Mulligan-Erasmus.ppt

Developing a System of EM:Developing a System of EM:International ExperiencesInternational Experiences

Terrence Mulligan DO, MPH, FACOEPTerrence Mulligan DO, MPH, FACOEPAsst Professor, Emergency MedicineAsst Professor, Emergency Medicine

Director, Emergency Medicine Residency / SG Director, Emergency Medicine Residency / SG

Co-Director, Emergency Department / SEH Co-Director, Emergency Department / SEH

Erasmus Medical CenterErasmus Medical Center

Rotterdam, NetherlandsRotterdam, Netherlands

LECTURE OVERVIEWLECTURE OVERVIEW

• Emergency Medicine – The BasicsEmergency Medicine – The Basics• Who we areWho we are

• What we doWhat we do

• Where we are goingWhere we are going

• The Need for Global EM DevelopmentThe Need for Global EM Development• Global burden of diseaseGlobal burden of disease

• Training in International Emergency MedicineTraining in International Emergency Medicine• Opportunities for IEM development collaborationsOpportunities for IEM development collaborations

What is Emergency Medicine?What is Emergency Medicine?

What else is Emergency Medicine?What else is Emergency Medicine?

++

Emergency Medicine is a combination ofEmergency Medicine is a combination of

• A unique, horizontal body of clinical and academic A unique, horizontal body of clinical and academic

knowledge, skills and expertiseknowledge, skills and expertise

++• A A frameworkframework of administrative, managerial, clinical, and of administrative, managerial, clinical, and

systems integration that lays over the busy EDsystems integration that lays over the busy ED

Combined, this provides seamless, efficient, high-Combined, this provides seamless, efficient, high-quality care for quality care for acute, unscheduled, acute, unscheduled, undifferentiatedundifferentiated patientspatients

Basic Emergency Medicine 101Basic Emergency Medicine 101

• TREAT BEFORE YOU DIAGNOSETREAT BEFORE YOU DIAGNOSE• Indicated treatments should not be delayed simply because the Indicated treatments should not be delayed simply because the

diagnosis is not yet certaindiagnosis is not yet certain

• A detailed history is A detailed history is not essentialnot essential to start evaluation and to start evaluation and treatment of an unstable patient treatment of an unstable patient

• If a patient has multiple problems or injuries, treat the one that is If a patient has multiple problems or injuries, treat the one that is the greatest threat to life the greatest threat to life FIRSTFIRST

• ALWAYS assume the patient has a ALWAYS assume the patient has a life-threatening or limb-life-threatening or limb-threatening conditionthreatening condition until proven otherwise until proven otherwise

• Usually by a good H & P and very few tests…Usually by a good H & P and very few tests…

Emergency Medicine is a specialty of Emergency Medicine is a specialty of TIME, ACUITY & MANAGEMENTTIME, ACUITY & MANAGEMENT

Living in a fishbowlLiving in a fishbowl

• The ED is wide open to The ED is wide open to investigation by outsidersinvestigation by outsiders

•Literally open 24 hours/dayLiterally open 24 hours/day•Figuratively since we are the first to Figuratively since we are the first to contact the patientscontact the patients

• Not discussed at length in Not discussed at length in standard EM textsstandard EM texts

• Makes work interactions less Makes work interactions less stressfulstressful

• Results in better patient careResults in better patient care

The ERThe ER

The EDThe ED

Controlled chaos…Controlled chaos…

““Emergency Medicine: Emergency Medicine: Are we the Are we the SystemsSystems SpecialistsSpecialists?”*?”*

Emergency Medicine is the first medical Emergency Medicine is the first medical specialty generated by public health specialty generated by public health demographic pressuresdemographic pressures

EM evolved from its beginning with EM evolved from its beginning with systems integration and analysis as part systems integration and analysis as part of its everyday operationof its everyday operation

*“Emergency medicine: Are we the systems specialists?” Peter A Cameron. *“Emergency medicine: Are we the systems specialists?” Peter A Cameron. Emergency Medicine, Volume 15 Issue 1 Page 1  - February 2003Emergency Medicine, Volume 15 Issue 1 Page 1  - February 2003. .

Overall Integration of the EDOverall Integration of the ED

Ancillary ServicesAncillary ServicesNursingNursing

Medical StaffMedical Staff

CommunityCommunitySchoolsSchools

Managed CareManaged CareTertiary/referring HospitalsTertiary/referring Hospitals

AdministrationAdministrationGovernmentGovernment

Support ServicesSupport ServicesInpatient UnitsInpatient Units

Local/RegionalLocal/RegionalPolicePoliceEMSEMS

EDED

Emergency Medicine is a Emergency Medicine is a continuum of interlocking systemscontinuum of interlocking systems Multi-layered components in each of:Multi-layered components in each of:

Emergency medicineEmergency medicine

Emergency and critical care nursingEmergency and critical care nursing

EMS and pre-hospital systemsEMS and pre-hospital systems

Trauma and other hospital departmentsTrauma and other hospital departments

Disaster systemsDisaster systems

Public Health and Injury Prevention systemsPublic Health and Injury Prevention systems

Recruitment, Education, Training, Practice, Integration, Recruitment, Education, Training, Practice, Integration, Certification, CME, QualityCertification, CME, Quality

EMERGENCY MEDICINE DEVELOPMENT EMERGENCY MEDICINE DEVELOPMENT = SYSTEMS DEVELOPMENT= SYSTEMS DEVELOPMENT

Development of embedded, interdependent systemsDevelopment of embedded, interdependent systems

EMS EMS EM / EM Nursing EM / EM Nursing Critical Care Critical Care

DispositionDisposition

Multiple layers of development and intervention Multiple layers of development and intervention

ProvidersProviders

EducatorsEducators

AdministrationAdministration

LegislationLegislation

PolicyPolicy

Clinical and Academic EM Development is Clinical and Academic EM Development is only Stage 1…only Stage 1…

• Primary Primary stagesstages

• ClinicalClinical

• AcademicAcademic

• AdministrativeAdministrative

• Secondary StagesSecondary Stages

• More admin & academicMore admin & academic

• Interhospital, NationalInterhospital, National

• Tertiary StagesTertiary Stages

• Economic structureEconomic structure

• Legislative agendaLegislative agenda

• Health Policy formulationHealth Policy formulation

• International policyInternational policy

• Etc…Etc…

Why is there a need for Why is there a need for GLOBALGLOBAL development of Emergency Medicine?development of Emergency Medicine?

• Demographic shiftDemographic shift

• Epidemiologic shiftEpidemiologic shift

• EM overlooked by global public health policyEM overlooked by global public health policy

• Traditionally has focus on Traditionally has focus on

• Primary care Primary care

• Maternal / Child HealthMaternal / Child Health

• Public Health / ImmunizationPublic Health / Immunization

• Unscheduled, undifferentiated demandUnscheduled, undifferentiated demand

Demographic Shift: an overviewDemographic Shift: an overview

• The changing nature of populationsThe changing nature of populations

• OverpopulationOverpopulation

• UrbanizationUrbanization

• Gradual aging of the world populationGradual aging of the world population

Population explosionPopulation explosion

• 2000 years ago2000 years ago

• 300 million humans (USA) 300 million humans (USA)

• 200 years ago200 years ago

• 1 billion humans (China / India)1 billion humans (China / India)

• 7 years ago (October 1999)7 years ago (October 1999)

• 6 billion persons6 billion persons

• doubling in size in under 40 yearsdoubling in size in under 40 years

• 20502050

• 8-12 billion estimated8-12 billion estimated

World population growthWorld population growth

Demographic TransitionDemographic Transition

• Birth and death rates interact to produce growthBirth and death rates interact to produce growth• Growth is in an ordered sequence of changes in birth and death ratesGrowth is in an ordered sequence of changes in birth and death rates

Demographic Shift—UrbanizationDemographic Shift—Urbanization

For the first time in history, humans are For the first time in history, humans are predominantly urban dwellerspredominantly urban dwellers

• 1950 1950

• 29 per cent lived in cities29 per cent lived in cities

• 20052005

• > 50 per cent world-wide> 50 per cent world-wide

• 61 per cent urban population by 2030 61 per cent urban population by 2030

• 1996 1996 2030 2030

• 95 per cent of growth in urban areas95 per cent of growth in urban areas

The rise of the MegacityThe rise of the Megacity

MegacityMegacity

• city population > 10 million peoplecity population > 10 million people

• 20th century 20th century

• the century of urban sprawl the century of urban sprawl

• 21st century 21st century

• the century of the the century of the megacitymegacity

Megacities--currentMegacities--current

• 20072007

• 23 megacities worldwide23 megacities worldwide

• By 2015By 2015

• >40 megacities>40 megacities

• By 2025By 2025

• >5 billion city dwellers>5 billion city dwellers

• 90 percent of that increase will occur in developing 90 percent of that increase will occur in developing countriescountries

• Most of these megacities will be in Most of these megacities will be in

• Asia (has the most now)Asia (has the most now)

• AfricaAfrica

• Central & South AmericaCentral & South America

MEGACITIESMEGACITIES

RankRank CityCity PopulationPopulation

11 Tokyo, JapanTokyo, Japan 28 million28 million

22 New York City, United StatesNew York City, United States 20.1 million20.1 million

33 Mexico City, MexicoMexico City, Mexico 18.1 million18.1 million

44 Mumbai, India (Bombay)Mumbai, India (Bombay) 18 million18 million

55 Sao Paulo, BrazilSao Paulo, Brazil 17.7 million17.7 million

66 Los Angeles, United StatesLos Angeles, United States 15.8 million15.8 million

77 Shanghai, ChinaShanghai, China 14.2 million14.2 million

88 Lagos, NigeriaLagos, Nigeria 13.5 million13.5 million

99 KolkataKolkata, India (Calcutta), India (Calcutta) 12.9 million12.9 million

1010 Buenos Aires, ArgentinaBuenos Aires, Argentina 12.5 million12.5 million

Megacities—unsustainable?Megacities—unsustainable?

• unsustainable, unprecedented and ecologically unsustainable, unprecedented and ecologically disastrous for civilizationdisastrous for civilization

• Just 2 per cent of the Earth's land surfaceJust 2 per cent of the Earth's land surface• 75 per cent of industrial wood use 75 per cent of industrial wood use • 60 percent of human water use60 percent of human water use• 80 percent of all human produced carbon 80 percent of all human produced carbon

emissionsemissions

• The struggle to achieve an environmentally The struggle to achieve an environmentally sustainable economy for the 21st century will sustainable economy for the 21st century will be won or lost in the world's urban areasbe won or lost in the world's urban areas

Demographic Shift:Demographic Shift:the aging of the global populationthe aging of the global population

• 20072007• 630 million people > 60 yrs old630 million people > 60 yrs old• average age world-wide = 26 yearsaverage age world-wide = 26 years

• 20302030• more older people than younger in the world more older people than younger in the world • 75% of elderly will be living in developing 75% of elderly will be living in developing

countriescountries

• 20502050• >2 billion within 50 years over 65 yrs old>2 billion within 50 years over 65 yrs old• the average age in W. Europe will be 47 the average age in W. Europe will be 47

Demographic shifts cause Demographic shifts cause Epidemiologic shiftsEpidemiologic shifts

decreasing mortality rates decreasing mortality rates + +

increased life expectancyincreased life expectancy+ +

increased urbanizationincreased urbanization= = ________________________________________________________________________________

a shift away from infectious diseases a shift away from infectious diseases

Toward Toward non-communicable chronic disordersnon-communicable chronic disorders • Heart disease Heart disease • StrokeStroke• CancerCancer• TraumaTrauma

Main Causes of Mortality by Region Communicable Diseases

          Noncommunicable Diseases Injury-Related                 

Where is EM in Global Health policy?Where is EM in Global Health policy?

• Most attention has been given to traditional primary Most attention has been given to traditional primary care developmentcare development

• Infectious disease monitoringInfectious disease monitoring• ImmunizationsImmunizations• Maternal and child health issuesMaternal and child health issues• MalnourishmentMalnourishment

• Little concerted effort towards acute care services Little concerted effort towards acute care services is shown in middle- to low-income countriesis shown in middle- to low-income countries

Demographic and Epidemiologic ShiftDemographic and Epidemiologic Shift——What’s the bottom line?What’s the bottom line?

• Dramatic increases in urbanizationDramatic increases in urbanization

• Gradual aging of the populationGradual aging of the population

• Underestimation of the burden of non-Underestimation of the burden of non-

communicable diseasescommunicable diseases

• Especially in developing and underdeveloped nationsEspecially in developing and underdeveloped nations

• Lack of global health policy planning regarding Lack of global health policy planning regarding

acute care delivery systemsacute care delivery systems

Trends in EM Development Trends in EM Development

Countries With EM

0

5

10

15

20

25

30

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Years

Nu

mb

er

of

Co

un

trie

s

Number of Countries with EM

Current Development of Emergency Current Development of Emergency Medicine InternationallyMedicine Internationally

• EM as a mature specialty in only a few countriesEM as a mature specialty in only a few countries• EMS under-developed or non-existent in the EMS under-developed or non-existent in the

majority of countriesmajority of countries• World-wide nursing shortageWorld-wide nursing shortage

• severe undertraining in EM / critical care severe undertraining in EM / critical care nursingnursing

• Disaster, Trauma and Injury Prevention systems Disaster, Trauma and Injury Prevention systems grossly underdevelopedgrossly underdeveloped

• Systemic resistance to EM development despite Systemic resistance to EM development despite consensus of recognition of needconsensus of recognition of need

EM Org. - RedSpecialty - Purple Residency - BlueJournal - Yellow

EM Org. - RedSpecialty - Purple Residency - BlueJournal - Yellow

EM Org. - RedSpecialty - PurpleResidency - BlueJournal - Yellow

EM Org. - RedSpecialty - PurpleResidency - BlueJournal - Yellow

EM Org. - RedSpecialty - PurpleResidency - BlueJournal - Yellow

EM Org. - RedSpecialty - PurpleResidency - BlueJournal - Yellow

EM Org. - RedSpecialty - PurpleResidency - BlueJournal - Yellow

EM Org. - RedSpecialty - PurpleResidency - BlueJournal - Yellow

EM Org. - RedSpecialty - PurpleResidency - BlueJournal - Yellow

EM Org. - RedSpecialty - PurpleResidency - BlueJournal - Yellow

EM Org. - RedSpecialty -PurpleResidency - BlueJournal - Yellow

EM Org. - RedSpecialty -PurpleResidency - BlueJournal - Yellow

EM Org. - RedSpecialty - PurpleResidency - BlueJournal - Yellow

EM Org. - RedSpecialty - PurpleResidency - BlueJournal - Yellow

Similarities in EM Development InternationallySimilarities in EM Development Internationally

• Development often follows a commonly shared Development often follows a commonly shared structure regardless of national or cultural structure regardless of national or cultural differencesdifferences

• Most evolving patient care systems pass Most evolving patient care systems pass through similar developmental stagesthrough similar developmental stages

• The sequence of development experienced in The sequence of development experienced in advanced systems is useful as a template for advanced systems is useful as a template for development in other countriesdevelopment in other countries

TheThe 30 QUESTION 30 QUESTION Hypothesis Hypothesis

• EM development is roughly similar country-to-country EM development is roughly similar country-to-country despite local differencesdespite local differences

• The entire spectrum of EM Development can be The entire spectrum of EM Development can be compressed to relatively few fundamental questions compressed to relatively few fundamental questions

• 30 questions (?)30 questions (?)• 8 sub-divisions8 sub-divisions

• Specialty systems Specialty systems (4)(4)

• Academic development Academic development (4)(4)

• Education/Patient-care systems Education/Patient-care systems (4)(4)

• Management systems Management systems (3)(3)

• Economic Structure Economic Structure (2)(2)

• Legislative Structure Legislative Structure (2) (2)

• National Health Policy National Health Policy (4)(4)

• Local Variations Local Variations (5)(5)

SPECIALTY SYSTEMSNational organizationSpecialty trainingBoard certificationOfficial specialty statusACADEMIC DEVELOPMENTSpecialty journalResearch / DatabasesSubspecialty trainingProvider TrainingEDUCATION / PATIENT-CARE SYSTEMSFormal educational institutionStudent requirementsProvider TrainingGovernmental requirementsMANAGEMENT SYSTEMSQuality assurance Peer reviewHealth Insurance

The The 30 QUESTIONS30 QUESTIONS in EM Development in EM Development

ECONOMIC STRUCTUREReimbursement (Local, National)Hospital Markets / Managed CareLEGISLATIVE STRUCTURENational Health System Civil / Penal Law StructureNATIONAL HEALTH POLICYWelfare StructureCorporatist vs Liberalism vs ResidualismModes of GovernanceInfluence of Interest Groups / StakeholdersLOCAL VARIATIONSGender, Race and Religion related issuesSocioeconomic Status / GNPLinguistic / Cultural variations??????????

30 QUESTION Hypothesis30 QUESTION Hypothesis• 15-20 of the questions are shared by everyone15-20 of the questions are shared by everyone• 5-10 of the questions are shared by almost 5-10 of the questions are shared by almost everyoneeveryone• 5-10 are region - specific5-10 are region - specific

The 30 QUESTION Hypothesis in IEM Development

Specialty systems

Academic development

Education/Patient-care systems

Management systems

Economic Structure

Legislative Structure

National Health Policy

Local Variations

EM Development PyramidEM Development Pyramid

PRIMARY STAGESPRIMARY STAGESSpecialty systemsSpecialty systemsAcademic developmentAcademic developmentEducation/Patient-care systemsEducation/Patient-care systems

SECONDARY STAGESSECONDARY STAGESManagement systemsManagement systemsEconomic StructureEconomic Structure

TERTIARY STAGESTERTIARY STAGESLegislative Structure Legislative Structure National Health PolicyNational Health Policy

Local VariationsLocal Variations

Biggest Blocks to Progress Biggest Blocks to Progress

• PEOPLE WITHOUT UNDERSTANDING GIVING ADVICEPEOPLE WITHOUT UNDERSTANDING GIVING ADVICE• Specialists in other disciplinesSpecialists in other disciplines

• Other administratorsOther administrators

• PoliticiansPoliticians

• VESTED INTERESTS INTERFERINGVESTED INTERESTS INTERFERING• Other specialistsOther specialists

• Other departmentsOther departments

• Private companiesPrivate companies

• OTHER DEPARTMENTS HAVE LIMITED EXPOSURE TO OTHER DEPARTMENTS HAVE LIMITED EXPOSURE TO

FULLY FUNCTIONING EMERGENCY MEDICINEFULLY FUNCTIONING EMERGENCY MEDICINE

International EM: International EM: Lecture SummaryLecture Summary

• EM development involves multi-layer EM development involves multi-layer developmentdevelopment•Clinical / AcademicClinical / Academic•Administrative / ManagerialAdministrative / Managerial•Economic / Legislative / Health PolicyEconomic / Legislative / Health Policy

• Due to global demographic and epidemiologic Due to global demographic and epidemiologic shifts, EM more important than evershifts, EM more important than ever

• Training and exposure to international experiences avoids Training and exposure to international experiences avoids constantly “reinventing the wheel”constantly “reinventing the wheel”•International Fellowship programsInternational Fellowship programs

……assist countries in transition on how to assist countries in transition on how to refocus their health systems. How to cope refocus their health systems. How to cope with the double burden of disease - the old with the double burden of disease - the old agenda of communicable diseases - and the agenda of communicable diseases - and the new agenda of non-communicable diseases new agenda of non-communicable diseases which demand a quite different approach - which demand a quite different approach - quite different training, and quite different quite different training, and quite different resources.resources.

Gro Brundtland, WHOGro Brundtland, WHO

[email protected]@erasmusmc.nl

Why is International EM Why is International EM Faculty Development Faculty Development Needed ?Needed ?

• Need for improved quality and Need for improved quality and quantity of EM recently recognized quantity of EM recently recognized by many countriesby many countries

• EM as a defined specialty is a new EM as a defined specialty is a new idea in many countriesidea in many countries

• The physicians interested in The physicians interested in starting the specialty may lack starting the specialty may lack formal training in EMformal training in EM

• The skills and knowledge of EM The skills and knowledge of EM specialists are applicable and useful specialists are applicable and useful in any national health care systemin any national health care system

Specific Courses To Consider As Part of An International EM Fellowship

ƒ Spoken and / or written Englishƒ Medical statisticsƒ Animal surgical techniques for

researchƒ Medical photographyƒ Computer program operationƒ Humanities, ethics, or medical

historyƒ Library systems operationƒ Lab Medicine or Radiology

Technology

Specific Program Responsibilities To Consider Assigning to Core Faculty

ƒ Overall Department Directorƒ EM Residency Program Directorƒ E.D. Clinical Operations Directorƒ Research Directorƒ Medical Student Programs Directorƒ Quality Improvement Programs Directorƒ E.M.S. (pre-hospital) Coordinator or

Directorƒ Coordinator for residents from other

specialtiesƒ Liasons with other departments (such as

Trauma, Pediatrics, etc.)

Funding For International EM Fellowship Programs

ƒ Most require the fellows to have their own funding–Usually from the sending government, health ministry, or university–Minimum guaranteed funding requirement for a J1 visa currently is $ 800 per month–Agency for International Development & N.G.O.'s (such as Carelift International) have sponsored some fellows in the past

ƒ Extra funds must be budgeted for attendance at modular courses & state or national meetings

Emergency Medicine Residency Program Emergency Medicine Residency Program

at Erasmus MCat Erasmus MC

Three year training programThree year training program

50% of clinical rotations / stages spent in the Emergency 50% of clinical rotations / stages spent in the Emergency

DepartmentDepartment

Critical roles in each basic and full trauma responseCritical roles in each basic and full trauma response

Initial stabilization, treatment, diagnosis and disposition of Initial stabilization, treatment, diagnosis and disposition of

multiple patients with varied, undifferentiated complaintsmultiple patients with varied, undifferentiated complaints

Training in acute and chronic presentations of emergencies from Training in acute and chronic presentations of emergencies from

multiple disciplines (medical, surgical, obstetric, pediatric, etc)multiple disciplines (medical, surgical, obstetric, pediatric, etc)

Partnership with other specialists to provide prompt, appropriate, Partnership with other specialists to provide prompt, appropriate,

high quality, cost-effective medical care to our patientshigh quality, cost-effective medical care to our patients

6 AIOS currently, 1-2 more each year6 AIOS currently, 1-2 more each year

44thth and 5 and 5thth year Research and Academic Fellowships available year Research and Academic Fellowships available