Composition of the emergency medical service system

The composition of the emergency medical service system may change (additions or removals) based on the need for the element or changes in the medical care environment. In addition, the evaluation or analysis of management can allow for the improvement or emphasis of a particular component/element. In the modern era, the demand for specialized and high-quality emergency care is high. The establishment of an emergency medical service system in Korea was a relatively recent event, and currently the system is at the stage where evaluations for each component and improvements for weak components are taking place (National Emergency Medical Center, 2017).

Table 1. Composition of emergency medical service system.

No. Composition of emergency medical service system 1. Manpower

2. Education and training

3. Information & Communication system 4. Out-of-hospital transport agencies 5. Inter-facility transport agencies 6. Receiving facilities

7. Specialty care units

8. Registration of incident reports and dispatch 9. Public information & Education

10. Audit & Quality improvement 11. Disaster management

12. Mutual aids 13. Protocols 14. Financing

15. Medical oversight by physician

(A) Manpower

Manpower in the field of emergency medical service system is largely divided into the following: first responder and Emergency Medical Technicians (EMT), who are part of the pre-hospital phase; and emergency medical center physicians, emergency nurse practitioners, and other medical staff working at the emergency medical center, who are part of the in-hospital phase.

Table 2. Comparison of ranks and education process/duration of EMTs from different countries.

Categories Rank Education process/duration

Korea

Ambulance worker Emergency medical training (2 weeks) at the fire department

2^nd rank EMT 330 hours

1^st rank EMT University degree program (3–4 years)

A first responder may be a lay person, police officer, or public service worker who has received primary first aid training provided by the country or emergency care-related organizations. EMTs are the key taskforce for pre-hospital emergency medical care, and different countries may have different titles and ranking system for EMTs. Since EMTs at different ranks receive different training procedures and have different responsibilities, their rankings may be further subdivided. However, since there is no restriction on the workplace of EMS personnel from different specialties, emergency medical center physicians or emergency nurse practitioners can play a role in the pre-hospital phase and EMTs can work at the emergency medical center.

(B) Education and training

In most cases, family members of the patient are the first responders.

Therefore, providing education on basic CPR and trauma life support to these

lay people is important, aside from all other education and training (such as initial training, additional training, and mock exercises) required for public workers in the field of emergency care (the police, emergency care support centers, public health workers). Thus, the development of an appropriate educational program and securing well-trained lecturers are important to provide efficient education. Hiring personnel with complete training (certificates) for each speciality of emergency medical care will require an enormous amount of financial support from the government budget. Therefore, the development of the workforce via an independent educational system within the emergency medical service system relying on specialized academic societies for emergency medical care is more favorable. The appropriateness of the education should be frequently evaluated, and accepting feedback from the evaluations will improve the quality of the training program.

(C) Information & Communication system

In order to provide high-quality emergency medical service, the managers of each components of the emergency medical service system should be connected to work as a complete unit. The information and communication system is responsible for connecting the people in charge. Components of the communication system for emergency medical service include access, the registration of reported incidents and dispatch, and medical oversight.

Communication can be made via both landline and cellular (wireless) technologies. Although landlines traditionally constituted the major method, cellular phones are more widely used in the modern era, which can be very useful in emergency situations. The establishment of an information system via a communications network allows for not only the expansion of tasks that can be performed via communication, but also an increased quality of

emergency medical service. Information collected from different components of the emergency medical service using communications network can be utilized for research, evaluation, and medical oversight – therefore, the establishment of a stable information and communication system is an essential condition for advanced emergency medical service system.

Private ambulance company Occurrence of

emergency situation 119 EMS on-site service

· Registration of incident /

· Provide medical oversight

Related organization (i.e. 112) Emergency

medical center Central emergency medical center

Fig. 2. Mimetic diagram of the emergency medical information &

communication system in Korea.

The Emergency Medical Dispatch system essentially applies to the first responder who can react practically instantly to the events occurring at the accident site. Since this system actively connects the patient, the witness, and

the EMT and adequately controls the tasks/resources needed in an emergency situation, it is also called the neural network of the emergency medical service system (James, 2002).

(D) Transport issues

The transportation of emergency patients is largely divided into out-of-hospital and inter-facility transports, and the transportation system is composed of the following: means of transport, number of people in the vehicle, emergency medical center, and information and communication. Means of transport include land (ambulance), air (airplanes, helicopters), and water (emergency medical boat) transport. Patients from sites in the mountain regions or islands, where it is difficult to reach them or it would take longer to transport the patient via land, will require air transport. Meanwhile, island countries or regions often utilize emergency medical boats for water transport.

In Korea, there are two types of ambulances, general and specialty, based on the severity of the patient’s condition, while the U.S. operates three standardized types of ambulances. Air transport in Korea is operated by the 119 rescue center, and inter-facility transport is mostly performed via ambulances or private ambulances, which are not cost-free. The determination of the receiving facility should be primarily based on the distance between the site of the accident and the medical center, unless the patient requires special medical care offered only at certain medical centers. If the patient requires special treatment (e.g., emergency surgeries or cardiography/cerebral angiography), the patient should be transported to a medical center that offers these services. Medical oversight or information of the receiving facility during transportation should be available via the information and communication network between the ambulance and the medical center.

(E) Emergency medical centers (receiving facilities)

Emergency rooms in the emergency medical centers should have manpower and facilities to operate 24 hours a day in order to treat emergency patients who can come in at any time. In addition, information and communication equipment to share information with the ambulance, as well as separate ambulances for inter-facility transport need to be available.

Table 3. Current status of emergency medical centers.

Gyeonggi 65 7 24 34

Gangwon 21 3 4 14

Chungbuk 15 1 3 11

Chungnam 17 1 7 9

Jeonbuk 21 1 8 12

Jeonnam 41 2 3 36

Gyeongbuk 32 3 6 23

Gyeongbuk 38 2 7 29

Jeju 6 1 4 1

(National Emergency Medical Center, 2017)

The emergency room is the initial step of the in-hospital phase of the emergency medical service system, and it should be designed to perform appropriate emergency medical treatments (e.g., triage, life support). Rankings of emergency medical centers are set primarily based on the availability of resources or specialty care. Emergency rooms in each hospital are evaluated by the national government according to the regulations of emergency rooms in light of the role of the emergency medical center. Considering the

population of the local community and the balance with nearby local communities, each emergency medical center is given a ranking and appropriate task. For consistent improvement of emergency medical centers, the development of standardized evaluation guidelines to assess the appropriateness of emergency medical care and financial support for the centers are mandatory.

In Korea, emergency medical centers are categorized into one of four categories: National, regional, municipal, or local emergency medical center.

Long-term plans for establishment of treatment systems by emergency medicine specialists, quality improvements of the manpower in the emergency rooms, and the modernization of facilities/equipment in emergency rooms have been established. Each year, emergency medical centers are evaluated based on the above criteria, and different levels of financial support are provided based on the evaluation outcomes.

(F) Specialty care

In the emergency medical service system, the absence of specialty care centers that provide special medical treatments for patients in need of these treatment may result in confusion while determining the receiving facility or during inter-facility transport. This in turn may result in a lack of appropriate emergency medical care provided for the patient. Furthermore, it will be difficult to collect information regarding the number of patient or their prognosis, which may affect the planning or improvement of emergency medical services in the future. Therefore, analysis of the frequency (number) of patients and mortalities for neighboring regions needs to be performed prior to establishing a specialty care center at a prime location characterized by higher frequencies of accidents in nearby regions and better accessibility

to the center for the patients. In addition, a standardized transport-transfer protocol needs to be established beforehand in order to operate the center efficiently.

Currently in Korea, there are two specialty emergency care centers for pediatric patients and one specialty emergency care center for burns. In the future, the number of specialty care centers is expected to consistently increase.

(G) Registration of incident reports and dispatch

The access method to use the emergency medical service system is reporting, which is done via telephone calls. Responses to the report include the following: directing the ambulance to be dispatched; determination of the receiving facility; and consultation for first aid or medical oversight until the ambulance reaches the site. Access via telephone is done using different unique numbers in different countries (911 for the U.S., 999 for the U.K., 15 for France, 112 for Germany, and 119 for Japan). In Korea, there is an emergency ambulance service (119) and a police service (112).

Fig. 3. Emergency medical service report/registration system.

(H) Public information and education

Education for the public is mainly focused on the appropriate method to access emergency medical service, first aid protocols until the ambulance reaches the site, and appropriate measures for preventable traumatic injuries or diseases. These trainings will reduce the unnecessary utilization of the emergency medical service system, and therefore will help maximize the efficiency of the system. Training and education on first aid (primary first aid, basic life support) for the public needs to become more active. Furthermore, the national government should utilize mass-communication-based (TV, radio, Internet, or newspapers) advertisements to inform the public of preventive measures (e.g., the use of safety helmets) or information for emergency medical care (e.g., the prevention of influenza for specific seasons, food poisoning), at least against preventable traumatic injuries or diseases.

(I) Audit and quality improvement

In order to improve the emergency medical service system, evaluation and quality improvement of all components of the system regarding their medical accountability and appropriateness, as well as their cost-effectiveness, need to be performed constantly or regularly by the administration (government). Therefore, a standardized evaluation protocol for the following aspects needs to be developed: registration of incident reports and dispatch;

responses; field assessment and treatment; and hospital outcomes.

The establishment of an electronic information system allows for these tasks to be more conveniently performed, as well as the improved quality of the emergency medical service system. Evaluation should not point out the faults of individuals, but rather reveal issues in the management of the

system in order to come up with improvements and provide positive feedback.

(J) Disaster management

Since most disasters or large-scale accidents are accompanied by large numbers of casualties, the establishment of rescue plans as a part of the disaster prevention protocol is essential. The rescue plan should consider the characteristics of different regions based on the system utilized by local organizations for disease prevention (public organizations, emergency medical centers, and volunteer organizations). Afterwards, the administrative department for disease prevention should consider the plan and connect it with the disease prevention measures of other aspects to establish a nation-wide or region-wide disease prevention protocol.

Each emergency medical center should establish emergency plans for internal (regional or institutional) disaster and perform joint (with local organizations) or independent emergency drills. In addition, plans to store supplies for potential disastrous events – especially medical equipment and drugs – must be established and prepared under the support and control of the government.

(K) Mutual aid

For possible cases of disasters or large-scale accidents where emergency supplies from one regional facility are inadequate, or in cases where special equipment for emergency rescue is not available in the region, mutual aid plans between different regions must be established beforehand so that insufficient manpower/supplies can be accommodated from nearby unaffected regions. In general, these agreements are made under the government’s request or order – the unaffected region provides immediate

support, and the government provides financial support in the short future.

(L) Protocols

Protocols for emergency medical service should be standardized so that specific treatments are given under specific circumstances. This protocol can be developed not only for the medical field but also for related personnel (managers or administrative assistants of emergency medical service system).

The main focus of this protocol includes the standards for triage, treatment, transport, and transfer. The protocol for emergency medical service can be divided into the protocols that can be applied for both direct and indirect medical oversight and standing orders developed for indirect medical oversight – although standing orders are essentially a subset of the protocols. In other words, while the emergency medical doctor’s approval is required to perform a step in the protocol, the steps in standing orders can be performed without such approval. However, if the communication between EMTs and the physician is lost, EMTs should make decision on whether or not to perform the steps outlined in the protocol or standing orders, and these rights should be stated in law.

(M) Financing

For the improvement and development of emergency medical service system, diverse business plans and consequent financial support are mandatory. Financing the development of these new services is often from a tax-based system, but fees for using emergency medical service system and donations also contribute to this. Specific methods for financing include taxes (from liquor and tobacco), penalties for license registration, and government donations from a portion of the fines collected from various areas. Securing

and managing the funding is mostly legally regulated on the basis of Article 20 of the Emergency Medical Services Act of Korea. In addition, pursuant to Article 22, a portion of the medical cost of emergency patients is utilized for various business plans (money advances for outstanding balances, loans or donations for the development of emergency medical centers or installation of facilities/equipment for emergency medical services, and auxiliary businesses to ensure the smooth operation of emergency medical services) to improve the emergency medical services system in Korea.

Table 4. Securing the funding for the emergency medical system.

Funding for the emergency medical system (Emergency Medical Services Act , amended on 2011.8.4.)

1. A portion of fine/penalties collected by the Minister of Health and Welfare from medical care institutions, substituting for their suspension of service, according to the legislations on the National Health Insurance of Korea

2. Contributions or donations from institutions or organizations associated with emergency medical service

3. Government contributions

4. Profits made via utilization of funding

5. 20% of the fine/penalties from the Road Traffic Act Article 160(2 and 3) and Article 162(3)

(N) Medical Oversight

Medical oversight is a task defined as the pre-hospital phase treatment provided by EMTs with the authority and responsibilities specified in law under a physician’s supervision in order to improve the quality of emergency medical services. In general, medical oversight is divided into direct medical oversight, where the physician is dispatched to the site or is directly involved in the pre-hospital phase treatment of the patient via communication, and indirect medical oversight, which involves the development and application of protocols, education/training and its evaluation, and quality assurance.

Direct medical oversight involves receiving direct orders from the physician to perform adequate first aid treatment via communication. Although this system has clearly defined medical responsibilities, the EMT’s ability to collect and analyze the patient’s information and efficiently communicate the information to the physician is essential for the medical oversight via communication to be effective.

Indirect medical oversight is a very comprehensive form of medical oversight—all other forms of medical oversight that are not a part of direct medical oversight are considered indirect medical oversight. By utilizing the standardized protocol of indirect medical oversight—a form of indirect medical oversight allowing the EMTs to perform basic first aid treatments without the direct oversight of a physician—direct medical oversight can complement indirect medical oversight (National Emergency Management Agency, 2014).