68. Emergency Medical Services

Interventions for Emergency Care: Systems, Structures, and Organization

Emergency care must be appreciated as an entire system with interdependent components. These components include prehospital care, transportation, and hospital care. Each component is important, but all of them must work together to make a lasting effect on the health of a population. The organization and operation of the prehospital care system will vary by country, but it should be linked to the local hospitals or facilities where patients are taken. When prehospital transportation is poor or absent, deaths occur that could have been prevented even by inexpensive procedures (Mock and others 1998). For example, the majority of maternal deaths may fall into this category. Poor quality of care at the hospitals will lead to inhospital deaths and may eventually discourage communities that might have the capacity to promptly transfer patients to such facilities (Leigh and others 1997; Prevention of Maternal Mortality Network 1995). Skilled and motivated personnel, appropriate supplies, pharmaceuticals, equipment, coordination, and management oriented to the needs of the critically ill all contribute to make emergency care effective in reducing death and disability.

Prehospital Care

Prehospital care encompasses the care provided from the community (scene of injury, home, school, or other location) until the patient arrives at a formal health care facility capable of giving definitive care. This care should comprise basic and proven strategies and the most appropriate personnel, equipment, and supplies needed to assess, prioritize, and institute interventions to minimize the probability of death or disability. Most effective strategies are basic and inexpensive, and the lack of high-tech interventions should not deter efforts to provide good care. Even where resources allow them, the more-invasive procedures performed by physicians in some prehospital settings, such as intravenous access and fluid infusion or intubations, do not appear to improve outcomes, and evidence suggests that they may, in fact, be detrimental to outcomes (Liberman and others 2003; Sampalis and others 1994, 1995, 1997).

Prehospital care should be simple, sustainable, and efficient. Because resource availability varies greatly among and within countries, different tiers of care are recognized. Where no formal prehospital system exists, the first tier of prehospital care may be composed of laypeople in the community who have been taught basic techniques of first aid. Recruiting and training particularly motivated citizens who often confront emergencies, such as drivers of public transportation, to function as prehospital care providers can add to this resource.

The second tier comprises paramedical personnel who use dedicated vehicles and equipment and are usually able to get to patients and take them to hospitals within the shortest possible time. This second tier may involve the performance of advanced procedures, the administration of intravenous and other medications by physician or nonphysician providers, or both. This care is not always available in low-income countries; few trained personnel and inadequate funding make round-the-clock coverage impossible. Although providing advanced life-saving measures in the prehospital environment may be beneficial in some cases, these benefits may be negated if such measures divert scarce resources from more basic interventions that can benefit far larger numbers of patients (Hauswald and Yeoh 1997). In most low- and middle-income countries of Africa, Asia, and Latin America, high maternal and child mortality are linked to inadequate emergency care, especially poor access to quality hospital care. In these settings, it is imperative that resources be integrated, instead of one system for injuries and another for obstetric emergencies.

Personnel

Most of the world's population does not have access to formal prehospital care. No personnel are employed for the sole purpose of dealing with medical emergencies outside of hospitals, and no transportation is dedicated to the task of getting patients in need of emergency care into hospitals. There is a paucity of literature on the effect of first responders, except for one study that evaluated a program to train a core group of paramedics, who then trained thousands of lay first responders in northern Iraq and Cambodia. No data are available on the effectiveness of lay responders compared with the more trained paramedics.

The following discussion introduces a scenario in which the observed mortality rate reduction could be achieved in a developing country's health system by a small group of paramedics working together with a large group of trained lay responders. The scenario uses only emergencies caused by trauma, although it is expected that both the paramedics and the lay first responders would also save lives from medical or obstetric emergencies. Existing studies have not been large enough to document these effects, and they are not included in the estimates of cost-effectiveness.

Trained Lay Responders

A case is made for training lay persons able to recognize threatening conditions—whether obstetric, traumatic, or medical. Cultural reasons may require that those responding to obstetric emergencies be traditional birth attendants or similar persons in the community. Husum and colleagues demonstrated that lay people who are given first-aid skills could effectively respond to emergencies in a community with a high trauma burden (Husum, Gilbert, and Wisborg 2003; Husum, Gilbert, Wisborg, and others 2003). In Ghana, it was demonstrated that commercial taxi and minibus drivers trained in first aid could provide effective prehospital care (Mock and others 2002). Lay responders are likely to be successful where the burden of injuries and other emergencies is high. Attrition of both the responders and the skills is a concern unless they are put to frequent use.

Paramedical Personnel

In most middle-income countries and some cities of low-income countries, trained paramedical personnel render prehospital care (Mock and others 1998; Tannebaum and others 2001). As for lay responders, coverage varies by country. In most of Sub-Saharan Africa and Asia, paramedical personnel and ambulances transfer patients between health facilities and not from the scenes of injury or from homes (Joshipura and others 2003). In middle-income countries, though, they are a major component of existing emergency medical systems (Arreola-Risa and others 2000; Mock 2002). Their presence (coupled with vehicle ambulances) reduces the interval between the recognition of an emergency and the arrival at the hospital, and some evidence suggests that training them in basic life-saving skills improves patient outcomes (Ali and others 1997, 1998; Arreola-Risa and others 2000).

Effectiveness has also been demonstrated for well-placed dispatch sites in urban populations, where the vehicles and personnel can be optimized. There is no evidence, however, for the effectiveness of training prehospital care paramedical personnel in advanced life-saving skills (Sethi and others 2003). Shorter prehospital times, in general, are considered an important parameter of the quality of prehospital care. These times have the following components:

• Notification time is the time elapsed from occurrence of injury or recognition of severe illness until the EMS system is notified.

• Response time is the time elapsed from notification until arrival of an ambulance to the site of the ill or injured person.

• Scene time is the time taken by prehospital providers from arrival at until departure from the scene.

• Transport time is the time elapsed from leaving the scene until arrival at the hospital or other treatment facility.

Notification time is influenced by the availability of telecommunications. Response time is influenced by the capabilities of a dispatch center to handle emergency calls and especially by the geographic distribution of sites of ambulance dispatch. The greater in number and the more widely distributed the number of ambulance stations are, the shorter the response times are.

Geographic distribution and associated response times can be improved in some circumstances by using a tiered or layered response system. This system requires having a relatively larger number of basically trained and equipped first responders with wider geographic distribution and a smaller number of centrally located, more highly trained and equipped second responders. This system allows the first responders to respond more rapidly, with second responder involvement only if needed.

Accordingly, paramedical personnel should be introduced in large urban areas where they do not function at present and should be stationed at dispatch sites with dedicated vehicles, fast communications with the hospitals in the area, and links with other emergency services such as the fire and police departments. The communities served by the system should have a well-known and rapid method of calling the paramedical teams when an emergency arises. Because skills depreciate with time, these personnel require refresher courses. Where paramedical personnel already exist as part of the EMS, their numbers and organization (location, training, deployment, and monitoring) should be enhanced to improve response times and, hence, patient outcomes, especially for cardiac and obstetric emergencies. Availability of EMS for a given population can be looked at either as number of units on duty or number of sites of ambulance dispatch. They are usually closely related, with one or two units per site, but not in systems where a large number of units are on duty from one central dispatch station.

The recommended ratio of one unit for 50,000 people suggested by McSwain (1991) results in response times as low as four to six minutes. The ratio does not distinguish between basic life-support and advanced life-support capabilities. Traffic congestion, poor maps, and poor road signs may all increase this response time in cities with poor infrastructure. In Monterrey, Mexico, one unit per 100,000 people manages an average response time of 10 minutes. Hanoi, Vietnam, with one unit for 3 million people, has an average response time of 30 minutes (Mock and others 1998).

Where paramedical services exist alongside lay responder services, these two could be managed by the same organizational unit. The paramedical staff will be more successful in urban areas, where distances between dispatch sites, communities served, and hospitals are short. Other enabling factors are good telecommunications; rapid and dedicated transportation; and coordinating capacity among the community, hospitals, and other emergency services.

Intervention Cost and Effectiveness

Training lay responders is an intervention potentially available in low-income countries. Projections for costs and effectiveness have been made based on the following assumptions:

• Serving a population of 1 million requires 7,500 trainees. Sensitivity analysis ranges from 5,000 to 10,000 trained lay responders.

• Trained lay responders can be trained in half a day (St. John Ambulance 1996).

• Training would have to be repeated every three years to maintain efficacy.

• Annually, 2,500 laypeople would be trained on a rolling basis.

Using these assumptions (see annex 68.A for technical details on costing guidelines) would require the following:

• 1,250 days of trainees' time (0.5 days each) valued at salary level 1

• 62.5 trainer days of time, with a ratio of 20 trainees per trainer, valued at wages for salary level 3

• one training facility with a classroom (100 square meters) valued at rent for basic space for 62.5 days

• 2,500 copies of photocopied curricula annually valued at US$1 each.

The costs of providing trained paramedics can be estimated using the following assumptions:

• Trained paramedic responders can be trained in 25 days (St. John Ambulance 1996).

• Serving a population of 1 million requires 7,500 trainees. Sensitivity analysis ranges from 100 to 200.

• Training would have to be repeated every three years to maintain efficacy.

• Annually, 50 paramedics would be trained.

As a result, the following would be required:

• 25 x 50 = 1,250 days of paramedic trainee time (salary level 1)

• 125 trainer days, with a ratio of 10 trainees per trainer valued at salary level 3

• one training facility offering a classroom (100 square meters) valued at basic building values

• 50 photocopied curricula annually, valued at US$1 each

• one paramedic kit with stethoscope, gloves, bandages, and splint material for each trainee (kits would be renewed by patient contributions).

The trainees would offer volunteer services after training. We assume that volunteers are highly motivated individuals who consider emergency medical service to their community as the most rewarding use of their leisure time (Fiedler 2000). The opportunity cost of their recurrent emergency service is assumed to be zero. Communities or cultures that have a shortage of individuals with an ethic of volunteer service may have to devote funds toward maintaining incentives for "volunteer" paramedics to serve. In such cases, this strategy may not be cost-effective.

Table 68.3 shows the estimated costs of the lay first responders and paramedics intervention, drawing on the Disease Control Priorities Project's standardized input prices by region for low, best, and high estimates.

Outcomes

According to the World Health Organization burden-of-disease estimates, the global incidence of trauma is 410 per 100,000 or 4,100 per million. Husum, Gilbert, and Wisborg (2003) indicate that first-level responders and trained paramedics can lower mortality in trauma by 9 percent; thus, in 4,100 traumas, 370 lives can be saved. Dividing the sum of the costs in table 68.3 by the 370 deaths averted provides a rough estimate of costs per death averted. These costs per death averted are divided by the regional life expectancy at age 20 (LE 20), with the assumption that the average age of trauma is 20, to give the cost per life year saved. LE 20 is roughly 50 years in every region except Sub-Saharan Africa, where it is only 37 years. Shortages of equipment and supplies may reduce the effectiveness of the prehospital personnel.

It is possible to offer more refined "regional" estimates of the numbers of deaths averted by using local estimates of the burden of injuries instead of the global estimate of 4,100 injuries per million people. Yet given the uncertainty about regional variation in the effectiveness of the intervention based on administrative, infrastructure, and human resource capacity, it would perhaps give a false impression that a firm and universal basis exists to speculate quantitatively on the relative effectiveness of the intervention in various regions. As a result, the above estimates, as used in table 68.4, serve to inform global dialogue rather than offer specific empirical numbers.

Equipment and Supplies

Equipment and supplies should match the knowledge and skills of the personnel available to use them. Even teams with the least resources should have the following:

• protective wear, especially gloves and aprons

• a stretcher or the equivalent

• pressure dressings (bandages—elastic, if possible—and cotton or gauze dressings)

• splints—various sizes, made out of local materials

• radio, telephone, or other mode of rapid communication.

Annex 68.A provides a comprehensive list for better-resourced communities. Intervention cost and effectiveness cannot be estimated because no studies are available on this issue from low-income countries.

Traditional and Innovative Communications Systems

Nowhere is the demand for efficient communication and rapid transportation more critical than in emergency medical care. The best teams equipped with state-of-the-art technology and supplies will be wasted if they cannot be reached quickly or if they have no contact with the hospitals where patients are to be taken. Most of the world's population lives in areas where there is no telecommunications infrastructure, and this situation may not change significantly in the near future. Innovation is needed so that these populations can be enabled to access effective emergency care interventions that already exist without waiting for traditional telephone lines to get to their rural homes. Radio communication is one solution in such settings. Equipping traditional birth attendants and remote health units with radio receiver sets linked to local hospitals has been used to shorten the response time and reduce maternal deaths (Samai and Sengeh 1997). Cellular telephones may offer communities that are remote from standard communications infrastructure an opportunity to leap into a more modern and efficient mode.

Intervention Costs and Effectiveness

There are no studies from low-income countries on which to base intervention cost and effectiveness estimates. The costs will depend on whether the community adopts traditional communication or more modern communication systems. If radio communication were introduced, the purchase and maintenance of radio receivers, supplies, and government licensing costs would need to be estimated. If cellular telephones options were being explored, then the purchase of telephones, plans, licenses, and maintenance costs would need to be included. Where satellite towers need to be installed, however, this cost will be much higher than for all other components. Finally, if traditional landline installation is being considered, the lines, equipment, and telephone bills will need to be taken into account. The health sector may be able to share the costs of such interventions, especially traditional telephone lines, with other development and infrastructure units of a national government.

Basic and Advanced Transportation Systems

Transporting a patient from the location of the acute event to a hospital facility is a critical element of the prehospital component. Lack of transportation is often a major barrier to accessing emergency care (Lungu and others 2001; Samai and Sengeh 1997). In devising a prehospital system of transportation, one should consider locally available resources and the range of viable alternatives for transportation. In some countries such transportation may be part of a formal EMS system, whereas in other cases it is entirely informal. For example, commercial vehicles, the police, and relatives using private motorized or nonmotorized forms of transportation may bring seriously ill and injured patients to medical facilities (Andrews, Kobusingye, and Lett 1999; Joshipura and others 2003; Kobusingye and others 2002). A bicycle ambulance in Malawi set up to improve emergency obstetric care was actually used more often for injuries and medical emergencies (Lungu and others 2001).

Transportation should be accessible at short notice. A vehicle with a stretcher is ideal, but almost any transportation that will get a patient to a facility where definitive care can be obtained is acceptable. Although a fully fitted and equipped ambulance vehicle complete with trained paramedics delivers better outcomes, ethical and equity considerations dictate that before this vehicle is made available to an elite population in the urban areas, basic transportation must be assured for all who need emergency transportation and care.

In a city setting, a vehicle ambulance can make as many as 20 trips per day. On average this schedule will require salaries for an administrator and two crews, each comprising a driver and two paramedics or nurses, as well as expenses for communication, supplies, pharmaceuticals, and the costs of operating the vehicle. A study of a decision to develop an EMS in Kuala Lumpur (1.1 million people, 243 square kilometers) estimated that the purchase and staffing of 48 ambulances at US$53,000 each per year would be required, totaling US$2.5 million per year (Hauswald and Yeoh 1997). The authors noted that, despite the paucity of ambulances, severely injured or ill patients did get to a hospital with only minor delays by using taxis, family transportation, or the police. Ambulances need accurate maps, house numbers, and street or road signs, all of which might not be in place in low-income cities. It was estimated that ambulances were unable to locate patients in 20 percent of calls in Kuala Lumpur because of mapping and sign-age problems (Hauswald and Yeoh 1997).

A study conducted in Turkey found that ambulance vehicle costs were the leading component of capital costs (Altintas, Bilir, and Tuleylioglu 1999). The cost per trip was US$163, and the cost per patient transported was US$180.50, which the authors thought were beyond the means of the private sector. In state-run ambulance services in New Delhi, India, the cost per trip was approximately US$40, yet one in three of the ambulances served only to transport patients, with no paramedic staff on board (India, Government of Delhi 2001).

The debates in high-income countries about helicopter ambulances provide lessons for low-income countries. In some cases, helicopter services have been discontinued because they were not considered cost-effective (Hutton 1995). A study conducted in the United States, which concluded that helicopters were cost-effective, found that the cost per patient transported was US$2,214 and that for every 100 flights there were six survivors more than was predicted on the basis of injury severity indices (Gearhart, Wuerz, and Localio 1997). Each additional survivor cost an average of US$15,883, and the authors acknowledged that the helicopter had to be used fully to spread the high fixed costs across many patients and trips. A review of civilian helicopter ambulance programs in the United States concluded that the primary factor in the reduction of trauma mortality was not the speed at which the patient was transported but the administration of life-saving care by the helicopter medical crew at the scene or at the outlying hospital (Moylan 1988). In low-income countries, for the very few who benefit from such a high-end intervention, there are likely to be thousands who cannot access care even using the most basic means.

Intervention Costs and Effectiveness

Costing transportation systems requires the following assumptions:

• In an urban population, one ambulance unit can serve a population of 30,000 people. Thus, 1 million people would require 33 ambulance units (1 million/30,000).

• Each ambulance unit requires staffing of a rotation of six paramedic-drivers and a seventh paramedic-driver to cover vacation times and sick leaves.

• A supervisor oversees three ambulance units per year.

• A garage for the ambulance and communications equipment would be 100 square meters but would entail rental of office-style accommodations.

• A vehicle to be outfitted as an ambulance can be purchased for as much as an off-road vehicle with a useful life of nine years.

• The cost to modify the vehicle into a basic ambulance is US$5,000 for a useful life of nine years.

• The ambulance will require fuel and maintenance based on usage of 20,000 kilometers per year.

Given the preceding assumptions,

• The 231-member ambulance staff (33 ambulance units of 7 persons each) would be paid at salary level 2.

• The 10 administrators would be paid at salary level 2.

We ignore the additional burden on the health system from additional visits. Quite possibly, hospital costs will rise as more patients now get to the hospital with the help of ambulances. It is also possible that patients currently arrive in less desperate condition, so that the cost of care is lessened. No studies are available on which to base cost estimates to address those issues.

Table 68.5 shows the estimated costs of the ambulance intervention, drawing on the Disease Control Priorities Project's standardized input prices by region for low, best, and high estimates.

Outcome

Based on the World Health Organization's 2001 burden of disease estimates on epidemiology of trauma, ischemic heart disease, and obstetric emergencies, we estimate that for each 10,000 population there will be 9 deaths from trauma,¹ 11 deaths from ischemic heart disease,² and 2 deaths from lethal obstetric emergencies.³ For modeling purposes, we confine our attention to trauma, ischemic heart disease, and obstetric cases. Although many possible lethal emergencies may present, such as sepsis, malaria, snakebites, and asthma, by confining attention to the major emergency conditions we locate 2,200 (900 + 1,100 + 200) potentially savable lives in a population of 1 million. The savings are outlined is follows:

• Savings from trauma reductions. Saving lives from trauma depends on the quality of trauma care at the destination facility. In one year for 1 million people, there will be 4,100 trauma cases and 900 trauma deaths. With rapid resuscitation and oxygen available through use of ambulances, we assume we can save 300 lives.

• Savings from myocardial infarction management. In one year for 1 million people in low-income countries, 1,100 deaths will typically result from myocardial infarction. Low-dose aspirin provided to myocardial infarction victims lowers mortality by 18 percent (Weisman and Graham 2002). In a population without ambulance services, rapid aspirin administration cannot be ensured; with EMS, aspirin use can potentially be increased from about 0 percent to 100 percent for heart myocardial infarction. Therefore, instead of 1,100 deaths, there will be 1,100 x (1 - 0.18) deaths, saving 200 lives, but with only an average of five life years per life saved.

• Savings from emergency obstetrics management. Obstetric deaths for medically attended patients are approximately 100 times lower than for patients who do not receive medical care. Accordingly, an ambulance system essentially saves all of the obstetric emergencies from death; this saving would amount to 200 deaths averted in the case described previously. As a result, in the hypothetical population of 1 million people in low-income countries, 700 lives can be saved by an ambulance system focusing on three causes only: ischemic heart disease (200), obstetric (200), and trauma (300).

The middle section of table 68.6 displays the cost per death averted. To compute life years saved in the last section of the table, we assume that the 500 deaths averted from obstetric emergencies and trauma occur at age 20, but the 200 deaths averted from ischemic heart disease save only five additional life years per case. Regional life expectancy at age 20 years (estimated) is used as before.

Costs for a Rural Ambulance Service

The key difference determining higher costs for rural ambulances is that more ambulance units are necessary to cover the population. We assume that in rural areas one ambulance unit can cover a population of 10,000, although variation will occur, depending on population density and geographical topography. On the basis of this assumption, all of the cost estimates for rural ambulances are essentially three times higher for a population of 1 million, as are the costs per death averted and per life year gained. They are assumed to have the same effectiveness as the urban services because the increase in units aims at delivering the same quality of care as in the urban centers. This assumption may not hold true if the quality of care at the receiving facilities is lower than that in the urban areas.

Uncertainty of Estimates

Substantial uncertainty remains over the actual effectiveness of the interventions in emergency medicine. The tables in this chapter should be approached with due caution because ultimately the projections of the effectiveness of interventions have been patched together from a handful of intervention trials whose success may or may not be similar in other contexts. The projections include the following:

• Ambulance services can and do save lives by performing field stabilization and by hastening the arrival of critical patients when time makes a difference in the outcome.

• Only several dozen ambulance runs per year for a unit serving a population of 10,000 will actually have the potential to save lives.

• Ambulance services are more cost-effective in denser populations and when roads are more passable, making trips shorter.

• Training lay responders and paramedics can be relatively cost-effective.

The financial support of an ambulance unit may rely on the value perceived by the hundreds of patients who are comforted by having rapid access to care or by knowing ambulances are there if needed, even though their lives and health are not actually improved by ambulances.

Table 68.6 summarizes the best estimates of cost, cost per death averted, and cost per life year.

Health Facility-Based Subsystem

This subsystem refers to a level within the health care system where appropriate definitive care is delivered. Formal health facilities vary immensely between and within countries. In some countries, this subsystem may be a regional hospital with specialists; in others, a district hospital with general practitioners or nonspecialist doctors; and in still others, a health center with competent nonphysician clinicians. In some low-income countries, some types of emergency medical care, for conditions such as acute diarrhea or severe malaria, may be effectively delivered at a health center staffed by nondoctor clinicians. However, such a facility will be grossly inadequate for the management of a severe multiple injury or obstructed labor. The triage process in the prehospital subsystem should determine which patients receive transportation to which facility, instead of merely transportation to the nearest facility. Precious time and lives may be lost when patients are taken to facilities where the desired definitive care is not available.

Because the goal of an effective EMS is the provision of emergency care to all who need it—universal emergency care—the following section presents guidelines on the necessary inputs at different levels. Two of the components in hospital emergency care are discussed in more detail: (a) training and (b) equipment and supplies. The first level of formal health care is often staffed by nonphysician clinicians; the second level is staffed by at least one physician and other trained health care professionals; and the third is staffed by specialists in addition to other health care professionals. Some middle-income countries have additional levels (major emergency care centers), and some hospitals are specialized (chapters 65 and 66).

Training

Most in-service training for emergency care professionals working in hospitals is designed to address a particular problem, such as severe injuries, emergency pediatrics, or obstetric emergencies. Yet because of the resource constraints of low-income countries, the same personnel will be confronted with all these problems. Few courses in emergency care have been rigorously evaluated (Black and Brocklehurst 2003; Sethi and others 2003). The Advanced Trauma Life Support (ATLS) course for doctors has resulted in improved patient outcomes in some settings, although it may be too expensive for most low-income countries and inappropriate in settings where doctors do not see the majority of patients. In a tertiary hospital in Trinidad and Tobago, injury mortality was reduced by 50 percent following ATLS training (Ali and others 1993).

Life-saving obstetric skills training was found to contribute to a reduction in maternal deaths. In Kebbi state in Nigeria, this training led to a drop in case-fatality rates among women with obstetric complications from 22 percent to 5 percent. Similar trends were observed in other sites where the intervention was implemented (Oyesola and others 1997; Prevention of Maternal Mortality Network 1995). Emergency Triage Assessment and Treatment has been used in many countries to improve pediatric emergency care (WHO 2000). Other examples are Primary Trauma Care, which is a trauma management course to train doctors and other health workers in district hospitals and remote locations (Wilkinson and Skinner 2000), and Advanced Life Support in Obstetrics (see http://www.aafp.org/also). These courses have been beneficial in standardizing protocol-based emergency care, but their outcome evaluations are still awaited. Low-income countries need to identify training models for their versatile emergency care personnel, especially those working at middle-level facilities, who respond to different types of emergencies.

The costs of this intervention are not available in the literature and will require an estimation of trainer costs, space, materials, and refresher courses.

Equipment and Supplies

A specimen list of resources for emergency care required at different levels of facilities is provided in annex 68.A. This template is flexible, and countries can customize it to suit local conditions, such as existing facility levels and prevailing burden of emergency disease conditions. Equipment and supplies at each level should match the knowledge and skills of the personnel available to use them.

Systems Organization

Emergency care needs to be planned and implemented carefully. The various components that make up the EMS should be linked to ensure that the entire system operates as a unit. A coordinator should be responsible for monitoring and coordinating all emergency medical care in the community or district and should work with a committee to which the other components send representation. A community representative should be a key member of this committee.

Coordination costs are very important and should not be overlooked in the development of a new EMS. Such costs include the salary of the coordinator, an efficient telephone or communication system, a vehicle, fuel, and a budget to organize meetings of stakeholders at least twice a year (Bazzoli, Harmata, and Chan 1998; Nurok 2001).

Health Financing for Emergency Care

Emergency medical systems in low-income countries must be pro-poor in their orientation, which requires explicit consideration of how the poor interact with an EMS and how barriers to acute care for the poor can be overcome. Issues of access to an EMS become critical because the lack of money often keeps people from using emergency services. Direct payment of costs for transportation, medical treatment, and drugs makes lack of money a major barrier to EMS for the poor in every country. As a result, emergencies frequently cripple individuals and families financially in poor communities, often for many years in the future.

Financial protection for emergency health care is a necessity in low-income countries and has not received adequate attention. The goal of such protection is to ensure that individuals and families do not spiral down the pathway to abject poverty as a result of interaction with the national health system. Such financial protection may be achieved by a number of different means, including community financing (Ande and others 1997; Desmet, Chowdhury, and Islam 1999; Macintyre and Hotchkiss 1999). Community loan funds to cover transportation and other requirements for emergencies, especially for obstetrics, have been explored with mixed results (Essien and others 1997; Shehu, Ikeh, and Kuna 1997). Some experience seems to indicate that these approaches can indeed overcome several of the barriers to accessing emergency medical services and should be explored further.

Documentation and Quality Assurance

Quality of care is critical to the interaction of the poor with the EMS. Lack of funds, lower-paid jobs, social class distinctions, ethnicity, and other affiliations make the already vulnerable poor susceptible to receiving poor-quality care. For an EMS to maintain and improve the care of patients, systematic documentation and periodic audits, or other processes to ensure quality of care, need to be incorporated. Quality management systems that are simple, are continuous, and allow for rapid changes in the system need to be implemented.

Because of scarcity of resources, expensive machines and elite specialists should not be advocated for the urban privileged at the expense of the majority of the rural poor. The most difficult decisions concern balancing funds invested in the emergency care capacity of secondary and primary care centers with support for referral and transportation networks to feed tertiary care centers. These decisions are too variable and too system specific to yield to a uniform policy prescription. Two principles are advocated to inform these difficult decisions:

• Collect data on costs, capacities, and outcomes.

• Tighten the integration of the emergency care system to improve function and lead to wiser decisions on where to invest.

Legislative Instruments to Ensure Emergency Care

The issues discussed in the preceding sections supply the rationale for countries to have specific legislation addressing the provision of emergency care. This area requires major cooperation between public health and law, which together provide the legal framework for ensuring that all individuals who deserve emergency care can receive it, irrespective of their personal characteristics or their ability to pay. Having laws that protect trained individuals and laypeople as they provide such care is also important.