Accident and Emergency Medicine

Emergency Medicine Day

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In addition to decreasing the uninsured rate, ED overutilization might be mitigated by improving patient access to primary care and increasing patient flow to alternative care centers for non-life-threatening injuries. Financial disincentives, patient education, as well as improved management for patients with chronic diseases can also reduce overutilization and help to manage costs of care. Despite the practice emerging over the past few decades, the delivery of emergency medicine has significantly increased and evolved across diverse settings as it relates to cost, provider availability and overall usage.

Prior to the Affordable Care Act ACA , emergency medicine was leveraged primarily by "uninsured or underinsured patients, women, children, and minorities, all of whom frequently face barriers to accessing primary care".

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In rural communities where provider and ambulatory facility shortages exist, a primary care physician PCP in the ED with general knowledge is likely to be the only source of health care for a population, as specialists and other health resources are generally unavailable due to lack of funding and desire to serve in these areas.

Though typically quite separated, it is crucial that PCPs in rural areas partner with larger health systems to comprehensively address the complex needs of their community, improve population health, and implement strategies such as telemedicine to positively impact health outcomes and reduce ED utilization for preventative illnesses.

For all systems regardless of funding source, EMTALA mandates EDs to conduct a medical examination for anyone that presents at the department, irrespective of paying ability. That said, despite policy efforts and increased funding and federal reimbursement in urban areas, the triple aim of improving patient experience, enhancing population health, and reducing the per-capita cost of care remains a challenge without providers' and payers' collaboration to increase access to preventive care and decrease in ED usage.

As a result, many experts support the notion that emergency medical services should serve only immediate risks in both urban and rural areas. As stated above, EMTALA includes provisions that protect patients from being turned away or transferred before adequate stabilization. In the prehospital setting, providers must exercise appropriate judgement in choosing a suitable hospital for transport. Hospitals can only turn away incoming ambulances if they are on diversion and incapable of providing adequate care. However, once a patient has arrived on hospital property, care must be provided.

At the hospital, contact with the patient is first made by a triage nurse who determines the appropriate level of care needed. According to the Mead v. Legacy Health System, [59] a patient-physician relationship is established when "the physician takes an affirmative action with regard to the care of the patient".

Initiating such a relationship forms a legal contract in which the physician must continue to provide treatment or properly terminate the relationship. In emergency medicine, termination of the patient-provider relationship prior to stabilization or without handoff to another qualified provider is considered abandonment. In order to initiate an outside transfer, a physician must verify that the next hospital can provide a similar or higher level of care.

The unique setting of emergency medicine practice presents a challenge for delivering high quality, patient-centered care.

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Clear, effective communication can be particularly difficult due to noise, frequent interruptions, and high patient turnover. Many circumstances, including the regular transfer of patients in the course of emergency treatment, and crowded, noisy and chaotic ED environments, make emergency medicine particularly susceptible to medical error and near misses.

Maintaining public trust through open communication regarding harmful error, however, can help patients and physicians constructively address problems when they occur. Emergency Medicine is a primary, or first-contact point of care for patients requiring the use of the health care system. There are a variety of international models for emergency medicine training.

Among those with well developed training programs there are two different models: a "specialist" model or "a multidisciplinary model". Additionally, in some countries the emergency medicine specialist rides in the ambulance. For example, in France and Germany the physician, often an anesthesiologist, rides in the ambulance and provides stabilizing care at the scene. The patient is then triaged to the appropriate department of a hospital, so emergency care is much more multidisciplinary than in the Anglo-American model.

In countries such as the US, the United Kingdom, Canada and Australia, ambulances crewed by paramedics and emergency medical technicians respond to out-of-hospital emergencies and transport patients to emergency departments, meaning there is more dependence on these health-care providers and there is more dependence on paramedics and EMTs for on-scene care.

Emergency physicians are therefore more "specialists", since all patients are taken to the emergency department. Most developing countries follow the Anglo-American model: 3 or 4 year independent residency training programs in emergency medicine are the gold standard. Some countries develop training programs based on a primary care foundation with additional emergency medicine training.

In developing countries, there is an awareness that Western models may not be applicable and may not be the best use of limited health care resources. For example, specialty training and pre-hospital care like that in developed countries is too expensive and impractical for use in many developing countries with limited health care resources.

International emergency medicine provides an important global perspective and hope for improvement in these areas. There are a lot of residency programs. Also it is possible to reach the certification with a two-year postgraduate university course after a few years of ED background. These programs nominally add one or more years to the ACEM training program. For medical doctors not and not wishing to be specialists in Emergency Medicine but have a significant interest or workload in emergency departments, the ACEM provides non-specialist certificates and diplomas.

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In Chile, Emergency and Emergency Medicine begins its journey with the first specialty program at the beginning of the 90s, at the University of Chile. CCFP EM emergency physicians outnumber FRCP EM physicians by a ratio of about 3 to 1, and they tend to work primarily as clinicians with a smaller focus on academic activities such as teaching and research. FRCP EM Emergency Medicine Board specialists tend to congregate in academic centers and tend to have more academically oriented careers, which emphasize administration, research, critical care, disaster medicine, and teaching.

They also tend to sub-specialize in toxicology, critical care, pediatrics emergency medicine, and sports medicine. The current post-graduate Emergency Medicine training process is highly complex in China. Because specialty certification in EM has not been established, formal training is not required to practice Emergency Medicine in China.

About a decade ago, Emergency Medicine residency training was centralized at the municipal levels, following the guidelines issued by The Ministry of Public Health. Residency programs in all hospitals are called residency training bases, which have to be approved by local health governments. These bases are hospital-based, but the residents are selected and managed by the municipal associations of medical education.

These associations are also the authoritative body of setting up their residents' training curriculum. All medical school graduates wanting to practice medicine have to go through 5 years of residency training at designated training bases, first 3 years of general rotation followed by 2 more years of specialty-centered training.

Emergency physicians usually work on a volunteering basis and are often anaesthesiologists, but may be specialists of any kind. Especially there is a specialisation training in pediatric intensive care. India is an example of how family medicine can be a foundation for emergency medicine training.

However, emergency medicine was only recognized as a separate specialty by the Medical Council of India in July The first cohort of locally trained emergency physicians graduated in It requires passing the two-part exam: first part and final part written and oral to obtain the SBEM certificate, which is equivalent to Doctorate Degree. Most programs are three years in duration, but some programs are four years long. There are several combined residencies offered with other programs including family medicine , internal medicine and pediatrics.

The US is well known for its excellence in emergency medicine residency training programs. This has led to some controversy about specialty certification. There are three ways to become board-certified in emergency medicine:. A number of ABMS fellowships are available for Emergency Medicine graduates including pre-hospital medicine emergency medical services , critical care, hospice and palliative care, research, undersea and hyperbaric medicine, sports medicine, pain medicine, ultrasound, pediatric Emergency Medicine, disaster medicine, wilderness medicine, toxicology, and critical care medicine.

In recent years, workforce data has led to a recognition of the need for additional training for primary care physicians who provide emergency care.

Route to the ED

Studies have shown that attending emergency physician supervision of residents directly correlates to a higher quality and more cost-effective practice, especially when an emergency medicine residency exists. In the United Kingdom, the Royal College of Emergency Medicine has a role in setting the professional standards and the assessment of trainees. Emergency medical trainees enter specialty training after five or six years of Medical school followed by two years of foundation training.

Specialty training takes six years to complete and success in the assessments and a set of five examinations results in the award of Fellowship of the Royal College of Emergency Medicine FRCEM. Historically, emergency specialists were drawn from anaesthesia, medicine, and surgery. Trainees in Emergency Medicine may dual accredit in Intensive care medicine or seek sub-specialisation in Paediatric Emergency Medicine. Emergency Medicine residency lasts for 4 years in Turkey.

These physicians have a 2-year Obligatory Service in Turkey to be qualified to have their diploma. After this period, EM specialist can choose to work in private or governmental ED's. The college of Physicians and Surgeons Pakistan accredited the training in Emergency Medicine in Emergency Medicine training in Pakistan lasts for 5 years. The initial 2 years involve trainees to be sent to three major areas which include Medicine and allied, Surgery and Allied and critical care.

It is divided into six months each and the rest six months out of first two years are spent in emergency department.

In last three years trainee residents spend most of their time in emergency room as senior residents. After fulfilling the requirement they become fellow of College of Physicians and Surgeons Pakistan in Emergency Medicine [1]. There are approximately 70 residents in different years of training. The list of Physicians cleared their exam from the College of Physicians and Surgeon Pakistan can be seen here [2]. The first residency program in Iran started in at Iran University of Medical Sciences, and there are now three-year standard residency programs running in Tehran, Tabriz, Mashhad, Isfahan, and some other universities.

All these programs work under supervision of Emergency Medicine specialty board committee.

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