International emergency medical services: assessment of developing prehospital systems abroad1

The Journal of Emergency Medicine, Vol. 17, No. 4, pp. 691– 696, 1999 Copyright © 1999 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/99 $–see front matter

PII S0736-4679(99)00065-7

Selected Topics: Prehospital Care

INTERNATIONAL EMERGENCY MEDICAL SERVICES: ASSESSMENT OF DEVELOPING PREHOSPITAL SYSTEMS ABROAD Michael J. VanRooyen,

MD, MPH, FACEP,* Tamara L. Thomas, Kathleen J. Clem, MD, FACEP†

MD, FACEP,†

and

*Center for International Emergency Medicine Studies, Department of Emergency Medicine, The Johns Hopkins Hospital, Baltimore, Maryland and †Department of Emergency Medicine, Loma Linda University, Loma Linda, California Reprint Address: Michael J. VanRooyen, MD, MPH, FACEP, Center for International Emergency Medicine Studies, Department of Emergency Medicine, The Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21287-2080

e Abstract—Many developing countries are experiencing a greater need for prehospital systems because of urbanization and changing population demographics, leading to greater death rates from trauma and cardiac illnesses. While emergency medical services (EMS) systems may take a variety of forms, they usually contain some system components similar to those found in the United States. In evaluating EMS abroad, it may be useful to compare the developing system type to one of five models of EMS delivery: hospital-based, municipal, private, volunteer, and complex. Using community-based services and available health providers can enable a developing system to function within a primary health network without overtaxing scarce resources. Developing such an approach can lead to creative and effective solutions for prehospital care in developing countries. © 1999 Elsevier Science Inc.

urban growth, economic expansion, medical and technological advancements, and public demand (1,2). Just as the U.S. experienced the need for an organized and unified approach to prehospital care, several developing countries increasingly need an organized EMS system to address growing urban health concerns. In addition, some countries have EMS systems in varying degrees of development that may be in need of reconstruction or updating. While this does not mean that every government or local provider desires a prehospital delivery system modeled after the U.S., many components are universally required in every system. The U.S. system, while unique in many aspects, contains basic prehospital system elements that may be beneficial and can be transposed to other developing programs. The purpose of this article is to describe the growing need for international EMS systems and suggest an approach toward prehospital system development on a global scale.

e Keywords—international; emergency medical services; emergency medicine; prehospital

INTRODUCTION THE GROWING NEED FOR EMS INTERNATIONALLY

Prehospital care is a relatively recent development, both in the United States (U.S.) and internationally. Changing health needs in countries experiencing economic and social growth are creating a greater demand for emergency medical services (EMS) systems. EMS development in the U.S. was stimulated by a combination of

Global demographics and health patterns have changed substantially in the last two decades, necessitating the expansion of prehospital care services in a growing number of developing countries (1,2). The primary reasons

Selected Topics: Prehospital Care is coordinated by Peter Pons,

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MD,

22 September 1998; 691

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for this are an increase in economic growth, urbanization, and health care system changes.

Economic Growth The stability of a country’s economy directly impacts the health of its people. Prehospital care and the support services that make it possible are similarly tied to a country’s economics. Some developing health systems are unable to provide even basic health services, much less support the expense of prehospital care. In countries with tremendous economic challenges, such as those in sub-Saharan Africa or regions of Asia, organized EMS systems are often nonexistent. These countries may benefit more from preventive health, public health care, and education as a means of addressing infectious disease threats and growing urban trauma (3). As a developing country progresses economically, the health network improves, and primary and tertiary health care services become more common, particularly in urban centers. A phenomenon known as “epidemiologic transition” occurs (1). People live longer, resulting in an increase in cardiovascular illnesses, instead of dying in younger years of infectious diseases. Survival in patients with cardiac arrest has been increased by the availability of prehospital defibrillation by EMS providers. This benefit may be one justification for developing EMS in urban centers.

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Health Care System Changes Countries affected by the population explosion and subsequent urban health problems are forced to address emergency care needs by developing or revising their EMS systems. These system changes may be further precipitated by a national crisis. The war in former Yugoslavia destroyed the prehospital system and led to a subsequent restructuring of the health system. In China, emergency medical systems have been influenced by the increasing demands of urbanization and outside foreign influences. Russia and the former Soviet Union have been forced to contend with major economic challenges to facilitate the transition to decentralized programs (6,7).

PREHOSPITAL SYSTEM MODELS To evaluate the structure and function of a foreign prehospital system, it may be useful to determine the modeltype by which a particular system may be categorized. This helps determine the operational plan, political considerations, and funding issues of the country being evaluated (1).

THE FIVE MODEL TYPES FOR EMS SYSTEMS Hospital-Based Systems

Urbanization In 1960, the largest city population densities were concentrated in developed countries. Previous giants like New York, London, and Paris are now dwarfed by urban megacities such as Mexico City, Sa˜o Paulo, Brazil, and Chongqing, China, now the largest city in the world with a population of ⬎ 30 million (4). By the year 2010, over 60% of the world’s population will be living in urban centers. This urban shift leads to “demographic transition,” resulting in increased population density (1). This, in turn, leads to a higher incidence of violent crime, traumatic injuries, and motor vehicle accidents, and thus a greater need for prehospital care services (1). The increase in urbanization not only increases the medical need but also encumbers an effective EMS response. Hong Kong, for example, uses motorcycles equipped with defibrillators, driven by trained personnel. These mobile units can reach a cardiac victim within a few minutes but may then wait 40 min or more for a prehospital transport vehicle (5).

In rural areas, EMS systems often are based at the hospital serving as the central regional medical resource. Hospitals hire EMS personnel, train them, and designate an administrator to oversee their efforts. In the developing systems overseas, hospital-based systems are usually the easiest to initiate and maintain. Medical control issues are less complicated because they rest primarily on the existing hospital personnel. This type of system is commonly seen in newly developed systems and in countries without well organized national programs. EMS in China, for example, consists almost entirely of hospital and emergency medical center based programs.

Jurisdiction-Directed Systems Jurisdiction-directed systems originate from a county or municipal level. EMS may be linked to the fire response network, which provides a structured environment for EMS system development. Medical oversight is most commonly contracted through private physicians. About

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half the EMS systems in the U.S. are jurisdiction-directed. Financial support for municipal services are typically tax or government funded. In the developing system, particularly in countries with a strong central government (e.g., China or the former Soviet Union), this is common. This is also the case in most European programs where funding comes from a state-sponsored, tax-based system, and the use of EMS is a medical benefit.

Private Systems This is the oldest type of system, originating from the funeral home-based ambulance services. In the U.S., many private organizations maintain substantial influence in municipal EMS systems because of their size and payer base. Foreign systems, however, are unlikely to have well developed private EMS programs since prehospital care is typically a state funded medical benefit.

Volunteer Systems The volunteer system has played a prominent role in EMS delivery in the rural United States and several western European regions. EMS providers form a network of volunteers who are privately trained. More densely populated areas require full-time responders and eventually move to a municipal or hospital-based system.

Complex Systems Complex EMS systems are an amalgam of the above system types and evolve secondary to resource limitations and shared resources, such as trauma centers, or the need for increased coverage and providers. System components are adapted to fit the political climate, regional government, geographic area, available resources, and payer mix. Complex systems exist in large cities, necessitating independent central dispatch, communication, and complex medical control. They base EMS personnel in major medical institutions or as a part of the municipal fire services. A combination often seen in developing countries is coexisting private and municipal systems. Problems may arise if they are working in competition rather than in a coordinated system. Complex models also include civilian and military coordination. This occurs in many countries during war and may remain in effect in times of relative peace, as seen in Israel. Jordan’s prehospital emergency care, for

693 Table 1. The Fifteen Essential EMS Components 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Manpower Training Communications Transportation Facilities Critical care units Public safety agencies Consumer participation Access to care Patient transfer Coordinated patient record-keeping Public information and education Review and evaluation Disaster plan Mutual aid

example, is the responsibility of the Civil Defense Directorate which provides ambulances and trained medics, with the Jordanian air force supplying helicopters and physicians for air medical evacuation (8).

COMPARING COMMON EMS SYSTEMS COMPONENTS Evaluation of a foreign EMS system can be both confusing and complicated even for those familiar with U.S. EMS systems. To evaluate the effectiveness of a foreign system, the basic system components must first be identified. Many developing countries assimilate system components from numerous outside foreign systems. At times, a confusing combination of American and European systems can be seen. This blending of systems is evident in EMS systems in China, where influences from the U.S., Italy, and Germany can be seen when comparing programs in various regions. It may help to become familiar with a variety of prehospital approaches before reviewing another country’s system. One predominant difference is the European premise of “bringing the doctor to the patient” while the U.S. “brings the patient to the doctor” (9). European systems often employ physicians in the patient’s prehospital management and have little acceptance for specialized prehospital nonphysician providers (10). A starting point for assessment of an EMS system is identification of existing EMS components and available resources. It may be useful to compare system components with the 15 essential EMS components as outlined by the Emergency Medical Systems Act (Table 1) (11). Despite regional differences, many of these components are present to a certain degree in developing prehospital programs. Burkle et al. compared the U.S. system with the EMS system in China and concluded that structural similarities exist despite profound cultural differences

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Table 2. Phase Approach for EMS Analysis, Planning, and Implementation Phase Phase I: Analysis System identification Transportation Destination Personnel Communication Needs assessment System analysis Technical analysis Political considerations Factors influencing EMS advancement Phase II: Planning essential components Establishing objectives Financial assessment Personnel Project administration Phase III: Implementation Legislation and governmental commitment Development of local leadership Course of action Funding

Description Identification of health facilities participating in prehospital care; capacity, personnel, capabilities, and support All existing methods of transportation Issues surrounding access to facilities, including restrictions to private facilities Number and training level of health care providers Evaluate all forms of communication In-depth assessment of health needs to gauge feasibility of EMS in a developing system Utilizing the 15 components of EMS (Table 1) to characterize a system Evaluation of the technical and hardware components of the system, including radios and communication Support from local, regional, and national authorities Address other issues that may be driving EMS advancement, such as political motivations Detailed objectives articulating stepwise implementation plan Address all system expenses, including startup costs and ongoing maintenance and personnel costs Recruitment, training, and payment of technical personnel Local project’s leadership within the government structure Formal governmental recognition and potential legislative approval Leadership development concurrent with program development Detailed timeline, action plan, and assignment of responsibility Delineation of budgets, addressing issues of startup and maintenance funds

and that components can be compared to analyze the developing EMS system, and likewise suggest the use of the 15 EMS components described in Table 1 (12–14). It must be recognized, however, that one or several components may be absent or exist in a different form in a foreign system. The U.S. formed a cohesive and comprehensive prehospital system that integrated many competing components only after legislation and a large amount of government funding helped it to do so. Therefore, a system assessment must be approached with maximal flexibility and minimal ethnocentrism, with the U.S. model serving only as a guide for identifying existing components.

APPROACH TO SYSTEM DEVELOPMENT Developing an EMS system in a country that has either an incomplete system or no EMS services at all can be approached in phases. These phases include analysis, planning, and implementation.

Phase I: Analysis To assist in EMS system development, one must be familiar with the current resources. The components of

the system that are present should be contrasted with the perceived needs as identified by local health care leaders. A good starting point is identification of the existing system, including capacity and level of care. A detailed system analysis must address issues of technology, transportation, available personnel, and communication (Table 2). The importance of a needs assessment cannot be overemphasized. Implementing or upgrading EMS in a community is expensive and depends on relatively advanced technology and resources. In developing countries with limited financial resources, choices must be made regarding the benefit of EMS vs. other health services. A cost-benefit analysis of a community’s needs is an important early step, and should be carefully planned as resources are considered for the development and maintenance of a prehospital system. The evaluation of the health infrastructure must be coupled with consideration of the need for resources in health education and preventive health measures. This concept is demonstrated by an EMS feasibility study in Kuala Lumpur, Malaysia, that showed that implementation of a system to deliver defibrillation to 85% of cardiac arrests in 6 min would cost $2.5 million per year, saving seven lives, three of which would be marred by significant neurologic injury. This study concludes that developing countries may need to consider alterna-

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tives to the North American EMS model (15). Examples like this illustrate the necessity for intensive planning. A difficulty experienced when designing a prehospital program in a developing setting is that of “technology hunger.” The Western model often serves as an example of technology-intensive medicine, perpetuating the notion that high tech equals high quality. It is not unusual that administrators of developing systems are interested in the acquisition of expensive technology to modernize services despite the need for cost-effective programs like education, public health, and primary health care (16). Political considerations remain an important issue whenever the feasibility of a new technology is assessed. In 1987, Costa Rica contracted with the U.S. Agency for International Development and the People to People Health Foundation’s Project HOPE for EMS improvement (17). This developmental program was endorsed by the president of Costa Rica, the minister of health, and several U.S. agencies. Any foreign consultation must be coupled with a strong program for local leadership development and be consistent with local political considerations. Political changes can affect the existing EMS system. War in the former Yugoslavia impacted Bosnia’s EMS system profoundly. Eighty percent of ambulance transports were for patients injured as a direct result of war (18,19). Ambulances in Sarajevo were encumbered by shelling and snipers and were able to transport only about 10% of patients requiring prehospital care to the local hospital. Those unable to contact the system found whatever transport means was available, including walking, horse carts, and private vehicles.

Phase II: Planning the Essential Components Essential components need to be in place before implementing a prehospital care delivery system. The 15 components of EMS in the U.S. represent a starting point but may not match a country’s resources and culture. It might thus be valuable to determine which components are essential and which can be implemented gradually (20). One possible approach is to implement essential components with a graduated plan for integration of other necessary components. Priority may be placed on achieving initial goals (Table 3a), and components for gradual implementation then may be added as resources become available (Table 3b). It is important to plan for all system requirements, if possible, to ensure the placement of such capability in the future. For example, during development of a hospital-based ambulance in Hangzhou, China, a complete EMS program was designed in the planning phase with a basic set

695 Table 3a: Initial Essential EMS Components 1. 2. 3. 4. 5. 6. 7.

Manpower Training Communications Transportation Facilities Access to care Coordinated patient record-keeping

Table 3b: EMS Components for Gradual Implementation 1. 2. 3. 4. 5. 6. 7. 8.

Critical care units Public safety agencies Consumer participation Patient transfer Public information and education Review and evaluation Disaster plan Mutual aid

of essential components implemented initially and graduated implementation of other components such as a quality improvement plan. All components were addressed in the planning phase so that secondary components could be implemented gradually at a later date.

Phase III: Implementation After the EMS system assessment and list of achievable objectives have been completed, a detailed action plan should be crafted to outline the system implementation steps. Issues of particular importance include the need for governmental participation and the development of local leadership. Leaders must be developed concurrently with the program since leadership support is the driving force behind continued program development and, ultimately, the future of the project. A mentor approach is a useful technique to link local leaders with expatriate personnel throughout the program’s development. A steering committee is helpful to troubleshoot and maintain program momentum.

FUTURE EMS NEEDS Countries most likely to require systems are those that have experienced economic growth coupled with increasing urbanization. Among these are portions of Central and South America, Southeast Asia, and the former Soviet Union. Opportunities for physicians and health workers interested in promoting EMS abroad include consulting arrangements for program development in selected developing regions. In addition, specific system component expertise and opportunities for bringing technology and

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materials are needed. Resuscitation education in subjects such as Advanced Cardiac Life Support is often a valuable component of exchange programs. Innovative approaches to EMS development may allow the promotion of prehospital care even in the absence of tertiary care systems. Using community-based services and available health providers can enable a developing system to function within a basic primary health network without overtaxing scarce resources. Developing such an approach challenges the Western paradigm of EMS and can lead to creative and effective solutions for prehospital care.

CONCLUSION Changing economies and population distribution in many developing countries have increased the need for

prehospital care systems. While EMS systems overseas may take a variety of forms, they usually contain system components in common with those found in the United States. For organizations and individuals working abroad, it is important to perform adequate assessments and to gauge the level of prehospital service at an appropriate and sustainable level. Most developing countries are incapable of supporting Western-style EMS systems, and inappropriate technology may divert necessary resources. Several organizations and individuals have worked successfully abroad to develop or refine EMS systems in developed or developing countries. These examples provide insight as to the opportunities and difficulties in developing a prehospital system overseas. EMS system development in another country requires a substantial investment of time and resources to see the project to its successful completion.

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