Emergency Medicine Development in Taiwan

INTERNATIONAL

REPORT/CONCEPTS

EmergencyMedicine Development in Taiwan From the Department of Emergency Medicine, ChangGung Memorial Hospital, Taipei, Taiwan, Republicof China. Receivedfor publication January i5, I996. Revisionreceived July 19, I996. Acceptedfor pubIication August 1, 1996. Copyright © by the American College of EmergencyPhysicians.

Michael J Bullard, MD Shiumn-Jen Liaw, MD

[Bullard M J, Liaw S-J, Chen J-C: Emergencymedicine development in Taiwan. Ann EmergMed November 1996;28:542-548]

Jih-Chang Chen, MD

INTRODUCTION Taiw~n is a dynamic and vibrant society of 21 million peopm, 14th on the world list of trading nations. As personal wealth in Taiwan has increased, so has the desire for an improved standard of living. Part of this expected improvement is in the area of medical care. Although life expectancy has increased from 56.3 years for women in 1952 to 77.6 years in 1993 and from 53,4 to 71.06 years for men, health care delivery, especially in the field of emergency medicine, still has much room for growth. Western medicine in Taiwan developed in the first half of the 20th century under Japanese influence. During the latter half of the century, Iaiwan has also looked to America--and to a lesser degree, Europe--for direction. Most practitioners in Taiwan are vertically integrated specialists, whereas primary care-related specialties such as family medicine and emergency me&cine have only recently been introduced and are fighting hard for recognition. Prehospital care has been placed in the hands of the fire department, with the island divided into 17 emergency medical services jurisdictions. Budgeting is the responsibility of the Department of Health.

MEDICAL CLIMATE In 199z~ Taiwan had 828 hospitals, ranging from 3,500bed medical centers to 20-bed local hospitals. About 40% of physicians work out of private offices, providing primary or specialty care. The rest are employed by hospitals, who not only provide the necessary inpatient and outpatient facilities but control compensation. Government hospitals pay physicians a salary, with year-end bonuses based on performance and seniority. Private hospitals offer various forms of incentive reimbursement based on productivity and other intangibles. Although private hospitals still pay their employees more than public institutions, the gap is

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narrowing. This equalization is helping curtail the practice by government physicians of moonlighting or setting up a part-time private clinic to supplement hospital income. With the development of government-supported health insurance programs (labor insurance in 1950, civil service insurance in 1958, farmers' insurance in 1985) that provide coverage for half of the population and economic improvements that have enhanced the ability of the other half to pay for care, overall hospital use--including emergency department patient volumes--has increased steadily In April 1995, Taiwan adopted a national health insurance program, essentially enrolling the entire population and making medical care available and affordable for all. Taiwan has nine medical schools, four government supported and five private. Training generally lasts 7 years and follows high school graduation. The final year of medical school is spent in a hospital as an intern. After this internship, the student must pass a licensure exam. Residency training is similar to that in North America: 3 years for general internal medicine, 4 years for general surgery, and an additional 2 to 3 years for subspecialization. Emergency medicine requires a residency program of at least 3 years; most medical centers offer 4-year straight training programs or 5-year dual board programs (eg, internal medicine or family medicine plus emergency medicine). EMERGENCY MEDICINE CLIMATE

Although most hospitals provide some form of emergency care, the gap between the level of care provided in the medical centers and that provided in local hospitals is large. Reminiscent of North America 30 years ago, local and community hospitals frequently rely on moonlighting residents, interns awaiting their compulsory military service, and academic underachievers who have not been accepted by the large teaching hospitals to provide after-hours ED coverage. Most teaching hospitals now provide at least daytime and evening ED attending physician coverage. One of the major impediments to change has been the tradition of dividing the ED into medicine, surgery, pediatrics, and gynecology, with no crossover responsibility Under this system, one speciahy may be overwhelmed by an influx of patients but the physicians from the other specialties would not help out because they have not had the training or experience and are unwilling to accept the responsibility of handling another speciahy's patients. This creates problems of efficiency and cost efficacy for low-volume EDs or during low-volume periods in any hospital. The increase in ED use and escalating demands to have an attending physician in charge have awakened hospital

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administrators to the cost and capability benefits of trained emergency physicians prepared to handle all types of patients. The medical establishment has been less enthusiastic in embracing such a change, however, believing they will lose some of their control over patients. The greatest burden of emergency care falls to the larger hospitals, with the majority of sicker patients transported by one of the smaller hospitals. Patients may be transferred early (often before stabilization) or sometimes late (possibly from the ICU), either at the behest of the family or the physician who feels out of his or her depth. Most patients are sent with a perfunctory transfer note, but physician-tophysician communication almost never takes place. Patients must purchase copies if they wish their radiographs to accompany them, and most patients arrive unannounced at the second ED. Direct ward and ICU transfer admissions are rare. This is partly a reflection of chronic bed shortages in the medical centers, and it adds greatly to the workload and leads to protracted patient stays in the ED. Overdistribution of patients to the larger centers is a reflection of both social and cultural norms and medical reality Many practitioners outside the larger hospitals trained before board certification examinations were mandatory. Critical care backup support in the smaller hospitals is often limited, especially at night and on weekends. The physicians on emergency duty in the smaller hospitals are generally quite junior and often try to redirect problem patients. In Chinese culture, after any adverse outcome it is normal to identify someone as having a moral responsibility or ability to pay damages. 1,2,3 For example, if a motorcycle and a car collide, the driver of the car is expected to pay, regardless of fault. This expectation is based on the belief that the ability to buy a car indicates greater wealth. Disagreements are usually settled through face-to-face negotiation without referral to the courts or the involvement of lawyers. This practice has translated into the anomalous situation in which, if a physician recognizes that a patient is critically ill and transfers the patient without doing anything and the patient dies, the family is unlikely to complain. However, if the physician tries hard to stabilize the patient but the patient dies anyway, the physician may be accused of mismanagement and sued by the family This situation reflects a diametric difference from our Western precepts about the role of the emergency physician. Fortunately, larger hospitals are recognized as being able to provide the best care and as the last bastion of care and are relatively immune from groundless blame; therefore physicians in these hospitals are free to do their best.

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Because of the ready availability of outpatient clinics in Taiwan, use of the ED by patients with minor illnesses or injuries is not a major problem. The atmosphere and patient-staff interaction in the hospital differ from that in North American hospitals in several important ways. Tradition and staffing levels require the family to provide much routine patient care that is generally handled in North America by the nursing staff (eg, daily hygiene, turning the patient, feeding, and emotional support). The family is the most important social unit in Chinese culture, with the needs of people outside this circle frequently ignored. As a result, many ED patients are accompanied by several family members loudly demanding that their loved one receive priority treatment; on arrival, each new family member is likely to seek out the physician to request an explanation of the patient's condition. This combination of factors leads most busy EDs to resemble a traditional Chinese market with patients, families, and caregivers all jostling for position and often shouting to be heard. EMERGENCY MEDICINE DEVELOPMENT

Recognition of the need to upgrade emergency care began m earnest in the late 1980s. The Veterans General Hospital in Taipei established the first emergency medicine residency training program--a 5-year internal medicine/emergency medicine dual board program--in 1989. In 1990, Chang Gung Memorial Hospital began requiring attending physician coverage in their ED 24 hours a day Also in 1990, the Western Pacific Association of Critical Care Medicine in Taiwan changed its name to the Society of Emergency and Critical Care Medicine (SECCM) to emphasize the importance of emergency medicine. This group has played a pivotal role in establishing the discipline. The SECCM membership comprises physicians active in three different disciplines: emergency medicine, critical care medicine, and trauma surgery. In 1995 the Society of Emergency Medicine was established to further the goals and needs of its members. Taiwan has 13 hospitals with emergency medicine training programs, totaling nearly 100 residents. The programs range in size from 42 residents (Chang Gung Memorial Hospital) to a single resident (Taoyuan Provincial Hospital). The government to date has officially recognized 17 specialties, including family medicine, and is considering adding emergency medicine to that list. SECCM gave honorary specialist certificates in 1992 to 807 members who met the society's criteria of adequate training and continuing medical education credits. Beginning in 1993, residency- and practice-eligible candidates were allowed

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to sit for emergency medicine, trauma surgery, or critical care medicine board examinations under the auspices of SECCM. Medical, surgical, anesthesia, family medicine, and pediatric specialists who practice in the ED for 2 years wilI remain practice eligible until the year 2000, at which time it is anticipated that the number of emergency medicine residents will be adequate to meet Taiwan's needs. The 76 successful emergency medicine board examination candidates, as well as those honorary specialists active in emergency medicine, form the core of this rapidly evolving specialty. Although trauma care is an integral part of the emergency medicine curriculum, fewer than half of the training institutions actually include emergency physicians in the provision of frontline trauma care. Only Chang Gung Memorial Hospital makes Advanced Trauma Life Support (ATLS) a requisite part of emergency training, but as more ATLS instructors are trained and courses become more widely available, SECCM hopes to make the training mandatory for all candidates applying to take the emergency medicine board examination. Previously, only surgeons treated trauma patients. It is hoped that ATLS training will enhance communication and cooperation with those surgeons responsible for trauma management and improve early care. The Taiwan Department of Health is attempting to establish islandwide databases for prehospital care, emergency medicine, and trauma in the hope that problems can be identified and solutions rationalized, Medical research funding in Taiwan comes from several sources. The National Science Council, the Department of Health, and the recently formed National Health Research Institute all provide grants based on the strength of a submitted proposal, the track record of the submitting researchers, and whether the proposal is in accordance with the area of research targeted each year by the various granting bodies. Some private hospitals have established their own research funds. Areas of research encouraged by the government over the past few years have included injury prevention, EMS use, benefits of emergency medical technician (EMT) training, and quality-assurance applications in the ED. EMERGENCY CARE

Although there is much variation among hospitals in the delivery of emergency care, several constants exist in basic structure. Some of these constants have been established through accreditation requirements. One such item is triage. On a patient's arrival a nurse triages the patient into one of four categories. If time allows, the nurse records a

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quick history and vital signs. Category 1 indicates unstable patients (those requiring immediate physician treatment), categoU 2 includes potentially unstable patients (requiring physician assessment within 10 minutes), category 3 includes patients with symptoms indicative of an urgent condition (requiring physician evaluation within 30 minutes), and category 4 comprises patients with minor complaints who are inappropriately seeking ED care. Sample demographic data from several busy EDs (Table 1) indicate that 15% to 20% of patients are classified in triage category 1 or 2. Overall admission rates range between 20% and 36%. After triage and depending on the ED organization structure, patients are usually seen next by a physician. In only two hospitals (Chang Gung Memorial and Shin Kong Wu Ho Su Memorial Hospital) are all adult ED patients evaluated by emergency physicians or residents under their supervision. In the other institutions emergency physicians are limited to medical emergencies, with surgeons in charge of surgical emergencies and pediatric residents in charge of Table 1.

Representative 1995 ED patient demographicsfrom five large EDs. Characteristics

CGMH

VGH*

NTUH

SR

NCKUH

No, of beds Hospital 3,500 2,700 1,996 700 800 El] 140 10O 70 69 60 ED visits/day 353 234 197 190 114 Ratio, M/F Nontrauma 1.23:1 1.92:1 .99:1 1.42:1 Trauma 2,43:1 1.91:1 1.73:1 2.60:1 2.40:1 Mean age (years) Overall 46 42.9 37 48 38 Nontraama 50 55.8 38 53 Trauma 34 35.7 32 42 Distribution Nontrauma 202 146 141 106 54 Trauma 84 33 24 61 32 Pediatrics 67 55 32 23 28 Triage class (%) 1 3.8 2.7 3.2 2.4 3.0 2 19.4 12.6 26.4 14.9 11.7 3 70.7 13.4 68.6 63,8 82.8 4 6.1 11.3 1.8 18.9 2.6 Admission (%) Total 35.4 14.7 12.9 23 36.5 ICU 4.8 NK 1.4 4.5 NK Turnover time (hours) 12 11.3 9 48t CGMH, ChangGungMemorialHospital,Taipei;VGH, Veterans6eneral Hospital,Taipei; NTUH, NationalTaiwanUniversityHospital,Taipai;SK, Shin KongWu Ho Su Memorial Hospital,Taipei;NCKUH, NationalChungKungUniversityHospital,Tainan;NK, not known. "1989 totals with 1991triage figures.8 *Patientsawaiting admissiononly.

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pediatric emergencies. To avoid conflicts with families, most patients are seen almost immediately, regardless of triage category However, histories and physical examinations are often cursory and reevaluations and dispositions delayed because of the constant pressure to see all new patients immediately. The responsible nurse usually waits for the physician to write an order before making first contact with the patient. Consultation for subspecialty opinion is common, but responsibility for patient management often remains in the hands of the emergency personnel until a hospital bed becomes available and the patient is transferred to that ward. From turnover times it is easy to see that patients often spend many hours or days in the ED awaiting a bed. This has made the observation unit a standard feature throughout Taiwan, with ICU holding units in most of the larger EDs. Most of these units do not provide invasive monitoring. It is not uncommon for ventilator demand to outstrip supply during peak periods, requiring families to provide bag-valve-mask ventilation until the patient is transferred or, if the family refuses to allow the patient to be transferred, a ventilator becomes available. Nonsalvageable patients are not infrequently discharged before or after CPR (sometimes pulseless), while being ventilated by their family, to allow them to die at home surrounded by their loved ones in keeping with cultural traditions. EMERGENCY DISEASE AND INJURY FEATURES

In Taiwan, accidents and adverse effects are the third leading cause of death behind cancer and cerebrovascular accidents (Table 2). Most trauma is blunt in nature. Traffic accidents in Taiwan have an annual mortality rate of 34 per 100,000 population, compared with 18 per 100,000 in the United States. Traffic accidents cause more than 1,000 patients each day to seek medical help. The estimated direct and indirect annual burden on the Taiwan economy is more than US$11.1 billion, almost one quarter of the government's yearly budget. With more than 12 million motorcycles crowded into a land mass of 14,000 square miles, piloted by mostly helmetless riders (no helmet in 90% of motorcycle accidents), a high incidence of morbid accidents is not surprising. A motorcycle helmet law has been introduced but has not yet passed a third reading in the legislature. Pedestrians also remain at high risk because of the lack of passable sidewalks (often blocked by motorcycles or illegal buildings). Despite Taiwan's limited land mass, new construction projects are constantly appearing. This constant construction has resulted in frequent workrelated accidents. Private o~mership of guns in Taiwan is

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illegal; therefore gunshot wounds are fortunately rare. Most successful suicides involve poisons or jumping. Medicinal overdoses almost always involve benzodiazepines, narcotic preparations, or amphetamines, making treatment relatively straightforward. Nonmedicinal toxins, unfortunately, are not so friendly; catastrophic parquet and organophosphate poisonings are common. Hydrochloric or sulfuric acid ingestion by suicidal young adults is common. As reflected in Table 2, there are several differences from those in the United States in the presenting features and disease patterns among seriously ill patients seeking emergency attention in Taiwan. Both hypertension and diabetes mellitus are common in Taiwan, but for several reasons, including the lack of adequate primary care, they are often inadequately controlled. As a result, cerebrovascular accidents and complications such as diabetic ketoacidos;s, infections, and kidney failure abound. Hepatitis B, an endemic disease in Taiwan, is now under control following the instigation 12 years ago of a mandatory immunization program for all newborns. The carrier rate for hepatitis B surface antigen, however, remains 15% to 20% among the adolescent and adult populations. Complications of chronic liver disease and hepatocellular carcinoma are common emergency problems# In North America, few physicians would list hepatoma rupture as part of their differential diagnosis for nontraumatic hemorrhagic shock. In Taiwan, it is always considered in patients with unexplained hypovolemic shock. Upper-gastrointestinal bleeding due to a combination of esophageal varices and peptic ulcer disease (aggravated by the frequent use of nonsteroidal ant;inflammatory drugs or corticosteroids often found in herbal preparations, prescribed by local physicians or purchased on the advice of the pharmacist) is also common. Many Taiwanese patients frequent both practitioners of Western and Chinese medicine in the hope that one

will find what the other one missed. The rate of ischemic heart disease is on the rise because of increasing affluence, which has led to increased meat consumption, smoking, and stress and decreased exercise. The rate of coronary artery disease mortality has increased slowly, from 47 per 100,000 population in 1952 to 57 per 100,000 in 1994-. As a result, chest pain m Taiwan does not command the ED resources that its North American counterpart does. PREHOSPITAL

CARE

In 1969 the government established 119 as the emergency telephone number for fire or ambulance assistance. To date the dispatch centers are not fully centralized, even for individual regions. Outside the cities a call to 119 is answered at the nearest fire station. Ambulances are staffed by fire fighters with basic EMT training, who respond to all calls. Although the local bureau of health, the fire chief, and designated hospital representatives are responsible for planning, training, and daily operations in each of the 17 regions, the central department of health must approve the annual budget and any program changes. In July 1995 the government enacted an EMS law that officially recognized and to some extent defined the roles of EMTs, along with the responsibilities of hospitals in the event of a medical emergency EMTI, or basic, training comprises at least 80 hours; EMT2 training, 240 hours. Both types of training are limited to basic airway skills (excluding intubation), basic CPR, provision of oxygen, spinal immobilization, splinting, and bandaging. Ambulance personnel in most regions have completed EMT1 or EMT2 training. Currently Taiwan has no paramedics. When paramedic training begins, trainees will be required to complete Table 3.

Comparison of demograFhic data among/our EMS regions. Table 2. Characteristic

The 10 leading causes o/death in Taiwan, 1994. Rank

Cause

t 2 3 4 5 6 7 8 9 10

Cancer Cerebrovascularaccident Accidents and adverse effects Cardiovascular disease Diabetes mellitus Chronic liver disease Nephritis, nephrotic syndrome Pneumonia Hypertension Bronchitis, emphysema,asthma

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No. Per 100,000Population 110.48 64.79 62.79 56.94 28.92 19.76 15.26 13.72 10.40 8.92

Taipei

Population 2,632,863 Calls/ .43 10,0O0 population/day Transports/ .26 10,000 population/day Response time 3.94 (minutes) Scene time (minutes) 4.6 Transport time 7.03 (minutes) % Trauma cases 45.78 % Nontrauma cases 54.24

Keelung 400,000 .32

Tainan 1,700,000 .30

Ilan* 460,000 .39

.21

.20

.32

4.39

5.26

6.6

5.26 7,56

3.54 10.56

3.6 17.7

61.2 38.8

64.4 35.6

76.9 23.1

*qlanCountyis a rural EMSdistrict covering825.1squaremiles.

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at least 2,000 hours, but the details of their curriculum and privileges have yet to be fully clarified. Hospitals are also expected to have their own ambulances and to be able to respond with a nurse, physician, or both to the scene of a disaster or at the request of the dispatch center. To address the problem of medical direction and control, an EMS director course is planned for December 1996 under the auspices of SECCM. After completion of the course the government will be lobbied to appoint a medical director for each region in an attempt to improve EMT compliance with care guidelines. Table 3 details prehospital data front 4 of the 17 EMS regions. The overall call rates and transport rates are much lower than those reported in North America. Braun et al 5 reported call rates ranging from .9 per 100,000 population per day in Hawaii to 5.2 per 10,000 population per day in Washington DC. Cadigan et al 6 suggested 1 transport per 10,000 population per day as a basis for system planning. In Taiwan the call rate is only .3 to .4 per 10,000 per day This low rate partially reflects the public view that ambulances are for transportation only and that they are unaware that EMTs can help or don't want them to. Most nontrauma victims are brought to the ED by private vehicle. In Keelung, data on transport times tend to support the practice for nontraumatic arrests. The EMS law permits only physicians or paramedics (of which there is still none in Taiwan) under medical supervision (possibly off-line) Table 4.

Distribution of patients requesting help in 119 calls. Injury or Illness

Keelung

Ilan

Trauma (%)

Tota/ Motorcycle accident Fall of<5 m Pedestrian Motor vehicle accident Laceration/crush injury Assault Fail of>5 m Other Nontrauma (%) Total Altered consciousness Attempted suicide Shortness of breath Cerebrovascular accident Syncope Gastrointestinal bleeding Chest pain Other *Accidents involvingpedestriansincluded,

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81.2 25,9 9.6 6.6 6.3 4.4 3.3 1.9 3.1

76.9 49.7* 5.9

38.8 12.1 4.0 3.7 2.8 2.1 1.7 1.7 10.8

23.1 5.4 2.23 1.1 1.8 1.7 .6 .9 6.3

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to defibrillate or intubate. Given a response time of 4.39 minutes and a scene time of 5.26 minutes, patientsusing private transport could reach the ED as much as 10 minutes earlier than if they used EMS. A review of 100 consecutive dead-on-arrival patients brought to the Chang Gung Memorial Hospital ED revealed that the EMS/p~vate vehicle transport ratio was 65:35; 8 of the 18 patients who arrived in ventricular fibrillation were transported by private car. Pour patients from each group regained hemodynamic stability and were admitted to an ICU. The lone survivor arrived by private vehicle7 Table 4 offers an etiologic distribution of patients using EM5 in Keelung and Ilan county Given that most patients who request an ambulance are trauma patients and transport times are relatively short, EMT2 training may provide the most cost-effective EMS model until demands change or scientific proof can be presented to support the superiority of paramedic-based systems. In medicine we rightly focus on the need for scientific evidence to support recommendations to improve quality of care. At the same time we must recognize that existing systems and societal and cultural beliefs may significantly affect the speed, extent, or method of these attempted changes. Therefore, in Taiwan, gaining the public trust is essential for full implementation of an emergency care system. To upgrade the EMS system we must provide safeguards for our prehospital and emergency care providers to allow them to work without fear of financial liability in the case of an adverse outcome. In Taiwan the public has little faith in any government-directed system, preferring to rely on "guanxi" (a network of connections and favors developed through personal contact). In times of emergency this personal network often proves deficient. Through documentation of improved outcomes and media coverage of training and what care can and should be provided by ambulance and hospital personnel, we hope to gain public trust. Emergency medicine has already established several residency training programs. Emergency board certification examinations are now entering their fourth year. Hospital accreditation now requires fixed attending physicians in the ED. In SECCM, emergency physicians have been the most active in trying to introduce improved standards of emergency care in the hospitals and in the prehospital arena. It is hoped that the department of health will soon grant emergency medicine specialty status, making it the 18th recognized specialty in Taiwan, and confirm its rightful place in Taiwan's medical matrix.

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REFERENCES 1. HeartzetRW: Harmonyin conflict. Taipei:CavesBook,1988:226-238. 2. YangB: Theugly Chinaman.Sydney:Allen & Unwin, 1992:64-65. 3. YangKS: Socialorientationand individualmodernityamongChinesestudentsin Taiwan.J SocPsycho11981;131:161-162.

4. ChenDS, Hsu NHM, SungJL. et al: A massvaccinationprogramin TaiwanagainsthepatitisB virus infection in infants of hepatitisB surfaceantigen-carriermothers.JAMA 1987;257:25972603. 5. BraunO, MeCallionR, FazackerlyJ: Characteristicsof midsizedurbanEMS systems.Ann EmergMefl t 990;19:536-546.

The authors thank Shi-Ming Wang, MD, National Taiwan University Hospital; ShengChuan Hu, MD, Veterans General Hospital; Hang Chang, MD, Shin Kong Wu He Su Memorial Hospital; and Ming-Che Tsai, MD, National Cheng Kung University Hospital, for providing patient information and statistical data on their respective EDs and regional EMS systems. They also acknowledge the assistance of the department of health in providing national statistics and Shu-Fen Chang for her tireless efforts in preparing the manuscript. Reprint no. 47/1/77012 Address for reprints:

Michael J Bullard, MD

6. CadiganRT, BugarinCE: Predictingdemandfor emergencyambulanceservice.Ann Emerg Med 1989;18:618-621.

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7. ChiuCC.BullardMJ, Liaw SJ, et ah Dead-on-arrivalpatients:A sevenmonthanalysisat Keelung.J EmergCrit CareMed 1995;6:143-148.

Taoyuan Hsien

8. Hu SC: Clinicaland demographiccharacteristicsof 13,911medicalemergencypatients.J FormosanMed Assoc 1991;90:675-680.

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