are operated under the supervision of the Ministry of Health with nationally universal phone number (115), though the EMS coverage is poor outside large cities.• The EMS are outsourced to private sectors in some areas.• Legislation exists to standardize EMS.• EMS personnel are physicians and nurses; they are trained as such but not standardized training curriculum for prehospital trauma care.
||• Nationwide EMS coverage even in remote countryside.• People's awareness of EMS roles and how to use it.
||• The present system is able to accommodate regional heterogeneity.• The cost is being taken care by federal agencies• Increasing awareness leads to measures towards gaining higher maturity.
||• Nationwide EMS coverage even remote islands.• People's awareness of EMS roles and how to use it.• Standardization mechanisms.
||• Well established policy, governance and financing system supporting the EMS.• Islandwide coverage with 15 minutes average response time.• ‘1990 Suwa Seriya’ has embraced new technology in providing this remarkable service including a locally developed real-time vehicle tracking system monitored by the central command and control center, and an ambulance navigation and routing system for faster reach to the patient location.
||• The Act that support the policy to develop and improve the quality of care.• The formal leading agency, as NIEMS, has driven the system continuously.• Emergency Physician cover the EMS system.
||• National organizations of emergency medicine specialists and emergency medical technicians exist.• Good inter-agency coordination and collaboration• Improving public awareness on EMS.• Increasing opportunities for training to both the public and healthcare workers.
||• Legislation exists to endorse development of nationwide coverage of standardized EMS.• People's awareness of nationally uniform phone number.
||• The EMS service is not closely related to the hospital.• Lack of continuous training.• The shortage of emergency resources leads to the prominent turning of ambulances.• High work pressure and frequent personnel turnover.• Difficulties in selecting destination hospitals (they have a discretion of not accepting the patients).
||• The financial provision by the government is very insufficient• There is no defined dedicated EMS legislation defining responsibilities towards providing EMS to the common peoples• The in-hospital care is also in a very poor state leading to unfavorable outcomes and ultimately being blamed for poor EMS.
||• Increasing demands are lengthening response time to reach the patients• Municipality-based system: small municipalities have difficulties to deal with increasing demands.• Difficulties in selecting destination hospitals (they have a discretion of not accepting the patients).
||• Need to smoothen out patient handing over to hospital emergency unit with prior communication to hospital focal point.• Need to establish formal licensing and renewal system for paramedics• Need for further strengthening inter-agency communication and collaborations.
||• The increase in demands of service.The school of paramedic is a small number.• The quality control of NGO EMS unit is unclear.• The number of emergency physician is minimal compared to the Thai population.
||• Health is still low in priority for national leadership.• Implementation of the national hotline and the referral system needs continuous funding and support from the government.
||• Insufficient resource allocation for EMS (overwhelmingly scarce resources compared to demands).• Inappropriate privatization of EMS functions.• Unable to attract professional, high-quality and job-loving human resources.
||• Improve the welfare of EMS personnel.• Improving the hospital selection mechanism.• Organizations should be merged to respond to increasing demands by efficiently using existing resources.
||• Better financial allocation• Dedicated agency to monitor EMS• Defined regulation towards EMS• Protocolized communication and collaboration between prehospital and in-hospital institutes.
||• Small EMS organizations should be merged to respond to increasing demands by efficiently using existing resources.• Improving the hospital selection mechanism.
||• Use of more technological assistance in victim identification, ambulance tracking and communication between multiple stakeholder agencies.
||• Ministry of internal affair will have more responsibility in basic EMS unit.• Online medical direction will be implemented in all areas.
||• The national legislative body is still discussing a bill on EMS. With more support from the public, it is hoped that this will be passed soon.
||• More resources should be allocated to EMS.• Need to reevaluate the partnership with private sectors (command control centers should be governed by public sector).• Recognized EMS as a profession by the government and opened the code for paramedic training at the university.• Systematic and compulsory first aid training for children in schools and communities.
EMS, emergency medical services; NGO, non-governmental organizations.
Essential elements of EMS systems
We tried to identify essential elements of EMS to be strengthened to achieve matured systems based on experts’ descriptions of favorable points, barriers, and future directions of the systems (Table 1). Obviously, the favorable points are important system components. The barriers and future directions reflect the lack of components that facilitate improvements of the system.
Most experts dwelled around the prime importance of governmental policy and national governing bodies through legislature in implementing the nationwide EMS systems; further they emphasized the need for continuing stable funding sources for maintenance and upgrading the system; a few identified better community awareness of EMS as an asset. A couple of systems highlighted better coordination between government and private sector (volunteers and philanthropic organizations) as a necessity with regulations while another system appreciated advanced technological assistance as a plus point of their EMS.
Most of the experts also emphasized the need for a structured standardized training/licensing and accreditation system for EMS physicians and paramedics while a couple of experts concerned with challenges in maintaining necessary workforce in delivering quality EMS care.
The majority of them mentioned difficulties in smooth handover to institutional care and suggested technological support for patient tracking and selecting the correct healthcare destination. Most mature EMS systems are challenged by the increasing demand for their services and call upon necessary surge strategies.
The final ideal model of EMS for each country cannot be seen, which does not yet exist; however, we may be able to foresee it as a future vision. By comparing the system components with those of other countries, it is possible to examine the strengths and weaknesses of each component separately and in detail. We may import or imitate the strengths of other countries. The ideal system model, which would differ from country to country, will emerge by examining the elements that contain problems or are completely lacking and considering how to overcome them.
Detailed system evaluations and comparisons have a potential to provide a vision of the future EMS. Despite the preliminary nature of the comparisons in this paper, we believe that we have identified the following elements that need to be strengthened to approach the ideal as closely as possible.
Some elements found in relatively matured systems are likely to be useful if appropriately applied in developing systems. These include a high level of government policy, stable financing, legislature, having a single governing body responsible for nationwide services, and sector-wide coordination. Matured systems always possess these components and premature systems are in the process of fulfilling the insufficiencies. We can assume that their achievements would promise further improvements in the services.
In contrast, human resource issues, reflecting characteristics of each country, may require different approaches. Qualified workforce in matured systems is achieved through standardized training curriculum, licensing systems, and recognition as professionals. These are not sufficient in some developing countries. Human resource development taking a long time cannot address the current shortage; qualified personnel are likely to move to another position or migrate to prosperous countries. Some countries have activated volunteers or non-governmental organizations to fill the gap. This strategy may be useful in other resource-constrained settings and possibly worth considering even for matured systems with rapidly increasing demands.
In relatively matured systems, more emphasis is placed on coordinating between prehospital services and institutional care identified as areas that need attention and having avenues for improvements. This issue appears to be small in premature system because of their relatively simple healthcare system, but it has a potential to be a large problem in the future as the healthcare infrastructure becomes complex. In this regard using technological assets is promising in strengthening coordination mechanisms as feasible and some systems already experimented with that. Furthermore, all systems should have responsive capacities to meet increasing service demands.
Our identified focused research topics will help to improve the system through collaborative learning and sharing experiences. Collating experiences of multiple countries with differing geographical, environmental, and epidemiological and extracting transferable lessons across the board will give a chance for expedite system development. Of course, this requires further research to work out more details of the EMS systems.
Our preliminary compassion of 7 Asian country EMS profiles and expert opinions provided us with a basic understanding of the level of standards according to the WHO trauma system maturity index. We indicated the potential of comparative research to identify important components of the EMS systems to be strengthened.
Conflict of interest statement
The authors declare no conflict of interest.
All authors contributed to the descriptions of EMS system; Ratnayake A and Nakahara S integrated the descriptions into the manuscript; all authors contributed to interpretation and revision of the descriptions and approved the final version.
Ethical approval of studies and informed consent
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